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Which Operation Is Best?

  • Sayeed Ikramuddin
  • Gonzalo Torres-Villalobos

There is no clear consensus as to which is the best operation in bariatric surgery. Perhaps a better question is, “Which is the right operation for the given patient?” No operation is uniformly accepted as the best one. There are too many confounding factors to make this kind of decision making possible. Primarily, the lack of long-term follow-up, established definitions of success, and paucity of randomized data make this unfeasible. In addition, patients may have different goals or biases that determine which operation they choose. Importantly, not all bariatric surgeons perform all bariatric procedures. The preceding sections have reported the outcomes of laparoscopic adjustable banding (LAGB), roux-en-Y gastric bypass (RYGB), sleeve gastrectomy (SG) and the biliopancreatic diversion/duodenal switch (DS) operation. Specific considerations have also been covered for adolescent patients. This chapter attempts to put these data into perspective and offer recommendations that are suitable for a particular patient or clinical circumstance. The appropriate choice of operation begins with a full assessment of the patient’s reasons for choosing as well as expectations of weight loss surgery. Information can then be gathered from the history and physical examination, laboratory data, imaging and endoscopic studies, and prior operative notes. Arbitrarily, choice of procedure can be determined by weight, presence of comorbid illness, age, plans of conception, or relevant previous surgery. Collectively, some of these factors can be used to determine a patient’s perioperative risk, which might represent an independent way to choose an operation. For example, what would be the best operation for a 26-year-old superobese man with a history of a previous Nissen fundoplication? Certainly even the most singularly aligned surgeon to a particular operation might give pause to the fact that there needs to be particular consideration in this case and that his or her “best” operation, or any operation for that matter, may not be appropriate.

The four most commonly performed procedures for morbid obesity at this time are RYGB, LAGB, DS, and SG. Each procedure has advantages and disadvantages; accordingly, it is important to consider multiple factors when recommending the type of surgery. Few randomized trials exist comparing the different procedures. Algorithms using review of the literature have been developed to match a given patient to a given operation. This algorithm has not yet been tested in a clinical setting and cannot be absolute.

Keywords

Bariatric Surgery Gastric Bypass Morbid Obesity Sleeve Gastrectomy Laparoscopic Sleeve Gastrectomy 
These keywords were added by machine and not by the authors. This process is experimental and the keywords may be updated as the learning algorithm improves.

