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January 2007: Combating Morbid Obesity

01 Jan 2007

Dr. Rami Lutfi has a great interest in the surgical treatment of morbid obesity. At a certain point, after reaching a certain weight, dieting and exercise and all non-surgical weight loss measures do not work; surgical intervention must be considered as a treatment option. This was the conclusion of the National Institutes of Health Consensus Statement in 1991. The statement remains true and unchanged to this day. Dr. Lufti performs minimally invasive laparoscopic surgery, which reduces postoperative pain, shortens recovery time, and improves quality of life. He has dedicated two extra years of training in an Advanced Laparoscopic Fellowship at Vanderbilt University.

Combating Morbid Obesity

Dr. Rami Lutfi
Bariatric Surgeon
Weiss Memorial Hospital
(773) 561-7710

If you are severely overweight you are not alone. Obesity in the United States has become an epidemic; over 60 million Americans have a Body Mass Index (BMI) over 30, the point which divides ‘overweight’ from ‘obese.’ BMI is a measurement of the relative percentage of fat and muscle mass in the human body in relation to height. Morbid obesity, also known as “clinically severe obesity,” is a disease of excess energy stores in the form of fat. Morbid obesity correlates with a Body Mass Index (BMI) of 35 kg/m2 and over, or with 80 pounds or more of excess weight.

What Research Tells Us
In March 2004, the Journal of the American Medical Association (JAMA) published statistical evidence that among the leading causes of preventable death in this country, obesity ranked at a close second to smoking. Obesity caused 400,000 deaths in the year 2000, while tobacco was responsible for 435,000 deaths. In 1990, deaths due to obesity numbered 300,000 nationally. Obesity-related deaths had risen by an alarming one-third in only 10 years. If nothing is done to reverse this trend, obesity will top the preventable death list in America by the year 2010.

Morbid obesity causes many directly or indirectly related illnesses, known as co-morbidities. These conditions, identified in the 1985 National Institutes of Health Consensus Conference include [2, 3]:

  • Hypertension
  • Hypertrophic cardiomyopathy
  • Hyperlipidemia
  • Diabetes
  • Cholelithiasis (Gall Bladder Disease)
  • Obstructive sleep apnea
  • Hypoventilation
  • Degenerative arthritis
  • Psychosocial impairments

Published scientific reports document that non-operative methods alone, such as diet and exercise, have not been effective in achieving medically significant long-term weight loss in severely obese adults. The majority of patients regain all the weight lost over the next five years [4, 5]. Research compared medical weight reduction to the surgical treatment of morbid obesity. The medical weight management trial was a 10-12 week study, with an average weight loss of 5.5 pounds per participant [6]. Alternatively, post-surgical results at Vanderbilt University showed average weight loss for their severely obese patients to be 32.6 pounds after 1 month, 59.1 pounds after 3 months, and 83.5 pounds after 6 months!

At this time, surgery is the only solution that provides significant weight loss for the morbidly obese patient. Additionally, this weight loss is sustained over time, resolving most obese-related conditions. This leads to improved quality of life and a decrease in early death from obesity.

Surgical Options for the Morbidly Obese
Surgery can achieve weight loss in three ways. The first is by limiting the ability to eat large amounts of food in a purely restrictive operation, such as the LAP-BAND® System procedure. The LAP-BAND® System procedure is a relatively simple operation that involves placing an adjustable band around the top portion of the stomach, creating a small pouch that limits volumes of food that can be eaten at one time. This causes an earlier feeling of satiety, or fullness. This surgery leads to weight loss of about 50-60 percent of the excess weight over three years time. The weight loss is gradual and the procedure is reversible.

The second way surgery can achieve weight loss is by causing severe malabsorption of the ingested food. This is known as a malabsorptive procedure such as Bilio-Pancreatic Diversion (BPD). BPD is a more complex operation: the stomach is reduced in size (but not dramatically) and the small intestine is divided, bypassing the majority of its length, limiting the available surface for food absorption. Since food is no longer well absorbed, weight loss occurs rapidly. This surgery causes greater weight loss, reaching 80 percent of excess weight, but at the expense of a higher rate of diarrhea and malabsorption, which can lead to serious diseases and malnutrition.

