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SAGES guideline for clinical application of laparoscopic bariatricsurgery

SAGES Guidelines Committee

Surgery for Obesity and Related Diseases 5 (2009) 387–405

Received 20 March 2008; accepted 25 March 2008

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GB Adjustable gastric bandMI Body mass indexPD Biliopancreatic diversionS Duodenal switchBWL Excess body weight lossGB Roux-en-Y gastric bypassIH National Institutes of HealthBG Vertical banded gastroplasty

reamble

Approximately one-third of US adults are obese [1]. Theealth consequences of severe obesity have been well de-cribed [2]. Current evidence suggests surgical therapies offerhe best hope for substantial and sustainable weight loss in thextremely obese [3], with resultant mortality reduction [4].hese truths, coupled with improved minimally invasive bari-tric procedures, have driven a fourfold increase in the popu-ation-based rate of bariatric surgery over recent years [5].

This document is intended to guide surgeons applyingaparoscopic techniques to the practice of bariatric surgery.t will not address credentialing of surgeons or centers,hich is the focus of SAGES Guideline for Institutionsranting Bariatric Privileges Utilizing Laparoscopic Tech-

This statement was prepared by the Guidelines Committee of theociety of American Gastrointestinal and Endoscopic Surgeons (SAGES),ith input from the Clinical Issues Committee of the American Society foretabolic and Bariatric Surgery (ASMBS). The final document was ap-

roved by the SAGES Board of Governors June, 2008, and co-endorsed byhe ASMBS Board of Governors June, 2008.

The SAGES guidelines for clinical application of laparoscopic bariatricurgery have been worked out for the Journal of Surgical Endoscopy.hese guidelines are also used for this journal by courtesy of Springercience�Business Media LLC and SAGES.

Reprint requests: SAGES Guidelines Committee Society of Americanastrointestinal Endoscopic Surgeons (SAGES), 11300 West Olympicoulevard, Suite 600, Los Angeles, CA 90064, USA

se-mail: [email protected]

550-7289/09/$ – see front matter © SAGES 2008oi:10.1016/j.soard.2009.01.010

iques and ASMBS Guideline for Granting Privileges inariatric Surgery. The current recommendations are gradednd linked to the evidence utilizing the definitions in ap-endices A and B.

AGES Disclaimer

Clinical practice guidelines are intended to indicate the bestvailable approach to medical conditions as established byystematic review of available data and expert opinion. Recom-endations are not intended to be exclusive given the complexity

f the health care environment. These guidelines are intended toe flexible and should be applied with consideration of the uniqueeeds of individual patients and the evolving medical literature.hese guidelines are applicable to all physicians who are cre-entialed appropriately and who address the clinical situationn question, regardless of specialty.

Guidelines are developed under the auspices of SAGES andhe Guidelines Committee, and are approved by the Board ofovernors. Each guideline undergoes multidisciplinary review

nd is considered valid at the time of production based on datavailable. Recent developments in medical research and prac-ice pertinent to each guideline will be reviewed, and guide-ines will be updated on a periodic basis.

SMBS Disclaimer

Guidelines are not intended to provide inflexible rulesr requirements of practice and are not intended, norhould they be used, to state or establish a local, regional,r national legal standard of care. Ultimately, there arearious appropriate treatment modalities for each patient,nd the surgeon must use judgment in selecting frommong feasible treatment options. ASMBS cautionsgainst the use of guidelines in litigation in which thelinical decisions of a physician are called into question.he ultimate judgment regarding appropriateness of any
pecific procedure or course of action must be made by
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388 SAGES Guidelines Committee / Surgery for Obesity and Related Diseases 5 (2009) 387–405

he physician in light of all the circumstances presented.hus, an approach that differs from this guideline, stand-

ng alone, does not necessarily imply that the approachas below the standard of care. To the contrary, a con-

cientious physician may responsibly adopt a course ofction different from that set forth in the guideline when,n the reasonable judgment of the physician, such coursef action is indicated by the condition of the patient,imitations on available resources or advances in knowl-dge or technology. All that should be expected is thathe physician will follow a reasonable course of actionased on current knowledge, available resources, and theeeds of the patient, in order to deliver effective and safeedical care. The sole purpose of this guideline is to

ssist practitioners in achieving this objective.

ntroduction and rationale for surgery

The United States of America has experienced a steadyise in obesity prevalence over the last 20 years and cur-ently ranks second in the world [6]. At the turn of theillennium, nearly two-thirds of Americans were over-eight or obese, and almost 5% were morbidly obese [7].his trend is ominous, because morbid obesity predisposesatients to comorbid diseases which affect nearly everyrgan system. These include: type 2 diabetes, cardiovascu-ar disease, hypertension, hyperlipidemia, hypoventilationyndrome, asthma, sleep apnea, stroke, pseudotumor cere-ri, arthritis, several types of cancers, urinary incontinence,allbladder disease, and depression [8–10]. Obesity short-ns life expectancy [11], with increasing body mass indexBMI) resulting in proportionally shorter lifespan [12]. Withver 300,000 victims in the USA each year, morbid obesitys projected to overtake smoking as the leading cause ofeath in the near future [13].

There are now more than nine million morbidly obesemericans who need help. However, nonoperative manage-ent with diet, exercise, behavior modification, and medi-

ations rarely achieves adequate durable weight loss [14].our long-term studies of nonoperative management of obe-ity showed an average weight loss of only 4% [15–18]. Inhe recent Swedish Obese Subjects prospective controlledtudy, medical management over ten years was associatedith 1.6% increase in body weight compared with 13.2%eight loss after gastric band and 25% weight loss afterastric bypass [19]. Since the advent of minimally invasiveherapies, there has been a dramatic increase in gastrointes-inal procedures that produce significant sustainable weightoss with low complication rates [19–22]. Surgically in-uced weight loss is associated with resolution or improve-ent of comorbid diseases in 75–100% of patients [22], and

educed mortality compared with medically treated patients23–25]. Public awareness and demand, along with im-roved systems for surgeon training and delivery of care,
ave combined to fuel a national explosion in bariatric m
rocedures. In 2003, 102,798 operations were performed inhe USA, compared with only 13,365 in 1998 [26].

ustification for surgical treatment of obesity

● Weight-loss surgery is the most effective treatment formorbid obesity, producing durable weight loss, im-provement or remission of comorbid conditions, andlonger life (level I, grade A).

volution of contemporary surgical options

Operations to alter the gastrointestinal tract and produceeight loss have been applied for half a century. Weight-

oss operations may cause malabsorption, restriction of foodntake, or a combination of the two. The original operationor morbid obesity, the jejunoileal bypass, was first per-ormed in 1954. However, this purely malabsorptive oper-tion led to unacceptable morbidity and mortality related toacterial overgrowth and liver damage [27]. Focus shiftedway from purely malabsorptive procedures until the 1970shen biliopancreatic diversion (BPD) was first described

28], with eventual description of duodenal switch (DS) in993 [29]. This operation has been applied laparoscopicallyith effective weight loss [30].Gastric bypass was introduced by Mason in 1966 as a

ombined restrictive–malabsorptive procedure [31]. Severalariations and modifications of the original procedure havevolved over time, such as complete gastric transection,eduction in gastric pouch size, and application of a Roux-n-Y [32]. As of 2003, Roux-en-Y gastric bypass (RGB)ccounted for over 80% of all bariatric procedures done inhe USA [26]. Laparoscopic RGB was popularized andalidated in the early 1990s by Wittgrove and Clark [33],nd several corroborating series have followed [34–37].ifferences exist in the technique for laparoscopic gastroje-

unostomy as part of the procedure, including transoralircular stapler [33], transgastric circular stapler [35], lineartapler [36], and handsewn [37], but all are supported in theiterature as producing similar safety and weight loss results.

