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Why I Support Bariatric Surgery (Part 3)



So now, that we have extensively discussed the issue of risk in previous posts, let us turn our view to the benefits of bariatric surgery.

In this discussion let us be very clear about the following:

1) Bariatric surgery does not, nor is it intended to, address the many ‘root causes’ of obesity. Its only raison d’être is to help patients with weight-related health problems sustain a degree of weight loss that is, for the vast majority of people (i.e. 19 out of 20), simply impossible to sustain with diet and exercise alone.

2) To be honest, bariatric surgery is not even about weight loss! To put it bluntly, the real reason to even consider bariatric surgery is because of its positive impact on comorbid conditions (which is why I refuse to call it weight-loss surgery or WLS). While many patients appreciate the fact that bariatric surgery may help them attain and sustain a lower body weight – the real benefit, at least from a medical perspective, can only be measured in improvements in health and quality of life. In fact, if ‘bariatric’ surgery only improved health (with no weight loss), it would still be a worthwhile intervention.

3) I have already addressed the issue or surgical risk vs. the risk of not having surgery in previous posts. Thus, readers will recall that even the surprisingly small risk of undergoing laparoscopic bariatric surgery, may exceed the risk of not having surgery in obese people, who are otherwise healthy. These are NOT the folks who should be strongly considering surgery. On the other hand, the more obesity-related complications the patient has, the smaller the relative risk of undergoing surgery. So, I am by no means advocating for simply operating on anyone who is obese. In any obese patient without comorbidities or significant impairment of quality of life, even the rather small risk of surgery is clearly not worth taking.

4) Surgery is not for everyone. As pointed out in previous posts, we turn away many patients, who may meet both the BMI and medical criteria for surgery because we do not think that they will be able to make or sustain the considerable lifestyle changes that are required for surgery to ‘succeed’. Some patients may slip through the ‘cracks’ because they manage to convince (I will not say intentionally mislead) us to think they will cope, when they clearly will not. But we certainly do our very best to try and identify such patients and turn them away from surgery.

5) Surgery is invasive and traumatic! It impacts dramatically on normal gut anatomy and function. Whether it just restricts normal passage of food through the gut (as in adjustable gastric banding), reduces the size of the stomach (as in sleeve gastrectomy), or additionally reroutes food through the gut (as in gastric bypass or biliopancreatic diversion), surgery has a profound, and in most cases, permanent impact on the anatomy and functioning of the digestive system. Tampering with an essentially ‘healthy’ gastro-intestinal system should never be considered trivial. This amazingly complex system has evolved through eons of human evolution to serve one of the most important biological functions – to digest and assimilate our food and drink – our only source of nutrients and calories. The expectation that this system can simply be surgically tampered with, without some very significant and sometimes dramatic consequences, is both naive and irresponsible. Of course bariatric surgery entails risk and there are very real consequences – the only question is whether or not these risks and consequences outweigh the risk and consequences of leaving things as they are – a question that I will address in the following.

With these caveats out of the way, let us look at the potential benefits of surgery (and, please remember, I AM NOT A SURGEON!).

I will limit my discussion to people who have higher BMIs and do have significant comorbidities, because this is the population that we see in our clinic.

One of the most common comorbidities (about 30% of patients) is diabetes mellitus.

Let us look at what it means for a 40 year old (the average age of our patients) to be told they are diabetic.

The diagnosis diabetes means, that this patient will now have to begin medical treatment, usually metformin, which she will hopefully tolerate without the often significant intestinal adverse effects (cramps and/or diarrhea) and will hopefully help lower her HBa1c levels to below 7, a level that should ward off the many complications of this disorder. She will also now need to regularly check her blood glucose levels and quite substantially change her diet and lifestyle to try and keep her diabetes under control. In addition, she will have to start seeing her doctor or nurse several times a year and perhaps go for annual checkups of her eyes and feet.

Unfortunately, given that diabetes is a chronic progressive condition, she may soon belong to the rather large number of patients where metformin alone is not enough to control their diabetes. The next step would be to consider sulphonylureas or even daily insulin injections, treatments that not only carry a small but important risk of hypoglycemia as well as an almost obligatory risk of further weight gain. Of course, these treatments also mean even more daily checking of blood glucose levels (perhaps even several times a day) and more visits to the nurse or doctor (I am not even mentioning cost here).

