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Guidelines on Overweight and Obesity: Electronic Textbook
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Surgery for Weight Loss

Surgery is one option for weight reduction for some patients with severe and resistant obesity. The aim of surgery is to modify the gastrointestinal tract to reduce net food intake. Most authorities agree that weight loss surgery should be reserved for patients with severe obesity, in whom efforts at other therapy have failed, and who are suffering from the complications of obesity.

Considerable progress has been made in developing safer and more effective surgical procedures for promoting weight loss. Surgical interventions commonly used include gastroplasty, gastric partitioning, and gastric bypass. These procedures are designed primarily to reduce food consumption. They have replaced previous procedures that were designed to promote malabsorption of nutrients. The latter procedures were fraught with side effects that made their use impractical or dangerous.

Evidence Statement: Gastrointestinal surgery (gastric restriction [vertical gastric banding] or gastric bypass [Roux-en Y]) can result in substantial weight loss, and therefore is an available weight loss option for well-informed and motivated patients with a BMI greater than or equal to 40 or greater than or equal to 35, who have comorbid conditions and acceptable operative risks. Evidence Category B.

Rationale: According to the National Institutes of Health's Consensus Development Conference on Gastrointestinal Surgery for Severe Obesity (523), the risk for morbidity and mortality accompanying obesity increases with the degree of overweight. Thus, treatment of clinically severe obesity involves an effort to create a caloric deficit sufficient to result in weight loss and reduction of weight-associated risk factors or comorbidities. Surgical approaches can result in substantial weight loss, i.e., from 50 kg (110 lb) to as much as 100 kg (220 lb) over a period of 6 months to 1 year.  A major limitation of nonsurgical approaches is the failure to maintain reduced body weight in many individuals. 

Surgical procedures in current use (gastric restriction [vertical gastric banding] and gastric bypass [Roux-en Y]) can induce substantial weight loss, and serve to reduce weight-associated risk factors and comorbidities. Compared to other interventions available, surgery has produced the longest period of sustained weight loss. Assessing both perioperative risk and long-term complications is important and requires assessing the risk/benefit ratio in each case. Patients whose BMI equals or exceeds 40 kg/m2 are potential candidates for surgery if they strongly desire substantial weight loss, because obesity severely impairs the quality of their lives. Less severe obese patients (BMIs between 35 and 39.9 kg/m2) also may be considered for surgery. This group primarily includes those patients with high-risk comorbid conditions (cardiovascular, sleep apnea, uncontrolled type 2 diabetes) or weight-induced physical problems interfering with performance of daily life activities.

A recent retrospective study of severely overweight patients with noninsulin-dependent diabetes, who were referred for consideration of a gastric bypass procedure, allowed for a comparison of those who opted for the surgical procedure versus those who did not undergo the procedure because of personal preference or refusal of insurance payment. Patients undergoing the surgical procedure had a decrease in mortality rate for each year of follow-up (594).  This latter observation provides initial documentation of the significant impact that reduction in weight may have on mortality.

Most of the surgery studies primarily included women of childbearing age. Caution should be exercised in selecting candidates for surgery to treat obesity, as pregnancy demands increase nutritional needs and a normal need for weight gain. Women with reproductive potential should be advised to avoid pregnancy until their weight has stabilized postoperatively and potential micronutrient deficiencies have been identified and treated.

Of special note is that many of the studies reported to date have not had population samples representative of the general severely overweight population with respect to race, ethnicity, cultural or socioeconomic background, or gender.

Evidence Statement: Patients opting for surgical intervention should be followed by a multidisciplnary team (medical, behavioral, and nutritional). Evidence Category D.

Rationale: As for all other interventions for obesity, an integrated program should be in place that will provide guidance concerning the necessary dietary regimen, appropriate physical activity, and behavioral and social support both prior to and after the surgical procedure.

Evidence Statement: Lifelong medical surveillance after surgical therapy is a necessity. Evidence Category C.

Rationale:Since surgical procedures result in some loss of absorptive function, the long-term consequences of potential nutrient deficiencies must be recognized and adequate monitoring must be performed, particularly with regard to vitamin B12, folate, and iron. Some patients may develop other gastrointestinal symptoms such as "dumping syndrome" or gallstones. Occasionally, patients may have postoperative mood changes or their presurgical depression symptoms may not be improved by the achieved weight loss. Thus, surveillance should include monitoring of indices of inadequate nutrition and modification of any preoperative disorders. The table below illustrates some of the complications that can occur following gastric bypass surgery.

Table IV-7: Gastric Bypass Surgery Complications: 14-Year Follow-Up

Complicatons Number Percent
Vitamin B12 deficiency 239 39.9
Readmit for various reasons 229 38.2
Incisional hernia 143 23.9
Depression 142 23.7
Staple line failure 90 15.0
Gastritis 79 13.2
Cholecystitis 68 11.4
Anastomotic problems 59 9.8
Dehydration malnutrition 35 5.8
Dilated pouch 19 3.2
Data derived from source (Pories WJ (595)) and modified based on personal communications.
Recommendation: Weight loss surgery is an option for carefully selected patients with clinically severe obesity (BMI greater than or equal to40 or greater than or equal to35 with comorbid conditions) when less invasive methods of weight loss have failed and the patent is at high risk for obesity-associated morbidity or mortality.  Evidence Category B.
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