Perioperative nutritional

RYGB had <5% loss of initial weight and 26.5% of

patients had <20% loss of initial weight at 10 years (64

[EL 3]). There is no consensus about what constitutes

inadequate weight loss after bariatric surgery, but a range

from <20% to 40% of EBW has been suggested in the literature.

The initial evaluation in patients with inadequate

weight loss should include a thorough nutritional history

and radiologic assessment of the pouch integrity.

Communication between the upper and lower portions of

the stomach may occur in as many as 12% of patients

when the stomach is only stapled across to occlude the

lumen but still remains in anatomic continuity. This rate

can be reduced to 2% with a divided gastric bypass, but

division of the stomach does not completely eliminate the

problem (527 [EL 3], 706 [EL 3]). When this complication

is present, a revisional surgical procedure is reason

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be important if the pouch is intact; making it smaller or

narrowing the anastomotic diameter, however, may not

result in further weight loss (748 [EL 3]). Studies are currently

under way to evaluate techniques of endoscopic

suturing to narrow a dilated gastrojejunal anastomosis

(749 [EL 3]). Patients who have undergone a gastroplasty

can be considered for revision even if the gastroplasty is

intact, inasmuch as further weight loss is common after

conversion of gastroplasty to gastric bypass (517 [EL 3]).

Some physicians recommend conversion to a malabsorptive

distal RYGB for patients with RYGB who do not have

adequate weight loss; however, a significant risk of protein-

calorie malnutrition is associated with this procedure,

and conversion should be considered only for patients

with severe, life-threatening obesity (71 [EL 3]). Others

have suggested converting a RYGB to a BPD/DS, but data

are too few to analyze satisfactorily.

Stricture

or

Small

Obstruction

Endoscopic dilation has become the preferred method

for managing stomal strictures because it is a safe and

commonly effective therapy (750 [EL 3], 751 [EL 2]).

The reoperation rate from failed endoscopic dilation of

stomal stenosis is low (5%). The rate of reoperation for

stomal stenosis is less than 1% (752 [EL 3]).

complication after bariatric surgery. There are several

potential causes of such obstruction, including adhesions,

strictures, internal hernias, mesenteric volvulus, and intussusception

(392 [EL 4], 480 [EL 4], 678 [EL 4], 753 [EL

4], 754 [EL 4], 755 [EL 3]). A rare cause of small bowel

obstruction after gastric bypass is intussusception of the

common channel (distal small bowel) proximally into the

enteroenterostomy (755 [EL 3]). Other potential sites for

intussusception are the biliopancreatic or gastric limbs

into the enteroenterostomy, although such involvement

would be uncommon. After BPD, the surgical rate for

enterolysis of adhesions is reported as 1% (125 [EL 3],

756 [EL 3], 757 [EL 4]). Although operation rates are not

commonly reported, surgical intervention is often required

in the management of strictures at the site of the jejunojejunostomy

and internal hernias into mesenteric defects. It

is hoped that changes in surgical techniques during laparoscopic

procedures (closing of mesenteric defects) will be

associated with lower rates of these complications (678

[EL 4]). Overall, the rate of small bowel obstruction after

open RYGB is no higher than that after any major gastric

operation.
9.15.3.

Ulceration

Anastomotic ulceration after bariatric surgery is commonly

managed medically and rarely needs reoperation.

Surgical modifications to the RYGB, including a smaller

gastric pouch containing little or no acid, have been associated

with lower prevalences of this complication (758

[EL 3]). Disruption of a stapled gastric pouch or a gastro

gastric fistula will significantly increase the risk of marginal

ulceration (525 [EL 3]).

Surgical

In a series of their first 92 BPD-treated patients,

Marceau et al (547 [EL 3]) reported that surgical revision

was necessary in 14 patients to diminish diarrhea, improve

low serum albumin levels, or both. In 11 of these patients,

the common channel was increased from 50 cm to 100 cm

and was successful in achieving the aforementioned

results, without substantial weight gain (547 [EL 3]).

Thus, lengthening of the common channel is generally recommended

by most investigators to ameliorate severe

malabsorption (125 [EL 3], 208 [EL 2], 515 [EL 3], 567

[EL 3]).
There are several indications for surgical revision.

