 Reference ranges

 End and review

Question 29 of 207

A 34 year old women with morbid obesity is referred for consideration of bariatric surgery. Which of the following options is
associated with the highest long term failure rates?

Gastric band

Intra gastric balloon

Roux en Y bypass

Sleeve gastrectomy

Duodenal switch

Intragastric balloon is really only suitable as a bridge to a more definitive surgical solution.

Bariatric surgery: the main operations

Gastric banding: band applied to upper stomach which can be inflated or deflated with normal saline. This affects satiety. Over a 5
year period complications requiring further surgery occur in up to 15% cases.

Roux-en-Y gastric bypass: a gastric pouch is formed and connected to the jejunum. Patients achieve greater and more longterm
weight loss than gastric banding.

Sleeve gastrectomy: body and fundus resected to leave a small section of stomach

Biliopancreatic diversion +/- duodenal switch: bypass the small bowel. Greatest weight loss but a very complex procedure
associated with malnutrition and diarrhoea.

Vertical banded gastroplasty (stomach stapling): rarely performed due to longterm failure rate.
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Bariatric surgery

Obesity is a major health problem in the Western world. Surgical solutions to the problem have evolved dramatically over the past
few years. Randomised controlled trials have shown that dramatic weight loss can be achieved following surgical interventions
compared with standard medical therapy. The weight loss process is also more durable following surgery than with non surgical
interventions.

Case selection
BMI >/= 40 kg/m2 or between 35-40 kg/m2 and other significant disease (for example, type 2 diabetes, hypertension) that could be
improved with weight loss.
Pre-requisites to surgery (NICE UK Guidelines)

 All non-surgical measures have failed to achieve or maintain adequate clinically beneficial weight loss for at least 6 months.
 Will receive intensive specialist management
 They are generally fit for anaesthesia and surgery
 They commit to the need for long-term follow-up
 First-line option for adults with a BMI > 40 kg/m 2 in whom surgical intervention is considered appropriate; consider orlistat if
there is a long waiting list.

Surgical options

Adjustable  Laparoscopic placement of adjustable band

gastric band around proximal stomach.
 Contains an adjustable filling port
 Effective method for lifestyle control
 Reversible
 Takes longer to achieve target weight
 Complications such as band erosion (rare),
slippage or loss of efficacy may require re-
intervention

Gastric bypass  Combines changes to reservoir size with

malabsorptive procedure for more enduring
weight loss.
 Technically more challenging
 Risks related to anastomoses (2% leak rate)
 Irreversible
 Up to 50% may become B12 deficient

Sleeve  Resection of stomach using stapling devices

gastrectomy  Less popular now as initial promising results not
sustained

References
1. National Institute for Health and Clinical Excellence. Obesity: the prevention, identification, assessment and management of
overweight and obesity in adults and children. www.nice.org.uk/CG189

2. Leff DR, Heath D. Surgery for obesity in adulthood. BMJ 2009;339:b3402

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