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Morbid obesity is a chronic
lifelong, multi-factorial, congenital disorder, causing the patient to have excessive fat deposits and associated
medical, psychological, physical, social and economic problems [1].
Aetiological factors include the involvement of hereditary, biochemical,
hormonal, environmental, behavioural, health and cultural elements. Extreme
forms of obesity are hardly likely to respond to diet, behavioural therapy or
medication [1]. Obesity is directly correlated
with type II diabetes and cardiovascular disease [2,
3]. Non-surgical treatments for morbid obesity
have relapse rates of up to 90%, irrespective of the choice of conservative
treatment [1, 3].
As early as 1991, the US National Institute of Health issued a statement
recognising the known lack of success with conservative forms of treatment,
noting that operations to constrict or bypass the stomach were justified for
fully informed and consenting patients and constituted an acceptable risk [4,
5]. Safe and effective surgical treatment
increases the life expectancy and quality of life for extremely obese
individuals [6, 7].
Minimally invasive surgery or laparoscopic procedures have made
inroads into almost every surgical discipline, and they have shown a more
marked increase since the beginning of the 1990s due to on-going improvements
in operating techniques. Vertical banded gastroplasty, gastric bypass and
biliopancreatic diversion are now performed laparoscopically (Chua and
Mendiola [8], Wittgrove et al. [9],
Cleator et al. [10]). The operations most
amenable to laparoscopic techniques are adjustable gastric banding and
Roux-en-Y gastric bypass.
A body mass index (BMI = body weight in kilogrammes divided by body
height in metres squared) of 40 or over constitutes clinical obesity
requiring medical treatment. Surgical treatment is considered to be
justified if desired by the patient and accepted as indicated by the
surgeon. Patients with a BMI of 35–40 should be considered for surgical
treatment if they are suffering from associated conditions that would be
likely to improve as a result of weight loss.
The patient should have a BMI of 40 kg/m2 or
more, i.e.
45 kg or more above the ideal weight according to a body-weight table and
depending on physical constitution (a BMI of 40 corresponds approximately to
45 kg overweight in relation to ideal weight and average height). If the BMI
is between 35 and 40 kg/m2 (i.e. fewer than 45 kg above ideal
weight), the risk of a proposed operation would need to be justified by a
serious medical problem that could be substantially improved if the patient
were to lose weight. A highly motivated patient and an interdisciplinary
treatment approach are more influential on the outcome than strict exclusion
criteria that are rejected repeatedly year after year. The follow-up to the
fitting of an adjustable gastric band, including band adjustment,
psychological care and dietary counselling, forms a major part of the
treatment. The operation should never be performed unless proper follow-up
is assured. Further recommendations issued by the American Society for
Bariatric Surgery (ASBS) and the International Federation of Surgery for
Obesity (IFSO) say that a centre should have sufficient experience in open
and laparoscopic intestinal surgery. Furthermore, it should have access to a
suitable infrastructure of trained dieticians, psychologists, well-motivated
nursing staff and, if possible, a self-help group. The appropriate equipment
such as examination couches, operating tables, hospital beds and instruments
should be available in case it is necessary to switch from laparoscopy to
open surgery. Peri-operative monitoring facilities are also necessary. That
the surgeons should have appropriate training and experience goes without
saying. Informed consent from the patient, i.e. the first interview with the
patient, takes time and is extremely important. The success or failure of
this type of operation depends, more than almost any other, on the patient s
co-operation and compliance. The patient needs to be fully informed about
obesity as a disorder, laparoscopic gastric banding, possible complications,
warning signs and symptoms and the post-operative follow-up.
The usual patient history is taken and a physical examination
performed, and, additionally, endocrinological disorders need to be properly
managed and treated. Internal examination by a specialist, an ultrasound
scan of the abdomen and spirometry are recommended by the anaesthesiologist
in our centre. If gallstones are present, they should be removed at the same
time, because gallstone complications are frequent with intensive weight
loss [11]. The patient sees the
anaesthetist for the test results a few days before the operation. Dietary
counselling and a psychological diagnosis of eating disorders are essential
to determine which procedure should be appropriate for the patient. It is
also highly advisable for the patient to have compressive stockings fitted
by the ward nurse before admission to the ward, to prevent deep-vein
thrombosis. On the day of admission to hospital, the patient should bring
documents confirming that the cost will be reimbursed by the health
insurance fund. In our department, we prefer to obtain informed consent from
the patient well before the date for the operation.
