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Primary Care Perspective on Bariatric Surgery

      The role of primary care physicians in identifying potential candidates for bariatric surgery and providing them with long-term postoperative care is gaining rapidly in importance. With the increased use of surgical procedures as treatment options for obesity, a knowledge of bariatric surgery is essential for providing optimal care. During the past decade, the number of bariatric procedures has increased, and refinements of these procedures have made them safer and more effective. Primary care physicians should know how to identify appropriate surgical candidates and be familiar with available procedures, aware of potential complications and benefits, and able to provide lifelong monitoring and follow-up care. Thus, the primary care physician must be informed about surgical criteria, types of procedures, outcomes, complications, and the long-term monitoring needs of these patients.
      BMI (body mass index), RNYGB (Roux-en-Y gastric bypass), VBG (vertical-banded gastroplasty)
      Primary care physicians frequently play a key role in assisting overweight or obese patients in their efforts to control excess weight. Both dietary and exercise counseling, along with occasional medication use, have been the primary treatments available to health care providers. However, these approaches are not successful for most patients.
      Obesity continues to grow at epidemic proportions in the United States and other developed nations.
      • Mokdad AH
      • Serdula MK
      • Dietz WH
      • Bowman BA
      • Marks JS
      • Koplan JP
      The spread of the obesity epidemic in the United States, 1991-1998.
      More than 50% of the US population is overweight, and at least 22% of the population is obese.
      • National Institutes of Health
      Clinical Guidelines on the Identification, Evaluation, and Treatment of Overweight and Obesity in Adults—The Evidence Report.
      • Coelho JC
      • Campos AC
      Surgical treatment of morbid obesity.
      Obesity is now the second most common cause of death in the United States.
      • MacLean LD
      • Rhode BM
      • Nohr CW
      Late outcome of isolated gastric bypass.
      The estimated cost of obesity in 1995 exceeded $99 billion, $50 billion of which was for medication and medical care; the rest was for indirect losses such as decreased work productivity.
      • National Institutes of Health
      Clinical Guidelines on the Identification, Evaluation, and Treatment of Overweight and Obesity in Adults—The Evidence Report.
      Citizens in the United States spend an additional $30 billion annually for diet programs and supplements.
      • Wolf AM
      • Colditz GA
      Current estimates of the economic cost of obesity in the United States.
      However, the safety, efficacy, and long-term results of these programs remain questionable.
      • National Task Force on the Prevention and Treatment of Obesity, National Institutes of Health
      Very low-calorie diets.
      Bariatric surgery to restrict the reservoir size of the stomach or to cause purposeful malabsorption resulting in weight loss was introduced in the 1960s. Although the early procedures produced suboptimal results, improved procedures continue to be developed. In the past decade, bariatric procedures as a treatment of obesity have elicited increasing interest. As more obese patients seek bariatric surgery, the role of primary care physicians has increased and is more likely to include identifying possible surgical candidates, screening patients, and providing long-term follow-up.
      Physicians unfamiliar with newer data may be unaware that significant refinements of bariatric surgical procedures have made these procedures safer and more effective, reducing morbidity and mortality and resulting in beneficial weight loss and more predictable long-term outcomes.
      • MacLean LD
      • Rhode BM
      • Nohr CW
      Late outcome of isolated gastric bypass.
      • Bakr AA
      • Fahim T
      Laparoscopic adjustable gastric banding is a safe and effective treatment for morbid obesity.
      • Balsiger BM
      • Kennedy FP
      • Abu-Lebdeh HS
      • et al.
      Prospective evaluation of Roux-en-Y gastric bypass as primary operation for medically complicated obesity.

      OBESITY

      DEFINITION

      Body mass index (BMI) is one of the most reliable methods used to report the relationship between body weight and frame size or height. The optimal BMI for a healthy person is between 18.5 and 25 kg/m2. Persons considered overweight have a BMI of 25 to 30 kg/m2. Persons with a BMI of more than 30 kg/m2 are considered obese; those with a BMI of 40 to 50 kg/m2 are considered morbidly obese; and those with a BMI of more than 50 kg/m2 are considered superobese.
      • Coelho JC
      • Campos AC
      Surgical treatment of morbid obesity.
      • Kuczmarski RJ
      • Carroll MD
      • Flegal KM
      • Troiano RP
      Varying body mass index cutoff points to describe overweight prevalence among U.S. adults: NHANES III (1988 to 1994).

      HEALTH RISKS

      Many diseases and conditions treated by primary care physicians are directly related to obesity. As BMI increases, so does the incidence of morbid conditions related to obesity
      • Coelho JC
      • Campos AC
      Surgical treatment of morbid obesity.
      (Table 1
      • Coelho JC
      • Campos AC
      Surgical treatment of morbid obesity.
      • Choban PS
      • Onyejekwe J
      • Burge JC
      • Flancbaum L
      A health status assessment of the impact of weight loss following Roux-en-Y gastric bypass for clinically severe obesity.
      • Calle EE
      • Rodriguez C
      • Walker-Thurmond K
      • Thun MJ
      Overweight, obesity, and mortality from cancer in a prospectively studied cohort of U.S. adults.
      ). For example, evidence
      • Kuczmarski RJ
      • Carroll MD
      • Flegal KM
      • Troiano RP
      Varying body mass index cutoff points to describe overweight prevalence among U.S. adults: NHANES III (1988 to 1994).
      shows that the age-related lifetime risk of hypertension in men and women aged 45 to 54 years will double as their average BMI increases from 25 to 35 kg/m2. Other disease processes that increase in obese patients include type 2 diabetes mellitus, sleep apnea, steatohepatitis (fatty liver), degenerative joint disease, and infertility.
      • Coelho JC
      • Campos AC
      Surgical treatment of morbid obesity.
      TABLE 1Morbid Conditions Commonly Related to Obesity
      Data from references 3, 10, and 11.
      Chronic venous stasis
      Coronary heart disease
      Diabetes mellitus
      Dysmenorrhea
      Gallbladder disease
      Gastroesophageal reflux disease
      Hirsutism
      Hypertension
      Infertility
      Osteoarthritis
      Peripheral vascular disease
      Pulmonary insufficiency
      Skin infections
      Sleep apnea
      Urinary incontinence
      Increased prevalence of endometrial, colon, prostate, and breast cancer
      Increased prevalence of depression and other psychiatric disorders
      * Data from references
      • Coelho JC
      • Campos AC
      Surgical treatment of morbid obesity.
      ,
      • Choban PS
      • Onyejekwe J
      • Burge JC
      • Flancbaum L
      A health status assessment of the impact of weight loss following Roux-en-Y gastric bypass for clinically severe obesity.
      and
      • Calle EE
      • Rodriguez C
      • Walker-Thurmond K
      • Thun MJ
      Overweight, obesity, and mortality from cancer in a prospectively studied cohort of U.S. adults.
      .