The most common indications are inadequate long-term

weight loss in the presence of weight-mediated medical

problems, metabolic complications of malabsorptive

surgery, or significant side effects, technical complications,

or both of the initial procedure. In these patients,

revisions are often effective without excessive risks (758762

[EL 3-4]). Inadequate weight loss is most frequently

noted after solely gastric restrictive procedures and often

attributed to staple-line dehiscence (758 [EL 3], 763 [EL

3], 764 [EL 3]). Generally, conversion to a RYGB is

advised because it has been shown to lead to acceptable

weight loss (758 [EL 3], 759 [EL 3], 763 [EL 3], 765 [EL

3], 766 [EL 3]). Roller and Provost (767 [EL 3]) reported

their experience involving patients with failed gastric

restrictive procedures who underwent revision to a RYGB

procedure. They found a 16.7% complication rate and a

54.3% loss of EBW in patients who had undergone multiple

revisional procedures, in comparison with a 9.3%

complication rate and a 60.6% loss of EBW in patients

who had undergone only one revisional procedure (767

[EL 3]).
The jejunoileal bypass is no longer recommended for

the treatment of obesity because of the high incidence of

serious complications (615 [EL 3]). Nevertheless, it is

estimated that more than 100,000 patients underwent this

operation in the United States in the past and are at risk for

metabolic complications if the bypass is still intact (762

[EL 3]). Reversal of jejunoileal bypass can be performed

safely. It can lead to improvement of most metabolic complications,

with the exception of the immune complex

arthropathy (758 [EL 3], 761 [EL 3]). VBG reversal is

generally associated with considerable weight gain.

Therefore, conversion to a RYGB is advised (517 [EL 3],

758 [EL 3], 768-770 [EL 3]). Severe protein malnutrition

associated with BPD or BPD/DS is an indication for surgical

revision involving lengthening of the common and

alimentary channels to improve absorption (125 [EL 3],

453 [EL 4], 567 [EL 3]).
Other complications of initial bariatric procedures

necessitating surgical revision include stomal stenosis

unresponsive to nonsurgical therapy, alkaline-mediated

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can be converted to RYGB with acceptable

outcomes in amelioration of these symptoms and weight

control (758 [EL 3], 771 [EL 3]). Nonetheless, perioperative

complications including PE and anastomotic leaks

have been reported (758 [EL 3], 765 [EL 3]). Anastomotic

ulcerations after RYGB have become less common as a

result of a decrease in the size of the gastric pouch containing

little or no acid (758 [EL 3]). In general, there are

higher risks for complications after revision of a bariatric

procedure, in comparison with the primary procedure;

therefore, these revisions must be performed only by experienced

bariatric surgeons.
9.15.5.

Surgical

Restoration of normal gut continuity should be performed

in the presence of complications not amenable or

responsive to surgical revision or conversion with appropriate

medical management. Examples of complications

necessitating surgical reversal include severe malnutrition,

organ failure, or psychiatric emergencies (753 [EL 4]).
9.15.6.

Increased

Malabsorption

Procedure

Laparoscopic reoperation and conversion to a RYGB

can successfully induce weight loss and can be performed

safely in patients with inadequate restrictive bariatric procedures

(72 [EL 3], 772-774 [EL 3]). In patients who have

failed to achieve long-term weight loss after a LAGB procedure,

conversion to BPD/DS has been successful. This

conversion is also safe because the proximal duodenal

anastomosis is away from the gastric band, as opposed to

performance of a RYGB conversion (775 [EL 3]). In a

series of 57 patients who lost an average of 87% weight

after conversion from a restrictive procedure to BPD,

however, 24% required PN, 22% developed hypoalbuminemia,

and 16% had a late bowel obstruction (776 [EL

3]).
A failed RYGB can also be converted to a distal

bypass. Among 1,450 patients undergoing RYGB by

Sapala et al (777 [EL 3]), 805 had primary operations and

645 were converted from restrictive procedures. In 38

patients who failed to lose weight with the RYGB, conversion

to a modified BPD was performed without dismantling

the original gastric exclusion, resulting in a

sustained weight loss (777 [EL 3]).
10. PHYSICIAN RESOURCES

Interested physicians may refer to several key textbooks,

journals, Web sites, and guidelines for information

regarding various aspects in the care of bariatric surgical

patients (Table 21). In general, the textbooks provide basic

concepts, whereas certain journals are replete with pertinent

and specific reports. Many of the journal articles contain

sound experimental design and valid conclusions,

although careful scrutiny is advised before extrapolation
of their results to a specific clinical practice. Web sites are,

for the most part, biased toward the experience of the

clinical group sponsoring the educational material.

