This is the current release of the guideline.

This guideline updates a previous version: Society of American Gastrointestinal Endoscopic Surgeons (SAGES). Guidelines for the clinical application of laparoscopic bariatric surgery. Los Angeles (CA): Society of American Gastrointestinal Endoscopic Surgeons (SAGES); 2003 Jul. 5 p. [25 references]

Levels of evidence (I-III) and grades of recommendations (A-C) are defined at the end of the "Major Recommendations" field.

Justification for Surgical Treatment of Obesity

• Weight-loss surgery is the most effective treatment for morbid obesity, producing durable weight loss, improvement or remissions of comorbid conditions, and longer life (level I, grade A).

Guidelines for Selecting Validated Bariatric Procedures

• Laparoscopic roux-en-y gastric bypass (RGB), gastric banding by vertical banded gastroplasty (VBG) or adjustable gastric band (AGB), and biliopancreatic diversion (BPD) with or without duodenal switch (±DS) are established and validated bariatric procedures that provide effective long-term weight loss and resolution of co-morbid conditions (level II, grade A).
• Laparoscopic sleeve gastrectomy (LSG) is validated as providing effective weight loss and resolution of comorbidities to 3 to 5 years (level II, grade C).

Guidelines for Patient Selection

• 1991 National Institute of Health (NIH) consensus guidelines provide valid but incomplete patient selection criteria for contemporary bariatric procedures including laparoscopic BPD ± DS, RGB, VBG and AGB (level II, grade A).
• Other well-selected patients may benefit from laparoscopic bariatric surgery by experienced surgeons:
  • BMI >60 kg/m² (level II, grade A).
  • Patients >60 years (level II, grade B).
• Adolescent bariatric surgery (age <18 years) has been proven effective but should be performed in an experienced center (level II, grade B). Patient selection criteria should be the same as used for adult bariatric surgery (level II, grade C).
• Individuals with BMI 30 to 35 kg/m2 may benefit from laparoscopic bariatric surgery (level I, grade B).

Guidelines for Bariatric Programs

• Bariatric surgery programs should include multidisciplinary providers with appropriate training and experience (level III, grade C).
• Institutions must accommodate the special needs of bariatric patients and their providers (level III, grade C).
• Participation in support groups may improve outcomes after bariatric surgery (level II, grade B).

Guidelines for Preoperative Preparation

• A psychological evaluation is commonly part of the preoperative work-up of bariatric patients (level III, grade C).
• Treated psychopathology does not preclude the benefits of bariatric surgery (level II, grade B).
• Preoperative weight loss may be useful to reduce liver volume and improve access for laparoscopic bariatric procedures (level II, grade B), but mandated preoperative weight loss does not affect postoperative weight loss or comorbidity improvements (level I, grade B).

Guidelines for Laparoscopic BPD ± DS)

• In BPD, the common channel should be 60 to 100 cm, and the alimentary limb 200 to 360 cm (level II, grade C).
• DS diminishes the most severe complications of BPD, including dumping syndrome and peptic ulceration of the anastomosis (level II, grade C).
• BPD is effective in all BMI >35 kg/m² subgroups, with durable weight loss and control of comorbidities beyond 5 years (level II, grade A).
• Laparoscopic BPD provides equivalent weight loss, shorter hospital stay, and fewer complications than open BPD (level III, grade C).
• BPD may result in greater weight loss (level II, grade A) and resolution of comorbidities (level II, grade B) than other bariatric surgeries, but with the highest mortality rate (level II, grade A).
• After BPD ± DS, close nutritional surveillance and supplementation are needed (level III, grade C).

Guidelines for Laparoscopic Roux-en-y Gastric Bypass (RGB)

• In laparoscopic RGB, a small lesser-curvature-based pouch that excludes the gastric fundus and a 75 to 150 cm alimentary (Roux) limb are effective for most patients (level II, grade B).
• Alimentary limbs >150 cm may improve intermediate-term weight loss but also may increase nutritional complications (level III, grade C).
• Laparoscopic RGB is similar in efficacy to open RGB (level I, grade A) with reduced early complications and risk of hernia (level II, grade B).
• Long-term follow-up is recommended and may improve weight-loss outcomes (level III, grade C).

Guidelines for Laparoscopic Adjustable Gastric Band (AGB)

• The pars flaccida approach for laparoscopic AGB placement should be used in preference to the perigastric approach in order to decrease the incidence of gastric prolapse (level II, grade A).
• Laparoscopic AGB is effective in all BMI subgroups, with durable weight loss and control of comorbidities past 5 years (level I, grade A).
• Intermediate-term weight loss after laparoscopic AGB may be less than after laparoscopic RGB (level I, grade A).
• Frequent outpatient visits are suggested in the early postoperative period. Band filling should be guided by weight loss, satiety, and patient symptoms (level III, grade C).

Guidelines for Revisional Bariatric Surgery

• Prior to elective procedures, anatomy should be defined by review of available records, plus radiographic and/or endoscopic assessment (level II, grade B).
• Laparoscopic revisional procedures may be performed safely, but with more complications than primary bariatric procedures, therefore the relative risks and benefits of laparoscopy should be considered on a case-by-case basis (level III, grade C).

Definitions:

Levels of Evidence

Grades of Recommendation

None provided

The type of supporting evidence is identified and graded for each recommendation (see the "Major Recommendations" field).

Not applicable: The guideline was not adapted from another source.

2003 Jul (revised 2008 Oct)

Society of American Gastrointestinal and Endoscopic Surgeons - Medical Specialty Society

Society of American Gastrointestinal Endoscopic Surgeons (SAGES)

SAGES Guidelines Committee

Not stated

Members of the Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) disclose potential conflicts of interest and pertinent financial relationships prior to serving as faculty for SAGES-sponsored educational events, delivering presentations at scientific meetings, etc. Additionally, members of SAGES Committees disclose their potential conflicts of interest and pertinent financial relationships annually as a condition of committee membership.

This is the current release of the guideline.

This guideline updates a previous version: Society of American Gastrointestinal Endoscopic Surgeons (SAGES). Guidelines for the clinical application of laparoscopic bariatric surgery. Los Angeles (CA): Society of American Gastrointestinal Endoscopic Surgeons (SAGES); 2003 Jul. 5 p. [25 references]

None available

This summary was completed by ECRI on March 22, 2004. The information was verified by the guideline developer on April 27, 2004. This information was updated by ECRI Institute on November 14, 2008. The updated information was verified by the guideline developer on December 5, 2008.

This NGC summary is based on the original guideline, which is subject to the guideline developer's copyright restrictions.