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Bariatric surgery  mechanisms, indications and outcomes Bariatric surgery mechanisms, indications and outcomes Document Transcript

  • doi:10.1111/j.1440-1746.2010.06391.xA D VA N C E S I N C L I N I C A L P R A C T I C E jgh_6391 1358..1365Bariatric surgery: Mechanisms, indications and outcomesPaul E O’BrienCentre for Obesity Research and Education, Monash University, Melbourne, Victoria, AustraliaKey words AbstractObesity, weight loss, bariatric surgery, gastricbanding, gastric bypass, satiety, appetite. The rising problem of obesity is causing major health problems, reduced quality of life andlaparoscopic surgery. reduced life expectancy. It now generates approximately 10% of all health costs. The progression of the problem indicates preventive measures have been unsuccessful so far.Accepted for publication 7 May 2010. Only bariatric surgical treatments have been able to achieve substantial and durable weight loss. Gastric banding and gastric bypass are used in more than 90% of bariatric operations.Correspondence The proportion of each varies from greater than 95% bands in Australia, about 50/50 inProfessor Paul O’Brien, Centre for Obesity Europe and USA and nearly 100% bypass in South America. The availability of follow upResearch and Education, Monash Medical is a prime determinant of choice. Understanding the mechanisms of effect for the bariatricSchool, The Alfred Hospital, Melbourne, procedures is central to optimizing their effect. The traditional narrow concepts of restric-Vic. 3004, Australia. Email: tive (blocking the transit of food) and malabsorptive (preventing the absorption of food) should be discarded and the importance of induction of satiety, change of taste, diversion of chyme, neural and hormonal mediation and the effects of aversion need to be included. The primary mechanism of effect for gastric banding is the generation of a background of satiety and early post-prandial satiation via specifically structured vagal afferents at the level of the band. At five years after banding or bypass, there is typically a loss of 30–35 kg representing 50–60% of excess weight. This weight loss has been shown to be associated with major improvement or complete resolution of multiple common and serious health problems plus improvement in quality of life and in survival. Level 1 evidence supports the use of the gastric band over optimal lifestyle therapy. Randomized controlled trials has shown gastric banding to achieve better weight loss, health and quality of life than optimal lifestyle therapies for adults above a BMI of 30 and adolescents above a BMI of 35. In adults with mild to severe obesity and type 2 diabetes gastric banding leads to remission in three out of four individuals. Perioperative risk is significant with gastric bypass and late revisional procedures can be required after both procedures. Gastric banding is indicated in any adult who has a BMI over 30, has problems with their obesity and has made substantial effort to reduce their weight by lifestyle methods. Gastric bypass or biliopancreatic diver- sion should be considered in those with BMI greater than 35 if banding is contraindicated or has been unsuccessful. are suffering the disease of obesity. A similar rate of growth isThe evolution of obesity occurring in Australia with a current prevalence of approximatelyObesity is likely to be the disease of the 21st century. The growth 22% or 2.9 million adults.5of obesity is worldwide, a pandemic, with the World Health Orga-nization (WHO) estimating more than 1.6 billion people are cur-rently overweight and 400 million obese.1 The rapid increase hasbeen best demonstrated by the careful population measurements Obesity and its treatment is becomingby the Centers for Disease Control and Prevention (CDC) in the an important part of gastroenterologyUnited States.2 They show the prevalence of obesity has acceler- Acknowledgment of the problem of obesity is the first step toated after 1980. Between 1960 and 1980 the percentage of adults dealing with it. This has come slowly as the traditional view thatwho were obese increased only marginally, from 13.4% to 14.4%. weight control is a personal responsibility is strongly embedded.In the next 20 years it doubled to 30.4%.2 It has continued to Increasingly, governments, healthcare managers and physiciansincrease during the present decade. It had risen to 33.8% in 20083 have accepted that we now live in an obesigenic environment, thatand projected figures for 2010 and 2020 are 37.4% and 44.2%, the obesity is causing much illness, premature death and highrespectively.4 Currently, more than 77 million adults in the USA healthcare costs and that the medical community should seek to1358 Journal of Gastroenterology and Hepatology 25 (2010) 1358–1365 © 2010 Journal of Gastroenterology and Hepatology Foundation and Blackwell Publishing Asia Pty Ltd
