Management of morbid obesity - The Journal of Family Practice

Free 

2.5 CME 

credits 

Management 

of morbid 

obesity: 

❙ Bariatric surgery 

in context 

Todd M. Sheperd, MD 

❙ Surgical options 

Henry Buchwald, MD, PhD 

❙ Before and after surgery: 

The team approach 

to management 

Christopher D. Still, DO 

A SUPPLEMENT TO 

The role 

of bariatric 

surgery 

This supplement to THE JOURNAL OF FAMILY PRACTICE was supported by a grant from 

Ethicon Endo-Surgery, Inc. It has been edited and peer reviewed by THE JOURNAL OF FAMILY PRACTICE. 

THE JOURNAL OF 

FAMILY 

PRACTICE 

March 2005 www.jfponline.com 

Sponsored by the University 

of Cincinnati College of Medicine

Management of morbid obesity: The role of bariatric surgery 




Publication date: March 2005 

Expiration date: March 2006 

Learning objectives: 

Upon completion of this program, participants should be able to: 

■ Place bariatric surgery in the context of 

overall management of obesity 



surgery 

■ Identify and refer patients who may be candidates 

for bariatric surgery 

■ Advise patients on the benefits and risks associated 

with various bariatric surgical procedures, as well as 

the long-term commitment required 

■ Participate in preoperative assessment and treatment, 

if indicated 

■ Participate in postoperative management and follow-up 

Sponsorship 

The University of Cincinnati College of Medicine designates this 

educational activity for a maximum of 2.5 category 1 credits 

toward the AMA Physician’s Recognition Award. Each physician 

should claim only those hours that he/she actually spent on the 

activity. This CME activity has been planned and implemented in 

accordance with the Essential Areas and Policies of the 

Accreditation Council for Continuing Medical Education (ACCME) 

through the joint sponsorship of the University of Cincinnati College 

of Medicine and Dowden Health Media. The University of 

Cincinnati College of Medicine is accredited by the ACCME to provide 

continuing medical education for physicians. 

Audience 

Family physicians and other primary care practitioners. 

Acknowledgment: 

This CME activity is supported by an unrestricted educational 

grant from Ethicon Endo-Surgery, Inc. 

Faculty Disclosures 

■ Dr Sheperd reports no financial relationship with any 

company whose products are mentioned in this supplement. 

■ Drs Buchwald and Still serve as consultants to Ethicon Endo- 

Surgery, Inc. 

COPYRIGHT © 2005 BY DOWDEN HEALTH MEDIA, MONTVALE, NJ 

2 Supplement to The Journal of Family Practice March 2005 

Bariatric surgery in context . . . . . . . . . . . . . . . . . . 3 


Assistant Clinical Professor 

Department of Family Medicine 

Michigan State University College of Human Medicine 

Traverse City, Mich 

Surgical options . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10 


Professor, Department of Surgery 

Owen H. and Sarah Davidson Wangensteen Chair 

in Experimental Surgery Emeritus 

University of Minnesota Medical School 

Minneapolis, Minn 

Before and after surgery: 

The team approach to 

management . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18 


Director, Center for Nutrition and Weight Management 

Geisinger Health Care System 

Danville, Pa 

CME posttest . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26 

CME registration form and 

program evaluation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27

Bariatric surgery in context 


Assistant Clinical Professor 

Department of Family Medicine 

Michigan State University College of Human Medicine 

Traverse City, Mich 

Obesity is now pandemic in the United States and 

other industrialized countries (FIGURE 1), 1-3 the 

result by and large of a combination of inappropriate 

diets and inadequate exercise. And the problem is 

no longer confined to industrialized countries. Rapid 

Westernization of diet and lifestyle among urban 

dwellers in India, China, and elsewhere has been followed 

by an alarming rise in obesity-related health 

problems. 4,5 

The morbidly obese patient presents a particular 

challenge because of the massive weight loss that 

needs to be achieved. It was for this patient that 

bariatric surgery was first proposed in the 1950s, 

leading to emergence of a surgical specialty that last 

year performed more than 140,000 operations in the 

United States. As Henry Buchwald will discuss in the 

next article, the safety and efficacy of bariatric surgical 

techniques have improved over the years and a 

substantial body of evidence has been accumulated. 

The clinician often is reluctant to consider bariatric 

surgery as an option even though nonsurgical treatments 

for severe obesity remain far from ideal. When all 

available options for managing morbid obesity are compared, 

it is difficult to dismiss operative therapy as a 

viable consideration. 

Startling statistics 

Obesity is defined as a body mass index (BMI) greater 

than 30 kg/m 2 . The pre-obesity or overweight stage 

includes BMIs of at least 25 kg/m 2 but less than 30 kg/m 2 . 

