Laparoscopic surgical concepts of morbid obesity

According to the WHO, obesity and obesity with associated morbidity constitute a chronic, multi-factorial condition requiring treatment. Conservative treatment has been shown in long-term studies to be ineffective in morbid obesity. Surgical treatments break down into restrictive, malabsorptive, combined restrictive and malabsorptive or motility-reducing procedures.

Laparoscopic implantation of an adjustable gastric band is an efficient restrictive measure for treating the majority of patients with this condition. The adjustable gastric band enables weight loss and food intake to be adapted to the individual patient’s need. Of these patients, 80–90% can expect to lose 55–70% of their excess weight. Vertical banded gastroplasty is losing ground among the restrictive options. Preliminary experiences are encouraging, but the long-term results are disappointing when assessed by the standard criteria. Gastric bypass is gaining ground in Europe and is a standard procedure in the USA. This operation is estimated to give a 70–80% loss in excess weight, and provides a better quality of life than do restrictive procedures. The biliopancreatic diversion with duodenal switch combines a sleeve gastrectomy with a duodeno-ileal switch to achieve maximum weight loss. Consistent excess weight loss of between 70% and 80% is achieved, with acceptable decreased long-term nutritional complications. The laparoscopic approach to this procedure has successfully created a surgical technique with optimum benefit and minimal morbidity, especially in the super-obese patient. Intra-gastric stimulation is the least invasive surgical procedure at present. However, the excess weight loss is lowest with this method, at only 32% in the first 2 years after the operation.

Provided that safety recommendations are observed, laparoscopic operations for obesity have a fairly low risk. The mortality rate in centres with experienced staff is less than 0.3%. The death rate due to untreated morbid obesity is significantly higher than in a comparable group of patients after surgery.