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Surgery_Schwartz. in the second postoperative year (9.6%) in those undergoing RYGB compared to before surgery (7.6%). Risk factors for alcohol use disorders included male gender, younger age, and preoperative smoking or alcohol use.271 At 7-year follow-up in LABS, there was a progressive and sig-nificant increase over time in the prevalence of regular alcohol consumption for both RYGB and LAGB. In addition, alcohol use disorders, illicit drug use, and treatment for substance use disorders, increased over the 7-year period for RYGB only.272 Overall, these rates were high, with 20% of RYGB participants reporting incident alcohol use disorder symptoms within 5 years of surgery.In addition, there may be an increased risk for suicide273-275 following bariatric surgery, although the etiology is unclear and the data is varied and complex to interpret.276 The Utah mortality study showed a 58% increase in all non–disease-related causes of death in the RYGB group compared to the matched control population,


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Surgery_Schwartz. the data is varied and complex to interpret.276 The Utah mortality study showed a 58% increase in all non–disease-related causes of death in the RYGB group compared to the matched control population, including a small but significant increase in suicides, accidents, and intentional poisonings.202 Similar findings were observed in the second Utah Obesity Study.203 An observational study using Pennsylvania state data found that suicide rates were 13.7 per 10,000 among men and 5.2 per 10,000 among women among postbariatric surgery patients in Pennsylvania over 10 years, which were both significantly higher than age and sex-matched rates in the United States. In addition, the majority (70%) of these deaths occurred in the first 3 years following surgery when clinical follow-up is incomplete.277Finally, there is evidence that vitamin and micronutrient deficiencies are common following bariatric surgery including calcium, vitamin D, iron, zinc, and copper, and others. Guide-lines suggest


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Surgery_Schwartz. there is evidence that vitamin and micronutrient deficiencies are common following bariatric surgery including calcium, vitamin D, iron, zinc, and copper, and others. Guide-lines suggest that all patients should be screened for deficiencies preoperatively as some deficiencies predate the surgical pro-cedure (see “Follow-Up Postoperative Care”). After surgery, patients must be provided daily nutritional supplementation and undergo routine long-term monitoring for deficiencies (see Table 27-4). Data continue to suggest that the prevalence of micronutrient deficiencies is increasing, while monitoring is decreasing. Aside from these recommendations, there is insuf-ficient evidence currently regarding optimal dietary and nutri-tional management following bariatric procedures, including how to treat some of the specific complications of bariatric operations such as chronic nausea and vomiting, hypoglyce-mic episodes, failed weight loss, and anastomotic ulcers and


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Surgery_Schwartz. including how to treat some of the specific complications of bariatric operations such as chronic nausea and vomiting, hypoglyce-mic episodes, failed weight loss, and anastomotic ulcers and strictures.1,278-280REOPERATIVE (REVISION AND CONVERSION) BARIATRIC SURGERYIntroductionSurgical treatments for chronic diseases such as obesity often require additional or revisional surgical procedures when the primary procedure did not sufficiently treat the underly-ing disease. This is true in joint replacements when treating osteo-arthritis, coronary-artery bypass graft surgeries when treating coronary artery disease, and bariatric surgery in the treatment of obesity.281 Additionally, we suspect that obesity is a heteroge-neous disorder282 and is therefore being treated with a variety of procedures with different mechanisms of action.63 Given this, it is not surprising that some patients are “treatment failures” with respect to improvements in weight, comorbidities, and quality of life. Also,


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Surgery_Schwartz. with different mechanisms of action.63 Given this, it is not surprising that some patients are “treatment failures” with respect to improvements in weight, comorbidities, and quality of life. Also, older bariatric surgical procedures such as the jejunal-ileal bypass, the VBG, and early gastric bypass procedures (which utilized a horizontal and/or partitioned stomach) require revision because of a higher complication rate.283,284 Initial bariatric sur-gery cases have averaged greater than 150,000 cases per year for the last 15 years.285 For these reasons, reoperative bariatric sur-gery has become increasingly prevalent over the last decade. Despite its increasing prevalence, there are challenges in assess-ing the frequency and effectiveness of these procedures. Reopera-tive bariatric surgery has been difficult to categorize meaningfully and to quantify due to the multiple procedure codes, many with little specificity. Reports in the literature range from 5% to 50% depending on the


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Surgery_Schwartz. has been difficult to categorize meaningfully and to quantify due to the multiple procedure codes, many with little specificity. Reports in the literature range from 5% to 50% depending on the primary procedure.283Multiple retrospective, as well as case-matched and case-controlled studies of revisional bariatric surgery, demonstrate they are effective with benefits to weight loss and overall health,281,283 although this is not without some controversy. The literature supports reoperative bariatric surgery in two situa-tions: treatments of insufficient weight loss or weight regain and the treatment of acute and chronic complications.281,285 There are many revisional procedures and approaches that are effective. There is no data-driven evidence to guide in the selection of which patient will benefit most from revisional bariatric surgery. Additionally, there is no evidence-based consensus as to which revisional surgical approach is most optimal in any given situa-tion.283 Currently,


