Bariatric Surgery Can Address
Comorbidities of Obesity
J.R. Salameh, MD, FACS
, is Chairman of the Department of Surgery
and Medical Director of the Center for Bariatric Surgery at Virginia Hospital Center
and the Medical Director of the Virginia Hospital Center Physician Group-Surgical Specialists
. After his MD from Saint Joseph University (Beirut), he did General Surgery training at Georgetown University and a Laparoscopic/Minimally Invasive Surgery Fellowship at Baylor College of Medicine. He was associate professor of surgery and director of the Surgery Simulation Center at the University of Mississippi Medical Center and is clinical associate professor of surgery at Georgetown University. He is a Fellow of the American College of Surgeons, and member of the Society of Surgery of the Alimentary Tract and other societies. He has authored numerous publications and journal articles.
Morbidly obese patients (BMI ≥40) see their PCPs an average of 6.6 times per year, mostly for obesityassociated comorbidities, said J.R. Salameh, MD, FACS, Virginia Hospital Center Physician Group-Surgical Specialists, citing a survey of 350 referring physicians.
Bariatric, or weight loss, surgery is an option if the surgery’s goals are understood— to improve health, improve quality of life, and increase lifespan, and not as a cosmetic procedure.
Obesity as a Disease
The AMA, CMS, and other entities recognize obesity as a disease because of its association with increased risks of diabetes, hypertension, sleep apnea, osteoarthritis, and some cancers. Life expectancy decreases as BMI increases—for adults with BMI over 45, a decrease of up to 20 years.
Medical therapy—diet, exercise, and pharmacotherapy—results in long-term weight loss for only about 5% of obese patients.
In addition to health impacts, quality-of-life and economic issues come into play. For example, Dr. Salameh noted in the year before bariatric surgery, a patient’s medication cost averages $10,592. The year after, it averages $1,878.
“With BMI measurement and the classification of obesity as a disease, the PCP has two excellent, objective ways to approach the topic,” said Dr. Salameh. “Weight loss surgery is a tool to help patients make changes in lifestyles and improve health.”
Surgeons perform two main types of bariatric surgery. Restrictive procedures (e.g., sleeve gastrectomy or adjustable gastric banding) reduce how much the stomach can hold. Combined restrictive and malabsorptive procedures (e.g., gastric bypass) reduce stomach size and shorten the digestive tract. Gastric bypass is more frequently performed nationally, but about 60% of Dr. Salameh’s surgeries are sleeve gastrectomies, which have a good risk-benefit profile and are growing in use. Gastric banding is declining in use. Surgery only takes place under certain criteria, including BMI ≥40, or 35 with serious existing comorbidity; failure at previous nonsurgical attempts; and commitment to adhere to postoperative care and lifestyle changes.
Patients, on average, lose 65% of excess weight after one year. More importantly, diabetes, sleep apnea, hypertension, and hyperlipidemia are resolved or improved in most patients. But bariatric surgery means a lifetime of dietary and activity changes, and recidivism occurs. “The goal is not ‘ideal body weight,’ but a healthier weight longterm,” he stressed.
Bariatric Center of Excellence
In 2012, Virginia Hospital Center was granted recognition as a Bariatric Surgery Center of Excellence, currently one of three in Northern Virginia, accredited by the American College of Surgeons and American Society for Metabolic and Bariatric Surgery. The Center must report outcomes, which surpass national averages. Standards and other background are available at www.mbsaqip.org.
Results of a Randomized Trial
A study in NJEM (“Bariatric surgery versus intensive medical therapy in obese patients with diabetes,” April 26, 2012) concluded bariatric surgery is significantly more effective than medical therapy in treating uncontrolled diabetes mellitus in obese patients. One group had intensive medical therapy alone; the other also had gastric bypass or sleeve gastrectomy. The condition improved in 12% in the medical group, versus 42% in the bypass and 37% in the gastrectomy cohorts. Drug usage to lower glucose, lipid, and blood pressure levels decreased significantly after both procedures, but increased in patients receiving medical therapy only.