      NONSURGICAL VS SURGICAL RESULTS

      The usual obesity treatments (diet, exercise, and medication) have not slowed the increase in obesity. Studies show a nearly 100% failure rate during a 5-year period for persons who diet for weight control.
      • National Institutes of Health
      Clinical Guidelines on the Identification, Evaluation, and Treatment of Overweight and Obesity in Adults—The Evidence Report.
      • National Task Force on the Prevention and Treatment of Obesity, National Institutes of Health
      Very low-calorie diets.
      • Johnson D
      • Drenick EJ
      Therapeutic fasting in morbid obesity.
      Although all groups have difficulty controlling adult obesity, persons who were obese in childhood have the poorest record of controlling obesity as adults. In contrast, at least two thirds of patients who undergo gastric bypass surgery are able to keep off at least 50% of their excess weight for 10 years or longer.
      • MacLean LD
      • Rhode BM
      • Nohr CW
      Late outcome of isolated gastric bypass.
      • Sugerman HJ
      • Kellum JM
      • Engle KM
      • et al.
      Gastric bypass for treating severe obesity.

      EARLY BARIATRIC SURGERY

      The first commonly used bariatric procedure in the 1960s was the jejunoileal bypass. In this procedure, the proximal jejunum was connected directly to the distal ileum, leaving more than 90% of the small intestine out of the intestinal stream of ingested nutrients (blind loop). This bypass created substantial global malabsorption, which led to predictable weight loss but often unacceptable adverse effects (eg, steatorrhea, diarrhea, vitamin deficiencies, oxalosis). Blind-loop problems also could develop. Many patients have required a reversal of this procedure. Since the late 1970s, the jejunoileal bypass has been abandoned.
      • Consensus Development Conference Panel
      Gastrointestinal surgery for severe obesity.

      CURRENT INDICATIONS

      In 1998, the National Heart, Lung, and Blood Institute Consensus Panel recommended surgery for weight loss as “an option for carefully selected patients with clinically severe obesity (BMI =40 or =35 with comorbid conditions) when less invasive methods of weight loss have failed and the patient is at high risk for obesity-associated morbidity or mortality.”
      • National Institutes of Health
      Clinical Guidelines on the Identification, Evaluation, and Treatment of Overweight and Obesity in Adults—The Evidence Report.
      Comorbid conditions commonly considered indications for bariatric surgery in patients with a BMI between 35 and 40 kg/m2 include diabetes mellitus, poorly controlled hypertension or hyperlipidemia, steatohepatitis, coronary artery disease, and obstructive sleep apnea.
      Other requirements for surgery include the absence of substance abuse, major psychosis, or untreated depression; a full understanding of the risks, benefits, and uncertainties of the procedure; and a willingness to comply with the preoperative and postoperative evaluation.

      TYPES OF BARIATRIC SURGERY

      Modifications in the original procedures and the development of new techniques have led to 3 basic concepts for bariatric surgery: gastric restriction by gastric banding (vertical-banded gastroplasty [VBG] and adjustable banding), gastric restriction with bypass (Roux-en-Y gastric bypass [RNYGB]), and a combination of gastric restriction and selective malabsorption (duodenal switch).
      • Brolin RE
      Bariatric surgery and long-term control of morbid obesity.
      • Choban PS
      • Jackson B
      • Poplawski S
      • Bistolarides P
      Bariatric surgery for morbid obesity: why, who, when, how, where, and then what?.