  • PE O’Brien Bariatric surgery—current statusaddress it as a disease. This attitude is growing strongly in gastro- bariatric surgery. In Australia, there were less than 400 bariatricenterology. Obesity is a disease of overnutrition. It is driven in part procedures in 1993. In 2008 there were more than 14 000. World-by gut hormones and liver-derived insulin resistance. It generates wide, it is estimated that a total of 344 000 procedures were per-diseases such as non-alcoholic steatohepatitis, several common GI formed in that year.14 Roux Y gastric bypass, both laparoscopic andcancers and gastro-oesophageal reflux disease. Endoscopic and open, was the most common (47%) followed by gastric bandingsurgical procedures on the gut are leading the attempts to generate (42%), sleeve gastrectomy (5%) and BPD (2%).14 The trend insubstantial weight loss in the obese. Leading journals are encour- Europe is for RYGB to increase, although gastric banding remainsaging the GI physician and surgeon to be knowledgeable and dominant. The opposite trend is occurring in the USA with gastricskilled in managing this disease.6 banding now moving ahead of RYGB in frequency. In Australia, gastric banding is the method of choice in more than 95% of bariatric procedures.Increased recognition of the The major differences in surgical approaches across the worldco-morbidities and costs can be seen to be derived directly from the funding of the proce-Obesity is a one of the most virulent of pathogens. It causes or dures and their follow up requirements. Gastric banding is uniqueexacerbates numerous common and serious diseases. Type 2 dia- among surgical procedures in that the placement of the band isbetes is the paradigm of an obesity-derived disease. There are now simply the first step of a process of care that continues perma-an estimated 285 million people with type 2 diabetes world-wide.7 nently. The adjustment of the band to achieve control of appetite isIncreased weight and diabetes has been directly and strongly the central component of effect and therefore the follow uplinked through two major epidemiological studies, the Nurses’ program is crucial. The uptake of gastric banding is directly relatedHealth study of 112 000 women8 and the Male Health Profession- to the healthcare support for this follow up process. In Australia,als study of 51 000 males.9 From baseline BMI values in the low follow up is covered under Medicare and banding has become the20s, they have shown a direct and substantial rise in diabetes with preferred approach. In Europe, there is generally little funding forweight increase. For the Nurse’s Health study, from a baseline of follow up and banding struggles. In South America, there is noBMI of 22, there is 5 times the risk at BMI 25, 27 times the risk at aftercare funding and almost no banding.BMI 30 and 93 times at BMI 35. The central question is not which operation is best but when Obesity contributes to ischaemic heart disease, stroke and the bariatric surgery becomes indicated. All current proceduresdiseases that are linked to the metabolic syndrome, such as hyper- achieve substantial weight loss. The type of procedure is the detail.tension, the dyslipidaemias, obstructive sleep apnoea, non- Given the prevalence and pathogenicity of obesity, weight loss isalcoholic steatohepatitis and polycystic ovary syndrome. Cancer arguably the most powerful treatment in medicine today. Substan-risk is markedly increased, particularly for colorectal cancer10 but tial weight loss has major benefits to health, survival and quality ofalso oesophageal, pancreatic, renal, endometrial, breast and gall life. Type 2 diabetes is the paradigm of an obesity related disease.bladder cancers.11 In addition, back pain, degenerative diseases of With sufficient weight loss many patients will have remission ofthe hips and knees and depression are common. Mortality risk is their disease.15 Most will have improvement in control of bloodmarkedly increased with obesity, now competing with smoking as sugar levels. Hypertension, obstructive sleeps apnoea, dyslipi-the most prevalent preventable cause of death.12 daemia, non-alcoholic steatohepatitis, polycystic ovary syndrome, Costs of the obesity