# 2/28/05 njm

# Summary of Surgical Treatment of Obesity 

# Primary Care Discussion Forum

During February 2005 the IHS Primary Care Discussion Forum focused on
surgical treatment of obesity. Topics included case scenarios,
feasibility, utilization, cost effectiveness, and safety.

**Case Scenarios Reviews:**

**32 yo mother of twins 10days s/p gastric bypass presents to her
primary care provider complaining of hiccups, feeling anxious, heart
rate 105, history of anxiety attacks and depression, has been unable to
swallow her Zoloft.**

Take home points:

1\. How old are the twins? Obesity surgery should be offered only after
failure of medical management- not for post partum baby weight.

2\. Zoloft- one of the preop screens prior to obesity surgery should be
a psychological evaluation. Although being on Zoloft is not
exclusionary.

3\. Anxiety and tachycardia in the immediate post op period spells leak.
This patient needs to go back to her surgeon (now) for treatment.

**A 27 yo hypertensive diabetic male with a BMI of 41 was referred for
obesity surgery 7 months ago and now returns to his primary care
provider having lost over 80 lbs. But can hardly eat; he is having bouts
of epigastric pain that can last for hours.**

Take home points:

1\. The referral of such a young patient with significant co morbidities
was well made. He more than likely is off his diabetic meds by now and
probably has been able to stop or cut back on his antihypertensives.

2\. Rapid weight loss is often associated with cholilithiasis. He may be
having attacks of biliary colic. An ultrasound would be in order. Other
possibilities might include: slipped gastric band, reflux, or
anastomotic stricture.

**The 39 yo diabetic female who weighed 450 lbs. .... Developed chronic
diarrhea after surgery.**

Take home points: 1. Again excellent patient referral -- this patient
may greatly benefit from surgical intervention. However, it is very
important for the primary care provider to be involved in the long term
care of the patient. Knowing the type of procedure she had and the
potential long term metabolic consequences can be critical.

2\. Some procedures result in the need for long-term supplements and
compliance can be an issue.

3\. Diarrhea is inherent in some of the procedures for obesity- this
patient should have received preop information and education on what to
expect long term.

**Discussion:**

**Should all obese patients be offered surgical intervention?**

Of course not.... Patient selection is critical to the success and
safety of the procedure. Patient compliance is important. Preoperative
evaluation can include cardiac, pulmonary, nutritional, and
psychological evaluations.

**Can we afford it?**

As poignantly noted, life/death health care issues within the IHS are
already in funding crisis in some areas. The obesity problem is also
about life and death. Surgical treatment has been shown to be the most
effective treatment for weight loss and can add 10-15 years to a
patient's life by reversal or improvement in co morbidities such as
diabetes, hypertension, hyperlipidemia, sleep apnea, degenerative joint
disease, and depression

**How are primary care providers addressing the issue now?**

As noted in the dialogue, multidisciplinary approaches are being used.
Many providers already have nutrition and exercise programs for their
diabetic patients. Some have wisely tapped into regional programs for
guidance. When resources allow, patients are being referred to
established programs for surgery.

**Would non-surgical programs to address this issue be safer?**

Safety is a concern. Risks are inherent in any surgical intervention.
Researching the results of the surgical center to which referrals are
made and establishing a relationship with that center can enhance
safety. Careful preoperative assessment can help establish the patient's
risk/benefit ratio.

**What about cost? Effectiveness?**

Surgical costs vary among geographic areas, surgeons, and procedure
types. From \$10,000-\$40,000. Cost savings in regards to decreased
needs for medications (anti hypertensives and diabetics) and decreased
needs to access the health care system help offset the initial upfront
costs of the surgery. However, surgical treatment also requires
follow-up and often supplements.

As noted by the US Preventative Task Force 'no nonsurgical interventions
provide sustained and significant weight loss beyond 1 year'.

While there is a paucity of data on the cost effectiveness of obesity
surgery- of the studies

available most note a cost effectiveness at least as good as other
common interventions we accept, such as dialysis.

**Other Resources available:**

Surgical Treatment of Obesity: Discussion Forum Primer

<http://www.ihs.gov/MedicalPrograms/MCH/M/documents/SurgObes12705.doc>

American Society for Bariatric Surgery

<http://www.asbs.org/>

<http://www.asbs.org/html/rationale/rationale.html>

Frangou, Christina. "Costs, Outcomes, Safety: Bypass Debate Continues."
[General Surgery News.]{.underline} McMahon Publishing Group, November
2004 . Vol. 31 No 11.

Frangou, Christina, and Rosemary Frei, MSc. "Bariatric Surgery Saves Big
Money In the Long Run, Evidence Suggests" [General Surgery
News.]{.underline} McMahon Publishing Group. November 2003. Vol. 30. No.
11.

International Bariatric Surgery Registry

> <http://aboutplastic.surgery.uiowa.edu/ibsr/>

Jones, Daniel B., et al., "Gastric Bypass and Adjustable-Band Surgery
for Obesity." [Contemporary Surgery.]{.underline} Dowden Journal. Vol
59. No. 9.

Martin, Louis F., ed. [Obesity Surgery]{.underline} . McGraw-Hill, 2004

Schirmer, Bruce David. " Laparoscopic Bariatric Surgery." [The Surgical
Clinics of North America Minimal Access Surgery, Part I.]{.underline}
Ed. Carol E.H. Scott-Conner.W. B. Saunders, August 2000\]

Schirmer, B., "Laparoscopic Roux-en-Y gastric bypass: results and
followup." [Surgical Rounds.]{.underline} Romaine Pierson Publishers,
Inc. February 2004, Vol.27 No. 2.

Szomstein, Samuel. et al., "Revisional Bariatric Surgery: A Review."
[General Surgery News.]{.underline} McMahan Publishing Group. June 2004.
Vol. 31. No. 6.

YourSurgery.com: Bariatric Surgery -- Patient Education

> <http://www.yoursurgery.com/ProcedureDetails.cfm?BR=1&Proc=5>

**From Chuck North**

**Single digit need to treat (NNT) obesity are remarkable statistics -
should spur us on** 

1\. Manage obesity as a chronic relapsing disease 

2\. Use BMI as a vital sign to screen for overweight/obese patients and
to decide treatment (PPV=97%) 

3\. Modest weight loss (10%) positively affects prevention/treatment of
hypertension (NNT=3), diabetes (NNT=9) and hyperlipidemia 

4\. Effective treatments exist for overweight/obese patients and a
combination of diet and exercise provides the best results (NNT=7) 

5\. Counsel patient to achieve a goal of 10% reduction in weight (500 to
800 kcal/day decrease to affect 1-2 pound loss/week) 

6\. Counsel patient to exercise to achieve a goal of any increased
energy expenditure 

7\. Weight loss has an impact on important disease states and risk
factors.  Effective strategies exist for the management of obesity when
viewed as a chronic relapsing disease. 

 

Orzano AJ, Scott JG.Diagnosis and treatment of obesity in adults: an
applied evidence-based review. J Am Board Fam Pract. 2004
Sep-Oct;17(5):359-69.
<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15355950>

I would like to thank all the respondents for their input and Dr.Myriam
Curet and Dr. Michael Wilcox for their expertise. HB

For those interested videotapes on the Obesity Epidemic are available
through the Network for Continuing Medical Education by contacting the
IHS Clinical Support Center; Two Renaissance Square, Suite 780, 40 North
Central Avenue, Phoenix, Arizona 85004. CME credits are available.