Article    Correction    Table of Contents                    Full Text of this article Free    PDF of this article (PDFs free after 6 months)    Summary for Patients    Summary for Patients (PDF)    Figures/Tables List    Video News Release    Related articles in Annals  Services    Send comment/rapid response letter    Published comments/rapid response letters    Notify a friend about this article    Alert me when this article is cited    Add to Personal Archive    Download to Citation Manager    ACP Search                            Get Permissions  Google Scholar    Search for Related Content  PubMed Articles in PubMed by Author:    Maggard, M. A.    Shekelle, P. G.    Related Articles in PubMed    PubMed Citation    PubMed

CLINICAL GUIDELINES

Meta-Analysis: Surgical Treatment of Obesity

Melinda A. Maggard, MD, MSHS; Lisa R. Shugarman, PhD; Marika Suttorp, MS; Margaret Maglione, MPP; Harvey J. Sugerman, MD; Edward H. Livingston, MD; Ninh T. Nguyen, MD; Zhaoping Li, MD, PhD; Walter A. Mojica, MD, MPH; Lara Hilton, BA; Shannon Rhodes, MFA; Sally C. Morton, PhD; and Paul G. Shekelle, MD, PhD

5 April 2005 | Volume 142 Issue 7 | Pages 547-559

Background: Controversy exists regarding the effectiveness of surgery for weight loss and the resulting improvement in health-related outcomes.

Purpose: To perform a meta-analysis of effectiveness and adverse events associated with surgical treatment of obesity.

Data Sources: MEDLINE, EMBASE, Cochrane Controlled Trials Register, and systematic reviews.

Study Selection: Randomized, controlled trials; observational studies; and case series reporting on surgical treatment of obesity.

Data Extraction: Information about study design, procedure, population, comorbid conditions, and adverse events.

Data Synthesis: The authors assessed 147 studies. Of these, 89 contributed to the weight loss analysis, 134 contributed to the mortality analysis, and 128 contributed to the complications analysis. The authors identified 1 large, matched cohort analysis that reported greater weight loss with surgery than with medical treatment in individuals with an average body mass index (BMI) of 40 kg/m² or greater. Surgery resulted in a weight loss of 20 to 30 kg, which was maintained for up to 10 years and was accompanied by improvements in some comorbid conditions. For BMIs of 35 to 39 kg/m², data from case series strongly support superiority of surgery but cannot be considered conclusive. Gastric bypass procedures result in more weight loss than gastroplasty. Bariatric procedures in current use (gastric bypass, laparoscopic adjustable gastric band, vertical banded gastroplasty, and biliopancreatic diversion and switch) have been performed with an overall mortality rate of less than 1%. Adverse events occur in about 20% of cases. A laparoscopic approach results in fewer wound complications than an open approach.

Limitations: Only a few controlled trials were available for analysis. Heterogeneity was seen among studies, and publication bias is possible.

Conclusions: Surgery is more effective than nonsurgical treatment for weight loss and control of some comorbid conditions in patients with a BMI of 40 kg/m² or greater. More data are needed to determine the efficacy of surgery relative to nonsurgical therapy for less severely obese people. Procedures differ in efficacy and incidence of complications.

Editors' Notes Context The effectiveness of surgical therapy in the treatment of obesity is unclear. Contribution Many published studies of obesity surgery have significant limitations, and case series make up much of the evidence. Evidence is complicated by the heterogeneity of procedures studied. However, surgery can result in substantial amounts of weight loss (20 to 30 kg) for markedly obese individuals. One cohort study documented weight loss for 8 years with associated improvements in comorbid conditions, such as diabetes. Complications of surgery appear to occur in about 20% of patients. Implications Those considering surgical treatment for obesity should understand that, although patients who have surgery can lose substantial amounts of weight, the evidence base for these treatments is limited. –The Editors

 

Author and Article Information

From the Southern California Evidence-Based Practice Center (which includes RAND Health Division, Santa Monica, California, and the Greater Los Angeles VA Healthcare System, Los Angeles) and the University of California, Los Angeles, Los Angeles, California.

Grant Support: By the Agency for Healthcare Research and Quality, U.S. Department of Health and Human Services. At the time of this review, Dr. Maggard was a Veterans Affairs Robert Wood Johnson Clinical Scholar at the University of California, Los Angeles, and the West Los Angeles VA Medical Center.

Potential Financial Conflicts of Interest: Honoraria: H.J. Sugerman (Ethicon Endo-Surgery).

Requests for Single Reprints: Melinda A. Maggard, MD, MSHS, Department of Surgery, University of California, Los Angeles, Medical Center, CHS Room 72-215, 10833 Le Conte Avenue, Los Angeles, CA 90095; e-mail, mmaggard{at}mednet.ucla.edu.

