Surgery for Obesity

by Edward Eaton Mason MD, Ph.D.

(from ISBR Newsletter, Fall 1999)

My surgical colleague and I were comparing notes about our own weight loss after operation. He had a five vessel coronary bypass and I had my sigmoid colon and gallbladder removed. These were both "old fashioned" open operations, with the usual amount of surgical trauma. We both lost weight following surgery. It has been over a year now and neither of us is back to our preoperative weight. Neither of us would recommend our operation for the purpose of weight control, nor do we believe the catabolic effect of surgery is desirable.

Every year there are more morbid obese and those seeking bariatric surgery are heavier. Intestinal bypass was considered the preferred surgical treatment at one time. Then it became gastric bypass. Since 1980, I have been promoting vertical banded gastroplasty. In Europe, the adjustable gastric band is now very popular. FDA approval is needed before it can be marketed in the U.S.A. I recently reviewed transposition of the terminal ileum to the duodenum which provides glucagon-like peptide-1 (GLP-1) whenever glucose is ingested.1 Also known as the "ileal-brake" hormone, GLP-1 slows down or stops emptying of the stomach and slows motility of the small bowel. It also provides all of the effects one might desire for the treatment of type-2 diabetes. Ileal transposition needs formal study in humans before it can be recommended, however. At the June 1999 ASBS meeting, there was discussion regarding research into an implanted electrical stimulator to pace the stomach. Recently there was news regarding research where pacing the vagus nerve in the neck made the depressed patients laugh and lose weight.

Bariatric surgery still does not have sufficient data from enough patients with any procedure to say which operation is best. I am concerned about the goals of surgeons and patients and their level of interest in what really goes on inside the body after alterations of the anatomy. I am concerned about the focus on the superficial and results from the first year with a lack of concern about how life will be affected when patients are 10 and 20 years older.

A few years ago, the NBSR analyzed changes in obesity surgery that occurred over the last decade.2 There was a progressive shift from simple to more complex operations or, to state this in other terms, from gastroplasty to gastric bypass. Even within these broad categories there was a shift from one operation to a variety of operations. Within bypass operations there was an increase in more malabsorptive procedures, moving away from the standard Roux-en-Y Gastric Bypass (RGB). There was an increase in stomach resection to reduce risk of peptic ulcer in the gastroenterostomy stoma and duodenum. Excess acid is still needed to produce peptic ulcers, whether helicobacter pylori bacteria are present or not. There is a vast amount of medical literature regarding the effect of alterations to the upper digestive tract upon ulcer production. We are leaving the century of ulcer surgery but should not ignore what was learned lest we repeat mistakes of the golden age in stomach research.

Recently, I wrote a paper reviewing risks of various operations and encouraging surgeons to inform their patients of the exact pouch size and (for bypass operations) lengths of the biliopancreatic, alimentary and common limbs. Patients need to know what they are getting into and should not choose an operation without knowing the true risks. The operative technique should not be modified to suit the approach. Even more important, the operation chosen should not be based upon the length(s) of incision(s) in the abdominal wall.

Surgery for obesity first became noticed because of remarkable weight loss produced by intestinal bypass. Obesity surgery survived many complications and side effects of intestinal bypass. For the vast majority of patients today, there is no operation that will control weight to a "normal" level without introducing risks and side effects that over a lifetime may raise questions about its use for surgical treatment of obesity. If surgeons do not obtain the needed data to evaluate these technical variations in operations, over a lifetime, the benefits may cease to be available for the severely obese. We need more effort in obtaining 5, 10 and 15 year follow-up.

1. Mason EE. Ileal transposition and enteroglucagon/GLP-1 in obesity surgery. Obesity Surgery 9: 223-228, 1999.

2. Mason EE, Tang S, Renquist KE, Cullen J, Doherty C, Maher JW, I(N)BSR Contributors. A decade of change in obesity surgery. Obesity Surgery 7: 189-197, 1997.

3. Mason EE, Hesson W. Informed consent for obesity surgery. Obesity Surgery 8:419-428, 1998.

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