A third, “hybrid” operation, combines these two operations to provide pronounced and sustainable weight loss, while limiting the risk of chronic diarrhea and malabsorption. This procedure is called Roux-en-Y gastric bypass. In this operation, the stomach is divided to create a small gastric pouch, and the small intestine is substantially reduced. This procedure causes decreased ability to eat (restrictive component) and limited ability for absorption (malabsorptive component). Gastric bypass is the most commonly performed weight loss operation in the United States (140,000 performed in 2004), providing significant weight loss between 60-70 percent of excess weight while rarely causing any malnutrition, as long as patients continue taking their vitamin supplements and follow nutritional guidelines.

Benefits of Gastric Bypass and Weight Loss Surgery
Bariatric surgery has faced increasing scrutiny from insurance companies and media as it has grown in popularity and public awareness: it is the ‘topic of the day.’ Often, the media will distort statistics and outcomes to sensationalize a story to grab attention and sell their product: be it a magazine or a newspaper or an alarming feature on a TV news show that leaves a viewer spellbound in its drama. Recent, well-designed scientific studies have looked at the survival benefit of weight loss surgery closely to reverse some of the negative spin the media has placed on life-changing and life-saving procedures. These studies followed morbidly obese bariatric surgery patients and compared their risk of death to non-surgical morbidly obese individuals over 5 to 15 years. The studies showed an 89 percent decrease in risk of death from obesity after bariatric surgery over 5 years and a 33 percent decrease in the risk of death from obesity after bariatric surgery after 15 years [7,8]. This does not correspond with the perception the media has painted over gastric bypass surgery: perception is one thing; rigorous scientific inquiry is another.

Aside from prolonging life, gastric bypass has repeatedly shown a marked improvement in quality of life. At Vanderbilt University, 95 percent of patients nearly doubled their score on the Quality of Life (QOL) questionnaire as early as 3 months postoperatively.

Co-morbidities, the diseases and health issues directly or indirectly related to morbid obesity, undergo significant improvement. The results below are from the data of over 500 patients; and investigators worldwide have reported similar results:

Co-morbidities (directly or indirectly obesity-related conditions) Patients Cured (off medications) Patients Showing Improvement (decreased medication dose)
Diabetes Mellitus 88% 100%
Hypertension 61% 88%
GERD 84% 96%
Obstructive Sleep Apnea 74% 93%
Joint pain 59% 88%
Urinary Incontinence 66% 83%

DeMaria, E; Annals of Surgery Vol. 235, No. 5, 640-647
Schauer, P; Annals of Surgery Vol. 232, Oct 2000 pp 515-529

Highly Qualified Team at Your Service
At Weiss Memorial Hospital, we have a dedicated multidisciplinary team of specially trained individuals to provide all aspects of care for obese individuals. As the head of the Bariatric Program at Weiss, I have received extensive training in laparoscopic bariatric surgery. Laparoscopic (minimally invasive) surgery causes significantly less pain, shorter hospital stays, shorter recovery times, and above all, reduction in wound complications. We use the most advanced technology for simultaneous laparoscopic and endoscopic bariatric surgical procedures.

If you have questions about obesity, bariatric surgery, or your surgical options, call our center, the Chicago Bariatric Institute at Weiss at (773) 561-5085.

References
[1] Vol. 291 no. 10, march 10, 2004.
[2] Hubert, H.B., et al., Obesity as an independent risk factor in gross obesity. Circulation, 1983. 67: p. 968-977.
[3] Health Implications of Obesity. NIH Consensus Development Conference Statement. Ann Int Med, 1985. 103: p. 1073-77.
[4] Perri, M.G. and P.R. Fuller, Success and failure in the treatment of obesity: where do we go from here? Med Exerc Nutr Health, 1995. 4: p. 255-272.
[5] National Task Force on the Prevention and Treatment of Obesity: Very low calorie diets. JAMA, 1993. 270: p. 967-974.
[6] Safer, D.J., Diet, behaviour modification and exercise. A review of obesity treatments from a long term perspective. South Med J, 1991. 84(12): p. 1470-4.
[7] Christou, N.V. Surgery decreases long-term mortality, morbidity, and health care use in morbidly obese patients Ann Surg 2004 Sep;240(3):416-23.
[8] Flum D.R., Dellinger F.P.Impact of gastric bypass operation on survival: a population-based analysisJ Am Coll Surg 2004 Oct;199(4):543-51.

LAP-BAND® is a registered trademark of Allergan, Inc.