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Surgical Treatment of Obesity: Who Is an Appropriate Candidate?

      The increasing prevalence and far-reaching medical, social, and economical implications of obesity have made it a national health-care crisis in the United States. About one in every three persons is at least 20% above “ideal” body weight, and approximately 5% have direct weight-related serious health problems (morbid obesity), including hypertension, hyperlipidemia, coronary artery disease, adult-onset diabetes mellitus, degenerative osteoarthropathy, and obstructive sleep apnea. Morbidly obese patients have an estimated 6- to 12-fold increase in mortality. In addition, they have a substantially diminished quality of life, not only physically but also psychosocially due to overt and occult prejudice. Weight reduction must be aggressively pursued in these patients. Medically supervised weight-control programs have been inef- fective because patients cannot maintain pronounced long-term weight loss. In contrast, current operative methods have been proved to be effective in helping patients achieve and maintain permanent weight reduction. Several operations have been designed and assessed; with these procedures, weight loss is achieved by inducing malabsorption, maldigestion, early satiety, or a combination of these outcomes. Although these operations have associated side effects and limitations, the expected benefits outweigh the risks. For optimal results, patients must be carefully selected and treated by a multidisciplinary group.
      BMI (body mass index)
      Obesity in the United States is a national health-care crisis for which health-care expenditures are substantial and are escalating. Previous estimates suggested that as many as 20% of men and 27% of women are more than 20% above “ideal” body weight, as defined by the Metropolitan Life Insurance Tables' or by body mass index (BMI) BMI = weight [in kilograms] divided by height [in square metersl)' of greater than 27.3.
      • Williamson DF
      Descriptive epidemiology of body weight and weight change in U.S. adults.
      The latest National Health and Nutrition Examination Survey (1988 through 1991) showed that these figures had increased to 31 % for men and 35% for women. Thus, about 58 million people in the United States are obese.
      • Clark MM
      • Ruggiero L
      • Pera Jr, V
      • Goldstein MG
      • Abrams DB
      Assessment, classification, and treatment of obesity: behavioral medicine perspective.
      • Martin LF
      • Hunter SM
      • Lauve RM
      • O'Leary JP
      Severe obesity: expensive to society, frustrating to treat, but important to confront.
      Although mild to moderate obesity BMI of 28 to 35) has obvious but inconstant associated morbidity, the more severe types of obesity BMI greater than 35) indicate definite and consistent medical morbidity. These severe variants of obesity have been termed “morbid obesity” or are referred to in the lay media as “medically complicated obesity” (patients do not like to be referred to as being “morbid”). Patients have morbid obesity when they are 100% or more above ideal body weight, are at least 45.4 kg above ideal body weight, or have a BMI greater than 35; thus, most women who weigh more than 108.9 kg and most men who weigh more than 122.5 kg would be considered morbidly obese. A better and more appropriate definition of morbid obesity includes patients who have direct weight-related serious morbidity, such as hypertension, type II diabetes mellitus, mechanical arthropathy, lipid-related cardiac disease, and sleep apnea.
      • Clark MM
      • Ruggiero L
      • Pera Jr, V
      • Goldstein MG
      • Abrams DB
      Assessment, classification, and treatment of obesity: behavioral medicine perspective.
      • Benotti PN
      • Forse RA
      The role of gastric surgery in the multidisciplinary management of severe obesity.
      The estimated prevalence of morbid obesity in the United States is about 2% for men and 6% for women.' Although the actual early mortality risk for women with morbid obesity is not well defined, men between 25 and 34 years of age with a BMI greater than 40 have a documented 12-fold increase in overall mortality in comparison with normal-weight men.
      • Drenick EJ
      • Bale GS
      • Seltzer F
      • Johnson DG
      Excessive mortality and causes of death in morbidly obese men.
      Within this context, weight-related morbidity accounted for an increase in health-care expenditures of $68.8 billion in 1990.
      • Martin LF
      • Hunter SM
      • Lauve RM
      • O'Leary JP
      Severe obesity: expensive to society, frustrating to treat, but important to confront.
      In this article, we provide a brief overview of the complications of morbid obesity and attempt to determine who might be an appropriate candidate for weight -reduction surgical treatment or a so-called bariatric operation. The types of bariatric operations, their associated side effects and limi- tations, and the expected success in weight loss are reviewed objectively. The goal of this review is to clarify for primary health-care providers the role and success of bariatric surgical treatment in this select patient group with morbid obesity. A recent National Institutes of Health Consensus Conference on surgical treatment of obesity provided credibility for an operative approach (especially with third-party payers) by presenting a strongly supportive summary statement that recommended bariatric surgical treatment once appropriate medical indications are fulfilled.
      • Anonymous
      NIH conference. Gastrointestinal surgery for severe obesity. Consensus Development Panel.