Patients with BMIs greater than 40 kg/m 2 are considered 

to be extremely or morbidly obese (class III obesity), as 

are those with BMIs greater than 37 kg/m 2 and obesityrelated 

comorbidity. 6 Although other measures of obesity 

are available, BMI is easily determined; moreover, it is 


FAMILY 

PRACTICE 

used as the standard for weight determination in the 

majority of clinical studies of obesity. 7 

On basis of these BMI criteria, approximately 65% 

of adults in the United States are overweight, and 

31%—an 8% increase in 1 decade—are obese. 1 More 

than 15% of adolescents are overweight, up from about 

5% in the early 1970s (FIGURE 2). 7 In the last 10 to 15 

years, the average BMI of the US population has 

increased from 24.9 to 26.5 kg/m 2 . 8 

The prevalence of class III obesity rose even 

faster—today, an estimated 2.2% to 4.7% of 

Americans are morbidly obese. 1,2,8 The prevalence is 

particularly high among US women, 6.3% of whom 

are now morbidly obese, while among non-Hispanic 

black women the rate is now 15%. 1 Using data from 

the Behavioral Risk Factor Surveillance System, Sturm 

calculated that the prevalence of BMIs of 40 kg/m 2 and 

higher quadrupled between 1986 and 2000, while the 

prevalence of BMIs of 50 kg/m 2 and higher—the heaviest 

Americans—increased by a factor of 5. 9 

When obesity remains untreated 

Left untreated, obesity is implicated in the development 

of multiple comorbidities including hypertension, type 2 

diabetes, coronary artery disease, osteoarthritis, and 

some types of cancer (TABLE 1). 10,11 Because most of 

these diseases are correlated directly with BMI, 10,12 the 

patient with class III obesity is most likely to have them. 

Not surprisingly, obesity also is associated with 

increased risk of mortality—it contributes directly to 

approximately 280,000 deaths per year. 13 Even though 

class III patients represent a minority of the obese population, 

mortality in this subgroup is disproportionately 

high (relative risk, 1.9-2.6). 13,14 

Recent analyses have estimated that in 2000, 

March 2005 Supplement to The Journal of Family Practice 3


FIGURE 1 

400,000 deaths in the United States were attributable to 

poor diet and lack of regular physical activity. 15 In addition, 

loss of normal life expectancy for 25-year-olds 

with class III obesity is estimated to be as much as 20 

years for black men, 13 years for white men, 5 years for 

black women, and 8 years for white women. 16 

Whether obesity contributes directly to mortality 

independently of poor diet and sedentary lifestyle 

remains controversial. 17 Moreover, there is disagreement 

about the effect of weight loss on mortality because of 

the difficulty in separating intentional weight loss from 

disease-related weight loss. In a recent prospective 

study, Gregg et al concluded that intentional weight loss 

is associated with a 24% reduction (relative risk, 0.76; 

95% CI, 0.60-0.97) in mortality. 18 

Diabetes 

Type 2 diabetes mellitus is clearly linked to obesity. 

The estimated 10-year odds ratio for the development 

of type 2 diabetes is 17 in men and women with BMIs 

greater than 30 kg/m 2 . For patients with BMIs greater 

than 35 kg/m 2 , the odds ratio increases to 34 in women 

and 41 in men. 10 Approximately 11% of men and 

20% of women with class III obesity also have type 2 

Prevalence of obesity among US adults 

1991 2003 

In 1991, the highest obesity (BMI ≥30 kg/m2 ) prevalence rate by state among US adults was 15% to 19%, and it was documented in only 4 

states. In 2003, this prevalence rate was noted in 15 states; moreover, 31 states had rates of 20% to 24%, and 4 states had rates of more than 

25%. Adapted from Behavioral Risk Factor Surveillance System (BRFSS), Centers for Disease Control and Prevention, and Mokdad et al. 2 

No data 25% 


diabetes. 10 Multiple studies involving men, women, 

and various ethnic groups have confirmed an association 

between morbid obesity and type 2 diabetes. 10,11,19 

The effect of weight loss on type 2 diabetes can be 

significant. For example, Anderson and Konz reported 

that for every 5-kg weight loss, the average fasting glucose 

level decreased by 18 mg/dL. 12 In particular, bariatric 

surgery is associated with dramatic and prolonged 

improvement in blood glucose control. Blood glucose values 

are normalized in 77% to 86% of patients with type 

2 diabetes who undergo surgery for morbid obesity. 20-23 

Coronary artery disease 

Obesity has been identified as an independent risk factor 

for the development of coronary artery disease 

(CAD) in both men and women. The magnitude of the 

risk is similar to that of other coronary risk factors, 

including hyperlipidemia, hypertension, and cigarette 

smoking. 12,24 The relative risk for the development of 

CAD in patients with BMIs greater than 30 kg/m 2 is 

approximately 1.6 times that of their normal-weight 

counterparts, even after adjusting for other CAD risk 

factors. 11,24,25 In morbidly obese patients, the relative risk 

of CAD is approximately 1.7 to 2.2 times greater than

in their normal-weight 

counterparts. 10,11 It has been 

calculated that for every 

kilogram of weight gained 

after high school, the risk 

of CAD increases by 5.7% 

in women and by 3.1% in 

men. 12 Data on the effects 

of bariatric surgery on the 

onset or progression of 

CAD are lacking, and 

prospective cohort studies 

have failed to demonstrate 

a reduction in cardiovascular 

mortality when intentional 

weight loss is 

achieved nonsurgically. 26 

FIGURE 2 

Hypertension 

Men with class III obesity 

are 1.7 to 4.6 times more 

likely to have hypertension than matched normal-weight 

controls. In morbidly obese women, the risk increases by 

a factor of 1.4 to 5.5. 2,10 

As with diabetes, weight loss ameliorates hypertension. 

In obese patients, every 1-kg decrease in body 

weight is accompanied by an average decrease of 0.6 

mm Hg in systolic blood pressure and 0.34 mm Hg in 

diastolic pressure. 12 The beneficial effect of weight loss 

on blood pressure is consistently seen when weight loss 

is achieved through lifestyle modification; 27 however, it 

may not occur when weight loss is achieved with 

appetite-suppressing drugs. 6,12,28,29 Bariatric surgery is 

associated with complete resolution of hypertension in 

60% to 70% of patients with morbid obesity. 22,30 

Arthritis 

The risk of osteoarthritis, predominantly in the weightbearing 

joints, is increased in all obese patients. 11,31 In 

patients with class III obesity, the relative risk for 

osteoarthritis is 10. 11 The knee joint is particularly vulnerable—for 

every 5-unit increase in BMI, the relative 

risk for bilateral knee arthritis increases by 2.6. 31 An 

increasing prevalence of hip arthritis also has been correlated 

directly with increasing BMI. 

