Bariatric treatments for adult obesity - Institute of Health Economics

Rimonabant may be considered for patients with dyslipidemia associated with metabolic syndrome(low HDL cholesterol and high triglyceride concentrations) and in patients who are concurrentlyattempting to stop smoking. The drug should be avoided for patients with pre-existing majordepressive illness or with liver or kidney function impairment. 4For patients who fail to respond to the antiobesity medications—that is, who fail to lose 2 kilogramsafter four weeks or 4 to 5 kilograms after 3 months—drug therapy should be discontinued becauselong-term success is unlikely. 30 In contrast, if the drug is effective it should be continued becausewithdrawal of an effective antiobesity drug can lead to rapid weight regain and worsening of cardiometabolicrisk factors. 30SurgeryDefinitionBariatric surgery promotes weight loss primarily through gastric restriction and intestinal diversion. 31Some procedures contain both restriction and diversion elements. In addition to structural alterationof the gastrointestinal tract, bariatric surgery may also influence the levels of the gut hormones thatare involved in energy regulation. 32Brief historySince the introduction of bariatric surgery in the 1950s, various surgical procedures have beendeveloped and have undergone continuing modification and refinement. 33 Minimally invasivelaparoscopic surgery became the technique of choice in the 1990s. 33TypesBariatric surgeries can be divided into three categories:(1) restrictive—producing weight loss by limiting the amount of food ingested(2) mal-absorptive—producing weight loss by limiting the amount of nutrient absorbed(3) mixed—producing weight loss through both mechanisms 34,35Several commonly performed surgical procedures are listed in Table T.4. Bariatric surgeries can beperformed by either open or laparoscopic approaches; currently, most bariatric procedures are beingperformed laparoscopically. 36 Gastric bypass and laparoscopic adjustable gastric banding (LAGB) arethe most commonly performed procedures internationally. Sleeve gastrectomy is a new treatmentthat is gaining popularity, 37 whereas vertical banded gastroplasty, jejunoileal bypass, and minigastricloop bypass have been abandoned. 38,39Table T.4: Bariatric surgeryProcedureadjustable gastric bandingvertical banded gastroplastysleeve gastrectomyRoux-en-Y gastric bypassbiliopancreatic diversion with duodenal switchbiliopancreatic diversionSource: Fried et al, 2007 33,34,40Mechanism of actionrestrictiverestrictiverestrictiverestrictive and mal-absorptive (mixed)restrictive and mal-absorptive (mixed)mal-absorptiveBariatric treatments for adult obesity 70