      COMPLICATIONS OF MORBID OBESITY

      Numerous studies have documented increased morbidity and mortality in obese people. Obesity (BMI greater than 28) increases the incidence of risk factors for coronary heart disease such as hyperlipidemia, hypertension, and type II diabetes mellitus. In addition, cancer of the endometrium, colon, prostate, and possibly breast, as well as pulmonary insufficiency and sudden unexplained cardiac arrest, have a high prevalence in obese people.
      • Clark MM
      • Ruggiero L
      • Pera Jr, V
      • Goldstein MG
      • Abrams DB
      Assessment, classification, and treatment of obesity: behavioral medicine perspective.
      • Benotti PN
      • Forse RA
      The role of gastric surgery in the multidisciplinary management of severe obesity.
      Most of these data are from studies involving obese people with a wide spectrum of disease. In a study of men and women with morbid obesity (mean BMI of 38 for men and 41 for women), Sjostrom
      • Sjostrom LV
      Morbidity of severely obese subjects.
      found that diabetes, angina pectoris, and symptomatic peripheral vascular disease were 24, 37, and 105 times more frequent, respectively, than in randomly selected, agematched men and women. Other studies show that a BMI greater than 35 dramatically increases health risk.
      • Sjostrom LV
      Mortality of severely obese subjects.
      These observations may be underestimated because data on extremely obese people (weight greater than 158.8 kg) are scant due to logistic problems in data collection.'
      Weight loss with weight maintenance reduces the prevalence of cardiovascular risk factors' and, in many patients, reverses diabetic, hypertensive, and pulmonary dysfunction, as well as minimizes progression of musculoskeletal disorders associated with morbid obesity.
      • Benotti PN
      • Forse RA
      The role of gastric surgery in the multidisciplinary management of severe obesity.
      Thus, weight reduction should be aggressively pursued in patients with morbid obesity.

      TREATMENT

      For initial management, conservative options such as supervised low-calorie diets in conjunction with behavior therapy and exercise should be attempted. Unfortunately, results with this type of strategy are disappointingr
      • Benotti PN
      • Forse RA
      The role of gastric surgery in the multidisciplinary management of severe obesity.
      • Sjostrom LV
      Mortality of severely obese subjects.
      of subjects who are successful in losing a substantial amount of weight, only 5 to 10% (the latter percentage being optimistic) will maintain the loss for more than a few years.
      • Sjostrom LV
      Mortality of severely obese subjects.
      “Yo-yo” dieting, which leads to “weight cycling,” may actually have a higher associated mortality risk than does a constant, massive overweight problem.
      • Clark MM
      • Ruggiero L
      • Pera Jr, V
      • Goldstein MG
      • Abrams DB
      Assessment, classification, and treatment of obesity: behavioral medicine perspective.
      • Benotti PN
      • Forse RA
      The role of gastric surgery in the multidisciplinary management of severe obesity.
      Because current modes of medi- cal treatment are usually ineffective in patients with morbid obesity, surgical methods (especially Roux-en-Y gastric gastric bypass) have been assessed and, despite their more invasive nature, have demonstrated a much higher success rate (80% or greater) in helping patients achieve and maintain longterm weight loss.
      • Capella JF
      • Capeila RF
      The weight reduction operation of choice: vertical banded gastroplasty or gastric bypass?.