Total knee and hip arthroplasty rates are strongly 

associated with progressive obesity. In morbidly obese 


FAMILY 

PRACTICE 

Prevalence of overweight among US children and adolescents 

Prevalence (%) 

20 

15 

10 

5 

0 

■ 1971-1974 

■ 1988-1994 

■ 1999-2000 

2-5 6-11 

Age (yr) 

12-19 

From 1977 to 2000, the prevalence of overweight (95% of BMI for age) increased 5% among children 

aged 2 to 5 years, 11% among children aged 6 to 11 years, and 10% among adolescents (12-19 yr). Data 

derived from First National Health and Nutrition Examination Survey (NHANES I), 1971-1974; NHANES 

III, 1988-1994; and NHANES 1999-2000. Adapted from Ogden et al. 7 

men, the odds ratios of total knee and hip arthroplasty 

are 16 and 9, respectively. 32 Morbidly obese women are 

19 times more likely to undergo knee replacement than 

normal-weight controls. 32 

In patients with established arthritis, weight loss is 

associated with decreased pain and increased function. 

33 Weight loss also has been associated with 

decreased progression of knee arthritis, 34 but not of hip 

arthritis. 35 Joint pain is alleviated after bariatric surgery, 

and surgical patients also are more likely to be physically 

active than their nonsurgical counterparts. 36,37 

Cancer 

Observational studies have noted that elevated BMIs 

were associated with increasing risk of several cancers, 

including but not limited to, cancer of the breast, colon, 

prostate, ovaries, and uterus (FIGURE 3). 10,38 Although 

precise mechanisms have not been elucidated, a likely 

hypothesis is that accumulating adipose tissue affects 

circulating levels of tumor-promoting peptides and 

steroid hormones. 39 

The relative risk of colon cancer in patients with 

BMIs greater than 35 kg/m 2 is 1.8 to 2.2. 9,38 As is seen 

with other obesity related conditions, increasing obesity 

escalates the risk of cancer. Studies of women have shown 

that intentional weight loss was associated with a reduced 



TABLE 1 

Cardiovascular 

Dyslipidemia 

Coronary artery disease 

Cardiomyopathy 

Hypertension 

Congestive heart failure 

Deep vein thrombosis 

Pulmonary embolism 

Pulmonary hypertension 

Cor pulmonale 

Cerebrovascular 

Stroke 

Idiopathic intracranial 

hypertension 

Medical conditions that may be associated with severe obesity 

Respiratory 

Sleep apnea 

Asthma 

Hypoventilation syndrome 

Chronic obstructive 

pulmonary disease 

Gastrointestinal 

Gastroesophageal reflux 

Fatty liver 

Nonalcoholic steatohepatitis 

Cholelithiasis 

Hernia 

Genitourinary 

Urinary stress incontinence 

Hypogonadism 

Psychoneurologic 

Depression 

Migraine headache 

Pseudotumor cerebri 

Carpal tunnel syndrome 

Integumentary 

Venous stasis 

Superficial thrombophlebitis 

Cellulitis 

Panniculitis 

Postoperative wound infection 

Fungal infections 

Adapted from Mun EC, Blackburn GL, Matthews JB. Current status of medical and surgical therapy for obesity. 

Gastroenterology. 2001;120:669-681; American Obesity Association. AOA fact sheets: health effects of obesity. 

Available at http://www.obesity.org/subs/fastfacts/Health_Effects.shtml. Accessed December 29, 2004. 

incidence of all cancers, as well as breast and colon cancer. 

40,41 These studies did not specify the methods of 

weight loss, and it has yet to be determined whether surgically 

induced weight loss reduces cancer risk. 

The high cost of obesity 

About $50 billion annually are spent on direct care of obesity-related 

complications and another $30 billion are 

spent on weight-loss products and programs. 6 This sum 

accounts for nearly 5% of all medical costs in the United 

States. 6 In addition to the cost of treating associated medical 

conditions, obese patients are less productive and 

more prone to disability. 42 Thus, strategies aimed at reducing 

the burden of obesity are likely to have a major impact 

on the US health care system and society as a whole. 

Psychosocial impact 

Patients with class III obesity often have significant psy- 


Endocrine 

Insulin resistance 

Impaired glucose tolerance 

Type 2 diabetes 

Impotence 

Amenorrhea 

Dysmenorrhea 

Polycystic ovary syndrome 

Infertility 

Hirsutism 

Gynecomastia 

Musculoskeletal 

Low back pain 

Vertebral disc herniation 

Osteoarthritis 

Malignancies 

Breast cancer 

Endometrial cancer 

Colon cancer 

Prostate cancer 

Uterine cancer 

chosocial complications that can be attributed to their 

weight. In particular, morbidly obese patients report 

impaired mobility, reduced energy levels, a high degree of 

emotional distress, and impaired psychosocial functioning 

(eg, social isolation, feelings of failure and hopelessness). 