      GASTRIC RESTRICTION

      Gastric restriction procedures decrease the volume capacity of the stomach. Food distends the small proximal pouch, providing satiety. After the proximal pouch has emptied into the distal stomach, the food is digested and absorbed. Originally known as gastroplasty, gastric partitioning, or stomach stapling, the procedure was developed after weight loss was observed in patients who required a subtotal gastrectomy for other diagnoses. Today, 2 widely accepted techniques are used for gastric restriction. The first technique, VBG (1), involves the creation of a pouch in the proximal stomach with a volume of 10 to 20 mL using a polymeric silicone ring or mesh band (Silastic; Dow Corning, Midland, Mich) affixed to the surrounding tissue. This band provides stability by not allowing the pouch outlet to expand. This, in turn, slows the emptying of the proximal pouch and theoretically increases the duration of satiety.
      Figure thumbnail gr1
      FIGURE 1Vertical-banded gastroplasty. Redrawn with permission from JAMA.
      • Brolin RE
      Bariatric surgery and long-term control of morbid obesity.
      Another method is adjustable silicone gastric banding (2) with a silicone band that encircles the very proximal stomach, creating a 10- to 20-mL proximal pouch above the band. To accommodate the caloric needs of the patient, this band is adjustable by inflation through a subcutaneous reservoir. Patients may require multiple adjustments to the band after surgery. The reversibility of an adjustable gastric band is theoretically an additional advantage for some patients.
      • Kothari SN
      • DeMaria EJ
      • Sugerman HJ
      • Kellum JM
      • Meador J
      • Wolfe L
      Lap-band failures: conversion to gastric bypass and their preliminary outcomes.
      However, repetitive surgical procedures of any type increase risks and should not be approached lightly.
      Figure thumbnail gr2
      FIGURE 2Adjustable silicone gastric banding. Redrawn with permission from JAMA.
      • Brolin RE
      Bariatric surgery and long-term control of morbid obesity.
      Whether adjustable banding is better than traditional gastric restriction procedures is unknown. There are no well-done, side-by-side, long-term studies comparing the 2 procedures. Also, weight loss appears to be more gradual in patients who have an adjustable band. This slower weight loss may be caused by the less aggressive inflation of the adjustable band, which does not restrict intake as much as VBG. Therefore, early follow-up data may not be representative of long-term outcomes. Patients in 1 small US study (N=36) had a high rate of conversion to gastric bypass surgery after unsuccessful weight loss with a gastric band.
      • Kothari SN
      • DeMaria EJ
      • Sugerman HJ
      • Kellum JM
      • Meador J
      • Wolfe L
      Lap-band failures: conversion to gastric bypass and their preliminary outcomes.
      However, in Europe, Australia, and other countries, the gastric band remains the preferred bariatric procedure.
      • Coelho JC
      • Campos AC
      Surgical treatment of morbid obesity.
      • Choban PS
      • Jackson B
      • Poplawski S
      • Bistolarides P
      Bariatric surgery for morbid obesity: why, who, when, how, where, and then what?.
      • Kothari SN
      • DeMaria EJ
      • Sugerman HJ
      • Kellum JM
      • Meador J
      • Wolfe L
      Lap-band failures: conversion to gastric bypass and their preliminary outcomes.
      • Dargent J
      Laparoscopic adjustable gastric banding: lessons from the first 500 patients in a single institution.

      GASTRIC RESTRICTION WITH BYPASS

      First reported in 1967,
      • Mason EE
      • Ito C
      Gastric bypass in obesity.
      RNYGB has become the most common bariatric procedure in the United States.
      • Sugerman HJ
      • Kellum JM
      • Engle KM
      • et al.
      Gastric bypass for treating severe obesity.
      It involves transection of the stomach that results in a pouch of the proximal stomach with a capacity of 10 to 20 mL. The surgical procedure is completed with a Roux-en-Y gastrojejunostomy that allows the stomach contents to drain directly into the jejunum, bypassing the distal stomach, duodenum, and proximal jejunum
      • Coelho JC
      • Campos AC
      Surgical treatment of morbid obesity.
      (3). The bypass is important because it produces mild malabsorption, which contributes to weight loss. The length of the Roux limb usually varies between 75 and 150 cm. In patients with a BMI greater than 60 kg/m2, the Roux limb is sometimes lengthened to 150 cm proximal to the ileocecal valve, creating substantially increased malabsorption. Weight loss and nutritional deficiencies tend to be directly proportional to the Roux limb length. The RNYGB procedure predictably results in more weight loss than does gastric banding or gastroplasty alone.
      Figure thumbnail gr3
      FIGURE 3Roux-en-Y gastric bypass. Redrawn with permission from JAMA.
      • Brolin RE
      Bariatric surgery and long-term control of morbid obesity.
      Some patients who undergo RNYGB experience a temporary loss of appetite or a change in their sense of taste.
      • Sugerman HJ
      • Kellum JM
      • Engle KM
      • et al.
      Gastric bypass for treating severe obesity.
      Although the exact mechanism of such changes has not been elucidated, the changes themselves are probably a contributing factor to the greater weight loss after RNYGB.

      GASTRIC RESTRICTION WITH MALABSORPTION

      An alternative approach to RNYGB is biliopancreatic bypass. It combines some of the characteristics of gastric bypass with an intentional effort to promote selective malabsorption. In this procedure, after a hemigastrectomy, the biliopancreatic limb of the bypass is anastomosed with the small intestine 50 cm or more from the ileocecal valve. The resulting limited length of intestine for both digestion and absorption results in malabsorption and weight loss. Unfortunately, the original procedure increases the incidences of malnutrition and deficiencies of fat-soluble vitamins. A modification of this surgery, the biliopancreatic bypass with duodenal switch (4), results in fewer adverse effects (eg, abdominal bloating, steatorrhea, malnutrition) by increasing the length of the common intestinal limb to 100 cm and preserving the pylorus. However, calcium deficiency is a major concern and requires close surveillance.
      • Marceau P
      • Hould FS
      • Simard S
      • et al.
      Biliopancreatic diversion with duodenal switch.
      Figure thumbnail gr4
      FIGURE 4Biliopancreatic bypass with duodenal switch. Redrawn with permission from JAMA.
      • Brolin RE
      Bariatric surgery and long-term control of morbid obesity.

      RESULTS OF BARIATRIC SURGERY

      WEIGHT LOSS

      The ultimate objective of any bariatric surgical procedure is satisfactory reversal of weight-related morbidity by weight loss. Large studies of gastric bypass surgery show that the usual expected first-year weight loss is about 60% of excess weight. The excess weight loss in the second year is about 70%, followed by 60% through the fifth year. Approximately 60% of patients remain at this plateau, but about 30% ultimately regain some weight. Gastric bypass procedures not only reduce overall weight but also convincingly reduce body fat.
      • Monteforte MJ
      • Turkelson CM
      Bariatric surgery for morbid obesity.

