Morbid obesity is a disease that is treated most successfully with surgery. The armamentarium with which the surgeon may approach this disease has increased in diversity and complexity since the initial distal intestinal bypasses that were performed in the last century. As our understanding of the etiology of obesity has improved, the procedures have been adapted to treat this disease better. The approach to each bariatric patient should be individualized. Although weight loss and improvement in health are paramount goals of obesity surgery, the manner in which these goals are attained need not be driven completely by dogma and mystery. Using evidence-based trials, bariatric surgical procedures have been refined, and continue to undergo further development. Through this outcomes-driven approach, bariatric procedures have become increasingly safe and efficacious. Choosing the appropriate procedure for each patient should not be based solely on a menu-driven approach. Although weight loss by BPD tends to be the most profound and this operation may be suited better to the superobese patient; this has not been demonstrated definitively. For individuals who are at risk for nutritional problems and in whom the irreversibility of RYGB is unacceptable, a banding procedure may be preferred. A sweet-eater will fail a banding procedure and may be more likely to succeed with a gastric bypass. The safety and efficacy of all of these procedures have been demonstrated. Clearly, steep learning curves exist for all; however, by using an intelligent and sound approach to preoperative work-up, meticulous surgical technique, prompt response to complications, and sustained postoperative follow-up, favorable outcomes can be achieved.
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