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Bariatric Surgery: A Systematic Review and Meta-Analysis
Abstract & Commentary
By Namir Katkhouda, MD, FACS, Professor of Surgery, Chief, Minimally Invasive Surgery, University of Southern California (USC)-Los Angeles, CA. Dr. Katkhouda is a consultant for Baxter, Ethicon, Storz, and Gore.
Synopsis: Effective weight loss was achieved in morbidly obese patients after undergoing bariatric surgery. A substantial majority of patients with diabetes, hyperlipidemia, hypertension, and obstructive sleep apnea experienced complete resolution or improvement.
Source: Buchwald H, et al. Bariatric surgery: A systematic review and meta-analysis. JAMA. 2004;292:1724-1737.
Introduction: about 5% of the us population is morbidly obese. This disease remains largely refractory to diet and drug therapy, but generally responds well to bariatric surgery.
Objectives: To determine the impact of bariatric surgery on weight loss, operative mortality outcome, and 4 obesity comorbidities (diabetes, hyperlipidemia, hypertension, and obstructive sleep apnea).
Data sources and selection of papers: Electronic literature search of MEDLINE, Current Contents, and the Cochrane Library databases plus manual reference checks of all articles on bariatric surgery published in the English language between 1990 and 2003. Two levels of screening were used on 2738 citations.
Data extraction: A total of 136 fully extracted studies, which included 91 overlapping patient populations (kin studies), were included for a total of 22,094 patients. Nineteen percent of the patients were men and 72.6% were women, with a mean age of 39 years (range, 16-64 years). Sex was not reported for 1537 patients (8%). The baseline mean body mass index for 16,944 patients was 46.9 (range, 32.3-68.8).
Data synthesis: A random effects model was used in the meta-analysis. The mean (95% confidence interval) percentage of excess weight loss was 61.2% (58.1%-64.4%) for all patients; 47.5% (40.7%-54.2%) for patients who underwent gastric banding; 61.6% (56.7%-66.5%), gastric bypass; 68.2% (61.5%-74.8%), gastroplasty; and 70.1% (66.3%-73.9%), biliopancreatic diversion or duodenal switch. Operative mortality (≤ 30 days) in the extracted studies was 0.1% for the purely restrictive procedures, 0.5% for gastric bypass, and 1.1% for biliopancreatic diversion or duodenal switch. Diabetes was completely resolved in 76.8% of patients, and resolved or improved in 86.0%. Hyperlipidemia improved in 70% or more of patients. Hypertension was resolved in 61.7% of patients and resolved or improved in 78.5%. Obstructive sleep apnea was resolved in 85.7% of patients and was resolved or improved in 83.6% of patients.
Conclusions: Effective weight loss was achieved in morbidly obese patients after undergoing bariatric surgery. A substantial majority of patients with diabetes, hyperlipidemia, hypertension, and obstructive sleep apnea experienced complete resolution or improvement.
This is a very important paper that illustrates the effectiveness of bariatric surgery. It shows that more than 45% of excess weight loss can be achieved with all 4 operations. The lap band has clearly had the lowest weight loss, but it also confirms that it is the most benign, with a mortality of 0.1%. The biliopancreatic bypass has the highest mortality (1.1%) but the most effective weight loss. The gastric bypass is in between.
It is possible that the complication rate of the lapband has been underestimated. Buchwald and colleagues found a much higher complication rate, finding that, at 10 years, the complication rate of the lap band is increased. As a matter of fact, as much as we are witnessing an enthusiasm for the lap band in the United States, the bypass and the sleeve are becoming more popular in Europe. We are left with the Australian data that surpasses everybody else. Are we dealing with a different population? Is the follow-up more intensive? The reasons for the superior data is unclear at this point
The study of Sugarman and colleagues also shows that the metabolic consequences of obesity are reversed in more than 75%. This is maybe the most important message of this study, as the operation really gives the patients their life back. When this data is compared to other methods such as the gastric pacing or the intragastric balloon, (less than 20% excess body weight loss) or even medication (Orlistat, Meridia, Xenical), one can conclude safely that surgery is the most effective technique to deal a long-term blow to the epidemic.