Obesity has become a worldwide epidemic, affecting well over 25 percent of individuals in industrialized countries. In the US alone, more than 60 million adults and 9 million adolescents are overweight or obese [having a Body Mass Index (BMI) of 30 or greater]. 

Approximately $80 billion are spent annually to treat obesity and its accompanying comorbid conditions, including but not limited to: diabetes mellitus type II, hypertension, sleep apnea, asthma, severe degenerative joint disease, cardiovascular disease, congestive heart failure, hyperlipidemia, gastroesophageal reflux disease, non-alcoholic steatohepatitis, lower extremity venous stasis, stress incontinence, and depression. These comorbidities can and often do become life-threatening, directly accounting for the increased mortality of the morbidly obese. 
 

While many explanations for obesity exist, effective treatment has proven a difficult challenge for the medical community. Historically many strategies have been employed, to include diets, behavior modification, exercise programs, and various medications; unfortunately, these alone have resulted in failure to achieve clinically significant weight loss and healthy weight maintenance for most.  Surgical treatment for morbid obesity has been the only proven method of achieving consistent long-term weight loss, comorbidity improvement and/or resolution, and subsequent mortality reduction.
 

Surgical treatment for obesity, known as bariatric surgery, has been available for several decades, though early on the long-term results were suboptimal. Early operations such as the jejuno-ileal bypass focused on significant malabsorption. 

While producing successful weight loss this procedure also resulted in unacceptable long-term malnourishment complications frequently leading to liver failure and death; due to this, it was eventually abandoned for a purely restrictive operation known as the vertical-banded gastroplasty (VBG), or “stomach stapling.” 

Early success rates with VBG were favorable, but greater than five year results proved less than satisfactory, largely due to late development of problems such as gastric outlet obstruction or gastro-gastric fistula caused by staple line breakdown and resulting in weight regain.
 

Today’s operative strategies have proven more successful for producing durable long-term weight loss with fewer complications than techniques formerly utilized.  The Roux-en-Y gastric bypass (RNYGB) has become the “gold standard” bariatric procedure performed in the United States. This operation combines a restrictive component with a mild malabsorptive component (see Figure 1).  RNYGB provides excellent long-term results for weight loss (65-70 percent EBW) and comorbidity resolution. 

RNYGB can be performed both laparoscopically and through an open incision; the trend has shifted strongly toward laparoscopic procedures which are inherently characterized by fewer complications, shorter hospital stays, and significantly accelerated recovery periods.
 

The laparoscopic adjustable gastric band (Lap-Band), an almost exclusively laparoscopic procedure that has been performed on over 200,000 patients worldwide, is the most recent surgical weight loss option gaining momentum in the US. The Lap-Band provides restriction to the upper stomach by creating a small gastric “pouch” (see Figure 2). The degree of restriction can be adjusted with ease postoperatively via percutaneous port access. 

This restriction provides optimum satiety with only a small meal. Although weight loss with Lap-Band is slower as compared with RNYGB, studies at the four- to five-year mark demonstrate results that rival RNYGB with regard to both weight loss and comorbidity resolution. Surgical risks and complications are considerably fewer and less severe because gastrointestinal anatomy is not disrupted.  The Lap-Band can be placed safely in the outpatient surgery setting for most patients with minimal time off work.
 

The sleeve gastrectomy and biliary pancreatic diversion with duodenal switch (BPD-DS) are two other bariatric operations currently available; however, they are usually performed at large academic centers and are typically reserved for the super morbidly obese. Close follow up is extremely important with the BPD-DS to avoid complications caused by micronutrient deficiencies. 
 

Locally, the Roux-en-Y gastric bypass and Lap-Band are options currently available to surgically treat obesity.  These operations, combined with an extensive multidisciplinary program, have produced excellent results.
 

Prior to being considered for bariatric surgery, prospective patients must meet criteria based on recommendations from the National Institutes of Health.  The patient must have a BMI of at least 35 with at least one comorbidity present or a BMI of 40 or greater with or without comorbidity to be considered. The patient must have made multiple previous dietary attempts at weight loss. 
 

Additionally, the patient must complete a preoperative multidisciplinary preparatory regimen to include evaluation by a registered dietician, consultation with an exercise physiologist, a psychological evaluation, and extensive behavioral health education. A full team of internists and specialists are available for those patients who require additional medical clearance and/or preparation to optimize the patient’s health status prior to surgery; this may include a required weight loss to assist with the laparoscopic approach. 

For all patients, a two-week liquid diet regimen is required prior to surgery which shrinks the liver volume, making it more pliable and more easily retracted, resulting in safer and improved access to the esophageal hiatus.
 

Follow up is an essential part of bariatric surgery. RNYGB requires periodic follow up with micronutrient laboratory testing at least annually to assure that the patient remains metabolically sound. Calcium citrate, vitamin B12, and multivitamin supplements are necessary lifelong postoperatively due to the degree of malabsorption resulting from RNYGB. Reductions in medications will likely be needed as comorbidities improve or resolve as a result of weight loss. 

Dietary changes are also required. High protein, low carbohydrate (sugar-free), and low fat are the mainstay. The first six months the patient takes in approximately 600 cal/day, then gradually increases to about 1,000-1,200 cal/day for lifelong maintenance.
 

For Lap-Band patients, periodic adjustments are needed to ensure appropriate satiety and portion control. The first adjustment is made about 6 weeks after placement.  Additional adjustments are needed when satiety increases and weight loss plateaus.  Most Lap-Band adjustments are performed under fluoroscopic guidance; however, adjustments may also be performed in the bariatric surgeon’s office without fluoroscopy. 

If weight loss slows and the Lap-Band patient can eat more easily without feeling restriction, an adjustment is likely needed.  As with RNYGB, dietary and behavioral/lifestyle changes must be made to make surgery successful.
 

While it is the only proven modality to significantly affect obesity and comorbid conditions, surgery is only one tool in the weight loss arsenal. As resources become more limited and health care costs further escalate, our focus must be prevention of obesity and maintenance of a healthy weight – and education must be at the forefront of the attack. It is imperative that appropriate diet and exercise habits are instilled at an early age. 

Our children are suffering from obesity at increasingly alarming proportions, and their life expectancies are becoming less than their parents’ as the incidence of obesity continues to skyrocket. Even with aggressive medical and educational intervention, positive changes may take several generations to fully realize.  Until then, surgical intervention is and likely will remain the most effective treatment for the disease of morbid obesity.

If you have patients with qualifying co-morbidities present, who exhibit a desire & strong determination to lose weight, and who would benefit from either traditional bypass or banding procedures, please call Physician Referral at 800-909-8326. You may also direct your patient to http://www.stjohns.com/services/weightmanagement.aspx or have them call St. John’s Clinic-General & Specialty Surgery at 417-820-3800 and ask for the bariatric coordinator.