      WHO IS AN APPROPRIATE CANDIDATE FOR WEIGHT-LOSS SURGICAL PROCEDURES?

      In general, the indications for surgical treatment established by the 1991 National Institutes of Health Consensus Development Conference Panel
      • Anonymous
      NIH conference. Gastrointestinal surgery for severe obesity. Consensus Development Panel.
      include a BMI greater than 40 or a BMI greater than 35 in combination with life-threatening cardiopulmonary problems or severe diabetes mellitus. Nonetheless, strict absolute weight determinants should serve only as an overall guide, especially in regard to thirdparty payers (Table 1). For instance, few thoughtful physicians would argue that a 40-year-old man with hypertension, type II diabetes mellitus, severe degenerative joint disease in his knees and lower back area, and sleep apnea who has a BMI of only 33 does not have morbid obesity. Thus, all patients with severe, direct weight-related morbidity (Table 2) may be considered, but each patient should be considered individually.
      Table 1Criteria Usually Required by Third-Party Payers of Bariatric Surgical Treatment
      • Body weight greater than 100% above ideal body weight
        As defined by the Metropolitan Life Insurance Tables.1
      • Weight-related serious comorbidity (see Table 2)
      • Failed attempts with nonoperative, supervised weight-reduction programs
      • No substance abuse, psychoses, or uncontrolled depression
      * As defined by the Metropolitan Life Insurance Tables.
      • Clark MM
      • Ruggiero L
      • Pera Jr, V
      • Goldstein MG
      • Abrams DB
      Assessment, classification, and treatment of obesity: behavioral medicine perspective.
      Table 2Complications of Morbid Obesity
      • Degenerative joint disease (“mechanical” arthropathy)
      • Hypertension
      • Hyperlipidemia
      • Coronary artery disease
      • Type II diabetes mellitus
      • Sleep apnea
      • Lower extremity venous and lymphatic obstruction
      • Obesity-related pulmonary hypertension
      For some patients who have a history of failed conservative treatments and a BMI of approximately 35, a trial of pharmacologic appetite suppression might be the next reasonable choice, especially if the weight-related morbidity is not severe.
      • Manson JE
      • Faich AG
      Pharmacotherapy for obesity-do the benefits outweigh the risks?.
      Substantial and prolonged weight loss (greater than 50% of excess body weight), however, would be distinctly unusual with this approach, and thus this type of regimen should not be expected to be successful in most patients with morbid obesity and severe comorbidities due to weight.
      The overall guidelines should be as follows. Patients who fulfill the absolute weight criteria and have active weightrelated morbidity or younger obese subjects (older than 20 years of age) who have a family history of weight-related morbidity but who have not yet experienced any complications should be considered preliminary candidates. Chronologie age,
      • Murr MM
      • Sidadati MR
      • Sarr MG
      Results of bariatric surgery for morbid obesity in patients older than 50 years.
      previous abdominal operations, or previous bariatric procedures that are functionally ineffective
      • Behrens KE
      • Smith CD
      • Kelly KA
      • Sarr MG
      Reoperative bariatric surgery: lessons learned to improve patient selection and results.
      are not necessarily contraindications. In contrast, active substance abuse and psychiatric disorders (for example, schizophrenia, borderline personality disorder, active suicidal ideation, or uncontrolled depression) should be considered absolute contraindications.
      Once a likely candidate has been identified, he should be referred for a nutritional and psychologic assessment. At the Mayo Clinic, this referral involves a multidisciplinary team of physicians with a special interest in obesity, dietitians, psychologists or psychiatrists interested in behavior modification and eating disorders, and a surgeon with experience in bariatric procedures. The initial approach involves an introductory educational process, counseling about appropriate dietary and exercise programs, and an initial trial with a reduced calorie diet in conjunction with some type of super vised weight-loss program (such as Weight Watchers or TOPS [Take Off Pounds Sensibly]).
      During the assessment process, the primary-care physician has an important role. He should inform the patient about the health risks of severe obesity and discuss the various available options. This concept cannot be overemphasized even though many physicians have a nihilistic attitude toward successful treatment of severe obesity. On the basis of the previously described studies of the dismal success rate of permanent, self-induced weight loss, attempts at diet-induced weight loss are usually futile. A bariatric operation, however, is a validated approach that has a much greater success rate of maintenance of an effective weight loss. The problem is not losing weight but rather maintaining weight loss.
      • Anonymous
      NIH conference. Gastrointestinal surgery for severe obesity. Consensus Development Panel.
      • Sjostrom LV
      Mortality of severely obese subjects.
      Ideally, the discussion of a possible weight-loss operation should be initiated by the primary health-care provider. Realistic expectations about the extent of weight loss and the positive effect on associated weight-related comorbidities (both organic and psychologic) should be discussed and contrasted with the morbidity and potential mortality of a bariatric operation. In summary, the patient must be well informed and convinced of the decision to proceed with the “aggressive” approach of a bariatric operation.