Unlike many other types of surgical
intervention, the operation for
obesity represents the first stage of treatment. Regular check-ups and
active patient compliance are essential for a successful outcome. A
prophylactic single dose of antibiotics and low-molecular-weight heparin are
recommended. On the day of the operation the patient is allowed to sip some
tea or water. On post-operative day 1, the diet run-in phase begins after an
oral Gastrografin X-ray has been taken. If possible, the patient should be
given another dietary counselling session before the first band adjustment.
Further checks may vary according to the particular operation; naturally,
individual needs are taken into consideration.
The gastric bypass procedure was published as a treatment for morbid
obesity as early as 1967 by Mason and Ito (see [1]).
The introduction of laparoscopy surgery led to the development of many new
procedures, although the principle of the gastric bypass remained the same.
The concept of the gastric bypass is that the gastric pouch and the
malabsorption effect of a Roux-en-Y anastomosis with an 80 to 120-cm
length of the limb will cause a feeling of fullness. Between 1993 and
1999, Wittgrove and Clark [12] performed
over 500 laparoscopic bypass procedures. The stomach is transected with a
linear stapler (3.5-mm staples, 45 mm long) to form a proximal gastric
pouch. The Roux-en-Y limb is brought to the upper abdomen either behind
the colon and stomach, with an incision at the base of the mesentery of
the transverse colon, or is placed in an ante-colic position. The
end-to-side anastomosis of the remaining part of the stomach is made
either with a circular stapler under percutaneous endoscopic control, or
with an anastomosis technique that uses a linear stapler, side-to-side, as
described by Lönroth et al. [13].
The small-bowel anastomosis is also made with a linear stapler.(According
to Lonroth)
The average weight loss resulting from a gastric bypass is 60–70% of
the excess weight after 5 years and 55–60% after 10 years; 90% of patients can
expect to achieve this result [14,
15]. A comparative study [16]
at our hospital showed that higher weight loss and a better quality of life
were obtained than with a vertical banded gastroplasty or the adjustable
gastric band. The complications specific to this operation are anastomotic
leakage 0.5 to 9%; marginal ulcer 4.5–16%; long-term micro-nutrient
deficiencies in B12, folate and iron of up to 73%; weight regain in the
long-term follow-up studies; and a mortality rate of 0.1–2.5% [9,
10, 11,
12, 13,
14, 15,
16, 17].
Higa et al. reported a total complication rate of 14.8% in a series of 1,500
consecutive patients [18]. The laparoscopic
gastric bypass is a viable alternative to traditional open techniques. It is
as safe and effective and can be performed with equal or greater efficiency.
Vitamin (A, D, E and B12 and folic acid) and mineral (calcium) supplements are
obligatory.
Biliopancreatic diversion/duodenal switch
The basic principle of the biliopancreatic
diversion/duodenal
switch (BPD/DS) procedure is similar to that of the biliopancreatic bypass.
Scopinaro et al., who developed the procedure, report the largest experience
with biliopancreatic bypass. The procedure, in a series of 2,241 patients
operated on during a 21-year period, caused a mean permanent reduction of
approximately 75% of the initial excess weight [19].
The authors report that during the first 3 to 4 months after the surgery,
patients have decreased appetites related to the dumping syndrome. Scopinaro,
Marinari, and Camerini reported similar early results with the laparoscopic
technique [20].
The duodenum is divided between the stomach and the bile
ducts,
diverting pancreatic juice and bile. The duodenal stump is then closed.
Ninety percent of the stomach is removed. The small intestine is divided.
Using this separated section of small intestine, the surgeon makes a new
connection to the open end of the duodenum. The remaining end of the
small intestine is re-attached approximately 30 in. from the colon. This
biliopancreatic segment now carries the digestive enzymes and bile. Food
and digestive juices mix in the final short 30-in. section of the
intestine. Baltasar et al. [21] and
Feng and Gagner [22] described a
laparoscopic variant of the biliopancreatic bypass, the duodenal switch
procedure. Instead of performing a distal gastrectomy, the surgeon performs a
 sleeve
gastrectomy along the vertical axis of the stomach, preserving the
pylorus and initial segment of the duodenum, which is then anastomosed
to a segment of the ileum, similar to the above procedure, to create the
alimentary segment. Preservation of the pyloric sphincter is designed to
be more physiological. The sleeve gastrectomy decreases the volume of
the stomach and also decreases the parietal cell mass, with the intent
of decreasing the incidence of ulcers at the duodeno-ileal anastomosis.
However, the basic principle of the procedure is similar to that of the
biliopancreatic bypass, i.e. it produces selective malabsorption by
limiting food digestion and absorption to a short, common ileal segment.