43,44 Psychosocial complications are reinforced by 

social, educational, and workplace stigmatization—potential 

partners, teachers, school administrators, employers, 

and even physicians and other health professionals tend to 

rate obese individuals unfavorably compared with individuals 

of normal weight. 44,45 Several studies have used validated 

survey instruments to demonstrate that the quality 

of life decreases as BMI increases and that as weight is lost, 

patients report improved quality of life. 44-46 

Nonsurgical treatment 

Nonsurgical treatment for extremely obese patients 

includes lifestyle changes (eg, diet and exercise), pharmacologic 

therapy, alternative drug therapies and tech-

niques, and psychotherapy 

(TABLE 2). A substantial 

body of literature is available 

for assessment of these 

options. 

Morbidly obese patients 

typically are more than 100 

lb (~45 kg) overweight. 

Therefore, they need to be 

managed with treatments 

that have the potential to 

achieve substantial weight 

reductions and thereby correct 

obesity-related metabolic 

abnormalities. To date, 

all nonsurgical treatments 

for obesity have demonstrated 

maximum average 

weight-losses of 3 to 6 kg. 6,47 

In addition, noncompliance 

rates approximate 50%, 

and relapse rates after cessa- 

FIGURE 3 

Relative risk for any cancer 

tion of treatment approach nearly 100%. 6,47 Clearly, the 

primary care physician has few effective nonsurgical 

options for the morbidly obese patient. 

Lifestyle changes 

Modification of diet (restriction of caloric intake) and 

aerobic exercise (increased energy consumption) form 

the mainstay of lifestyle changes. Dietary changes can 

decrease weight approximately 3 to 6 kg and adding 

exercise to a diet may be more effective than diet alone. 6 

No specific type of diet (eg, low-calorie vs low-carbohydrate) 

has been shown to be superior when caloric 

intakes of the diets are equivalent. 6,48 When used as 

monotherapy, exercise offers minimal improvement, but 

it may prevent additional weight gain and improves cardiovascular 

fitness. 6 

As mentioned, the major concerns about using 

lifestyle changes in the treatment for the morbidly obese 

patient are the relatively small impact on the patient’s 

total weight, the high rates of attrition, and the high rates 

of weight regain over time. 47 

Pharmacologic therapy 

Numerous medications have been used in the management 

of morbid obesity, but only two of them, 

2.0 

1.5 

1.0 

0.5 

0.0 

■ Men 

■ Women 

1.00 1.00 0.97 

BMI and cancer mortality 

1.08 


FAMILY 

PRACTICE 

18.5-24.9 25.0-29.9 30.0-34.9 35.0-39.9 ≥40 

Risk for death from all cancers increased as BMI increased in more than 900,000 US adults followed for 

16 years. Morbidly obese persons (BMI ≥40 kg/m 2 ) had the highest cancer death rates, with overall rates 

52% higher in men and 62% higher in women, compared with normal-weight adults. The most common 

weight-related cancer was liver cancer in men (combined risk ratio, 4.52 for BMI ≥35 kg/m 2 ) and cancer of 

the corpus and uterus in women (combined risk ratio, 6.25 for BMI ≥35 kg/m 2 ). Overweight and obesity 

were linked to 14% of deaths from cancer in men and 20% in women. Adapted from Calle et al. 39 

1.09 

BMI (kg/m 2 ) 

1.23 1.20 

1.32 

1.52 

1.62 

sibutramine and orlistat, have been approved for longterm 

use. The US Food and Drug Administration includes 

the proviso that these 2 agents be administered in conjunction 

with a reduced-calorie diet. 

Sibutramine suppresses appetite through its inhibition 

of norepinephrine, serotonin, and dopamine reuptake. 

In clinical studies, patients taking sibutramine had 

a weight loss that was about 4 to 5 kg greater than that 

in placebo patients after 1 year of treatment. 28,29,47,49 

Even more significant, these studies excluded patients 

with BMIs greater than 40 kg/m 2 . Indeed, no studies of 

the efficacy of sibutramine in morbidly obese patients 

have been completed. 

Attrition rates in sibutramine trials have ranged 

from 17% to 47%. The most common side effects 

were dry mouth, anorexia, insomnia, constipation, 

and headache. 28,29,49 The agent also has been associated 

with small elevations of blood pressure and heart 

rate and should be administered with caution in 

patients with hypertension, particularly when it is 

uncontrolled or poorly controlled. 

Orlistat is a lipase inhibitor that prevents absorption 

of dietary fats in the stomach and small intestine. 

A Cochrane review of 11 orlistat trials indicated that 

patients taking orlistat had a 2.7-kg weight loss 



TABLE 2 

NIH guidelines for treatment of obesity 

BMI (kg/m 2 ) 

25-26.9 27-29.9 30-34.9 35-39.9 ≥40 

Lifestyle Yes, with ≥2 Yes, with ≥2 

therapy risk factors or risk factors or Yes Yes Yes 

comorbidities comorbidities 

Drug Yes, with 

therapy* No risk factors or Yes Yes Yes 

comorbidities 

Bariatric No No No Yes, with Yes 

surgery comorbidities 

*Drug therapy is indicated in patients who fail to lose 0.45 kg a week during 6 months of lifestyle therapy. 

Adapted from NHLBI Obesity Education Initiative. The Practical Guide to the Identification, Evaluation, 

and Treatment of Overweight and Obesity in Adults. NIH Publication No. 00-4084. October 2000. 

greater than patients taking placebo (95% CI, 2.3- 

3.1). 49 Attrition rates ranged from 14% to 52% (average, 

33%). Orlistat is associated with a high incidence 

of gastrointestinal side effects; they occurred 16% to 

40% more often in orlistat patients than in placebo 

patients. The most common of these, occurring in 15% 

to 30% of patients taking orlistat, were fatty/oily stool, 

fecal urgency, and oily spotting. Fecal incontinence 

occurred in 6% of patients in the 3 studies that reported 

this side effect. 

