Authors' objectives:

This review aims to assess the available evidence on the effectiveness of gastric restrictive surgery for morbid obesity. This updates earlier ICSI reports published in 1994, 1996 and 2000.

Authors' recommendations: With regard to gastric restrictive surgery for clinically severe obesity in adults, the ICSI Technology Assessment Committee concludes: - Gastric surgery may be considered for patients 18 years of age or older with a body mass index (BMI) of 40 kg/m2 or greater, or a BMI of 35 kg/m2 or greater with significant comorbid conditions such as type II diabetes, hypertension, hyperlipidemia, and obstructive sleep apnea, and who have failed to achieve and maintain significant weight loss following medical therapy. - In terms of mortality, Roux-en-Y gastric bypass (RYGB), vertical banded gastroplasty (VBG), and laparoscopic adjustable gastric banding (LAGB) are relatively safe, with less than 1.0% perioperative mortality in experienced centers. - An increase in complication frequency from bariatric surgery may result from patients at high surgical risk such as those with severe congestive heart failure, metastatic cancer, cirrhosis with portal hypertension, uncontrolled bleeding disorders or active infections. Patients with uncontrolled serious psychiatric disorders such as schizophrenia and those with active substance abuse are also at high risk. The patient needs to comprehend the implications of the procedure for the patients lifestyle and be willing to comply with the follow-up regimen (Mattison and Jensen, 2004). - Bariatric surgery is safe and effective for sustained weight loss in appropriately selected patients who receive long-term medical surveillance through a comprehensive follow-up program. Most of the weight loss is maintained after 10 years follow-up (Conclusion Grade I). - Large studies have shown that RYGB may result in weight loss of 60% to 70% of excess weight (%EWL). - VBG shows substantial weight loss efficacy but less than that for RYGB. In addition, VBG has a high rate of serious morbidity, including a reoperation rate of up to 30% from stoma obstruction and staple-line disruption. Therefore, the evidence supports the overall superiority of RYGB over VBG in safety and efficacy for bariatric surgery. - Comparative studies on laparoscopic techniques for RYGB and VBG showed a comparable weight loss efficacy to their open counterparts but a large variation in morbidity. The most recent studies, however, show a comparable frequency of morbidity to open techniques but with a shorter hospital stay and recovery time for patients undergoing laparoscopic surgery. Overall, the evidence supporting this conclusion is of fair to poor quality due to small sample sizes and short follow-up periods. To perform laparoscopic bariatric surgery safely and effectively, specialized training is needed to achieve adequate expertise (Conclusion Grade II). - The evidence has not shown that laparoscopic adjustable gastric banding (LAGB) is equally as efficacious in terms of weight loss compared to RYGB. Longer-term studies of LAGB (follow-up of over 4 years) are lacking. Preliminary results show that a %EWL of 40% to 60% may occur but significant morbidity such as band slippage (up to 12% to 18% of patients) may require reoperation. Newer surgical techniques to prevent band slippage are being studied (Conclusion Grade III). - There are long-term studies that show improvements in mortality as well as in obesity-related comorbidities such as type 2 diabetes, hypertension, obstructive sleep apnea, and hyperlipidemia in patients receiving bariatric surgery. - The bariatric surgical procedure is one part of a lifelong surveillance program that performs critical functions to aid the patient in achieving and maintaining a healthier weight. The bariatric team needs to monitor the patient for any surgical complications, nutritional deficiencies, medical conditions and psychosocial issues, along with the status of pre-existing medical comorbidities. A specialized multidisciplinary team that includes dieticians, physicians, counselors, and other health care personnel needs to be closely involved with the patients follow-up.

Authors' methods: Review

Project Status: Completed

URL for project: http://www.icsi.org/knowledge/detail.asp?catID=107&itemID=282

Year Published: 2005

English language abstract: An English language summary is available

Publication Type: Not Assigned

Country: United States

Organisation Name: Institute for Clinical Systems Improvement

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Contact Email: icsi.info@icsi.org

Copyright: Institute for Clinical Systems Improvement (ICSI)