      SURGICAL FAILURE

      The surgical failure rate for restrictive surgery or restrictive surgery with gastric bypass depends in part on the experience of the surgeon and the surgical center and on the type of operation. Long-term studies at the Mayo Clinic have shown that VBG has unacceptable success rates of 39% at 3 years and only 20% at 10 years.
      • Balsiger BM
      • Kennedy FP
      • Abu-Lebdeh HS
      • et al.
      Prospective evaluation of Roux-en-Y gastric bypass as primary operation for medically complicated obesity.
      • Balsiger BM
      • Poggio JL
      • Mai J
      • Kelly KA
      • Sarr MG
      Ten and more years after vertical banded gastroplasty as primary operation for morbid obesity.
      The major reasons for poor outcome are failure of the staple lines, resulting in disruption of the gastric partitioning, stenosis of the gastric outlet, distention of the gastric pouch, or a maladaptive eating disorder in which the patient “defeats” the operation with calorie-dense food and frequent meals throughout the day.

      POTENTIAL HEALTH BENEFITS

      QUALITY OF LIFE

      Using the SF-36 questionnaire, which assesses quality of life in the areas of physical activities, social functioning, physical role activities, emotional factors, bodily pain, general mental health, vitality, and general health perceptions, Choban et al
      • Choban PS
      • Onyejekwe J
      • Burge JC
      • Flancbaum L
      A health status assessment of the impact of weight loss following Roux-en-Y gastric bypass for clinically severe obesity.
      found improvement after bariatric surgery. In 7 of the 8 categories, improvement was considerable in patients whose intervention was gastric bypass surgery. These data were most impressive when patients had reached their weight loss plateau. Other authors report a decrease in sick leave and disability after gastric bypass surgery in patients aged 47 to 60 years.
      • Narbro K
      • Ågren G
      • Jonsson E
      • et al.
      Sick leave and disability pension before and after treatment for obesity: a report from the Swedish Obese Subjects (SOS) study.

      DIABETES MELLITUS

      The association of obesity with type 2 diabetes mellitus is almost universal. The increasing prevalence of type 2 diabetes mellitus in the United States and other developed countries has been linked directly to the increasing weight of the populace. Several studies of gastric bypass procedures show rapid improvement in type 2 diabetes mellitus; glucose intolerance resolves in most patients. Such patients also have some mitigation in their risk of diabetic complications.
      • Pories WJ
      • Swanson MS
      • MacDonald KG
      • et al.
      Who would have thought it? an operation proves to be the most effective therapy for adult-onset diabetes mellitus.

      HYPERTENSION

      Half of patients with hypertension will have resolution of their elevated blood pressure level after substantial weight loss induced by bariatric surgery. Patients who do not achieve normalization of blood pressure level may nevertheless be able to reduce their intake of antihypertensive medication.
      • Balsiger BM
      • Kennedy FP
      • Abu-Lebdeh HS
      • et al.
      Prospective evaluation of Roux-en-Y gastric bypass as primary operation for medically complicated obesity.
      • Choban PS
      • Onyejekwe J
      • Burge JC
      • Flancbaum L
      A health status assessment of the impact of weight loss following Roux-en-Y gastric bypass for clinically severe obesity.

      CARDIOVASCULAR HEALTH

      Studies show that weight reduction improves cardiovascular health.
      • Galanis DJ
      • Harris T
      • Sharp DS
      • Petrovitch H
      Relative weight, weight change, and risk of coronary heart disease in the Honolulu Heart Program.
      Weight loss not only lowers lipid levels but also improves ventricular function.
      • Alpert MA
      • Terry BE
      • Lambert CR
      • et al.
      Factors influencing left ventricular systolic function in nonhypertensive morbidly obese patients, and effect of weight loss induced by gastroplasty.

      SLEEP APNEA

      Convincing evidence links sleep-disordered breathing and sleep apnea to obesity, especially of the upper body. Symptoms related to sleep apnea may improve after weight loss, including weight loss after bariatric surgery.
      • Kyzer S
      • Charuzi I
      Obstructive sleep apnea in the obese.
      One large study (N=313) illustrated this finding with patients who had undergone placement of an adjustable gastric band.
      • Dixon JB
      • Schachter LM
      • O'Brien PE
      Sleep disturbance and obesity: changes following surgically induced weight loss.
      Many obese patients will improve sufficiently after weight loss to no longer require use of an oral airway device or continuous positive airway pressure treatment; however, patients should consult their physicians about having a repeated sleep study before discontinuing treatment for sleep apnea.

      PSEUDOTUMOR CEREBRI

      Another well-known complication of obesity is pseudotumor cerebri, believed to result from increased abdominal pressure in obese persons that leads to increased intracranial pressure. Initial results of several small studies of bariatric procedures for patients with pseudotumor cerebri indicate substantial improvement and resolution of symptoms in almost all patients, but follow-up data are lacking.
      • Sugerman HJ
      • Felton III, WL
      • Sismanis A
      • Kellum JM
      • DeMaria EJ
      • Sugerman EL
      Gastric surgery for pseudotumor cerebri associated with severe obesity.

