This meta-analysis on surgical treatment of obesity supports the American College of Physicians' clinical guideline in this issue. Surgery is more effective than nonsurgical treatment for weight lo...

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Meta-analysis: surgical treatment of obesity.

Objective To evaluate the short-term outcomes for laparoscopic Roux-en-Y gastric bypass in 275 patients with a follow-up of 1 to 31 months. Background Data The Roux-en-Y gastric bypass is a highly successful approach to morbid obesity but results in significant perioperative complications. A laparoscopic approach has significant potential to reduce perioperative complications and recovery time. Methods Consecutive patients (n = 275) who met NIH criteria for bariatric surgery were offered laparoscopic Roux-en-Y gastric bypass between July 1997 and March 2000. A 15-mL gastric pouch and a 75-cm Roux limb (150 cm for superobese) was created using five or six trocar incisions. Results The conversion rate to open gastric bypass was 1%. The start of an oral diet began a mean of 1.58 days after surgery, with a median hospital stay of 2 days and return to work at 21 days. The incidence of early major and minor complications was 3.3% and 27%, respectively. One death occurred related to a pulmonary embolus (0.4%). The hernia rate was 0.7%, and wound infections requiring outpatient drainage only were uncommon (5%). Excess weight loss at 24 and 30 months was 83% and 77%, respectively. In patients with more than 1 year of follow-up, most of the comorbidities were improved or resolved, and 95% reported significant improvement in quality of life. Conclusion Laparoscopic Roux-en-Y gastric bypass is effective in achieving weight loss and in improving comorbidities and quality of life while reducing recovery time and perioperative complications.

Outcomes After Laparoscopic Roux-en-Y Gastric Bypass for Morbid Obesity

Apparatus and methods are described for treatment of morbid obesity using minimally invasive techniques. The apparatus includes a system of components that may be used separately or in combination for effectively reducing stomach volume, bypassing a portion of the stomach and/or small intestines, reducing nutrient absorption in the stomach and/or small intestines and/or depositing minimally or undigested food farther than normal into the intestines, thereby stimulating intestinal responses. The components described include an artificial stoma device, a gastric sleeve device, an intestinal sleeve device, a combined gastrointestinal sleeve device and permanent and detachable attachment systems. Also described are devices for delivering and deploying the components of the system.

Apparatus and methods for treatment of morbid obesity

Roux-en-Y gastric bypass (RYGB) is an effective treatment for severe obesity. However, many patients regain weight over time. The mechanisms for this are unclear, and several factors may contribute, including dilation of the gastrojejunal anastomosis. This study aimed to assess the feasibility of endoscopic gastrojejunal anastomotic tightening and to determine the effect of tightening on body weight. Eight patients with significant weight regain and dilated gastrojejunal anastomosis after RYGB were included in this pilot study. Sutures were placed endoscopically at the rim of the anastomosis. When tightened, the sutures formed tissue placations, reducing the size of the anastomotic aperture. The average preprocedure body mass index (BMI) was 40.5, and the patients had regained a mean of 24 kg from their post-RYGB nadir. The average pouch length was 5.7 cm, and the average anastomotic diameter was 25 mm. The average postreduction diameter was 10.0 mm (68% reduction). Six of the eight patients showed weight loss (mean, 10 kg) at 4 months. Repeat procedures were performed for three patients who had lost 4, 5, and 9 kg, respectively with the initial procedure. After the second anastomotic reduction, the final diameters were, respectively, 14, 5, and 5 mm. The first patient did not have further weight loss. The remaining two patients showed a total weight loss of 19 and 20 kg, respectively, at 5 months. All 11 reductions were accomplished without significant complication. The average postreduction BMI was 37.7, and the percentage of excess weight loss was 23.4%. Peroral endoscopic suturing to tighten dilated gastrojejunal anastomoses appears technically feasible and safe. This procedure is associated with variable but significant weight loss, and preliminary results suggest that it may offer a new treatment option for postbypass weight regain in selected patients.

Peroral endoscopic reduction of dilated gastrojejunal anastomosis after Roux-en-Y gastric bypass: a possible new option for patients with weight regain

The present invention provides devices and methods for attachment of an endoluminal gastrointestinal device, such as an artificial stoma device, a gastrointestinal bypass sleeve device (200) or an attachment cuff (214), within a patient’s digestive tract for treatment of obesity.

Devices and methods for attaching an endolumenal gastrointestinal implant

Gastric bypass is considered by many to be the gold standard for surgical treatment of obesity. Gastric bypass was a natural evolution from gastric operations that were used for the treatment of peptic ulcer disease. Gastric bypass, first described in 1967, has undergone many modifications. It presently exists as a hybrid operation. Gastric bypass operation has been extensively scrutinized and evaluated against other operations for the treatment of obesity. Co-morbidities due to severe obesity are usually ameliorated or arrested after the weight loss from gastric bypass. Gastric bypass operation is now being performed with a perioperative morbidity of less than 10%. The average percentage excess weight loss with gastric bypass is 70%. The success rate, defined as 50% excess weight loss after at least 2 years of follow-up, is 85%. The metabolic deficiencies of gastric bypass are controllable with supplemental intake. This report with special references to the Fobi pouch operation, a modification of gastric bypass done by the author, presents the evolution, modifications, risk, outcome, and future trends of gastric bypass for treatment of obesity.