      EXPECTED RESULTS OF BARIATRIC SURGICAL TREATMENT

      In general, with the current weight-loss procedures (not the former “gastric staplings”), patients lose a mean of about 50 to 60% of their excess body weight (weight above ideal body weight) or experience a decrease in the BMI of about 10 kg/ m2 during the first 12 to 24 months postoperatively. Thus, realistic expectations are that patients who weigh 136.1 kg will achieve a weight of about 90.7 to 99.8 kg (not 54.4 to 68 kg). Although several long-term studies have shown a tendency for modest weight gain (5 to 7 kg) after the first 2 postoperative years, long-term maintenance of an overall mean weight loss of about 50% of excess body weight can be cxpectcd.
      • Clark MM
      • Ruggiero L
      • Pera Jr, V
      • Goldstein MG
      • Abrams DB
      Assessment, classification, and treatment of obesity: behavioral medicine perspective.
      • Martin LF
      • Hunter SM
      • Lauve RM
      • O'Leary JP
      Severe obesity: expensive to society, frustrating to treat, but important to confront.
      • Benotti PN
      • Forse RA
      The role of gastric surgery in the multidisciplinary management of severe obesity.
      Of more importance, however, are the effects of this weight loss on the associated weight-related comorbidities. Several well-designed studies have shown that type II diabetes mellitus almost completely resolves in about 90% of patients. In about two-thirds of patients, hypertension disappears 4 years postoperatively. Serum concentrations of high-density lipoprotein improve, and total serum cholesterol and triglyceride levels decline substantially. Associated improvement in cardiac variables, such as left ventricular wall thickness and left ventricular function, has been demonstrated. In addition, pulmonary function and musculoskeletal disability improve concomitantly with the weight loss. The disappearance of symptomatic obstructive sleep apnea after early weight loss of only 15 to 20 kg is dramatic.
      • Benotti PN
      • Forse RA
      The role of gastric surgery in the multidisciplinary management of severe obesity.
      In addition to the objective diminishments in medical comorbidities, substantial psychologic benefits of weight reduction are evident, but they are not as easily quantified. Subjective improvements in mood, self-esteem, self-confidence, body image, and activity level are usually appreciated by the patient and the family members. Associated decreases in depression, anxiety, and irritability have been noted.
      • Clark MM
      • Ruggiero L
      • Pera Jr, V
      • Goldstein MG
      • Abrams DB
      Assessment, classification, and treatment of obesity: behavioral medicine perspective.
      • Anonymous
      NIH conference. Gastrointestinal surgery for severe obesity. Consensus Development Panel.