Most orlistat trials also excluded patients with 

BMIs greater than 40 kg/m 2 , which limits application of 

these data to patients with class III obesity. 49 Both orlistat 

and sibutramine may improve quality-of-life parameters 

and may have a modest beneficial impact on lipid 

levels and metabolic parameters (eg, blood glucose, 

hemoglobin A 1c). However, discontinuation of therapy 

is associated with return of previously lost weight. 49 

Alternative therapies 

Obese patients often turn to alternative therapies such as 

hypnosis, acupuncture, and over-the-counter dietary supplements. 

Studies of hypnosis and acupuncture have 

shown that these techniques do not provide consistent 

improvement over placebo (ie, sham procedure). 50,51 

Over-the-counter dietary supplements that have been 

studied include chitosan, chromium picolate, Ephedra 


sinica, Garcinia cambogia, 

glucomannan, guar gum, 

hydroxy-methyl butyrate, 

plantago psyllium, pyruvate, 

yerba maté, and yohimbe. A 

systematic review of such 

studies concluded that none 

of these agents have shown 

consistent results in promoting 

weight loss; moreover, 

safety is a significant concern 

with several of them. 52 Thus, 

they cannot be recommended 

for use in clinical practice, 

at least until further research 

has been performed. 

Psychotherapy 

Structured psychotherapy 

aimed at weight reduction includes behavioral modification 

techniques (eg, stimulus control, self-monitoring, 

and cognitive restructuring) that increase compliance 

with dietary changes, exercise regimens, or both. 53 No 

one technique has been proven superior when judged by 

the amount of weight lost. 6 The majority of weight loss in 

patients undergoing psychotherapy and supervised 

lifestyle change occurred during the first year of treatment. 

At 5-year follow-up, there was no statistically significant 

difference between intervention and control 

groups. 6 Programs with the most patient contact tended 

to produce the largest weight loss. 6 

Summary 

The family physician is often the morbidly obese patient’s 

first contact with the health care system, there by providing 

an opportunity to influence management in a patientoriented 

manner that focuses on outcomes such as weight 

loss, associated comorbidities, and quality of life. 

Nonsurgical treatments for morbid obesity have significant 

limitations including minimal total weight loss, little 

or no effect on comorbidities and quality of life, and lack 

of sustainment over time. Bariatric surgery, on the other 

hand, offers greater and longer-lasting weight loss 54 and 

better improvement in clinically relevant outcomes. 21,22 

Sackett wrote that evidence-based medicine is “the 

integration of the best research evidence with clinical

expertise and patient values.” 55 Because we now have 

access to a significant body of literature on the management 

of obesity, we can initiate evidence-based discussions 

with patients, which may help to create a treatment plan 

aimed at reducing the morbidity associated with severe 

obesity. For the patient with morbid obesity, this will likely 

include a discussion about bariatric surgery. ■ 

REFERENCES 

1. Flegal KM, Carroll MD, Ogden CL, Johnson CL. Prevalence and trends in 

obesity among US adults, 1999-2000. JAMA. 2002;288:1723-1727. 

2. Mokdad AH, Ford ES, Bowman BA, Dietz WH, Vinicor F, Bales VS, Marks 

JS. Prevalence of obesity, diabetes, and obesity-related health risk factors, 

2001. JAMA. 2003;289:76-79. 

3. Wang Y, Monteiro C, Popkin BM. Trends of obesity and underweight in 

older children and adolescents in the United States, Brazil, China, and Russia. 

Am J Clin Nutr. 2002;75:971-977. 

4. World Health Organization. World Health Report 2002. Available at: 

http://www.who.int/whr/2002/en/. Accessed November 6, 2004. 

5. Sinha R, Anderson DE, McDonald SS, Greenwald P. Cancer risk and diet in 

India. J Postgrad Med. 2003;49:222-228. 

6. National Institutes of Health. Clinical guidelines on the identification, evaluation, 

and treatment of overweight and obesity in adults: The evidence 

report. Bethesda, MD: US Department of Health and Human Services; 1998. 

7. Ogden CL, Flegal KM, Carroll MD, Johnson CL. Prevalence, and trends in 

overweight among US children and adolescents, 1999-2000. JAMA. 

2002;288:1728-1732. 

8. Freedman DS, Khan LK, Serdula MK, Galuska DA, Dietz WH. Trends and 

correlates of class 3 obesity in the United States from 1990 through 2000. 

JAMA. 2002;288:1758-1761. 

9. Sturm R. Increases in clinically severe obesity in the United States, 1986- 

2000. Arch Intern Med. 2003;163:2146-2148. 

10. Field AE, Coakley EH, Must A, et al. Impact of overweight on the risk of 

developing common chronic diseases during a 10-year period. Arch Intern 

Med. 2001;161:1581-1586. 

11. Must A, Spadano J, Coakley EH, Field AE, Colditz G, Dietz WH. The disease 

burden associated with overweight and obesity. JAMA. 1999;282:1523- 

1529. 

12. Anderson JW, Konz EC. Obesity and disease management: Effects of weight 

loss on comorbid conditions. Obes Res. 2001;9(suppl 4):326S-334S. 