Mason and Printen developed a purely restrictive oper-tion, the gastroplasty, in the early 1970s [38]. This opera-ion later developed into vertical banded gastroplastyVBG) [39], and ultimately laparoscopic VBG by the 1990s40]. Despite efforts to simplify the procedure [41], gastro-lasty operations decreased and only accounted for 7% ofS bariatric procedures in 2002 [26]. Stomach banding foreight loss, originally introduced in the 1980s with non-

djustable devices, became popular in the early 1990s [42].n 1993, Belachew and Legrand placed the first laparoscopicdjustable gastric band (AGB) using the LAPBAND® sys-em (Allergan Inc, Irvine, CA, USA) [43]. Although therere multiple versions of AGB available for laparoscopic use,
ost published results derived from the LAP-BAND® sys-

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389SAGES Guidelines Committee / Surgery for Obesity and Related Diseases 5 (2009) 387–405

em. Laparoscopic adjustable bands quickly became popularorldwide because of the relative ease of placement and

afety. The LAP-BAND® system was not approved for usen the USA until 2001, and utilization has increasedteadily. A recent worldwide survey revealed the laparo-copic AGB accounted for 24% of obesity operations, while6% were laparoscopic RGB and 23% were open gastricypass [44].

Another contemporary restrictive procedure that derivesrom the concept of vertical gastroplasty is the laparoscopicleeve gastrectomy (LSG). LSG developed as a first-stagerocedure before duodenal switch or gastric bypass in high-isk patients [45, 46]. Studies have shown that LSG used inhis manner reduces weight, comorbidities, and operativeisk (ASA score) at the time of a second bariatric procedure47–49]. There is increasing application of LSG as a pri-ary weight loss operation [45, 46, 50, 51]. Evolving data

emonstrate LSG provides substantial weight loss and res-lution of comorbidities to 3–5 years’ follow-up [45, 47,2–54]. Early comparative data demonstrate percent EBWLt 1 year superior to AGB and approaching that of RGB andPD [55]. There are other minimally invasive weight lossrocedures in developmental stages. Gastric pacing, whichas been in development in Europe for over 10 years, hashown acceptable safety and early efficacy (�15 months),hough its use is appropriately limited to clinical trials untilore mature data become available [56].

uidelines for selecting validated bariatric procedures

● Laparoscopic RGB, gastric banding by VBG or AGB,and BPD�DS are established and validated bariatricprocedures that provide effective long-term weightloss and resolution of co-morbid conditions (level II,grade A).

● LSG is validated as providing effective weight lossand resolution of comorbidities to 3–5 years (level II,grade C).

atient selection considerations

According to the 1991 National Institutes of HealthNIH) consensus conference on gastrointestinal surgery forevere obesity, patients are candidates if they are morbidlybese (BMI �40 kg/m2 or �35 kg/m2 with comorbidities),ave failed attempts at diet and exercise, are motivated andell informed, and are free of significant psychologicalisease [57]. In addition, the expected benefits of operationust outweigh the risks. Surgery for morbid obesity has a

ow failure rate, with a mean EBWL of 61.2% [22]. Adversevents vary between procedures, but may reach 20% in highisk patients. Mortality rates approximate 0.1% for gastricanding, 0.5% for RGB, and 1.1% for BPD [22]. There are
o absolute contraindications to bariatric surgery. Relative l
ontraindications to surgery may include severe heart fail-re, unstable coronary artery disease, end-stage lung dis-ase, active cancer diagnosis/treatment, cirrhosis with portalypertension, uncontrolled drug or alcohol dependency, andeverely impaired intellectual capacity. Crohn’s diseaseay be a relative contraindication to RGB [58] and BPD

59], and is listed by the manufacturer as a contraindicationo the LAP-BAND® system. Laparoscopic surgery may beifficult or impossible in patients with giant ventral hernias,evere intra-abdominal adhesions, large liver, high BMIith central obesity or physiological intolerance of pneu-operitoneum. Surgeons performing bariatric surgery

hould possess the necessary skills to perform open bariatricurgery in the event it becomes necessary to convert to anpen procedure [32].

Weight loss surgery for individuals with BMI 30–35g/m2 and comorbidities merits consideration given theoor results of nonoperative weight loss regimens [60]. Oneontrolled trial of laparoscopic AGB in this group founduperior weight loss, resolution of metabolic syndrome andmprovement in quality of life versus medical managementt 2-year follow-up [61]. Another report of 37 patientsndergoing RGB showed excellent weight loss and near-omplete resolution of comorbidities [62]. Further data areecessary before surgery for BMI �35 kg/m2 becomestandard practice.

Early in the laparoscopic bariatric era, many traditionalrograms declined super-obese (BMI �50 kg/m2) or super-uper-obese patients (BMI �60 kg/m2) because of per-eived high risk and technical challenge. However, as en-osurgical techniques and equipment have improved,aparoscopic RGB and AGB have been more liberally ap-lied at extreme BMIs, with consequent health and quality-f-life benefits, acceptable rates of morbidity and mortality,ut lower EBWL [63–71]. Laparoscopic BPD�DS maylso be appropriate for super-obese patients given the supe-ior weight loss over laparoscopic RGB [72].

Age restrictions are less rigidly employed in the currentra of refined anesthesiology, effective critical care, andigh quality surgical outcomes. Laparoscopic bariatric sur-ery has been performed in patients older than 55–60 years73–75], but with comparatively less weight loss, longerength of stay, higher morbidity and mortality, and lessomplete resolution of comorbidities compared withounger patients. Still, the reduction in comorbidities sup-orts use of laparoscopic RGB or laparoscopic AGB inell-selected older patients [76–83].At the time of the NIH consensus conference in 1991,

ariatric surgery for morbidly obese children and adoles-ents was not advised because of insufficient data. How-ver, with pediatric obesity increasing in prevalence andeverity, interest in adolescent bariatric surgery is growing84]. RGB is well tolerated and produces excellent weightoss in patients younger than 18 years with 10-year fol-
ow-up [85–91]. Advocates believe weight reduction at an

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arly age will prevent or minimize emotional and physicalonsequences of obesity [92]. Well-designed prospectivetudies are just emerging to better define the place fordolescent bariatric surgery [93].

uidelines for patient selection

● 1991 NIH consensus guidelines provide valid but in-complete patient selection criteria for contemporarybariatric procedures including laparoscopic BPD �DS, RGB, VGB and AGB (level II, grade A).