The potential for metabolic complications exists with this procedure.
Patients undergoing the duodenal switch procedure require long-term
medical follow-up and regular monitoring of fat-soluble vitamins,
vitamin B12, iron and calcium.
Marceau et al. [23] reported on
465 patients with a duodenal switch procedure compared with 252 patients who
underwent the biliopancreatic bypass. In addition to the preservation of the
duodenum, the common segment was elongated to 100 cm. The authors noted
similar weight loss in the two groups. In the duodenal switch group, a lower
incidence of metabolic abnormalities such as protein malnutrition was noted,
which prompted reversal of the procedure in 1.7% of those undergoing
biliopancreatic bypass vs only 0.1% after the duodenal switch procedure. The
excess weight loss varied between 70% and 90%, depending on the length of
the common segment and alimentary limb. The biliopancreatic diversion with
duodenal switch combines a sleeve gastrectomy with a duodeno-ileal switch to
achieve maximum weight loss. Consistent excess weight loss of between 70%
and 80% is achieved, with acceptable decreased long-term nutritional
complications. With a higher entry weight, the super-obese patient (BMI
>50 kg/m2) benefits the greatest from a procedure that produces a
higher mean excess weight loss. The laparoscopic approach to this procedure
has successfully created a surgical technique with optimum benefit and
minimum morbidity, especially in the super-obese patient [24].
Vertical banded gastroplasty
Vertical banded gastroplasty
(VBG) is a purely non-adjustable
restrictive procedure and, recently, has been performed laparoscopically [25,
26]. In this procedure the upper stomach
near the oesophagus is stapled vertically for about 2.5 in. (6 cm) to create
a smaller stomach pouch. The outlet from the pouch is restricted by a band
or ring that slows the emptying of the food and thus creates the feeling of
fullness. Moreover, MacLean and colleagues reported staple-line perforations
in 48% of patients, of whom 36% underwent re-operation [27].
Preliminary experiences are encouraging [26]
but the long-term results of VBG are disappointing when assessed by the
standard criteria [28].
In a prospective non-randomized 9-year follow-up study we could
demonstrate an advantage of the adjustable restrictive procedure, namely the
adjustable gastric band (AGB) [29]. The
overall re-intervention rate for long-term complications in 1,011 patients
was 15.6% for the VBG and 7% for the AGB group (P<0.0001). No
statistically significant difference in outcome in terms of weight loss,
reduction of co-morbidity and improvement in quality of life following AGB
or VBG was observed. VBG was performed from 1977 but, therefore, was
abandoned by our institute in 2001.
Early experience gained in Europe with the LAP-BAND system made by
Bioenterics (Inamed Corporation, USA) led to repeated modification of
the technique and resulted in great improvements in outcome [30,
31, 32,
33, 34,
35, 36,
37, 38,
39]. As with the adjustable band, the
so-called Swedish band (SAGB, Obtech AG, ETHICON), which makes a smaller
pouch, significantly reduced the post-operative complication rate [40,
41, 42,
43]. The AGB is a 12-mm-wide soft
silicone band with an elastic balloon that can be inflated by injection
according to individual need. The band is fitted around the upper part
of the stomach, dividing it into two sections, the smaller of which is
above the band and has a capacity of approximately 15–20 ml (pouch); the
larger remaining part is below the band. The constriction is called a
stoma. The following are the main differences in technique for gastric
banding: by means of a calibration balloon positioned in the stomach,
the site of incision is determined at the small curvature. At this site,
a 0.5 to 1-cm window is placed close to the cardia. The fenestration is
continued along the posterior wall of the gastro-oesophageal junction up
to the angle of His. Another so-called pars flaccida technique starts at
the medial edge of the right crus of the diaphragm after incision of the
pars flaccida of the lesser omentum dissecting to the angle of HIS
(Fig. 3). Tunnelled suturing is obligatory to
prevent band slippage and to ensure that the fundus does not slide under
the band. We also recommend gastropexy in addition to the stomach wall
suture (fundus sutured to the left side of the diaphragm). The AGB makes
it possible for the surgeon to alter the stoma diameter. Laparoscopic
implantation of an AGB requires approximately the same level of skill as
laparoscopic Nissen fundoplication. As with all laparoscopic procedures,
there is a learning curve [44,
45] for banding that can vary quite
substantially. Good surgical training, careful patient selection and
inter-disciplinary follow-up management are some key factors.
