0
We're unable to sign you in at this time. Please try again in a few minutes.
Retry
We were able to sign you in, but your subscription(s) could not be found. Please try again in a few minutes.
Retry
There may be a problem with your account. Please contact the AMA Service Center to resolve this issue.
Contact the AMA Service Center:
Telephone: 1 (800) 262-2350 or 1 (312) 670-7827  *   Email: subscriptions@jamanetwork.com
Error Message ......
Review Article |

Safety of Laparoscopic vs Open Bariatric Surgery:  A Systematic Review and Meta-analysis FREE

Jennifer Reoch, BSc; Salvatore Mottillo, BSc; Avi Shimony, MD; Kristian B. Filion, PhD; Nicolas V. Christou, MD, PhD; Lawrence Joseph, PhD; Paul Poirier, MD, PhD; Mark J. Eisenberg, MD, MPH
[+] Author Affiliations

Author Affiliations: Divisions of Cardiology and Clinical Epidemiology (Ms Reoch, Mr Mottillo, and Dr Eisenberg) and Lady Davis Institute for Medical Research (Ms Reoch, Mr Mottillo, and Drs Shimony and Eisenberg), Jewish General Hospital/McGill University, Faculty of Nursing (Ms Reoch), Department of Epidemiology, Biostatistics, and Occupational Health (Drs Joseph and Eisenberg) and Divisions of Clinical Epidemiology (Dr Joseph) and Bariatric Surgery (Dr Christou), McGill University Health Center, McGill University, and Faculty of Medicine, University of Montreal (Mr Mottillo), Montreal, and Faculty of Pharmacy, Quebec Heart and Lung Institute, Quebec (Dr Poirier), Quebec, Canada; and Division of Epidemiology and Community Health, School of Public Health, University of Minnesota, Minneapolis (Dr Filion).


Arch Surg. 2011;146(11):1314-1322. doi:10.1001/archsurg.2011.270.
Text Size: A A A
Published online

Objective To perform a systematic review and meta-analysis evaluating the risk of reoperation, wound infection, incisional hernia, anastomotic leak, and all-cause mortality associated with laparoscopic vs open bariatric surgery at a minimum of 12 months' follow-up.

Data Sources We systematically searched the Cochrane Library, EMBASE, and MEDLINE databases through June 1, 2010, for randomized controlled trials comparing laparoscopic with open bariatric surgery.

Study Selection We included all randomized controlled trials that reported weight loss outcomes and complications at a minimum of 12 months' follow-up and had a minimum of 50 patients. We identified 6 randomized controlled trials, which randomized 510 patients.

Data Extraction Data were extracted by 2 reviewers on study design, baseline characteristics, and surgical procedure. The outcome data extracted included change in weight and body mass index and the incidence of reoperation, wound infection, incisional hernia, anastomotic leak, and all-cause mortality.

Data Synthesis We used random-effects models, which accounted for within-study and between-study variability, to estimate pooled risk ratios (95% CIs). Compared with open surgery, laparoscopic surgery was associated with lower risk of wound infection (relative risk [RR], 0.21; 95% CI, 0.07-0.65) and incisional hernia (RR, 0.11; 95% CI, 0.03-0.35). The risk of reoperation (RR, 1.06; 95% CI, 0.70-1.61), anastomotic leak (RR, 0.64; 95% CI, 0.14-2.95), and all-cause mortality (RR, 0.86; 95% CI, 0.22-3.28) may be similar for laparoscopic and open bariatric surgery.

Conclusion Laparoscopic surgery may be a safer treatment than open surgery for patients requiring bariatric surgery.

Figures in this Article

Morbid obesity is a serious problem in North America. Increasing by 52.0% from 2000 to 2005, the prevalence of morbid obesity (defined as body mass index, calculated as weight in kilograms divided by height in meters squared, ≥40) in the United States is estimated at 5.7%.1,2 Morbid obesity is associated with increased risk of mortality and morbidity, including arthritis, back pain, cardiovascular disease, diabetes mellitus, and hypertension.35

Bariatric surgery is an efficacious treatment of morbid obesity and has been shown to promote considerable weight loss and to reduce the risk of cardiovascular disease, certain cancers, and all-cause mortality.610 Bariatric surgery can be performed laparoscopically (via a small incision in the abdomen) or using an open procedure (ie, laparotomy). Laparoscopic bariatric surgery has been performed since 1993 and has quickly surpassed open surgery in popularity.11 Between 2004 and 2006, more than 16 000 laparoscopic gastric bypass procedures were performed compared with approximately 6000 open gastric bypass procedures in academic medical centers across the United States.12 Based on results of observational studies and small randomized controlled trials (RCTs), laparoscopic technique is thought to reduce length of hospital stay and risk of complications; however, this has not been substantiated. Because of the increasing popularity of bariatric surgery for the treatment of morbid obesity, it is important to identify the safest method.

Our objective was to pool the results of previous RCTs comparing the risk of complications associated with laparoscopic vs open bariatric surgery. Specifically, we compared the risk of reoperation, wound infection, incisional hernia, anastomotic leak, and all-cause mortality associated with laparoscopic vs open bariatric surgery.

DATA SOURCES AND SEARCHES

We systematically searched the Cochrane Library, EMBASE, and MEDLINE databases through June 1, 2010, using the following terms: adjustable gastric banding, bariatric, bariatric surgery, biliopancreatic diversion with duodenal switch, bypass, gastric bypass, gastric pacing, gastric stimulation, gastroplasty, implantable gastric stimulation, jejunoileal bypass, ligation, obesity, Roux-en-Y, sleeve gastrectomy, vertical banded gastroplasty, and weight loss. We limited our search to RCTs involving adults and published in English. References from previous RCTs and reviews were examined for potentially relevant publications not identified in the database search.