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Selected References

  1. Ablassmaier B, Klaua S, Jacobi CA, et al. Laparoscopic gastric banding after heart transplantation. Obes Surg 2002;12(3):412–415PubMedCrossRefGoogle Scholar
  2. Abu-Abeid S, Gavert N, Klausner JM, et al. Bariatric surgery in adolescence. J Pediatr Surg 2003;38(9):1379–1382PubMedCrossRefGoogle Scholar
  3. Alexander JW, Goodman H. Gastric bypass in chronic renal failure and renal transplant. Nutr Clin Pract 2007;22(1):16–21PubMedCrossRefGoogle Scholar
  4. Alexander JW, Goodman HR, Gersin K, et al. Gastric bypass in morbidly obese patients with chronic renal failure and kidney transplant. Transplantation 2004;78(3):469–474PubMedCrossRefGoogle Scholar
  5. Almogy G, Crookes PF, Anthone GJ. Longitudinal gastrectomy as a treatment for the high-risk super-obese patient. Obes Surg 2004;14(4):492–497PubMedCrossRefGoogle Scholar
  6. Anthony T, Bergen PC, Kim LT, et al. Factors affecting recurrence following incisional herniorrhaphy. World J Surg 2000;24(1):95–100;discussion 1PubMedCrossRefGoogle Scholar
  7. Baltasar A, Bou R, Bengochea M, et al. Duodenal switch: an effective therapy for morbid obesity–intermediate results. Obes Surg 2001;11(1):54–58PubMedCrossRefGoogle Scholar
  8. Birgisson G, Park AE, Mastrangelo MJ Jr, et al. Obesity and laparoscopic repair of ventral hernias. Surg Endosc 2001;15(12):1419–1422PubMedGoogle Scholar
  9. Brolin RE, Bradley LJ, Taliwal RV. Unsuspected cirrhosis discovered during elective obesity operations. Arch Surg 1998;133(1):84–88PubMedCrossRefGoogle Scholar
  10. Buchwald H. A bariatric surgery algorithm. Obes Surg 2002;12(6):733–746; discussion 47–50PubMedCrossRefGoogle Scholar
  11. Buchwald H, Avidor Y, Braunwald E, et al. Bariatric surgery: a systematic review and meta-analysis. JAMA 2004;292(14):1724–1737PubMedCrossRefGoogle Scholar
  12. Burger JW, Luijendijk RW, Hop WC, et al. Long-term follow-up of a randomized controlled trial of suture versus mesh repair of incisional hernia. Ann Surg 2004;240(4):578–583 discussion 83–85PubMedGoogle Scholar
  13. Capella JF, Capella RF. Bariatric surgery in adolescence. is this the best age to operate? Obes Surg 2003;13(6):826–832Google Scholar
  14. Chu CA GM, Quinn T, et al. Two-stage laparoscopic biliopancreatic diversion with duodenal switch: an alternative approach to super-super morbid obesity. Surg Endosc 2002;16(Abs):S069Google Scholar
  15. Costanza MJ, Heniford BT, Arca MJ, et al. Laparoscopic repair of recurrent ventral hernias. Am Surg 1998;64(12):1121–1125 discussion 6–7PubMedGoogle Scholar
  16. Cottam D, Qureshi FG, Mattar SG, et al. Laparoscopic sleeve gastrectomy as an initial weight-loss procedure for high-risk patients with morbid obesity. Surg Endosc 2006;20(6):859–863PubMedCrossRefGoogle Scholar
  17. Csendes A, Burgos AM, Smok G, et al. Effect of gastric bypass on Barrett's esophagus and intestinal metaplasia of the cardia in patients with morbid obesity. J Gastrointest Surg 2006;10(2):259–264PubMedCrossRefGoogle Scholar
  18. de Jong JR, van Ramshorst B, Timmer R, et al. Effect of laparoscopic gastric banding on esophageal motility. Obes Surg 2006;16(1):52–58PubMedCrossRefGoogle Scholar
  19. DeMaria EJ, Sugerman HJ, Kellum JM, et al. Results of 281 consecutive total laparoscopic Roux-en-Y gastric bypasses to treat morbid obesity. Ann Surg 2002;235(5):640–645 discussion 5–7CrossRefGoogle Scholar
  20. Dixon JB, Dixon AF, O'Brien PE. Improvements in insulin sensitivity and beta-cell function (HOMA) with weight loss in the severely obese. Homeostatic model assessment. Diabet Med 2003;20(2):127–134PubMedCrossRefGoogle Scholar
  21. Dixon JB, O'Brien PE. Gastroesophageal reflux in obesity: the effect of lap-band placement. Obes Surg 1999;9(6):527–531PubMedCrossRefGoogle Scholar
