Nonsurgical and surgical treatment of obesity

Obesity is emerging as one of the greatest health care problem of our time. One in three Americans is now clinically obese. Morbid obesity is associated with a medley of comorbid conditions and poor long-term outcomes. Overweight and obese individuals should be treated with diet, exercise, and behavioral therapy. The failure of this approach is an indication for pharmacologic therapy. Bariatric surgery should be considered in adult patients with a documented BMI greater than or equal to 35 and related comorbidity or a BMI of at least 40 (Table 2). Bariatric surgery reduces obesity-related complications and reduces long-term morbidity, mortality, and health care resources use. Adjustable gastric banding (AGB), vertical banded gastroplasty (VBG), Roux-en-Y gastric bypass (RYGB), and biliopancreatic diversion (BPD) are all effective procedures in the treatment of morbid obesity. In terms of weight loss, BPD-DS is superior to RYGB, RYGB is superior to AGB, and ABG is superior to VBG. An increased risk of perioperative complications exists in procedures requiring stapling and anastomoses. The reoperation rate is higher for adjustable gastric banding and VBG. There is no ideal bariatric procedure, and because positive and negative effects differ among the procedures, the choice of procedure should be tailored to the patient's BMI, perioperative risk, metabolic situation, comorbidities, and patient and surgeon preference as well as to the surgeon's expertise [77].