Introduction
The National Health and Nutrition Examination Survey recently reported that 34,9% of US adults are overweight or obese [1,2,3]. Obesity is associated with significant comorbidities such as hypertension, dyslipidemia, coronary artery disease, diabetes, osteoarthritis, and obstructive sleep apnea. Mortality rates in the morbidly obese men are 12 times higher at age 25-34 years and 6 times higher at age 35-44 years compared with those of non obese in the same age ranges [4]. Obesity is associated with increased prevalence of socioeconomic hardship due to higher rate of disability, widespread discrimination and early retirement. Conservative treatments such as diet and exercise, medical therapy and behavioral modification program have been notorious to fail.
The treatment of obesity and its primary comorbidities costs the US health care system close to $ 100 billion every year. In addition, consumers spend in excess of $ 33 billion annually on weight reduction products and services [5]
Minimally Invasive Approach in Bariatric Surgery
In 1993, Wittgrove and Clark performed the first roux-en-y gastric bypass using laparoscopic technique (LRYGB) [6]. Several literatures have reported the advantages of laparoscopic approach such as reduced intraoperative blood loss, less post-operative pain, lower pulmonary complication, shorter hospital stay and earlier return to normal activities compared to those with open technique [7] while producing similar weight loss result.
Surgical Treatment for Morbidly Obese Patients
Current surgical techniques for treatment of morbid obesity can be classified into 3 categories: malabsorptive, restrictive or combination between the two.
Pure restrictive procedure such as gastric banding serves only to restrict food intake without interfering normal digestive process. Vertical banded gastroplasty (VBG) and laparoscopic adjustable gastric banding (LAGB) fall in this category. In VBG, the stomach is partitioned near the gastroesophageal junction, creating a small gastric pouch and outlet, which is still in continuity with the remainder of the stomach. Early weight loss results after VBG was approximately 60% of excess body weight. Even tough it is associated with low morbidity (<1%), significant number of patients regain substantial weight in 3-5 years postoperatively. LAGB procedure is accomplished by placement of inflatable silicone prosthetic device around the gastric cardia to limit oral intake. The mortality rate is extremely low, only 1 in 2000 patients, whereas morbidity rate has been reported to be approximately 19%. The average gastric banding patient loses 1 to 2 pounds per week. This result is inferior in term of number and timing compared to that in RYGB, but its still a very good option with good patient selection.
Sleeve Gastrectomy (SG) is a relatively new treatment for morbid obesity. This procedure was originally published by Marceau et all in 1993. Recently it has been proposed as a single-step procedure because of adequate weight loss achieved after this procedure alone. Excess body weight after this surgery are 40.7 and 52.8 at 3 and 6 months respectively [8]. Long term complication has not been available because of the young age of this procedure, but SG has been proven to be safe based on short term data.
RYGB is the most commonly performed bariatric surgery in America. Estimation showed that over 160.000 gastric bypass procedures were performed in the US in 2005. It combines both restrictive and malabsorptive procedures. A 30-50 cc gastric pouch is created which then connected to the alimentary limb. This small pouch satisfies the restrictive component of the operation. Creation of roux limb with variable length is the malabsorptive counterpart of this procedure. Most large series reported 65 to 85% reduction in excess body weight after this procedure which maintained after 10 year follow up. Nationwide mortality rate is approximately 5 per 1000 patients. Specific complications after RYGB include anastomotic leak, stenosis, internal hernia and dumping syndrome. Other nonspesific complications include post operative hemorrhage, infection and bowel obstruction.
Summary
Although medical therapy is the first-line treatment for morbid obesity, it has limited short-term and almost nonexistent long-term success. Currently, bariatric surgery is the best long term definitive treatment for morbidly obese patients. The introduction of minimally invasive technique has brought significant advantages to the patients. LRYGB is currently the gold standard procedure because of its excellent long term results and safety. Single step sleeve gastrectomy is a promising procedure which has started to gain popularity due to its satisfactory result and minimal complication especially in high risk surgical candidates.
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