Authors' objectives:

The aim of this study was to assess the efficacy and safety of different surgical techniques in the treatment of morbid obesity

Authors' results and conclusions: Since Cochrane Collaboration carried out a systematic review about the topic in 2001, the search was done since that date, giving priority to systematic revisions. Of the other six revisions found, Buchwald et al, 2004 is mentioned in detail. Cochrane Collaboration performed a systematic revision which included 18 studies. Sixteen controlled randomized clinical trials (RCT) compare the differences among the different surgical techniques, whereas one RCT and one non-randomized study compare the surgical procedures to medical treatments. The subjects analyzed were mostly females between 33 and 47 years old, with a weight between 115 and 175 kilograms. Buchwald et al published a systematic review that analyzed 139 studies (of which only 5 were RCT and in most cases were case series). The study population was female in 70% of the cases, with an average age of 39, and an average baseline body mass index (BMI) of 46.8 (ranging between 32 and 69). Weight loss Cochrane review shows that with horizontal gastroplasty (one RCT) a weight reduction greater than that accomplished with a low-calorie-intake diet is achieved (between 23 and 28 kilograms in two years). Surgical treatments (except for biliopancreatic diversion, where evidence is scarce) are more effective than non-surgical, with a reduction of 25-44 kilograms at 1-2 years, with a steady weight loss of 20 kg. in 8 years. In Buchwald et als publication, the average weight loss was 47.5% for gastric banding, 61.6% for gastric by-pass, 68.2% for gastroplasty and 70.1% for biliopancreatic diversion with duodenal switch. The mean BMI decrease was 14.2. In all the cases the reductions were statistically significant. Operative mortality Perioperative mortality is between 0% and 1.5%, with no significant differences among the different techniques. Buchwald et al published an operative mortality (<30 days) of 0.1% for purely restrictive procedures, 0.5% for gastric by-pass, and 1.1% for biliopancreatic diversion with duodenal switch. The most frequent complications were: subphrenic abscess (7%), atelectasis or pneumonia (4%), pulmonary symptoms (6.2%) and wound infections (4%). Comorbidities Benefits such as normalization of glycemia levels, reduction in blood pressure measurements, and improvement of lipid panel were observed. However, there is no conclusive data published about long-term results, nor references to associated mortality. Comparison among techniques Gastric Banding vs Vertical Banded Gastroplasty: Cochrane Collaboration reports that those who underwent gastric banding lost less weight in studies with a 1-3-year follow-up, but the results are somewhat better at 5 years (43 vs. 35 Kg). As regards complications, the results are misleading depending on the publication, without differences in mortality. Gastric Banding vs Gastric by-pass: no conclusive results were found showing a greater benefit of one technique over the other, nor differences as regards complications. Some publications show a minor advantage for gastric banding in the short term. Horizontal gastroplasty vs Gastric by-pass: a greater weight loss has been reported for gastric by-pass than for horizontal gastroplasty (35-42% vs 16-29%, p<0.05) assessed at 12 months. No significant differences have been observed in perioperative mortality. Surgical approach The different laparoscopic techniques have proved to be relatively safe (mainly if performed by well-trained operators), with a shorter hospital stay and lower rates of readmission and complications. However, their long term efficacy is still unknown.

Authors' recommendations: Although the available evidence suggests a greater weight loss with surgical treatments than with non-surgical, no conclusive data has been found as regards comorbidities and long-term life quality. It must be taken into account that most studies were performed to subjects with a BMI of 35-40 who could not lose weight with conventional medical treatments. Of all the surgical techniques, the most accepted and well-known is the gastric bypass. The different laparoscopic techniques have proved to be relatively safe, with a shorter hospital stay and lower rates of readmission and complications. However, their long term efficacy is still unknown. It is a very complex treatment which implies a mayor surgical procedure, and which affects the patient physically, psychologically and socially. For these reasons the surgical treatments for obesity are not always covered by health organizations. The coverage is restricted to special patients who comply with strict criteria: - BMI over 40 for more than 5 years, or BMI over 35 with other important comorbidities. - At least one year of documented attempts to decrease weight including diet, physical exercise and drug treatment. - Psychological assessment of the patient s state to undergo such a treatment. - Over 18 years of age.

Authors' methods: Overview

Project Status: Completed

URL for project: http://www.iecs.org.ar/

Year Published: 2004

English language abstract: An English language summary is available

Publication Type: Not Assigned

Country: Argentina

Organisation Name: Institute for Clinical Effectiveness and Health Policy

Contact Address: Dr. Emilio Ravignani 2024, Buenos Aires - Argentina, C1414 CABA

Contact Name: info@iecs.org.ar

Contact Email: info@iecs.org.ar

Copyright: Institute for Clinical Effectiveness and Health Policy (IECS)