Recent Modalities in Surgical Management of Morbid Obesity

Abstract

Obesity has become major health and socioeconomic problem in both developed and developing countries, because of its high prevalence and causal relationship with serious medical and psychological complications, such as diabetes, hypertension, hyperlipidemia, respiratory problems, arthritis, hernia, cancer and other medical problems related to obesity. The most common definition of morbid obesity is a body mass index (BMI) of 40 Kg /m2 or more. The etiology of this condition is multi factoral including; genetic, environmental, behavioral, neuro-endocrinal and psychological factors, the exact etiology is unknown. Diet, physical exercise or medical therapy has not proved to be efficient in treating morbid obesity in the long term. Surgical therapy is the only effective and proven therapy for patients with morbid obesity. Bariatric operations prolong survival and resolve co morbid medical conditions associated with it. With the increasing use of surgery to treat massively overweight patients, the National Institutes of Health (NIH) proposed that bariatric surgery should be considered for persons with a body-mass index of 40 or more and BMI of 35 in patients with coexisting illnesses. Surgical treatment was developed over the last 50 years. It classified into three types according to the principle of effect: Mal-absorptive operations: These procedures induce decreased absorption of nutrients by shortening the functional length of the small intestine e.g. Biliopancreatic diversion (BPD), which has two variants, Scopinaro method and duodenal switch method. Restrictive operations: These procedures reduce the storage capacity of the stomach and as a result early satiety arises, leading to a decreased caloric intake. (e.g., vertical banded gastroplasty (VBG), laparoscopic adjustable gastric banding (LAGB), and sleeve gastrectomy). Combined mal-absorptive and restrictive operations: e.g., gastric bypass procedures. ( RYGBP) Each of these operations has a different amount of typically anticipated weight loss usually expressed as a percentage of the weight above a BMI of 25 lost after surgery or the percentage of excess body weight loss (%EBWL), the impact on obesity-related co-morbidities and side effects that can affect quality of life. Each procedure requires a motivated individual willing to undergo lifelong follow-up and adherence to lifelong vitamin supplementation regimens. The availability of a laparoscopic approach for bariatric operations cause major changes in the field, including a major increase in the number of procedures performed as well as an increased public and professional awareness and understanding of the field. One inconvenience is that laparoscopic procedures have a more complex learning curve which may be associated with an increase in postoperative complications. Experience of the surgeon and surgical team and providing preoperative and postoperative support is critical to the success of bariatric surgery. It is obvious from the number of procedures practiced that the ideal operation for morbid obesity has not been developed. We need to remember that there is always the right patient for the right surgery.