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Surgery_Schwartz. benefit most from revisional bariatric surgery. Additionally, there is no evidence-based consensus as to which revisional surgical approach is most optimal in any given situa-tion.283 Currently, there is also little evidence as to which bariat-ric surgical procedure will be efficacious for any specific given patient.286,287Principles and Preoperative EvaluationAs with any other decisions for surgery, revisional or addi-tional bariatric surgery requires evaluating the risks and the benefits of the procedure for specific patient situations. It has been observed that the weight loss following revisional pro-cedures is less than with a primary procedure.288 Reoperations in general are associated with morbidity and mortality that is higher than with primary bariatric procedures281,288,289 but are acceptably low if careful selection of patients is coupled with 9Brunicardi_Ch27_p1167-p1218.indd 120523/02/19 2:21 PM 1206SPECIFIC CONSIDERATIONSPART IIadequate surgeon experience.281,290


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Surgery_Schwartz. are acceptably low if careful selection of patients is coupled with 9Brunicardi_Ch27_p1167-p1218.indd 120523/02/19 2:21 PM 1206SPECIFIC CONSIDERATIONSPART IIadequate surgeon experience.281,290 Reoperative bariatric surgery should be undertaken by experienced bariatric surgeons in cen-ters with the wide range of medical resources to manage these complex patients.281 In some situations, it is reasonable to con-sider a two-stage or an open vs. laparoscopic approach.285 When evaluating a patient for revisional bariatric surgery, it is most important to establish clearly the reason for revision.283,291 Is the issue a surgical complication, insufficient weight loss, or weight regain? Is there a discernable anatomic cause for the patient’s symptoms (e.g., abdominal pain, nausea, vomiting, heartburn or reflux, nutritional deficiency)? In situations of noninitial weight loss or weight regain, what is the best justification that can be made? Are there behavioral, or other nonsurgical


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Surgery_Schwartz. heartburn or reflux, nutritional deficiency)? In situations of noninitial weight loss or weight regain, what is the best justification that can be made? Are there behavioral, or other nonsurgical modifications that might significantly help to attain further weight loss? Will the patient be able to set into place the behavioral modification required of the revisional surgical approach? With consideration for revision, it is reasonable to place less emphasis on absolute weight loss and focus on the comorbidity and quality of life states. A comprehensive preoperative evaluation is required to fully answer these and other questions.The preoperative evaluation for bariatric surgical revision should include• Review of the initial surgical operative note to understand the exact initial procedure• Anatomic evaluation of the GI track utilizing upper gastroin-testinal endoscopy and radiology to identify known bariatric surgical complications• An extensive nutritional evaluation• A behavioral


Surgery_Schwartz

Surgery_Schwartz. evaluation of the GI track utilizing upper gastroin-testinal endoscopy and radiology to identify known bariatric surgical complications• An extensive nutritional evaluation• A behavioral health evaluation with a focus on the adaption to the initial bariatric procedure and potential adaptation to a revisional procedure• A full medical evaluation to determine the patient’s suitability to undergo anesthesia and a surgical procedure288,291The results from these evaluations are used to formulate a hypothesis to explain the patient’s symptoms and outcome from the initial procedure and to assess their suitability for and the potential benefits from the potential revisional surgical options. It will come down to a risk-benefit discussion between the sur-geon, other members of the multidisciplinary support team, and the patient.281Treatment for Insufficient Weight Loss or Weight RegainVertical Banded Gastroplasty. Reversal of VBG is associ-ated with significant weight gain. Revision of the VBG


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Surgery_Schwartz. support team, and the patient.281Treatment for Insufficient Weight Loss or Weight RegainVertical Banded Gastroplasty. Reversal of VBG is associ-ated with significant weight gain. Revision of the VBG to a re-VBG was associated with poor outcomes.292 VBGs have been safely converted with open and laparoscopic approaches to RYGB and SG.293-295 Conversion of VBG to BPD/DS pro-cedures has limited data with higher leak rate and mortality.296Adjustable Gastric Band. There are increasing reports of LAGB failure and disappointing weight loss over the last decade.289,297,298 Removal of the band without an additional bar-iatric procedure has been associated with significant weight regain.289 Repositioning or replacement of the band is techni-cally possible; however, the long-term weight loss outcomes are mixed.299-301 When converting an LAGB to another bariatric pro-cedure, there is some evidence to suggest possibly fewer com-plications with a two-step approach when significant adhesions or a


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Surgery_Schwartz. are mixed.299-301 When converting an LAGB to another bariatric pro-cedure, there is some evidence to suggest possibly fewer com-plications with a two-step approach when significant adhesions or a thick gastric capsule are present. This two-step approach would include removal of the band, allowing 3 to 6 months for gastric tissue healing, and then completing the conver-sion.302,303 However, one-stage conversions have been reported with acceptable outcomes.297 Good outcomes have been dem-onstrated with conversion of LAGBs to SG, RYGB, and BPD/DS.285,297 Several investigators advocate that a failed restrictive bariatric surgery due to poor weight loss should include a revi-sion option with a malabsorptive component.285Sleeve Gastrectomy. Approximately 5% to 10% of primary SG procedures have been reported to require revision for poor weight loss outcomes.304,305 The literature supports conversion to RYGB and BPD/DS.306 There is controversy regarding resleeve gastrectomy.307,308Roux-en-Y


