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Treatment of Obesity
Treatment of Obesity Harvey J. Sugerman, M.D. The presentations we have just heard provide a thorough update on the clinical management of the severely obese patient. Clearly, obesity has become an epidemic throughout the world. Even for countries where obesity is not believed to be a problem, such as China, Japan, and Korea, this is no longer true. A significant part of the epidemic may be due to the influx of fast-food restaurants into these countries. Our lifestyle has become increasingly sedentary. Physical education is no longer strongly supported in many of our elementary or high schools. Children have become “couch potatoes.” They sit in front of the TV screen, play computer games, or live on the Internet. Also, the complications of obesity, including diabetes, hypertension, and sleep apnea, usually thought to be problems in adults, are exploding in our adolescents. Unfortunately, the long-term efficacy of nonsurgical weight loss leaves much to be desired. Although the loss of 10% of excess body weight will have a significant benefit in terms of obesity-related morbidity, we have found that the greater the weight loss after surgery, the greater the likelihood that hypertension and diabetes will be corrected.1 As with the adverse effects of the discredited jejunoileal bypass operation, pharmaceutical adjuncts to weight loss have also had their major complications with valvular heart disease and pulmonary hypertension following treatment with Redux. Although the newer agents appear to be safe, the amount of weight loss achieved with orlistat or sibutramine is underwhelming, and these medications are quite expensive. Newer agents are in the pipeline and, hopefully, these will be both safe and more effective. Clearly, as Dr. Klein has emphasized, similar to diabetes or hypertension, medical treatment of obesity will require life-long therapy. It has been shown in many studies that once pharmaceutical therapy is withdrawn, weight recidivism will occur. Dr. Schauer has shown us, both in his own work as well as that of others, that laparoscopic Roux-enY gastric bypass has become an effective procedure for the treatment of severe obesity. The operation has evolved over the past several years at many centers to become a very safe procedure. More and more
bariatric surgeons, with significant support and motivation by the corporate surgical instrument companies, are learning how to do the procedure. Some have charged into the operation without adequate training, to the detriment of their patients. However, this problem is resolving as did the transient marked increase in common bile duct injury with the development of laparoscopic cholecystectomy. From an endoscopist’s point of view, the two major long-term complications that can occur with gastric bypass are a marginal ulcer, especially in patients taking nonsteroidal antiinflammatory drugs (NSAIDs), and stenosis at the gastrojejunal anastomosis. The latter responds to endoscopic dilatation and may be urgently needed to prevent the dehydration or recurrent vomiting that can lead to Wernicke-Korsikoff encephalopathy or peripheral neuropathy from thiamine deficiency. The FDA approved the laparoscopic adjustable silicone gastric band procedure last June for use in the United States. During the initial evaluation we and others at centers throughout the United States had major concerns regarding the safety and efficacy of this procedure, including the significant problem of esophageal dilatation and dysphagia. Centers in Australia and Europe have reported much better results with this device. The reason for this discrepancy is not clear. Its use is associated with a very low mortality risk. No randomized studies have been performed, to date, comparing these results to those of Roux-en-Y gastric bypass. There is a real concern about late weight recidivism following Roux-en-Y gastric bypass. Our data in adolescents who have undergone obesity surgery show excellent weight loss with correction of obesity comorbidity up to 10 years after mostly gastric bypass surgery, and these patients still show a significant weight loss at 14 years after surgery.2 However, a few of them, as well as our adult patients, have regained all or most of their weight 10 or more years after the operation. Long-term follow-up in this population is extremely difficult. In a study by Pories et al.,3 with 98% follow-up that included phone contact and primary care physician data, the average loss of excess weight was 66% at 2 years, 60% at 5 years, 50% at 10 years, and 47% at 14 years. Thus
From the Department of Surgery (H.A.S.), Virginia Commonwealth University, Richmond, Virginia. Correspondence: H.A. Sugerman, Virginia Commonwealth University, Box 980519, Richmond, VA 23298.
476
쑖 2003 The Society for Surgery of the Alimentary Tract, Inc. Published by Elsevier Inc.
1091-255X/03/$—see front matter doi:10.1016/S 1 0 9 1 - 2 5 5 X ( 0 3 ) 0 0 0 5 1 - 9
Vol. 7, No. 4 2003
weight recidivism clearly exists. This appears to be primarily a result of nibbling high-fat junk foods (potato or corn chips). In some instances patients do not develop “dumping” symptoms with the ingestion of carbohydrates, and some even crave sugar. A few have marked dilatation of the gastrojejunal anastomosis and claim that they do not achieve early satiety. This could be prevented by placing a band above the gastric outlet, such as a combination vertical banded gastroplasty with gastric bypass. Perhaps in the future this problem may be treated endoscopically with injection of a polymer being developed for gastroesophageal reflux disease. Many surgeons believe that these severely obese patients need a malabsorptive procedure for longterm maintenance of weight loss. Currently the most popular malabsorptive operation is a partial biliopancreatic bypass with duodenal switch. Unfortunately there has been no randomized trial comparing this operation to the gastric bypass. At present, there is no “legal” CPT billing code for the duodenal switch procedure. We have had institutional review board approval to perform this randomized trial; however, private insurance companies will not support “research” studies. The National Institutes of Health
Treatment of Obesity
477
will not fund surgical treatment of patients. Thus it is now extremely difficult to perform the necessary clinical studies. In summary, we need better drugs for the treatment of obesity. Surgery is currently the most effective treatment and, with rare exception, the best approach for the severely obese patient with a BMI greater than 40 who has significant obesity-related comorbidity problems. However, we have yet to determine the optimal surgical procedure. Surgery is a very expensive solution to our worldwide massive obesity problem. What is clearly needed is a much more aggressive and effective worldwide prevention program beginning in elementary school. REFERENCES 1. Sugerman HJ, Wolfe LG, DeMaria EJ, Kellum JM, et al. Diabetes and hypertension in severe obesity and effects of gastric bypass induced weight loss. Annals Surg (in press). 2. Sugerman HJ, Sugerman EL, DeMaria EJ, Kellum JM, et al. Bariatric surgery for severely obese adolescents. J GASTROINTEST SURG 2003;7:102–108. 3. Pories WJ, Swanson MS, MacDonald KG, Long SV, et al. Who would have thought it? An operation proves to be the most effective therapy for adult-onset diabetes mellitus. Ann Surg 1995;222:339–350.
