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INTRODUCTION
Morbid obesity is a major public health risk throughout the world. Much of the associated morbidity and mortality is related to co-morbid conditions which include, cardiac disease, diabetes mellitus type II, obstructive sleep apnoea, hypertension, dyslipidaemia, gastro-oesophageal reflux disease, degenerative joint disease and some forms of cancer.
Surgical treatment of morbid obesity has been well established as being safe and effective (1). Both short and long-term improvement of co-morbidities has been well documented (2-7). Medical treatment for this disease has included dietary manipulation, behaviour modification and medications. Long term effects of non surgical treatment have been limited (8). The indications for surgical management of obesity are summarized below.
INDICATIONS FOR SURGERY
Surgical therapy should be considered for individuals who:
have a body mass index (BMI) of greater than 40 kg/m2
OR
have a BMI greater than 35 kg/m2 with significant co-morbidities.
AND
can show that dietary attempts at weight control have been ineffective.
PERI-OPERATIVE AND LONG TERM MANAGEMENT CONSIDERATIONS
Patients should have a clear understanding of expected benefits, risks, and long term consequences of surgical treatment.
Surgeons must be aware of the diagnosis and management of complications specific to bariatric surgery.
SURGICAL TECHNIQUES
Bariatric surgical procedures are divided into two types, restrictive and malabsorptive. With either type of procedure, follow up is imperative to monitor for potential serious sequelae and operative failure. These operations should only be done performed within the confines of an obesity treatment program intent on maintaining long-term follow-up as well as long-term outcomes evaluation.
The operations which have been most frequently performed are the laparoscopic gastric banding, vertical banded gastroplasty and biliopancreatic diversion (BPD) and it's variations. Roux en Y gastric bypass is also an option - much more commonly employed in North America than in Europe or the rest of the world. (9-13).
The indications for laparoscopic treatment of obesity are the same as for open surgery. Not all patients are suitable for laparoscopic bariatric surgery, and conversion to an open bariatric procedure is sometimes necessary.
Virtually all bariatric operations can be performed with laparoscopic techniques, although advanced laparoscopic skills (such as intracorporeal knot tying, use of angled scopes to achieve multiple viewing angles, and two-handed organ and tissue manipulation are required) are required (14-20).
Laparoscopic Adjustable Gastric Banding Page
REFERENCES
1. Kellum JM, DeMaria EJ, Sugerman HJ. The surgical treatment of morbid obesity. Current Problems in Surgery 1998 ;35: 796-851
2. McGoey BV, Deitel M, Saplys RFJ et al. Effect of weight loss on musculoskeletal pain in the morbidly obese. J Bone Joint Surg (Br) 1990; 72-B: 322-3
3. Charuzi I, Ovnat A, Peiser J et al. The effect of surgical weight reduction on sleep quality in obesity-related sleep apnea syndrome. Surgery 1985; 97: 535-8.
4. Herrera MF, Deitel M. Cardiac function in massively obese patients and the effect of weightloss. Can J Surg 1991; 34: 431-4.
5. Pories WJ, MacDonald KG, FlickingerEG, et al: Is type II diabetes mellitus (NIDDM) a surgical disease? Ann Surg 1992;215:633-643.
6. Deitel M, Stone E, Kassam HA et al. Gynecologic-obstetric changes after loss of massive excess weight following bariatric surgery. J Am Coll Nutr 1988; 7: 147-53.
7. Carson JL, Ruddy ME, Duff AE et al. The effect of gastric bypass surgery on hypertension in morbidly obese patients. Arch Intern Med 1994; 154: 193-200.
8. Gastrointestinal surgery for severe obesity: National Institutes of Health Consensus Development Conference Statement. Am J Clin Nutr 1992; 55: 615S-9S.
9. Mason EE, Doherty C, Cullen JJ et al. Vertical banded gastroplasty: evolution. World J Surg 1998; 22: 919-24.
10. Linner JH, Drew RL. Why the operation we prefer is the Roux-Y gastric bypass. Obes Surg 1991; 1:305-6.
11. Scopinaro N, Adami GF, Marinari GM et al. Biliopancreatic diversion. World J Surg 1998; 22: 936-46.
12. Lagace M, Marceau P, Marceau S et al. Biliopancreatic diversion with a new type of gastrectomy: some previous conclusions revisited. Obes Surg 1995; 1: 411-18.
13. Kuzmak LI. A review of 7 years experience with silicone gastric banding for morbid obesity. Obes Surg 1991; 1: 403-08
14. Wittgrove AC, Clark GW, Schubert KR .Laparoscopic Gastric Bypass, Roux-en-Y: and results in 75 patients with 3-30 months follow-up. Obes Surg 1997; 6:500-504.
15. Belachew M, Legrand M, Vincent V, Lismonde M, LeDocte N, Deschamps V. Laparoscopic adjustable gastric banding. World J Surg 1998: 22: 955-63.
16. Chua TY, Mendiola RM. Laparoscopic vertical banded gastroplasty: the Milwaukee experience. Obes Surg 1995; 5: 636-38.
17. Lonroth H, Dalenback J, Haglind E et al. Laparoscopic bypass: another option in bariatric surgery. Surg Endosc 1996; 6: 500-04.
18. Wittgrove AC, Clark GW. Laparoscopic Gastric Bypass: a 5 year prospective study of 500 patients from 3-60 months. Obes Surg 2000; 10: June (in press).
19. Schauer PR, Ikramuddin S, Gourash W, Ramanathan R, Luketich J. Outcomes after laparoscopic Roux-en-Y gastric bypass for morbid obesity. Ann Surg 2000: Oct. (in press).
20. Catona A, La Manna L, Forsell P. The Swedish adjustable gastric band: laparoscopic technique and preliminary results. Obes Surg 2000; 10: 15-21.
This statement was modified from the position taken by the Society of American Gastrointestinal Endoscopic Surgeons (SAGES) and the American Society for Bariatric Surgery (ASBS).