● Other well-selected patients may benefit from laparo-scopic bariatric surgery by experienced surgeons:– BMI �60 kg/m2 (level II, grade A).– Patients �60 years (level II, grade B).

● Adolescent bariatric surgery (age �18 years) has beenproven effective but should be performed in a spe-cialty center (level II, grade B). Patient selection cri-teria should be the same as used for adult bariatricsurgery (level II, grade C).

● Individuals with BMI 30–35 kg/m2 may benefit fromlaparoscopic bariatric surgery (level I, grade B).

ariatric program and facility

The etiology of morbid obesity seems to involve genetic,nvironmental, metabolic, and psychosocial factors [94].herefore, treatment of the bariatric patient lends itself to a

eam approach for systematic evaluation and management95]. Although a multidisciplinary team is seen as an im-ortant component of a bariatric surgery practice [32, 56,6, 97], no comparative clinical trials have proven this. Theeam leader is the surgeon, who is complimented by nurses,hysician extenders and clerical staff for scheduling, insur-nce precertification, and coordination of patient flow. Theurgeon must have acquired the proper education andands-on training as per the SAGES Guidelines for Institu-ions Granting Bariatric Privileges Utilizing Laparoscopicechniques. Other important team members include nutri-

ionists, psychologists with specific training and experience,nd medical subspecialists (endocrinologists, anesthesiolo-ists, radiologists, pulmonologists, gastroenterologists, etc.)o help evaluate and optimize patients preoperatively and torovide care postoperatively if necessary [32, 96, 97].

The institutional needs of a bariatric program extendcross outpatient and inpatient environments. It is importanto have office and hospital furniture, equipment, clothing,xtures, beds, and wheelchairs that are appropriate andomfortable for patients with morbid and supermorbid obe-ity. In the operating room, specially rated tables and at-achments, extra-long instruments, and appropriate staplersnd retractors are necessary [97]. Healthcare providers and
taff must be experienced with and sensitive to the special d
eeds of bariatric patients, and protected against ergonomicnd lifting injuries.

Postoperative support groups are also an important aspectf a bariatric program and may improve postoperative resultsnd limit relapse [32, 97, 98, 99]. Two nonrandomized studiesave shown that patients attending support groups achievereater weight loss than those who do not [100, 101].

Hospital annual case volume above 100 may be associatedith reduced morbidity and mortality and improved costs

102]. Higher surgeon volume has been associated with re-uced mortality [103]. Center of Excellence designation pro-rams have gained traction [95] and are maintained by themerican College of Surgeons [104] and the American Soci-

ty for Metabolic and Bariatric Surgery [105].

uidelines for bariatric programs

● Bariatric surgery programs should include multidisci-plinary providers with appropriate training and expe-rience (level III, grade C).

● Institutions must accommodate the special needs ofbariatric patients and their providers (level III,grade C).

● Participation in support groups may improve out-comes after bariatric surgery (level II, grade B).

reoperative workup

The preoperative evaluation is similar for all bariatricrocedures. The components include determining a pa-ient’s indications for surgery, identifying issues which maynterfere with the success of the surgery, and assessing andreating comorbid diseases. Typical assessment includessychological testing, nutrition evaluation, and medical as-essment [97, 106].

sychological evaluation

Patients referred for bariatric surgery are more likelyhan the overall population to have psychopathology such asomatization, social phobia, obsessive–compulsive disor-er, substance abuse/dependency, binge-eating disorder,ost-traumatic stress disorder, generalized anxiety disorder,nd depression [107]. Patients with psychiatric disordersay have a suboptimal outcome after bariatric surgery

107]. However, no consensus recommendations exist re-arding preoperative psychological evaluation [106, 108]. Aecent survey reported that 88% of US bariatric programstilize some psychological evaluation, with half requiring aormal standardized assessment [106]. Many insuranceompanies require such psychological evaluation prior toranting precertification for a bariatric procedure. Neverthe-ess, the bulk of evidence shows no relationship betweenreexisting axis I psychiatric diagnosis or axis II personality
isorder and total weight loss [106, 109, 110]. It is not

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ertain which psychosocial factors predict success follow-ng bariatric surgery [108], yet many programs excludeatients who are illicit drug abusers, have active uncon-rolled schizophrenia or psychosis, severe mental retarda-ion, heavy alcohol use, or lack of knowledge about theurgery [106].

utrition consult

The nutrition professional is an integral part of multidis-iplinary bariatric care [111, 112]. He or she is charged withutritional assessment, diet education regarding postopera-ive eating behaviors, and preoperative weight loss efforts113]. Preoperative very-low-calorie diet for 6 weeks haseen shown to reduce liver volume by 20% and to improveccess to the upper stomach during laparoscopic surgery114, 115], with 80% of the volume change occurring in therst 2 weeks [114]. Furthermore, patients who are able tochieve 10% EBWL preoperatively have shorter hospital-zation and more rapid weight loss [116].

Despite the wide utilization of preoperative nutritionalfforts, and the requirement by many insurance companiesor dietary counseling, data are still needed to prove asso-iation with postoperative weight loss or dietary compliance117, 118]. No evidence-based, standardized dietary guide-ines exist for either pre-or postoperative nutritional man-gement of the bariatric patient, and no convincing dataupport the need for routine use of nutrition specialists afterperation. Outcome studies and clinical trials are necessaryo help define the role of the nutrition professional in theariatric team.

reoperative medical evaluation

Medical assessment prior to bariatric surgery is similar tobdominal operations of the same magnitude. Thoroughistory and physical examination with systematic review issed to identify comorbidities that may complicate the sur-ery. Consultation with a medical subspecialist is oftenecessary to optimize medical conditions to reduce periop-rative risk.

Routine laboratory evaluation typically includes com-lete blood count, metabolic profile, coagulation profile,ipid profile, thyroid function tests, and ferritin. Vitamin12, and fat-soluble vitamin levels may be evaluated ifonsidering a malabsorptive procedure. Cardiovascularvaluation includes electrocardiogram and possible stressest to identify occult coronary artery disease. Respiratoryvaluation may include chest X-ray, arterial blood gas, andulmonary function tests. Sleep apnea may be diagnosed byleep study and the patient started on continuous positiveirway pressure prior to surgery. Upper endoscopy may besed if suspicion of gastric pathology exists. If H. pylorinfection is present, preoperative therapy is advised [119].he liver may be assessed by hepatic profile and ultrasound.

n cases of suspected cirrhosis, biopsy may be indicated. t

ltrasound may be used to detect gallstones, allowing theurgeon to decide on concomitant cholecystectomy [98,20].

uidelines for preoperative preparation

● A psychological evaluation is commonly part of thepreoperative work-up of bariatric patients (level III,grade C).

● Treated psychopathology does not preclude the bene-fits of bariatric surgery (level II, grade B).

