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Surgical Management of Obesity Metabolism Clinical and Experimental 92 (2019) 206–216 Contents lists available at ScienceDirect Metabolism Clinical and Experimental journal homepage: www.metabolismjournal.com Surgical management of obesity Jacob Nudel a,b,VivianM.Sancheza,c,⁎ a Department of Surgery, Boston University School of Medicine, Boston, MA, United States of America b Institute for Health System Innovation and Policy, Boston University, Boston, MA, United States of America c Department of Surgery, VA Boston Healthcare System, Boston, MA, United States of America article info abstract Article history: Weight loss surgery is the most effective intervention for addressing obesity and related metabolic disorders such Received 14 September 2018 as diabetes. We describe common surgical procedures as well as emerging and investigational procedures in Received in revised form 12 December 2018 terms of their capacity to induce weight reduction and their risk profiles. We then discuss the impact of weight Accepted 14 December 2018 loss surgery on important obesity related disorders including diabetes, cardiovascular disease, and non-alcoholic fatty liver disease. The question of operative choice is discussed with respect to benefits and risks of common pro- Keywords: cedures. Reoperative weight loss surgery, an increasingly common element of weight loss surgical practice, is Bariatric surgery fl Gastric bypass reviewed. We brie y discuss the metabolic mechanism of action of weight loss surgery. Lack of access to and Weight loss under-utilization of weight loss surgery represent important challenges to adequate obesity treatment, and we Gastrectomy review these topics as well. Postoperative complications © 2018 Published by Elsevier Inc. Obesity Metabolic diseases Cardiovascular diseases Contents 1. Introduction.............................................................. 207 1.1. BMICriteria........................................................... 207 1.2. ImprovementofComorbidities................................................... 207 1.3. ImprovedSurvivalwithBariatricSurgery.............................................. 207 2. ProceduresandOutcomes........................................................ 207 2.1. RYGB.............................................................. 207 2.1.1. WeightLoss....................................................... 207 2.1.2. Complications...................................................... 208 2.2. SG............................................................... 208 2.2.1. WeightLoss....................................................... 209 2.2.2. Complications...................................................... 209 2.3. GastricBanding(GB)....................................................... 209 2.3.1. WeightLoss....................................................... 209 2.3.2. Complications...................................................... 209 2.4. BiliopancreaticDiversion..................................................... 209 2.4.1. WeightLoss....................................................... 209 2.4.2. Complications...................................................... 209 2.5. VagalNerveBlocker....................................................... 210 2.5.1. WeightLoss....................................................... 210 2.5.2. Complications...................................................... 210 2.6. GastricImbrication........................................................ 210 Abbreviations: ASMBS, American Society for Metabolic and Bariatric Surgery; BMI, body mass index; CT, computed tomography; GB, gastric banding; GERD, gastroesophageal reflux disease; MBSAQIP, Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program; NAFLD, non-alcoholic fatty liver disease; NASH, non-alcoholic steatohepatitis; NSAID, non-steroidal anti-inflammatory drug; OSA, obstructive sleep apnea; SG, sleeve gastrectomy; RYGB, Roux-en-Y gastric bypass; VTE, venous thromboembolism; WLS, weight losssurgery. ⁎ Corresponding author at: Department of Surgery, Boston University School of Medicine, 1400 VFW Pkwy, SS112, West Roxbury, MA 02132, United States of America. E-mail address: [email protected] (V.M. Sanchez). https://doi.org/10.1016/j.metabol.2018.12.002 0026-0495/© 2018 Published by Elsevier Inc. J. Nudel, V.M. Sanchez / Metabolism Clinical and Experimental 92 (2019) 206–216 207 2.6.1. WeightLoss....................................................... 210 2.6.2. Complications...................................................... 210 3. EmergingandEndoscopicApproaches.................................................. 210 3.1. EndoluminalRYGBAnalogues................................................... 210 3.2. RoboticSurgery......................................................... 