Gettysburg Medical News
by Phillip Hoffsten
29 November 2006

Surgery for Overweight

            The obesity problem in our society has reached epidemic proportions.  Recent statistics indicate the two thirds of our population is overweight meaning a body mass index greater than 27.  For a person my 6-foot 2-inch height the most one can weigh and be “normal" is 196 pounds.  By medical terms if I weighed 225 pounds or more I would be defined as obese (Body Mass Index 30 or more).  And if I weighed 252 pounds or more I would be defined as morbidly obese (Body Mass Index greater than 40).  On average a 20-year-old individual who is morbidly obese gives away 13 years of life span due to their obesity, not to mention all the problems that occur while they are still alive.  The statistics for development of obesity in our young population are scarier than those for the older individuals.

             To this time there has been no medical or lifestyle change that has been effective for the general population to deal with the obesity epidemic.  However, in this month’s issue of the Cleveland Clinic Journal of Medicine there is a review of the results of surgical treatment for morbid obesity.  According to present criteria, a person is eligible for surgical treatment of their obesity if their body mass index is greater than 40.  Alternatively, they are eligible if they have a body mass index of 35 associated with medical complications such as diabetes or hypertension.

             Surgical procedures to deal with morbid obesity were first considered in the 1960s.  More recently gastric bypass surgery and gastric banding have emerged as the most effective and safest procedures.  Finally, a large enough number of these procedures has been done to evaluate results and compare surgical versus nonsurgical treatment of morbid obesity.

             On average individuals undergoing gastric bypass surgery lost 70% of their excess body weight.  Those undergoing gastric banding lost 50% of their excess weight.  On average individuals undergoing any type of surgery for their obesity had resolution of their diabetes in 83% of cases.  Other symptoms that resolved included:  1.  Headache-57%,  2.  High cholesterol-63%,  3.  Metabolic syndrome-80%,  4.  Polycystic ovary syndrome-80%,  5.  Sleep apnea-75%,   6.  Asthma-82%,  7.  Hypertension-60%, 8.  Gastroesophageal reflux-75%,  9.  Urinary incontinence-50%,  10.  Arthritis-50%, 11.  Quality of life improved-95%,  12.  Decreased death rate-89%.

             Thus when obesity surgery works the benefits are huge.  What about the side effects and the complications.  Mortality surrounding the surgery is around 4% which is better than surgery for coronary artery bypass, colon surgery, or any of several abdominal surgeries.  Gallstones developed in approximately 1/3 to ½ of individuals undergoing extensive weight loss from the surgery.  Bowel obstructions, ulcers, wound infections, bleeding problems, and blood clot problems all can occur and need to be dealt with in the postoperative period.  On average one in five individuals undergoing gastric bypass surgery has some postoperative complication.  Once a person is 6 months out from the surgery the potential complications decrease considerably.  By then the most problematic complications include nutritional deficiencies such as vitamin B12 deficiency, iron deficiency, calcium deficiency, and vitamin D deficiency.  These must all be treated with nutritional supplements.

             In the 1980s an article published documenting the success rate of morbidly obese individuals achieving effective weight loss and maintaining it for 10 years.  The answer was that only 2% of morbidly obese individuals were successful in losing weight and maintaining their weight loss.  That same article documented no benefit to the entire group of morbidly obese individuals trying “diet and exercise".  The 2% who were successful in losing weight had a significantly reduced mortality compared to the 98% that did not.  When one compares two percent success with “diet and exercise" to the modern surgical result of 70% success it would seem the choice of treatment is obvious.  In one study the 5-year death rate for those undergoing obesity surgery was 0.68% as compared to an age-matched weight-matched control group which had a 16% mortality.

             The review from the Cleveland Clinic Journal of Medicine mentioned above emphasizes that gastric surgery is not a total immediate answer by itself.  The dietary restrictions enforced by the surgery are only part of the answer.  The person must undergo other lifestyle changes in addition and pay meticulous attention to the postoperative medical considerations such as vitamin supplements. Be that as it may, it is my professional medical opinion that those morbidly obese individuals who are serious about achieving weight control seem to have but one meaningful solution to the problem at this time.  What may happen with new medications and hormonal treatments in the future is still unknown.  To this time there are no medical therapies anywhere near as predictably successful as gastric surgery.