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Clinical Crossroads | Clinician's Corner

A 52-Year-Old Woman With Obesity Review of Bariatric Surgery

Christina C. Wee, MD, MPH, Discussant
JAMA. 2009;302(10):1097-1104. doi:10.1001/jama.2009.1197.
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Ms J is a 52-year-old woman with severe obesity and depression, anxiety, and osteoarthritis who has not been able to sustain weight loss through dieting and is now considering having weight loss surgery. She would like to know the long-term effects of surgery, including its psychological consequences. The article discusses the consequences of the 2 most commonly performed bariatric procedures, Roux-en-Y gastric bypass and laparoscopic adjustable gastric banding, and their effects on weight loss, comorbidities, psychological function, and overall quality of life. Evidence suggests average weight loss at 10 years after surgery of 25% and 13%, respectively. The risk of perioperative mortality varies with patient factors and surgeon experience but is typically less than 1% with experienced surgeons. Roux-en-Y gastric bypass has a higher complication rate than laparoscopic adjustable gastric banding. Many obesity-related comorbidities such as diabetes and hypertension resolve or improve with weight loss, and quality of life generally improves in parallel with weight loss. However, depression and anxiety, as Ms J experiences, do not necessarily improve as a result of surgery.

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A 52-Year-Old Woman With Obesity
Posted on August 15, 2009
Juan Carlos Rodriguez Garcia, MD.
Internal Medicine and infectious diseases consultant Complejo Hospitalario. Pontevedra. Spain
Conflict of Interest: None Declared
1) When is it appropriate to consider weight loss surgery? Be well-informed and motivated. Have a BMI >40. Have acceptable risk for surgery. Have failed previous non-surgical weight loss. Adults with a BMI >35 who have serious comorbidities such as diabetes, sleep apnea, obesity-related cardiomyopathy, or severe joint disease may also be candidates. (1)
2) How effective is surgery and how much can one expect to lose from surgery? The mean overall percentage of excess weight lost was 61% (95% CI 58-64%), varying according to the specific bariatric procedure performed. (2, 3, 4)
3) What are the risks associated with surgery and what is its effect on mortality? Procedure-related mortality depends upon the type of procedure, surgical experience, and patient characteristics. A meta-analysis estimated that, overall, 30-day operative mortality was 0.1% for purely restrictive procedures, 0.5 percent for gastric bypass, and 1.1% for biliopancreatic diversion or duodenal switch. (5, 9, 10) The striking benefits on important obesity-related morbidity contrast with relatively disappointing results in the management of severe obesity with medical and behavioral therapy.
4) What is the effect of surgery on psychological function and overall quality of life? Several studies have demonstrated that bariatric surgery is effective in reducing obesity-related comorbidities, while having additional benefits such as reducing monthly medication costs and the number of sick days and improving quality of life. A benefit on overall and cause-specific mortality has also been demonstrated. (7, 8) The striking benefits on important obesity-related morbidity contrast with relatively disappointing results in the management of severe obesity with medical and behavioural therapy. The Swedish Obese Subjects Trial (SOS) is the largest trial comparing surgical versus medical treatment of morbid obesity and confirm clearly this observations. (6)
Surgically treated patients were significantly less likely to require medications for cardiovascular disease or diabetes at two and six years. Among those not already requiring such medications, surgery reduced the proportion who required initiation of treatment. Costs of medications were reduced significantly in the surgically treated group. Surgically treated patients had dramatic improvement in scores on validated measures of quality of life compared with only minor and sporadic improvement in medically treated patients at two years. The magnitude of benefit was related mostly to the degree of weight loss, which was greater in the surgical group. Similar benefits were observed on validated batteries of psychiatric dysfunction. At 10 years of follow-up overall outcome was still significantly better in the surgical than the medically treated group. (7, 9)
5) What do you recommend for Ms J? I recommend she undergo bariatric surgery with laparoscopic adjustable gastric banding because of its simplicity and lower complication rates. As an alternative treatment I would choose laparoscopic Roux-en-Y gastric bypass. Bariatric surgery needs to be performed in conjunction with a comprehensive follow-up plan consisting of nutritional, behavioral, and medical programs.
All persons and of course all patients needs quality of life. Everything has a price, but in my point of view, I say: “do it, Ms J”.
1. Guidelines for Bariatric Centers of Excellence. ASBS Newsletter 2003.
2. Buchwald, H, Avidor, Y, Braunwald, E, et al. Bariatric surgery: a systematic review and meta-analysis. JAMA.2004; 292: 1724.
3. Maggard, MA, Shugarman, LR, Suttop, M, et al. Meta-analysis: surgical treatment of obesity. Ann Intern Med 2005; 142: 547.
4. Santry, HP, Gillen, DL, Lauderdale, DS. Trensds in bariatric surgical procedures. JAMA 2005; 294: 1909.
5. Lancaster, RT, Hutter, MM; Bands and bypasses: 30-day morbidity and mortality of baratric surgical procedures as assessed by prospective, multi-center, risk-adjusted ACS- NSQIP data. Surg Endosv 2008; 22: 2554
6. Sjostrom, L, Narbro, K, Sjostrom, CD, et al: Effects of bariatric surgery on mortality in Swedish obese subjects. N. Engl J Med 2007; 357: 741.
7. Sjostrom, L, Lindroos, AK, Peltonen, M, et al. Lifestyle, diabetes, and cardiovascular risk factors 10 years after bariatric surgery. N. Engl J Med 2004; 351: 2683.
8. Ryden, A, Sullivan, M, Torgerson, JS, et al. A comparative controlled study of personality in severe obesity: a 2–y follow after intervention. Int J Obes Relat Metab Disord 2004 ; 28: 1485.
9. Mun, EC, Pi-Sunyer, FX, Martin, KA, et al. Surgical management of severe obesity. Up To Date. Ver 17.2. 2009.
10. Mun, EC, Friedman, LS, Pories, SE, et al. Complications of bariatric surgery. Up To Date. Ver 17.2. 2009.
Dr Rodriguez reports no relevant financial interests.
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