● Preoperative weight loss may be useful to reduce livervolume and improve access for laparoscopic bariatricprocedures (level II, grade B), but mandated preoper-ative weight loss does not affect postoperative weightloss or comorbidity improvements (level I, grade B).

urgical techniques and outcomes (presented in orderf introduction above)

aparoscopic biliopancreatic diversion

ntroduction. After jejunoileal bypass was abandoned121], most of the bariatric community focused on restric-ive operations [122]. However, Scopinaro revisited thealue of malabsorption in his description of the BPD in theate 1970s [28]. Since then, modifications have included theuodenal switch [123], the sleeve gastrectomy [29], and theaparoscopic approach [124]. DS diminishes the most se-ere complications of BPD, including dumping syndromend peptic ulceration of the anastomosis [125]. Sleeve gas-rectomy spares the lesser curvature, vagus nerves and py-orus, in contrast to the original distal gastrectomy, thoughheoretical beneficial effects on eating behavior, weight lossnd side-effects are not universally reported [125, 126]. Theaparoscopic approach decreases wound complications, painnd hospital length of stay [127].

echnical considerations. Standard technique for BPD�DSnvolves dividing the small bowel 250 cm above the ileo-ecal valve with a stapler, and then forming a biliopancre-tic limb by connecting the bowel proximal to the transec-ion to a point 100 cm above the ileocecal valve. The bowelistal to the transection is elevated as an alimentary limb tohe upper abdomen. Sleeve resection creates a tubularizedtomach of approximately 100 cm3. The duodenum is di-ided 3 cm distal to the pylorus, and duodenoileostomystablishes continuity of the alimentary limb. Limb lengthsetermine weight loss and complications. A common limbhat is too long will provide inadequate weight loss, whereasne too short will cause debilitating diarrhea and nutritionaleficiencies. Gastric remnant size should provide some re-triction but not prevent initiation of protein digestion.

Whether BPD should be tailored to patient characteris-
ics such as age, size or BMI is uncertain [128]. Scopinaro,

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n his original animal study [129], found ‘insertion of theypass into the ileum at a distance from the ileocecal valvequivalent to one-sixth of the intestinal length allows ade-uate weight loss with minimal complications.’ However,y the time of his human studies [28], he noted that ‘thexact length of the common ileal segment and the length ofhe jejunum in the biliopancreatic tract required to achieveaximum weight reduction with minimum complications

ave yet to be determined.’ Hess [130] reports excellentesults by measuring small bowel length and then distrib-ting 10% to the common channel and 40% to the alimen-ary limb. A large Spanish series reports excellent outcomesith a common channel of 60 cm and an alimentary limb of00–360 cm [131, 132]. A US study suggests commonhannels longer than 100 cm result in inferior results [132].n a comparative study of outcomes and complications, 100m common channel was superior to 50 cm, and sleeveastrectomy was superior to distal gastrectomy [125].hough there is a paucity of comparative data between opennd laparoscopic BPD, a few comments can be made on thetility of the minimally invasive procedure. Firstly, becausehe details of the resection and reconstruction are the same,ong-term outcomes are likely to be similar. Indeed, at 1 andyears follow-up, weight loss is similar to that achieved by

pen surgery [133, 134]. Laparoscopic BPD has reducedospital stay and complications, mainly due to a lower ratef wound infections and dehiscence [127]. LaparoscopicPD is an advanced, complex and feasible technique inariatric surgery, and one which has a steep learning curve135].

utcomes. BPD � DS initiates dramatic weight loss duringhe first 12 postoperative months, which continues at alower rate over the next 6 months. Weight loss is durablep to at least 5 years postoperatively. Ninety-five percent ofatients with BMI �50 kg/m2, and 70% of those with BMI50 kg/m2, achieve greater than 50% excess body weight

oss [29, 136, 137]. Weight may be regained over time138], highlighting the importance of long-term follow-up.

BPD dramatically impacts comorbidities. At least 90%

ercent EBWL after bariatric procedures [145]

peration Mean follow-up (years)

1 2

PD % EBWL 71.8 75.1Aggregate N 896 1623# studies 4 3

GB (proximal) % EBWL 67.3 67.5Aggregate N 1627 385# studies 7 5

GB % EBWL 42 57.2Aggregate N 4456 3383# studies 11 11

* 42 patients with 8-year follow-up and band not removed [146]

f patients with type 2 diabetes will cease diabetic medica- c

ions by 12–36 months [127, 128, 139]. Of hypertensiveatients 50–80% will be cured, with another 10% experi-ncing improvement [140–142]. Up to 98% of patients withbstructive sleep apnea symptoms will have resolution143, 144].

Although BPD, RGB, and AGB are all superior to non-urgical therapy, the relative effectiveness of these proce-ures has not been fully compared. Data available are rarelyandomized or controlled, and often compare non-equiva-ent cohorts. Nonetheless, available data suggest the weightoss effect of BPD is greater and more durable than lapa-oscopic AGB [143, 145]. Likewise, BPD may be superioro RGB in patients with BMI �50 kg/m2 [71].

A meta-analysis examining studies published between990 and 2003 found BPD resulted in more weight loss andmprovement of diabetes, hyperlipidemia, hypercholesterol-mia, hypertriglyceridemia, and obstructive sleep apneahan any other type of bariatric procedure [22].

Despite the favorable reports of the biliopancreatic di-ersion and duodenal switch procedure for the treatment oforbid obesity, it has been slow to gain widespread accep-

ance [29].

ostoperative. An upper gastrointestinal series is typicallyerformed in the early postoperative period to exclude con-rast extravasation. If normal, a clear liquid diet is com-enced, with gradual introduction of solids. Discharge is

sually within 4–5 days.Close follow-up is recommended in the postoperative

eriod. For example, visits at 2 and 6 weeks, then quarterlyor the first year, biannually for the second year, and annu-lly thereafter would be one acceptable strategy [126, 131].ssessments are made by both the surgeon and nutritionist,

nd biochemical surveillance by complete blood count,hemical metabolic profile, and parathormone level is per-ormed at intervals. An exercise program is helpful, as areultivitamin, iron, vitamin D, and calcium supplements.

omplications. The 30–day mortality of early laparoscopicPD series ranges from 2.6 to 7.6% [134, 147]. Major

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omplications, which occur in up to 25% of cases, may

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nclude early occurrence of anastomotic leak, duodenaltump leak, intra-abdominal infection, hemorrhage, and ve-ous thromboembolism [29, 147–150], or later bowel ob-truction, incarceration or stricture [151].

The performance of a sleeve gastrectomy as part of thePD�DS allows patients two-thirds of their preoperativeietary volume without specific food intolerances. Between0 and 98% maintain normal serum albumin 3 years afterurgery [29, 126]. Diarrhea is a frequent chronic complica-ion of BPD. Common channel length of 50 cm is associatedith reports of diarrhea in most patients [126], whereas

ength of 100 cm is not [29]. Iron deficiency is common,ith serious iron deficiency anemia (hemoglobin �10 mg/l) occurring in 6% of patients [152]. Surveillance of bio-hemical and hematological markers of iron deficiencyhould drive replacement. Calcium and vitamin D malab-orption are also common, manifesting as secondary hyper-arathyroidism [153]. Supplements do not prevent develop-ent of secondary hyperparathyroidism. Increase in bone

esorption is known to occur irrespective of parathormoneevels, suggesting a phenomenon of bone reshaping parallelo the loss of weight [154]. Due to fat malabsorption result-ng from BPD, supplementation of fat-soluble vitamins isecommended. Deficiency of these vitamins is more likelyith a shorter common channel.Cholelithiasis postoperatively occurs in 6% [155] to 25%

28]. Some surgeons advocate for routine cholecystectomyiven the alteration in endoscopic accessibility to the biliaryract, whereas others argue for delayed cholecystectomynly if symptoms develop, since cholecystitis occurs un-ommonly after BPD [156].

uidelines for laparoscopic BPD � DS

● In BPD, the common channel should be 60–100 cm,and the alimentary limb 200–360 cm (level II, gradeC).

