What is the most effective operation for adults with severe and complex obesity?

Accessing, undergoing, and achieving a successful outcome from surgery for “severe and complex obesity” is difficult and requires determination and effort. Here, we consider “severe and complex obesity” to mean that an individual’s health is compromised by his or her weight to the extent that surgery can be considered to be an appropriate option.1 Surgery may be offered to adults with a body mass index (BMI) of ≥40, or a BMI of ≥35 with an obesity related disease, and it can be very successful. An average 50% of excess weight may be lost in the first few years after surgery, and if this is sustained it is associated with long term reduction in overall mortality and decreased incidences of diabetes, myocardial infarction, stroke and cancer.1 2 This treatment, however, requires careful consideration and serious commitment, with the need to demonstrate full engagement in a structured weight loss programme, to have tried all appropriate non-invasive measures of weight loss, and persevered for referral to a specialist surgical team.1 Once surgery is approved it is necessary to choose which operation to undergo.

Worldwide, three operations predominate: laparoscopic adjustable gastric band surgery (gastric band), laparoscopic Roux-en-Y gastric bypass (gastric bypass), and laparoscopic sleeve gastrectomy. In gastric band surgery an adjustable band is placed around the top of the stomach (fig 1⇓). Gastric bypass, which takes longer to perform than a band and requires more operative skill, involves creation of a small gastric pouch that is attached to a limb of intestine so ingested food bypasses the duodenum and proximal small intestine (fig 2⇓). In sleeve gastrectomy, which is technically less complex than a bypass, the greater curvature of the stomach is resected (fig 3⇓).