pandemic are large. The direct healthcare metabolic syndrome, gastro-oesophageal reflux disease, asthmacosts in the United States for obesity during 2010 are estimated to and depression have been shown to improve or disappear.16 Obesebe US$194 billion4 and the Americans themselves are spending people who lose weight live longer than a comparative group ofUS$59 billion on all the options offered to fight fatness. The total obese without weight loss. Comparison of the long-term survivalannual direct health care cost of overweight and obesity for Aus- of patients after gastric banding with a community group whotralia for the year 2005 has been estimated to be $21 billion.13 were obese showed a 72% reduction in the relative risk of dying.17Evolution of bariatric surgery The hierarchy of obesity therapiesBariatric surgery began in the 1950s with jejuno-ileal bypass. Itwas superseded in the 1970s by gastric stapling procedures, such Obesity is a chronic disease. Resolution of the disease of obesityas Roux Y gastric bypass (RYGB), various forms of gastroplasty, requires substantial and durable weight loss. The therapeuticand by the malabsorptive procedure of biliopancreatic diversion options available are listed in Table 1 in order of their risk, side(BPD). All procedures were able to achieve substantial weight loss effects, invasiveness and costs. We should always begin with thein the morbidly obese and yet bariatric surgery during this time simplest and safest and work down the list. Lifestyle therapiesreally had no impact at a community level as it failed to attract (diet, exercise, behavioral change) should always be the first lineeven 1% of those suffering the problem. Factors such invasiveness, of management. Multiple randomized controlled trials (RCTs)risks of death or complications and unknown long term effects have shown that a modest weight loss of between 2 and 5 kg canwere discouraging this approach. be achieved at 12 months.18–21 This level of weight loss is associ- In the last 15 years, the application of a laparoscopic approach ated with a clinically valuable reduction of metabolic risk22–24 butto complex abdominal surgery including bariatric surgery, the generally will not solve the problems of obesity. Lifestyle thera-development of the laparoscopic adjustable gastric banding proce- pies should be applied optimally and sought to be maintaineddure (gastric banding), improved safety and the better documen- permanently. If, however, they fail to resolve the obese patient’station of clinical effectiveness has led a surge of interest in problems, the next level of therapy should be considered. CurrentJournal of Gastroenterology and Hepatology 25 (2010) 1358–1365 1359© 2010 Journal of Gastroenterology and Hepatology Foundation and Blackwell Publishing Asia Pty Ltd
  • Bariatric surgery—current status PE O’BrienTable 1 Weight loss approaches and their relative risks, side effects, Table 2 How do bariatric procedures work?invasiveness and costs Bariatric Surgery—Options for Weight Loss EffectRanking Approach Risk 1. Reduce appetite, induce satietyby risk score 2. Alter the taste of food1. Lifestyle changes—eat less, more activity and 1 3. Restrict intake exercise, modify behaviour. 4. Divert nutrients from duodenum2. Drugs and very low energy diets 2 5. Malabsorption of nutrients3. Endoscopic approaches—intragastric balloon et al. 4 6. Increase energy expenditure4. Gastric Banding 5 7. Aversion effect—dumping, steatorrhoea, vomiting5. Sleeve gastrectomy 76. Roux en Y gastric bypass (RYGB) 87. Open biliopancreatic diversion (BPD) 98. Laparoscopic biliopancreatic diversion 10drug therapies add little further benefit.25 Very low energy diets canbe effective if taken correctly but are inevitably short term. Therecent versions of the intragastric balloon have yet to show effec-tiveness by RCT and remain short term options. In spite of vigor-ous research effort, no additional endoscopic approaches are yetavailable which can provide even medium term benefit. The bariatric surgical procedure of gastric banding becomes thenext option to consider. It should be preferred ahead of otherbariatric procedures on the hierarchy of risk (Table 1) for threereasons: 1 Safety profile.26,27 Mortality after gastric banding is rare. In systematic reviews, mortality has occurred in 1 in 200026 or 1 in 3000,28 ten to fifteen times less than for RYGB in the same reviews. At the Centre for Bariatric Surgery (CBS) in Melbourne we have now treated over 5700 patients with gastric banding without mortality. 