Bariatric Surgery
Surgery for obesity is considered the way forward by many, in a world that has resigned to the fact that it has failed miserably in dealing with the worsening life style issues in any particular individual. Many physicians tout bariatric surgery as the pinnacle of diabetes treatment, with the ability to reverse diabetes and provide a cure. People who try hard to maintain a balanced view try to distinguish "cure" from "remission" and see bariatric procedures as stop gap interventions to reset the pathological point if you may, hoping that lifestyle changes may kick in at the new point.
Studies with increasing follow up post bariatric surgery seem to be suggesting that weight regain is a significant function of time-from-surgery. But is the time spent in a lower weight range beneficial for the individual in the longer term? Is the weight loss cost effective to the population in the longer term? I live in the United Kingdom, where bariatric surgery as well as access to obesity medications are free, thanks to the NHS and the tax payer at the time of this writing. I suspect the lean members of the public despair at the enormous and increasing cost of obesity treatment that they have to provide for, but remain ethically and emotionally torn to voice their concerns for fear of being accused of political incorrectness in a socialist healthcare system. Health Care Analysis 1997.
Obesity is only one of the many illness attributable to lifestyle issues. Yet it features highly on the wish list of many to be removed from being treated for free, perhaps only second to avoiding treatment of COPD, produced by tobacco smoking. I would do well not to get embroiled in the ethical discussions of that issue on this page, and instead will try to focus on the indications, benefits and costs of bariatric surgery here.
Studies with increasing follow up post bariatric surgery seem to be suggesting that weight regain is a significant function of time-from-surgery. But is the time spent in a lower weight range beneficial for the individual in the longer term? Is the weight loss cost effective to the population in the longer term? I live in the United Kingdom, where bariatric surgery as well as access to obesity medications are free, thanks to the NHS and the tax payer at the time of this writing. I suspect the lean members of the public despair at the enormous and increasing cost of obesity treatment that they have to provide for, but remain ethically and emotionally torn to voice their concerns for fear of being accused of political incorrectness in a socialist healthcare system. Health Care Analysis 1997.
Obesity is only one of the many illness attributable to lifestyle issues. Yet it features highly on the wish list of many to be removed from being treated for free, perhaps only second to avoiding treatment of COPD, produced by tobacco smoking. I would do well not to get embroiled in the ethical discussions of that issue on this page, and instead will try to focus on the indications, benefits and costs of bariatric surgery here.
BARIATRIC PROCEDURES:
Obsolete: Jaw Wiring, Jejuno-ileal Bypass In Vogue: Gastroplication, Gastric banding (laparoscopic), Laparoscopic Vertical Banded Gastroplasty (VBG), Laparoscopic Adjustable Silicone gastric Band (ASGB), Gastric bypass, Biliopancreatic diversion, Biliopancreatic diversion with duodenal switch Gastric Stapling / Gastroplication Started in the 1980s Reduces stomach size to 50 mls Cholecystectomy performed simultaneously Fallen out of favour despite modifications Laparoscopically adjustable silicone gastric band (ASGB) 715 patients Mean BMI 43.1 kg/m2 Mean operative time 78 min Post-op hospitalization time 1.2 days At 2 years: Average BMI dropped from 43.3 to 32.1 kg/m2 8% patients required reoperations Surg Endosc. 2002 Feb;16(2):230-3. Epub 2001 Oct 05. Laparoscopic vertical banded gastroplasty (VBG) 250 patients Operative time 95 minutes At 4 years: Morbidly obese patients achieved BMI of 29 Half of patients BMI >50 achieved BMI 35 Re-operation rate 2% Surg Endosc. 2002 Nov;16(11):1566-72. Epub 2002 Jun 14 Gastric Bypass Most effective treatment Only recommended for morbid obesity Up to 30% weight loss attainable Patients may even come off insulin totally Up to 3% improvement in glycated Hb. Takes 168 mts, 196 mts, 210 mts The mortality rate for gastric bypass surgery averages around 1% Biliopancreatic diversion (BPD) Complicated malabsorptive operation, Portions of the stomach are removed The small pouch is connected directly to the final segment of the small intestine, completely bypassing the duodenum and the jejunum. Less frequently used High risk for nutritional deficiencies. BPD with Duodenal switch A variation of BPD Duodeno-ileostomy + Jejuno-ileostomy This keeps a small part of the duodenum in the digestive pathway and thus leaves a larger portion of the stomach intact, including the pyloric valve that regulates the release of stomach contents into the small intestine. |
PROCEDURES COMPARED:
Laparoscopic bypass Vs Open gastric bypass LGB Fewer ITU admissions Shorter hospital stay OGB Resulted in better reversal of obesity complications Am Surg. 2003 Jul;69(7):547-53; discussion 553-4 Post surgery improvements in obesity co- morbidity Weight loss starts soon after surgery and continues for 2 years Diabetes mellitus resolves in 85% to 90% Hypertension resolves in 66% to 75% Urinary incontinence resolves in 95% of patients. Acid reflux disappears in most patients Sleep apnoea resolves or improves Fertility is restored in many Surg Endosc. 2002 Feb;16(2):230-3. Epub 2001 Oct 05 Bypass procedures are associated with greater risk reductions than restrictive procedures, probably related to the greater degrees of weight loss produced by this method. Ann Surg. 2004 Sep;240(3):416-23. The alterations in gut hormone profiles produced by the greater weight loss might also be a factor through improvement of hyperinsulinism, as insulin may well have atherogenic and carcinogenic potential. Read more on bariatric surgery and gut hormone changes |
Recurrence of obesity after surgery The Swedish Obesity Study found recurrence of hypertension with weight regain at 7 years after surgery (banding) (not seen in the gastric bypass surgery studies ) |
BARIATRIC SURGERY TRIALS / EVIDENCE
Swedish Obesity Study (SOS)- Surgical Banding Improvements in Diabetes mellitus (47%) and hypertension (42%) (less than in the American studies) 23% of body weight lost in the SOS (using mostly gastroplasty and banding procedures) (less than with gastric bypass which produces up to 35% of body weight loss) Read the Cochrane analysis of bariatric surgery for morbid obesity |