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Surgery_Schwartz. been reported to require revision for poor weight loss outcomes.304,305 The literature supports conversion to RYGB and BPD/DS.306 There is controversy regarding resleeve gastrectomy.307,308Roux-en-Y Gastric Bypass. Approximately, 10% to 20 % of patients after a primary RYGB will have inadequate weight loss or weight regain at 2 years, and a subset of these will require a revisional surgical procedure.309 Options for revision include banding over the Roux-en-Y bypass, gastric pouch and gas-trojejunal revisions, RYGB limb lengthening, and conversion to a duodenal switch.281,285 Each of these options has strengths and weaknesses in specific situations. Endoscopic revisions to reduce the gastric pouch and/or gastrojejunal stomal size have been shown to arrest weight gain with short-term weight loss, but the studies have been small and are noncontrolled.Treatment of Surgical ComplicationsVertical Banded Gastroplasty. Several complications have been indications for revision/conversion of


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Surgery_Schwartz. loss, but the studies have been small and are noncontrolled.Treatment of Surgical ComplicationsVertical Banded Gastroplasty. Several complications have been indications for revision/conversion of VBGs: wide outlet, pouch dilation, staple line erosion, stoma stenosis, band erosion, band dehiscence, and GERD. Most often conversion is under-taken, and VBGs have been safely converted to RYGB.281,285Adjustable Gastric Band. The following LAGB complica-tions may require additional or revisional surgery: early band obstruction, severe or chronic gastric prolapse or symmetrical gastroesophageal dilatation, band erosion, port and tubing prob-lems, severe or persistent esophageal dysmotility, or psycho-logical intolerance to restriction of band. The literature supports repair of tubing and port problems and revision of LAGB to SG, RYGB, BPD/DS in oneor two-stage revisional operations.285,297Sleeve Gastrectomy. Complications that may require a revi-sional procedure after sleeve gastrectomy are


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Surgery_Schwartz. and revision of LAGB to SG, RYGB, BPD/DS in oneor two-stage revisional operations.285,297Sleeve Gastrectomy. Complications that may require a revi-sional procedure after sleeve gastrectomy are staple line leaks, sleeve stricture and sleeve dilatation, and gastroesophageal reflux. Obstruction due to stricture usually at the angularis inci-sura will require first-line treatment of endoscopic dilation and may require a revision to a RYGB. Staple line leaks are ini-tially controlled with endoscopic stenting or drainage. Acute and chronic leaks may develop into fistulous disease and require conversion to RYGB. Persistent gastroesophageal reflux may also require conversion to RYGB.281,285Roux-en-Y Gastric Bypass. Several complications after pri-mary RYGB have been demonstrated as indications for revi-sional surgery: gastric pouch dilatation, gastrojejunostomy dilation/stricture, marginal ulcers, bowel loss due to internal hernia or volvulus, roux stasis syndrome, gastrogastric fistu-las,


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Surgery_Schwartz. for revi-sional surgery: gastric pouch dilatation, gastrojejunostomy dilation/stricture, marginal ulcers, bowel loss due to internal hernia or volvulus, roux stasis syndrome, gastrogastric fistu-las, anastomotic structures or ulcers, and metabolic/endocrine derangements. These require a revision focused on the mecha-nism of the complication. Reversal of an RYGB is reserved for severe instances of intractable nausea/vomiting, extreme weight loss and malnutrition, metabolic abnormalities, nonhealing ulceration or leaks, and patient choice. It has been performed rarely, and case reports indicate successful resolution of endo-crine, metabolic, and nutritional abnormalities with improved Brunicardi_Ch27_p1167-p1218.indd 120623/02/19 2:21 PM 1207THE SURGICAL MANAGEMENT OF OBESITYCHAPTER 27metabolic parameters. However, 50% to 88% of patients have been reported to regain significant weight.281,285Biliopancreatic Diversion With Duodenal Switch. Acute complications are similar to RYGB and


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Surgery_Schwartz. parameters. However, 50% to 88% of patients have been reported to regain significant weight.281,285Biliopancreatic Diversion With Duodenal Switch. Acute complications are similar to RYGB and treated the same. The most severe chronic complication is protein-calorie malnutri-tion, and incidence ranges from 1% to 6%. Management is meticulous nutritional evaluation and nutritional and pancreatic enzyme support, with surgery as a fall back if weight and pro-tein stores are not stabilized. Surgery would entail lengthening the common channel and is rarely necessary.281SPECIAL ISSUES IN BARIATRIC SURGERYBariatric Procedures in AdolescentsThe major controversy with regard to adolescents undergoing bariatric surgery includes the general aversion to subjecting an adolescent to surgery as well as the concern for the second-ary side effects of bariatric surgery on remaining growth and development. Clearly the younger the patient, the more relevant the latter concern becomes. Bariatric surgery in


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Surgery_Schwartz. concern for the second-ary side effects of bariatric surgery on remaining growth and development. Clearly the younger the patient, the more relevant the latter concern becomes. Bariatric surgery in adolescents has been performed more frequently, with only 800 cases a year in 2003 increasing to 1600 cases in 2009, but overall rates are much lower than in adults.310,311 Much of the clinical outcomes data have been extrapolated from the adult literature, and more evidence is needed to demonstrate whether weight loss is dura-ble over time, the impact on obesity-related conditions such as T2DM, hypertension, and others, and how often patients experi-ence shortand longer-term complications.A meta-analysis involving 131 adolescents undergoing bariatric surgery demonstrated a 17.8 to 22.3 kg/m2 decrease in BMI after RYGB.312 They also observed improvement of hyper-tension in more than half the patients and sleep apnea resolution in all 131 patients. There were four mortalities in this cohort,