  22. Dolan K, Creighton L, Hopkins G, et al. Laparoscopic gastric banding in morbidly obese adolescents. Obes Surg 2003;13(1):101–104PubMedCrossRefGoogle Scholar
  23. Duchini A, Brunson ME. Roux-en-Y gastric bypass for recurrent nonalcoholic steatohepatitis in liver transplant recipients with morbid obesity. Transplantation 2001;72(1):156–159PubMedCrossRefGoogle Scholar
  24. Eid GM, Mattar SG, Hamad G, et al. Repair of ventral hernias in morbidly obese patients undergoing laparoscopic gastric bypass should not be deferred. Surg Endosc 2004;18(2):207–210PubMedCrossRefGoogle Scholar
  25. El-Serag HB, Johanson JF. Risk factors for the severity of erosive esophagitis in Helicobacter pylori–negative patients with gastroesophageal reflux disease. Scand J Gastroenterol 2002;37(8):899–904PubMedCrossRefGoogle Scholar
  26. Fielding GA. Laparoscopic adjustable gastric banding for massive superobesity (>60 body mass index kg/m2). Surg Endosc 2003;17(10):1541–1545PubMedCrossRefGoogle Scholar
  27. Fielding GA, Duncombe JE. Laparoscopic adjustable gastric banding in severely obese adolescents. Surg Obes Relat Dis 2005;1(4):399–405discussion 7PubMedCrossRefGoogle Scholar
  28. Fisher BL, Pennathur A, Mutnick JL, et al. Obesity correlates with gastroesophageal reflux. Dig Dis Sci 1999;44(11):2290–2294PubMedCrossRefGoogle Scholar
  29. Flanagan L Jr. Gastric bypass after cardiac transplantation. Obes Surg 1995;5(2):183–185PubMedCrossRefGoogle Scholar
  30. Flum DR, Salem L, Elrod JA, et al. Early mortality among Medicare beneficiaries undergoing bariatric surgical procedures. JAMA 2005;294(15):1903–1908PubMedCrossRefGoogle Scholar
  31. Forsell P, Hallerback B, Glise H, et al. Complications following Swedish adjustable gastric banding: a long-term follow-up. Obes Surg 1999;9(1):11–16PubMedCrossRefGoogle Scholar
  32. Frezza EE, Ikramuddin S, Gourash W, et al. Symptomatic improvement in gastroesophageal reflux disease (GERD) following laparoscopic Roux-en-Y gastric bypass. Surg Endosc 2002;16(7):1027–1031PubMedCrossRefGoogle Scholar
  33. Gentileschi P, Kini S, Catarci M, et al. Evidence-based medicine: open and laparoscopic bariatric surgery. Surg Endosc 2002;16(5):736–744PubMedCrossRefGoogle Scholar
  34. Gianetta E, Civalleri D, Bonalumi U, et al. [2 cases of death caused by hepatic insufficiency after jejuno-ileal bypass for obesity]. Minerva Chir 1979;34(15–16):1087–1096PubMedGoogle Scholar
  35. Gomez Escudero O, Herrera Hernandez MF, Valdovinos Diaz MA. [Obesity and gastroesophageal reflux disease]. Rev Invest Clin 2002;54(4):320–327PubMedGoogle Scholar
  36. Himpens J, Dapri G, Cadiere GB. A prospective randomized study between laparoscopic gastric banding and laparoscopic isolated sleeve gastrectomy: results after 1 and 3 years. Obes Surg 2006;16(11):1450–1456PubMedCrossRefGoogle Scholar
  37. Howard RJ, Patton PR, Reed AI, et al. The changing causes of graft loss and death after kidney transplantation. Transplantation 2002;73(12):1923–1928PubMedCrossRefGoogle Scholar
  38. Hu FB, Manson JE, Stampfer MJ, et al. Diet, lifestyle, and the risk of type 2 diabetes mellitus in women. NEJM 2001;345(11):790–797PubMedCrossRefGoogle Scholar
  39. Inge TH, Garcia V, Daniels S, et al. A multidisciplinary approach to the adolescent bariatric surgical patient. J Pediatr Surg 2004;39(3):442–447discussion 6–7PubMedCrossRefGoogle Scholar
  40. Keeffe EB, Gettys C, Esquivel CO. Liver transplantation in patients with severe obesity. Transplantation 1994;57(2):309–311PubMedCrossRefGoogle Scholar
  41. Kellogg TA, Andrade R, Maddaus M, et al. Anatomic findings and outcomes after antireflux procedures in morbidly obese patients undergoing laparoscopic conversion to Roux-en-Y gastric bypass. Surg Obes Relat Dis 2007;3(1):52–57discussion 8–9PubMedCrossRefGoogle Scholar
  42. Kim WW, Gagner M, Kini S, et al. Laparoscopic vs. open biliopancreatic diversion with duodenal switch: a comparative study. J Gastrointest Surg 2003;7(4):552–557PubMedCrossRefGoogle Scholar
