SAGES GUIDELINES FOR LAPAROSCOPIC
AND CONVENTIONAL SURGICAL TREATMENT OF MORBID OBESITY
This guideline was prepared jointly by SAGES and the ASBS
Morbid obesity (also referred to as clinically severe obesity) is recognized
as a major public health risk throughout the world. In the U.S.A. alone, over
four million people suffer from this chronic disease. Much of the associated
morbidity and mortality is related to co-morbid conditions which include, but
are not limited to, cardiac disease, diabetes mellitus type II, obstructive
sleep apnea, hypertension, dyslipidemia, gastroesophageal reflux disease, stress
urinary incontinence, arthritis of the weight bearing joints, infertility and
Surgical treatment of morbid obesity has been well established as being safe
and effective (1). Both short and long-term improvement of co-morbidities has
been well documented (2-7). Medical treatment for this disease has included
dietary manipulation, behavior modification and medications. These have been
tried singularly and in combinations, but with only limited long-term positive
results. The National Institute of Health consensus conference in 1991
established widely accepted guidelines and indications for the surgical
management of severe obesity (8). The indications for surgical management of
obesity are summarized below.
INDICATIONS FOR SURGERY
Surgical therapy should be considered for individuals who:
have a body mass index (BMI) of greater than 40 kg/m2
have a BMI greater than 35 kg/m2 with significant co-morbidities.
can show that dietary attempts at weight control have been ineffective.
PERI-OPERATIVE AND LONG TERM MANAGEMENT CONSIDERATIONS
The overall care of patients undergoing bariatric surgery (weight reduction
surgery) requires programs which address both perioperative care and long-term
management. Careful preoperative evaluation and patient preparation are
critical. Patients should have a clear understanding of expected benefits,
risks, and long term consequences of surgical treatment. Surgeons must be aware
of the diagnosis and management of complications specific to bariatric surgery.
Patients require appropriate lifelong follow- up with nutritional counseling and
biochemical surveillance. Surgeons need to be aware of the needs of severely
obese patients in terms of facilities, supplies, equipment, staff and
procedures, and should plan the personal time, specialized staff and/or
multi-disciplinary referral system as required. This multi- disciplinary
approach includes medical management of comorbidities, dietary instruction,
exercise training, specialized nursing care and psychological assistance as
needed. Post-operative management of co-morbidities should be directed by the
practitioner familiar with the operation performed and the changes created.
Bariatric surgical procedures are divided into two types, restrictive and
malabsorptive. With either type of procedure, follow up is imperative to monitor
for potential serious sequelae and operative failure. These operations should
only be done performed within the confines of an obesity treatment Bariatric
program intent on maintaining long-term follow-up as well as long-term outcomes
The operations which have been most frequently performed are the Roux-en-Y
gastric bypass, vertical banded gastroplasty, the biliopancreatic diversion
(BPD) and it's variations, and the various gastric banding procedures (9-13). At
the time of this writing, the adjustable silicone gastric banding is limited in
its use under FDA protocol. The NIH conference of 1991 recognized the vertical
banded gastroplasty and gastric bypass procedures as acceptable procedures based
on available outcome data. (8)
Minimally invasive techniques have been used in bariatric surgery since 1993.
(14, 15). Laparoscopic bariatric procedures rely on videoscopic technologies to
allow surgeons to perform accepted bariatric operations in a minimally invasive
fashion. The benefits of a laparoscopic approach appear to be similar to those
realized with laparoscopic cholecystectomy, including but not limited to a
shorter recovery with an earlier return to normal activity. In addition, wound
complications such infections, hernias and dehiscences appear to be
The indications for laparoscopic treatment of obesity are the same as for
open surgery, as and have been outlined earlier in this document. Not all
patients are suitable for laparoscopic bariatric surgery, and conversion to an
open bariatric procedure is sometimes necessary. Surgeons must have the skills,
experience and equipment necessary to convert to and perform open bariatric
Virtually all bariatric operations can be performed with laparoscopic
techniques, although advanced laparoscopic skills are required (14-20). For safe
and effective laparoscopic treatment of obesity, advanced laparoscopic skills,
such as intracorporeal knot tying, use of angled scopes to achieve multiple
viewing angles, and two-handed organ and tissue manipulation are required.
