Obesity and Weight Reduction in IIH
The first evidence that bariatric surgery may be an option for IIH patients came in the form of case reports. Subsequently, a case series was published in which bariatric surgery was performed in 8 women with IIH and elevated CSF pressure. Seven patients underwent RYGB, and 1 patient underwent distal gastric bypass (BPD). Preoperative BMI was 49±3 kg/m and CSF pressure was documented as 353±35 mm H2O. Postoperatively, patients had an average weight loss of 57±5 kg with a significant decrease in BMI of 34±8 kg/m and CSF pressure of 168±12 mm H2O. All patients had reduction in symptoms, papilledema, and obesity-related co-morbidities. Patients were followed for 11 years, with minimal complications. The authors suggested that bariatric surgery may be a primary option for severely obese patients with IIH.
Since these initial reports on the effectiveness of bariatric surgery for IIH patients, there have been numerous other case reports and series, all retrospective. In a meta-analysis of the efficacy of bariatric surgery for IIH, a literature search identified 11 manuscripts that reported symptom and/or visual outcomes in a total of 62 patients. Of these cases, 55/62 (58%) underwent RYGB, 4/62 (6%) a primary gastroplasty, and 3/62 (5%) a primary AGB procedure. Two patients who underwent gastroplasty had failure, after which successful RYGB procedure was performed. Preoperative and postoperative BMI were available in only 21 patients; mean decrease in BMI was 16 kg/m, with the average weight loss being 45.5 kg. CSF pressures decreased by an average of 254 mm H2O in 13 patients. When data were available, 97% of patients (34/35) had resolution of papilledema, 92% of patients (56/61) had improvement or resolution of symptoms, and 92% (11/12) had improvement or resolution of visual field loss.
Bariatric surgery and CSF shunting procedures appear comparable in their success rates for improvement in symptoms and visual field loss. Though there is a lack of direct comparative data, when urgent intervention is required to prevent permanent visual loss, more traditional surgical options for IIH such as CSF diversion or ONSF may be more appropriate, as the beneficial effects of bariatric surgery are delayed. CSF diversion procedures and ONSF, however, are associated with significant complications, failure rates, and disadvantages, and also do not address the leading risk factor in IIH, obesity.
Bariatric surgery techniques are continuing to evolve, with the hope of fewer complications and improved success rates. SG has come to the forefront as a viable bariatric option, and may soon surpass AGB in its popularity. There are also other investigational procedures on the horizon for surgical weight loss. In light of this, the outcome data on bariatric surgery for IIH comes from RYGB, AGB, and gastroplasty, which is no longer commonly performed. Thus far, there is no published data on SG for IIH. There is also lack of long-term follow-up for the procedures reported with respect to symptom improvement, visual function, weight loss, weight regain, and complication rate.
The published literature for the use of surgical weight reduction in IIH is limited in being class IV evidence. Furthermore, much of the evidence is comprised of case reports and series, which are inherently biased toward positive outcomes. Nevertheless, bariatric surgery may be a viable surgical option to address obesity as the underlying risk factor in IIH and warrants further investigation by a prospective study, whether that be a randomized-controlled trial, a controlled trial, or a prospective-matched group cohort study.
Bariatric Surgery for IIH
The first evidence that bariatric surgery may be an option for IIH patients came in the form of case reports. Subsequently, a case series was published in which bariatric surgery was performed in 8 women with IIH and elevated CSF pressure. Seven patients underwent RYGB, and 1 patient underwent distal gastric bypass (BPD). Preoperative BMI was 49±3 kg/m and CSF pressure was documented as 353±35 mm H2O. Postoperatively, patients had an average weight loss of 57±5 kg with a significant decrease in BMI of 34±8 kg/m and CSF pressure of 168±12 mm H2O. All patients had reduction in symptoms, papilledema, and obesity-related co-morbidities. Patients were followed for 11 years, with minimal complications. The authors suggested that bariatric surgery may be a primary option for severely obese patients with IIH.
Since these initial reports on the effectiveness of bariatric surgery for IIH patients, there have been numerous other case reports and series, all retrospective. In a meta-analysis of the efficacy of bariatric surgery for IIH, a literature search identified 11 manuscripts that reported symptom and/or visual outcomes in a total of 62 patients. Of these cases, 55/62 (58%) underwent RYGB, 4/62 (6%) a primary gastroplasty, and 3/62 (5%) a primary AGB procedure. Two patients who underwent gastroplasty had failure, after which successful RYGB procedure was performed. Preoperative and postoperative BMI were available in only 21 patients; mean decrease in BMI was 16 kg/m, with the average weight loss being 45.5 kg. CSF pressures decreased by an average of 254 mm H2O in 13 patients. When data were available, 97% of patients (34/35) had resolution of papilledema, 92% of patients (56/61) had improvement or resolution of symptoms, and 92% (11/12) had improvement or resolution of visual field loss.
Bariatric surgery and CSF shunting procedures appear comparable in their success rates for improvement in symptoms and visual field loss. Though there is a lack of direct comparative data, when urgent intervention is required to prevent permanent visual loss, more traditional surgical options for IIH such as CSF diversion or ONSF may be more appropriate, as the beneficial effects of bariatric surgery are delayed. CSF diversion procedures and ONSF, however, are associated with significant complications, failure rates, and disadvantages, and also do not address the leading risk factor in IIH, obesity.
Bariatric surgery techniques are continuing to evolve, with the hope of fewer complications and improved success rates. SG has come to the forefront as a viable bariatric option, and may soon surpass AGB in its popularity. There are also other investigational procedures on the horizon for surgical weight loss. In light of this, the outcome data on bariatric surgery for IIH comes from RYGB, AGB, and gastroplasty, which is no longer commonly performed. Thus far, there is no published data on SG for IIH. There is also lack of long-term follow-up for the procedures reported with respect to symptom improvement, visual function, weight loss, weight regain, and complication rate.
The published literature for the use of surgical weight reduction in IIH is limited in being class IV evidence. Furthermore, much of the evidence is comprised of case reports and series, which are inherently biased toward positive outcomes. Nevertheless, bariatric surgery may be a viable surgical option to address obesity as the underlying risk factor in IIH and warrants further investigation by a prospective study, whether that be a randomized-controlled trial, a controlled trial, or a prospective-matched group cohort study.
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