Gastric Bypass Operation for Obesity

The Fobi-Pouch operation (FPO) for obesity is the product of clinical trials, more than 15 years of personal clinical experience and information gathered from publications, scientific meetings, and personal communications with other bariatric surgeons. The essence of the operation is the small vertical pouch (< 25 ml), an externally supported stoma, the interposed Roux-en-Y limb, the gastrostomy and the bypassed stomach marker to facilitate percutaneous transabdominal access to the bypassed segment. Patients undergoing this operation are usually given bowel prep the day before the operation, admitted the morning of the operation and started on subcutaneous heparin, prophylactic antibiotic and hydration. Antithrombotic sequential compression devices are regularly used. The hospital stay is usually 4 days. Our results and those of other surgeons who have used this modification substantiate the rationale for the modifications entailed in the FPO. Our longer-term experience and results are being compiled for publication.

https://link.springer.com/content/pdf/10.1381%2F096089298765554485.pdf

The Surgical Technique of the Fobi-Pouch Operation for Obesity (The Transected Silastic Vertical Gastric Bypass)

The gastric bypass (GBP) Operation is progressively being widely used to treat severe obesity. One problem with this operation is that it leaves the bypassed segment of the gastrointestinal tract not readily available for either mechanical, radiological or endoscopic evaluation. We have addressed this problem by putting a gastrostomy tube in the bypassed stomach at the time of the GBP. A radio-opaque marker placed around the gastrostomy site enables easy radiological localization of and thus easy percutaneous access to the bypassed stomach. The surgical technique is presented.

Access to the bypassed stomach after gastric bypass.

Standardization of the key measurements of a procedure’s finished anatomic configuration strengthens surgical practice, research, and patient outcomes A consensus meeting was organized to define standard versions of 25 bariatric metabolic procedures A panel of experts in bariatric metabolic surgery from multiple continents was invited to present technique descriptions and outcomes for 4 classic, or conventional, and 21 variant and emerging procedures Expert panel and audience discussion was followed by electronic voting on proposed standard dimensions and volumes for each procedure’s key anatomic alterations Consensus was defined as ≥ 70% agreement The Bariatric Metabolic Surgery Standardization World Consensus Meeting (BMSS-WOCOM) was convened March 22–24, 2018, in New Delhi, India Discussion confirmed heterogeneity in procedure measurements in the literature A set of anatomic measurements to serve as the standard version of each procedure was proposed After two voting rounds, 22/25 (880%) configurations posed for consideration as procedure standards achieved voting consensus by the expert panel, 1 did not attain consensus, and 2 were not voted on All configurations were voted on by ≥ 50% of 50 expert panelists The Consensus Statement was developed from scientific evidence collated from presenters’ slides and a separate literature review, meeting video, and transcripts Review and input was provided by consensus panel members Standard versions of the finished anatomic configurations of 22 surgical procedures were established by expert consensus The BMSS process was undertaken as a first step in developing evidence-based standard bariatric metabolic surgical procedures with the aim of improving consistency in surgery, data collection, comparison of procedures, and outcome reporting

/pdf/standardization-of-bariatric-metabolic-procedures-world-490ay03m4j.pdf

Standardization of Bariatric Metabolic Procedures: World Consensus Meeting Statement

Obesity and particularly morbid obesity is a lifelong problem that currently cannot be cured but can be controlled. Attempted control of obesity non-surgically results in 98% recividism. Weight loss is readily attainable, but weight loss maintenance is recalcitrant. Surgery currently provides the only long-term control of obesity. Surgery at best is a tool that the patient can use to effect the weight loss and weight loss maintenance. We have celebrated the golden anniversary of bariatric surgery in 2004. Obesity surgery is thus a relatively young field which is evolving. Operations currently used for the treatment of obesity fall into 3 categories: 1) restrictive operations such as vertical banded gastroplasty, silastic ring gastroplasty and gastric banding; 2) malabsorptive operations which include all the variations of the intestinal bypass; and 3) combined operations which utilize both restriction and malabsorption which include all the variations of short-limb gastric bypass, long-limb or distal gastric bypass and biliopancreatic diversion. The choice of the operation will be guided by the extent of the patient's obesity, the age of the patient, other co-morbid conditions of the patient, the cost of the operation, the patient's choice, and the surgeon's choice based on training, experience and geographical location. First and foremost, the operation chosen should be effective in causing weight loss and providing long-term weight loss maintenance with acceptable morbidity and mortality. Recommendations are made for choosing an operation for weight control based on effectiveness and safety.

Mathias Fobi

Papers

Gastric Bypass Operation for Obesity

The Surgical Technique of the Fobi-Pouch Operation for Obesity (The Transected Silastic Vertical Gastric Bypass)

Access to the bypassed stomach after gastric bypass.

Standardization of Bariatric Metabolic Procedures: World Consensus Meeting Statement

Choosing an operation for weight control, and the transected banded gastric bypass.