      OPERATIONS FOR WEIGHT CONTROL

      Ideally, weight-loss operative procedures would be directed at the cause of obesity-the satiety center in the hypothalamus. Because we do not completely understand the etiology, operations are designed to treat the symptom-that is, overeating-and thus are designed to “fool Mother Nature.” A brief anatomic description of the currently accepted operations is provided subsequently. A rudimentary knowledge of the anatomic changes and physiologic consequences involved will help physicians understand both the mechanisms by which these operations work and the associated problems that may arise due to the anatomic changes.
      Four basic approaches have been used in the design of operations to induce weight loss (Table 3).
      Table 3Surgical Approaches to Weight Loss
      See Figure 1.
      ConceptOperation
      Induce global malabsorptionJejunoileal bypass
      Should no longer be performed.
      Limit oral intake per mealGastroplasty or “gastric stapling,” vertical banded gastroplasty
      Limit oral intake per meal and induce “dumping” physiologyRoux-en-Y gastric bypass
      Induce selective maldigestion and malabsorptionBiliopancreatic bypass, extremely long limb gastric bypass
      * See Figure 1.
      Should no longer be performed.
      Induce Global Malabsorption.—The first operation for treatment of obesity was a jejunoileal bypass or small bowel bypass (Fig. 1 A). This approach involved bypass of more than 90% of the jejunoileum by allowing continuity of only 35.6 cm (14 inches) of jejunum and 10.2 em (4 inches) of ileum; thus, both malabsorption and severe steatorrhea were established. In theory, this was an attractive concept because a change in eating habits was not necessarily imposed; however, this operation was associated with an unsatisfactory incidence of severe, potentially life-threatening complications including acute hepatic failure, late development of cirrhosis, oxalate-induced nephropathy, an immune complex arthritis, and a host of metabolic deficiencies. This operation should no longer be performed. Knowledge about this operation is important because many patients who had this procedure performed 10 to 25 years ago may now have cirrhosis, oxalate-induced nephropathy (which is reversible in its early stage), and so-called bypass enteritis. The last two-mentioned problems respond well to reversal of the jejunoileal bypass (see subsequent discussion).
      Figure thumbnail gr1
      Fig. 1Bariatric operations. A, Jejunoileal bypass. Note that all but 35.6 cm (14 inches) of proximal jejunum and 10.2 cm (4 inches) of ileum are bypassed. B, Vertical banded gastroplasty partitions stomach into small-volume (less than 30 mL) pouch of proximal stomach along the lesser curvature that communicates with the rest of the stomach through a narrow (11 mm) channel banded with nonexpandable prosthetic material. C, Roux-en-Y gastric bypass separates cardia (volume, less than 10 mL) from rest of stomach; ingested food enters gut directly into limb of jejunum. D, Partial biliopancreatic bypass-after 80% gastrectomy, remaining stomach is sewn to proximal ileum (250 em from ileocecal junction), and pancreatobiliary secretions are diverted to distal ileum only 50 cm proximal to ileocecal junction; maldigestion is established and therefore malabsorption.
      Limit Oral Intake per Meal.—Because of problems with the jejunoileal bypass, the next approach developed was gastric partitioning or gastroplasty (the term “gastroplasty” suggests a change in the shape of the stomach). The concept was to partition the stomach into an extremely small upper part or “pouch” that communicates with the rest of the stomach through a narrow channel or “stoma.” The introduction of surgical stapling devices substantially improved this operation, and thus these gastroplasty procedures have been referred to as “gastric stapling.” Currently, the gastroplasty of choice is the vertical banded gastroplasty (Fig. 1 B). This operation partitions the stomach into an upper pouch about the size of a person's thumb (into which ingested food enters) that communicates with the rest of the stomach through an 11-mm channel. This channel is wrapped or “banded” with a ring of nonexpandable prosthetic material in order to prevent the stoma from enlarging and counteracting the efficacy of the operation. This approach was attractive in theory because it is technically easy to perform and involves no “bypass” of the intestinal tract. This operation is effective in patients who maintain a diet of “meat and potatoes” because it prevents ingestion of large amounts of food; however, as many as 50% of patients quickly realize that high-calorie soft foods and liquids (such as ice cream and milk shakes) rapidly “slide” through the stoma. These patients change their diet, and their weight increases, many times as high as their preoperative weight. At Mayo, we evaluated our results with vertical banded gastroplasty in 70 patients from 1985 through 1989.