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Surgery_Schwartz. in BMI after RYGB.312 They also observed improvement of hyper-tension in more than half the patients and sleep apnea resolution in all 131 patients. There were four mortalities in this cohort, but only one of them was potentially associated with the pro-cedure (Clostridium difficile colitis 9 months after operation). Morbidity in the adolescent literature ranges from 0% to 38%. The most common complication in the meta-analysis was nutri-ent deficiencies. The ASMBS pediatric guidelines suggest using BMI criteria similar to the adult population but with some modi-fications to comorbidity thresholds.313 They recommend con-sidering surgery in patients with a BMI of 35 kg/m2 or greater with major comorbidities (e.g., T2DM, severe nonalcoholic fatty liver disease, OSA) or a BMI of ≥40 kg/m2 or greater with minor comorbidities (e.g., hypertension, dyslipidemia, insulin resistance). One more recent multicenter, prospective study of bariatric surgery in adolescents, the Teen-Longitudinal


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Surgery_Schwartz. or greater with minor comorbidities (e.g., hypertension, dyslipidemia, insulin resistance). One more recent multicenter, prospective study of bariatric surgery in adolescents, the Teen-Longitudinal Assess-ment of Bariatric Surgery (Teen-LABS) study, is following 242 adolescent patients for at least 10 years, who underwent bariatric surgery at 5 academic centers.314 Fifty-one percent of adolescents had four or more major comorbid conditions before surgery. LRYGB, SG, and LAGB were performed in 66%, 28%, and 6% of patients, respectively. There were no deaths during the initial hospitalization or within 30 days of operation; major complications such as reoperation were reported in 19 patients (8%). Minor complications such as dehydration were reported in 15%. All reoperations and 85% of readmissions in the 30-day period were related to the bariatric surgery.315 Three-year follow-up data on the Teen-LABS cohort reported a mean weight loss of 28% for LRYGB and 26% for SG. Remission of


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Surgery_Schwartz. in the 30-day period were related to the bariatric surgery.315 Three-year follow-up data on the Teen-LABS cohort reported a mean weight loss of 28% for LRYGB and 26% for SG. Remission of T2DM occurred in 95% of participants who had had the con-dition before surgery, remission of abnormal kidney function occurred in 86%, remission of prediabetes in 76%, remission of elevated blood pressure in 74%, and remission of dyslipidemia in 66%. Rates of improvements in comorbid conditions, includ-ing T2DM, occurred at higher rates than in adults. Hypofer-ritinemia was found in 57% of the participants, and 13% of the participants had undergone one or more additional intraabdomi-nal procedures at 3 years.52 So despite the clinically significant improvements in weight, diabetes, cardiometabolic health, and weight-related quality of life that were observed at 3 years fol-lowing surgery, the reoperation and micronutrient risks warrant longer observation and further study.Cost EffectivenessIn a


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Surgery_Schwartz. and weight-related quality of life that were observed at 3 years fol-lowing surgery, the reoperation and micronutrient risks warrant longer observation and further study.Cost EffectivenessIn a Canadian study, including five systematic reviews, two eco-nomic evaluations, two reviews of guidelines, and six primary evidence-based guidelines, the cost effectiveness for the use of bariatric surgery in adolescents was reviewed.316 The limited available evidence suggested superior weight loss, resolution of comorbidities compared to nonsurgical interventions, and potential superior weight loss with RYGB compared to other procedures. Cost-effectiveness data was lacking, but limited evidence suggested that bariatric surgery was cost effective several years after intervention, but not immediately.316 A U.S. cost-effectiveness analysis of bariatric surgery in adolescents has been published. In addition to the cost of the surgery, peri-operative mortality, complications, and quality of life


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Surgery_Schwartz. A U.S. cost-effectiveness analysis of bariatric surgery in adolescents has been published. In addition to the cost of the surgery, peri-operative mortality, complications, and quality of life improve-ment were included in the modelled analysis. By the fifth year of follow-up, bariatric surgery was found to be cost effective in adolescent patients when compared to a cohort of patients with obesity who had not undergone surgery.317For adults, the overall impact of bariatric surgery to reduce expenditures sufficiently to achieve cost savings continues to be debated. In a Canadian matched cohort study prior to the laparoscopic era, it was shown that bariatric surgery decreases long-term direct healthcare costs and the initial costs of surgery can be amortized over 3.5 years.318 In two observational studies, bariatric surgery was shown to be cost saving over a relatively short period of time.319,320 In more recent observational studies, including the large SOS study and another an analysis


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Surgery_Schwartz. studies, bariatric surgery was shown to be cost saving over a relatively short period of time.319,320 In more recent observational studies, including the large SOS study and another an analysis of 30,000 single payor enrollees in the United States, show no evidence of overall cost savings.206,321,322In general, review of the evidence to date suggests that outpatient costs, including pharmacy costs, are significantly reduced after bariatric surgery. However, long-term inpatient hospital costs are increased or unchanged in those who have undergone bariatric surgery compared with matched nonsurgi-cal patients, so no long-term net cost benefit is achieved. Other modeled cost effectiveness studies are consistent with these results as well.323,324 So it is likely that bariatric procedures are cost effective, but do not produce cost savings, compared with nonsurgical treatments.Quality AssuranceBetween 1998 and 2003, with emergence of the laparoscopic technique for bariatric surgery, there