Although diabetes is a condition for which we have relatively good medical treatments, the annual risk of dying for a patient with diabetes is about 1 in 100. As none of these medical treatments are curative, treatment will continue over the next 10 to 15 years, by which time chances are that she will begin experiencing significant retinopathy, nephropathy, neuropathy and of course the almost obligatory atherosclerosis that accompanies this disorder.

Eventually, after about 20 years (remember that our patient is now still only in her 60s), she will have a substantial risk of losing her eyesight and/or kidney function, begin developing sores and ulcers on her feet that could lead to amputations, and of course, at any time, could experience a fatal heart attack or stroke.

This, unfortunately, is the natural course of type 2 diabetes, a condition that now affects 6 million Canadians and, in young people like this patient, is almost entirely accounted for by excess weight (or the lifestyles that leads to excess weight). There is no known medical treatment that can cure diabetes – once you are diabetic, treatment is for life.

Let us now consider the surgical alternative. Let us imagine, that this patient, at age 40 with her BMI of 47 meets a physician, who suggests she should perhaps consider the option of bariatric surgery. The doctor advises her that bariatric surgery, a relatively safe 45 to 90 min operation, offers an 80% chance of her diabetes going into complete remission for 5 to 10 years if not longer. During this time, she would still need to go for annual checkups, would need to follow a diet and take daily protein and vitamin supplements, but would be off her daily diabetes tablets and injections and, as one may expect, have virtually no risk of experiencing any diabetes-related complication for however long her diabetes remains in remission. In fact, there are studies showing an over 90% reduction in diabetes-related mortality upto 15 years following bariatric surgery. In addition, there is also a good chance that this operation would get her off her blood pressure pills, her CPAP machine, reduce her fatty liver disease, ease the pain in her hips and knees, improve her urinary incontinence and sex life, and reduce her risk of dying of cancer by 60%.

I am not making this scenario up or painting a too rosy picture because my surgical colleagues have somehow managed to brainwash me.

At least two highly credible non-surgical organisations have recently come out with positive recommendations on bariatric surgery – the American Heart Association and the International Diabetes Federation – no reasonable person would accuse either organisation to be involved in some secret conspiracy to drive more business to our surgical colleagues.

But these organisations are by no means alone. There are now countless position papers and detailed analyses from institutions like the UK National Institute for Health and Clinical Excellence (NICE) or the Canadian Agency for Drugs and Technologies in Health (CADTH) that have carefully evaluated the evidence – both the pros and cons – and come down heavily in favour of bariatric surgery as a treatment of choice for individuals with severe obesity, especially for those who also have significant comorbidities.

None of these reports depict bariatric surgery as being harmless or without risk. They all strongly recommend that patients are carefully selected, well prepared and receive long-term follow up for nutritional and other complications. Yet, they all recommend surgery as being a better alternative in terms of warding off complications, improving quality of life, and monetary savings compared to non-surgical treatment.

So unless, you want to believe in some major global ‘conspiracy theory’ that involves all of these government and non-government organisations, which for some unknown reason are now in cahoots with bariatric surgeons the world over, you would have to assume that modern bariatric surgery has some very strong evidence to support it.

Having myself worked closely with some of these organisations, I can assure you that these folks are not known to make rash recommendations or off-the-cuff decisions without carefully weighing the evidence.

So until someone comes up with a better or even equally effective (hopefully non-surgical) treatment for severe obesity, that delivers all of the same health benefits of surgery, I will have to continue discussing and, in most cases, recommending surgery to my patients.

But how exactly, does bariatric surgery deliver on this promise? How does it work? What are the real problems that any patient considering surgery must be aware of?

More on this in tomorrow’s post.

AMS
Istanbul, Turkey

8 Comments

  1. My husband has type 2 diabetes. He’s 55 and was diagnosed with it 17 years ago, when he had his final physical before retiring from the Navy (after serving 20 years). He has been on insulin for only the last 2 1/2 years, and is controlling his t2d very well with that, metformin, diet, and exercise. If his doctor were to recommend any kind of bariatric surgery as a “cure” for his t2d, he would be looking for another doctor, pronto. So far, he doesn’t have any of the problems that you say diabetics face after 20 years of diabetes – retinopathy, nephropathy, neuropathy, and atherosclerosis. He does have numbness in the bottoms of his feet, but how much of that is attributable to his diabetes and how much is from walking on steel ship decks for 20 years, and concrete floors for another 17 years is debatable. He has his eyes checked twice a year, just to make sure there’s nothing going wrong with them, and he has blood draws every 3 months for HbA1c, cholesterol, etc. He sees his case manager every six months, and his doctor once a year, unless he gets sick, which doesn’t happen very often. All of this is done at the Veterans Administration Medical Center at no cost to him, because he served in the Navy from 1974 to 1994 and is a Gulf War veteran.
    You seem to think that weight is a deciding factor in being/becoming a type 2 diabetic, but there is a decided genetic component to it. Not all t2d are fat, but most t2d have at least one relative who also has t2d. Both of my husband’s parents had t2d, as do 4 of his 6 brothers, none of whom were fat when they were diagnosed.
    Bariatric surgery is not a “cure” for t2d, it only puts it into remission for a short period of time. Doctors are going by HbA1c test results, which are an average of blood glucose over 3 months’ time. If patients haven’t been testing their blood on a daily basis, at the same frequency after surgery as they were before surgery, they aren’t seeing that their blood glucose spikes after meals or that they have lows. The average of those lows and highs can come out to a “normal” HbA1c. However, if their doctors did a glucose tolerance test, they would see that their t2d patients who have had bariatric surgery have had their t2d fall out of remission once those patients were a few months to a year past their surgeries. And those highs are doing damage while they’re untreated. How long do those highs go untreated? As long as doctors don’t do a glucose tolerance test and continue to go by their patients’ “normal” HbA1c, those high blood glucose spikes aren’t being treated, they’re causing damage, and type 2 diabetics have the mistaken impression that they are “cured”.
    Saying that type 2 diabetics are destined for amputations, blindness, etc within a certain range of time after being diagnosed with type 2 diabetes is scare-mongering and patently false. If type 2 diabetics take their medications, watch what they eat, exercise, and see their doctors regularly, they have a good chance of controlling their blood glucose and avoiding the worst of those complications you’ve described and living a long and productive life without having to mutilate their functioning digestive system.

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  2. Great overview of Bariatric surgery.
    Very interesting details of health damage.

    At BMI 44 I saw my family doctor for checkup and she didn’t say anything about those risks. I guess my health was ok at the time. Maybe she thought I’d never lose weight anyway.

    I’m now BMI 38, steady for 3 years.
    I dieted to lose weight for cosmetic reasons (though only in comparison to BMI 44 is BMI 38 cosmetically good ! ).

    It’s about time I resume my weight loss for health reasons. Thanks for eye-opener.
    All those details hit home more than vague ‘obesity is unhealthy’ comments.
    Reading about what really sick people have to go through makes me seem like a whiner if I complain about just having to stick to a diet.

    I am looking forward to tomorrow’s post.

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  3. @Vesta 44. I can only congratulate you and your husband for this remarkable course of events, which, unfortunately is far from typical. Of course there is no denying the important role of gentics in diabetes or the fact that not everyone with obesity gets diabetes (only 30%) in our clinic. As pointed out in yesterday’s post, outliers (good or bad) are just that – outliers. Probabilities are about statistics and chance. If all diabetics would indeed have the excellent course of your husband, I’d be the first to agree that we should immediately abandon surgery as an option. Indeed if your story was in any way ‘typical’, we should indeed be making far less fuss about diabetes or worrying about its treatment. Incidentally, however, about 60% of patients in most dialysis centres today are there due to diabetic nephropathy.

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  4. @ Dr Sharma – Of that 60%, how many of those diabetic patients religiously followed their doctors’ recommendations about testing their blood glucose, following a diabetic diet (counting carbs, dosing insulin for those carbs), exercising, and keeping a close watch on every aspect of their health that’s impacted by their diabetes? Yes, it’s a pain in the derriere to have to do all of that, and necessitates a complete change in the way one lives their life, but it can be done, and those complications can be avoided. They don’t have to happen. To me, doing all of that makes a lot more sense than mutilating a digestive system that’s functioning just fine, and inducing a whole new set of complications that can be worse than the complications from diabetes. If you don’t believe me that the complications from WLS can be worse, go read the stories at the Yahoo group, OSSG-gone_wrong some time, and then come back and tell me how WLS improved the lives of those women (quite a few of whom have died, years before their time).
    You say you aren’t a surgeon. Then I want to know how many patients you treat on a follow-up basis after they’ve had WLS. Have you seen, first-hand, the long-term success they’ve had? Have you seen, first-hand, what they’re dealing with when they have complications like continuous vomiting, hair loss, mal-absorbtion, vitamin deficiencies, nerve damage, memory loss, no energy, depression, etc, etc, etc (the list is too long for me to keep going on here). If you haven’t had to deal with patients, up close and personal, after you’ve recommended WLS to them, and they have debilitating complications, how can you in good conscience keep recommending a surgery that changes someone’s life for the worse more often than it improves it? Because, long-term, WLS isn’t any more successful than a diet. There are too many of us who have had WLS and regained some, most, or all of our weight back, and for what? Our health hasn’t improved any, and in a lot of cases, it’s even worse. WLS is an experiment that has failed, spectacularly, for the last 40 years, and for it to still be happening is a travesty of medical practice. Whatever happened to “first, do no harm”?

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  5. I think Canada is different from the states, and I think you, personally, are measured in how you recommend candidates for bariatric surgery. You lose your bearings with this statement, however:

    “So unless, you want to believe in some major global ‘conspiracy theory’ that involves all of these government and non-government organisations, which for some unknown reason are now in cahoots . . .”

    At the risk of sounding like a conspiracy theorist, in the US the FDA has just lowered BMI eligibility for lap-band surgery to 30, with no co-morbidities necessary. This was based on a study authored by unnamed scientists at Allergan, one of the makers of laproscopic bands, and approved by a review panel that was 60% bariatric surgeons (and, unlike you, many of their practices do indicate “weight loss” in their mission statements or even in their practice names). Now the FDA is considering lowering age requirements too, with the same panel making the decision, and based on the same study. It may not be a global conspiracy, but in the US it’s happening, and the reason is known. It’s called the profit motive. Allergan is allowed to supply the evidence because objective science is expensive. Taxpayers have bought the idea that privatized and profit-driven enterprises will always have their best interests at heart, and they won’t have to pay anything.

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  6. I think that people underestimate the impact that surgery will have on their quality of life and how this will positively impact everything else. You mention it at the beginning of the article, but the rest of it is all about obvious health benefits that will accrue to sick people.

    Before I had my surgery, I would have told you that being fat didn’t impact my life much at all. But now that I’ve lost 100 pounds I realize that it was impacting my life every day in every way. So I may not have had any obvious limitations and, by your criteria, would not have been a good candidate for surgery. But thank goodness I did it!

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  7. Hi doctor,I got a biatric bypass on nov 2010,I was 176 kg and now I am 110,trust me my life and my thoughts have changed, my life style and most important my sex life is the ultimate now

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  8. @vesta44
    I must say to you, that surgery has been my saving grace in life. I was an active almost 50 year old woman, who had gained over 200 lbs from a VERY stressful time in my life. The WWclinic helped me not only identify when and why I gained the weight to begin with, but also totally without any judgment . I had a bmi of 70 . I now have a bmi of 28 nineteen mos after mutilating my gastrointestinal mechanism. I would do it over every year if it kept me out of my prison. I am free, free, free. I am sooo thankful to the team you have no idea. I was totally informed of what could go wrong. I had a 1% chance of dieing in surgery. I also had a 100% chance of dieing from an obesity related disease. They also let me know the many things that could go wrong later… the surgeon made sure my husband understood this as well. My quality of life before surgery….. was driving a pickup truck simply because could not fit in a normal car behind the stearing wheels. My husband had to do many of the chores outside as it was getting too hard for me. I could not ride my horses (that has been my whole world before becoming so obese) . Couldn’t hold my grandchildren on my lap, as I didn’t have one. couldn’t go for a drive with friends as usually could not use their seat belts, and never ever could fit in the back seat of a vehicle . Sex was almost impossible even though we both enjoy sex. Had to sleep with a full mask on every night which was very sexy… Bloodpressure was going up and up. Was severely depressed.

    Now 255 lbs down, and feeling great, I have a full life. I do what I want and where I want. I bought a new horse and ride all summer long, with my grandchildren. By the way the hairloss is temporary , from the stress of surgery as much as from any other reason. My hair came in curly and full.

    If you ever looked on the WLS sites that are support groups you see the ones that don’t work as well as all the ones who are like me and very happy now. On my site we have over 1000 members and we do surveys every once in a while to check who would do it again and who would not. I have only seen one woman who said she would not, she was only 3 mos out of surgery and was depressed about hair loss already, and was obvious she was one who slipped through the cracks as Dr. Sharma has suggested.

    Don’t just look on the sites where surgeries have failed as that is all you will see. How many stories have you seen? How many surgeries are done every day???? Try to look at the forest as opposed to the individual trees.

    Love you Dr. Sharma and appreciate your work in this area.

    Robin

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