Surgical treatment of obesity

Obesity is very prevalent. Most treatments fail owing to hard-wired survival mechanisms, linking stress and appetite, which have become grossly maladaptive in the industrial era. Antiobesity (bariatric) surgery is a seemingly drastic, efficacious therapy for this serious disease of energy surfeit. Technical progress during the last two decades has greatly improved its safety. The surgical principles of gastric restriction and/or gastrointestinal diversion have remained largely unchanged over 40 years, although mechanisms of action have been elucidated concomitant with advances in knowledge of the molecular biology of energy balance and appetite regulation. Results of bariatric surgery in large case-series followed for at least 10 years consistently demonstrate amelioration of components of the insulin-resistance metabolic syndrome and other comorbidities, significantly improving quality of life. Furthermore, bariatric surgery has convincingly been demonstrated to reduce mortality compared with nonoperative methods. This surgery requires substantial preoperative and postoperative evaluation, teaching, and monitoring to optimize outcomes. In the absence of effective societal changes to restore a healthy energy balance, bariatric surgery is an important tool for treating a very serious disease.     

Surgical treatment of obesity

The surgical treatment of obesity has existed for over 50 yr. Surgical options have evolved from high-risk procedures infrequently performed, to safe, effective procedures increasingly performed. The operations used today provide significant durable weight loss, resolution or marked improvement of obesity-related comorbidities, and enhanced quality of life for the majority of patients. The effect of bariatric surgery on the neurohormonal regulation of energy homeostasis is not fully understood. Despite its effectiveness, less than 1% of obese patients are treated surgically. The perception that obesity surgery is unsafe remains a deterrent to care.     

Surgical treatment of obesity

Opinion statement Obesity has emerged as one of the most complex and debilitating diseases affecting the world’s population. It is estimated that more than two thirds of Americans are overweight and more than 20% are obese. This disease is associated with many morbid conditions, including hypertension, coronary artery disease, hypoventilation, sleep apnea syndrome, diabetes mellitus, and an increased incidence of certain malignancies. Medical interventions for achieving and maintaining significant weight loss have generally failed, leaving surgery as the only effective treatment for durable weight loss. A number of surgical options are available today and can be grouped into two categories based on the mechanism of how the weight loss is achieved. Restrictive procedures include vertical banded gastroplasty (VBG), adjustable gastric banding (AGB), and Roux-en-Y gastric bypass (RYGB), although the latter does have some altered absorption as well. Largely malabsorptive procedures include biliopancreatic diversion (BPD) and biliopancreatic diversion with duodenal switch (BPD-DS). Whereas VBG has largely fallen out of favor due to inadequate long-term weight loss, the other procedures have proven successful in achieving and maintaining adequate weight loss. In addition, each has proven successful in reversing or ameliorating many of the comorbidities associated with obesity. RYGB is the most common procedure performed in the United States and is considered the gold standard. It has the best short- and long-term results for safety, efficacy, and durability, and it has been proven to be superior in results to those for AGB. In experienced hands, this technically challenging procedure can now be performed laparoscopically. This method has the same weight loss and health benefits as the open procedure while achieving all the added benefits of a minimally invasive approach. Long-term data seem to support the malabsorptive procedures as most effective in the superobese. All the procedures require compliance and long-term nutritional follow-up.     

Surgical approaches to the treatment of obesity

Bariatric surgery, through its efficacy and improved safety, is emerging as an important and broadly available treatment for people with severe and complex obesity that has not responded adequately to other therapy. Established procedures, such as Roux-en-Y gastric bypass and adjustable gastric banding, account for more than 80% of bariatric surgical procedures globally. Sleeve gastrectomy has emerged as a stand-alone procedure. Truly malabsoptive procedures, such as biliopancreatic diversion and its duodenal switch variant, have a diminishing role as primary procedures, but remain an option for patients who do not respond adequately to less disruptive procedures. The procedures vary considerably in their postoperative morbidity and mortality; pattern and extent of weight loss; nature and severity of long-term complications; and nutritional requirements and risks. There is no perfect procedure--an informed risk and benefit assessment should be made by each patient. Gastroenterologists also need to be familiar with the risks and benefits of current and emerging procedures as they are likely to be increasingly involved in the integrated care of these patients.     