● DS diminishes the most severe complications of BPD,including dumping syndrome and peptic ulceration ofthe anastomosis (level II, grade C).

● BPD is effective in all BMI �35 kg/m2 subgroups,with durable weight loss and control of co-morbiditiesbeyond 5 years (level II, grade A).

● Laparoscopic BPD provides equivalent weight loss,shorter hospital stay, and fewer complications thanopen BPD (level III, grade C).

● BPD may result in greater weight loss (level II, gradeA) and resolution of comorbidities (level II, grade B)than other bariatric surgeries, but with the highestmortality rate (level II, grade A).

● After BPD � DS, close nutritional surveillance and
supplementation are needed (level III, grade C). m
aparoscopic Roux-en-Y gastric bypass

ntroduction. Gastric bypass was first developed in the960s as a means to combine restrictive, malabsorptive, andehavioral components to achieve weight loss. Physiologichanges in the gastrointestinal tract after gastric bypassdumping, neuroendocrine responses, etc.) also appear tonfluence weight loss and comorbidity improvements whichay precede weight loss. Since then, modifications have

ncluded use of a small lesser curvature-based gastric pouch,astric transection, Roux-en-Y reconstruction, and varia-ions in length of the alimentary limb [157, 158]. Feasibilityf the laparoscopic approach to RGB was first shown in thearly 1990s [33].

echnical considerations. The stomach is divided to form amall proximal gastric pouch and the small intestine iseconstructed using a Roux-en-Y to form an alimentaryimb.

Although accurate measurement of pouch volume is dif-cult and prospective data are lacking, a retrospective studyas suggested that smaller pouches may be associated withreater weight loss [159]. Most surgeons choose the tran-ection point by measuring from the esophagogastric junc-ion or by counting vascular arcades.

When creating the Roux-en-Y bypass, the jejunum isypically divided below the ligament of Treitz, and the distalegment is elevated and surgically connected to the gastricouch to create the alimentary (Roux) limb, with variationsn the path and method for anastomosis. The proximalowel segment, also called the biliopancreatic limb, is usu-lly connected to the alimentary limb 75–150 cm distal tohe gastrojejunostomy. This reconstruction serves to bypasshe distal stomach, duodenum and a portion of jejunum toreate malabsorption [157].

Several authors have addressed the issue of limb lengthuring RGB. In BMI �50 kg/m2 patients, both retrospective160] and prospective [161, 162] data fail to show a benefitor alimentary limbs longer than 150 cm. However, BMI50 kg/m2 patients who were randomized to a 250 cm

ather than a 150 cm alimentary limb did show improvedeight loss at 18 months, though the study was not powered

o confirm this benefit at longer follow-up [162]. Othertudies have examined the use of alimentary limbs longerhan 300 cm for BMI �50 kg/m2 patients, and have foundmproved weight loss over standard RGB, but with in-reased nutritional deficiencies and need for reoperation163, 164].

Laparoscopic RGB is a technically demanding proce-ure; the available literature suggests an experience of 50–50 cases is required for surgeons to become safe androficient [34, 36, 165–168].

utcomes. The literature comparing laparoscopic RGB topen RGB and to contemporary medical and surgical treat-
ents for obesity includes several prospective randomized

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ontrolled trials [161, 169–175], a large prospective case-ontrolled cohort study [19], numerous case series, and fouretaanalyses [2, 21, 22, 176].Surgical therapy is clearly more effective than medical

herapy in terms of weight loss and resolution of comor-idities. Morbidly obese patients employing behavioral andedical therapies alone actually gain weight in the long

erm [2, 19]. Surgical patients have lower 5 year mortalityersus nonsurgical patients (0.68% versus 6.17%), despite.4% perioperative mortality [177].

Patients who undergo laparoscopic RGB typically expe-ience 60–70% EBWL, with �75% control of comorbidi-ies [2, 19, 21, 22]. In general, these outcomes are betterhan banding procedures, which have 45–50% EBWL andess predictable improvement of comorbidities, but are lesshan BPD � DS which has 70–80% EBWL with excellentontrol of comorbidities [22].

Open and laparoscopic RGB have similar efficacy. Inrospective randomized trials [169–171, 174], there are noignificant differences in weight loss up to 3 years follow-p. Similar results have been reported in cases series [176].

ostoperative. Close, long-term follow-up is recommendedor patients after bariatric surgery [57]. A typical exampleor recommendations of follow-up after laparoscopic RGBould be at 1–3 weeks, followed by quarterly visits during

he first year and annually thereafter, to assess weight loss,esolution of comorbidities, long-term complications, andeed for continuing education and support. Patients areounseled to eat small, frequent meals of high protein andow carbohydrate content. They should take long-term vi-amin supplements (multivitamins, Vitamin B12, and cal-ium with some patients requiring iron supplementation)nd undergo periodic blood testing to identify and treateficiencies early. Patients should be encouraged to developegular exercise practices. Two retrospective studies on thempact of follow-up on outcomes after laparoscopic RGBave been done; one suggests patient follow-up does notlay an important role while the other reports improvedeight loss in patients compliant with follow-up at 1 year

178, 179].

omplications. The mortality rate after RGB ranges from.3% in case series to 1.0% in controlled trials, and the ratef preventable and nonpreventable adverse surgical eventss 18.7% [21]. The mortality rate in a review of selectedaparoscopic RGB series ranged from 0.5% to 1.1% [180].afety of laparoscopic RGB has been compared to open

mprovement of comorbidities after bariatric procedures [22]

peration Diabetes resolved Hypercholesterolemi

anding 47.8% 71.1%GB 83.8% 93.6%PD 97.9% 99.5%

GB, with laparoscopic patients having reduced incidence a

f iatrogenic splenectomy, wound infection, incisional her-ia and perioperative mortality, but higher rates of bowelbstruction, intestinal hemorrhage, and stomal stenoses181].

The most frequently reported perioperative complica-ions associated with laparoscopic RGB are wound infection2.98%), anastomotic leak (2.05%), gastrointestinal tractemorrhage (1.93%), bowel obstruction (1.73%), and pul-onary embolus (0.41%), while the most frequently re-

orted late complications are stomal stenosis (4.73%),owel obstruction (3.15%), and incisional hernia (0.47%)181].

uidelines for laparoscopic RGB

● In laparoscopic RGB, a small lesser-curvature-basedpouch that excludes the gastric fundus and a 75–150cm alimentary (Roux) limb are effective for mostpatients (level II, grade B).

● Alimentary limbs longer than 150 cm may improveintermediate-term weight loss but also may increasenutritional complications (level III, grade C).

