Dangerous Obesity Surgery

Obesity has reached epidemic proportions worldwide, and most of us would probably concur that those who are obese would rather not be.  Rick and I agree in this week's podcast, however, that at least one surgical solution to obesity isn't worth considering: duodenal switch.  That's after looking at a study comparing duodenal switch to gastric bypass in the current issue of Annals of Internal Medicine.

In this study, 60 so-called 'morbidly obese' people were enrolled and randomized to either the standard issue gastric bypass surgery, in use for many years now in bariatric surgery circles, or the duodenal switch operation.  You can assess the difference between the two operations yourself by looking at the original citation where diagrammatic representation makes things clearer.  31 of the 60 people got gastric bypass while the remainder underwent duodenal switch.  Patients who accrued to the study had a body mass index between 50 and 60.  Recall that overweight is a BMI greater than 25, while folks with a BMI that exceeds 30 are considered obese.  So these people were very, very obese to begin with.  A total of 58 enrollees completed the study.

For those who had duodenal switch, for the most part things looked good initially, with this group experiencing superior reductions in cholesterol, body weight and other measures.  Both groups saw decreases in blood pressure, glucose, insulin, and C-reactive protein, one measure of inflammation.  Yet here's the rub:  over time, the duodenal switch group experienced depletion of vitamins A and D, and iron, so much so that some developed night blindness and required intravenous administration of iron supplements.  In total, over the two year follow-up, 32% of gastric bypass patients had experienced an adverse event, compared to 62% of duodenal switch patients!  In our minds, the positive aspects of more dramatic weight loss and improvement of other risk factors does not compensate for the nutritional compromise seen with duodenal switch, and we agree that the operation should likely be abandoned.  

Obesity surgery is undertaken to improve quality of life and reduce or eliminate risk factors for chronic disease and early death.  For those who are morbidly obese and relatively young, the hope is to preserve their lives and enable them to live a more normal lifespan.  In this study many of the subjects were women of childbearing age, but creating profound nutritional impairment in these women runs counter to the object of bariatric surgery, as they will likely either not be able to get pregnant or maintain a pregnancy with such malabsorption issues.  Moreover, for any bariatric surgery candidate of either gender, long term need for IV supplementation of vitamins and minerals isn't moving toward normalcy.

People who develop this degree of obesity don't do so overnight.  As we have talked about in numerous podcasts, weight and controlling overweight is something all healthcare providers should discuss each time someone interacts with the healthcare system.  We recall a study we've talked about in the last few years where only a very small percentage of primary care physicians actually addressed the issue of weight at all even among patients they saw regularly.  It's our hope that this is changing as societally we have become much more aware of our growing obesity problem.  For individuals awareness is also needed.  Obesity doesn't develop overnight, and we all must take charge of our own health and weight.

Other topics this week include lifestyle and diabetes risk among older people, also in Annals, non-steroidal anti-inflammatory drugs and miscarriage in the Canadian Medical Association Journal, and intracranial carotid stenting in NEJM.  Until next week, y'all live well.

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Nuttapong December 14, 2012 at 4:24 pm

Finally, a bariatric ckoobook with pictures!! You all know I've had a bee in my bonnet about that for a while now. Not only are the full color photos tantalizing, the recipes are great too. I prepared the Oven Baked Fried Chicken which is a dish of chicken breasts coated with spices and rolled oats and fried in the oven. This recipe is very clever and very delicious. In addition to the recipes, the book gives a comprehensive overview the bariatric diet regime all stages. It covers gastric banding, gastric bypass and, biliopancreatic diversion. The book even gives the low down on artificial sweeteners, protein powders, and a well-stocked bariatric pantry. I give this one four lap bands. [. . . ]

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