2 Minimal invasiveness. It is truly minimally invasive, not Figure 1 The adjustable gastric band placed at the very top of the just because of the laparoscopic approach but also the stomach with no significant gastric pouch above. It is proposed that minimal dissection needed to place the band. Outpatient compression of vagal afferents within this area of gastric cardia mediate the satiety effect. placement is now standard practice for many groups in the USA and Canada with the mean length of post operative stay of 2 h.29 Thus it can be placed with less risk and less time in being a key factor.30 Satiety is the background feeling of not being hospital than a liver biopsy. hungry, without relationship to eating. Satiation is the feeling of 3 Complete and easy reversibility. There is no intention of satisfaction after eating. Both are induced by optimal setting of the reversal of gastric banding. It has occurred in only 128 of band adjustment.30 As a result the gastric banding patient can 5710 (2.2%) of CBS patients. However obesity is not a follow the eating guidelines which center on eating a small amount curable disease. Better treatments are inevitable and the of good food slowly. They eat the amount of food that could be option of reversibility allows the potential to change over to compressed into half a cup (125 gm) three or less times per day. newer therapies in the future. Food must be chewed well. Swallowed food is squeezed across the The other bariatric procedures are available for consideration area of the band by oesphageal peristalsis. Between two and sixshould gastric banding be contraindicated or has failed. Less than peristaltic waves are needed to clear a single small bite of food.1% of our patients at CBS have required conversion. Feelings of satiation are generated with each squeeze.31–33 Eating for a maximum period of 20 min and taking one bite per minute generates enough signals to achieve satiation. Figure 1 shows theHow does bariatric surgery work? position of the band at the cardia of the stomach. Note that there isA key requirement, not yet fulfilled for all bariatric procedures, is no ‘pouch’ of stomach above the understand better how the therapeutic effect is achieved. Table 2 At optimal adjustment, the band compresses the cardia of thelists some of the likely mechanisms. There has been a major stomach to generate a sense of satiety, of reduced appetite through-increase in our understanding of mechanisms for gastric banding out the day. With eating, multiple additional signals are generated.and RYGB in recent years. Neural and hormonal mediators for this effect have been sought. A The induction of satiety and satiation after gastric banding has number of gut peptides are known to influence appetite. Ghrelinbeen demonstrated in a prospective blinded crossover study as is the only hormone that increases appetite (orexigenic).1360 Journal of Gastroenterology and Hepatology 25 (2010) 1358–1365 © 2010 Journal of Gastroenterology and Hepatology Foundation and Blackwell Publishing Asia Pty Ltd
  • PE O’Brien Bariatric surgery—current statusGlucagon-like pepetide-1 (GLP-1), peptide YY (PYY), pancreatic tained for at least 24 months.37 However, this same cross-sectionalpolypeptide (PP), gastric inhibitory peptide (GIP) and cholecysto- and prospective study did not confirm the previously reportedkinin (CCK) are known to decrease appetite (anti-orexigenic). postprandial rise of the incretin, GLP-138 which brings into questionNone of these appear to change in either basal or post-prandial the proposed role of incretins in the effect of RYGB on type 2circulating level with the gastric band. diabetes.39 Diet-induced thermogenesis is noted in the rat model of The vagal afferents are most likely the key mediators of this RYGB40 but remains to be established as an effect in humans.effect through activation of intraganglionic lamellar endings(IGLEs).34,35 These are specifically structured vagal afferenttension/distension receptors attached to the connective tissue Comparison of bariatric surgery withsheath of the myenteric ganglia. They are sensitive to distension non-surgical therapiesand distortion and are slowly adapting. Additional possible vagal We have performed three RCTs in which we have comparedafferent mediators include the intramuscular arrays (IMAs)34 gastric banding with optimal non-surgical programs. The initialwhich lie within the circular and longitudinal muscle, are long RCT was of mild to moderately obese adults (BMI 30–35). Westraight varicose axons running parallel to the muscle fibres. They compared optimal non-surgical