References and Abstracts, Obesity Surgery, August 1999

Article References & Abstracts
OBESITY SURGERY

Author Drenick EJ; Bale GS; Seltzer F; Johnson DG
Title Excessive mortality and causes of death in morbidly obese men.
Source JAMA 1980 Feb 1;243(5): p443-5
ISSN 0098-7484
Abstract A group of 200 morbidly obese men (average weight, 143.5 kg; age, 23 to 70 years) were admitted to a weight control program between 1960 and 1977 and were followed up for a mean period of 7 1/2 years. There was complete follow-up until the termination of the study or until death for 185 men. Fifteen men were followed up for fractional periods. Fifty of the 200 died during the course of the study. Life-table techniques, comparing the mortality among the obese with that among men in the general population, demonstrated a 12-fold excess mortality in the obese in the age group 25 to 34 years and a sixfold excess in the age group 35 to 44 years. This ratio diminished with advancing age. Cardiovascular disease was reported as the cause of death more frequently and malignancies less frequently than they were for men in the US general population.
Author Drenick EJ
Title Definition and health consequences of morbid obesity.
Source Surg Clin North Am 1979 Dec;59(6): p963-76
ISSN 0039-6109
Author Still CD; Jensen GL.
Institution Penn State Geisinger Health Care System Danville, Pennsylvania; Vanderbilt University
Medical Center Nashville, Tennessee
Title Obesity
Source In Rakel: Conn's Current Therapy 1999, 51st ed., 1999 W. B. Saunders Company
Title Treatment of obesity in adults. Council on Scientific Affairs [see comments]
Source JAMA 1988 Nov 4;260(17): p2547-51
ISSN 0098-7484
Abstract Concern with weight control should begin sufficiently early in life to reduce the risk of developing obesity. The complex etiology of obesity is, in part, responsible for the difficulty physicians encounter in treating this condition. Prevention is the "treatment" of choice. Early identification of individuals genetically at risk can be helpful in targeting those most likely to gain excess weight. Numerous dietary regimens have been devised in an attempt to achieve progressive weight loss in obese individuals. Since the ultimate goal of a weight-reduction program is to lose weight and maintain the loss, a nutritionally balanced, low-energy diet that is applicable to the patient's life-style is most appropriate. Increasing energy expenditure through physical activity, in addition to decreasing energy intake, generally improves results in the management of obesity. Major changes in eating and exercise behaviors are necessary to ensure long-term weight control. Diet, exercise, and behavior modification are interdependent and mutually supportive. A comprehensive weight-reduction program that incorporates all three components is more likely to lead to long-term weight control.
Author Shamblin JR; Shamblin WR
Title Bariatric surgery should be more widely accepted.
Source South Med J 1987 Jul; 80 (7): p861-5
ISSN 0038-4348
Abstract Bariatric surgery is not widely accepted by the general medical profession because of several misconceptions. Many physicians believe that morbidly obese persons could lose weight if they used their willpower, that bariatric surgery is a major operation in a high-risk population, and that weight loss is unpredictable, follow-up is poor, the reoperation rate is high, and late weight gain is common. Using the results of our series of 500 vertical Silastic ring gastroplasties and a collected series of 3,237 cases, we respond to these objections. Nonsurgical methods of weight loss are successful in less than 5% of morbidly obese patients. The operative mortality in the collected cases was 0.2%. The average percentage of excess weight lost is 66%, with only 10% of patients failing to lose at least 40% of their excess weight. With diligence, a follow-up of more than 90% can be obtained. The reoperation rate among experienced surgeons averages 1% to 2% per year. Mild late weight gain occurs in about 15% of cases, but significant weight gain occurs in less than 5% of patients. We believe that vertical staple gastroplasty is safe and effective and that it should be accepted as such by the medical profession.
Author Field RJ Jr; Field RJ 3d; Park SY
Title Vertical banded gastroplasty: is obesity worth it?
Source J Miss State Med Assoc 1992 Dec; 33 (12): p423-32
ISSN 0026-6396
Abstract Obesity is a public health issue of major concern for the United States and other developed nations. In the last several decades, bariatric surgery has developed as a means of treating morbid obesity. Vertical banded gastroplasty (VBG) is an attractive procedure because it has fewer side effects than other forms of bariatric surgery and maintains physiological continuity of the gut. VBG was performed in 36 patients at a rural community hospital from 1982-1990. There was only one intraoperative complication necessitating splenectomy and two early postoperative complications--gastric leak and marginal stress ulcer--necessitating reexploration. Twenty-five patients were available for follow-up, at which time they were an average of 6.4 years out of surgery. Two of these patients had died, both from cardiac arrest months or years after VBG. The remainder had gone from a preoperative average of 86.7% over ideal weight according to 1983 Metropolitan Life insurance Tables to 54.5% over ideal weight. Mean BMI for this group had changed from 41.2 preoperatively to 34.7 at follow-up. Success was defined as weight loss to < 60% over ideal or BMI < 35, removing the individual from the morbidly obese category. According to this criteria, VBG provided successful weight loss in 72% of subjects in the follow-up group. Weight loss results may have been biased as a significant number of patients were lost to follow-up and may have constituted failures. In general, most individuals did not make concomitant changes in diet or sedentary life-style which would have supported weight loss effected by VBG. Moreover, regain of weight was progressive and possibly inexorable. Nearly all individuals nonetheless reported great satisfaction with their surgery. VBG is a viable option in the treatment of morbid obesity, but criteria for success needs to be better defined in order to determine whether the procedure is "worth it."
