|
|
|
|
|
|
||||||||||||||
|
Supreme Court Hears Arguments in Michigan Diversity Case Budget Outlook Mixed for Medical Schools, Hospitals Striking a 'Match': New Graduates Ready for Their Next Step Gastric Bypass Surgery Offers New Hope for the Morbidly Obese Innovations in Medical Education: Medical Scholars in the Making A Word From the President: Setting Global Standards for Medical Education Viewpoint: Guiding the 'IOM Generation' A Day in the Life of a Medical Student
|
|
Gastric Bypass Surgery Offers New Hope for the Morbidly Obese
Diana Sims was dead set against it. One in 200 people die in this operation. She had a husband and a 6-year-old child. How could she take such a risk? Then she saw her sister-in-law's results. Overweight all of her life like Diana, she began to shed pounds rapidly and, for the first time, keep them off. Before long, she was 100 pounds lighter. Diana began to reconsider. The quality of her life was deteriorating. Like many of the women in her family, she suffered from morbid obesity and the health risks that accompany what doctors have come to understand as a disease that has reached epidemic proportions. After going on countless diets in which she would initially lose weight only to gain it (and more) back, Diana was running out of options. Clearly, she had illustrated the determination to change her life - but her genes were stacked against her. At age 36, Diana, just 5'1", weighed in at 250 pounds. Her cholesterol was 300, and painful arthritis in her joints made it difficult to climb stairs. She was frightened of acquiring the heart disease that ran in her family. "I didn't want to leave my son without a mother," she says. "This was something I had to do for myself." And so, after carefully researching the surgery and weighing the pros and cons, Diana went to internationally known bariatric surgeon Harvey Sugerman, M.D., and asked to undergo gastric bypass surgery. As an individual who had repeatedly demonstrated the motivation to lose weight by continued dieting, and as a woman genetically predisposed to obesity, she was a perfect candidate. So was Diana's mother. Jean McFerrin decided to undergo the surgery while her daughter was still wavering, although waiting for her insurance to approve the procedure delayed Jean's surgery until November 2002, more than a month after Diana's operation. At 232 pounds and with high cholesterol and high blood pressure, Jean also was a good candidate for gastric bypass. With no complications following her surgery, Jean was out of the hospital in four days. She now weighs 183 pounds, and is still losing weight. Her cholesterol and blood pressure are down. "I feel a whole lot better about myself," she says. "I feel like I have an attainable goal now: I am going yo be slimmer, and I don't have to worry about ever putting it back on. The quality of my life is better. I don't hurt as much as I used to, and I look forward to putting my clothes on in the morning." The evolution of gastric bypassToday's most common form of gastric bypass surgery is a derivative of a procedure pioneered in 1966 by Edward E. Mason, MD, Ph.D., professor emeritus at the University of Iowa Roy J. and Lucille A. Carver College of Medicine. Of the several surgical variations of gastric bypass now available, the most widely used is the "Roux-en-Y" procedure. This operation achieves its effect by permanently blocking off a small, thumb-sized portion of the stomach through which all food is processed. The opening of that pouch is sewn to a portion of bowel two feet past the initial part of the small intestine. This is the "bypass" part of the procedure; it ensures that what little food the stomach can accommodate will be less readily absorbed, less readily turned into fat-producing calories. Gastric bypass may seem like a godsend for the treatment of the morbidly obese, but it is a major, complex surgery fraught with often-unforeseen variables, some life-threatening. Diana Sims was one of a statistically small number of patients who experience leakages in the staple lines of their stomachs. She had to endure additional operations, a feeding tube in her stomach, and extreme discomfort for nearly two months, during which nothing could pass her lips but crushed ice. Her physicians eventually sealed the leak, and Diana slowly gained strength and emerged from the surgery a woman almost unrecognizable to her loved ones. She's dropped 75 pounds so far, and wants to drop 50 more. Her cholesterol is down, her arthritis pain has lessened, and her self-esteem is growing. "I feel much better about myself now," she says. "Although when I walk by glass windows, I still see the person I was, even though I am a lot thinner now. It's going to take some time to get used to the change." Obesity as epidemic
"Obesity has been largely overlooked as a major public health concern," says Dr. Mason. "It wasn't even called a disease until it was demonstrated that it could be corrected by an operation. That showed patients that something could be done and that their condition was not due to slothfulness. It was due to something that they couldn't help; it was a disease that deserved to be treated." Eric J. DeMaria, MD, professor in the Department of Surgery and director of the Minimally Invasive Surgery Center at the Medical College of Virginia at Virginia Commonwealth University (VCU), agrees that obesity has erroneously been placed low on campaign lists to raise awareness about preventable illnesses. "Obesity is not a well-championed healthcare concern, at least not until relatively recently in this country," Dr. DeMaria says. "We've all heard about cancer and heart disease, but obesity is a common risk factor for both of those problems under certain circumstances. Because so many patients who suffer these other well-publicized and well-supported health care problems actually have obesity as an underlying risk factor, a recalculation of its impact on public health puts obesity as the No. 2 health concern in the U.S. And the dramatic increase in children with obesity problems in the US suggests that this is an epidemic escalating out of proportion to any other disease in this country." So when is one considered "obese"? Traditionally defined as 100 pounds overweight, the clinical definition for obesity now accepted by most bariatric surgeons is either a body mass index (BMI) of 40 or above, or a BMI of 35-40 with co-morbid conditions brought on by overweight. When releasing his 2001 report