Trouble-free banding requires experience and practice. De Jong and van
Ramshorst report a re-operation rate of 30% in their first 50 patients
and a significant reduction of 13% for the next 47 [45].
Elmore et al. report that the largest number of complications occurred
in the first 25 patients [46].
Angrisani and colleagues [47] report
disappointing
results
in the early laparoscopic operations. Table 2 gives
a summary of complications. Weight loss is given in the literature as
BMI 43–46 pre-operatively to BMI 28–32 post-operatively. The target of a
50–60% reduction of excess weight is achievable [31,
47, 48,
49, 50,
51, 52].
Belachew et al. [31] have demonstrated
that 80% of their patients reduced their excess weight by 60%. OBrian
et al. [38] reported excess weight loss
of 51% in the first year, 58% in the second, 61% in the third and 68% in
the fourth year post-operatively. Studies with a follow-up of over 5
years confirm that the weight loss is long-term. A prospective study in
our department, comparing the two bands, found no difference in weight
loss and complication rate between LAP banding and SAGB after a 4-year
follow-up [53]. Complications break
down into peri-operative and late complications. Top priority is given
to the prevention of complications, however. Thorough training and an
inter-disciplinary approach to therapy are essential. We believe that
the laparoscopically implanted AGB, both the LAP-BAND system and SAGB,
is an efficient treatment method for patients with morbid obesity. It
dispenses with the need for open surgery on the stomach or small
intestine, which remain intact in terms of anatomy and digestive
physiology. Long-term metabolic complications are not anticipated.
Weight loss and food intake can be adapted to individual patient needs.
Of the patients, 80–90% can expect to lose 60–70% of their excess
weight.
It is much easier with this method than with other procedures for the
surgeon to remove the band and restore the original situation. The
surgical technique is difficult in the learning phase, but it becomes
easy with practice and is fairly low risk provided that the safety
recommendations are observed. All these reasons make gastric banding a
relatively safe and efficient treatment for morbid obesity, and it is
likely to be an important surgical addition to the treatments available
for most of these patients.
In 1995, Cigaina et al.
discovered, when experimenting with pigs,
that electrical stimulation of the stomach wall resulted in characteristic
patterns of gastric peristalsis in both directions [54].
A further pig study demonstrated that stimulation of the stomach wall
influenced the animals
eating habits. Animals whose stomach wall had been stimulated ate less.
Weight loss is attributed to lower absorption of food or absorption in the
gut [55].
In February 2000, a
randomised, placebo-controlled double-blind trial
was launched in the USA and Europe to check the clinical effectiveness
and safety of the Transcend implantable gastric stimulator.
The implantable gastric stimulation (IGS) system consists of two
electrodes that are introduced into the stomach wall with a needle. A
wire connects the electrodes to a 60×40×10.3-mm stimulator, which is
implanted below the left costal arch in a subcutaneous pouch and can be
programmed from outside. A suitable site is selected on the stomach wall
in the gastro-oesophageal transition region, at which the electrodes can
be placed in a strictly intra-mural position. The needle entry and exit
points should be 2.5 cm apart and are marked with electrocautery. The
electrodes are then introduced under gastroscopic control to prevent
perforation of the stomach wall The probe is secured proximally with two
PDS sutures and distally with a clip. The
conductor wire is then taken to the outside and connected to the
stimulator system. Forty-eight IGS systems have been implanted in
patients throughout Europe in a clinical trial. There have been no
serious complications, either post-operatively or later. Among the
implants in Austria, two patients required tightening of the connection
between the wire and the stimulator. This was done under local
anaesthetic in day surgery. Current results of trials in all the centres
show a significant excess weight loss of 32% after 15 months with a
stimulator. All the implantations of IGS systems have been successful,
and there have been no life-threatening or fatal complications [56,
57].
The principle of gastro-intestinal stimulation for weight loss in
morbid obesity is currently one of the least invasive surgical techniques.
Many more studies and examinations of eating habits and quality of life will
be necessary before clear statements about the ranking of implantable
gastric stimulation can be made in comparison with other treatment methods
for morbid obesity. Whether the high costs (about five-times higher than the
material cost of an AGB) will be justified in terms of outcome remains to be
seen from further studies.