Title International Federation for the Surgery of Obesity. Statement on patient selection for bariatric surgery.
Source Obes Surg 1997 Feb; 7 (1): p41
ISSN 0960-8923
Author Cowan GS Jr; Hiler ML; Buffington C
Institution Department of Surgery, University of Tennessee College of Medicine, Memphis, USA.
wcinc@mindspring.com.
Title Criteria for selection of patients for bariatric surgery.
Source Eur J Gastroenterol Hepatol 1999 Feb; 11 (2): p69-75
ISSN 0954-691X
Abstract International criteria for bariatric surgery and bariatric surgeons have been well-defined in terms of the current state of the art and are presented together with weight tables and a list of co-morbidities of morbid obesity. The bariatric surgeon should make the primary judgement concerning bariatric surgery using these criteria as guidelines only, not strict rules; others who use these criteria should govern themselves in a like, fair-minded, fashion. Medical insurers' and their agents' criteria, if excessively restrictive relative to the guidelines, may reflect an ingrained prejudice against the morbidly obese, manifesting itself in an unfair, unethical and immoral bias. It is the essence of humane and equitable behaviour on the part of all concerned that the morbidly obese receive non-discriminatory, appropriate treatment, care and medical insurer coverage for their disease and its comorbidities.
Title Gastrointestinal surgery for severe obesity.
Source Consensus Statement 1991 Mar 25-27;9(1): p1-20
Abstract The National Institutes of Health Consensus Development Conference on Gastrointestinal Surgery for Severe Obesity brought together surgeons, gastroenterologists, endocrinologists, psychiatrists, nutritionists, and other health care professionals as well as the public to address: the nonsurgical treatment options for severe obesity, the surgical treatments for severe obesity and the criteria for selection, the efficacy and risks of surgical treatments for severe obesity, and the need for future research on and epidemiological evaluation of these therapies. Following 2 days of presentations by experts and discussion by the audience, a consensus panel weighed the evidence and prepared their consensus statement. Among their findings, the panel recommended that (1) patients seeking therapy for severe obesity for the first time should be considered for treatment in a nonsurgical program with integrated components of a dietary regimen, appropriate exercise, and behavioral modification and support, (2) gastric restrictive or bypass procedures could be considered for well-informed and motivated patients with acceptable operative risks, (3) patients who are candidates for surgical procedures should be selected carefully after evaluation by a multidisciplinary team with medical, surgical, psychiatric, and nutritional expertise, (4) the operation be performed by a surgeon substantially experienced with the appropriate procedures and working in a clinical setting with adequate support for all aspects of management and assessment, and (5) lifelong medical surveillance after surgical therapy is a necessity. The of the consensus panel's statement follows.
Author Hsu LK; Benotti PN; Dwyer J; Roberts SB; Saltzman E; Shikora S; Rolls BJ; Rand W
Institution Department of Psychiatry, Tufts University School of Medicine, New England Medical Center, Boston, Massachusetts 02111, USA.
Title Nonsurgical factors that influence the outcome of bariatric surgery: a review.
Source Psychosom Med 1998 May-Jun; 60 (3): p338-46
ISSN 0033-3174
Abstract OBJECTIVE: Severe obesity (ie, at least 100% overweight or body mass > or =40 kg/m2) is associated with significant morbidity and increased mortality. It is apparently becoming more common in this country. Conventional weight-loss treatments are usually ineffective for severe obesity and bariatric surgery is recommended as a treatment option. However, longitudinal data on the long-term outcome of bariatric surgery are sparse. Available data indicate that the outcome of bariatric surgery, although usually favorable in the short term, is variable and weight regain sometimes occurs at 2 years after surgery. The objective of this study is to present a review of the outcome of bariatric surgery in three areas: weight loss and improvement in health status, changes in eating behavior, and psychosocial adjustment. The study will also review how eating behavior, energy metabolism, and psychosocial functioning may affect the outcome of bariatric surgery. Suggestions for additional research in these areas are made. METHOD: Literature review. RESULTS: On average, most patients lose 60% of excess weight after gastric bypass and 40% after vertical banded gastroplasty. In about 30% of patients, weight regain occurs at 18 months to 2 years after surgery. Binge eating behavior, which is common among the morbidly obese, may recur after surgery and is associated with weight regain. Energy metabolism may affect the outcome of bariatric surgery, but it has not been systematically studied in this population. Presurgery psychosocial functioning does not seem to affect the outcome of surgery, and psychosocial outcome is generally encouraging over the short term, but there are reports of poor adjustment after weight loss, including alcohol abuse and suicide. CONCLUSIONS: Factors leading to poor outcome of bariatric surgery, such as binge eating and lowered energy metabolism, should be studied to improve patient selection and outcome. Long-term outcome data on psychosocial functioning are lacking. Longitudinal studies to examine the long-term outcome of bariatric surgery and the prognostic indicators are needed.
