In Brief

Article Outline

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The history of weight loss surgery (WLS) is marked by trial and error. In the past, now-outdated procedures carried unacceptably high risks. Weight loss associated with operations was questionable, and long-term health benefits were unknown. For many years, WLS was the option of last resort for the most extremely debilitated patients. But things have changed, and dramatically so. Unbridled growth in severe obesity has been matched by advances in surgical techniques and technologies available for its treatment.

Today, WLS confers many benefits beyond robust and durable weight loss. Recent studies demonstrate its ability to put diabetes into remission, improve cardiovascular disease, and reduce the overall risk of death. Advances in WLS have also enabled it become as safe as other major operations like colectomy and coronary artery bypass grafting.

Over the past decade, the number of weight loss procedures performed in the United States soared by 800%. This massive increase in WLS procedures raised concerns among third party payers and government agencies about provider qualifications and patient safety. These issues have been addressed by data showing that quality has kept pace with quantity, a phenomenon due in part to the establishment of bariatric surgery fellowships and, most importantly, the publication of evidence-based standards for the care of WLS patients.

The first such report was born from a medication error that killed Boston Globe journalist Betsy Lehman and led to the subsequent creation of the Betsy Lehman Center for Patient Safety and Medical Error Reduction (Lehman Center). This organization's mission is to improve patient safety by developing evidence-based, best practice standards of care.

In 2004, the Lehman Center and the Massachusetts Department of Public Health convened an Expert Panel to assess weight loss procedures, identify issues related to patient safety, and develop evidence-based best practice recommendations. The Panel worked with more than 100 specialists to examine every facet of care of obese patients.

The resulting document set the standard for care of WLS patients. Its recommendations influenced health care policy and medical practice in the United States and abroad. Because of the growth of literature pertaining to surgical weight loss and improvement in techniques, the Lehman Center reconvened the Expert Panel in 2007 to update the earlier systematic literature review and evidence-based recommendations. The new report is even more comprehensive than the first. It covers every practice area in the original publication as well as 2 new topics: endoscopic interventions and policy and access.

Today the number of WLS procedures performed still continues to grow. This is most likely to continue, at an accelerating pace, as evidence on their safety and efficacy mounts and more insurers provide coverage. Today, there are approximately 15 million people in the United States with a body mass index (BMI) greater than 40 kg/m² and the World Health Organization (WHO) estimates that more than 400 million adults currently have class I obesity (BMI >30).

Unfortunately, there are not enough weight loss surgeons trained in minimally invasive techniques to accommodate the numbers of obese patients who qualify for WLS, nor are specialists on hand in every emergency room to treat those who have already had operations. As a result, general surgeons will increasingly be called on to care for WLS patients. One goal of this monograph is to highlight common complications and review their initial management by nonspecialists who may encounter patients in emergency rooms or in clinics, years after their WLS surgery.

General surgeons and those pursuing careers as weight loss surgeons should be well versed in the contents of the 2009 Lehman Center report and this monograph. Those embarking on a career in WLS may also benefit from fellowship training and practice in an American College of Surgeons (ACS) or American Society for Metabolic and Bariatric Surgery (ASMBS) designated Center of Excellence.

WLS patients are particularly challenging. Not only does their body habitus pose technical challenges, the operations themselves can cause severe malnutrition and complications if signs and symptoms go unrecognized. General surgeons should be familiar with the many different types of WLS procedures and their complications. Bariatric surgery has taken on many forms since the first operations in the 1950s. Five decades later, no single “best” operation has emerged from the available options.

This monograph, based on the 2009 Lehman Center report, presents information needed to deliver appropriate, evidence-based, best practice care. The material in these pages addresses a wide range of issues related to WLS. It includes an overview of the types of procedures performed today as well as ones that have been phased out over time. The information is designed to familiarize general and weight loss surgeons with anatomical changes from WLS, improve their understanding of mechanisms of action, and help them recognize and appropriately react to problems encountered in WLS patients.

Sections on complications are broken down by those that pertain to all weight loss procedures as well as those that are specific to each technique. The material is presented in ways that increase knowledge of various symptoms and their implications for patient safety and well-being during every phase of treatment—intraoperative, early postoperative, and late postoperative. Complications discussed range from bowel ischemia and leaks to gallstone formation and nutritional deficiencies.

Procedure-specific adverse effects are categorized by types of surgery—restrictive, malabsorptive, or a combination of both. Potential problems associated with the former include those related to the adjustable gastric band (AGB), sleeve gastrectomy (SG), and vertical banded gastroplasty (VBG). The 2 most popular procedures, Roux-en-Y gastric bypass (RYGB) and AGB, are discussed in depth.

Complications associated with RYGB, arguably the gold standard weight loss operation, are described in ways that will help general and weight loss surgeons distinguish between conditions that require immediate, potentially life-saving action and those that call for stabilization and referral to the patient's weight loss surgeon or nearest full-service bariatric facility.

In the remaining sections of the monograph, we review populations that present unique challenges. These include patients with extreme obesity (BMI >50) and pediatric/adolescent cases. The latter, although controversial, make up the fastest growing subgroup of WLS patients. Material covered includes criteria for performing WLS in children and adolescents, and potential complications (eg, problems with bone growth, recidivism, pregnancy, and emotional, physical, and psychological issues).

Revision operations are considered as well as investigational methods of weight management. Among the former, we review the main reasons patients undergo revisional surgery, and the symptoms and complications that can result from it. We describe what nonspecialists can expect to see, and how best to deal with unexpected consequences of WLS. Investigational areas include the intragastric balloon (IGB) and endoluminal approaches, such as the endoluminal sleeve and transgastric creation of a small gastric pouch.

“Other Areas of Clinical Research” covers WLS to treat diabetes in patients with BMI less than 35 kg/m² and the use of RYGB to prepare obese transplant candidates for surgery. This section also discusses laparoscopic RYGB in obese patients waiting for kidney transplants and preoperative SG in those under consideration for liver and lung transplants.

The section entitled “Risks versus Rewards of WLS” offers information that can help health care providers answer questions patients might ask about WLS. Such topics as eligibility, screening criteria, how much weight they can expect to lose, insurance coverage, and the importance of a multidisciplinary approach are discussed. Benefits reviewed include, among others, postoperative improvement or resolution of type 2 diabetes, cardiac dysfunction, gastroesophageal reflux disease (GERD), degenerative joint disease, and nonalcoholic steatohepatitis.

All of the above information will equip those who read this monograph to deliver evidence-based, best practice care to WLS patients. They are not alone in this pursuit. Professional societies, government agencies, health insurers, and accreditation bodies are dedicated to that same end. We review steps to protect WLS patients, including surgical accreditation and Centers of Excellence. We also provide the latest data on exercise, pre- and postoperative diets, meal planning, eating strategies, and nutritional complications (eg, dehydration, food intolerances).

With nearly a quarter of a million people having WLS each year, most health care professionals either are or will be treating patients who have had an AGB, SG, or RYGB. To serve their best interests and deliver the latest evidence-based treatment, they need to be familiar with the basics of surgical procedures, weight loss devices, anatomical changes, nutritional needs, and the early signs and symptoms of common complications. This monograph provides comprehensive information that can serve as the basis for prompt, accurate diagnoses and effective action.