For Morbid Obesity
by Emily J. Major
In today’s society where good looks, physical fitness, appearance, and good health are used to measure success, confidence, and self-control, it is ironic that eating disorders are so prevalent in our culture. People are so concerned with how other people view their physical appearance that when they cannot meet their own or others’ expectations they often develop eating disorders. However, anorexia nervosa and bulimia nervosa are not the only types of eating disorders. Today there is an increasing number of obese people who suffer from overeating. These people find it especially difficult to have the kind of lifestyles that they desire. Obesity and associated medical complications take the lives of thousands of people each year. Many obese individuals are aware of current or possible medical problems, but though they have tried diverse measures to solve their eating problems by using suppression drugs, commercial diet programs, behavioral therapies, hypnosis, exercise programs, jaw wiring, etc., they only experience regaining the weight after it is lost. Surgical intervention, which started in the 1960’s, however, has gained increased popularity in the last 40 years as a means of controlling and maintaining weight loss for morbidly obese individuals. This web site will provide you with general facts concerning surgical intervention for obese patients, claims made by other web sites, as well as evidence and results based on scientific findings. The goal for this web site is to help readers understand the surgical procedures, the benefits and risks involved, and to answer questions that potential candidates for surgical intervention may have.
Who Qualifies for Surgery?
According to the SurgiLite web site (surgilite.net/Introduction.htm), although it is necessary to undergo pre-operative evaluation and testing to determine medical problems, your ideal body weight, and possibly metabolic, endocrine, and gastrointestinal evaluation, this general list of criteria should help you determine if you are a possible candidate for surgical procedures to lose weight:
Surgical Options and Risks
The two most commonly practiced procedures in bariatric surgery today are Roux-en-Y gastric bypass (or gastric exclusion) and vertical banded gastroplasty (or vertical ring gastroplasty). In 1991 at a Consensus Conference sponsored by the National Institutes of Health it was concluded that "the surgical procedures currently in use (gastric bypass and vertical banded gastroplasy) are capable of inducing significant weight loss in severely obese patients, and in turn, have been associated with amelioration of most of the comorbid conditions that have been studied (www-surgery.med.ohio-state.edu/divisions/genr.obesity.htm)." These procedures have replaced simple gastric stapling and intestinal bypass performed in the 1980’s.
SurgiLite (surgilite.net/gastricbypass.htm) presents a clear, non-biased description of gastric bypass: "A small pouch of approximately 10-20cc is created in addition to bypassing the lower portion of the stomach. A small opening is then created in the small stomach pouch. The upper intestine is divided and the lower divided end is then brought up and joined to the new stomach opening. A new hook-up in the lower intestine establishes continuation of the entire digestive track. Food then enters the small stomach pouch, causing a sensation of fullness before it slowly empties into the intestine through the newly reconstructed stomach intestine opening or shunt." SurgiLite also points out the important fact that the procedure produces a dumping syndrome. Patients are forced to avoid sugars, complex starches, and fatty foods, or else a feeling of shakiness, sweating, palpitations, and diarrhea develop.
Cherryhill Centers for Surgical Weight Loss (www.weightlosssurgery.com/faq.html) claim that gastric exclusion is the most effective weight reducing surgery. The center feels that many physicians do not tell patients about gastric exclusion because the doctors do not recognize morbid obesity as a disease. They point out that their bariatric surgeons are committed to following the gastric exclusion patient forever. This web site, though it clearly favors gastric exclusion, gives clear facts and offers advice on obtaining more information and how to become an authorized candidate for the surgery.
Surgical Services enthusiastically presents the newest discovery in roux-en-Y gastric bypass: Laparoscopic Obesity Surgery. "Laparoscopically, we completely divide the stomach, forming a pouch that holds less than one ounce (www.lap-associates.com/SurgicalServices/lap_bypass.htm)." The advantages of the laparoscopic surgery as compared to the open surgery are explained: the patient is only in the hospital for 2-4 days, rather than 3-6 days; back to normal level of activity in 7-10 days rather than 2-4 weeks; back to work in 10-20 days instead of 3-6 weeks; the scar is 5 inches long, rather than 12-24 inches, however surgery is longer with laparoscopic surgery and weight loss of 75-100% of excess weight is equal with both surgeries.
The Ohio State University Comprehensive Weight Management Program (www-surgery.med.ohio-state.edu/divisions/genr/obesity.htm) makes a clear point about deciding between Roux-en-Y gastric bypass and vertical banded gastroplasty: one must take into consideration their eating habits. "With the gastric bypass, the patient must learn to balance the advantage of a somewhat greater weight loss against the disadvantage of a higher risk of some nutrient deficiencies." They also state that they usually prefer the gastric bypass because it is associated with somewhat greater weight loss and better long term weight maintenance.
