Surgery: Treating the Severely Obese Lead in: According to the World Health Organization, globally there are now more than 1 billion overweight adults, and at least 300 million of them are obese. During the last 40 years, obesity has reached epidemic proportions. There are more obese people each year, and the severity is increasing. In the United States alone, 300, 000 deaths are associated with obesity. Thesis: Many obese people fail diet after diet.

For them, bar iatric surgery is an option even though risks are involved (Flancbaum, et al. 7; Goodman par 3; "The Weight" par 2). Overview Obesity is climbing the charts as being a major killer of our population. This paper informs the reader on how bar iatric surgery treats the severely obese. Focus is given on who should have bar iatric surgery, how the surgery works, risks of bar iatric surgery, and what the patient can expect.

Bariatric surgery is reserved for people who have been unable to lose weight on professionally managed weight-loss programs and those with obesity-related conditions such as diabetes, or the risk of them. When surgery is an option for weight loss The best candidates for bar iatric surgery are patients who have a body mass index (BMI) of 40 or greater, or 35 or greater and associated obesity-related conditions such as diabetes, heart disease, and sleep apnea (see figure 1. 1, pg 8 & table 1, pg 6). In terms of pounds, qualifying for surgery estimates to being 100 pounds above ideal body weight. A patient must have also gone through some sort of organized weight loss program in the past, and failed to maintain weight loss (Flancbaum, et al.

15). How surgery promotes weight loss Gastrointestinal surgery for obesity, also called bar iatric surgery, alters the digestive process. The operations promote weight loss by closing off parts of the stomach to make it smaller. These procedures are referred to as restrictive procedures because they cut down on the amount of food the stomach can hold. These types of procedures are less common due to the complications involved (Flancbaum, et al.

27, 52). The most popular operations combine stomach restriction with a partial bypass of the small intestine. These procedures create a direct connection from the stomach to the lower segment of the small intestine, literally bypassing portions of the digestive tract that absorb calories and nutrients. These are known as mal absorptive operations. Mal absorptive operations produce effective weight loss, and often reverse the health problems (see table 2, pg 6) associated with severe obesity (Flancbaum, et al. 50, 67).

What different surgeries entail Bariatric surgery evolved out of operations for cancer or peptic ulcers disease in which the large portions of the stomach or small intestines were removed. Surgeons adapted these operations to treat the severely obese because patients undergoing these procedures tended to lose excessive weight after surgery. In 1954, doctors Kreme n and Liner pioneered the first bar iatric surgery to treat obesity. This surgery was known as the bypass (JIB), or intestinal bypass and was considered mal absorptive. JIB involved shortening the length of the small intestine available for digestion and absorption of food, and by bypassing a large segment of the small bowel which was taken out (see figure 2, pg 9).

This procedure resulted in extreme weight loss but long term observation revealed many complications and by 1980 this procedure came to a haul t. Complications included malnutrition, severe vitamin / mineral deficiency, and severe diarrhea (Levy 159). In the late 1960's and 70's, Dr. Edward Mason began use of a procedure called Roux-en-Y gastric bypass (RYGB), also a mal absorptive procedure. This has since become the surgery of choice (see figure 2, pg 9). Over 75 percent of surgeons prefer using this procedure because risks are minimal and can be treated.

This surgery involves separating the stomach into two compartments: a small upper compartment and the lower compartment in which food cannot enter after surgery. Food will pass from the small intestine, bypassing the lower part of the stomach. Complications included vitamin deficiency, diarrhea, and dumping syndrome-food passes quickly from stomach pouch to the intestine (Flancbaum, et al. 55-56). The most common restrictive procedure used today is the also known as vertical band (GVB). This procedure was also introduced by Dr.

Edward Mason in the 1970's, and is the second most common procedure outside of the gastric bypass (see figure 2, pg 9). The operation creates a small pouch, one ounce in size, near the crossing of the stomach and the esophagus, using a vertical placed staple line Food passes through the pouch into the rest of the stomach. GVB works by limiting the food that can be eaten in one sitting. Complications (see table 3, pg 7) were commonly vitamin deficiency.

And technical problems related to staples pulling out, allowing the stomach to return to normal size (Flancbaum, et al. 53). Risks of surgery The most serious risk is a risk of dying in the period right around the time of surgery. Overall, the risk of dying is in the neighborhood of 1 percent within the first month or two for both surgeries. Usually death occurs from one of three causes: heart attack, blood clot, or a leak at the connection between the stomach and the small intestine (McGowan 34). There are certain nutritional consequences in both operations.

Certain vitamins and minerals that are not absorbed have to be supplemented, usually just as a pill. For example, a multi-vitamin, vitamin B-12, calcium supplements and iron supplements have to be taken on a daily basis after surgery (see table 3 & 4, p 7). In VBG vitamin deficiency is less than 5 percent, whereas in RYGB the percentage is much higher-10-20 percent. Because the risk is much higher in RYGB, supplements have to be monitored and taken for life (Flancbaum, et al. 87; Levy 161-162). Approximately 10 to 20 percent of patients who have weight-loss surgery require a follow-up to correct complications.

Abdominal hernias were the most common complication requiring follow-up in RYGB surgery; breakdown of the staple line and stretched stomach outlets were common in VBG surgery (Flancbaum 95; Levy 163). What to expect after surgery Right after surgery, most patients lose weight quickly and continue to lose weight for 18-24 months after the procedure. It is more common for weight loss to be greater when RYGB is performed-60-75 percent of excess body weight is lost, whereas in VBG, the result is 40-60 percent of excess body weight. Both procedures restrict food intake, but because RYGB limits the amount of sugar intake, the results are greater (Flancbaum, et al.

65, 73). Although most patients regain a percentage of the weight they lose, many maintain a long-term weight loss of about 100 pounds. In RYGB, patients regained an average of 10-15 percent of their excess body weight; in VBG, patients regained 25-40 percent of their excess body weight ("Surgery" par 9; Flancbaum, et al. 73, 87).

Both surgeries improve most obesity-related conditions. For example, blood sugar levels of obese patients with diabetes often return to normal after surgery. Other disorders that often dissolve are sleep apnea, hypertension and heart function. Many patients note better moods, higher self esteem and enhanced quality of life (Flancbaum 67). Conclusion Since first introduced in the 1950's, bar iatric surgery has been the answer for many severely obese patients who could not lose weight with conventional dieting. Different procedures have evolved over the years, the most successful being Roux-en-Y gastric bypass (RYGB).

For many patients, conditions associated with obesity improve or completely resolve after surgery. Bariatric surgery provides a reliable tool to help achieve a better quality of life along with long term weight loss. Table 1: Health Risks in relation to BMI BMI Obesity Category Health Risks Without Medical Problems Health Risks With Medical Problems Below 19 Underweight Slight Minimal 19-24 Normal None Minimal 25-29 Overweight Minimal Moderate 30-34 Obese Moderate High 35-39 Severely Obese High Very High 40-49 Morbidly Obese Very High Extreme 50+ Super Obese Extreme Very Extreme Classification based upon World Health Organization; see The Doctor's Guide to Weight loss Surgery. Table 2: Weight Loss Surgery on Obesity-Related Conditions Condition Improved Completely Resolved Type II diabetes 93 percent 89 percent Hypertension 90 percent 66 percent Abnormal blood lipids 85 percent 70 percent Sleep apnea 72 percent 40 percent See The Doctor's Guide to Weight Loss Surgery.

Table 3: Complications after Weight Loss Surgery RYGB VBGProtein-calorie malnutrition 0 0 Micronutrient & vitamin deficiency 10-20 percent.