Bariatric surgery - poll - Forum

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Montag surgeon

Bariatric surgery - poll - Ärzteforum

Post#1 »

I would like to poll the group regarding bariatric surgery. I admit to a strong negative bias.

My question is spurred by the discovery that our hospital is proceeding toward establishing a "Bariatric Surgery Center" and has circulated propaganda indicating that negative opinions about bariatric surgery are the result of past "bariatric entrepeneurs" who no longer exist.

I am interested mostly in the group's opinion regarding the procedures intended to cause weight loss, although I am also interested in the what everyone thinks about the rest of the field. What is the safest/most effective procedure? Are the studies indicating "better health" of different sorts after the surgery convincing? And finally, does anybody know a patient ten years out who is happy?

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Re: Bariatric surgery - poll - Ärzteforum

Post#2 »

There are two procedures which have passed the test of time, Mason's Vertical Banded Gastroplasty and the gastric bypass. They will help the patients lose a lot of weight, which will probably increase their life expectancy and definitely help their diabetes and arthritis and lipid profile. As in everything, patient selection is very important. The patients should be motivated to lose weight, having failed dieting, and realize, truly, that the operation will prevent their bodies from doing what their bodies and minds have been set on for their entire life. This prevention of their 'natural' physical and psychic desires and drives will not be pleasant, especially for the first four months. They will not magically lose the desire and habit of overeating, but will have these traits blocked by an uncomfortable operation and side-effects. That said, I think the operations are a very good thing. I especially like the gastric bypass, which is foolproof in obtaining and maintaining weight loss. Unfortunately the Vertical Banded Gastroplasty may be circumvented by a clever patient who drinks high caloric liquids. This action causes the dumping syndrome in the bypass patient. Many patients will be unhappy. But they will lose weight and live longer. And of course they were not happy before the operation either. Of course you have to do the operations well. You need good retraction and light and an anesthesiologist who is comfortable with the morbidly obese. Preop they need medical, psychiatric(don't do these operations on the mentally ill) and nutritional consultations. They must walk after the surgery, the same day. Special chairs are needed(many of these patients never get in a bed) Heparin/Venodynes, etc.

I am not really an enthusiast, I just really believe that these operations are safe and effective for many patients.

Grandpa Phil

Re: Bariatric surgery - poll - Ärzteforum

Post#3 »

At the hospital where I trained, there was one surgeon who performed many bariatric surgery cases. I will try to keep this anonymous.

He only used the gastric bypass (gastric exclusion plus small diameter gastrojejunostomy) procedure. He felt that the other procedures did not work as well, particularly in the long term. He was particularly critical of the vertical banded gastroplasty, because he said the "tube" created that connects the proximal and distal gastric pouches enlarged rapidly, preventing long term effectiveness. As he put it, as soon as one of his patients leaves the hospital, McDonalds "calls out to them, eat here, eat here!", i.e. they STRESS their suture lines.

Most of his patients lost over 100 lbs in the first year and then leveled off. There was a fair share of perioperative complications, including some anastomotic leaks that caused varying degrees of catastrophes.

However, having done many of those procedures and participated in the patients' followup care, I can honestly say that the most important part of the surgery was the ancillary support staff. He had full time nurses and dieticians who rigorously followed each and every patient. They were extensively evaluated preoperatively, which always included a psychiatric evaluation to make sure they could handle the psychologic stress of no longer being fat. Many of the women (or so I was told) ended up getting divorced after the procedure, because their husbands could not deal with having a wife who was NOT obese.

If you become involved in such a center, make sure you evaluate each patient carefully and recruit a motivated support staff. The surgery alone may work for a while, but it will be lifelong dietary modification and psychological support that will ultimately contribute to the success or failure of your endeavor.

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Re: Bariatric surgery - poll - Ärzteforum

Post#4 »

Cannot add much to the excellent summary. Can offer only the perspective of one who performed obesity surgery very occasionaly but treated not a few complications referred from the private or outlying sector.

Vertical banded gastroplasty and gastric bypass are the operation of choice, the former however easier to perform.

Expect that results of large series by from specialized center will be MUCH better than your own results.

Anyone doing these operations must be prepared to deal with early and late surgical complications; and there WILL be complications.

Intra-abdominal complications such as suture line leak or gastric necrosis are initially SILENT to your examining hand beacuse of the thick abdominal wall and IP fat. If soft sighs of catastrophe (i.e, tachycardia, tachypnea and so forth) not recognized early patients will suffer great morbidity and a few will die.

In brief, you cannot do, safely, this type of surgery without the support of partners, staff, and other supportive services.

During the 1990's a successful private surgeon was flying every week from Capetwon to Johannesburg (a 2 hours + flight) to perform a few of these procedures on patients gathered for him by his local friend. He was flying back on the same day. We were seeing a few of his patients with leaks of stoma obstruction. In another country I treated 2 leaks and 3 total ostruction of the VBG outlet operated in an academic center which performed more than 2000 of such procedures with published " excellent results".

As a results of the aforementioned, my current view is: Morbid obese patients are problematic, the operation may be problematic, surgeons who chose to perform such operations have occasionally problems (a few of them are problematic themselves), and must be ready to deal with these problems. Many patients lose weight but have persisting or new problems.

Yes, I have seen a patient or two HAPPY 10 years after.


Re: Bariatric surgery - poll - Ärzteforum

Post#5 »

Bariatric surgery definitely has a role in the treatment of morbid obesity and its complications. Well selected patients benefit from either veritcal banded gastroplasty (VBG) or gastric bypass (which I alomst never perfrom). The majority of my patients keep about 50% of their EXCESS body weight off after two years buth these are highly selected, motivated and well counselled patients. I think that the VBG is an excellent operation which is relatively easy to perform and has few complications.

I usually turn down one in two candidates.


Re: Bariatric surgery - poll - Ärzteforum

Post#6 »

I know of no surgery that cannot be overcome by poor eating habits. I know of some happy patients 10 years postop--but all of them underwent significant behavior modification. Research bears this out: Behavior modification and counseling are the key. Surgery is at best an adjunct.

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