      • Nightengale ML
      • Sarr MG
      • Kelly KA
      • Jensen MD
      • Zinsmeister AR
      • Palumbo PJ
      Prospective evaluation of vertical banded gastroplasty as the primary operation for morbid obesity.
      At 3 years postoperatively, only 38% of patients had lost (and maintained) at least 50% of their excess weight. Despite our unsatisfactory results, many groups throughout the United States still advocate this operation because of its safety and absence of severe metabolic side effects.
      Figure thumbnail gr2
      Fig. 2Weight loss after Roux-en-Y gastric bypass (left panel) and partial biliopancreatic bypass (right panel). lb = pounds; postop = postoperatively; SEM = standard error of mean.
      Limit Oral Intake per Meal and Induce a “Dumping” Physiology.—Because of the inability of the gastroplasty to prevent ingestion of high-calorie liquids, the gastric bypass (Fig. 1 C) has been used by many surgeons, including our own group at Mayo. This operation separates the cardia of the stomach completely from the rest of the stomach. This proximal gastric pouch (volume, less than 30 mL) is drained directly into a segment of jejunum and thereby “bypasses” the vast majority of the stomach (which normally functions as a reservoir for large meals) and all the duodenum. This operation works both by preventing ingestion of large amounts of food at any meal and by inducing a dumping syndrome (at least for the first year postoperatively) if the patient ingests a high-carbohydrate meal of liquids or soft foods (such as ice cream). This operation, in our experience and that of other investigators.
      • Benotti PN
      • Forse RA
      The role of gastric surgery in the multidisciplinary management of severe obesity.
      • Capella JF
      • Capeila RF
      The weight reduction operation of choice: vertical banded gastroplasty or gastric bypass?.
      seems to be effective for inducing and maintaining satisfactory weight loss (Fig. 2 left panel). Potential side effects of the gastric bypass are malabsorption of both iron (usually only clinically significant in menstruating women) and vitamin B12; the latter necessitates daily oral or monthly parenteral supplementation.
      • Martin LF
      • Hunter SM
      • Lauve RM
      • O'Leary JP
      Severe obesity: expensive to society, frustrating to treat, but important to confront.
      • Benotti PN
      • Forse RA
      The role of gastric surgery in the multidisciplinary management of severe obesity.
      Induce Selective Matdigestion and Malabsorption.—The partial biliopancreatic bypass (Fig. 1D) was designed for the extremely obese patient-the so-called super obese (greater than 225% above ideal body weight; generally, weight is more than 181.4 kg). This operation involves an 80% gastrectomy (to limit the volume of oral intake) and a rearrangement of small bowel anatomy to the extent that the biliary and pancreatic secretions are diverted to the distal ileum, 50 em proximal to the ileocecal junction. The ingested food enters the small bowel in the proximal ileum but does not mix with the digestive enzymes except in the distal 50 cm of ileum; thus, both a mal digestion and a relative malabsorption are established. This operation is the most effective bariatric procedure for inducing and maintaining intense weight loss (Fig. 2 right panel). Nonetheless, it has many potential side effects, such as deficiencies of the fatsoluble vitamins (A, 0, E, and K) and malabsorption of iron, calcium, and vitamin B12 4 Oral or parenteral supplementation of many of these vitamins and minerals may be necessary. Although some investigative groups have advocated this operation as their first-line surgical procedure, at Mayo, we reserve this technique for the super obese person with severe morbidity or, occasionally, for the patient in whom a previous bariatric procedure has failed and lifethreatening weight-related morbidity is present. We have performed only 11 of these operations during the past 11 years.
      Modified Procedures.—In addition to the four basic operations, several “modifications” have been used by surgeons around the world. Most of these modifications have involved use of one of the four basic approaches with some additional “twist” to maximize efficacy of weight loss. Many of these modifications should still be considered experimental because well-controlled trials of efficacy and morbidity are lacking. The current “hot topic” is a laparoscopic (minimally invasive) approach to gastric “banding,” in which an adjustable band is placed around the proximal stomach. This represents a type of gastric partitioning or gastroplasty, and results will probably be similar to those with vertical banded gastroplasty. In our opinion, long-term studies are needed before intense enthusiasm and universal adoption of this minimally invasive procedure can be advocated.

