Surgical management of morbid obesity.

Obesity imposes devastating health and financial tolls on society and those who suffer from it. Despite the growing awareness of the problem, the obesity epidemic, along with its associated complications, continues to expand at an alarming rate (1). The current nomenclature used to measure an individuals degree of obesity is BMI, which is calculated by dividing weight (in kilograms) by the square of height (in meters) (Table 1). Based on these criteria, the CDC (Centers for Disease Control and Prevention) reports a doubling of the obese population (BMI 30 kg/m) in the period between 1976–1980 and 2001– 2002 to reach an estimated number of 63 million obese people. Currently in the U.S., nearly two-thirds of adults are overweight (BMI 25 kg/m), nearly onethird are considered obese (BMI 30 kg/ m), and 4.7% are extremely obese (BMI 40 kg/m) (2). The financial cost of obesity in the U.S. is estimated to be in excess of $100 billion/year (3). In addition to increased risk of diabetes and other comorbid diseases, obese individuals may expect significant decreases in life expectancy (4) (Table 2). This obesity-related diminution in longetivity directly contributes to 280,000 deaths annually in the U.S. (5). Medical (nonsurgical) weight loss therapies include combinations of diet, exercise, behavioral therapies, and medications. In 1998, an NIH (National Institutes of Health) expert panel, upon critical review of the literature, concluded that these modalities, either alone or in combination, can induce modest weight loss that confers health benefits to the patients (6). However, the weight loss induced by these therapies is often short lived. Furthermore, medical management must continue indefinitely to be effective, or weight regain is common. Such medical therapies have not been shown to be effective in maintaining long-term weight loss in a morbidly obese patient population. Thus, most physicians realize that surgery remains the best option for many morbidly obese patients. Because severe obesity is associated with increased risk for premature death, the 1991 NIH consensus panel set out guidelines for surgical therapies in patients with extreme obesity (BMI 40 kg/m or 35–40 kg/m with comorbidities) (7) (Table 3). A follow-up NIH consensus meeting was held recently in June 2004, and new recommendations will be available in the near future. A more recent procedure, adjustable gastric banding, is expected to be included in the updated surgical procedures.