Surgical intervention as a strategy for treatment of obesity

A very large number of weight-reducing surgical techniques have been developed over the last 25 years. Today only a handful of these techniques can be recommended. Gastric bypass, vertical banded gastroplasty, and variable banding can all be recommended although gastric bypass should be reserved for heavier patients. For the heaviest, biliopancreatic diversion or biliopancreatic diversion with duodenal switch might be considered. The controlled intervention study Swedish Obse Subjects has shown that most but not all cardiovascular risk factors are improved over 10 years by surgically induced weight loss. Quality of life as well as cardiac structure and function are dramatically improved. The average weight loss for gastric bypass and vertical banded gastroplasty was 16% after 10 years. No non-surgical treatment available today can achieve such results, not even over 2 years. Surgical treatment for obesity needs to become much more common, particularly in obese patients with metabolic disturbances.     

Surgical treatment of morbid obesity: role of the gastroenterologist

AIM: Obesity is an increasing medical problem with associated disorders such as type 2 diabetes mellitus, cardiovascular disorders and many others. The chance to develop co-morbidity is related to the body mass index (BMI) (weight in kg divided by height in metres2) and increases exponentially when the BMI is above 40 (morbid obesity). Permanently effective treatment of morbid obesity is necessary to prevent the development of co-morbidities and to improve the life expectancy of these patients. To date, surgical intervention is the only treatment that can provide the required long-lasting reduction of the excess weight. DISCUSSION: Two types of surgical intervention are currently used, restrictive (including vertical banded gastroplasty (VBG) and adjustable gastric banding) and malabsorptive procedures (gastric bypass, biliopancreatic diversion (BPD)). These interventions effectively reduce weight, with on average a permanent reduction of the excess weight by 60% after gastric restrictive procedures. However, long-term follow-up has shown that up to 30-40% of patients require additional surgical interventions to maintain the acquired weight loss. Long-term failures are dependent on the primary intervention. After VBG the most common problems are occlusion of the outlet by a foreign body, vertical staple line disruption, band stenosis and band erosion. For the adjustable silicone gastric band outlet problems similar to the VBG, band erosion and particularly pouch dilation or slippage have been reported. Failure of the gastric bypass are mainly due to stenosis of the gastro-jejunostomy and stoma ulcers, whereas BPD mainly has metabolic long-term complications. CONCLUSION: The gastroenterologist has an important role in the diagnosis (stoma stenosis, band erosion, staple line disruption, foreign body) and treatment (dilatation, removal of foreign body) of the complications associated with surgical procedures for morbid obesity. In light of the increasing number of procedures performed, a basic knowledge of the currently used techniques and the associated complications is important.     

Surgical management of obesity

Bariatric surgery has undergone significant change in the past several decades. There are now several attractive surgical options for the management of clinically severe obesity (body mass index > 40 kg/m2). Gastric restrictive procedures predominate and have been performed with acceptable complication rates. Long-term weight loss is frequently > 50% excess weight with amelioration of obesity-related illnesses. Laparoscopic approaches are increasingly popular. Patient selection and appropriate follow-up remain challenging aspects of patient care. In summary, bariatric surgery is a reliable option for the surgical management of clinically severe obese patients.     

Surgical treatment for obesity and its impact on non-alcoholic steatohepatitis

Non-alcoholic steatohepatitis (NASH) in obese and severely obese populations is associated with the metabolic syndrome, with features of the syndrome predicting those who will have NASH rather than simple steatosis, a more benign form of non-alcoholic fatty liver disease. Substantial weight loss is proving the most effective therapy for obesity-related conditions. Improvements have seen the development of less invasive procedures. There is growing evidence that laparoscopic adjustable gastric banding and roux-en-Y gastric bypass provide effective therapy.     