      MORTALITY AND SHORT-TERM MORBIDITY

      Livingston and Ko
      • Livingston EH
      • Ko CY
      Assessing the relative contribution of individual risk factors on surgical outcome for gastric bypass surgery: a baseline probability analysis.
      identified 4 specific influential predictors of major complications with RNYGB: male sex, revisional surgery, increasing age, or increasing weight before surgery.
      A recent meta-analysis of more than 3000 patients reported a combined mortality of 0.14% for restrictive procedures and of 0.3% for combination procedures (restriction and Roux-en-Y).
      • Monteforte MJ
      • Turkelson CM
      Bariatric surgery for morbid obesity.
      Other studies suggest a mortality rate of 1% to 1.5%.
      • Lundell L
      • Ruth M
      • Olbe L
      Vertical banded gastroplasty or gastric banding for morbid obesity: effects on gastro-oesophageal reflux.
      Morbidity varies considerably by procedure and treatment center. Immediate postoperative complications include wound problems in almost 15% of patients. The introduction of minimally invasive laparoscopic techniques to the field of bariatric surgery has led to a substantial decrease in the risk of wound-related complications. Wound problems include infections, seromas, dehiscence, or hernias.
      • National Task Force on the Prevention and Treatment of Obesity, National Institutes of Health
      Very low-calorie diets.
      Table 2
      • MacLean LD
      • Rhode BM
      • Nohr CW
      Late outcome of isolated gastric bypass.
      • Bakr AA
      • Fahim T
      Laparoscopic adjustable gastric banding is a safe and effective treatment for morbid obesity.
      • Balsiger BM
      • Kennedy FP
      • Abu-Lebdeh HS
      • et al.
      Prospective evaluation of Roux-en-Y gastric bypass as primary operation for medically complicated obesity.
      • Dargent J
      Laparoscopic adjustable gastric banding: lessons from the first 500 patients in a single institution.
      • Marceau P
      • Hould FS
      • Simard S
      • et al.
      Biliopancreatic diversion with duodenal switch.
      • Abu-Abeid S
      • Szold A
      Results and complications of laparoscopic adjustable gastric banding: an early and intermediate experience.
      • Doldi SB
      • Micheletto G
      • Lattuada E
      • Zappa MA
      • Bona D
      • Sonvico U
      Adjustable gastric banding: 5-year experience.
      • Gambinotti G
      • Robortella ME
      • Furbetta F
      Personal experience with laparoscopic adjustable silicone gastric banding in the treatment of morbid obesity.
      • Olbers T
      • Lonroth H
      • Dalenback J
      • Haglind E
      • Lundell L
      Laparoscopic vertical banded gastroplasty—an effective long-term therapy for morbidly obese patients?.
      summarizes selected studies of several types of bariatric surgery and illustrates the variability among procedures. Venous thromboembolism should be expected in 1% of patients, even with appropriate preventive measures. Fatal pulmonary embolism can occur in as many as 0.2% of patients and may occur several weeks postoperatively. Anastomotic leaks occur in about 1% of patients and are a serious complication, even if detected early. As might be anticipated, frequent vomiting is more common after restrictive procedures, occurring in as many as 30% of patients
      • Monteforte MJ
      • Turkelson CM
      Bariatric surgery for morbid obesity.
      • Balsiger BM
      • Poggio JL
      • Mai J
      • Kelly KA
      • Sarr MG
      Ten and more years after vertical banded gastroplasty as primary operation for morbid obesity.
      (Table 3
      • National Institutes of Health
      Clinical Guidelines on the Identification, Evaluation, and Treatment of Overweight and Obesity in Adults—The Evidence Report.
      • Coelho JC
      • Campos AC
      Surgical treatment of morbid obesity.
      • Bakr AA
      • Fahim T
      Laparoscopic adjustable gastric banding is a safe and effective treatment for morbid obesity.
      • Balsiger BM
      • Kennedy FP
      • Abu-Lebdeh HS
      • et al.
      Prospective evaluation of Roux-en-Y gastric bypass as primary operation for medically complicated obesity.
      • Sugerman HJ
      • Kellum JM
      • Engle KM
      • et al.
      Gastric bypass for treating severe obesity.
      • Dargent J
      Laparoscopic adjustable gastric banding: lessons from the first 500 patients in a single institution.
      • Abu-Abeid S
      • Szold A
      Results and complications of laparoscopic adjustable gastric banding: an early and intermediate experience.
      • Doldi SB
      • Micheletto G
      • Lattuada E
      • Zappa MA
      • Bona D
      • Sonvico U
      Adjustable gastric banding: 5-year experience.
      • Gambinotti G
      • Robortella ME
      • Furbetta F
      Personal experience with laparoscopic adjustable silicone gastric banding in the treatment of morbid obesity.
      • Olbers T
      • Lonroth H
      • Dalenback J
      • Haglind E
      • Lundell L
      Laparoscopic vertical banded gastroplasty—an effective long-term therapy for morbidly obese patients?.
      • Blachar A
      • Federle MP
      • Pealer KM
      • Ikramuddin S
      • Schauer PR
      Gastrointestinal complications of laparoscopic Roux-en-Y gastric bypass surgery: clinical and imaging findings.
      ).
      TABLE 2Comparison of Bariatric Procedures
      BMI = body mass index; BPD-DG = biliopancreatic diversion with distal gastrectomy; BPD-DS = biliopancreatic diversion with duodenal switch; FU = follow-up; IGB = isolated gastric bypass; LAGB = laparoscopic adjustable gastric banding; LASGB = laparoscopic adjustable silicone gastric banding; LOS = length of hospital stay; LVBG = laparoscopic vertical-banded gastroplasty; NA = not available; RNYGB = Roux-en-Y gastric bypass.
      BMI (kg/m2)No. of complications
      Complication rates varied in their definitions for reporting.
      StudyProcedureMean age (y)No. of patients
