26 July 2007

Obesity: is surgery an option?

You've tried every diet on the market. But every time those kilos just find their way back to your tummy, thighs and hips. Should you consider surgery? DietDoc investigates.

A recent edition of the Pretoria News featured an article on bariatric surgery, entitled "When diets and exercise fail, surgery can help", written by Barbara Cole.

This article reported on how Natashua Fourie lost 34kg since November 2006, following keyhole laparoscopic surgery for morbid obesity.

According to the report, the surgeons, who are authorised to perform such operations at St Augustine's Hospital in Durban, have recorded even greater successes, including one patient who lost 120kg of weight after this type of operation.

What do these operations entail?
Bariatric surgery involves a reduction in the size of the digestive tract to restrict how much food the patient can eat and absorb. Most of the present-day techniques reduce the size of the stomach.

For example, gastroplasty involves placing stainless steel staples across the top of the stomach, leaving a small opening so that only a small amount of food can pass into the stomach at any one time.

A gastric bypass, on the other hand, also entails a reduction in the size of the stomach (with the aid of staples) and connecting the part of the stomach that is still functioning to the small intestine (Krause, 2000).

Laparotomy vs. laparoscopic surgery
Initially, bariatric surgery always involved a laparotomy (surgical opening of the abdomen). But nowadays keyhole laparoscopic surgery, which only requires small incisions in the abdomen, has become more popular. The latter procedure is much less invasive and faster, thus exposing the patient to less risk during the operation.

In one study conducted at the University of California, researchers found that laparoscopic bypass surgery took less operation time, caused less blood loss, reduced the length of time that patients were in intensive care after surgery and the length of their stay in hospital (Nguyen et al, 2000).

An Italian study reports that, on average, laparoscopic procedures took 60 minutes to perform compared to up to 3,5 hours for the more invasive, full-scale operations (Angrisani et al, 2007).

From the point of view of the patient undergoing surgery, it is evident that the more recent keyhole surgery techniques are faster and safer.

Can one expect the same weight-loss results from keyhole surgery?
A German research team, which studied 100 patients who underwent laparoscopic adjustable gastric banding, found that this procedure produced excellent results with an average weight loss of nearly 60% eight years post-operatively with reductions in BMI from 46.8 to 32.3 kg/m (Weiner et al, 2003). These researchers concluded that laparoscopic adjustable gastric banding is safe and has a lower complication rate than other bariatric operations.

Nguyen and coworkers (2000) also concluded that the keyhole technique produces the same initial weight loss as the more invasive surgical procedure.

According to the Pretoria News report, Natashua Fourie was treated with the keyhole procedure. Her mother and a friend had the same operation and lost 29kg and 25kg, respectively.

Who qualifies for bariatric surgery?
In my reading of the scientific literature, a number of authors repeatedly stated that "bariatric surgery is NOT to be regarded as a cosmetic procedure, but as a life-saving intervention in patients who suffer from morbid obesity."

People who only need to shed a few kilos or who have a BMI of less than 35 are usually not regarded as candidates for bariatric surgery. In fact, the majority of studies I investigated were treating patients with BMIs exceeding 40.

If your BMI is lower than 40, surgeons may, therefore, only consider you as a candidate for bariatric surgery if you have severe comorbidities such as diabetes mellitus, very high blood pressure or raised blood fat levels, and if you are at risk of suffering a heart attack.

In the absence of glucose conditions, most surgeons would recommend that you use diet and exercise, plus medications such as Xenical, to lose your excess weight.

Morbidly obese teenagers
It was interesting to read that in the US, where 25% of children and teenagers are overweight or obese, the National Institutes of Health regard a small number of adolescents who are severely obese (with BMIs exceeding 50kg/m) as eligible for bariatric surgery.

The children (from as young as 12 years) who received bariatric surgery also suffered from type 2 diabetes, hypertension, and other serious medical conditions such as degenerative joint disease.

In the majority of these young patients, bariatric surgery had very positive results: significant weight loss for up to 14 years after the operation, disappearance of comorbidities, and greatly improved self-image.

Text copyright: Dr I.V. van Heerden, DietDoc
24 July 2007

(Angrisani, L et al (2007). Surg Obes Relat Dis, Vol3(2):127-32; Cole, B (2007). When diets and exercise fail, surgery can help. Pretoria News, 20 July, p 11; Krause (2000). Food, Nutrition & Diet Therapy. 10th Edition. Mahan LK & Escott-Stump, S Editors. WB Saunders Co, Philadelphia; Nguyen, NT et al (2000). J Am Coll Surg, Vol 191(2):149-55; Sugerman, HF et al (2003). J Gastrointest Surg, Vol 7(1):102-7; Weiner, R et al (2003). Obes Surg, Vol 13(3):427-34.)


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