13. Allison DB, Fontaine KR, Manson JE, Stevens J, VanItallie TB. Annual 

deaths attributable to obesity in the United States. JAMA. 1999;282:1530- 

1538. 

14. Calle EE, Thun MJ, Petrelli JM, Rodriguez C, Heath CW Jr. Body-mass index 

and mortality in a prospective cohort of US adults. N Engl J Med. 

1999;341:1097-1105. 

15. Mokdad AH, Marks JS, Stroup DF, Gerberding JL. Actual causes of death in 

the United States, 2000. JAMA. 2004;291:1238-1245. 

16. Fontaine KR, Redden DT, Wang C, Westfall AO, Allison DB. Years of life lost 

due to obesity. JAMA. 2003;289:187-193. 

17. Beasley JW. Obesity and years of life lost. Letter to the editor. JAMA. 

2003;289:1777. 

18. Gregg EW, Gerzoff, RB, Thompson TJ, Williamson DF. Intentional weight 

loss and death in overweight and obese US adults 35 years of age and older. 

Ann Intern Med. 2003;138:383-390. 

19. Stevens J, et al. Sensitivity and specificity of anthropometrics for the prediction 

of diabetes in a biracial cohort. Obes Res. 2001;9:696-705. 

20. Schauer PR, et al. Effect of laparoscopic Roux-en-Y gastric bypass on type 2 

diabetes mellitus. Ann Surg. 2003;238:467-484. 

21. Pories WJ, MacDonald, KG Jr, Morgan EJ, Sinha MK, et al. Surgical treatment 

of obesity and its effect on diabetes: 10-year follow-up. Am J Clin Nutr. 

1992;55:582-585. 

22. Buchwald H, Avidor Y, Braunwald E, et al. Bariatric surgery: a systematic 

review and meta-analysis. JAMA. 2004;292:1724-1737. 

23. Sugerman HJ, Wolfe LG, Sica DA, Clore JN. Diabetes and hypertension in 

severe obesity and effects of gastric bypass-induced weight loss. Ann Surg. 

2003;237:751-756. 

24. Mahamat A, et al. Body mass index, hypertension, and 5-year coronary heart 

disease incidence in middle aged men: the PRIME study. J Hypertens. 

2003;21:519-524. 

25. Wilson PWF, D’Agostino RB, Sullivan L, Parise H, Kannel WB. Overweight 

and obesity as determinants of cardiovascular risk: the Framingham experience. 

Arch Intern Med. 2002;162:1867-1872. 

26. Williamson DF, Pamuk E, Thun M, Flanders D, Byers T, Heath C. 

Prospective study of intentional weight loss and mortality in overweight 


FAMILY 

PRACTICE 

white men aged 40-64 years. Am J Epidemiol. 1999;149:491-503. 

27. Mulrow CD, Chiquette E, Angel L, et al. Dieting to reduce body weight for 

controlling hypertension in adults. In: The Cochrane Library. Issue 4. 

Chichester, UK: John Wiley & Sons, Ltd; 2004. 

28. Smith MB. Randomized placebo-controlled trial of long-term treatment with 

sibutramine in mild to moderate obesity. J Fam Pract. 2001;50:505-512. 

29. Wirth A, Krause J. Long-term weight loss with sibutramine: a randomized 

controlled trial. JAMA. 2001;286:1331-1339. 

30. Sjörström CD, Lissner L, Wedel H, Sjöström L. Reduction in incidence of diabetes, 

hypertension and lipid disturbances after intentional weight loss 

induced by bariatric surgery: the SOS intervention study. Obes Res. 

1999;7:477-484. 

31. Stürmer T, Gunther KP, Brenner H. Obesity, overweight and patterns of 

osteoarthritis: the Ulm Osteoarthritis Study. J Clin Epidemiol. 2000;53:307- 

313. 

32. Wendelboe AM, Hegmann KT, Biggs JJ, et al. Relationships between body 

mass indices and surgical replacements of knee and hip joints. Am J Prev 

Med. 2003;25:290-295. 

33. Messier SP, Loeser RF, Miller GD, et al. Exercise and dietary weight loss in 

overweight and obese older adults with knee osteoarthritis: the Arthritis, 

Diet, and Activity Promotion Trial. Arthritis Rheum. 2004;50:1501-1510. 

34. Huang MH, Chen CH, Chen TW, et al. The effects of weight reduction on 

the rehabilitation of patients with knee osteoarthritis and obesity. Arthritis 

Care Res. 2000;13:398-405. 

35. Flugsrud GB, Nordsletten L, Espehaug B, Havelin LI, Meyer HE. Weight 

change and the risk of total hip replacement. Epidemiology. 2003;14:578- 

584. 

36. Sjörström L, Lindroos AK, Peltonen M, et al. Lifestyle, diabetes and cardiovascular 

risk factors 10 years after bariatric surgery. N Engl J Med. 

2004;351:2683-2693. 

37. Dixon JB, Dixon ME, O’Brien PE. Quality of life after Lap-Band placement: 

influence of time, weight loss and comorbidities. Obes Res. 2001;11:713- 

721. 

38. Calle EE, Rodriguez C, Walker-Thurmond K, Thun MJN. Overweight, obesity, 

and mortality from cancer in a prospectively studied cohort of US adults. 

N Engl J Med. 2003;348:1625-1638. 

39. Calle EE, Thun MJ. Obesity and cancer. Oncogene. 2004;23:6365-6378. 

40. Trentham-Dietz A, Newcomb, PA, Egan KM, et al. Weight change and risk 

of postmenopausal breast cancer (United States). Cancer Causes Control. 