      EXPECTED REALISTIC OUTCOMES

      Weight Loss.—The goals of bariatric surgical treatment are to induce and maintain long-term weight loss of at least half the preoperative excess body weight; with this amount of weight loss, the patient's weight should be low enough that the weight-related comorbidities are reversed or ameliorated. Although success is usually based on the amount or relative percent of excess body weight that is lost, the important criterion of true success is resolution of the direct weight-related comorbidities (Table 2). Although most patients lose more than 50% of their excess weight, a realistic goal is to attain a target loss of at least 50% of their excess weight;
      • Clark MM
      • Ruggiero L
      • Pera Jr, V
      • Goldstein MG
      • Abrams DB
      Assessment, classification, and treatment of obesity: behavioral medicine perspective.
      • Martin LF
      • Hunter SM
      • Lauve RM
      • O'Leary JP
      Severe obesity: expensive to society, frustrating to treat, but important to confront.
      • Benotti PN
      • Forse RA
      The role of gastric surgery in the multidisciplinary management of severe obesity.
      further weight loss is considered an added benefit. Because most patients achieve their target weight, they can consider themselves “successful,” and this outcome is positive feedback. Patients must be counseled that they will not be “thin” as a result of this operation, but their weight will decrease to a more functional, healthy range; however, they will still be overweight (for example, preoperative weight of 136.1 kg would decrease to 90.7 kg). With satisfactory weight loss, adult-onset diabetes, hypertension, and hyperlipidemia and its consequences of coronary artery disease will diminish or resolve, and no further pharmacologic treatment will be necessary.
      • Benotti PN
      • Forse RA
      The role of gastric surgery in the multidisciplinary management of severe obesity.
      The potentially life-threatening sleep apnea responds extremely well to weight reduction and usually completely resolves.
      • Benotti PN
      • Forse RA
      The role of gastric surgery in the multidisciplinary management of severe obesity.
      Degenerative Joint Disease and Low-Back Pain.—Although destructive changes in articular surfaces do not resolve, further progression of articular cartilaginous destruction seems to be slower. More evident, however, is the pronounced diminishment in symptoms, probably due to the decrease in body weight on dependent weight-bearing joints.
      • Benotti PN
      • Forse RA
      The role of gastric surgery in the multidisciplinary management of severe obesity.
      Diminishment of knee and hip pain is greater than that of low-back pain. Long-standing morbid obesity can lead to irreparable joint destruction, but surgical arthroplasty is contraindicated in morbidly obese patients; surgically induced weight reduction should result in weight loss that will allow orthopedic joint replacement. This latter indication for an operative approach to weight loss may be justified in older patients (those older than 60 years of age) (see subsequent discussion).

      PSYCHOSOCIAL EFFECTS OF WEIGHT LOSS

      The psychosocial ramifications of extreme obesity and subsequent weight loss cannot be underestimated in our society. Our culture “worships” thinness, and both obvious and occult prejudice occur against obese persons in most social settings, including the home and workplace. With pronounced, visibly obvious weight loss, numerous changes occur in the social and interpersonal relationships of the patient. The patient may lose friends, may have sexual difficulties with spouse, and may be treated differently at work and elsewhere. These changes can be emotionally upsetting, and professional counseling is necessary not only preoperatively but also postoperatively. Before the operation, families and couples should discuss and even anticipate these changes in an attempt to prevent or recognize them postoperatively. Physicians likewise must be empathetic about the extent of the psychosocial changes.

