OBESITY
BARIATRIC SURGERY The Sooner the Better Gregg Jossart, MD, FACS In 1995, surgeon Walter Pories published an article in Annals of Surgery titled, “Who Would Have Thought It? An Operation Proves to Be the Most Effective Therapy for Adult-Onset Diabetes Mellitus.”1 Almost two decades have passed, and we are in the middle of an obesity-related diabetes epidemic. In the United States, there are more than 100 million Americans with diabetes and prediabetes, and more than 72 million Americans with obesity. Two-thirds of adult-onset diabetes is directly associated with obesity. Obesity is also associated with more than forty other medical problems, including heart disease, cancer, sleep apnea, and orthopedic problems. All of these problems, including the obesity itself, tend only to worsen with time. The numerous medical problems can be treated to some extent with medications, CPAP devices, and physical therapy, but the core problem that remains is the obesity. Dietary and exercise weight-loss attempts are always the best starting point but, unfortunately, failure does occur and obesity persists. Recent commentary published in the journal Lancet Diabetes & Endocrinology claims that once people develop obesity, it is next to impossible to return to a healthy weight without bariatric surgery.2 Christopher Nolan, a clinical psychologist, noted that the average adult with sustained obesity has less than a 1 percent chance of returning to and maintaining a healthy body weight without surgery. Obesity surgery has the highest cure rate of obesity and its related illnesses but has been viewed as a last-resort option and thought to be dangerous. That view is changing due to newer, safer procedures and how well diabetes is cured with surgery. In April of 2013, the American Society for Metabolic and Bariatric Surgery (ASMBS) and the American Association of Clinical Endocrinologists (AACE) made recommendations that include obesity surgery as an earlier treatment option in the obesity disease process.3 Surgery has the highest cure rate of obesity-related diabetes when it is in the earliest stage, not when a patient has had diabetes for ten years and is approaching 400 or more pounds in weight. In the last twenty years, numerous advancements in surgical weight reduction have occurred that now make it a great option to consider earlier on in the obesity and diabetes disease process. The advancements include laparoscopic approach, safety, and lower-risk procedures. The evolution from open surgery to laparoscopic surgery started in 1994 and, currently, almost all weightloss surgery is done laparoscopically. Patients have less pain, fewer complications, and require only one to two nights in the hospital. The laparoscopic approach and the increased surgeon experience have reduced complication rates to the point that bariatric surgery has been proven to be safer even than gallbladder surgery. The most significant changes in bariatric surgery in the last ten years are related to the choice of procedures and the outcomes in diabetics. The gastric band procedure was approved by the FDA in 2001 and was placed in more than 20,000 patients in California. It has become much less common over the past few years beWWW.SFMS.ORG
cause of problems that develop from the device wrapped around the stomach. Essentially, the band can be effective but has a high removal rate. The gastric bypass and the duodenal switch have been the best operations for diabetes over the last twenty years. The intestinal bypass that is created causes significant malabsorption of calories consumed. Malabsorption has the ability to achieve a more durable weight loss and perhaps a better cure of diabetes but also yields more long-term nutritional deficiencies and other complications related directly to the intestinal bypass. Currently, all of these procedures have been proven to achieve weight loss and diabetes resolution and all are approved by insurance companies. The newest procedure that is now selected by more than 50 percent of patients is the sleeve gastrectomy (Figure 1, below). The sleeve gastrectomy (or gastric sleeve) only reduces stomach volume without changing the intestines (as in gastric bypass) or introducing a foreign body (as in gastric banding). This allows for a balance between portion size and range of food choices with fewer side effects. Insurance companies started approving this procedure in 2010 and it has increased from 2 percent in 2008 to over 50 percent of all procedures in America in 2014. This procedure is most appealing to patients as it avoids all the potential problems of the more complex bypass operations as well as the foreign-body
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