Weight loss and co-morbidity
Weight loss from BMIs of 43–46 pre-operatively to BMIs of 28–32 is
reported in the literature. The target of a 50–60% reduction in excess
weight is achievable. Studies with a long-term follow-up of over 5 years
confirm that weight loss is maintained after obesity surgery. A prospective
study in our department has shown that 80% of associated disease has either
improved or resolved completely only 3 years after VBG, adjustable gastric
banding and Roux-en-Y gastric bypass [16]
have been performed. Morbid obesity is associated with a large number of
health risks [58]. Studies have produced
evidence of a significant reduction in blood sugar and cholesterol levels
and blood pressure even with a modest weight loss of
only
10% after surgical treatment. The improvement in co-morbidity is in direct
proportion to weight loss after gastric banding. In 50% of patients with
associated disease (diabetes, high blood pressure, dyslipidaemia), this had
resolved after only 1 year, with significant improvement in a further 24% of
patients [58]. Dixon and OBrien
[59] describe 83% of patients with high
blood pressure (78 out of 88), which was normal after 17 months (RR
<140/90). Dixon and OBrien
[59] documented the effects on 48
consecutive patients with reflux disease (GERD) and gastric banding. Of the
GERD patients, 76% were found to be symptom free only 3 weeks after the
operation. The effect was directly linked to the banding system rather than
weight loss. Examination of 32 patients with bronchial asthma 12 months
after banding noted a significant improvement of this condition in all of
them (100%) based on the number of attacks, medication requirements,
hospitalisation and physical stress [60].
Dixon et al. [60] reported a
reduction of sleep apnoea and a significant reduction in obstructive airways
disease in patients with the LAP-BAND system.
Similar results were published by Alvarez-Cordero et al. [61].
Nine out of ten of his patients needed no medication for hypertension, and
six out of 11 no longer needed medication by mouth for diabetes. Sleep
apnoea resolved in all patients who had suffered from this disorder before
their operation [60]. Improvement in
co-morbidity as a result of significant weight loss due to adjustable
gastric banding and gastric bypass is confirmed in many publications [58,
59, 60,
61, 62,
63, 64,
65]. If the patient fails to lose weight
quickly enough, complications such as band slippage or leakage should be
ruled out before the patient is referred to the psychologist and dietician.
Quality of life is significantly improved in morbid obesity patients [66,
67, 68,
69], both in terms of life expectancy [70]
and physical activity, as well as satisfaction [66].
According to an analysis by Weiner et al. [67],
quality of life improved significantly in 92% of patients. Our studies
have shown a direct correlation between quality of life and BMI [7].
Moreover, statistically significant improvements in all areas of life (social
contacts, physical activity, self-confidence, and sexuality, working and
family life) were demonstrated after a BMI reduction of 5 [7].
The bariatric analysis and reporting outcome system (BAROS) has now
become the accepted assessment method for quality of life and treatment
outcome after AGB surgery. The BAROS assessment score covers weight loss
(–1 for weight increase to +3 for 75–100% excess weight loss),
co-morbidity (–1 for deterioration to +3 for completely resolution) and
the quality of life questionnaire (self-esteem, physical activity,
social contacts, job satisfaction, sexuality (+3, maximum and –3,
minimum). Points are lost for complications (1 point) and re-operation
(1 point). A score of 7–9 points is thus an excellent result, 4–6 points
is good and 1–3 points is a satisfactory score, with –3 to 0 points
indicating failed treatment. The health status and quality of life (QoL)
assessment after surgery for obesity is summarised in Table 3
[16]. Favretti et al. report on 170
LAP-BAND-system patients, with excellent and good results in 48% [68].
The failure rate in this group is reported as 10%. Klaiber et al.
reported the failure rate in their patients with the SAGB system as only
3.9% [50].
Because the band system is
adjustable, the stoma can be adjusted in
a female patient to assure a normal pregnancy if this occurs [71].
Patients rate the success of adjustable gastric banding very highly due to
weight loss, reduction in co-morbidity and the improvement of quality of
life it gives them. The positive assessment and laparoscopic implantation
techniques result in a high level of acceptance among patients, GPs,
specialists in internal medicine, psychologists, dieticians and sports
researchers [69, 72].
The overall BAROS assessment of laparoscopically implanted gastric
banding, band-assisted gastroplasty and stomach bypass shows a significantly
higher rate of excellent results for the stomach bypass [16]. In terms of failure of a surgical
procedure Orlistat (Roche) could be a good option as an adjuvant medical
therapy [73].
Surgical treatment for obesity has proved that it is the best and
most effective means of preventing the life-threatening complications and
serious degenerative problems associated with pathological obesity. It is
indicated by the ineffectiveness of non-surgical treatment methods and the
high risk resulting from untreated obesity [70,
74]. Safe, effective surgical treatment
methods increase life expectancy and quality of life for patients with
extreme excess weight.
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