Search Results for "why i support bariatric surgery"
If You Think Bariatric Surgery Is A Quick Fix – Don’t Do It!
Over the next three days, I will be attending the XVI World Congress of the International Federation for the Surgery of Obesity and Metabolic Disorders (IFSO) in Hamburg, Germany. One of the presentations that I will give at this conference has the title: “Why Bariatric Surgery Is Not A Quick Fix”. Much of what I will be presenting in this talk was summarized in a recent series of posts on the pros and cons of bariatric surgery, that regular readers will recall. For readers, who have joined recently or do not read every post, here are links to this series, which I believe most people, who do not regularly deal with this issue will likely find of considerable interest. Why I Support Bariatric Surgery (Part 1) Why I Support Bariatric Surgery (Part 2) Why I Support Bariatric Surgery (Part 3) Why I Support Bariatric Surgery (Part 4) Why I Support Bariatric Surgery (Part 5) Why Bariatric Surgery Can Fail (Part 1) Why Bariatric Surgery Can Fail (Part 2) Why Bariatric Surgery Can Fail (Part 3) Why Bariatric Surgery Can Fail (Part 4) Why Bariatric Surgery Can Fail (Part 5) As always, all comments are appreciated. AMS Hamburg, Germany
Is Bariatric Surgery Riskier and Less Beneficial in Men?
Regular readers of these pages will recall the recent article series on the pros and cons of bariatric surgery. As I pointed out, this is a rapidly evolving field of medicine and new data is now accumulating at an unprecedented pace. Yesterday, JAMA released a new study in which Matthew Maciejewski and colleagues report the results of a large retrospective propensity-matched case-control analysis of patients who underwent Roux-en-Y bariatric surgery at Veteran Administration (VA) centres across the US. This study is remarkably different from previously reported bariatric surgical studies in that it involves a predominantly male (74%), older (mean age 49 years – if you consider that old?!?), heavier (>30 had a BMI > 50), and sicker patients. Overall, the study shows that over an almost seven-year follow-up, bariatric surgery compared to usual care, did not significantly reduce the mortality risk of these older, severely obese high-risk men. These results contrast strongly with the consistently positive outcomes that have now been reported in younger, healthier, and predominantly female populations. Thus, contrary to expectations, where greater benefits are generally expected with greater disease burden, this study does not support the use of roux-en-y bariatric surgery in older severely obese men. The authors attribute this lack of positive effect of surgery in part to the rather high surgical risk of these patients. In fact, 11 of the 847 (1.3%) cases died within 30 days of surgery, a rate that is four times that reported in lower risk populations. As this surprisingly high perioperative mortality essentially cancels out any potential survival benefit, the authors suggest that lower-risk procedures like adjustable gastric banding or sleeve gastrectomies, which have considerably lower perioperative risk than Roux-en-Y gastric bypass, may need to be considered in these patients. However, the authors also note that reduction in comorbidities, medication use, and over all costs, were not significantly reduced in these patients – a finding for which they offer no ready explanation. These findings, that follow closely on previous week’s post on the paucity of obesity studies in men, highlight that it may be wrong to simply expect men to have the same benefits of bariatric surgery commonly reported in women. While the authors caution that roux-en-y bariatric surgery may confer no survival benefit in older and sicker severely obese men, performing such surgery may still be an option as the associated weight loss at least results in an improved quality of… Read More »
Why Bariatric Surgery Can Fail (Part 5)
So, just to wind down this series, I would like to finish with an aspect of bariatric surgery that is seldom talked about. It is particularly relevant to patients at the extreme end of obesity. Many of these patients will have lived with severe obesity for a long time. They will have very few social contacts (except perhaps on the internet). Many will not have partaken in what others would consider very ‘normal’ activities: going to a cinema, strolling around in a mall or park, shopping for shoes or clothes, having a mani-pedi or even just their hair done, getting on an airplane or even just into a regular car (let alone drive one). As they lose weight, gain back their health and energy, and begin venturing out again, they will face all kinds of challenges both physically and mentally. Many will have the support they need and do just fine. But others, will flounder, feel socially incompetent – like a new immigrant to a foreign country. Trips to a supermarket or the public library can be daunting. It even takes time to recognize that that person reflected in the store window is really and actually you! This process of ‘rehabilitation’, which eventually can encompass issues like facing the job market or considering going back to school is not easy. Very little research seems to have been done on these issues – I can only imagine a whole new field for occupational and recreational therapists and social workers. Bariatric surgery is truly life changing – in the real sense of the word. I hope that this series of articles has perhaps touched on some issues that many may not have considered before. I hope that those who have themselves experienced some of these issues or have seen them in their own patients can relate to some of these difficulties and see them reflected in my posts. Bariatric surgery is about far more than finding a competent surgeon. it is a very individual and personal decision – one that can empower – one that requires courage and determination. It is definitely not a ‘cop-out’ or ‘conceding defeat’ or even remotely ‘taking the easy way out’. It is most certainly not just about surgery. Never have so many people around the world been in the need of or decided to undergo surgery – this is work in progress. As for most conditions… Read More »
Why Bariatric Surgery Can Fail (Part 3)
Bariatric surgery is certainly life changing – for better or for worse! This can lead to some unexpected consequences that can include an important (positive or negative) impact on friendships and romantic relationships. Any reader of the past few posts will by now have realised that despite all of its potential benefits, undergoing bariatric surgery is certainly no walk in the park. Having good social support and being in a happy and stable relationship has been shown to be a good prognostic factor for success. In our program we ask patients to bring their spouses or partners to visits with the surgeons – we will often see the whole family if need be – bring a close friend – whoever. You cannot do this without their support – their support will determine your outcome. (Not telling your family or friends or even your family doctor about your plans to have surgery (e.g. on a quick trip to Mexico) – is NOT A GOOD IDEA!). To be clear – there is an overwhelming amount of evidence that most patients will experience positive improvements in virtually all dimensions of health and quality of life – from mobility and pain to energy levels, self-esteem and sexual function. However, there are important exceptions! In fact, the 1997 Guidelines of the American Society for Bariatric Surgery already notes, “Marital satisfaction increases, but only if marital satisfaction existed before surgery. If marital discord exists preoperatively, the improved self image may lead to divorce postoperatively“. This, may well be an understatement! There is no doubt that anecdotally, very significant partnership problems can arise resulting in all kinds of complex psychodynamic issues, including passive-aggressive behaviours, intimate sabotage, and ultimately divorce. While a full analysis of this problem is beyond the scope of this post – the problem is by no means trivial but perhaps not that hard to understand. Bariatric surgery is not simply life changing for the patient – it is also life changing for their partners, families, and anyone they may have a close relationship to. This, perhaps not unexpectedly, can lead to significant relationship problems that many couples may not be able to overcome. One commonly reported problem is jealousy that develops when the operated spouse begins receiving new and positive attention. As post-surgical patients develop a more positive self-image and a whole new appearance and outlook at life, their partners can very often feel… Read More »
Why Bariatric Surgery Can Fail (Part 1)
Last week, we looked at bariatric surgery, its risks, its benefits, its mode of action, and explored how it affects nutrition and eating behaviour. This week (continuing in this series), I would like to explore some very different (many would perhaps say even more important) aspects that needs careful consideration in any decision for or against surgery. In this week’s posts I will turn our attention to the substantial impact that surgery can have on mental health and psychosocial circumstances, which may ultimately make all the difference between ‘success’ and ‘failure’. Clearly, one of the biggest impacts that bariatric surgery (or for that matter, any significant dietary intervention) can have, is that food can no longer be readily used as a coping strategy. Simply turning to food for comfort, stress reduction, venting, boredom, or even celebration is hard to do, when your stomach is the size of a golf ball (or a small banana) or any overindulgence results in explosive diarrhea (as in the case of dumping syndrome). So while, ‘binging’ may no longer be a realistic option, the emotions that precipitated such behaviours in the first place may need (and will often find) other outlets. Just how intense such unresolved emotions can be, is perhaps illustrated by the case of a patient, who, having undergone adjustable gastric banding at another centre, came to us because she had begun ‘self-adjusting’ her band by deflating it on an almost daily basis to allow a binge and subsequently over-tightening it to prevent further eating during the rest of the day. Indeed, maladaptive coping behaviours following bariatric surgery have been widely described and assessing these should be part of any pre- and post-bariatric surgical assessment and follow-up. A related issue, is the often described recurrence of drug or alcohol misuse observed in some post-surgical patients, a behaviour, which not surprisingly and has been associated with weight regain. This problem can perhaps be conceptualised as a ‘natural’ response to no longer being able to use food as a drug and should certainly prompt caution and ongoing screening in patients with significant past histories of addiction disorders. Another major determinant of outcomes can be due to the fact that, as weight comes off, patients lose the ‘protective’ barrier and ‘isolation’ of excess weight, leaving them feeling exposed and vulnerable – they suddenly becomes ‘visible’ and attract attention – a situation that many patients do not… Read More »