2000;11:533-542. 

41. Parker ED, Folsom AR. Intentional weight loss and incidence of obesityrelated 

cancers: the Iowa Women’s Health Study. Int J Obes. 2003;27:1447- 

1452. 

42. Wolf AM. Economic outcomes of the obese patient. Obes Res. 

2002;10(suppl 1):58S-62S. 

43. Kolotkin RL, Crosby RD, Williams GR, Hartley GG, Nicol S. The relationship 

between health-related quality of life and weight loss. Obes Res. 

2001;9:564-571. 

44. Van Gemert WG, Van Dielen F, Soeters PB, Greve JW. Quality of life before 

and after weight-reducing surgery and cost-effectiveness analysis. In: Dietal 

M, Cowan SM, eds. Update: Surgery for the morbidly obese patient. 

Toronto, Ont: FD communications; 2000:595-602. 

45. Puhl R, Brownell KD. Bias, discrimination, and obesity. Obes Res. 

2001;9:788-805. 

46. Larsson U, Karlsson J, Sullivan M. Impact of overweight in obesity on healthrelated 

quality of life: a Swedish population study. Int J Obes. 2002;26:417-424. 

47. Jain A. What Works for Obesity? A Summary of the Research Behind 

Obesity Interventions. London, England: BMJ Publishing Group; April 

2004. 

48. Pirozzo S, Summerbell C, Cameron C, Glasziou P. Advice on low-fat diets for 

obesity. In: The Cochrane Library. Issue 4, 2004. Oxford, England: update 

software. 

49. Padwal R, Li SK, Lau DCW. Long-term pharmacotherapy for obesity and 

overweight (Cochrane Review). In: The Cochrane Library. Issue 3. 

Chichester, UK: John Wiley & Sons, Ltd; 2004. 

50. Ernst E. Acupuncture/acupressure for weight reduction? A systematic review. 

Wien Klin Wochenschr. 1997;109:60-62. 

51. Allison DB, Faith MS. Hypnosis as an adjunct to cognitive-behavioral psychotherapy 

for obesity: a meta analytical reappraisal. J Consult Clin Psychol. 

1995;54:513-515. 

52. Pittler MH, Ernst E. Dietary supplements for body-weight reduction: a systematic 

review. Am J Clin Nutr. 2004;79:529-536. 

53. Poston WS 2nd, Foreyt JP. Successful management of the obese patient. Am 

Fam Phys. 2000;61:3615-3622. 

54. Colquitt J, Clegg A, Sidhu M, Royle P. Surgery for morbid obesity. (Cochrane 

Review). In: The Cochrane Library. Issue 3. Chichester, UK: John Wiley & 

Sons, Ltd; 2004. 

55. Sackett DL, Straus SE, Richardson WS, Haynes RB. Evidence-based medicine: 

How to practice and teach EBM, second edition. London, England: 

Churchill Livingstone; 2000. 



Surgical options 


Professor, Department of Surgery 

Owen H. and Sarah Davidson Wangensteen Chair 

in Experimental Surgery Emeritus 

University of Minnesota Medical School 

Minneapolis, Minn 

The weight loss that occurs after bariatric surgery 

is achieved and maintained through restriction 

of food intake, malabsorption of food, or both. 

Ideally, eating behavior will be modified after surgery—patients 

are likely to consume smaller quantities 

of food more slowly. 

The number of bariatric procedures performed 

around the world has grown markedly and probably 

will increase exponentially as surgery is recognized as an 

effective treatment. Its risks are decreasing, and its benefits 

include the reduction, if not elimination, of many 

comorbidities. A 31-country survey performed by the 

International Federation for the Surgery of Obesity 

(IFSO) showed that the worldwide frequency of 

bariatric surgery has increased from 40,000 in 1998 to 

more than 146,000 in 2003. 1 

In the United States, about 103,000 bariatric operations 

were performed in 2003, and more than 140,000 

were performed in 2004. France, which reported 

12,000 procedures in 2003, ranks second in frequency, 

followed by Brazil and Italy. The United States also has 

the greatest number of bariatric surgeons (850, according 

to the 2003 IFSO survey), followed by France, Italy, 

and the United Kingdom, with about 200 each. 

Weight loss after surgery 

For practical and ethical reasons, it is currently impossible 

to perform a true randomized controlled trial (RCT) 

of bariatric surgery; that is, a blinded study in which 

patients are randomized to surgery or placebo. Most 

studies have been RCTs that compared different surgical 

procedures or surgery to nonsurgical management 

(drugs and/or diet or no treatment), nonrandomized 

controlled studies of surgery vs nonsurgery, and 

prospective cohort studies of surgery vs nonsurgery. In 


recent years, several systematic reviews of these data 

have been completed, permitting an assessment of the 

effects of bariatric surgery on weight loss, comorbidities, 

and quality of life. 

Analysis of pooled data from randomized controlled 

trials of bariatric surgery in the United States, United 

Kingdom, and Canada found dramatic weight reduction 

across the board. 2 In 5 US trials reviewed by the National 

Institutes of Health, mean weight loss was 76 kg (range, 

9.7-159) after 1 to 4 years. 2 Mean weight loss in a UK 

National Health Service review of 6 trials was 45.1 kg 

(range, 9.7-57.9) after 1 to 4 years, while mean weight 

loss in 4 randomized trials and 1 prospective cohort 

study reviewed by the Canadian Task Force on 

Preventive Health Care was 29.9 kg (range, 17-45.5) 

after 2 to 5 years. 2 Wound infection, gastric leaks, and 

other complications were reported, and up to 25% of 

patients required revisional procedures within 5 years. 