Current Author Addresses: Drs. Maggard, Li, Mojica, and Horton; Ms. Suttorp, Ms. Maglione, Ms. Solomon, Ms. Jungvig, and Ms. Rhodes: Department of Surgery, University of California, Los Angeles, Medical Center, CHS Room 72-215, 10833 Le Conte Avenue, Los Angeles, CA 90095.

Dr. Livingston: The University of Texas Southwestern Medical Center, 5323 Harry Hines Boulevard, Dallas, TX 75235-9156.

Dr. Nguyen: University of California, Irvine, Medical Center, 101 City Drive, Building 55, Orange, CA 92868.

Related articles in Annals:

Clinical Guidelines
Pharmacologic and Surgical Management of Obesity in Primary Care: A Clinical Practice Guideline from the American College of Physicians
Vincenza Snow, Patricia Barry, Nick Fitterman, Amir Qaseem, Kevin Weiss, AND for the Clinical Efficacy Assessment Subcommittee of the American College of Physicians*

Annals 2005 142: 525-531. [ABSTRACT][SUMMARY][Full Text]  

Clinical Guidelines
Meta-Analysis: Pharmacologic Treatment of Obesity
Zhaoping Li, Margaret Maglione, Wenli Tu, Walter Mojica, David Arterburn, Lisa R. Shugarman, Lara Hilton, Marika Suttorp, Vanessa Solomon, Paul G. Shekelle, AND Sally C. Morton

Annals 2005 142: 532-546. [ABSTRACT][SUMMARY][Full Text]  

Summaries for Patients
Treating Obesity with Drugs and Surgery: A Clinical Practice Guideline from the American College of Physicians

Annals 2005 142: I-55. [Full Text]  

Letters
Correction: Meta-Analysis: Surgical Treatment of Obesity

Annals 2005 143: 468. [Full Text]  

This article has been cited by other articles:

				G. P. August, S. Caprio, I. Fennoy, M. Freemark, F. R. Kaufman, R. H. Lustig, J. H. Silverstein, P. W. Speiser, D. M. Styne, and V. M. Montori Prevention and Treatment of Pediatric Obesity: An Endocrine Society Clinical Practice Guideline Based on Expert Opinion J. Clin. Endocrinol. Metab., December 1, 2008; 93(12): 4576 - 4599. [Abstract] [Full Text] [PDF]

				M. Malone Recommended Nutritional Supplements for Bariatric Surgery Patients Ann. Pharmacother., December 1, 2008; 42(12): 1851 - 1858. [Abstract] [Full Text] [PDF]

				D. Arterburn Bariatric surgery BMJ, July 31, 2008; 337(jul31_1): a755 - a755. [Full Text]

				Surgery for obesity in adults DTB, June 1, 2008; 46(6): 41 - 45. [Abstract] [Full Text] [PDF]

				X. Chu, R. Erdman, M. Susek, H. Gerst, K. Derr, M. Al-Agha, G. C. Wood, C. Hartman, S. Yeager, M. A. Blosky, et al. Association of Morbid Obesity With FTO and INSIG2 Allelic Variants Arch Surg, March 1, 2008; 143(3): 235 - 240. [Abstract] [Full Text] [PDF]

				M. J F Bult, T. van Dalen, and A. F Muller Surgical treatment of obesity Eur. J. Endocrinol., February 1, 2008; 158(2): 135 - 145. [Abstract] [Full Text] [PDF]

				G. Schernthaner and J. M. Morton Bariatric Surgery in Patients With Morbid Obesity and Type 2 Diabetes Diabetes Care, February 1, 2008; 31(Supplement_2): S297 - S302. [Full Text] [PDF]

				B. I. Omalu, D. G. Ives, A. M. Buhari, J. L. Lindner, P. R. Schauer, C. H. Wecht, and L. H. Kuller Death Rates and Causes of Death After Bariatric Surgery for Pennsylvania Residents, 1995 to 2004 Arch Surg, October 1, 2007; 142(10): 923 - 928. [Abstract] [Full Text] [PDF]

				J. W Anderson, S. B Conley, and A. S Nicholas One hundred pound weight losses with an intensive behavioral program: changes in risk factors in 118 patients with long-term follow-up Am. J. Clinical Nutrition, August 1, 2007; 86(2): 301 - 307. [Abstract] [Full Text] [PDF]

				E. Steiger Jonathan E. Rhoads Lecture: Experiences and Observations in the Management of Patients With Short Bowel Syndrome JPEN J Parenter Enteral Nutr, July 1, 2007; 31(4): 326 - 333. [Abstract] [Full Text] [PDF]

				J. P. Dunn and S. M. Jagasia Management of Type 2 Diabetes After Bariatric Surgery Clin. Diabetes, July 1, 2007; 25(3): 112 - 114. [Full Text] [PDF]

