Considering Surgery For Treatment Of Obesity
Improving physicians' knowledge is important, because the rate of obesity in the United States has risen from 15.3 percent to 23.9 percent over the past 10 years.
Obesity increases the risks not only for diabetes but also for high blood pressure, coronary artery disease and stroke.
For Rebecca Lopez, 65, a diabetic who had been fighting to lose weight since her teens, stomach surgery freed her from having to take insulin to control her disease.
"The surgery gave me back my life," she said. "But you have to go into it for the right reasons and be willing to change your life. You're doing it for the wrong reason if you're doing it only to look better."
When Lopez first brought up the idea of gastric bypass surgery to her regular physician, he discouraged her, saying the procedure was too dangerous. To Lopez, it seemed his advice stemmed more from anecdotal experience than from actual scientific data. So she went for an independent evaluation.
Although the surgery has several variants, the basic procedure involves stapling off a large portion of the stomach and reattaching the intestine to the remaining portion. Because of their decreased stomach capacity, patients are unable to eat as much food and they feel sated much faster.
Lopez's story is not uncommon, according to Eric DeMaria, M.D., medical director of the Duke Weight Loss Surgery Center. When discussing the possibility of weight-loss surgery with their patients, physicians should address both the benefits of the surgery and the risks of not doing the surgery, he said. For this, they need data, he said.
To help inform physicians on the risks and benefits of gastric bypass surgery, also known as bariatric surgery, DeMaria reported the latest scientific findings in a "Clinical Therapeutics" feature article in the May 24, 2007, issue of the New England Journal of Medicine.
"Many physicians may not truly understand the risks and benefits of bariatric surgery, so they are reluctant to recommend it," DeMaria said. "We believe patients considering the surgical approach need to go to a comprehensive center where they are seen not only by surgeons but also by nutritionists and psychologists who can discuss all aspects of the patients' care."
He cited recent studies which showed that patients face the greatest risk if the surgeon performs fewer than 25 gastric bypass procedures per year or if fewer than 50 such procedures are performed at the hospital per year. Patients are at the lowest risk when the surgeon performs more than 100 gastric bypass procedures per year at a hospital where more than 150 procedures are performed per year.
Lopez, whom DeMaria operated on in April 2004, has gone from a presurgery weight of 286 pounds to her current weight of 171. She said the surgery itself is just the beginning.
"People who go into it thinking the surgery will cure everything by itself will fail," she said. "You still have to watch what you eat, exercise and basically change your approach to life."
DeMaria said that for bariatric surgery to be successful, patients and physicians need to develop a long-term plan to cover all aspects of care after surgery.
"The operation should not be performed unless systematic follow-up is available and the patient is committed to such care," DeMaria said. "As in the evaluation before surgery, care after surgery should involve the coordinated efforts of physicians, nutritionists and psychologists. Unfortunately, many patients do not receive such systematic care after surgery and may have worse outcomes as a result."
One of the most important parts of the presurgery evaluation should be the discussion of the patient's knowledge of possible risks and expectations about how life will change after the operation.
"With surgery, you still have to watch what you eat, but it works," Lopez said. "Since my teens, I've tried all the diets, yet none of the weight came off, and I couldn't get off the insulin. It was a horrible circle that is now broken."