STUDY SELECTION

Studies eligible for inclusion met the following criteria: (1) they randomized patients to laparoscopic vs open bariatric surgery, (2) they reported weight loss outcomes and complications (reoperation, wound infection, incisional hernia, anastomotic leak, and all-cause mortality), (3) they had a follow-up period of at least 12 months, and (4) they had 50 or more patients. The sample size criterion was included to minimize the effects of publication bias. All studies that did not meet these criteria were excluded.

DATA EXTRACTION

Our study was performed according to the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-analyses) statement for reporting systematic reviews and meta-analyses (Figure 1).13 Two reviewers (J.R. and S.M.) independently extracted data using a standardized extraction form. The rate of disagreement for extracted data was less than 5% between the 2 reviewers. Disagreements were resolved by consensus or, when necessary, by a third reviewer (M.J.E.). Data extracted included the following: patient population, type of procedure, duration of procedure, length of hospital stay, baseline characteristics (age, sex, weight, and body mass index), study design characteristics (eg, setting, number of patients per treatment arm, and length of follow-up period), and outcome data (change in weight and body mass index and the incidence of reoperation, wound infection, incisional hernia, anastomotic leak, and all-cause mortality).

Place holder to copy figure label and caption
Graphic Jump Location

Figure 1. PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-analyses) flow diagram of randomized controlled trials (RCTs).13

QUALITY ASSESSMENT

We used the Cochrane Collaboration's tool for assessing the risk of bias,14 focusing on the following 6 criteria: (1) sequence generation; (2) allocation concealment; (3) blinding of participants, personnel, and outcome assessors; (4) incomplete outcome data; (5) selective outcome reporting; and (6) other sources of bias. Each RCT was classified as “high quality,” “low quality,” or “unclear quality” for each criterion.

DATA SYNTHESIS AND META-ANALYSIS

We used random-effects models by DerSimonian and Laird,15 which accounted for within-study and between-study variability, to estimate pooled risk ratios (95% CIs). Forest plots were created for each outcome. We used a 0.5 continuity correction for trials with no events in one or both treatment groups. We calculated I2 statistics to estimate the proportion of overall variation that was attributable to between-trial heterogeneity. We assessed for publication bias using the modified test for small-study effects by Harbord et al.16 For data handling and statistical analyses, we used commercially available software (Excel 200717 [Microsoft Corporation, Redmond, Washington] and STATA 9.018 [StataCorp LP, College Station, Texas]).

SEARCH FINDINGS AND STUDY INCLUSION

Our literature search identified 2446 potentially relevant studies (Figure 1); 159 were retrieved for full-text assessment, and 6 met our inclusion criteria. The remaining 153 studies were excluded for the following reasons: (1) they were not an RCT (n = 94), (2) they did not compare laparoscopic with open bariatric surgery (n = 40), (3) they did not include outcomes relevant to our study (n = 10), (4) they did not include a comparison group (n = 7), (5) the total sample size was fewer than 50 patients (n = 1), or (6) the follow-up period was less than 12 months (n = 1). The RCT19 excluded for having fewer than 50 patients did not report enough relevant outcomes to warrant inclusion.

RISK OF BIAS

The risk of bias was unknown for many included RCTs (Figure 2). Specifically, 3 RCTs2022 did not report sequence generation, and 4 RCTs2023 did not report allocation concealment. Only 1 RCT21 blinded the participants to their treatment group, and none mentioned whether outcome assessors were blinded.2025 Two RCTs21,25 did not provide the number of patients at follow-up periods, and 1 RCT25 reported weight loss outcomes in a figure; therefore, the risk of incomplete outcome data was unknown. Finally, 2 RCTs20,21 used blocked randomization with fixed block sizes in an unblinded trial, and 1 study22 had an unbalanced prevalence of comorbidity between the treatment groups; these RCTs were classified as having a high risk of other sources of bias. Using the modified test for small-study effects by Harbord et al,16 our results suggest that there was no publication bias among the RCTs in our meta-analysis for reoperation (P = .18), wound infection (P = .95), incisional hernia (P = .22), or anastomotic leak (P = .99).

Place holder to copy figure label and caption
Graphic Jump Location

Figure 2. Quality assessment of 6 included randomized controlled trials (RCTs) using the Cochrane Handbook for Systematic Reviews of Interventions.14

BASELINE CHARACTERISTICS

Reported baseline data were similar across laparoscopic and open bariatric surgery groups (Table 1). The mean age ranged from 37 to 42 years, and the percentage of female patients ranged from 68% to 92%. All patients were considered to have morbid obesity. The mean weight at baseline, reported in 3 RCTs, ranged from 130.7 to 152.2 kg. The mean body mass index at baseline ranged from 41 to 52.

Table Graphic Jump LocationTable 1. Baseline Characteristics Reported in Included Randomized Controlled Trials
STUDY DESIGN AND OPERATIVE CHARACTERISTICS

The 6 included RCTs randomized a total of 262 patients to laparoscopic bariatric surgery and 248 patients to open bariatric surgery (Table 2). Follow-up periods ranged from 12 to 24 months. Four RCTs reported the prevalence of loss to follow-up, which ranged from 0.0% to 2.0%. Operative time ranged from 150 to 245 minutes in the laparoscopic group and from 76 to 202 minutes in the open group. The mean length of hospital stay ranged from 3 to 6 days in the laparoscopic group and from 4 to 8 days in the open group, suggesting that laparoscopic surgery was associated with, on average, a reduction of 1 to 3 days in the hospital. We were unable to pool the data on length of hospital stay because only 2 studies reported standard deviations.

