Bariatric Surgery

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Bariatric surgery is the practice of bypassing parts of the digestive tract to allow a morbidly obese patient (BMI > 40) to lose weight either through consuming less food or through malabsorption. Malabsorption refers to food passing directly through the digestive tract without the nutrients being absorbed by the body. This practice is only recommended for patients for whom other weight-loss options, including medical diets, have failed, and if the patient has a serious condition assumed to be caused by the weight, such as diabetes or sleep apnea. They are usually at least 100 pounds overweight. These patients must have failed earlier psychological attempts at changing behavior, such as Weight Watchers or Jenny Craig. There can be no uncorrected metabolic diseases that may be responsible for the obesity, such as low thyroid function. Most importantly, the patients are screened (and most eliminated) for any psychological imbalance or unrealistic expectations of surgery and of weight loss.

The first surgeries, jejunoileal bypasses, were performed in the 1950s at the University of Minnesota, in order to cause malabsorption by bypassing most of the intestines and result in weight loss. This uncontrolled malabsorption almost always led to severe negative consequences, and the procedure is no longer considered safe. Drs. Edward Mason and Chikashi Ito developed the gastric bypass in the late 1960s at the University of Iowa.

In the late 1970s, Dr. Ward Griffin refined the gastric bypass into its currently most popular form, the Roux-En-Y (RYGBP). The RYGBP surgically bypasses most of the stomach and a small amount of the small intestine. Theoretically, patients with reduced stomach size feel full more quickly, rather than losing weight due to intentional malabsorption. This procedure is widely agreed to be fairly safe as the mortality risk is less than 0.5 percent. There is still considerable controversy over the procedure because it can have severe complications. If patients do not follow the correct diet, they can easily reverse the effectiveness of the surgeries that reduce the volume of the stomach or rupture the staples, and malabsorption can lead to severe diarrhea, bloating, cramping, and various diseases caused by vitamin deficiency.

Bariatric surgery can now be done using the minimally invasive laparoscopic technique (which depends on long tiny cameras and instruments inserted through tubes called trocars), rather than the traditional open approach. More controversial procedures include the biliopancratic diversion and duodenal switch, which both cause controlled malabsorption. The adjustable gastric band (lap-band), which controls the volume of the stomach by physically encircling it, is currently being developed. Bariatric surgery leads to long-term lifestyle changes (patients have to eat less and may be able to consume fewer sweets, for example), and frequently requires either surgical revision of the original procedure because the stomach stretches or cosmetic surgery to remove excess skin.

In a complex way, this surgery is a type of placebo or behavior modification through the radical procedure of surgery. Such procedures are well known in the history of aesthetic surgery. Thus, when this patient population was given the standard Minnesota Multiphasic Personality Inventory (MMPI) before and after surgery, they showed marked psychological improvement even if they did not show significant weight loss. There was a clear distinction between the psychological profile of obese men and women independent of the procedure. This is a strong indicator that obese men and obese women responded differently to their obesity and to the surgery. In general, there was a change in self-assessment concerning their physical appearance and reports that the patients experienced an improvement in current relationships and sexual functioning. And yet, while there was little change in eating habits, there was some minor behavioral change subsequent to weight loss.

SLG/Kathy Mancuso

See also Craig; Hormones used in Dieting; Metabolism; Nidetch

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