Therefore, appropriate training in advanced laparoscopic techniques is
mandatory. These skills are most appropriately acquired through a residency,
fellowship, or courses which detail the indications for bariatric procedures,
the various operative approaches -both open and laparoscopic, and the advanced
skills necessary to perform these operations. Additionally, the long-term care
of these patients needs to emphasized and taught. Before attempting such a
procedure independently, the surgeon should be preceptored by a surgeon
experienced in the techniques. Finally, these procedures require a well-trained
operating team familiar with the equipment, instruments and techniques of
Morbid obesity is a significant health concern. Medical management fails to
sustain weight loss, and management of the co-morbidities is expensive and often
ineffective. Bariatric surgery currently provides the only significant,
sustained weight loss. Laparoscopic techniques, based on their "open"
counterparts, are available. When performed by appropriately trained surgeons,
laparoscopic approaches appear to hasten the patient's recovery and return to
normal function. Experience and training in bariatric surgery, advanced
laparoscopic surgery skills, and a commitment to long-term patient management
- Kellum JM, DeMaria EJ, Sugerman HJ. The surgical treatment of morbid
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- Pories WJ, MacDonald KG, FlickingerEG, et al: Is type II diabetes mellitus
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- Deitel M, Stone E, Kassam HA et al. Gynecologic-obstetric changes after
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- Carson JL, Ruddy ME, Duff AE et al. The effect of gastric bypass surgery
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- Gastrointestinal surgery for severe obesity: National Institutes of Health
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- Mason EE, Doherty C, Cullen JJ et al. Vertical banded gastroplasty:
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- Linner JH, Drew RL. Why the operation we prefer is the Roux-Y gastric
bypass. Obes Surg 1991; 1: 305-6.
- Scopinaro N, Adami GF, Marinari GM et al. Biliopancreatic diversion. World
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- Kuzmak LI. A review of 7 years experience with silicone gastric banding
for morbid obesity. Obes Surg 1991; 1: 403-08
- Wittgrove AC, Clark GW, Schubert KR .Laparoscopic Gastric Bypass,
Roux-en-Y: and results in 75 patients with 3-30 months follow-up. Obes Surg
- Belachew M, Legrand M, Vincent V, Lismonde M, LeDocte N, Deschamps V.
Laparoscopic adjustable gastric banding. World J Surg 1998: 22: 955-63.
- Chua TY, Mendiola RM. Laparoscopic vertical banded gastroplasty: the
Milwaukee experience. Obes Surg 1995; 5: 636-38.
- Lonroth H, Dalenback J, Haglind E et al. Laparoscopic bypass: another
option in bariatric surgery. Surg Endosc 1996; 6: 500-04.
- Wittgrove AC, Clark GW. Laparoscopic Gastric Bypass: a 5 year prospective
study of 500 patients from 3-60 months. Obes Surg 2000; 10: June (in press).
- Schauer PR, Ikramuddin S, Gourash W, Ramanathan R, Luketich J. Outcomes
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This statement was reviewed and approved by the Boards of Governors of the
Society of American Gastrointestinal Endoscopic Surgeons (SAGES) and the American
Society for Bariatric Surgery (ASBS) May, 2000. It was prepared jointly by
members of SAGES and ASBS.
Requests for reprints should be sent to:
Society of American Gastrointestinal Endoscopic Surgeons (SAGES)
2716 Ocean Park Boulevard, Suite 3000
Santa Monica, CA 90405
Tel: (310) 314-2404
Fax: (310) 314-2585
SAGES Publication #30