Table Graphic Jump LocationTable 2. Study Design and Operative Characteristics Reported in Included Randomized Controlled Trials
COMPLICATIONS

Complications reported for each RCT include reoperation, wound infection, incisional hernia, anastomotic leak, and all-cause mortality (Table 3). The number of patients who required reoperation ranged from 1 to 20 patients in the laparoscopic group and from 0 to 21 patients in the open group. The risk of reoperation was similar in the 2 groups (relative risk [RR] of laparoscopic vs open surgery, 1.06; 95% CI, 0.70-1.61), albeit with a wide 95% CI (Figure 3). Most RCTs included in our meta-analysis reported anastomotic leak (4 studies) and intestinal obstruction (3 studies) as reasons for reoperation (Table 4). The incidence of wound infection ranged from 0 to 1 in the laparoscopic group vs 1 to 8 in the open group. The risk of wound infection was substantially lower in the laparoscopic group (RR, 0.21; 95% CI, 0.07-0.65) (Figure 4). The incidence of incisional hernia was 0 in the laparoscopic group and ranged from 1 to 10 in the open group. The risk of incisional hernia was substantially lower in the laparoscopic group (RR, 0.11; 95% CI, 0.03-0.35) (Figure 5). The incidence of anastomotic leak ranged from 0 to 2 in the laparoscopic group and from 0 to 3 in the open group. The risk of anastomotic leak was lower in the laparoscopic group (RR, 0.64; 95% CI, 0.14-2.95); however, the 95% CI was wide (Figure 6). Finally, the incidence of all-cause mortality ranged from 0 to 2 in the laparoscopic group and from 0 to 2 in the open group. Although the point estimate suggested that the risk of all-cause mortality was similar for both groups, the result is debatable because of the wide 95% CI (RR, 0.86; 95% CI, 0.22-3.28) (Figure 7).

Place holder to copy figure label and caption
Graphic Jump Location

Figure 3. Relative risk (RR) of reoperation in laparoscopic vs open bariatric surgery. The point estimate suggests that the risk of reoperation is similar for laparoscopic vs open bariatric surgery; however, the 95% CI is wide and does not preclude an effect. Diamond indicates overall summary estimate for the analysis (width of the diamond represents the 95% CI); width of the solid square, studies weight within the meta-analysis; and dot, the study-specific point estimate.

Place holder to copy figure label and caption
Graphic Jump Location

Figure 4. Relative risk (RR) of wound infection in laparoscopic vs open bariatric surgery. Laparoscopic surgery is associated with a lower risk of wound infection compared with open bariatric surgery (RR, 0.21; 95% CI, 0.07-0.65). See the legend to Figure 3 for an explanation of the symbols in the Forest plot.

Place holder to copy figure label and caption
Graphic Jump Location

Figure 5. Relative risk (RR) of incisional hernia in laparoscopic vs open bariatric surgery. Laparoscopic surgery is associated with a lower risk of incisional hernia compared with open bariatric surgery (RR, 0.11; 95% CI, 0.03-0.35). See the legend to Figure 3 for an explanation of the symbols in the Forest plot.

Place holder to copy figure label and caption
Graphic Jump Location

Figure 6. Relative risk (RR) of anastomotic leak in laparoscopic vs open bariatric surgery. The point estimate suggests that the risk of anastomotic leak is similar for laparoscopic vs open bariatric surgery; however, the 95% CI is wide and does not preclude an effect. See the legend to Figure 3 for an explanation of the symbols in the Forest plot.

Place holder to copy figure label and caption
Graphic Jump Location

Figure 7. Relative risk (RR) of all-cause mortality in laparoscopic vs open bariatric surgery. The point estimate suggests that the risk of all-cause mortality is similar for laparoscopic vs open bariatric surgery; however, the 95% CI is wide and does not preclude an effect. See the legend to Figure 3 for an explanation of the symbols in the Forest plot.

Table Graphic Jump LocationTable 3. Complications Reported in Included Randomized Controlled Trials
Table Graphic Jump LocationTable 4. Reasons for Reoperation and Causes of Mortality
WEIGHT LOSS OUTCOMES

Weight loss outcomes at 12 months' follow-up were reported in 5 of 6 RCTs (Table 5). Four RCTs reported the mean change in body mass index, which ranged from −11.6 to −15.0 in the laparoscopic group and from −10.6 to −15.5 in the open group. Two RCTs reported the mean weight loss in kilograms, which ranged from −35.0 to −39.0 kg in the laparoscopic group and from −34.4 to −41.0 kg in the open group. Only 1 study25 reported the mean (SD) percentage change in excess body weight, which was −68% (−15%) for the laparoscopic group and −62% (−14%) for the open group.

Table Graphic Jump LocationTable 5. Weight Loss Outcomes at 12 Months' Follow-up Reported in Included Randomized Controlled Trials

Several review articles2628 have examined laparoscopic and open bariatric surgery. A Cochrane Collaboration study26 published in 2009 reviewed data on mortality, reoperation, complications, and weight loss; however, this study did not statistically pool data to provide comparative treatment effects. Two other articles27,28 reviewed data from observational studies and RCTs examining complications and found that rates of wound infection and incisional hernia were lower with laparoscopic surgery, whereas the rate of small-bowel obstruction was higher with laparoscopic surgery. Most important, these reviews did not directly compare laparoscopic and open bariatric surgical procedures, and no comparative treatment effects were available.

Two previous meta-analyses29,30 examined laparoscopic and open bariatric surgery. Buchwald et al29 showed that the absolute risk of mortality was low, similar to that reported herein. Maggard et al30 pooled data on weight loss, complications, and mortality for laparoscopic and open bariatric surgery groups. The risks of wound infection and incisional hernia were lower in the laparoscopic group compared with the open group. However, this meta-analysis included observational and RCT data, complicating interpretation of their results. Our study provides evidence based exclusively on RCTs to avoid the possible selection bias associated with observational studies.