● Laparoscopic RGB is similar in efficacy to open RGB(level I, grade A), with reduced early complicationsand risk of hernia (level II, grade B).

● Long-term follow-up is recommended and may im-prove weight-loss outcomes (level III, grade C).

aparoscopic adjustable gastric banding

ntroduction. In the 1980s, gastroplasty was the most com-on restrictive bariatric procedure, with the most com-only performed iteration being the vertical banded gastro-

lasty. However, due to poor long-term weight loss [182,83] and a high rate of late complications, alternatives tohis operation were sought [184].

Open gastric banding procedures inspired laparoscopicGB, first described in 1993 [43], which involves the place-ent of a restrictive inflatable balloon device around the

astric cardia, approximately 1 cm below the gastroesoph-geal junction. This balloon is connected by tubing to aubcutaneous port which is attached to the rectus sheath.aline injected into the port will cause balloon inflationhich results in narrowing of the stomach at the level of thealloon.

Various brands of laparoscopic AGB exist, though onlyhe LAP-BAND® system and the REALIZE(TM) adjust-

ved Hypertension resolved Sleep apnea resolved

38.4% 94.6%75.4% 86.6%81.3% 95.2%

a impro

ble gastric band (Ethicon Endosurgery, Cincinnati, OH)

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urrently have Food and Drug Administration (FDA) ap-roval for use in the USA. The equivalence between the twoDA-approved devices in the USA has been demonstrated185], but comparative trials with others devices do not yetxist.

echnical considerations. The laparoscopic AGB is bestlaced via a pars flaccida approach, that is, via a retro-astric tunnel between the pars flaccida medially and thengle of His laterally. This has equivalent efficacy to thenitially described perigastric approach, but has a signif-cantly decreased rate of band slippage (i.e., gastric pro-apse) [186 –188]. The pars flaccida approach results inore extraneous tissue, particularly the lesser curvature

at pad, being incorporated into the band. Compensationy placing a band of greater diameter may be required toimit stomal obstruction.

At the time of placement, a peroral calibration balloonay be placed into the stomach, filled with 15–25 cc of

aline, allowing the band is to be fastened below this level.15–25 cc pouch is thereby created.AGB avoids the risks of gastrointestinal stapling and

nastomosis and allows complete reversibility. Most au-hors agree laparoscopic AGB is less technically demandingnd less morbid than laparoscopic RGB [71, 189]. However,otential disadvantages of laparoscopic AGB compared toaparoscopic RGB include the ongoing need for band ad-ustments, delayed or unsatisfactory weight loss [190], andnique indications for reoperation such as pouch dilation,sophageal dilation, band slippage, band erosion, port-siteomplications, or leaks from the device [185].

utcomes. Laparoscopic AGB has been compared to inten-ive pharmacotherapy, behavioral modification, diet modi-cation, and exercise in patients with BMI 30–35 kg/m2. In

his population, laparoscopic AGB was seen to be moreffective in reducing weight, resolving metabolic derange-ents, and improving quality of life [61].Laparoscopic AGB is very effective at producing weight

oss, with patients losing approximately 50% of their excessody weight [22, 191]. This weight loss occurs in a gradualanner, with approximately 35% EBWL by 6 months, 40%

y 12 months, and 50% by 24 months. This percentageppears to remain stable after 3–8 years based on the fewtudies providing this length of follow-up [145, 192–194].owever, as many as 25% of laparoscopic AGB patients

ail to lose 50% of their excess body weight by 5 years [22,90].

Laparoscopic AGB has positive effects on the comor-idities of obesity. Type 2 diabetes is improved in about0% of patients, due to increased insulin sensitivity andncreased pancreatic beta-cell function [195], and diabeticedications are eliminated in 64% [196, 197]. FollowingGB, resolution of type 2 diabetes mirrors weight loss, and

herefore is slower to occur than after RGB or BPD where 2

he diabetes is seen to begin to improve before significanteight loss [196, 198].Symptoms of gastroesophageal reflux disease may be

liminated in at least 89% at 12 months, even in patientsith large hiatal hernias [199, 200], but with the side-effectf impaired lower esophageal sphincter relaxation and pos-ible altered esophageal motility [201]. Rate of obstructiveleep apnea drops from 33% to 2% in laparoscopic AGBatients [202]. Major quality-of-life improvements are seenfter AGB placement, with all subscales of the SF–36 gen-ral quality-of-life questionnaire significantly improved,articularly in areas of bodily pain, general health percep-ion, and mental health perception [203–205].

The short-term (�12 months) weight loss of laparo-copic AGB is inferior to RGB [206]. This discrepancy iseen to continue, with a randomized controlled trial illus-rating that EBWL at 5 years was 47.5% for AGB versus6.6% for RGB [207]. Still, life-threatening complicationsre less frequent in laparoscopic AGB as compared to lapa-oscopic RGB.

ostoperative. Successful weight loss after laparoscopicGB requires close follow-up for band adjustments, edu-

ation, and support. In the absence of comparative data,uidelines for follow-up and adjustment are based on man-facturer recommendations and expert opinion. Physiciansith extensive experience placing and managing the AGB

dhere to a number of basic tenets necessary for successfuleight loss. Immediately after operation, oral intake is re-

tricted to liquids and soft foods to prevent vomiting andislodgment of the band. After a recovery period, the diet isransitioned to solid foods that induce satiety and no-calorieiquids between meals. Eventually, a wide range of foods isolerated, though whole meats and heavy breads may alwaysause dysphagia or regurgitation. To avoid protein–caloriealnutrition and loss of lean body mass, diets should focus

n protein and complex carbohydrate intake, with a limiteduantity of simple sugars and fats. Physical activity is rec-mmended to maintain lean body mass and to improveardiovascular fitness and total weight loss.

In the initial postoperative period, most advocate leavinghe band unfilled. The first adjustment usually occurs about

weeks after placement with initial and subsequent fillolumes determined by band type and patient factors. Fluidhould be added if weight loss falls below expectations, orf meal volumes increase with loss of satiety. Adjustment isot needed if there is adequate weight loss, satiety, andolerance. Fluid should be removed for vomiting, coughing,hoking, or significant solid food intolerance. Bands may bedjusted with or without radiographic guidance with accept-ble results [208].

omplications. Case series and systematic reviews put earlyortality rates after laparoscopic AGB at 0.05–0.4% [21,

09], compared with laparoscopic RGB at 0.5–1.1% [180],

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pen RGB at 0.5–1.0% [21, 22], open BPD at 1.1% [21],nd laparoscopic BPD at 2.5–7.6% [134, 147, 148].

Regarding relative morbidity rates, comparative data areew. Overall complications and major complications areess common in laparoscopic AGB than laparoscopic RGBr laparoscopic BPD, in a single-center experience [151].

Recent review of a multicenter, prospective US trial ofaparoscopic AGB placement by the perigastric approach205] found uncommon occurrence of gastrointestinal per-oration (1%) or other visceral injury (1%). Band-relatedomplications accumulated over 5-year follow-up, such aslippage/pouch dilatation (24%), esophageal dilatation (8%)nd stomal obstruction (14%). Port-site complications, in-luding pain, port displacement, and leak, arose in about 7%f patients. Mean explantation or major revision rate by 9ears was 33%.