      SPECIAL SITUATIONS

      Repeated Bariatric Surgical Treatment.—Bariatric opera tive approaches may fail, long-term weight loss may not be achieved, or severe complications may occur; in these situations, a revisionary operation is necessary. In our experience,
      • Behrens KE
      • Smith CD
      • Kelly KA
      • Sarr MG
      Reoperative bariatric surgery: lessons learned to improve patient selection and results.
      reoperative approaches were necessary for unsatisfactory weight loss, for metabolic complications of jejunoileal bypass, and for operative complications (less commonly) of previous bariatric procedures such as stomal obstruction, alkaline- or acid-reflux esophagitis, or anastomotic ulcer. Weight loss after reoperation was greater with conversion to gastric bypass than with conversion to vertical banded gastroplasty. We believe that metabolic complicacomplications after jejunoileal bypass should be managed not only by takedown of the jejunoileal bypass but also by concomitant conversion to a gastric bypass; reversal to normal anatomy leads to regain of weight in 80 to 90% of patients to their original weight. Although metabolic complications of jejunoileal bypass were corrected, a relative dissatisfaction was evident among several patients because of changes in eating habits induced by the gastric bypass; patients require specific counseling about these changes in eating habits before takedown of the jejunoileal bypass. Stomal complications and esophageal reflux symptoms were reversed in all patients. Thus, a previous bariatric operation should not be a contraindication to reoperation. Repeated bariatric surgical treatment is safe and effective in carefully selected patients.
      • Behrens KE
      • Smith CD
      • Kelly KA
      • Sarr MG
      Reoperative bariatric surgery: lessons learned to improve patient selection and results.
      Chronologic Age.—Because of concern about higher mortality rates in older patients, age greater than 50 years was regarded as a potential contraindication to a bariatric operation.
      • Benotti PN
      • Forse RA
      The role of gastric surgery in the multidisciplinary management of severe obesity.
      As bariatric procedures have become more widespread, numerous operations have been performed in selected patients older than 50 years of age. Many advances and improvements have been made in operative techniques and perioperative operative management. In our experience, age has not been a factor in the results of treatment.
      • Murr MM
      • Sidadati MR
      • Sarr MG
      Results of bariatric surgery for morbid obesity in patients older than 50 years.
      Weight Weight loss and its benefits were achieved in patients older than 50 years of age, with acceptable perioperative morbidity and no operative mortality. Subjective improvement in quality of life was reported by 81% of these patients. Severe obesity and advanced age further predispose patients to an increased risk of adverse outcomes. Age should not be considered a contraindication to operative treatment in patients with obesity-related medical conditions.

      SURVIVAL VERSUS QUALITY OF LIFE

      In younger patients (those younger than 60 years of age), the goals of bariatric surgical treatment are to increase longevity and improve quality of life. In a patient older than 60 years of age who has morbid obesity based on weight criteria alone, a controversial issue is whether weight reduction will substantially improve long-term survival; however, quality-of-life issues now become paramount. If the patient has severe degenerative joint disease (as would be expected), joint replacement would he contraindicated because of the person's weight; therefore, mobility is decreased, ability to increase exercise is functionally and realistically unlikely, and quality of life is poor. This scenario may be a reasonable indication for bariatric surgical treatment in selected patients.

      SUMMARY

      Obesity is a national health-care crisis. Because we do not understand the basic causes of overeating, the symptom—that is, overeating—must be treated. In selected patients, a weight-reduction operation will increase life expectancy, improve quality of life, and decrease long-term health-care expenditures by preventing the development of incapacitating chronic weight-related morbidity.

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