Clinical outcome of gastric banding and gastric bypass in morbidly obese patients

Abstract

Obesity has become a global problem and an obesity epidemic has risen. Bariatric surgery has become the first treatment of choice in patients who have a BMI greater than 35 kg/m2 with significant comorbid conditions and patients who have a BMI greater than 40 kg/m2 with or without any significant comorbid conditions.

Laparoscopic adjustable gastric banding (LAGB) and (laparoscopic) gastric bypass (GB) are the two procedures mostly performed worldwide. In Chapter 2 LAGB has shown to be a safe procedure, with good mid term weight loss results in the majority (77%) of the patients, but with a high reoperation rate. In Chapter 3 it is shown that after 8 years of follow-up, 39% of the patients were lost to follow-up after LAGB and the majority of these patients (60%) were therapy failures. Long term follow-up of the total LAGB group resulted in a fair outcome in 32% of patients. The most frequent complication and reason for reoperation after LAGB is slippage of the gastric band. Uncertainty exists of the best treatment of a slipped band. In Chapter 4 it is shown that rebanding for slippage is not a prognostic factor for inadequate weight loss. In patients successfully treated by LAGB, rebanding for band slippage should be considered, as good long term success was found in 62% of these patients.

The main benefits of the GB are the high percentage (71%) of successfully treated patients, and the higher percentage of weight loss in the short term (Chapter 5). However, the GB is associated with surgery related mortality and morbidity. Comparing the two most performed procedures shows that significantly more patients had good treatment results (excess weight loss > 50 %) after a GB than after LAGB (76% versus 40% after 2 years of follow-up, P = 0,03) (Chapter 6). In terms of complications, the most obvious difference existed in severe early complications after GB compared to LAGB (11% vs 0%). In conclusion, the GB compared to LAGB results in increased weight loss, in a higher number of patients, but is associated with a higher incidence of severe early complications. A secondary GB procedure after failed LAGB (40-50%) is a technically more demanding procedure than primary GB. Our study presented in Chapter 7 shows that it can be performed equally safe and effective as a primary GB.

In Chapter 8 we show that reconstructive surgery after successful bariatric surgery improves significantly patients’ physical functioning, mental well being, physical appearance, social acceptance, self-efficacy towards eating and intimacy. The contribution of reconstructive surgery plays a substantial role in the multidisciplinary treatment of the morbidly obese patient.

Bariatric surgery has proven to be safe and the most effective answer to the obesity epidemic. In the near future a new definition of successful bariatric treatment should be formulated including weight loss, comorbidities and quality of life. This new consensus should be the purpose of future studies and lead to the selection of the appropriate bariatric procedure for the individual obese patient.