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Surgery_Schwartz. cost effective, but do not produce cost savings, compared with nonsurgical treatments.Quality AssuranceBetween 1998 and 2003, with emergence of the laparoscopic technique for bariatric surgery, there was rapid increase in the number bariatric surgical procedures performed. With bariatric surgeons becoming accustomed to laparoscopic techniques and laparoscopic surgeons learning bariatric procedures and patient care, there were realistic concerns regarding the safety of bar-iatric surgery.325 In 2004, ASMBS utilized the volume-outcome concept of centers of excellence and developed the first bar-iatric surgical accreditation program, ASMBS-Center of Excel-lence (COE). In 2005, the American College of Surgeons (ACS) initiated the ACS Bariatric Surgery Center Network (BSCN). Brunicardi_Ch27_p1167-p1218.indd 120723/02/19 2:21 PM 1208SPECIFIC CONSIDERATIONSPART IIThese accreditation programs verified that bariatric surgery centers had the infrastructure and equipment to care for the


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Surgery_Schwartz. 120723/02/19 2:21 PM 1208SPECIFIC CONSIDERATIONSPART IIThese accreditation programs verified that bariatric surgery centers had the infrastructure and equipment to care for the morbidly obese, experienced and qualified surgeons and staff, appropriate preand postoperative processes in place, and reported outcome data on all surgical cases.325In 2012, these two bariatric surgical accreditations merged into a single unified program, the Metabolic and Bar-iatric Surgery Accreditation and Quality Improvement Program (MBSAQIP). The MBSAQIP has continued to grant accredita-tion only after a rigorous review process during which a center proves that it can maintain certain physical resources, human resources, and standards of practice.326 Additionally, prospec-tive outcome data is collected at the clinical center and validated based on standardized definitions and submitted to the quality improvement program. Centers receive back risk-stratified anal-ysis of their data as a means to


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Surgery_Schwartz. at the clinical center and validated based on standardized definitions and submitted to the quality improvement program. Centers receive back risk-stratified anal-ysis of their data as a means to compare with the national statis-tics/standards and are then required to utilize the data in quality improvement projects at their center. This newer focus on qual-ity improvement over centers of excellence will likely continue to improve the quality of bariatric surgery in the United States. Recently, in a systematic review, bariatric facility accreditation by this program has been associated with improved outcomes (length of stay, mortality, morbidity).327Plastic Surgery After Weight LossPatients who have undergone bariatric surgery are often left with skin and subcutaneous tissue deformities. Additional prob-lems include skin rashes and maceration under folds in the pan-nus, thighs, and breasts; body odor; and poorly fitting clothes. Excess skin can also be a limiting factor in exercise


Surgery_Schwartz

Surgery_Schwartz. Additional prob-lems include skin rashes and maceration under folds in the pan-nus, thighs, and breasts; body odor; and poorly fitting clothes. Excess skin can also be a limiting factor in exercise and sexual activity. Plastic and reconstructive surgery is now a part of the continuum of care for bariatric surgery patients. Reconstructive surgery requires careful preoperative planning and is based on the patient’s deformities and priorities. Timing of plastic and reconstructive surgery is typically deferred until weight sta-bility at approximately 1 to 2 years postoperatively to ensure improved healing. Excess tissue of the lower torso is the most common area for which patients undergo surgical intervention and a standard abdominoplasty is typically performed. More radical body contouring can include a circumferential abdomi-noplasty and lower body lift.328,329 This procedure involves excision of tissue from the buttocks and lateral thighs, with skin undermining down the thighs.


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Surgery_Schwartz. can include a circumferential abdomi-noplasty and lower body lift.328,329 This procedure involves excision of tissue from the buttocks and lateral thighs, with skin undermining down the thighs. Circumferential abdomino-plasty removes redundant skin of the lower abdomen, flattens the abdomen, and incorporates the lower body lift. It requires central undermining to the xiphoid and minimal lateral under-mining of the superior flap. The central abdominal fascia often requires imbrication. If simultaneous abdominal hernia repair is performed, this performs the function of fascial imbrication by creating a repair with some degree of fascial tension. The closure of the superior flap to the inferior skin edge incorporates lateral tension to narrow the waist and advance the anterolateral thighs. Medial thighplasty also may be needed for patients with significant excess medial thigh skin.Mid-back and epigastric deformity, along with sagging breasts, are corrected with an upper body lift. The


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Surgery_Schwartz. Medial thighplasty also may be needed for patients with significant excess medial thigh skin.Mid-back and epigastric deformity, along with sagging breasts, are corrected with an upper body lift. The upper body lift is a reverse abdominoplasty, removal of mid-torso excessive skin, and reshaping of the breasts. For highly selected individu-als, and with a well-organized team, a single-stage total body lift, which includes a circumferential abdominoplasty, lower body lift, medial thighplasty, an upper body lift, and breast reshap-ing, can be performed safely in under 8 hours (Figs. 27-30 and 27-31).330 Increasing numbers of patients are seeking these cor-rective procedures, and data about the results is evolving. There Figure 27-30. Preoperative frontal, right lateral, and left anterior oblique views of a 36-year-old, 150-lb (68-kg) 5'6" woman who lost 120 lb (54 kg) 2 years after laparoscopic Roux-en-Y bypass procedure. She desired a one-stage total body lift and bilateral


