2007年5月20日

Obesity - Surgery

Surgery Morbid obesity, commonly defined as a BMI >40 , is estimated to increase mortality by as much as twelvefold in men between 25 and 34 years of age and sixfold between 35 and 45 years of age.

Deaths from cardiovascular disease, diabetes, and accidents have been documented. In response to typically ineffective treatment using diet, exercise, and available drugs, surgical approaches are increasingly being employed. The potential benefits of surgery include major weight loss and improvement in hypertension, diabetes, sleep apnea, CHF, angina, hyperlipidemia, and venous disease. Several different approaches have been used, sometimes without adequate long-term assessment of efficacy and complications.


Jejunoileal bypass surgery has been abandoned because of complications, which included electrolyte disturbances, nephrolithiasis, gallstones, gastric ulcers, arthritis, and hepatic dysfunction, with cirrhosis occurring in as many as 7% of patients.




Two procedures in common use today are the vertical-banded gastroplasty and the Roux-en-Y gastric bypass. The former is a purely restrictive procedure, while the latter combines restriction with slight malabsorption and may also reduce appetite via suppression of the gastric hormone ghrelin, which stimulates appetite. Gastric bypass is most often performed by laparotomy but may be performed laparascopically in some patients.
vertical-banded gastroplasty




Roux-en-Y gastric bypass




A third procedure, laparascopic adjustable gastric banding, is widely used in Europe and Australia and is being introduced in the United States. This procedure may be viewed as “less drastic” than gastric bypass but appears capable of producing substantial weight loss, albeit with shorter periods of follow-up.
laparascopic adjustable gastric banding



Following the National Institutes of Health Consensus Conference on Gastrointestinal Surgery for Severe Obesity in 1991, it was recommended that suitable patients be selected using the following criteria:

(1) a BMI > 35 with an associated comorbidity or a BMI > 40;
(2) repeated failures of other therapeutic approaches;
(3) at eligible weight for 3 to 5 years;
(4) capability of tolerating surgery;
(5) absence of alcoholism, other addictions, or major psychopathology; and
(6) prior clearance by a psychiatrist. It is recommended that an appropriately experienced surgeon work together with nutritionists and other support personnel; evaluation and follow-up programs should be monitored closely.

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