  43. Lawson ML, Kirk S, Mitchell T, et al. One-year outcomes of Roux-en-Y gastric bypass for morbidly obese adolescents: a multicenter study from the Pediatric Bariatric Study Group. J Pediatr Surg 2006;41(1):137–143discussion 43PubMedCrossRefGoogle Scholar
  44. Leslie D, Kellogg TA, Ikramuddin S. Bariatric surgery primer for the internist: keys to the surgical consultation. Med Clin North Am 2007;91(3):353–381, xPubMedCrossRefGoogle Scholar
  45. Liakakos T, Karanikas I, Panagiotidis H, et al. Use of Marlex mesh in the repair of recurrent incisional hernia. Br J Surg 1994;81(2):248–249PubMedCrossRefGoogle Scholar
  46. Locke GR 3rd, Talley NJ, Fett SL, et al. Risk factors associated with symptoms of gastroesophageal reflux. Am J Med 1999;106(6):642–649PubMedCrossRefGoogle Scholar
  47. Luyckx FH, Desaive C, Thiry A, et al. Liver abnormalities in severely obese subjects: effect of drastic weight loss after gastroplasty. Int J Obes Relat Metab Disord 1998; 22(3):222–226PubMedCrossRefGoogle Scholar
  48. Mattar SG, Velcu LM, Rabinovitz M, et al. Surgically-induced weight loss significantly improves nonalcoholic fatty liver disease and the metabolic syndrome. Ann Surg 2005;242(4):610–617discussion 8–20PubMedGoogle Scholar
  49. Meier1 Kriesche HU, Arndorfer JA, Kaplan B. The impact of body mass index on renal transplant outcomes: a significant independent risk factor for graft failure and patient death. Transplantation 2002;73(1):70–74PubMedCrossRefGoogle Scholar
  50. Mognol P, Chosidow D, Marmuse JP. Laparoscopic sleeve gastrectomy as an initial bariatric operation for high-risk patients: initial results in 10 patients. Obes Surg 2005;15(7):1030–1033PubMedCrossRefGoogle Scholar
  51. Nair S, Verma S, Thuluvath PJ. Obesity and its effect on survival in patients undergoing orthotopic liver transplantation in the United States. Hepatology 2002;35(1):105–109PubMedCrossRefGoogle Scholar
  52. Nilsson M, Johnsen R, Ye W, et al. Obesity and estrogen as risk factors for gastroesophageal reflux symptoms. JAMA 2003;290(1):66–72PubMedCrossRefGoogle Scholar
  53. Patterson EJ, Davis DG, Khajanchee Y, et al. Comparison of objective outcomes following laparoscopic Nissen fundoplication versus laparoscopic gastric bypass in the morbidly obese with heartburn. Surg Endosc 2003;17(10):1561–1565PubMedCrossRefGoogle Scholar
  54. Pontiroli AE, Folli F, Paganelli M, et al. Laparoscopic gastric banding prevents type 2 diabetes and arterial hypertension and induces their remission in morbid obesity: a 4-year case-controlled study. Diabetes Care 2005;28(11):2703–2709PubMedCrossRefGoogle Scholar
  55. Pories WJ, Swanson MS, MacDonald KG, et al. Who would have thought it? An operation proves to be the most effective therapy for adult-onset diabetes mellitus. Ann Surg 1995;222(3):339–350discussion 50–52PubMedCrossRefGoogle Scholar
  56. Prachand VN, Davee RT, Alverdy JC. Duodenal switch provides superior weight loss in the super-obese (BMI > or =50 kg/m2) compared with gastric bypass. Ann Surg 2006;244(4):611–619PubMedGoogle Scholar
  57. Raftopoulos I, Awais O, Courcoulas AP, et al. Laparoscopic gastric bypass after antireflux surgery for the treatment of gastroesophageal reflux in morbidly obese patients: initial experience. Obes Surg 2004;14(10):1373–1380PubMedCrossRefGoogle Scholar
  58. Regan JP, Inabnet WB, Gagner M, et al. Early experience with two-stage laparoscopic Roux-en-Y gastric bypass as an alternative in the super-super obese patient. Obes Surg 2003;13(6):861–864PubMedCrossRefGoogle Scholar
  59. Reich D, Rothstein K, Manzarbeitia C, et al. Common medical diseases after liver transplantation. Semin Gastrointest Dis 1998;9(3):110–125PubMedGoogle Scholar