The Surgeon General's Call to Action to Prevent and Decrease Overweight and Obesity, David Satcher, MD, said that overweight and obesity - associated with approximately 300,000 deaths a year - may soon cause as much preventable disease and death as cigarette smoking, which currently is associated with more than 400,000 deaths each year in the United States. Dr. Satcher's report estimated the total direct and indirect costs attributed to overweight and obesity to be $117 billion in 2000. The Department of Health and Human Services estimates that in 1999, 34 percent of US adults aged 20 to 74 years were overweight, and an additional 27 percent were obese. Dr. Satcher drew a connection with these alarming numbers and similarly rising rates of the CO-morbid conditions that often accompany obesity. "Failure to address overweight and obesity could wipe out some of the gains we've made in areas such as heart disease, several forms of cancer, and other chronic health problems," said the former surgeon general. CO-morbid conditions 'disappear'Kenneth MacDonald, MD, chief of gastrointestinal surgery and professor of surgery at the Brody School of Medicine at East Carolina University, has performed hundreds of gastric bypass procedures. He has witnessed again and again the disappearance of CO-morbid conditions in his patients as their excess weight drops off. "Virtually every medical problem associated with obesity - high cholesterol, high blood pressure, type 2 diabetes, sleep apnea, arthritis, even fertility in women - we see dramatic improvement in after gastric bypass," says Dr. MacDonald. "Gastric bypass is paradoxical compared to most elective surgeries in that the patients who can benefit most are often the sickest," adds Dr. DeMaria. "It's a situation where you can treat obesity as the underlying cause of life-threatening conditions like coronary artery disease, diabetes, sleep apnea, and hypertension and in most cases see these conditions resolve themselves." Like his colleagues, Dr. MacDonald believes that surgery is the only effective treatment for obesity. "Medical therapies, pills, any of the available diets, are rarely successful," he says. "Less than five percent of people maintain adequate weight loss over a 5-year period, and most gain it back, one-third of those people even gaining additional weight back." Such was the case with Diana, a veteran dieter, who gained 50 pounds back after losing 30 on the Atkins diet. Despite trying every diet on the market, "I just got bigger every year," she says. Demand outpacing supply
The growing amount of public attention being paid to the obesity epidemic is accompanied by a surging national interest in the surgery that can seemingly "make it go away." Dr. Sugerman, MD, David M. Hume Professor of Surgery and chief of the Division of General Surgery at VCU, has been performing surgery to treat severe obesity since 1979 and has done gastric bypasses since 1981. He estimates that he has performed about 2,000 operations on obese patients and cites four major factors for the growing popular demand for gastric bypass surgery. "First of all," begins Dr. Sugerman, "the operation has become safer and more effective in most patients, and the co-morbidity resolution has become apparent to primary care physicians, making them more willing to refer their patients to surgery." Dr. Sugerman adds that the advent of minimally invasive surgery has made potential patients less fearful. Much gastric bypass surgery is now done laparoscopically, "making it more attractive to patients and doctors." "Thirdly, there has been the exposure in the national media of famous patients like Carnie Wilson and Al Roker. They've been on the cover of People, done the talk-show circuit, and America has seen their results with their own eyes." Finally, Dr. Sugerman believes the greater willingness of insurance companies to pay for the procedure has meant more patients. This has also made it economically lucrative to the surgeons whose talents are in demand. "It is from an economic point of view attractive to surgeons to do it, and it's become attractive to academic medical centers to do it because it's a money-making opportunity, as well as an opportunity for resident education." Georgeann Mallory, R.D., executive director of the American Society for Bariatric Surgery (ASBS) - an association co-founded in 1983 by Dr. Mason, who served as its first president - says that membership and interest in the society are increasing exponentially. "Last year, from 2001 to 2002, we had a 39 percent increase in membership," says Mallory. "That brings us to 1,307 members, 800 of whom are surgeons. We've had our largest growth mostly in the past five years." The ASBS estimates that 63,100 gastric bypass procedures were performed in 2002, compared with 23,100 in 1997, and 16,200 in 1992. The growing number of obese patients seeking gastric bypass surgery has placed a strain on the limited number of surgeons trained to do the procedure. Although there is no certification for bariatric surgery, most surgeons agree that it requires additional training beyond the general surgery residency. "I think that you definitely need additional training and experience beyond the normal general surgery residency before you embark on performing this procedure," Dr. MacDonald says. "Too many people are starting out with no experience and causing a lot of trouble initially and also trying to reinvent the wheel. We've learned a lot over the years about what works and what doesn't, and people need to study the history of bariatric surgery before they start trying their own operations." In the meantime, demand for the surgery is far outpacing supply, leaving many skilled bariatric surgeons with one- to two-year waiting lists. "If you do the numbers and compare the potential patients for surgery, which is around 12 to 13 million Americans, to the maybe 1,000 surgeons who are involved in the ASBS, I think you get a number like 14,000 patients to each doctor," calculates Dr. DeMaria. "And," he adds, "if you think that a surgeon who is doing general surgery can do comfortably maybe a hundred of these surgeries a year as part of a general surgical practice without it completely taking over his or her practice, then in 20 years, you're not even going to make a dent in your share of the public who could have surgery." By Barbara A. Gabriel |
||||||||||||
|
||||||||||||||
|
Contact Us © 1995-2008 AAMC Terms and Conditions Privacy Statement |