Surgical options for obesity

Several bariatric procedures are available that have excellent long-term weight loss results and are backed by several large clinical trials. Purely restrictive procedures like VBG have fallen out of favor because of inadequate long-term weight loss. Gastric bypass and the BPD are well-studied and show significant resolution of obesity-related comorbidities. Long-term nutritional consequences are seen more commonly after malabsorptive procedures like the BPD than after hybrid malabsorptive-restrictive procedures like the gastric bypass. Because compliance and long-term nutritional follow-up are mandatory after any bariatric procedure, purely malabsorptive procedures should be reserved for super obese patients who are at risk for inadequate long-term weight loss. Furthermore, minimally invasive techniques have evolved and essentially have eliminated the high incidence of postoperative wound complications and incisional hernias frequently seen after open gastric bypass. Until the development ofa similarly successful procedure, gastric bypass will continue to be the gold standard bariatric procedure with its concurrent sustained weight loss benefits and resolution of comorbidities.     

Endoscopic treatment of obesity

Obesity is a worldwide epidemic, complex metabolic disease associated with a variety of severe comorbidities. Bariatric surgery provides the patients with the benefits of sustained weight loss and improves obesity-related comorbidities, but can result in potentially life-threatening complications. Gastrointestinal endoscopy has recently been proposed as a scarless and noninvasive approach to obesity. Most of the current endoluminal devices and techniques are comparable to restrictive surgery. A variety of medical devices and procedures have been evaluated in recent years; however, with the exception of the intragastric balloon, evaluation of all the other endoluminal procedures is limited by the numbers of patients treated, the short follow-up and especially by the study design. Today, only a few devices have been evaluated in randomized controlled trials. The preliminary results of the first studies are extremely promising, but definitive statements cannot be drawn yet.     

Endoscopic treatment of obesity

BACKGROUND:

The increasing incidence of obesity and overweight among children and adolescents will be reflected by the imminent increase in the number of obese patients who require more definitive methods of treatment. There is great interest in new, safe, simple, nonsurgical procedures for weight loss.

OBJECTIVE:

To provide an overview of new endoscopic methods for the treatment of obesity.

METHODS:

An English-language literature search on endoscopic interventions, endoscopically placed devices and patient safety was performed in the MEDLINE and Cochrane Library databases.

RESULTS:

The literature search yielded the following weight loss methods: space-occupying devices (widely used), gastric capacity reduction, modifying gastric motor function and malabsorptive procedures. A commercially available intragastric balloon was the most commonly used device for weight loss. In specific subgroups of patients, it improved quality of life, decreased comorbidities and served as a bridge to surgery. More evidence regarding the potential benefits and safety of other commercially available intragastric balloons is needed to clarify whether they are superior to the most commonly used one. Moreover, early experiences with transoral gastroplasty, the duodenaljejunal bypass sleeve and an adjustable, totally implantable intragastric prosthesis, indicate that they may be viable options for obesity treatment. Other agents, such as botulinum toxin and a device known as the ‘butterfly’, are currently at the experimental stage.

CONCLUSION:

New endoscopic methods for weight loss may be valuable in the treatment of obesity; however, more clinical experience and technical improvements are necessary before implementing their widespread use.     

Pharmacological treatment of obesity

This review offers an overview of physiological agents, current therapeutics, as well as medications, which have been extensively used and those agents not currently available or non-classically considered anti-obesity drugs. As obesity - particularly that of central distribution - represents an important triggering factor for insulin resistance, its pharmacological treatment is relevant in the context of metabolic syndrome control. The authors present an extensive review on the criteria for anti-obesity management efficacy, on physiological mechanisms that regulate central and/or peripheral energy homeostasis (nutrients, monoamines, and peptides), on beta-phenethylamine pharmacological derivative agents (fenfluramine, dexfenfluramine, phentermine and sibutramine), tricyclic derivatives (mazindol), phenylpropanolamine derivatives (ephedrin, phenylpropanolamine), phenylpropanolamine oxytrifluorphenyl derivative (fluoxetine), a naftilamine derivative (sertraline) and a lipstatine derivative (orlistat). An analysis of all clinical trials - over ten-week long - is also presented for medications used in the management of obesity, as well as data about future medications, such as a the inverse cannabinoid agonist, rimonabant.