therapy, including lifestyle mea-are particular concentrated in the fundus of the stomach, have sures, drug therapy and very low energy diets with the gastric bandclose proximity to the interstitial cells of Cajal, the pacemaker and showed significantly better weight loss, health and quality ofcells of the smooth muscle. Morphologically, they appear capable life for the banding group.41 Adverse events were similar betweenof detecting distension or distortion of the gastric wall but elec- groups. The gastric band patients had lost 86% of their excesstrophysiological study does not support this role.36 weight (%EWL) compared to 21% EWL in the non-surgical group The mechanisms involved in RYGB (Fig. 2) are less defined and (Fig. 3). This substantial weight loss effect has remained at 6 yearsprobably multiple. The traditional concept of distension of the small follow up. The gastric banding participants showed almost com-gastric pouch and delayed emptying through a narrow stoma has plete resolution of the metabolic syndrome, from 38% to 3% (vsbeen considered a central effect. There is an enhanced post-prandial 38% to 24%; a non-significant change) and markedly improvedrise of the satiety-inducing hormone, PYY, an effect that is sus- quality of life as measured by the SF-36. The second study was of obese adults (BMI 30–40) with type 2 diabetes. There was 73% remission rate of diabetes in the gastric band group and 13% in the lifestyle group.42 Again, the metabolic syndrome was significantly improved in the banding group alone. The third RCT was of obese adolescents (BMI > 35; age 14–18 years).43 The gastric band group lost 79% of their excess weight and showed a significant improvement on the metabolic syndrome which reduced from 36% to zero. There was also an improved quality of life. Comparison between bariatric surgical procedures Table 3 lists a range of comparators and the position of each current option against these comparators. The key outcome com- parators between procedures are weight loss, health benefit andFigure 2 The RYGB involved complete separation of a small section ofupper stomach from the body of stomach, creation of a roux en Y length Figure 3 Weight loss, expressed as % of excess weight lost (%EWL)of proximal jejunum which is anastomosed to the proximal gastric in a RCT of gastric banding versus optimal non-surgical therapy in mildpouch. Intake is restricted by the small pouch, gastric emptying is to moderately obese patients (data derived from continued follow up ofrestricted by the narrow gastrojejunostomy and food is diverted from gastric banding patients from the RCT41). The gastric banding groupthe duodenum. show durability of the weight loss at 6 years follow up.Journal of Gastroenterology and Hepatology 25 (2010) 1358–1365 1361© 2010 Journal of Gastroenterology and Hepatology Foundation and Blackwell Publishing Asia Pty Ltd
  • Bariatric surgery—current status PE O’BrienTable 3 Comparison of attributes of the principal bariatric proceduresAttribute Gastric band RYGB Sleeve gastrectomy BPD +/- DSSafe +++ ++ ++ +Effective ++ ++ ++ +++Durable +++ +++ ? +++Side effects + ++ + ++Reversible easily Yes No No NoMinimally invasive +++ ++ ++ +Controllable/adjustable Yes No No NoLow revision rate + + ? +Requires follow up +++ ++ + ++ There have been multiple observational studies of the various comorbidities of obesity and generally these have reported either total remission or major improvement. Of particular relevance to the gastroenterologist are the studies of gastro-esophageal reflux disease45 and non-alcoholic steatohepatitis.46 What are reasonable expectations of risks? Death is worst thing that can happen to a bariatric surgical patient. Mortality rates associated with gastric bypass of up to 2% were common47–49 but appear to have improved in recent years. The National Institutes of Health (NIH) in the USA has funded a longitudinal assessment of bariatric surgery, known as the LABS study, to provide careful evaluation of the outcomes from bariatric surgery. The perioperative safety data have now been published.27Figure 4 Systematic review of the weight loss achieved in the A total of 4776 patients were enrolled and treated at 10 sites,medium term (3–10 years) by the principal bariatric surgical procedures specifically selected for their bariatric surgical expertise. RYGBof gastric banding, gastric bypass (RYGB) and biliopancreatic diversion and gastric banding were used. There were 15 deaths in the RYGB(BPD) (Modified from Reference 44). patients (0.44%) and no deaths in the gastric banding