Our study was designed to compare the risk of complications associated with laparoscopic vs open bariatric surgery. We found that laparoscopic surgery lowered the risk of wound infection by 79% and the risk of incisional hernia by 89% compared with open surgery. The risks of reoperation, anastomotic leak, and all-cause mortality were similar for the 2 types of surgery. Too few investigations have been conducted to conclude that there is no difference in the risk of these complications; therefore, additional studies may be necessary. We were unable to pool weight loss data at 12 months' follow-up because of the heterogeneous reporting. However, RCTs reporting weight loss showed no clinically important difference between laparoscopic and open surgery. Our results suggest that laparoscopic surgery is the operation of choice for patients undergoing bariatric surgery because it reduces the risk of wound infection and incisional hernia. However, we were unable to include in our study other important complications, such as pulmonary findings, small-bowel obstruction, hemorrhage, and gastrointestinal tract results.

Because laparoscopic bariatric surgery is characterized by smaller incisions, reducing the healing time and exposure to microorganisms, it is not surprising that it is associated with a lower risk of wound infection and incisional hernia compared with open surgery. Observational cohort studies12,3137 have corroborated this hypothesis. Given the inherent limitations of observational studies, such as potential selection bias, confounding, and investigator bias, it was necessary to evaluate the risk of these complications in RCTs. The sample sizes of the individual RCTs included in our meta-analysis were too small to provide reliable conclusions about the safety of laparoscopic vs open bariatric surgery. By pooling data across RCTs, we obtained more precise 95% CIs. Hence, we showed a decrease in the risk of wound infection and incisional hernia among patients undergoing laparoscopic bariatric surgery compared with those undergoing open bariatric surgery.

The risk of reoperation was similar in the laparoscopic and open surgery groups. However, given the wide 95% CIs and the few studies reporting reoperation in our meta-analysis, more studies may be needed to confirm this. Previous observational studies36,37 found no difference in the risk of reoperation between laparoscopic and open bariatric surgery. In contrast, a cross-sectional study38 of more than 19 000 patients undergoing bariatric surgery in 2005 found increased reoperation in the open surgery group compared with the laparoscopic surgery group (odds ratio [OR], 3.71; 95% CI, 2.47-5.59). Hence, a difference in the risk of reoperation between laparoscopic and open bariatric surgery remains debatable. The information available herein and in the literature about anastomotic leak is inconclusive.31,33,35,36 However, the risk of anastomotic leak decreases as bariatric surgeons gain more experience.31 Although no firm conclusions can be drawn, our results suggest that laparoscopic and open bariatric surgical procedures are associated with a similar risk of anastomotic leak.

Our findings indicate that bariatric surgery is a safe method of weight loss, as there was little mortality associated with laparoscopic and open procedures among a low-risk young population. Previous high-quality trials68,39 have illustrated the potential benefits of obesity surgery. The improvements gained with bariatric surgery far outweigh the small risk of mortality associated with the procedure.

We were unable to pool the weight loss data at 12 months' follow-up because of a large variability in the types of weight loss outcomes reported. Four RCTs reported the mean change in body mass index, which was the most common weight loss outcome reported, but only 1 RCT provided the standard deviation. Furthermore, 12-month weight loss data may be too short to be indicative of end results for bariatric surgery. The included RCTs did not report long-term weight loss data; therefore, additional RCTs may be necessary.

Our meta-analysis has several potential limitations. First, because of the limited number of RCTs comparing laparoscopic with open bariatric surgery, our meta-analysis did not have sufficient precision to conclusively compare the effects of laparoscopic and open surgery on the risks of reoperation, anastomotic leak, or all-cause mortality. Second, owing to heterogeneous reporting, we were unable to pool weight loss data. A standard weight loss outcome is necessary to effectively compare weight loss between these surgical procedures. Furthermore, additional RCTs with longer follow-up data are needed to provide meaningful weight loss outcomes for bariatric surgery. Third, owing to inconsistent reporting of complications, we were unable to address the risk associated with other complications (eg, pulmonary findings, cardiovascular events, bowel obstructions, hemorrhage, or gastrointestinal symptoms). More information on these complications is required to provide a more complete comparison of laparoscopic and open bariatric surgery. Fourth, as is true for most systematic reviews and meta-analyses, our meta-analysis may have been affected by publication bias. However, we assessed for publication bias using the modified test for small-study effects by Harbord et al16 and found no effect. Fifth, one of our included RCTs used a hand-assisted laparoscopic technique. The hand-assisted technique makes use of a larger incision than traditional laparoscopic surgery, and it may not be appropriate to pool these techniques. However, a previous prospective study40 of 272 patients compared hand-assisted with laparoscopic gastric bypass and found no difference in the risk of complications. Therefore, we included the hand-assisted technique in the laparoscopic bariatric surgery group.

In conclusion, although data from RCTs are limited, our meta -analysis demonstrates that laparoscopic bariatric surgery is associated with a substantially lower risk of wound infection and incisional hernia compared with open bariatric surgery. The differences between laparoscopic and open bariatric surgery with regard to the risks of reoperation, anastomotic leak, and all-cause mortality remain unknown. However, the risk of all-cause mortality is low in both groups among this young population. Weight loss may be similar between the 2 groups at 12 months. Further research using a standardized method of reporting weight loss and a longer follow-up period is needed to conclusively determine the most efficacious technique for bariatric surgery. Given the current information, we believe that laparoscopic and open bariatric surgical procedures are safe, but laparoscopic bariatric surgery seems to be the technique of choice.

Correspondence: Mark J. Eisenberg, MD, MPH, Divisions of Cardiology and Clinical Epidemiology, Jewish General Hospital, McGill University, 3755 Côte Ste-Catherine Rd, Ste H-421.1, Montreal, QC H3T 1E2, Canada (mark.eisenberg@mcgill.ca).

Accepted for Publication: February 20, 2011.