      Reported at the beginning of the study.
      LOSInitialFinalMean duration of FUEarlyLateMortality
      Marceau et al
      • Marceau P
      • Hould FS
      • Simard S
      • et al.
      Biliopancreatic diversion with duodenal switch.
      BPD-DG37233NA4632100 mo16.7NA1.6
      BPD-DS37457NA473051 mo16.3NA1.9
      MacLean et al
      • MacLean LD
      • Rhode BM
      • Nohr CW
      Late outcome of isolated gastric bypass.
      IGBNA274NA48.7
      Approximate, based on reported data.
      31.4
      Approximate, based on reported data.
      5.5 yNANA0.3
      Abu-Abeid & Szold
      • Abu-Abeid S
      • Szold A
      Results and complications of laparoscopic adjustable gastric banding: an early and intermediate experience.
      LAGB38.13911.243.129.813 mo13.10
      Bakr & Fahim
      • Bakr AA
      • Fahim T
      Laparoscopic adjustable gastric banding is a safe and effective treatment for morbid obesity.
      LAGB31.3392.744.236.66.7 mo15.32NA0
      Dargent
      • Dargent J
      Laparoscopic adjustable gastric banding: lessons from the first 500 patients in a single institution.
      LAGB39.45004.243NA3 y2.24.6NA
      Doldi et al
      • Doldi SB
      • Micheletto G
      • Lattuada E
      • Zappa MA
      • Bona D
      • Sonvico U
      Adjustable gastric banding: 5-year experience.
      LASGB37.91723.846.332.63 yNANA0
      Gambinotti et al
      • Gambinotti G
      • Robortella ME
      • Furbetta F
      Personal experience with laparoscopic adjustable silicone gastric banding in the treatment of morbid obesity.
      LASGB43162242.632.215 mo1.94.90
      Olbers et al
      • Olbers T
      • Lonroth H
      • Dalenback J
      • Haglind E
      • Lundell L
      Laparoscopic vertical banded gastroplasty—an effective long-term therapy for morbidly obese patients?.
      LVBG4013934133.25 yNA81.4
      Represents 2 patients: 1 died 5 weeks postoperatively of a pulmonary embolism, and 1 died 1 year postoperatively of a myocardial infarction.
      Balsiger et al
      • Balsiger BM
      • Kennedy FP
      • Abu-Lebdeh HS
      • et al.
      Prospective evaluation of Roux-en-Y gastric bypass as primary operation for medically complicated obesity.
      RNYGB4219184934
      Approximate median, 2 years; mean not available.
      11.56.8
      Does not include ventral hernias in 17% of patients.
      0.5
      * BMI = body mass index; BPD-DG = biliopancreatic diversion with distal gastrectomy; BPD-DS = biliopancreatic diversion with duodenal switch; FU = follow-up; IGB = isolated gastric bypass; LAGB = laparoscopic adjustable gastric banding; LASGB = laparoscopic adjustable silicone gastric banding; LOS = length of hospital stay; LVBG = laparoscopic vertical-banded gastroplasty; NA = not available; RNYGB = Roux-en-Y gastric bypass.
      Reported at the beginning of the study.
      Complication rates varied in their definitions for reporting.
      § Approximate, based on reported data.
      // Represents 2 patients: 1 died 5 weeks postoperatively of a pulmonary embolism, and 1 died 1 year postoperatively of a myocardial infarction.
      Approximate median, 2 years; mean not available.
      # Does not include ventral hernias in 17% of patients.
      TABLE 3Common Complications of Bariatric Surgery
      Data from references 2, 3, 7, 8, 13, 18, and 32–36. GERD = gastroesophageal reflux disease; LASGB = laparoscopic
      Any surgeryLASGBRNYGB
      Early complicationsBleedingBand infectionAnastomotic leak
      Bowel perforationBand malfunction
      DeathBand slippage
      Deep venous thrombosis/ pulmonary embolism
      Dehydration
      Dysphagia
      Peritonitis
      Pneumonia
      Pulmonary embolism
      SBO
      Wound infection
      Late complicationsCholecystitisAnorexiaInternal hernia (SBO)
      CholelithiasisBand erosionMarginal ulcers
      Dilated pouchBand infectionPancreatitis
      DysphagiaBand malfunctionStricture
      GERDBand slippage
      Incisional herniaReservoir leakage (adjustable gastric band only)
      Malnutrition
      Vitamin B12 deficiency
      * Data from references
      • National Institutes of Health
      Clinical Guidelines on the Identification, Evaluation, and Treatment of Overweight and Obesity in Adults—The Evidence Report.
      ,
      • Coelho JC
      • Campos AC
      Surgical treatment of morbid obesity.
      ,
      • Bakr AA
      • Fahim T
      Laparoscopic adjustable gastric banding is a safe and effective treatment for morbid obesity.
      ,
      • Balsiger BM
      • Kennedy FP
      • Abu-Lebdeh HS
      • et al.
      Prospective evaluation of Roux-en-Y gastric bypass as primary operation for medically complicated obesity.
      ,
      • Sugerman HJ
      • Kellum JM
      • Engle KM
      • et al.
      Gastric bypass for treating severe obesity.
      ,
      • Dargent J
      Laparoscopic adjustable gastric banding: lessons from the first 500 patients in a single institution.
      and
      • Abu-Abeid S
      • Szold A
      Results and complications of laparoscopic adjustable gastric banding: an early and intermediate experience.
      ,
      • Doldi SB
      • Micheletto G
      • Lattuada E
      • Zappa MA
      • Bona D
      • Sonvico U
      Adjustable gastric banding: 5-year experience.
      ,
      • Gambinotti G
      • Robortella ME
      • Furbetta F
      Personal experience with laparoscopic adjustable silicone gastric banding in the treatment of morbid obesity.
      ,
      • Olbers T
      • Lonroth H
      • Dalenback J
      • Haglind E
      • Lundell L
      Laparoscopic vertical banded gastroplasty—an effective long-term therapy for morbidly obese patients?.
      ,
      • Blachar A
      • Federle MP
      • Pealer KM
      • Ikramuddin S
      • Schauer PR
      Gastrointestinal complications of laparoscopic Roux-en-Y gastric bypass surgery: clinical and imaging findings.
      . GERD = gastroesophageal reflux disease; LASGB = laparoscopic