group, a highly significant difference. These findings are consistent withadverse events at the medium term (3–10 years). Short term data the systematic reviews.26,28(<3 years) are largely irrelevant and long term data (>10 years)would be preferable but are almost totally absent. Systematic Gastric bandingreview of the medium term weight loss outcomes for gastric band-ing26,28,44 have shown no difference between RYGB and gastric This is my preferred option for the primary treatment of severebanding but suggest there is a better weight loss with biliopancre- obesity. When applied properly, it is effective, safe and gentle.atic diversion. Insufficient studies of the latter procedure preclude Adjustability permits maintenance of effect as long as the band isdefinitive conclusion. Figure 4 shows the relative % EWL for the in place. Reversibility permits access to other therapeutic optionsthree principal procedures. that may be developed in the future. There is a need for long term The effects of bariatric surgery on type 2 diabetes have been skilled aftercare and there is a maintenance requirement, withsubject of two systematic reviews.15,28 Buchwald reported 86% of approximately 10% needing some revisional procedure in1835 patients from multiple case studies showed remission or 10 years. Removal and replacement of the band for abnormalimproved control.15 Maggard et al.28 reviewed 21 case series and proximal gastric enlargement is effective and revised patients havereported a range of 64–100% showing remission or improvement. a weight loss equal to the total group.Numerous methodological problems existed in most of the pub-lished reports. RCTs constituted less than 5% of 618 studies, thedefinition of diabetes and its remission were not adequately Roux en Y gastric bypassdescribed and there was extensive but poorly reported loss to Roux en Y gastric bypass (RYGB) has been known to be the mostfollow up. Nevertheless, there was a trend towards better outcomes effective of the stomach stapling procedures since the 1980s.50 Itfor the RYGB patients than the gastric band patients with complete achieves good weight loss, particularly in the short term. Howeverremission reported in 70.1% (95% CI 59–83) at more than 2 years it carries significant risk, it is non-adjustable and essentially notafter RYGB and 58.3% (95% CI 42–74) after gastric banding. reversible. Its effectiveness tends to fade with time. In the firstThere was a direct relationship between weight loss and remission 12 months after RYGB, a weight loss of 60–70% EWL can beacross the studies. expected. This effect is maintained for 12 months and then begins1362 Journal of Gastroenterology and Hepatology 25 (2010) 1358–1365 © 2010 Journal of Gastroenterology and Hepatology Foundation and Blackwell Publishing Asia Pty Ltd
  • PE O’Brien Bariatric surgery—current statusa gentle fade to average 50% EWL for those still attending follow Needs and challengesup at 5 years. It is very effective in resolving type 2 diabetes,possibly through a post-prandial increase of the incretins GLP-1 Bariatric surgery is never a quick fix. It is a process of care thatand GIP. It is now commonly, but not universally, performed begins with a careful initial clinical evaluation and detailed patientlaparoscopically. The significant mortality of 0.44% seen in the education and it continues beyond the operative procedure throughLABS study involved expert bariatric surgeons.27 The community a permanent follow up. All procedures have the potential for perio-mortality rate was reported as 1.9% for the 15 years between 1990 perative complications and death. Revisional surgery is relativelyand 2004 and is probably still at or above 1.0%.49 In the LABS common as maintenance of the correct anatomy is intrinsic tostudy, 109 of the patients had further abdominal surgery. effectiveness. But bariatric surgery can provide a solution to the problem of obesity. It achieves substantial weight loss, improved health and quality of life and a longer life. We need to optimizeBiliopancreatic diversion these benefits and minimize the risks and the costs. The followingIt is the most metabolically severe of the current options and are some of the areas for further research and development:therefore hasn’t proved to be popular with patients or surgeons in 1 A better understanding of the mechanisms of action of eachspite of favorable published outcomes. Biliopancreatic diversion procedure is required to enable optimum surgery and follow(BPD) has been available for 30 years51 and yet remains a very up.minor part of bariatric surgery. Worldwide, it constitutes less than 2 We need careful data management for all patients. Bariatric2% of bariatric surgery.14 However, it does generate good weight surgical procedures should be incorporated into nationalloss and should be considered on occasions as a second line bari- clinical registries to enable objective assessment of the risksatric surgical option. and benefits across the community. 