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Surgery_Schwartz. oblique views of a 36-year-old, 150-lb (68-kg) 5'6" woman who lost 120 lb (54 kg) 2 years after laparoscopic Roux-en-Y bypass procedure. She desired a one-stage total body lift and bilateral brachioplasties, which were performed in the manner described in the text. (Used with permission from Dennis Hurwitz, MD, Clinical Professor of Plastic Surgery, University of Pittsburgh.)Brunicardi_Ch27_p1167-p1218.indd 120823/02/19 2:21 PM 1209THE SURGICAL MANAGEMENT OF OBESITYCHAPTER 27Figure 27-31. Frontal, right lateral, and left anterior oblique views 6 weeks after surgery for the woman in Fig. 27-24. The scars indicate the circumferential abdominoplasty, lower body lift, upper body lift, breast reshaping, and autoaugmentation through a keyhole pattern and bilateral brachioplasties. All redundant skin has been removed, leaving well-positioned scars and feminine features. (Used with permission from Dennis Hurwitz, MD, Clinical Professor of Plastic Surgery, University of Pittsburgh.)is a


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Surgery_Schwartz. skin has been removed, leaving well-positioned scars and feminine features. (Used with permission from Dennis Hurwitz, MD, Clinical Professor of Plastic Surgery, University of Pittsburgh.)is a hypothesis that if body image is improved with corrective surgery, that weight maintenance in the longer-term may also be positively affected. Several matched controlled studies suggest that plastic surgery after bariatric surgery may improve long-term weight loss results.328,331FUTURE IMPORTANT QUESTIONSThe volume and quality of literature in the field of bariatric sur-gery has grown tremendously in the last 10 years. High-quality evidence now shows that bariatric surgical procedures result in greater weight loss than nonsurgical treatments, improved sur-vival, and are more effective at inducing remission of T2DM in people with obesity. More information is still needed about the long-term durability of comorbid health improvements and long-term complications after each of the different


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Surgery_Schwartz. remission of T2DM in people with obesity. More information is still needed about the long-term durability of comorbid health improvements and long-term complications after each of the different bar-iatric surgical procedures. In addition, the underlying specific mechanism(s) of action for both bariatric and metabolic surgery is still incompletely understood. Future knowledge will come from translational human studies, the ongoing longer-term stud-ies and data registries, randomized studies comparing surgical to nonsurgical treatments, integrated health care systems data, and national “big data” networks. The following are some of the high-priority questions that future research will address.• What are the specific mechanisms of action responsible for weight loss and the T2DM response to bariatric surgical procedures?• What patient level factors can predict success with weight loss, health improvements, and cost savings after bariatric surgical procedures? Understanding preand


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Surgery_Schwartz. to bariatric surgical procedures?• What patient level factors can predict success with weight loss, health improvements, and cost savings after bariatric surgical procedures? Understanding preand postsurgery predictors will help to tailor an individual’s treatment.• Is bariatric surgery more effective than nonsurgical care for the longer-term treatment of T2DM in people with less severe obesity (class 1 obesity, BMI <35)?• With more standardized reporting of complications across bariatric studies, what are the long-term complication rates after different bariatric procedures?• What is the effect of bariatric surgery on long-term microvas-cular and macrovascular event rates?• What are the reproductive and mental health outcomes includ-ing risk for self-harm and suicide, alcohol use disorders, sub-stance abuse, and other risk-taking behaviors?REFERENCESEntries highlighted in bright blue are key references. 1. Arterburn DE, Courcoulas AP. Bariatric surgery for obesity and metabolic


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Surgery_Schwartz. sub-stance abuse, and other risk-taking behaviors?REFERENCESEntries highlighted in bright blue are key references. 1. Arterburn DE, Courcoulas AP. Bariatric surgery for obesity and metabolic conditions in adults. BMJ. 2014;349:g3961. 2. Kremen AJ, Linner JH, Nelson CH. An experimental evalua-tion of the nutritional importance of proximal and distal small intestine. Ann Surg. 1954;140(3):439-448. 3. Mason EE, Ito C. Gastric bypass. Ann Surg. 1969;170(3): 329-339. 4. Griffen WO Jr, Young VL, Stevenson CC. A prospective comparison of gastric and jejunoileal bypass procedures for morbid obesity. Ann Surg. 1977;186(4):500-509. 5. Mason EE. Vertical banded gastroplasty for obesity. Arch Surg. 1982;117(5):701-706. 6. Brolin RE, Robertson LB, Kenler HA, Cody RP. Weight loss and dietary intake after vertical banded gastroplasty and Roux-en-Y gastric bypass. Ann Surg. 1994;220(6):782-790. 7. Waaddegaard P, Clemmesen T, Jess P. Vertical gastric banding for morbid obesity: a long-term follow-up