bariatric surgeons, with significant support and motivation by the corporate surgical instrument companies, are learning how to do the procedure. Some have charged into the operation without adequate training, to the detriment of their patients. However, this problem is resolving as did the transient marked increase in common bile duct injury with the development of laparoscopic cholecystectomy. From an endoscopist’s point of view, the two major long-term complications that can occur with gastric bypass are a marginal ulcer, especially in patients taking nonsteroidal antiinflammatory drugs (NSAIDs), and stenosis at the gastrojejunal anastomosis. The latter responds to endoscopic dilatation and may be urgently needed to prevent the dehydration or recurrent vomiting that can lead to Wernicke-Korsikoff encephalopathy or peripheral neuropathy from thiamine deficiency. The FDA approved the laparoscopic adjustable silicone gastric band procedure last June for use in the United States. During the initial evaluation we and others at centers throughout the United States had major concerns regarding the safety and efficacy of this procedure, including the significant problem of esophageal dilatation and dysphagia. Centers in Australia and Europe have reported much better results with this device. The reason for this discrepancy is not clear. Its use is associated with a very low mortality risk. No randomized studies have been performed, to date, comparing these results to those of Roux-en-Y gastric bypass. There is a real concern about late weight recidivism following Roux-en-Y gastric bypass. Our data in adolescents who have undergone obesity surgery show excellent weight loss with correction of obesity comorbidity up to 10 years after mostly gastric bypass surgery, and these patients still show a significant weight loss at 14 years after surgery.2 However, a few of them, as well as our adult patients, have regained all or most of their weight 10 or more years after the operation. Long-term follow-up in this population is extremely difficult. In a study by Pories et al.,3 with 98% follow-up that included phone contact and primary care physician data, the average loss of excess weight was 66% at 2 years, 60% at 5 years, 50% at 10 years, and 47% at 14 years. Thus
From the Department of Surgery (H.A.S.), Virginia Commonwealth University, Richmond, Virginia. Correspondence: H.A. Sugerman, Virginia Commonwealth University, Box 980519, Richmond, VA 23298.
476
쑖 2003 The Society for Surgery of the Alimentary Tract, Inc. Published by Elsevier Inc.
1091-255X/03/$—see front matter doi:10.1016/S 1 0 9 1 - 2 5 5 X ( 0 3 ) 0 0 0 5 1 - 9
Vol. 7, No. 4 2003
weight recidivism clearly exists. This appears to be primarily a result of nibbling high-fat junk foods (potato or corn chips). In some instances patients do not develop “dumping” symptoms with the ingestion of carbohydrates, and some even crave sugar. A few have marked dilatation of the gastrojejunal anastomosis and claim that they do not achieve early satiety. This could be prevented by placing a band above the gastric outlet, such as a combination vertical banded gastroplasty with gastric bypass. Perhaps in the future this problem may be treated endoscopically with injection of a polymer being developed for gastroesophageal reflux disease. Many surgeons believe that these severely obese patients need a malabsorptive procedure for longterm maintenance of weight loss. Currently the most popular malabsorptive operation is a partial biliopancreatic bypass with duodenal switch. Unfortunately there has been no randomized trial comparing this operation to the gastric bypass. At present, there is no “legal” CPT billing code for the duodenal switch procedure. We have had institutional review board approval to perform this randomized trial; however, private insurance companies will not support “research” studies. The National Institutes of Health
Treatment of Obesity
477
will not fund surgical treatment of patients. Thus it is now extremely difficult to perform the necessary clinical studies. In summary, we need better drugs for the treatment of obesity. Surgery is currently the most effective treatment and, with rare exception, the best approach for the severely obese patient with a BMI greater than 40 who has significant obesity-related comorbidity problems. However, we have yet to determine the optimal surgical procedure. Surgery is a very expensive solution to our worldwide massive obesity problem. What is clearly needed is a much more aggressive and effective worldwide prevention program beginning in elementary school. REFERENCES 1. Sugerman HJ, Wolfe LG, DeMaria EJ, Kellum JM, et al. Diabetes and hypertension in severe obesity and effects of gastric bypass induced weight loss. Annals Surg (in press). 2. Sugerman HJ, Sugerman EL, DeMaria EJ, Kellum JM, et al. Bariatric surgery for severely obese adolescents. J GASTROINTEST SURG 2003;7:102–108. 3. Pories WJ, Swanson MS, MacDonald KG, Long SV, et al. Who would have thought it? An operation proves to be the most effective therapy for adult-onset diabetes mellitus. Ann Surg 1995;222:339–350.