3 There is a need for more randomised controlled trials to define the benefits of weight loss on various comorbidities ofSleeve gastrectomy obesity. More study is needed in particular for the patientsThe sleeve is the first element of the duodenal switch procedure, a with metabolic diseases—type 2 diabetes, metabolic syn-variant of the BPD. It has lately become popular as a single drome, non-alcoholic steatohepatitis, the dyslipdidaemias,procedure because of ease of surgery, relative effectiveness and polycystic ovary syndrome and obstructive sleep apnoea.perceived lack of need for close follow up. A systematic review of 4 We need to know more about who should be offered bariatricthe 36 studies available to mid-2009 showed 55% EWL at surgery, and define the most safe and efficient pathways for3 years.52 There has been only one medium term study which assessment, surgery and aftercare.reports a 40% weight regain by 5 years.53 There is a general expec- 5 We need better cost-effectiveness evaluation of the bariatrictation that the sleeve will fail to maintain acceptable levels of surgical approach to disease management in comparisonweight loss in the medium term as the tube of residual stomach with existing options.inevitably expands. Continuation to completion of the duodenal Bariatric surgery has the potential to be one of the most impor-switch would then need to be considered. Leaks are relatively tant and powerful treatment approaches in medicine. High qualityfrequent (>1%) and tend to persist for months generating morbid- of clinical care, good science and comprehensive data manage-ity, anxiety and costs. ment will allow optimal application of this approach to be realized. Disclosures: CORE receives unrestricted research grants from Allergan and Applied Medical.Who should be considered and whoshould not?There is level 1 evidence supporting a better outcome for using Referencesgastric banding in the mild to moderately obese (BMI 30–35)when compared with lifestyle therapy.41,42 This approach is cost- 1 World Health Organisation. Obesity: preventing and managing the global epidemic. Report of a WHO consultation. World Healtheffective.54,55 When the two treatment paths are modeled over time, Organ. Tech. Rep. Ser. 2000; 894: 1–253.the gastric banding approach is dominant i.e. it provides increased 2 Ogden CL, Yanovski SZ, Carroll MD, Flegal KM. The epidemiologynumber of quality-adjusted life years at a lower cost than the of obesity. Gastroenterology 2007; 132: 2087–102.existing option of non-surgical therapies. Any person who is obese 3 Flegal KM, Carroll MD, Ogden CL, Curtin LR. Prevalence and(BMI > 30), is suffering from the medical, physical or psychoso- trends in obesity among US adults, 1999–2008. JAMA 2010; 303:cial consequences of the obesity and has diligently sought a solu- 235–41.tion through a range of lifestyle options over time, should be 4 Wang Y, Beydoun MA, Liang L, Caballero B, Kumanyika SK. Willconsidered for gastric banding. Because the stapling group of all Americans become overweight or obese? estimating thesurgical options lack level 1 data, are of greater risk, and are not progression and cost of the US obesity epidemic. Obesity 2008; 16:controllable or reversible, maintenance of existing cutoff of 2323–30. 5 Report: The Growing Cost of Obesity—Three Years On. Melbourne:BMI > 40 or BMI > 35 with major comorbidities should remain Access Economics, 2008.for these procedures. 6 Ahima RS. Obesity: much silence makes a mighty noise. Gastric banding is unsuitable for those who are mentally defec- Gastroenterology 2007; 132: 2085–6.tive or otherwise unable to engage in the ‘partnership’ needed for 7 Shaw JE, Sicree RA, Zimmet PZ. Global estimates of the prevalenceoptimal outcome. Other contraindications include portal hyperten- of diabetes for 2010 and 2030. Diabetes Res. Clin. Pract. 2009; 87:sion and remote living which could preclude adequate follow up. 4–14.Journal of Gastroenterology and Hepatology 25 (2010) 1358–1365 1363© 2010 Journal of Gastroenterology and Hepatology Foundation and Blackwell Publishing Asia Pty Ltd
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