In contrast, parallel review of a subsequent trial whichmplemented the pars flaccida technique [205] found re-uced slippage/pouch dilatation (7%), esophageal dilatation1%), and stomal obstruction (2%) at 1-year. Non-US sur-eons have also championed the pars flaccida method [186–88, 210, 211] to reduce band-specific complications. Oneure pars flaccida series with 7-year follow-up reported2% slippage/pouch dilatation, however the cumulative re-peration rate was 32% [211].

uidelines for laparoscopic AGB

● The pars flaccida approach for laparoscopic AGBplacement should be used in preference to the peri-gastric approach in order to decrease the incidence ofgastric prolapse (level II, grade A).

● Laparoscopic AGB is effective in all BMI subgroups,with durable weight loss and control of comorbiditiespast 5 years (level I, grade A).

● Intermediate-term weight loss after laparoscopic AGBmay be less than after laparoscopic RGB (level I,grade A).

● Frequent outpatient visits are suggested in the earlypostoperative period. Band filling should be guided byweight loss, satiety, and patient symptoms (level III,

ortality/morbidity after laparoscopic bariatric procedures

peration 30-day mortality[21, 95, 134,147, 148, 180,208]

Overallcomplications[151]

Majorcomplications[151]

ap AGB 0.05–0.4% 9% 0.2%ap RGB 0.5–1.1% 23% 2%ap BPD 2.5–7.6% 25% 5%

grade C). d

evisional surgery

Patients may require revision of prior bariatric proce-ures because of: (1) anatomic failure with persistent orecurrent obesity, (2) development of secondary complica-ions, or (3) need for reversal.

natomic failure. In planning revisional bariatric opera-ions, surgeons must have an understanding of the priorrocedures and typical anatomic complications, as well ashe current state of the relevant anatomy. In past decades,everal procedures have been employed and have sinceallen out of favor [212]. A number of pure restrictiverocedures that involved gastric partitioning with staplesave been limited by stomal dilation or recanalization ofondivided staple lines [213, 214]. Even procedures accept-ble by today’s standards, such as VBG [215], RGB [216],nd AGB are at risk for anatomic derangement that may bemenable to surgical revision [217, 218, 219]. In recentears, the explosion of bariatric surgery has also resulted inpplication of interventions that may create unfamiliar anat-my and complications for surgeons performing revisionalrocedures [220]. For all these reasons, it is vital the sur-eon makes every effort to define the prior procedure(s)erformed by medical record review and preoperative ra-iographic and endoscopic assessment [221, 222].

Upper GI contrast studies may define the location andntegrity of gastric staple lines, as well as the nature andatency of outflow from the proximal stomach [223]. En-oscopy will assess for ulcers and internalized foreign bod-es, and may allow for therapeutic dilatation in some cases.ndirect evidence of gastric or intestinal motor dysfunctionay also be appreciated. Finally, in some cases, imaging byT scan will allow for visualization of pathology in ex-luded portions of the anatomy or suggest internal hernias.

Patients who never lose weight may have had a technicalomplication such as incomplete stapling [224, 225], or annappropriate operation. Those who regain weight afterears may have suffered staple line recanalization or behav-oral failure [226]. Reoperation on a previous gastroplastysually involves creating a Roux-en-Y, if not alreadyresent, to a newly stapled proximal stomach pouch abovell prior gastric interventions [227–230]. However, BPD,GB, and other operations have also been employed in this

etting [231–233]. Likewise, most authors advocate RGBor revision of AGB because of complications or insuffi-ient weight loss [217–219], although other operations haveeen applied [234, 235]. Finally, in cases of failedPD�DS some have advocated use of a pouch reductionrocedure [236], and in failed RGB use of either AGB tomprove the restrictive component [237] or lengthening tomprove the malabsorptive component [238]. Comparativeata are lacking.

econdary complications. In some cases, bariatric proce-
ures require revision when unexpected complications

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merge over time. For example, the jejunoileal bypass re-ulted in dramatic weight loss, but became marred by theccurrence of malabsorptive complications including renalnd hepatic failure [122, 239]. The importance of long-termollow-up is a lesson that must not be forgotten as newrocedures are introduced.

Contemporary bariatric patients may seek revision dueo evolution of other conditions or complications, such asastroesophageal reflux (GER), bile reflux, complicatedlcers, or obstruction [240]. Severe GER may occur afterastroplasty or VBG in the absence of outflow obstruc-ion [229], whereas bile reflux may occur in procedureshat utilize Bilroth II gastrojejunostomy [220]. In eitherase, conversion to RGB is therapeutic [241]. Easilyreated marginal ulcers are common in the healing phase242], but later should raise concern for salicylate orSAID abuse [243], or gastrogastric fistula [224]. Lateastrogastric fistula closure may be a difficult procedureequiring laparotomy, sometimes with resection [225],hereas marginal ulcer perforation is more easily man-

ged with a laparoscopic approach [244]. Obstruction dueo internal herniation may require major resection andntestinal reconstruction [245].

Excessive weight loss, steatorrhea, or evolution of severeutritional complications, particularly protein–calorie mal-utrition, may indicate an excessively long malabsorptiveomponent. Proximal relocation of the pancreaticobiliaryecretions by intestinal reconstruction should be considered164]. One option is to relocate the junction of the biliarynd alimentary limbs more proximally, with a 50 cm dis-ance being suggested by Hamoui [246]. An alternative, and

technically easier operation is to leave the original anas-omosis intact and to create another enteroenterostomy 100m proximally, allowing for more proximal partial mixingf biliary and pancreatic secretions with the alimentary limbontents. This is effective in resolving malnutrition and

elative strengths of laparoscopic bariatric surgical procedures

AGB RGB

bjectiveowest perioperative risk �� ost effective durable weight loss � ��est comorbidity resolution � ��ost reversible �� est procedure to avoid reoperation due to:echnical complication - early �� echnical complication - late � ��etabolic complication - late ��

nadequate weight loss � ��ubjectiveowest need for outpatient visits � ��ewest metabolic consequences of poor follow-up �� urable weight loss with poor patient compliance � ��

Relative scale ��

iarrhea, while causing minimal weight gain [246]. How-

ver, complication rates are high even in this simple proce-ure, presumably due to the poor physiological state of thealnourished patient.

esire for reversal. Ease of reoperation after laparoscopicGB is one of the putative benefits, and up to 33% ofatients may come to reversal or major revision [210, 211].aparoscopic RGB and BPD cause more dramatic anatomichanges that trade ease and possibility of reversal for bettereight loss outcomes and independence from an implant-

ble device [246, 247].

ole of laparoscopy in revisional procedures. Revisionalariatric operations may be performed laparoscopically248–250] or via open technique [251, 252]. Complicationsre more common after reoperations than after primaryariatric procedures [253]. Surgeons may prefer an openpproach to address severe adhesions, or to permit tactileocalization of prior partitions in the stomach to avoid cre-ting undrained or ischemic segments during restapling230]. Foreign-body removal and partial gastric resectionay also be required [216]. Drain placement is often per-

ormed in response to a recognized increased possibility ofeak [254].

uidelines for revisional bariatric surgery

● Prior to elective procedures, anatomy should be de-fined by review of available records, plus radiographicand/or endoscopic assessment (level II, grade B).