Author Contributions:Study concept and design: Reoch, Mottillo, Filion, and Eisenberg. Acquisition of data: Reoch, Mottillo, and Shimony. Analysis and interpretation of data: Reoch, Mottillo, Shimony, Filion, Joseph, Poirier, and Eisenberg. Drafting of the manuscript: Reoch, Mottillo, Shimony, and Joseph. Critical revision of the manuscript for important intellectual content: Reoch, Mottillo, Shimony, Filion, Christou, Poirier, and Eisenberg. Statistical analysis: Mottillo, Shimony, and Joseph. Obtained funding: Mottillo, Filion, and Eisenberg. Administrative, technical, and material support: Mottillo, Poirier, and Eisenberg. Study supervision: Mottillo, Christou, and Eisenberg.

Financial Disclosure: None reported.

Funding/Support: This study was supported by grant 103506 from the Canadian Institutes of Health Research (CIHR). Ms Reoch is the recipient of a CIHR Health Professional Student Research Award. Dr Filion is supported in part by postdoctoral fellowships from the Heart and Stroke Foundation of Canada and the Fonds de la Recherche en Santé du Québec (FRSQ). Drs Joseph and Eisenberg are supported by the FRSQ Chercheur-National. Dr Poirier is an FRSQ Senior Physician-Scientist.

Previous Presentation: The abstract of this study was presented at McGill Cardiovascular Research Day; February 17, 2011; Montreal, Quebec, Canada; and the L. D. MacLean General Surgery Research Day; April 6, 2011; Montreal.

Additional Contributions: Tara Dourian, BA, assisted in data extraction.

Flegal KM, Carroll MD, Ogden CL, Curtin LR. Prevalence and trends in obesity among US adults, 1999-2008.  JAMA. 2010;303(3):235-241
PubMed   |  Link to Article
Sturm R. Increases in morbid obesity in the USA: 2000-2005.  Public Health. 2007;121(7):492-496
PubMed   |  Link to Article
Gilmore J. Body mass index and health.  Health Rep. 1999;11(1):31-43 [English], 33-47 [French]
PubMed
Tjepkema M. Adult obesity.  Health Rep. 2006;17(3):9-25
PubMed
Adams KF, Schatzkin A, Harris TB,  et al.  Overweight, obesity, and mortality in a large prospective cohort of persons 50 to 71 years old.  N Engl J Med. 2006;355(8):763-778
PubMed   |  Link to Article
Adams TD, Gress RE, Smith SC,  et al.  Long-term mortality after gastric bypass surgery.  N Engl J Med. 2007;357(8):753-761
PubMed   |  Link to Article
Batsis JA, Romero-Corral A, Collazo-Clavell ML, Sarr MG, Somers VK, Lopez-Jimenez F. Effect of bariatric surgery on the metabolic syndrome: a population-based, long-term controlled study.  Mayo Clin Proc. 2008;83(8):897-907
PubMed
Christou NV, Sampalis JS, Liberman M,  et al.  Surgery decreases long-term mortality, morbidity, and health care use in morbidly obese patients.  Ann Surg. 2004;240(3):416-424
PubMed   |  Link to Article
Sjöström L, Lindroos AK, Peltonen M,  et al; Swedish Obese Subjects Study Scientific Group.  Lifestyle, diabetes, and cardiovascular risk factors 10 years after bariatric surgery.  N Engl J Med. 2004;351(26):2683-2693
PubMed   |  Link to Article
Sjöström L, Narbro K, Sjöström CD,  et al; Swedish Obese Subjects Study.  Effects of bariatric surgery on mortality in Swedish obese subjects.  N Engl J Med. 2007;357(8):741-752
PubMed   |  Link to Article
Wittgrove AC, Clark GW, Tremblay LJ. Laparoscopic gastric bypass, Roux-en-Y: preliminary report of five cases.  Obes Surg. 1994;4(4):353-357
PubMed   |  Link to Article
Nguyen NT, Hinojosa M, Fayad C, Varela E, Wilson SE. Use and outcomes of laparoscopic versus open gastric bypass at academic medical centers.  J Am Coll Surg. 2007;205(2):248-255
PubMed   |  Link to Article
Moher D, Liberati A, Tetzlaff J, Altman DG. Preferred Reporting Items for Systematic Reviews and Meta-analyses: the PRISMA statement.  Ann Intern Med. 2009;151(4):264-269, W64PRISMA Group
Higgins J, Green S. Cochrane Collaboration: Cochrane Handbook for Systematic Reviews of Interventions. Chichester, England: Wiley-Blackwell; 2008
DerSimonian R, Laird N. Meta-analysis in clinical trials.  Control Clin Trials. 1986;7(3):177-188
PubMed   |  Link to Article
Harbord RM, Egger M, Sterne JA. A modified test for small-study effects in meta-analyses of controlled trials with binary endpoints.  Stat Med. 2006;25(20):3443-3457
PubMed   |  Link to Article
Microsoft Corporation.  Excel 2007 (Part of Microsoft Office Professional Edition) [computer program].  Redmond, WA: Microsoft Corporation; 2006
StataCorp LP.  STATA Statistical Software: Release 9 [computer program].  College Station, TX: StataCorp LP; 2005
Dávila-Cervantes A, Borunda D, Domínguez-Cherit G,  et al.  Open versus laparoscopic vertical banded gastroplasty: a randomized controlled double blind trial.  Obes Surg. 2002;12(6):812-818
PubMed   |  Link to Article
Nguyen NT, Goldman C, Rosenquist CJ,  et al.  Laparoscopic versus open gastric bypass: a randomized study of outcomes, quality of life, and costs.  Ann Surg. 2001;234(3):279-291
PubMed   |  Link to Article
Westling A, Gustavsson S. Laparoscopic vs open Roux-en-Y gastric bypass: a prospective, randomized trial.  Obes Surg. 2001;11(3):284-292
PubMed   |  Link to Article
Sundbom M, Gustavsson S. Randomized clinical trial of hand-assisted laparoscopic versus open Roux-en-Y gastric bypass for the treatment of morbid obesity.  Br J Surg. 2004;91(4):418-423
PubMed   |  Link to Article
van Dielen FM, Soeters PB, de Brauw LM, Greve JW. Laparoscopic adjustable gastric banding versus open vertical banded gastroplasty: a prospective randomized trial.  Obes Surg. 2005;15(9):1292-1298
PubMed   |  Link to Article
de Wit LT, Mathus-Vliegen L, Hey C, Rademaker B, Gouma DJ, Obertop H. Open versus laparoscopic adjustable silicone gastric banding: a prospective randomized trial for treatment of morbid obesity.  Ann Surg. 1999;230(6):800-807
PubMed   |  Link to Article
Luján JA, Frutos MD, Hernández Q,  et al.  Laparoscopic versus open gastric bypass in the treatment of morbid obesity: a randomized prospective study.  Ann Surg. 2004;239(4):433-437
PubMed   |  Link to Article
Colquitt JL, Picot J, Loveman E, Clegg AJ. Surgery for obesity.  Cochrane Database Syst Rev. 2009;(2):CD003641
PubMed
Gentileschi P, Kini S, Catarci M, Gagner M. Evidence-based medicine: open and laparoscopic bariatric surgery.  Surg Endosc. 2002;16(5):736-744
PubMed   |  Link to Article
Nguyen NT, Wolfe BM. Laparoscopic versus open gastric bypass.  Semin Laparosc Surg. 2002;9(2):86-93
PubMed   |  Link to Article
Buchwald H, Estok R, Fahrbach K, Banel D, Sledge I. Trends in mortality in bariatric surgery: a systematic review and meta-analysis.  Surgery. 2007;142(4):621-635
PubMed   |  Link to Article
Maggard MA, Shugarman LR, Suttorp M,  et al.  Meta-analysis: surgical treatment of obesity.  Ann Intern Med. 2005;142(7):547-559
PubMed
Jones KB Jr, Afram JD, Benotti PN,  et al.  Open versus laparoscopic Roux-en-Y gastric bypass: a comparative study of over 25,000 open cases and the major laparoscopic bariatric reported series.  Obes Surg. 2006;16(6):721-727
PubMed   |  Link to Article
Marsk R, Tynelius P, Rasmussen F, Freedman J. Short-term morbidity and mortality after open versus laparoscopic gastric bypass surgery. A population-based study from Sweden.  Obes Surg. 2009;19(11):1485-1490
PubMed   |  Link to Article
Nguyen NT, Ho HS, Palmer LS, Wolfe BM. A comparison study of laparoscopic versus open gastric bypass for morbid obesity.  J Am Coll Surg. 2000;191(2):149-157
PubMed   |  Link to Article
Paxton JH, Matthews JB. The cost effectiveness of laparoscopic versus open gastric bypass surgery.  Obes Surg. 2005;15(1):24-34
PubMed   |  Link to Article
Courcoulas A, Perry Y, Buenaventura P, Luketich J. Comparing the outcomes after laparoscopic versus open gastric bypass: a matched paired analysis.  Obes Surg. 2003;13(3):341-346
PubMed   |  Link to Article
Sekhar N, Torquati A, Youssef Y, Wright JK, Richards WO. A comparison of 399 open and 568 laparoscopic gastric bypasses performed during a 4-year period.  Surg Endosc. 2007;21(4):665-668
PubMed   |  Link to Article
Suter M, Giusti V, Heraief E, Jayet C, Jayet A. Early results of laparoscopic gastric banding compared with open vertical banded gastroplasty.  Obes Surg. 1999;9(4):374-380
PubMed   |  Link to Article
Weller WE, Rosati C. Comparing outcomes of laparoscopic versus open bariatric surgery.  Ann Surg. 2008;248(1):10-15
PubMed   |  Link to Article
Flum DR, Belle SH, King WC,  et al; Longitudinal Assessment of Bariatric Surgery (LABS) Consortium.  Perioperative safety in the longitudinal assessment of bariatric surgery.  N Engl J Med. 2009;361(5):445-454
PubMed   |  Link to Article
Hassan M, Kerlakian G, Curry T, Engel A, Bollmer C. Comparing outcomes of hand-assisted versus total laparoscopic gastric bypass.  Surg Obes Relat Dis. 2008;4(2):91-95
PubMed   |  Link to Article