      POTENTIAL LONG-TERM COMPLICATIONS

      DUMPING SYNDROME

      Dumping syndrome occurs because patients who undergo bariatric procedures are unable to eat foods high in concentrated sugar or fat. Dumping symptoms (eg, postprandial sweating, weakness, hypoglycemia, and generalized malaise) help condition patients to avoid high-energy, highosmolar junk foods that worsen the syndrome.
      • Coelho JC
      • Campos AC
      Surgical treatment of morbid obesity.
      This somewhat desirable complication is rarely severe except for a small group of patients (<1%); it leads to problems after even minimal nutritional intake and occurs only in patients who undergo a combination procedure involving a bypass.
      • Monteforte MJ
      • Turkelson CM
      Bariatric surgery for morbid obesity.
      Dumping symptoms are usually short-lived and disappear in almost all patients as they adapt to their bypass anatomy.

      NUTRITIONAL DEFICIENCIES

      All bariatric procedures have some risk of nutritional deficiency because of the resulting restriction of oral intake of nutrients. Vitamin deficiency occurs in about 11% of patients who have a combination procedure of gastric restriction and bypass.
      • Monteforte MJ
      • Turkelson CM
      Bariatric surgery for morbid obesity.
      Roux-en-Y procedures in particular increase the risk of deficiencies in iron, vitamin B12, or calcium.
      • Sugerman HJ
      • Brewer WH
      • Shiffman ML
      • et al.
      A multicenter, placebocontrolled, randomized, double-blind, prospective trial of prophylactic ursodiol for the prevention of gallstone formation following gastric-bypass-induced rapid weight loss.
      Also, biliopancreatic bypass procedures, by inducing selective malabsorption, can result in protein-energy malnutrition and deficiencies in the fat-soluble vitamins A, D, E, and K or in calcium. Hyperhomocystinemia has been reported in as many as two thirds of patients who undergo bariatric surgery. The mechanism of this condition may be folate deficiency.
      • Borson-Chazot F
      • Harthe C
      • Teboul F
      • et al.
      Occurrence of hyperhomocysteinemia 1 year after gastroplasty for severe obesity.
      Because elevated homocystinemia is an independent risk factor for cardiac disease, cardiovascular risk improvement from weight loss may be negated somewhat by an increased homocysteine level. Daily vitamin and mineral replacement therapy is essential for every bariatric patient. In general, 60 g of protein is recommended for patients with a malabsorptive component to their bariatric procedure.

      GASTROESOPHAGEAL REFLUX DISEASE

      Although originally proposed as a treatment for gastroesophageal reflux disease, VBG may actually increase gastroesophageal reflux.
      • Kim CH
      • Sarr MG
      Severe reflux esophagitis after vertical banded gastroplasty for treatment of morbid obesity.
      Studies report conflicting findings about the gastric banding procedure and the treatment of gastroesophageal reflux disease. One study reported a 5-fold increase in subsequent reflux symptoms.
      • Balsiger BM
      • Murr MM
      • Mai J
      • Sarr MG
      Gastroesophageal reflux after intact vertical banded gastroplasty: correction by conversion to Roux-en-Y gastric bypass.
      Differences in banding techniques and lack of uniform study parameters, such as inconsistent use of 24-hour pH monitoring, impede a clear-cut interpretation of comparative data. Gastric bypass has been shown to be effective in the treatment of gastroesophageal reflux disease
      • Frezza EE
      • Ikramuddin S
      • Gourash W
      • et al.
      Symptomatic improvement in gastroesophageal reflux disease (GERD) following laparoscopic Roux-en-Y gastric bypass.
      and to correct reflux symptoms after VBG.
      • Balsiger BM
      • Murr MM
      • Mai J
      • Sarr MG
      Gastroesophageal reflux after intact vertical banded gastroplasty: correction by conversion to Roux-en-Y gastric bypass.

      OSTEOPOROSIS OR METABOLIC BONE DISEASE

      Baseline bone density can be challenging to measure in the obese patient because of varying absorptiometry techniques and the effects of more soft tissue around bones.
      • Cundy T
      • Evans MC
      • Kay RG
      • Dowman M
      • Wattie D
      • Reid IR
      Effects of vertical-banded gastroplasty on bone and mineral metabolism in obese patients.
      However, even with technical variations, bone loss and weight loss seem to be related, especially in patients who have considerable weight loss. This bone loss appears to result not from hyperparathyroidism but from transient bone resorption of an unknown mechanism. Because most obese people have a higher-than-average bone density before weight loss, the clinical importance of a reduction in bone density has not been determined fully. Additional studies are required to explain the mechanism and importance of bone resorption. In addition, the possibility of long-term calcium malabsorption leading to calcium deficiency may play a greater role in the eventual development of osteoporosis. Patients undergoing malabsorptive procedures are especially at risk because of altered absorption of vitamin D.