● Laparoscopic revisional procedures may be performedsafely, but with more complications than primary bari-atric procedures, therefore the relative risks and ben-efits of laparoscopy should be considered on a case-

Comparative trials andmeta-analyses

Noncomparative trials

[22, 208] [21, 36, 134, 147, 165, 166, 210][72, 143, 145, 206, 207] [2, 19, 21, 29, 136, 137, 145, 193–195][22, 208] [126, 128, 139–141, 195, 199, 200]

[210, 211, 246, 247]

[21, 181, 205][181, 210, 211][29, 126, 152–154]

[22, 207] [190]

[57, 138, 178, 179]

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Bariatric surgery is medically indicated for morbidlybese patients who fail to respond to dietary, behavioral,utritional, and medical therapies, with clear evidence offficacy and safety. BMI and age-based candidacy guide-ines should not limit access for patients suffering withrogressive or poorly controlled obesity-related comor-idities if the risk-versus-benefit analysis favors surgery.aparoscopic RGB, AGB, and BPD have all been provenffective.

Given the marked paucity of prospectively collected com-arative data between the different bariatric operations, it re-ains impossible to make definitive recommendations for one

rocedure over another. At the present time, decisions areriven by patient and surgeon preferences, as well as consid-rations regarding the degree and timing of necessary out-omes versus tolerance of risk and lifestyle change.

Until the emergence of additional randomized controlledomparative studies, decisions between procedures will de-end upon the present evidence and the relative importancelaced by patients and surgeons on purported discriminatingactors.

ppendix A: Levels of evidence

evel I Evidence from properly conducted randomized, controlledtrials

evel II Evidence from controlled trials without randomizationOrCohort or case-control studiesOrMultiple time series, dramatic uncontrolled experiments

evel III Descriptive case series, opinions of expert panels

ppendix B: Scale used for recommendation grading

rade A Based on high-level (level I or II), well-performed studieswith uniform interpretation and conclusions by theexpert panel

rade B Based on high-level, well-performed studies with varyinginterpretation and conclusions by the expert panel

rade C Based on lower-level evidence (level II or less) withinconsistent findings and/or varying interpretations orconclusions by the expert panel

ppendix C: Summary of guidelines

Justification for surgical treatment of obesity

● Weight-loss surgery is the most effective treatment formorbid obesity, producing durable weight loss, im-provement or remissions of comorbid conditions, andlonger life (level I, grade A).

Guidelines for selecting validated bariatric procedures

● Laparoscopic RGB, gastric banding by VBG or AGB,
and BPD � DS are established and validated bariatric
procedures that provide effective long-term weightloss and resolution of co-morbid conditions (level II,grade A).

● LSG is validated as providing effective weight lossand resolution of comorbidities to 3-5 years (level II,grade C).

Guidelines for patient selection

● 1991 NIH consensus guidelines provide valid but in-complete patient selection criteria for contemporarybariatric procedures including laparoscopic BPD �DS, RGB, VBG and AGB (level II, grade A).

● Other well-selected patients may benefit from laparo-scopic bariatric surgery by experienced surgeons:– BMI �60 kg/m2 (level II, grade A).– Patients �60 years (level II, grade B).

● Adolescent bariatric surgery (age �18 years) has beenproven effective but should be performed in an expe-rienced center (level II, grade B). Patient selectioncriteria should be the same as used for adult bariatricsurgery (level II, grade C).

● Individuals with BMI 30–35 kg/m2 may benefit fromlaparoscopic bariatric surgery (level I, grade B).

Guidelines for bariatric programs

● Bariatric surgery programs should include multidisci-plinary providers with appropriate training and expe-rience (level III, grade C).

● Institutions must accommodate the special needs ofbariatric patients and their providers (level III,grade C).

● Participation in support groups may improve out-comes after bariatric surgery (level II, grade B).

Guidelines for preoperative preparation

● A psychological evaluation is commonly part of thepreoperative work-up of bariatric patients (level III,grade C).

● Treated psychopathology does not preclude the bene-fits of bariatric surgery (level II, grade B).

● Preoperative weight loss may be useful to reduce livervolume and improve access for laparoscopic bariatricprocedures (level II, grade B), but mandated preoper-ative weight loss does not affect postoperative weightloss or comorbidity improvements (level I, grade B).

Guidelines for laparoscopic BPD � DS

● In BPD, the common channel should be 60–100 cm, andthe alimentary limb 200–360 cm (level II, grade C).

● DS diminishes the most severe complications of BPD,including dumping syndrome and peptic ulceration ofthe anastomosis (level II, grade C).

● BPD is effective in all BMI �35 kg/m2 subgroups,with durable weight loss and control of comorbidities
beyond 5 years (level II, grade A).

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● Laparoscopic BPD provides equivalent weight loss,shorter hospital stay, and fewer complications thanopen BPD (level III, grade C).

● BPD may result in greater weight loss (level II, gradeA) and resolution of comorbidities (level II, grade B)than other bariatric surgeries, but with the highestmortality rate (level II, grade A).

● After BPD � DS, close nutritional surveillance andsupplementation are needed (level III, grade C).

Guidelines for laparoscopic RGB

● In laparoscopic RGB, a small lesser-curvature-basedpouch that excludes the gastric fundus and a 75–150cm alimentary (Roux) limb are effective for mostpatients (level II, grade B).

● Alimentary limbs �150 cm may improve intermedi-ate-term weight loss but also may increase nutritionalcomplications (level III, grade C).

● Laparoscopic RGB is similar in efficacy to open RGB(level I, grade A) with reduced early complicationsand risk of hernia (level II, grade B).

● Long-term follow-up is recommended and may im-prove weight-loss outcomes (level III, grade C).

Guidelines for laparoscopic AGB

● The pars flaccida approach for laparoscopic AGBplacement should be used in preference to the peri-gastric approach in order to decrease the incidence ofgastric prolapse (level II, grade A).

● Laparoscopic AGB is effective in all BMI subgroups,with durable weight loss and control of comorbiditiespast 5 years (level I, grade A).

● Intermediate-term weight loss after laparoscopic AGBmay be less than after laparoscopic RGB (level I,grade A).

● Frequent outpatient visits are suggested in the earlypostoperative period. Band filling should be guided byweight loss, satiety, and patient symptoms (level III,grade C).

Guidelines for revisional bariatric surgery

● Prior to elective procedures, anatomy should be de-fined by review of available records, plus radiographicand/or endoscopic assessment (level II, grade B).

● Laparoscopic revisional procedures may be performedsafely, but with more complications than primary bari-atric procedures, therefore the relative risks and ben-efits of laparoscopy should be considered on a case-by-case basis (level III, grade C).

cknowledgement.

Printing costs of this guideline were supported by Karl
torz.
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sages guideline for clinical application of laparoscopic bariatric surgery

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