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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.

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