Severe or morbid obesity (MO) is the most prevalent nutritional disorder in the Western world and is considered a real disease as it reduces life expectancy and is associated with a high rate of co-morbidity. Various forms of non-surgical treatment (diets, exercise, drugs) have been tried to reduce pathological body weight but, in the long-term, the only treatment proven to be effective, obtaining permanent and stable results in a high percentage of patients, is bariatric surgery.
Any surgical technique for severe obesity must be safe, with a morbidity of below 10% and a mortality rate below 1%, effective with a weight loss of over 50% in at least 75% of patients, it can be reproduced and provide a good quality of life with minimum side effects. In order to be able to guarantee success in this type of surgery, it is also vital to have a multi-disciplinary group (surgeon, endocrinologist, dietitian, psychiatrist) that can work together to indicate the right treatment and to monitor the patient after surgery.
Such surgery is indicated in patients with a BMI (body mass index) > 40 kg/m2 or a BMI between 35 and 40 kg/m2 with obesity-related co-morbidity or severe physical limitations that make it impossible to lead a normal life. The recommendations of the National Institutes of Health Consensus Development Conference which brought together many specialists on the subject in March 1991 must be followed closely.
Over the past decade, experience and results from the different bariatric surgery techniques has helped us learn more about the best surgical procedure for each patient. Another fundamental advance has been the incorporation of laparoscopic surgery into this type of surgical techniques, which has helped to significantly reduce complications.
Laparoscopic surgical procedures
These can be divided into three types:
- Restrictive (Vertical-banded gastroplasty and gastric banding)
- Malabsorptive (Biliopancreatic diversion and duodenal switch)
- Mixed (gastric bypass).
Of the different malabsorptive and/or restrictive techniques available for treating MO, most authors consider Roux-en-Y gastric bypass the 'gold standard' technique due to the excellent weight loss and low associated morbidity. In fact, in one survey conducted by the American Society for Bariatric Surgery, 70% of the surgical procedures were gastric bypass, in its different forms.
Advances in laparoscopic surgery have enabled this surgical technique to be used to treat MO, with all the advantages this has to offer compared to conventional surgery (lower morbidity, less post-operative pain, shorter hospital stay, etc.). Therefore, the advantages over laparotomy observed in other surgical conditions, such as lower morbidity and a shorter recovery time, also occur with laparoscopic bariatric procedures.
Due to the inherent conditions of the patient and the difficulty of the surgical technique, there are two learning curves for laparoscopic bariatric surgery. Firstly it is necessary to have experience in treating obese patients and secondly it is vital to have experience in advanced laparoscopic reconstructive surgery techniques.
Laparoscopic surgery for MO must comply with the same principles of conventional surgery and follow the same technical options.
The different procedures used in laparoscopic bariatric surgery use the following techniques:
- Restrictive: adjustable or non-adjustable gastric banding and vertical-banded gastroplasty (VBG)
- Malabsorptive: biliopancreatic diversion and duodenal switch
- Mixed: proximal or distal gastric bypass (GB)
Today the most commonly used laparoscopic technique is gastric banding, or more specifically adjustable gastric banding (using the different models available on the market). The short, medium and long-term results vary greatly according to different authors. In other words, for some they are good while for others they are just mediocre.
It is the easiest technique, which is probably why it is the most commonly used. However, one possible indication is that it should only be used in young patients (under the age of 25) with a BMI of less than 45 and specific dietary habits who accept a high rate of failure and possible surgical reintervention. One of the most experienced groups recognizes a high rate of early reintervention, up to 30% (Cadiére GB, unpublished data).