Weight loss programs, diets, and drug therapy have not shown long-term effectiveness in treating morbid obesity. A 1992 statement from the National Institutes of Health Consensus Development Conference affirmed the superiority of surgical over nonsurgical approaches to this condition. Bariatric surgical procedures work in 1 of 2 ways: by restricting a patient's ability to eat (restrictive procedures) or by interfering with ingested nutrient absorption (malabsorptive procedures). Many of these procedures can be performed by a laparoscopic approach, which has been shown to reduce operative morbidity. In the United States, the primary operative choice for morbidly obese patients has recently shifted from vertical banded gastroplasty (VBG) to the Roux-en-Y gastric bypass (RYGBP). VBG, a purely restrictive procedure, has fallen into disfavor because of inadequate long-term weight loss. RYGBP combines restriction and malabsorption principles, and has been shown to induce greater weight loss than VBG. Other procedures currently being offered include laparoscopic adjustable gastric banding; biliopancreatic diversion (BPD), including the duodenal switch (BPD-DS) variation; and distal gastric bypass (DGBP). The problem of obesity has reached epidemic proportions in the United States. More than 50% of adults are obese or overweight, and 5% are severely obese (body mass index [BMI] of Ն35) [1]. Numerous studies have demonstrated a strong relation between BMI and the development of lifeimpairing comorbidities, such as hypertension, diabetes (type 2), atherosclerosis, sleep apnea, and osteoarthritis. Obesity is associated with a higher risk of cancer (breast, colon, uterine) and premature death. Patients with severe or morbid obesity (BMI Ͼ35), the focus of this review, are consequently most severely affected by the disease, have a poor quality of life, and thus have the greatest need for weight loss therapy. Numerous medical and surgical treatments for severe obesity have come and gone over the years, underscoring the challenge and complexity of obesity management. The intent of this review is to summarize the current status of medical and surgical options for the treatment of severe obesity.
Management of obesity
The grounded theory proposes that the extent to which patients successfully negotiate tension-generating changes may be a major determinant in the long-term outcome of gastric bypass, both weight loss and psychosocial adjustment.
When patients are matched with 3-year follow-up according to time of surgery, age, sex and BMI, LRYGBP provides superior weight and co-morbidity reduction and can be done without severe complications. However, the LAGB is an effective weight loss tool and not every patient wishes to have the LRYGBP.
Routine postoperative GI series following gastric bypass is not beneficial. All true leaks are demonstrated when x-rays are indicated. We recommend GI series only when clinically indicated. GI series had low positive predictive value for leak.
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