Author Buckwalter JA; Herbst CA Jr
Institution Department of Surgery, University of North Carolina, School of Medicine, Chapel Hill 27514.
Title Leaks occurring after gastric bariatric operations.
Source Surgery 1988 Feb; 103 (2): p156-60
ISSN 0039-6060
Abstract A leak from the stomach is the most serious complication that occurs after a gastric bariatric operation. The experience with 19 leaks that occurred after 791 gastric bariatric operations performed at North Carolina Memorial Hospital from 1975 to 1986 is described. The incidence of leaks was higher (8.3%) after a second than after a first gastric bariatric operation (2.0%). Ten leaks were life threatening and nine were not. There were no deaths. The diagnosis was made on the basis of Gastrografin swallow in seven patients, clinical findings in six, oral dye studies in three, barium study, a sinogram, and operation in one patient each. Thirteen of 16 patients were operated on within 4 hours of the diagnosis of a leak. One patient with a life-threatening leak and two with non-life-threatening leaks were managed without operations. Three patients were discharged after uncomplicated courses and readmitted, and the diagnosis of a leak was established. To minimize morbidity and mortality related to a leak, it is imperative to (1) recognize that a leak can occur after any gastric bariatric operation, (2) perform a Gastrografin swallow when a leak is suspected, and (3) operate on the patient if the Gastrografin swallow is positive or if the clinical findings suggest a leak.
Author Bajardi G; Ricevuto G; Mastrandrea G; Latteri M; Pischedda G; Rubino G; Valenti D; Florena M
Institution Dipartimento di Discipline Chirurgiche ed Anatomiche, Universita degli Studi di Palermo.
Title [Postoperative venous thromboembolism in bariatric surgery]
Vernacular Title [Le tromboembolie venose post-chirurgiche in chirurgia bariatrica.]
Source Minerva Chir 1993 May 31; 48 (10): p539-42
ISSN 0026-4733
Abstract The authors discuss the problem of venous thromboembolism as a complication of bariatric surgery. They consider obese patients at risk for these complications, even if different opinions exist about this topic in the literature. They report their experience in bariatric surgery consisting of 53 patients submitted to biliopancreatic diversion. Antithrombotic prophylaxis consisted for every patient in elastic bandaging of the lower limbs, preoperative hemodilution, early post-operative mobilization, and subcutaneous heparin. Complications consisted in one popliteo-femoral deep venous thrombosis (DVT) (1.6%), and two pulmonary embolisms (PE) (3.2%) of which one caused patient's death; total morbidity for venous thromboembolism. These results compared with literature are similar with other series of bariatriac surgery and slightly higher than general surgery series. This difference is not however significant. Even in the absence of this significance, thromboembolism, as desumed from more than 2900 cases considered in the literature, remains the main cause of morbidity and mortality in the post-operative course of bariatric surgery patients, deserving particular attention in terms of prevention, also because of difficulty existing in early clinical diagnosis of DVT in obese people. Further studies intended to identify pathogenesis and risk factors of venous thromboembolism in obese people will allow a more correct prophylactic and therapeutic approach.
Author Cowan GS Jr
Institution International Federation for the Surgery of Obesity.
Title What do patients, families and society expect from the bariatric surgeon?
Source Obes Surg 1998 Feb; 8 (1): p77-85
ISSN 0960-8923
Abstract The expectations of patients, their families and society of the bariatric surgeon are often unrealistic, but for different reasons. The morbidly obese patient often expects 'everything' from bariatric surgery. The patient's family is frequently ambivalent. Society, on the other hand, tends to unrealistically regard the morbidly obese as billboards advertising them as willful deviants whose problems can all be resolved by 'just pushing away from the table'. This invalid stereotype has prompted some to incorrectly regard bariatric surgery as an undeserved reward for individuals who will not control their own behavior. The undeserved intentional deviant status of the morbidly obese causes members of society to harass, mock or otherwise mistreat this subpopulation. Society's harmful, destructive and unjust weight harassment 'fat-ism' has made the morbidly obese modern day moral equivalents of lepers. We conclude that society must be persuaded to accept weight harassment as 'politically incorrect', subject to the same consequences as any other form of bigotry. Once society regards the morbidly obese as victims, not perpetrators, of their nonsurgically curable disease, bariatric surgery results should become held to similar standards as surgery for carcinoma, cardiovascular and other diseases. Until then, the morbidly obese remain the last true bastion of prejudice.