In 1991, the National Institutes of Health panel made recommendations for treating severe obesity (odp.od.nih.gov/consensus/news/releases/084_release.htm). The panel concluded that when medically supervised dieting and intensive behavior modification fails, gastrointestinal surgery may be prescribed for more than one and a half million Americans who are morbidly obese. They particularly endorsed the vertical-banded gastroplasty. This surgery is "a form of restriction, in which a small pouch is made by stapling off a large section of the stomach, creating a narrow, restricted pathway to the intestinal tract." They strongly recommended evaluation of candidates by a multidisciplinary team with access to medical, surgical, psychiatric, and nutritional expertise. They warned readers that some patients "may gradually regain some of the weight lost as a result of the operation." They further stressed the vital importance of careful management of health whether treated surgically or medically.
Risks Involved, Side Effects, and Results
Risks and side effects occur with any operation, so it is important to understand the complications of Gastric Bypass and Vertical Band Gastroplasty before deciding to have the surgery. An immediate risk is the anesthetic risk which could cause bleeding from the spleen during surgery and vomiting post operatively. The perioperative risks are blood clots to the lungs and death. Death is usually due to a heart attack or sudden irregularity in the heart rhythm. Partial collapse of the lungs as well as post-operative pneumonia, which is the most common complication development may also occur. Delayed complications include gallstones, wound infection, leakage of staple lines, hair loss, development of ulcers, small bowel obstruction, vomiting, micronutrient defiences, and abdominal abscesses (http://surgilite.net/long.htm and http://www.weightlosssurgery.com/faq.html and http://www-surgery.med.ohio-state.edu/divisions/genr/obesity.htm).
Returning to your clinic for regular checkups and a complete physical within the first year are necessary to monitor your health, nutritional status, and weight loss. "By eating only at mealtimes and only until you are full, your daily food intake will be decreased enough to provide a weight loss of as much as five to six pounds per week during the first six weeks. Your weight loss should continue at the rate of one or two pounds per week for several months (http://surgilite.net/long.htm)." Besides weight loss, a number of associated disorders generally improve. Such as high blood pressure, diabetes, disturbances of heart and lung function, arthritis, as well as improvements in mood and psychosocial aspects (http://odp.od.nih.gov/consensus/news/releases/084_release.htm).
Exercises such as walking, swimming, tennis, bicycling, weight lifting and yoga are essential to weight loss and maintenance. Both the SurgiLite web page and the Ohio StateWeight Management Team stress that it is imperative to remember that these surgeries are not magical, they can be defeated by consuming too many calories. The patients must accomplish correct eating habits and make adjustments in personal habits, or else the surgery will have been a waste of time and money.
Other Web Sites…
The Atlantic Surgical Associates (http://www.stomachstapling.com/treatgoals.html) present a view which greatly favors surgical treatment for the morbidly obese. "The option of surgical treatment is a rational one supported by the time honored principle that diseases that harm call for therapeutic intervention that harms less. Surgical treatment is medically necessary because it is the only possibility for long term weight control for the severely obese."
A second web site warns candidates of the surgeries’ risky proposition. In 1997 MarketPlace investigates a number of cases in which a surgeon, Dr. Salmon developed his own procedure, combining stomach stapling and intestinal bypass. Patients were left with only one tenth the normal size intestine, just 70 cm. However Dr. McLean warned of the risk this surgery poses of malnutrition because it bypasses such a large amount of the small bowel. Other risks such as vomiting, diarrhea, gas, indigestion, infection, hair loss, numbness, fatigue, and anxiety were found in patients. After the hospital informed Dr. Salmon that he could no longer perform the surgery he left the country (http://cbc.ca/consumers/market.files/health/stomach.html).
Schauer, Ikramuddin, and Gourash (1999) describe a laparoscipically performed Roux-en-Y gastric bypass in a 28-year-old woman with morbid obesity. They claim that "surgery is the only treatment for morbid obesity that has been proven to achieve a significant long-term weight loss." They point out that over the recent decade there has been a trend favoring Roux-en-Y gastric bypass over vertical banded gastroplasty. Roux-en-Y more effectively diverts bile and pancreatic juice. The experience with their case suggests that laparoscopic gastric bypass is associated with low perioperative morbidity, short hospital stay, and rapid recovery. A year after laparoscopic Roux-en-Y surgery was performed their patient had lost 83% of her excess weight (Schauer, Ikramuddin, and Gourash, 1999, p. 105).
Another study supporting surgical control of morbid obesity by O’Brien et al. was evaluated prospectively in a consecutive series of 302 patients. O’Brien et al. focused on the use of the Lap-Band, an adjustable gastric banding system which is laparoscopically placed in the patient to reduce invasiveness. "The adjustability is achieved by the addition or removal of fluid from an inflatable balloon lining the inner surface of the band via a subcutaneous injection reservoir, which gives control of the degree of gastric restriction at all times after placement of the band( O’Brien et al., 1999, p. 114)." They found that the laparoscopic approach is associated with a low frequency of postoperative complications. The most important advantage is that the LapBand adjustable gastric banding has the ability to retain control over the degree of gastric restriction through intermittent adjustments of the band. This permits gentle and effective control. O’Brien et al. emphasize that the progressive weight loss still occurs at least four years after operation. "Because of the ongoing adjustability, the treating physician does not have the pressure to achieve optimal rates of weight loss early but rather can plot a gentle path, titrating the adjustments against weight loss and the general well-being of the patient (O’Brien p. 118)."
