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Bariatric surgery: Treatment modality for metabolic disease
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Obesity is associated with increased mortality and increased rates of multiple comorbidities such as malignancy, diabetes, hypertension, cardiovascular disease, obstructive sleep apnea. Obesity rates are increasing in 31 U.S. states and no states have experienced reductions in the rates of obesity, according to one study from Trust for America’s Health. Effective treatment options must be found for this epidemic.
Bariatric surgery is currently the most successful means of obtaining sustainable weight loss. In fact, two recent studies by Sjostrom et al and Adams et al have demonstrated that bariatric surgery reduces overall mortality in the morbidly obese. In addition, several studies have demonstrated resolution or reduction in severity of diabetes (72% to 86% resolution), hypertension (62% resolution, 78% improved), hyperlipidemia (70% improved), obstructive sleep apnea (86% to 93% resolution), non-alcoholic steatoheapatititis and depression. These rates differ by surgical technique, with greater responses to Roux-en-Y gastric bypass vs. gastric banding. Unfortunately, many of the studies examining the impact of bariatric surgery on resolution of comorbidities are small and retrospective in nature. Given the concomitant reduction in comorbid conditions, bariatric surgery is considered by some to be “metabolic surgery”,” that is, a therapeutic modality for the treatment of metabolic disease rather than just for the cosmetic treatment of obesity.
Given the potential for bariatric surgery to improve longevity and quality of life, many academic centers are conducting prospective research in this field. The National Institutes of Health is sponsoring the Longitudinal Assessment of Bariatric Surgery (LABS) consortium to design and conduct clinical, epidemiological and behavioral trials in bariatric surgery.
 Dara P. Schuster |
There remain significant clinical questions to be answered in regard to bariatric surgery. Guidelines need to be established on patient selection criteria: When to intervene and at what age? This is particularly important given the increasing use of bariatric surgery in morbidly obese adolescents. As with the adult population, there is a paucity of outcomes data in the adolescent population. However, proponents for early intervention hypothesize that not only would complication rates be less and the duration of comorbid conditions be shortened but early intervention in the adolescent/young adult could potentially “re-program” the fuel metabolism axis.
In this regard, there remain many unanswered mechanistic questions surrounding the pathophysiology of obesity and the impact of bariatric surgery on this pathophysiology. Are the benefits of bariatric surgery limited to weight reduction or are there other mechanisms such as modulation of adipocytokines and gut peptides that directly impact fuel storage and metabolism and lead to the resolution of metabolic diseases such as diabetes? The answer to these questions may lead to a better overall understanding of the etiology of obesity.
From a surgical perspective, bariatric surgery continues to evolve with improved techniques, shortened operative times and reduction in complication rates. The laparoscopic surgical approach provided a major breakthrough with significant reduction in complication rates and recovery time.
Techniques currently under study include the use of endoluminal techniques such as placement of endoluminal duodenojejunal tube/plastic sleeve, postsurgical endoluminal revision procedures such endoluminal suturing of plications of the anastomotic aperture and endoluminal vertical gastroplasty. These newer techniques require no anastomoses and could further reduce complication rates and the invasiveness of the procedure.
Finally, only a small number of people that could potentially benefit (<1%) from this therapy are referred and evaluated. The etiology for this appears to multifactorial including cost, physician/provider knowledge of the surgery, potential complications and necessary follow-up and patient understanding of risk/benefit. Research is underway that will help answer some of these questions. Education of providers and patients will also be necessary. In addition, there appears to be a failure of recognition of the severe consequences of obesity and the need for aggressive intervention by the individual and the health care profession.
Today’s bariatric surgery is very different from the original weight-reduction surgery of 20 years ago and deserves another look by providers and patients. Given the poor health outcomes of the morbidly obese patient and the potential for overall outcomes improvement, bariatric/metabolic surgery should be considered as an early option in the management of the morbidly obese patient, particularly in the setting of metabolic comorbidities such as diabetes, hyperlipidemia, hypertension and obstructive sleep apnea. Providers need to re-evaluate treatment strategies and implement more aggressive treatment plans.
Dara P. Schuster, MD, is an Associate Professor of Internal Medicine & Pediatrics at The Ohio State University.