Nevertheless, the experiences of these groups, typically

regional surgical teams, are worthwhile and can be adapted

to any clinical practice. Material on many of the Web

sites has been written by the dietitians working with the

bariatric surgeons, and their experience is invaluable.

Physicians, in general, have not had formal nutrition training.

Therefore, nutritional strategies should be reviewed

and studied by interested physicians. There are also several

symposia on bariatric surgery organized each year in

major medical institutions throughout the United States.

Lastly, clinical guidelines are generally evidence-based

and sponsored by a clinical society or governmental

agency, such as the National Institutes of Health. These

guidelines are valuable tools for developing a standard of

care and monitoring innovations over time.

Jeffrey

Mechanick

reports that he does not

have any relevant financial relationships with any commercial

interests.
Dr.

Robert

Kushner

Advisory Board honoraria from GI Dynamics, Merck &

Co., Inc., and Orexigen Therapeutics, Inc. and speaker

honoraria from sanofi-aventis U.S. LLC.

Harvey

Sugerman

speaker honoraria from Ethicon Endo-Surgery, Inc., consultant

fees from EnteroMedics, salary for his role as

Editor from Surgery

for

Obesity

Related

(official journal of the American Society for Metabolic &

Bariatric Surgery), and salary for his role as Review

Committee Chair from Surgical Review Corporation.

Primary Writers

J.

Michael

reports that he

does not have any relevant financial relationships with any

commercial interests.

Maria

Collazo-Clavell

reports that she does

not have any relevant financial relationships with any

commercial interests.
Dr.

Safak

not provided.

Adam

Spitz

relevant financial relationships with any commercial interests.

The Obesity Society Primary Writers
Dr.

Caroline

Apovian

received research grant support from the Dr. Robert C.

Atkins Foundation, Gate Pharmaceuticals (a division of

Teva Pharmaceuticals USA), GlaxoSmithKline, and

sanofi-aventis U.S. LLC and Advisory Board honoraria

from Merck & Co., Inc.

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Educational Resources on Bariatric Surgery

Textbooks

Buchwald H, Cowan GSM Jr, Pories WJ, eds. Surgical

Management

of

Obesity. Philadelphia, PA:

DeMaria EJ, Latifi R, Sugerman HJ. Laparoscopic

Bariatric

Surgery:

and

Austin, TX: Landes Bioscience, 2002.

Farraye F, Forse A, eds. Bariatric

Surgery:

Primer

Your

Practice. Thorofare, NJ: SLACK

Incorporated, 2006.

Inabnet WB, DeMaria EJ, Ikramuddin S, eds. Laparoscopic

Bariatric

Surgery. Philadelphia, PA:

Lippincott Williams & Wilkins, 2004.

Mitchell JE, de Zwann M, eds. Bariatric

Surgery:

A

Guide

Mental

Professionals. New

York, NY: Routledge, Taylor & Francis Group, 2005.

Sugerman HJ, Nguyen N, eds. Management

of

Morbid

Group, 2005.

Web

American Association of Clinical Endocrinologists http://www.aace.com

American Dietetic Association http://www.eatright.org

American Obesity Association http://www.obesity1.tempdomainname.com/

American Society for Metabolic & Bariatric Surgery http://www.asbs.org/

Association for Morbid Obesity Support http://www.obesityhelp.com/

International Federation for the Surgery of Obesity http://www.obesity-online.com/ifso/

Obesity Action Coalition http://www.obesityaction.org

The Obesity Society http://www.obesity.org

Clinical

guidelines

Guidelines for the Clinical Application of Laparoscopic Bariatric Surgery

http://www.guideline.gov/summary/summary.aspx?doc_id=4383&nbr=3301&string=bariatric+AND+surgery

Evidence Report

http://www.ncbi.nlm.nih.gov/books/bookres.fcgi/obesity/obesity.pdf
VA/DoD Clinical Practice Guideline for Management of Overweight and Obesity

http://www.oqp.med.va.gov/cpg/OBE/OBE_CPG/GOL.htm

SAGES/ASBS Guideline for Laparoscopic and Conventional Surgical Treatment of Morbid Obesity

http://www.asbs.org/html/lab_guidelines.html

Rationale for the Surgical Treatment of Morbid Obesity

http://www.asbs.org/Newsite07/patients/resources/asbs_rationale.htm

Guidelines for Granting Privileges in Bariatric Surgery

http://www.asbs.org/html/about/grantingprivileges.html

Suggestions for the Pre-Surgical Psychological Assessment of Bariatric Surgery Candidates

http://www.asbs.org/html/pdf/PsychPreSurgicalAssessment.pdf

A.S.P.E.N. Clinical Guidelines, Standards, and Safe Practices for Parenteral Nutrition

http://www.nutritioncare.org/lcontent.aspx?id=540

Commonwealth of Massachusetts Betsy Lehman Center for Patient Safety and Medical Error Reduction Expert

Panel on Weight Loss Surgery, Executive Report, December 12, 2007, Prepublication Copy

http://www.mass.gov/Eeohhs2/docs/dph/patient_safety/weight_loss_executive_report_dec07/pdf

62

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Dr.

