Gettysburg Medical News
The Clinical View
by P.E. Hoffsten, M.D.
19 June 2002

SURGERY FOR WEIGHT LOSS

    The problem of overweight in the United States is not only increasing in the number of people involved but it has increased in the degree to which the overweight is occurring.  Individuals with weight in excess of 300 lbs are occurring with much greater frequency than in the past.  When a person exceeds 100% over their ideal body weight, most insurance companies will authorize coverage for surgery to correct the overweight problem. Insurance companies quite appropriately recognize that the healthcare expense of allowing the individual to maintain the excessive body weight far exceeds the cost of a one-step surgical procedure to correct the problem.  The health benefits of successful surgery to correct overweight have a very high benefit to risk ratio.

       Historically, the first surgeries that were done to correct overweight involved bypassing a portion of the intestine.  After the stomach, comes an essential short section of intestine of called the duodenum.  This is less than three feet long.  This is followed by about six feet of intestine called the jejunum and finally about nine feet of intestine called the ileum.  Each of these different segments of small bowel have specialized functions in the absorption of food.  The original idea was to attach the short portion of intestine called the duodenum directly to the large bowel.  This essentially reduced the length of bowel available for absorption of food by about 17 feet.  This surgery was effective in weight loss for many people in the 1960’s but the medical complications made this surgery prohibitive and many of the people who had it done had to have it reversed.  Diarrhea and malnutrition for essential nutrients resulted in liver failure and kidney disease along with multiple vitamin deficiencies.

       The idea of the intestinal bypass was to cut down the area of intestine available for absorption of foods.  When this didn’t work, the next idea was to make the entry into the intestine so small that a person simply couldn’t eat enough to maintain a very heavy weight. Thus were born the procedures called gastric stapling.  Basically, these procedures reduced the size of the stomach down so the person simply didn’t have enough room to eat as much as they had been prior to the surgery.  This procedure generally resulted in a 50 lb weight loss or more but seemed to level off after about six months quite often far short of the desired results.  With time, the pathway through the stomach stretched and the person’s eating habits changed.  Weight regain at that time was very common. and thus the gastric stapling procedure fell out of vogue. The basic problem with this surgery was that it did not solve the problem of the person’s hunger. People who had gastric staplings done plateaued in their weight loss because their hunger continued and they found various high calorie foods that they could eat.

       In 1967, Dr. Mason introduced the idea of completely bypassing the stomach and letting food go directly into the jejunum.  The idea was tested over the next 14 years and by 1981, it became apparent that completely bypassing the stomach except for a small pouch at the top yielded better results than stapling procedures that allowed food to progress through the stomach but with a reduced size of the canal.  By 1987, it was apparent that the surgical procedure completely bypassing the stomach resulted in a 60% improvement in the weight loss that the surgical procedures achieved.  But more importantly, those patients who had gastric bypass surgery done ceased to be hungry.  The patients who had gastric stapling procedures done, remained hungry, lost about 50 lbs but then plateaued at that point.  Those individuals who had gastric bypass procedures done lost almost 80 lbs in the first year, were not hungry and had substantial improvements in their medical profile.

       At this time, surgery for those individuals who are more than 100% overweight should receive strong consideration. This is especially true if the individuals are in the 20-40 year old age group when prevention of diabetes, hypertension, heart disease and arthritis can still be achieved.  For the individual past 40 years of age who is already developing these problems, surgery would still be a consideration although the damage already being done is often not reversed.  At least the individual over age 40 can expect to avoid progression of the problems. Recently a hormone called ghrelin which stimulates appetite and hunger has been found to be produced by the stomach.  When a person has gastric bypass surgery, the amount of this hormone drops to very low levels and is almost certainly the explanation why this surgical procedure prevents hunger and results in such effective weight loss.

       Based on my observation of the complications, expense and nuisance that conditions such as diabetes, high blood pressure, heart disease, arthritis and being overweight presents, gastric bypass surgery at a young age appears to be an effective preventive step for those who are willing to consider it.  The procedure has now been tested for 35 years and the benefits far out way the risks.  The healthcare professionals at your local community clinic can help in advising the individual regarding this consideration and facilitate the surgery for those who elect to proceed.