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Surgery_Schwartz. vertical banded gastroplasty and Roux-en-Y gastric bypass. Ann Surg. 1994;220(6):782-790. 7. Waaddegaard P, Clemmesen T, Jess P. Vertical gastric banding for morbid obesity: a long-term follow-up study. Eur J Surg. 2002;168(4):220-222.Brunicardi_Ch27_p1167-p1218.indd 120923/02/19 2:21 PM 1210SPECIFIC CONSIDERATIONSPART II 8. Balsiger BM, Poggio JL, Mai J, Kelly KA, Sarr MG. Ten and more years after vertical banded gastroplasty as pri-mary operation for morbid obesity. J Gastrointest Surg. 2000;4(6):598-605. 9. Scopinaro N, Gianetta E, Civalleri D, Bonalumi U, Bachi V. Bilio-pancreatic bypass for obesity: II. Initial experience in man. Br J Surg. 1979;66(9):618-620. 10. Hess DS, Hess DW. Biliopancreatic diversion with a duodenal switch. Obes Surg. 1998;8(3):267-282. 11. Belachew M, Legrand MJ, Defechereux TH, Burtheret MP, Jacquet N. Laparoscopic adjustable silicone gastric band-ing in the treatment of morbid obesity. A preliminary report. Surg Endosc.


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Surgery_Schwartz. medical treatment in obese patients with type 2 diabetes: 5 year follow-up of an open-label, single-centre, randomised controlled trial. Lancet. 2015;386(9997):964-973. This is a randomized clinical trial comparing gastric bypass, biliopancreatic diversion, and medical treatment for the treatment of type 2 diabetes in people with obesity. It is only one of 2 randomized studies addressing this question with 5 year follow up, at this time. 83. Halperin F, Ding SA, Simonson DC, et al. Roux-en-Y gastric bypass surgery or lifestyle with intensive medical management in patients with type 2 diabetes: feasibility and 1-year results of a randomized clinical trial. JAMA Surg. 2014;149(7): 716-726. 84. Courcoulas AP, Goodpaster BH, Eagleton JK, et al. Surgical vs medical treatments for type 2 diabetes mellitus: a randomized clinical trial. JAMA Surg. 2014;149(7):707-715. 85. Ding SA, Simonson DC, Wewalka M, et al. Adjustable gastric band surgery or medical management in patients with type 2


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Surgery_Schwartz. VA, et al. Association between bariatric surgery and long-term survival. JAMA. 2015;313(1):62-70. 208. Maciejewski ML, Arterburn DE, Van Scoyoc L, et al. Bariatric surgery and long-term durability of weight loss. JAMA Surg. 2016;151(11):1046-1055. 209. Belle SH, Berk PD, Chapman WH, et al. Baseline characteristics of participants in the Longitudinal Assessment of Bariatric Surgery-2 (LABS-2) study. Surg Obes Relat Dis. 2013;9(6):926-935. 210. Courcoulas AP, Christian NJ, O’Rourke RW, et al. Preoperative factors and 3-year weight change in the Longitudinal Assessment of Bariatric Surgery (LABS) consortium. Surg Obes Relat Dis. 2015;11(5):1109-1118. 211. Mitchell JE, Christian NJ, Flum DR, et al. Postoperative behavioral variables and weight change 3 years after bariatric surgery. JAMA Surg. 2016;151(8):752-757. 212. Arterburn DE, Bogart A, Sherwood NE, et al. A multisite study of long-term remission and relapse of type 2 diabetes mellitus following gastric bypass. Obes Surg.


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Surgery_Schwartz. JAMA Surg. 2016;151(8):752-757. 212. Arterburn DE, Bogart A, Sherwood NE, et al. A multisite study of long-term remission and relapse of type 2 diabetes mellitus following gastric bypass. Obes Surg. 2013;23(1): 93-102. 213. Arterburn D, Bogart A, Coleman KJ, et al. Comparative effectiveness of bariatric surgery vs. nonsurgical treatment of type 2 diabetes among severely obese adults. Obes Res Clin Pract. 2013;7(4):e258-268. 214. Arterburn D, Powers JD, Toh S, et al. Comparative effectiveness of laparoscopic adjustable gastric banding vs laparoscopic gastric bypass. JAMA Surg. 2014;149(12):1279-1287. 215. Carlin AM, Zeni TM, English WJ, et al. The comparative effectiveness of sleeve gastrectomy, gastric bypass, and adjustable gastric banding procedures for the treatment of morbid obesity. Ann Surg. 2013;257(5):791-797. This is data from a statewide clinical registry, where outcomes of the 3 most common procedures; gastric bypass, sleeve gastrectomy, and laparoscopic adjustable banding


Surgery_Schwartz

Surgery_Schwartz. Ann Surg. 2013;257(5):791-797. This is data from a statewide clinical registry, where outcomes of the 3 most common procedures; gastric bypass, sleeve gastrectomy, and laparoscopic adjustable banding are compared. It showed that rates for both short term weight loss and overall complications for the sleeve gastrectomy were positioned between gastric bypass and laparoscopic adjustable banding. 216. Finks JF, Kole KL, Yenumula PR, et al. Predicting risk for serious complications with bariatric surgery: results from the Michigan Bariatric Surgery Collaborative. Ann Surg. 2011;254(4):633-640. 217. Birkmeyer NJ, Finks JF, English WJ, et al. Risks and benefits of prophylactic inferior vena cava filters in patients undergoing bariatric surgery. J Hosp Med. 2013;8(4):173-177. 218. Varban OA, Sheetz KH, Cassidy RB, et al. Evaluating the effect of operative technique on leaks after laparoscopic Brunicardi_Ch27_p1167-p1218.indd 121523/02/19 2:21 PM 1216SPECIFIC CONSIDERATIONSPART IIsleeve