Figures

Place holder to copy figure label and caption
Graphic Jump Location

Figure 1. PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-analyses) flow diagram of randomized controlled trials (RCTs).13

Place holder to copy figure label and caption
Graphic Jump Location

Figure 2. Quality assessment of 6 included randomized controlled trials (RCTs) using the Cochrane Handbook for Systematic Reviews of Interventions.14

Place holder to copy figure label and caption
Graphic Jump Location

Figure 3. Relative risk (RR) of reoperation in laparoscopic vs open bariatric surgery. The point estimate suggests that the risk of reoperation is similar for laparoscopic vs open bariatric surgery; however, the 95% CI is wide and does not preclude an effect. Diamond indicates overall summary estimate for the analysis (width of the diamond represents the 95% CI); width of the solid square, studies weight within the meta-analysis; and dot, the study-specific point estimate.

Place holder to copy figure label and caption
Graphic Jump Location

Figure 4. Relative risk (RR) of wound infection in laparoscopic vs open bariatric surgery. Laparoscopic surgery is associated with a lower risk of wound infection compared with open bariatric surgery (RR, 0.21; 95% CI, 0.07-0.65). See the legend to Figure 3 for an explanation of the symbols in the Forest plot.

Place holder to copy figure label and caption
Graphic Jump Location

Figure 5. Relative risk (RR) of incisional hernia in laparoscopic vs open bariatric surgery. Laparoscopic surgery is associated with a lower risk of incisional hernia compared with open bariatric surgery (RR, 0.11; 95% CI, 0.03-0.35). See the legend to Figure 3 for an explanation of the symbols in the Forest plot.