				E. J. DeMaria Bariatric Surgery for Morbid Obesity N. Engl. J. Med., May 24, 2007; 356(21): 2176 - 2183. [Full Text] [PDF]

				C. V. Thakar, V. Kharat, S. Blanck, and A. C. Leonard Acute Kidney Injury after Gastric Bypass Surgery Clin. J. Am. Soc. Nephrol., May 1, 2007; 2(3): 426 - 430. [Abstract] [Full Text] [PDF]

				L. Peluso and V. W. Vanek Efficacy of Gastric Bypass in the Treatment of Obesity-Related Comorbidities Nutr Clin Pract, February 1, 2007; 22(1): 22 - 28. [Abstract] [Full Text] [PDF]

				T. Byers and R. L. Sedjo Public Health Response to the Obesity Epidemic: Too Soon or Too Late? J. Nutr., February 1, 2007; 137(2): 488 - 492. [Abstract] [Full Text] [PDF]

				T. T. Ng, M. L. McGory, C. Y. Ko, and M. A. Maggard Meta-analysis in Surgery: Methods and Limitations Arch Surg, November 1, 2006; 141(11): 1125 - 1130. [Abstract] [Full Text] [PDF]

				J. M. Zigman and J. K. Elmquist In search of an effective obesity treatment: A shot in the dark or a shot in the arm? PNAS, August 29, 2006; 103(35): 12961 - 12962. [Full Text] [PDF]

				N. J. Greenberger and P. Sharma Update in Gastroenterology and Hepatology Ann Intern Med, August 15, 2006; 145(4): 294 - 298. [Full Text] [PDF]

				P. A. Simon and J. E. Fielding Public health and business: a partnership that makes cents. Health Aff., July 1, 2006; 25(4): 1029 - 1039. [Abstract] [Full Text] [PDF]

				P. E. O'Brien, J. B. Dixon, C. Laurie, S. Skinner, J. Proietto, J. McNeil, B. Strauss, S. Marks, L. Schachter, L. Chapman, et al. Treatment of Mild to Moderate Obesity with Laparoscopic Adjustable Gastric Banding or an Intensive Medical Program: A Randomized Trial Ann Intern Med, May 2, 2006; 144(9): 625 - 633. [Abstract] [Full Text] [PDF]

				T. A. Wadden and A. G. Tsai Bariatric Surgery: Crossing a Body Mass Index Threshold Ann Intern Med, May 2, 2006; 144(9): 689 - 691. [Full Text] [PDF]

				R. Morinigo, V. Moize, M. Musri, A. M. Lacy, S. Navarro, J. L. Marin, S. Delgado, R. Casamitjana, and J. Vidal Glucagon-Like Peptide-1, Peptide YY, Hunger, and Satiety after Gastric Bypass Surgery in Morbidly Obese Subjects J. Clin. Endocrinol. Metab., May 1, 2006; 91(5): 1735 - 1740. [Abstract] [Full Text] [PDF]

				H. F. Escobar-Morreale, J. I. Botella-Carretero, F. Alvarez-Blasco, J. Sancho, and J. L. San Millan The Polycystic Ovary Syndrome Associated with Morbid Obesity May Resolve after Weight Loss Induced by Bariatric Surgery J. Clin. Endocrinol. Metab., December 1, 2005; 90(12): 6364 - 6369. [Abstract] [Full Text] [PDF]

				H. P. Santry, D. L. Gillen, and D. S. Lauderdale Trends in Bariatric Surgical Procedures JAMA, October 19, 2005; 294(15): 1909 - 1917. [Abstract] [Full Text] [PDF]

				D. S. Zingmond, M. L. McGory, and C. Y. Ko Hospitalization Before and After Gastric Bypass Surgery JAMA, October 19, 2005; 294(15): 1918 - 1924. [Abstract] [Full Text] [PDF]

				K. A Kennel Review: sparse high quality evidence supports surgery for obesity Evid. Based Med., October 1, 2005; 10(5): 141 - 141. [Full Text] [PDF]

				Correction: Meta-Analysis: Surgical Treatment of Obesity Ann Intern Med, September 20, 2005; 143(6): 468 - 468. [Full Text] [PDF]

				B. Robbins Guidelines for the Treatment of Obesity AAP Grand Rounds, September 1, 2005; 14(3): 31 - 32. [Full Text] [PDF]

				Managing Obesity: Clinical Practice Guideline from the ACP Journal Watch (General), April 26, 2005; 2005(426): 1 - 1. [Full Text]

				V. Snow, P. Barry, N. Fitterman, A. Qaseem, K. Weiss, and for the Clinical Efficacy Assessment Subcommittee Pharmacologic and Surgical Management of Obesity in Primary Care: A Clinical Practice Guideline from the American College of Physicians Ann Intern Med, April 5, 2005; 142(7): 525 - 531. [Abstract] [Full Text] [PDF]

Rapid Responses: