Bariatric surgery

Bariatric surgery is a surgical intervention that causes changes in the alimentary tract that lead to weight loss in a short period of time. It is the most effective obesity treatment option.

There are a variety of different techniques, each one with its own particularity, indication and side effects. The decision to offer surgery should be provided by an experienced bariatric surgeon, and a multidisciplinary assessment in a specialized center is recommended. Unlike non-surgical treatment, the surgical options should not be offered in a step-up basis. The best procedure for a particular patient should be provided in the first place, for the best long-term results and safety.

Nowadays minimally invasive techniques (laparoscopy and robotics) are the standard procedure.

Surgical interventions were classically classified according to their influence in the alimentary tract as restrictive, hypoabsorptive/malabsorptive or combined. Today it is recognized that none of the effects are totally isolated.  Moreover, all have in common a metabolic effect with different intensities, which is characterized by the ability of changing the hormonal environment and induce changes in control of metabolic diseases (such as type 2 diabetes), fertility, sensation of hunger, satiety, and energy expenditure capacity.

Surgical techniques

Several procedures are described in the literature, nevertheless the most performed and accepted by the societies dedicated to obesity management are mentioned below(2):

Superobesity

The following techniques have a more pronounced hypoabsorptive effect and are indicated for morbid and superobese patients. They are composed by two parts that can be performed in one or two surgical steps. The first part is a sleeve gastrectomy.

Another particularity of these techniques is the preservation of the pylorus. This anatomical structure function as a valve in the way out of the stomach and controls gastric emptying as well as prevent reflux of the content below the stomach.

Superior results in metabolic diseases as type 2 diabetes are well-described, which highlights the metabolic effect of both procedures.

Despite the great results in weight loss and comorbidities resolution, concerns regarding nutritional deficits and technical complexity lead to a decrease in the performance of this techniques (less than 2% worldwide), reconsidered lately with the introduction of the two-step approach.

References

1.        Eisenberg D, Shikora SA, Aarts E, Aminian A, Angrisani L, Cohen R v., et al. 2022 American Society for Metabolic and Bariatric Surgery (ASMBS) and International Federation for the Surgery of Obesity and Metabolic Disorders (IFSO): Indications for Metabolic and Bariatric Surgery. Surgery for Obesity and Related Diseases. 2022 Oct;

2.        di Lorenzo N, Antoniou SA, Batterham RL, Busetto L, Godoroja D, Iossa A, et al. Clinical practice guidelines of the European Association for Endoscopic Surgery (EAES) on bariatric surgery: update 2020 endorsed by IFSO-EC, EASO and ESPCOP. Surg Endosc. 2020 Jun 23;34(6):2332–58.

3.        Goyal D, Watson RR. Endoscopic Bariatric Therapies. Curr Gastroenterol Rep. 2016 Jun 20;18(6):26.

4.        Gloy VL, Briel M, Bhatt DL, Kashyap SR, Schauer PR, Mingrone G, et al. Bariatric surgery versus non-surgical treatment for obesity: a systematic review and meta-analysis of randomised controlled trials. BMJ. 2013 Oct 22;347(oct22 1):f5934–f5934.

5.        Genco A, Soricelli E, Casella G, Maselli R, Castagneto-Gissey L, di Lorenzo N, et al. Gastroesophageal reflux disease and Barrett’s esophagus after laparoscopic sleeve gastrectomy: a possible, underestimated long-term complication. Surgery for Obesity and Related Diseases. 2017 Apr;13(4):568–74.

6.        Angrisani L, Santonicola A, Iovino P, Vitiello A, Higa K, Himpens J, et al. IFSO Worldwide Survey 2016: Primary, Endoluminal, and Revisional Procedures. Obes Surg. 2018;28(12):3783–94.

7.        Skogar ML, Sundbom M. Duodenal Switch Is Superior to Gastric Bypass in Patients with Super Obesity when Evaluated with the Bariatric Analysis and Reporting Outcome System (BAROS). Obes Surg. 2017;27(9):2308–16.

8.        Prachand VN, DaVee RT, Alverdy JC. Duodenal switch provides superior weight loss in the super-obese (BMI ≥50kg/m2) compared with gastric bypass. Ann Surg. 2006;244(4):611–7.

9.        de Luca M, Tie T, Ooi G, Higa K, Himpens J, Carbajo MA, et al. Mini Gastric Bypass-One Anastomosis Gastric Bypass (MGB-OAGB)-IFSO Position Statement. Obes Surg. 2018 May 29;28(5):1188–206.

10.      Marceau P, Biron S, Marceau S, Hould FS, Lebel S, Lescelleur O, et al. Long-Term Metabolic Outcomes 5 to 20 Years After Biliopancreatic Diversion. Obes Surg. 2015;

11.      Gebellí JP, Lazzara C, de Gordejuela AGR, Nora M, Pereira AM, Sánchez-Pernaute A, et al. Duodenal Switch vs. Single-Anastomosis Duodenal Switch (SADI-S) for the Treatment of Grade IV Obesity: 5-Year Outcomes of a Multicenter Prospective Cohort Comparative Study. Obes Surg. 2022 Oct 25;

12.      Pereira AM, Guimarães M, Pereira SS, Ferreira de Almeida R, Monteiro MP, Nora M. Single and dual anastomosis duodenal switch for obesity treatment: a single-center experience. Surgery for Obesity and Related Diseases. 2021;17(1).

13.      Finno P, Osorio J, García-Ruiz-de-Gordejuela A, Casajoana A, Sorribas M, Admella V, et al. Single Versus Double-Anastomosis Duodenal Switch: Single-Site Comparative Cohort Study in 440 Consecutive Patients. Obes Surg. 2020;(April).