Place holder to copy figure label and caption
Graphic Jump Location

Figure 6. Relative risk (RR) of anastomotic leak in laparoscopic vs open bariatric surgery. The point estimate suggests that the risk of anastomotic leak is similar for laparoscopic vs open bariatric surgery; however, the 95% CI is wide and does not preclude an effect. See the legend to Figure 3 for an explanation of the symbols in the Forest plot.

Place holder to copy figure label and caption
Graphic Jump Location

Figure 7. Relative risk (RR) of all-cause mortality in laparoscopic vs open bariatric surgery. The point estimate suggests that the risk of all-cause mortality is similar for laparoscopic vs open bariatric surgery; however, the 95% CI is wide and does not preclude an effect. See the legend to Figure 3 for an explanation of the symbols in the Forest plot.

Tables

Table Graphic Jump LocationTable 1. Baseline Characteristics Reported in Included Randomized Controlled Trials
Table Graphic Jump LocationTable 2. Study Design and Operative Characteristics Reported in Included Randomized Controlled Trials
Table Graphic Jump LocationTable 3. Complications Reported in Included Randomized Controlled Trials
Table Graphic Jump LocationTable 4. Reasons for Reoperation and Causes of Mortality
Table Graphic Jump LocationTable 5. Weight Loss Outcomes at 12 Months' Follow-up Reported in Included Randomized Controlled Trials

