Management of morbid obesity - The Journal of Family Practice

ing surgery. Gastric bypass also corrected or alleviated
other comorbidities of morbid obesity, including hypertension,
obstructive sleep apnea, cardiopulmonary failure,
arthritis, and infertility. 7
In the SOS study, incidence of diabetes was reduced
32-fold in surgical patients relative to controls at 2
years. At 8 years, there was still a 5-fold reduction in
diabetes incidence. 4 Incidence of hypertension was
reduced 2.6-fold in surgical patients relative to controls
at 2 years. However, by 8 years the surgical patients’
blood pressure had reverted to control values despite
maintenance of a 16% weight reduction. 4,8,9
Buchwald and colleagues recently conducted a systematic
review of published observational and interventional
trials involving bariatric surgery. 10 A total of 134
studies (5 randomized controlled trials, 28 nonrandomized
controlled trials or series with comparison groups,
and 101 uncontrolled case series) that included 22,094
patients were analyzed to determine the impact of specific
bariatric surgical procedures on weight loss, operative
mortality outcome, and 4 obesity comorbidities
(diabetes, hyperlipidemia, hypertension, and obstructive
sleep apnea). Results are summarized in Table 1.
For purposes of analysis, surgical procedures were
grouped into 5 main categories: (1) gastric banding, (2)
gastric bypass (this category consisted principally of
Roux-en-Y variations but included all procedures with
a gastric bypass component, such as gastroplasty with
gastric bypass and banding with gastric bypass), (3) gastroplasty,
(4) biliopancreatic diversion or duodenal
switch, and (5) mixed or other. A random-effects model
was used. Weight loss was reported as the mean percentage
of excess weight loss; changes in absolute
weight (kg), body mass index (BMI), and percentage of
initial weight were also reported where appropriate.
The baseline mean BMI for 16,944 patients was
46.9 kg/m 2 (range, 32.3-68.8). Mean percentage of
excess weight loss was 61.2% (95% CI, 58.1-64.4) for
all patients. Mean percentage excess weight loss by procedure
was: gastric banding, 47.5%; gastric bypass,
61.6%; gastroplasty, 68.2%; biliopancreatic diversion
or duodenal switch, 70.1%. Operative mortality in the
first 30 days 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%. There
FIGURE 5
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Risk of mortality after bariatric surgery *
(Kaplan Meier analysis)
Percent surviving
100
90
80
70
60
50
Surgery (n=1,035)
Control (n=5,746)
1 2 3 4 5
Years
* Relative risk vs controls, 0.11 (95% CI, 0.04-0.27)
Adapted from Christou et al. 11
P