H.

Livingston

have any relevant financial relationships with any commercial

interests.
Dr.

Robert

reports that he does not have any

relevant financial relationships with any commercial interests.

Dr.

B.

Sarwer

honoraria from Ethicon Endo-Surgery, Inc.

Wendy

Anderson

have any relevant financial relationships with any commercial

interests.
American Society for Metabolic & Bariatric Surgery

Primary Writer

John

reports that he has received speaker

honoraria from Allergan, Inc., Bariatric Advantage, Nestle

Australia, and Covidien AG, Medical Advisory Board

honoraria from Nestle Australia, consultant honoraria

from Bariatric Advantage, and consultant honoraria and

research grant support from Allergan, Inc.
American Association of Clinical Endocrinologists

Nutrition Committee Reviewers

Elise

Brett

employee salary from Novo Nordisk A/S.

Osama

reports that he has received speaker

honoraria from Amylin Pharmaceuticals, Inc., Merck &

Co., Inc., Novo Nordisk A/S, and Takeda Pharmaceuticals

America, Inc.
Dr.

M.

Molly

reports that she does not

have any relevant financial relationships with any commercial

interests.

Yi-Hao

reports that he receives employee

salary from Bristol-Myers Squibb Company.
The Obesity Society Reviewers
Dr.

Ken

reports that he does not have any relevant

financial relationships with any commercial interests.

Ms.

Cummings

any relevant financial relationships with any commercial

interests.
Dr.

Stephanie

Sogg

reports that she does not have any

American Society for Metabolic & Bariatric Surgery

Reviewers
Dr.

Philip

Schauer

Scientific Advisory Board honoraria from Ethicon Endo-

Surgery, Inc., Stryker Endoscopy, Davol Inc. (a subsidiary

of C. R. Bard, Inc.), Barosense, Inc, and SurgiQuest, Inc.,

consultant honoraria from Ethicon Endo-Surgery, Inc.,

Davol Inc. (a subsidiary of C. R. Bard, Inc.), and W. L.

Gore & Associates, Inc., and research grant support from

Ethicon Endo-Surgery, Inc., Stryker Endoscopy, Davol

Corporation, W. L. Gore & Associates, Inc., Baxter

International Inc., Covidien AG, and Allergan, Inc., and

serves on the Board of Directors for RemedyMD, Inc.

Scott

Shikora

Scientific Advisory Board honoraria from Covidien AG,

Ethicon Endo-Surgery, Inc., and Synovis Surgical

Innovations (a division of Synovis Life Technologies,

Inc.), consultant honoraria from EnteroMedics, and stock

options for his role as consultant from BariMD, Inc.

Jaime

reports that he has received speaker

honoraria and consultant fees from Ethicon Endo-Surgery,

Inc. and Allergan, Inc., Advisory Board honoraria from

Ethicon Endo-Surgery, Inc., and Review Committee member

fees from Surgical Review Corporation.

Michael

reports that he has received consultant

honoraria from EnteroMedics.
REFERENCES
Note:

All

sources

followed

an

evidence

[EL]

of

1,

3,

or

as

outlined

Table

The

evidence

(EL

and

2)

appear

red

easier

AACE/ACE Obesity Task Force. AACE/ACE positionstatement on the prevention, diagnosis, and treatment ofobesity. Endocr

Pract. 1997;3:162-208. [EL 4]

2.

AACE/ACE Obesity Task Force. AACE/ACE positionstatement on the prevention, diagnosis, and treatment ofobesity (1998 revision). Endocr

[EL 4]
3.

National Institutes of Health-National Heart, Lung,

and Blood Institute and North American Association

for the Study of Obesity. The practical guide: identification,

evaluation, and treatment of overweight and obesityin adults. http://www.nhlbi.nih.gov/guidelines/obesity/

prctgd_b.pdf. Published October 2000. Accessed for verification