  60. Rios A, Rodriguez JM, Munitiz V, et al. Factors that affect recurrence after incisional herniorrhaphy with prosthetic material. Eur J Surg 2001;167(11):855–859PubMedCrossRefGoogle Scholar
  61. Sarr MG. Is a bariatric procedure appropriate in patients with portal hypertension secondary to cirrhosis. Surg Obes Relat Dis 2006;2(3):405–406discussion 6–7PubMedCrossRefGoogle Scholar
  62. Schauer PR, Burguera B, Ikramuddin S, et al. Effect of laparoscopic Roux-en-Y gastric bypass on type 2 diabetes mellitus. Ann Surg 2003;238(4):467–484discussion 84–85PubMedGoogle Scholar
  63. Schauer PR, Ikramuddin S. Laparoscopic surgery for morbid obesity. Surg Clin North Am 2001;81(5):1145–1179PubMedCrossRefGoogle Scholar
  64. Schuster R, Curet MJ, Alami RS, et al. Concurrent gastric bypass and repair of anterior abdominal wall hernias. Obes Surg 2006;16(9):1205–1208PubMedCrossRefGoogle Scholar
  65. Sjostrom L, Lindroos AK, Peltonen M, et al. Lifestyle, diabetes, and cardiovascular risk factors 10 years after bariatric surgery. NEJM 2004;351(26):2683–2693PubMedCrossRefGoogle Scholar
  66. Spivak H, Hewitt MF, Onn A, et al. Weight loss and improvement of obesity-related illness in 500 U.S. patients following laparoscopic adjustable gastric banding procedure. Am J Surg 2005;189(1):27–32PubMedCrossRefGoogle Scholar
  67. Strauss RS, Bradley LJ, Brolin RE. Gastric bypass surgery in adolescents with morbid obesity. J Pediatr 2001;138(4):499–504PubMedCrossRefGoogle Scholar
  68. Strignano P, Collard JM, Michel JM, et al. Duodenal switch operation for pathologic transpyloric duodenogastric reflux. Ann Surg 2007;245(2):247–253PubMedCrossRefGoogle Scholar
  69. Sugerman HJ, DeMaria EJ, Kellum JM, et al. Effects of bariatric surgery in older patients. Ann Surg 2004;240(2):243–247PubMedCrossRefGoogle Scholar
  70. Sugerman HJ, Kellum JM Jr, Reines HD, et al. Greater risk of incisional hernia with morbidly obese than steroid-dependent patients and low recurrence with prefascial polypropylene mesh. Am J Surg 1996;171(1):80–84PubMedCrossRefGoogle Scholar
  71. Suter M, Dorta G, Giusti V, et al. Gastric banding interferes with esophageal motility and gastroesophageal reflux. Arch Surg 2005;140(7):639–643PubMedCrossRefGoogle Scholar
  72. Tichansky DS, Madan AK. Laparoscopic Roux-en-Y gastric bypass is safe and feasible after orthotopic liver transplantation. Obes Surg 2005;15(10):1481–1486PubMedCrossRefGoogle Scholar
  73. Varela JE, Wilson SE, Nguyen NT. Outcomes of bariatric surgery in the elderly. Am Surg 2006;72(10):865–869PubMedGoogle Scholar
  74. Wang Y. Cross-national comparison of childhood obesity: the epidemic and the relationship between obesity and socioeconomic status. Int J Epidemiol 2001;30(5):1129–1136PubMedCrossRefGoogle Scholar
  75. Weiss H, Nehoda H, Labeck B, et al. Organ transplantation and obesity: evaluation, risks and benefits of therapeutic strategies. Obes Surg 2000;10(5):465–469PubMedCrossRefGoogle Scholar
  76. Willett WC, Dietz WH, Colditz GA. Guidelines for healthy weight. NEJM 1999;341(6):427–434PubMedCrossRefGoogle Scholar
  77. Wilson LJ, Ma W, Hirschowitz BI. Association of obesity with hiatal hernia and esophagitis. Am J Gastroenterol 1999;94(10):2840–2844PubMedCrossRefGoogle Scholar
  78. Zimmet P, Alberti KG, Shaw J. Global and societal implications of the diabetes epidemic. Nature 2001;414(6865):782–787PubMedCrossRefGoogle Scholar
  79. Ziser A, Plevak DJ, Wiesner RH, et al. Morbidity and mortality in cirrhotic patients undergoing anesthesia and surgery. Anesthesiology 1999;90(1):42–53PubMedCrossRefGoogle Scholar

Copyright information

© Springer Science+Business Media, LLC 2008

Authors and Affiliations

  • Sayeed Ikramuddin
    • Gonzalo Torres-Villalobos
      • 1
    1. 1.Advanced Laparoscopic Surgery Fellow, University of Minnesota Department of SurgeryUniversity of Minnesota Medical CenterMinneapolis

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