In the study "When to advise surgery for severe obesity," JS Garrow states that the optimum rate of weight loss in obese patients is about 1 kg/week, which involves an energy deficit of 1000 kcal/day for about a year. Even with gastroplastic operations, often after about 18 months of losing weight, there is a tendency to regain lost weight. The patient learns what foods will be tolerated and with experience will develop strategies by which energy intake can be increased. Because it is difficult to maintain this degree of dietary restriction, maintenance of weight loss may be helped by fitting a nylon waist cord after weight loss. The nylon waist cord becomes uncomfortably tight if much weight is regained. Garrow believes that often the problem is not achieving weight loss, but maintaining weight loss. In cases such as these, Garrow feels that a waist cord fitted after weight loss is more appropriate that a surgical operation (Garrow, 1989, p.12).
Reeves-Darby, Soloway, and Halpert present a case report in which a patient who had had a gastric stapling procedure developed bezoars which are "foreign bodies composed of vegetable fiber or hair and result from poor motility of altered gastric anatomy" (Reeves-Darby, Soloway, and Halpert, 1990, p326). Reeves-Darby et al. claim that the results and success of gastric stapling procedures have been fair in terms of sustained weight loss and postsurgical complications. They warn that gastric bezoars should be considered a postsurgical complication of gastric stapling, especially if the patient’s initial weight loss is followed by a gain back to presurgical levels.
A final study from the Journal of Psychosomatic Research takes into consideration psychosocial aspects in gastric stapling surgery. Chandarana et al. (1988) evaluated thirty-one morbidly obese patients awaiting gastric stapling and thirty-one patients who had already undergone the procedure using four psychological self-report questionnaires: Eating Disorders Inventory, Millon Clinical Multiaxial Inventory, Locus of Control, and one developed by the authors. They found that sociability and self-confidence improved after surgery, thus it might have stemmed from both internal change as well as a more positive way in which patients were viewed by others. The surgery improved self image, health, interpersonal relationships, sexual function and mood. The overall results suggest that gastric stapling does confer significant benefit to morbidly obese individuals .
Surgical treatment for the morbidly obese is a procedure that must be carefully evaluated and understood by potential patients. The two most commonly practiced procedures are vertical banded gastroplasty and Roux-en-Y gastric bypass. Laparoscopic obesity surgery is favored by many surgeons because it has such advantages as a shorter hospital stay, a smaller scar, and the patient can return to normal levels of activity and work sooner. Choosing between the vertical banded gastroplasty and Roux-en-Y gastric bypass is a personal preference and patients will find supporters for each method. However the Ohio State University Comprehensive Weight Management Program highlights the fact that with gastric bypass there is a somewhat greater weight loss involved (http://www-surgery.med.ohio-state.edu/divisions/genr/obesity.htm).
Complications of both surgeries range from hair loss and small bowel obstruction to blood clots and death. The patient must understand the importance of returning to the clinic for regular check-ups, eating only at meal times, and exercising regularly. As with any type of treatment, surgery should be used when all other options have been exhausted. Most importantly, the patient must be aware that losing the weight is not the entire battle. Oftentimes, keeping the weight off past the initial 18 months following the surgery is the hardest part. As with any other treatment or surgery, the patient should carefully research surgeries for obesity and be sure that the procedure is safe and will have lasting results. Furthermore the patient must realize that no surgery for obesity has proven to be effective for everyone and that the risks and side effects are serious.
Chandarana P., Holliday R., Conlon P., Deslippe T. (1988). Psychosocial considerations in gastric stapling surgery. Journal of Psychosomatic Research, 32 (1) 85-92.
Garrow, JS. (1989). When to advise surgery for severe obesity. Postgraduate Medical Journal, 65 (759) 10-3.
O’Brien., Brown WA., Smith A., McMurrick PJ., Stephens M. (1999). Prospective study of a laparoscopically placed, adjustable gastric band in the treatment of morbid obesity. British Journal of Surgery, 86 (1) 113-118.
Reeves-Darby V., Soloway RD., Halpert R. (1990) Gastric bezoar complicating gastric stapling. American Journal of Gastroenterology, 85 (3) 326-327.
Schauer PR., Ikramuddin S., Gourash WF., (1999) Laparoscopic Roux-en-Y gastric bypass: a case report at one-year follow up. Journal of Laparoendoscopic and Advanced Surgical Techniques: Part A, 9 (1) 101-106.
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