      GALLSTONES

      Rapid reductions in weight, surgically induced or otherwise, are associated with the increased formation of gallstones. This complication occurs in as many as 30% of patients who have undergone a gastric bypass procedure. Reports indicate that cholecystitis that requires surgery occurs in about 27% of patients within 3 years after a bypass procedure.
      • Sugerman HJ
      • Brewer WH
      • Shiffman ML
      • et al.
      A multicenter, placebocontrolled, randomized, double-blind, prospective trial of prophylactic ursodiol for the prevention of gallstone formation following gastric-bypass-induced rapid weight loss.
      Approaches to this problem include a prophylactic cholecystectomy at the time of the bariatric procedure or prophylactic use of ursodiol (ursodeoxycholic acid) to decrease the formation of gallstones. Ursodiol increases cholesterol solubility and reduces the saturation of cholesterol in bile. Sugerman et al
      • Sugerman HJ
      • Brewer WH
      • Shiffman ML
      • et al.
      A multicenter, placebocontrolled, randomized, double-blind, prospective trial of prophylactic ursodiol for the prevention of gallstone formation following gastric-bypass-induced rapid weight loss.
      reported a reduction in gallstone formation to only 2% with use of 600 mg of ursodiol for 6 months after a gastric bypass. They suggested that the cost and the risk to patients of this medication are less than those for a routine or emergent cholecystectomy.

      GASTROGASTRIC FISTULA

      A gastrogastric fistula (along the staple lines of the proximal stomach pouch) may occur but is much less common today because of changes in surgical techniques that protect and isolate the staple lines. Leakage of ingested food through the fistula may allow the proximal pouch to empty faster, leading to increased volume of meals and increased appetite. Patients stop losing weight or begin regaining weight.
      • MacLean LD
      In discussion of: Capella JF, Capella RF. Gastro-gastric fistulas and marginal ulcers in gastric bypass procedures for weight reduction.
      Surgical intervention may be necessary to correct the fistula.

      ULCER OR STRICTURE

      Some patients may experience symptoms (stricture, bleeding, epigastric pain) related to a marginal or stomal ulcer, often due to the use of nonsteroidal anti-inflammatory drugs. Thus, the newer cyclooxygenase 2 inhibitors and all nonsteroidal anti-inflammatory drugs are contraindicated after the patient undergoes gastric bypass procedures. Primary care physicians may first identify this complication. Upper endoscopy can be helpful with diagnosis and treatment.

      EXCESS SKIN

      After rapid, substantial weight loss, patients who have undergone bariatric surgery may experience unsightly excess skin and skin folds. Removal of excess abdominal skin, referred to as an apron, is a frequent request. Other areas of excess skin may occur on the back, arms, buttocks, and lower extremities. In most circumstances, such excess skin is a cosmetic problem. However, in rare cases, skin ulceration and infection can lead to more serious medical problems. In another extreme situation, excess leg skin can interfere with ambulation. Before undergoing a bariatric procedure, patients should be aware of these long-term sequelae of rapid weight loss. Removal of excess skin usually is considered cosmetic; therefore, associated expenses typically are not covered by insurance plans. However, treatment for severe recurrent stasis dermatitis in susceptible areas (groin, beneath breasts) may be covered by insurance. Most cosmetic surgeons will refrain from removing excess skin unless the patient has reached and maintained goal weight for at least 1 year.

      BARIATRIC SURGERY AND PREGNANCY

      Primary care physicians may be asked about the advisability of pregnancy after bariatric surgery. This question is of particular concern for women who have had any procedure that bypasses the pylorus or disrupts gastroduodenal continuity. The stomach is important for production of hydrochloric acid essential for proper iron absorption and intrinsic factor, a requirement for vitamin B12 absorption. In addition, the duodenum is the major site of iron absorption.
      • Gurewitsch ED
      • Smith-Levitin M
      • Mack J
      Pregnancy following gastric bypass surgery for morbid obesity.
      However, 2 studies involving 111 pregnancies after gastric bypass surgery found minimal adverse effects with close medical supervision and proper vitamin and mineral supplementation.
      • Richards DS
      • Miller DK
      • Goodman GN
      Pregnancy after gastric bypass for morbid obesity.
      • Printen KJ
      • Scott D
      Pregnancy following gastric bypass for the treatment of morbid obesity.
      Severe iron deficiency anemia was noted in only 2 patients, and 1 mother produced low-fat breast milk, possibly due to malabsorption.
      Because obesity is not linked with poor pregnancy outcomes except in women with diabetes mellitus or hypertension, obese women who are contemplating pregnancy after bariatric surgery need to evaluate their options carefully. It is recommended that fertile bariatric patients delay pregnancy for at least the first 1 or 2 years after surgery.

      FOLLOW-UP CARE

      The decision to undergo bariatric surgery involves a lifelong commitment for the patient and the physician. Patients should see their surgeon for immediate postoperative care, but the primary care physician should become involved soon after the procedure. After release from postoperative care, the patient should be seen by either the surgeon or the primary care physician every 3 months. This follow-up will allow for early diagnosis of the more common long-term complications such as iron and vitamin B12 deficiency, incisional hernias, staple-line failure, gastritis, cholecystitis, and anastomotic problems. Also, primary care physicians may be in the best position to identify psychosocial problems such as depression. Psychological counseling is extremely important preoperatively and postoperatively. Counselors with an interest in eating disorders are an essential part of the bariatric team. Routine laboratory studies should include a complete blood cell count and iron studies every 3 months for the first year and annually thereafter. Also, vitamin B12 levels should be monitored periodically. Depending on the nutritional status of the patient, other studies may be indicated. Every patient should be monitored annually by the bariatric center for collection of long-term data. In addition to visiting their physician, patients should be encouraged to participate in support groups, which may improve outcomes and patient satisfaction.

      CONCLUSIONS

      Bariatric surgery is a safe, appropriate, and accepted treatment for morbid obesity when other methods have failed. Primary care providers should be aware of the indications for the procedure so that they can both counsel patients and make appropriate referrals. Although pharmacological agents to treat obesity are being developed, bariatric procedures will continue to be used at least in the near future as a treatment of morbid obesity. Because such patients require lifetime follow-up, primary care physicians play an integral part in the bariatric team.

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