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Surgery_Schwartz. KH, Cassidy RB, et al. Evaluating the effect of operative technique on leaks after laparoscopic Brunicardi_Ch27_p1167-p1218.indd 121523/02/19 2:21 PM 1216SPECIFIC CONSIDERATIONSPART IIsleeve gastrectomy: a case-control study. Surg Obes Relat Dis. 2017;13(4):560-567. 219. Birkmeyer JD, Finks JF, O’Reilly A, et al. Surgical skill and complication rates after bariatric surgery. N Engl J Med. 2013;369(15):1434-1442. 220. Wood GC, Benotti PN, Lee CJ, et al. Evaluation of the association between preoperative clinical factors and long-term weight loss after roux-en-y gastric bypass. JAMA Surg. 2016;151(11):1056-1062. 221. Still CD, Wood GC, Benotti P, et al. Preoperative prediction of type 2 diabetes remission after Roux-en-Y gastric bypass surgery: a retrospective cohort study. Lancet Diabet Endocrinol. 2014;2(1):38-45. 222. Tice JA, Karliner L, Walsh J, Petersen AJ, Feldman MD. Gastric banding or bypass? A systematic review comparing the two most popular bariatric procedures. Am J Med.


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Surgery_Schwartz. Endocrinol. 2014;2(1):38-45. 222. Tice JA, Karliner L, Walsh J, Petersen AJ, Feldman MD. Gastric banding or bypass? A systematic review comparing the two most popular bariatric procedures. Am J Med. 2008;121(10):885-893. 223. Padwal R, Klarenbach S, Wiebe N, et al. Bariatric surgery: a systematic review and network meta-analysis of randomized trials. Obes Res. 2011;12(8):602-621. 224. Trastulli S, Desiderio J, Guarino S, et al. Laparoscopic sleeve gastrectomy compared with other bariatric surgical procedures: a systematic review of randomized trials. Surg Obes Relat Dis. 2013;9(5):816-829. 225. Yang X, Yang G, Wang W, Chen G, Yang H. A meta-analysis: to compare the clinical results between gastric bypass and sleeve gastrectomy for the obese patients. Obes Surg. 2013;23(7):1001-1010. 226. Vest AR, Heneghan HM, Agarwal S, Schauer PR, Young JB. Bariatric surgery and cardiovascular outcomes: a systematic review. Heart. 2012;98(24):1763-1777. 227. Vest AR, Heneghan HM, Schauer PR, Young


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Surgery_Schwartz. and lung function in obese subjects with asthma. Respirat Med. 2012;106(5):651-660. 235. Beymer C, Kowdley KV, Larson A, Edmonson P, Dellinger EP, Flum DR. Prevalence and predictors of asymptomatic liver disease in patients undergoing gastric bypass surgery. Arch Surg. 2003;138(11):1240-1244. 236. Rabl C, Campos GM. The impact of bariatric surgery on nonalcoholic steatohepatitis. Semin Liver Dis. 2012;32(1): 80-91. 237. Iossi MF, Konstantakos EK, Teel DD, 2nd, et al. Musculoskeletal function following bariatric surgery. Obesity. 2013;21(6):1104-1110. 238. Vincent HK, Heywood K, Connelly J, Hurley RW. Obesity and weight loss in the treatment and prevention of osteoarthritis. PM R. 2012;4(5 suppl):S59-S67. 239. King WC, Chen JY, Belle SH, et al. Change in pain and physical function following bariatric surgery for severe obesity. JAMA. 2016;315(13):1362-1371. 240. Karlsson J, Taft C, Ryden A, Sjostrom L, Sullivan M. Ten-year trends in health-related quality of life after surgical and


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Surgery_Schwartz. bariatric surgery for severe obesity. JAMA. 2016;315(13):1362-1371. 240. Karlsson J, Taft C, Ryden A, Sjostrom L, Sullivan M. Ten-year trends in health-related quality of life after surgical and conventional treatment for severe obesity: the SOS intervention study. Int J Obes. 2007;31(8):1248-1261. 241. Kolotkin RL, Davidson LE, Crosby RD, Hunt SC, Adams TD. Six-year changes in health-related quality of life in gastric bypass patients versus obese comparison groups. Surg Obes Relat Dis. 2012;8(5):625-633. 242. Nickel MK, Loew TH, Bachler E. Change in mental symptoms in extreme obesity patients after gastric banding, part II: six-year follow up. Int J Psychiatry Med. 2007;37(1):69-79. 243. Schauer PR, Nor Hanipah Z, Rubino F. Metabolic surgery for treating type 2 diabetes mellitus: now supported by the world’s leading diabetes organizations. Cleve Clin J Med. 2017;84 (7 suppl 1):S47-S56. 244. Buchwald H, Estok R, Fahrbach K, et al. Weight and type 2 diabetes after bariatric surgery: