Obesity: Gastric Surgical Intervention

Obesity – Problem and Statistics

Obesity is a national problem today with no age group being spared from its ill effects (Newman, 2004; Bray et al., 2004). The rising weight of the American population is a growing source of concern as they are becoming heavier and more obese (Newman, 2004). According to research by RAND economist Roland Sturm (2007), there is a continuous elevation in the obesity rates (to the tune of 24 percent) in the United States of America between the years 2000 to 2005.

Obesity is defined as a BMI (body mass index) of 30 kg/m2 or more and is becoming a crucial medical challenge to America (McTigue et al., 2003). The BMI is an effective screening tool for measuring obesity and evaluating health risks to individuals. The body mass index correlates the total body fat of an individual with the risks and is considered to be the fifth vital sign during routine checkups for individuals (Centers for Disease Control and Prevention).

With an increase of 13 percent to 31 percent in adult obesity, the rates have tripled in the previous four decades (McTigue et al., 2003). Children in the age group of 6 to 11 years have also witnessed a three-fold rise in obesity and the age group of 12 to 19 has been reported with a more than 3 percent rise in obesity as compared to the rise about two decades back (American Cancer Society, 2005). Research confirms that a quarter of the young children aged four years are likely to remain obese for the rest of their adult lives. Still worse is the fact that about 80 percent of obese teenagers remain obese through their adult stages.

The implications for obesity are far more severe in the minority groups which have witnessed a rise from 6.5 percent to 27.4 percent within twelve years (Strauss & Pollack, 2001). These statistics and figures are troublesome because of the complications and implications of obesity. The obesity epidemic in America, not only poses a threat to the long life capacity of individuals, but it also causes numerous health problems and increases their risks of complications including diabetes, sleep disorders, hypertension, depression, exercise intolerance, and other such physical and mental problems (Ebbeling CB, Pawlak DB, Ludwig, 2002).

With the steady rise in severe obesity, the total number of people having a BMI over 40 has advanced to 50 percent. Similarly, there was a 75 percent rise in the number of people with a BMI of over 50 (Daniel J. DeNoon, 2007). Treating obesity is not an easy task and obese people find it difficult to maintain their weight loss (Dansinger ML et al. 2005). Keeping pace with this increased rise in morbid obesity is the phenomenal increase in the rate and popularity of gastric bypass surgery or intervention to treat obesity.

Surgical intervention or bypass surgery is the current and popular node of treating long term obesity and is conducted upon individuals with a body mass index of 35 kg/m2 or higher plus or a BMI of 40 or above (Davis MM, Slish K, Chao C, Cabana, 2006). Gauging by this criteria, about five to six percent of the American populace is suitable for gastric or bariatric surgery (Mustet al., 1999, in; Clark, 2006).

Indications for surgery

About 9 million adults and 2 million children are affected by extreme obesity and face the risks of immediate health problems and later serious risks, more specifically premature death (Munoz et al., 2007). The current medical and behavioral interventions to treat extreme and severe cases of obesity do not provide significant outcomes in adults and children and the bariatric surgeries have been proven to prolong weight control and improve the problems related to severe and extreme obesity, particularly diabetes (type 2), hypertension, the obstructive sleep apnea syndrome and other serious health problems (Anderson, 2008).

Evidence also suggests that adolescents lose substantial weight following bariatric surgery and thereby experience an improvement in the obesity-related problems, which confirms that “bariatric surgery performed in the adolescent period may be a more effective treatment for childhood-onset extreme obesity than delaying surgery for extremely obese youth until adulthood” (Researchers at the Division of Pediatric and Thoracic Surgery in; Anderson, 2008).

Other researchers have also noted the importance of bariatric surgery being performed “earlier during adolescence” rather than “in adulthood” (Ibid) for extreme obesity which has been onset in childhood. Most patients choose surgical intervention for treating obesity due to the medical problems related to it, while there are also significant numbers who choose to undergo gastric bypass due to “psychological and quality of life factors” (Munoz et al., 2007).

Indications for the surgical intervention evolved in America during the 1980s following which they were formulated in the year 1991 at the National Institutes of Health Consensus Development Conference on gastrointestinal surgery for severe obesity (National Institutes of Health Consensus Development Conference, 1992). It is here that the weight criterion for the surgical intervention was made broader from a BMI of 40 BMI to a BMI of 35.

Early intervention is considered vital in bariatric surgery since a longer duration of obesity conditions reduces the potential of a sustainable cure (Pories WJ et al., 1995; in; Kral, John and Erik Naslund, 2008). Thus, ‘early’ intervention refers to surgical consideration after the attainment of a critical BMI corresponding to early treatment of diabetes (Kral, John and Erik Naslund, 2008).

Types of procedures in gastric bypass surgery

Bariatric Operations

Bariatric Bypass Surgery

Bariatric or gastric bypass surgery is a surgical treatment for obese individuals with a body mass index of more than 35 or 40. This surgical intervention involves the use of procedures by reducing the gastric capacity or inducing malabsorption by reducing the length of the small intestine. The restrictive methods or procedures used in gastric bypass surgery are Vertical banded gastroplasty or the VBG and Gastric banding (Clark, 2006).

Jejunoileal bypass

The commonly used malabsorption procedure is the Jejunoileal bypass which has now been abandoned due to the malnutrition of protein-calorie and cirrhosis (Clark, 2006).

Roux-en-Y gastric bypass

The most commonly used surgical intervention for gastric bypass is the combination surgery called the Roux-en-Y gastric bypass. This surgery involves the construction of a 20 ml gastric pouch which is then connected to a variable-length Roux limb to bypass the small intestine (Clark, 2006).

Purely restrictive procedures

All primary bariatric surgeries must preferably be done laparoscopically (Kral, John and Erik Naslund, 2008). Surgeries which involve purely gastric restrictive procedures, for instance, the adjustable gastric bans and the vertical banded gastroplasty, reduce weight by restricting the stomach capacity to hold food and also by reducing the speed of the flow of ingested nutrients acquired through the food (Kral, John and Erik Naslund, 2008).

Gastric restriction combined with diversion

In surgeries involving gastric bypass in combination with diversion, the gastric bypass reduces the size of the stomach by approximately 5 percent of its total volume and the ingested food circumvents 95 percent of the stomach. This operation relies primarily upon gastric restriction to reduce weight for the first six to eighteen months of the surgery (Kral, John and Erik Naslund, 2008).

Diversionary malabsorptive procedures

In diversionary malabsorptive surgeries, the procedures circumvent the stomach and the long segments of the small intestine to decrease the total area of the mucosa which is available primarily for the absorption of the nutrients in the food (Kral, John, and Erik Naslund, 2008).

The biliopancreatic diversion is instrumental in the selective malabsorption of fat from food (Tataranni PA et al., 1996, in; Kral, John, and Erik Naslund, 2008) facilitating weight loss. However, this procedure causes additional complications as compared to gastric bypass through other related problems such as protein malnutrition, diarrhea, and other deficiencies of numerous vitamins (Scopinaro N et al., 1998; in; Kral, John and Erik Naslund, 2008).

Regulatory metabolic operations

The regulatory metabolic operations include the duodenal-jejunal bypass (Cohen R et al., 2007) and the ileal interposition (de Paula AL et al., 2006). These are investigational surgeries with minimal absorptive procedures but have significant metabolic effects due to the neuroregulatory brain-gut peptides (Kral, John and Erik Naslund, 2008). The peptides are involved in the function of employing mechanisms that are believed to reduce weight through certain effects on the appetite and the metabolism of the operations in the gastric bypass (Kral, John, and Erik Naslund, 2008).

Laparoscopic Adjustable Gastric Banding

In this surgical procedure, an inflatable band made out of silicone is encircled around the uppermost part of the stomach and then buckled tightly (Buchwald et al., 2005), and a small gastric pouch is created. The band also enables a slim outlet between the pouch and the stomach. Laparoscopic adjustable gastric banding has been reported with the lowest mortality rates but also yields minimum results in weight loss (Buchwald et al., 2005). To successfully lose weight with this procedure, the patients are required to follow up for ban adjustments.

Roux-en-Y Gastric Bypass

The RYGB results in restrictive as well as malabsorptive effects and leads to weight reduction amounting to 60% to 75% of the total body (Sugerman, 2007). This surgery is now performed by laparoscopic methods and creates a bypass of the duodenum. This is believed to have considerable effects on patients with type 2 diabetes (Sugerman, 2007).

Benefits of Bariatric Surgery

Weight loss

Weight loss is the most preferred and expected outcome of bariatric operations and has a high correlation to patient satisfaction (Kral, John and Erik Naslund, 2008). Research suggests that there are geographical differences in the outcomes of weight loss after following the same adjustable banding procedures; weight loss has shown to be with reduced complications and greater in Europe and Australia than in America (DeMaria and Jamal, 2005) while some studies have shown better weight loss in America (Parikh MS et al., 2005). However, these differences could also be due to the distinct eating behaviors and the availability of food in specific locations.

Reduction in Mortality

The primary goal of bariatric surgical intervention is to reduce mortality. Research and evidence prove low mortality rates among patients who have undergone bariatric surgery as compared to those who have resorted to conventional methods to overcome obesity (Sjöström, 2006). Other research statistics also confirm that mortality is reduced after bariatric surgical intervention to overcome obesity (Christou et al., 2004).

Reduced Comorbidity

An important positive result of bariatric surgery is a decrease in comorbidity, which improves tremendously depending upon the type of surgical procedure performed (Sugerman HJ and Kral JG, 2005). Lower blood pressure is also reported for as much as five years after the surgery, thereby reducing hypertension. Other positive changes have been noted including improvements in patients with diabetes (Sugerman HJ and Kral JG, 2005).

Pregnant obese women have the risk of providing unfavorable intrauterine conditions to the fetuses, thereby increasing the potential of these unborn children to be obese. Studies reveal that bariatric surgery performed improves the gestation and the delivery of the fetus followed by enhanced infant health (Kral, 2004). Research also confirms a reduction in the obesity levels following maternal bariatric surgery which was followed from two years to eighteen years after the operation (Kral JG et al., 2006).

Risks and Complications of Surgery

Perioperative Mortality

Bariatric surgery is associated with a mortality rate of about less than a percent and is generally caused due to postoperative pulmonary embolism or leakage from the intestinal anastomoses (Clark, 2006). Infections from wounds are also a short-term complication that may be apparent in about twenty percent of the patients (Christou, 2004). The long-term effects include frequent stools and vitamin deficiencies (Clark, 2006).

Complications, however, have reduced over time due to the adoption of laparoscopic procedures for conducting surgeries. The most common causes for death following bariatric surgeries are pulmonary embolism, intra-abdominal leaks, and myocardial infarction (Fernandez et al., 2004).

Surgical Complications Post Bariatric Surgery

Certain surgical complications can be caused post-operation, which are, however, specific to the kind of procedure adopted to perform the surgery (Kral, John and Erik Naslund, 2008). Band erosion may lead to pain and even ulcers and the enlargement of the pouch and slipping of the band can also result in vomiting (Kral, John and Erik Naslund, 2008).

The surgical approach adopted to operate also has considerable effects on the types of complications caused. Additional wound problems were reported in open procedures as compared to laparoscopic surgeries (Podnos et al., 2003). Surgeries conducted through open procedures also reported more cases of Incisional hernias as compared to laparoscopic treatments.

Deficiencies

The most crucial and long-term effects of bariatric surgeries are vitamin and mineral deficiencies in patients, particularly in patients who have undergone malabsorptive operations (Kral, John, and Erik Naslund, 2008). Iron deficiencies have been caused in patients who have undergone restrictive surgeries, especially in women.

Excessive vomiting has also resulted in thiamine deficiency which further resulted in neuropathy (Kral, John and Erik Naslund, 2008). Deficiencies of Vitamin B₁₂, [62] folate, calcium, and vitamin D are reported in patients who undergo gastric bypass and biliopancreatic diversion (Kral, John, and Erik Naslund, 2008).

Patients must have their blood nutrient levels monitored and take oral supplements of vitamins and minerals. Research also confirms bone loss in patients who have undergone bariatric bypass which often tends to stabilize due to the unaltered level of vitamin D (Kral, John and Erik Naslund, 2008).

Failure in weight loss

An important and challenging long-term complication of bariatric surgery is insufficient weight loss since re-operations are difficult and more complicated than primary surgical interventions (Kral, John and Erik Naslund, 2008).

Monetary Issues to Patients and Society

Bariatric surgery is believed to increase the costs to individuals and society, in general, owing to increased hospitalizations for surgery and post-surgical care (Anderson, 2008).

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