References

Flegal KM, Carroll MD, Ogden CL, Curtin LR. Prevalence and trends in obesity among US adults, 1999-2008.  JAMA. 2010;303(3):235-241
PubMed   |  Link to Article
Sturm R. Increases in morbid obesity in the USA: 2000-2005.  Public Health. 2007;121(7):492-496
PubMed   |  Link to Article
Gilmore J. Body mass index and health.  Health Rep. 1999;11(1):31-43 [English], 33-47 [French]
PubMed
Tjepkema M. Adult obesity.  Health Rep. 2006;17(3):9-25
PubMed
Adams KF, Schatzkin A, Harris TB,  et al.  Overweight, obesity, and mortality in a large prospective cohort of persons 50 to 71 years old.  N Engl J Med. 2006;355(8):763-778
PubMed   |  Link to Article
Adams TD, Gress RE, Smith SC,  et al.  Long-term mortality after gastric bypass surgery.  N Engl J Med. 2007;357(8):753-761
PubMed   |  Link to Article
Batsis JA, Romero-Corral A, Collazo-Clavell ML, Sarr MG, Somers VK, Lopez-Jimenez F. Effect of bariatric surgery on the metabolic syndrome: a population-based, long-term controlled study.  Mayo Clin Proc. 2008;83(8):897-907
PubMed
Christou NV, Sampalis JS, Liberman M,  et al.  Surgery decreases long-term mortality, morbidity, and health care use in morbidly obese patients.  Ann Surg. 2004;240(3):416-424
PubMed   |  Link to Article
Sjöström L, Lindroos AK, Peltonen M,  et al; Swedish Obese Subjects Study Scientific Group.  Lifestyle, diabetes, and cardiovascular risk factors 10 years after bariatric surgery.  N Engl J Med. 2004;351(26):2683-2693
PubMed   |  Link to Article
Sjöström L, Narbro K, Sjöström CD,  et al; Swedish Obese Subjects Study.  Effects of bariatric surgery on mortality in Swedish obese subjects.  N Engl J Med. 2007;357(8):741-752
PubMed   |  Link to Article
Wittgrove AC, Clark GW, Tremblay LJ. Laparoscopic gastric bypass, Roux-en-Y: preliminary report of five cases.  Obes Surg. 1994;4(4):353-357
PubMed   |  Link to Article
Nguyen NT, Hinojosa M, Fayad C, Varela E, Wilson SE. Use and outcomes of laparoscopic versus open gastric bypass at academic medical centers.  J Am Coll Surg. 2007;205(2):248-255
PubMed   |  Link to Article
Moher D, Liberati A, Tetzlaff J, Altman DG. Preferred Reporting Items for Systematic Reviews and Meta-analyses: the PRISMA statement.  Ann Intern Med. 2009;151(4):264-269, W64PRISMA Group
Higgins J, Green S. Cochrane Collaboration: Cochrane Handbook for Systematic Reviews of Interventions. Chichester, England: Wiley-Blackwell; 2008
DerSimonian R, Laird N. Meta-analysis in clinical trials.  Control Clin Trials. 1986;7(3):177-188
PubMed   |  Link to Article
Harbord RM, Egger M, Sterne JA. A modified test for small-study effects in meta-analyses of controlled trials with binary endpoints.  Stat Med. 2006;25(20):3443-3457
PubMed   |  Link to Article
Microsoft Corporation.  Excel 2007 (Part of Microsoft Office Professional Edition) [computer program].  Redmond, WA: Microsoft Corporation; 2006
StataCorp LP.  STATA Statistical Software: Release 9 [computer program].  College Station, TX: StataCorp LP; 2005
Dávila-Cervantes A, Borunda D, Domínguez-Cherit G,  et al.  Open versus laparoscopic vertical banded gastroplasty: a randomized controlled double blind trial.  Obes Surg. 2002;12(6):812-818
PubMed   |  Link to Article
Nguyen NT, Goldman C, Rosenquist CJ,  et al.  Laparoscopic versus open gastric bypass: a randomized study of outcomes, quality of life, and costs.  Ann Surg. 2001;234(3):279-291
PubMed   |  Link to Article
Westling A, Gustavsson S. Laparoscopic vs open Roux-en-Y gastric bypass: a prospective, randomized trial.  Obes Surg. 2001;11(3):284-292
PubMed   |  Link to Article
Sundbom M, Gustavsson S. Randomized clinical trial of hand-assisted laparoscopic versus open Roux-en-Y gastric bypass for the treatment of morbid obesity.  Br J Surg. 2004;91(4):418-423
PubMed   |  Link to Article
van Dielen FM, Soeters PB, de Brauw LM, Greve JW. Laparoscopic adjustable gastric banding versus open vertical banded gastroplasty: a prospective randomized trial.  Obes Surg. 2005;15(9):1292-1298
PubMed   |  Link to Article
de Wit LT, Mathus-Vliegen L, Hey C, Rademaker B, Gouma DJ, Obertop H. Open versus laparoscopic adjustable silicone gastric banding: a prospective randomized trial for treatment of morbid obesity.  Ann Surg. 1999;230(6):800-807
PubMed   |  Link to Article
Luján JA, Frutos MD, Hernández Q,  et al.  Laparoscopic versus open gastric bypass in the treatment of morbid obesity: a randomized prospective study.  Ann Surg. 2004;239(4):433-437
PubMed   |  Link to Article
Colquitt JL, Picot J, Loveman E, Clegg AJ. Surgery for obesity.  Cochrane Database Syst Rev. 2009;(2):CD003641
PubMed
Gentileschi P, Kini S, Catarci M, Gagner M. Evidence-based medicine: open and laparoscopic bariatric surgery.  Surg Endosc. 2002;16(5):736-744
PubMed   |  Link to Article
Nguyen NT, Wolfe BM. Laparoscopic versus open gastric bypass.  Semin Laparosc Surg. 2002;9(2):86-93
PubMed   |  Link to Article
Buchwald H, Estok R, Fahrbach K, Banel D, Sledge I. Trends in mortality in bariatric surgery: a systematic review and meta-analysis.  Surgery. 2007;142(4):621-635
PubMed   |  Link to Article
Maggard MA, Shugarman LR, Suttorp M,  et al.  Meta-analysis: surgical treatment of obesity.  Ann Intern Med. 2005;142(7):547-559
PubMed
Jones KB Jr, Afram JD, Benotti PN,  et al.  Open versus laparoscopic Roux-en-Y gastric bypass: a comparative study of over 25,000 open cases and the major laparoscopic bariatric reported series.  Obes Surg. 2006;16(6):721-727
PubMed   |  Link to Article
Marsk R, Tynelius P, Rasmussen F, Freedman J. Short-term morbidity and mortality after open versus laparoscopic gastric bypass surgery. A population-based study from Sweden.  Obes Surg. 2009;19(11):1485-1490
PubMed   |  Link to Article
Nguyen NT, Ho HS, Palmer LS, Wolfe BM. A comparison study of laparoscopic versus open gastric bypass for morbid obesity.  J Am Coll Surg. 2000;191(2):149-157
PubMed   |  Link to Article
Paxton JH, Matthews JB. The cost effectiveness of laparoscopic versus open gastric bypass surgery.  Obes Surg. 2005;15(1):24-34
PubMed   |  Link to Article
Courcoulas A, Perry Y, Buenaventura P, Luketich J. Comparing the outcomes after laparoscopic versus open gastric bypass: a matched paired analysis.  Obes Surg. 2003;13(3):341-346
PubMed   |  Link to Article
Sekhar N, Torquati A, Youssef Y, Wright JK, Richards WO. A comparison of 399 open and 568 laparoscopic gastric bypasses performed during a 4-year period.  Surg Endosc. 2007;21(4):665-668
PubMed   |  Link to Article
Suter M, Giusti V, Heraief E, Jayet C, Jayet A. Early results of laparoscopic gastric banding compared with open vertical banded gastroplasty.  Obes Surg. 1999;9(4):374-380
PubMed   |  Link to Article
Weller WE, Rosati C. Comparing outcomes of laparoscopic versus open bariatric surgery.  Ann Surg. 2008;248(1):10-15
PubMed   |  Link to Article
Flum DR, Belle SH, King WC,  et al; Longitudinal Assessment of Bariatric Surgery (LABS) Consortium.  Perioperative safety in the longitudinal assessment of bariatric surgery.  N Engl J Med. 2009;361(5):445-454
PubMed   |  Link to Article
Hassan M, Kerlakian G, Curry T, Engel A, Bollmer C. Comparing outcomes of hand-assisted versus total laparoscopic gastric bypass.  Surg Obes Relat Dis. 2008;4(2):91-95
PubMed   |  Link to Article

Correspondence

CME
Also Meets CME requirements for:
Browse CME for all U.S. States
Accreditation Information
The American Medical Association is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians. The AMA designates this journal-based CME activity for a maximum of 1 AMA PRA Category 1 CreditTM per course. Physicians should claim only the credit commensurate with the extent of their participation in the activity. Physicians who complete the CME course and score at least 80% correct on the quiz are eligible for AMA PRA Category 1 CreditTM.
Note: You must get at least of the answers correct to pass this quiz.
Please click the checkbox indicating that you have read the full article in order to submit your answers.
Your answers have been saved for later.
You have not filled in all the answers to complete this quiz
The following questions were not answered:
Sorry, you have unsuccessfully completed this CME quiz with a score of
The following questions were not answered correctly:
Commitment to Change (optional):
Indicate what change(s) you will implement in your practice, if any, based on this CME course.
Your quiz results:
The filled radio buttons indicate your responses. The preferred responses are highlighted
For CME Course: A Proposed Model for Initial Assessment and Management of Acute Heart Failure Syndromes
Indicate what changes(s) you will implement in your practice, if any, based on this CME course.
Submit a Comment

Multimedia

Some tools below are only available to our subscribers or users with an online account.

Web of Science® Times Cited: 23

Related Content

Customize your page view by dragging & repositioning the boxes below.

See Also...
Related Multimedia

Author Interview

Articles Related By Topic
Related Collections
PubMed Articles