211 3.3. IntragastricBalloon........................................................ 211 4. MechanismofActionofWeightLossandMetabolicSurgery........................................ 211 5. ImpactofSurgeryonDiabetesType2................................................... 211 6. ImpactofSurgeryonCardiovascularRisk................................................. 211 7. ImpactofSurgeryonNon-AlcoholicFattyLiverDisease........................................... 211 8. OperativeChoice............................................................ 212 9. ReoperationsforWeightGain...................................................... 212 9.1. RYGB.............................................................. 212 9.2. SG............................................................... 212 10. Delivery............................................................... 212 11. Conclusion.............................................................. 212 DeclarationsofInterest............................................................ 212 Funding................................................................... 213 Acknowledgments.............................................................. 213 AuthorContributions............................................................. 213 References................................................................. 213 1. Introduction which 2010 WLS patients were prospectively matched to a control group of 2037 patients who underwent standard medical therapy, the Obesity is a modern illness associated with weight-related mortality, risk-adjusted hazard ratio for mortality was 0.71 after a mean follow cardiovascular disease, diabetes, liver disease, obstructive sleep apnea up of 10.9 years [18]. A retrospective analysis that matched 2500 WLS (OSA), malignancy, functional impairment, as well as many other disor- patients to 7462 matched controls in the United States Veterans Affairs ders [1]. The medical costs of obesity exceed $100 billion per year [2]. system found that surgical patients had significantly decreased mortal- Over one third of American adults are obese, and obesity rates continue ity after one year of follow up, with a hazard ratio of 0.47 after five years to increase [3]. [20]. In a recently reported retrospective Israeli cohort of over 8000 WLS Weight loss surgery (WLS) is the most effective intervention to reduce patients, the adjusted hazard ratio for mortality among 25,000 matched body weight and obesity-associated diseases among obese patients and controls was 2.02 after four years [17]. has become a widely accepted approach to treating these disorders [4]. 2. Procedures and Outcomes 1.1. BMI Criteria The two most commonly performed procedures for weight loss are Joint guidelines from the American Association of Clinical Endocri- the sleeve gastrectomy (SG) and Roux-en-Y gastric bypass (RYGB), nologists, the Obesity Society, and the American Society for Metabolic which together account for the vast majority of initial bariatric surgical and Bariatric Surgery advise that WLS should be considered for patients procedures in the United States [21]. We discuss these procedures whose BMI is over 40 regardless of comorbidities, for patients with BMI below. Less commonly utilized procedures are enumerated and briefly of 35–40 in the presence of a severe obesity-related comorbidity, and discussed as well. for patients with BMI 30–35 in the presence of a severe obesity- related comorbidity such as diabetes [5]. Recent guidelines recommend 2.1. RYGB WLS for any diabetic patient with BMI over 40 or with BMI 35–40 and poor glycemic control despite aggressive medical therapy. They advise RYGB was traditionally regarded as the standard of care and until consideration of WLS for those with poorly controlled diabetes in pa- 2013 was the most popular bariatric operation [21]. RYGB involves di- tients with a BMI between 30 and 35. These guidelines also suggest low- viding the stomach to create a small pouch composed of cardia and fun- ering the BMI thresholds by 2.5 points for Asian populations [6]. dus known as the “gastric pouch.” The jejunum is divided distal to the ligament of Treitz. The distal “roux limb” is anastomosed to the gastric 1.2. Improvement of Comorbidities pouch such that food bypasses the proximal “biliopancreatic limb,” composed of the remnant stomach, duodenum, and associated WLS reliably induces rapid, marked, and durable weight loss pancreaticobiliary structures. Meanwhile, the biliopancreatic limb is among obese patients [7], and reduces the burden of multiple anastomosed to the roux limb at about 100 cm along its length such obesity-associated comorbidities including diabetes [8], cardiovas- that the two limbs converge and empty into a “common channel” [22].
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