However, operative mortality was extremely low (

loss of 20 kg (CI, 18-22) in surgical patients and of 0.7 

kg (CI, -0.8 to 2.2) in controls. 4 

Operative procedures 

Since bariatric surgery is the only broadly successful treatment 

for morbid obesity, physicians should familiarize 

themselves with commonly used operative procedures 

and their impact on the comorbidities associated with 

extreme obesity. There are 4 main categories of procedures: 

malabsorptive (eg, biliopancreatic diversion, duodenal 

switch), malabsorptive/restrictive (eg, Roux-en-Y 

gastric bypass), restrictive (eg, vertical banded gastroplasty, 

gastric banding), and neither malabsorptive nor 

restrictive (eg, gastric or vagal pacing). Despite their relative 

complexity, all can be performed laparoscopically, as 

well as by open abdominal surgery. Recently, robotics 

have been introduced into laparoscopic bariatric surgery. 

Malabsorptive procedures 

The current generation of malabsorptive procedures is 

descended from the jejunoileal bypass, the first operation 

to be performed for the purpose of weight reduction. 

5,6 Introduced in 1953-1954 by Varco and the team 

of Kremen, Linner, and Nelson, the jejunoileal bypass 

was highly effective for weight loss, but had unacceptably 

high morbidity. 5,6 Gas-bloat syndrome, steatorrhea, 

electrolyte imbalance, hepatic fibrosis and failure, 

nephrolithiasis, and impaired mentation were among 

the complications that led to gradual abandonment of 

the jejunoileal bypass in favor of the gastric bypass in 

the 1970s and 1980s. 

Newer malabsorptive procedures such as the biliopancreatic 

diversion and the duodenal switch share a 

key feature that averts most of these complications 

(FIGURE 2). No segment of the intestine is allowed to 

remain stagnant and become a breeding ground for bacteria. 

The surgeon creates an enteric limb for transit of 

food and a biliopancreatic limb for transit of bile and 

pancreatic juice. These join in a common channel where 

digestion and nutrient absorption take place. The biliopancreatic 

diversion is also known as the Scopinaro 

procedure after Nicola Scopinaro, its creator and 

staunchest advocate. 6 Since introducing the procedure in 

1979, Scopinaro has made a number of modifications. 

The current operation consists of a horizontal partial 

gastrectomy with closure of the duodenal stump, gastrojejunostomy 

with a long Roux limb, and anastomo- 

FIGURE 1 

Weight (kg) 

130 

120 

110 

100 

90 

80 

70 


FAMILY 

PRACTICE 

Weight change in the 

Swedish Obese Subjects Study 

Controls (n=1,031) 

Gastric banding (n=255) 

Vertical banded 

gastroplasty (n=834) 

Adapted from Sjöström et al. 

Gastric bypass (n=88) 

8 

0 

-2 0 2 

Years 

4 6 

sis of the long biliopancreatic limb to the Roux limb to 

create a short (50 cm) common channel. Potential complications 

include malodorous diarrhea, flatulence, anemia, 

stomal ulcers, bone demineralization, and protein 

malabsorption. 

The duodenal switch was pioneered by Marceau 

and colleagues (1993) and Hess and Hess (1998). 6 This 

is a complicated procedure in which a greater curvature 

sleeve gastrectomy is performed to leave a stomach with 

a capacity of approximately 100 mL, the duodenum is 

divided, and the enteric limb is anastomosed to the postpyloric 

duodenum. Like biliopancreatic diversion, the 

duodenal switch may be associated with diarrhea, flatulence, 

iron malabsorption, and calcium and protein 

malabsorption. These can be reduced or avoided by the 

use of mild antidiarrheal agents and mineral supplements, 

and maintenance of a diet containing 65 to 80 

gm of protein per day. 

Malabsorptive/restrictive procedures 

The first gastric bypass procedure was developed by 

Mason and Ito in the mid-1960s, with subsequent variations 

by Alden, Griffen, and associates; Linner and 

Drew; Torres and Oca; and others. 6 All combine intestinal 

malabsorption with gastric restriction, but rely 



FIGURE 2 

Biliopancreatic 

diversion 

Malabsorptive procedures 

Biliopancreatic diversion 

with duodenal switch 

primarily on the latter for weight loss. The Roux-en-Y 

bypass involves construction of a small upper gastric 

pouch (currently 20 mL or less) that empties food into the 

small intestine through a Roux limb gastrojejunostomy 

(FIGURE 3). The degree of malabsorption is determined 

by the extent of the bypass, which at a minimum 

includes the distal stomach, the duodenum, and the first 

segment of the jejunum. 

A modification known as the long-limb or distal 

Roux-en-Y bypass, involving a long Roux limb and a 

long bypassed limb that join to create a short common 

channel, was designed by Torres and Oca (and later 


FIGURE 3 

Malabsorptive/restrictive procedure 

Roux-en-Y 

gastric bypass 

Brolin) to further enhance malabsorption. 6 It may cause 

severe vitamin, mineral, and nutrient malnutrition and 

should be reserved for patients who are super-obese or 

have failed primary Roux-en-Y bypass. 

While considerably safer than the jejunoileal 

bypass, the Roux-en-Y gastric bypass is not without 

problems. Postoperative complications include the 

“dumping” syndrome, iron deficiency anemia, and lifelong 

vitamin B 12 malabsorption. Should the bypassed 

distal stomach become obstructed, the resulting dilation 

can lead to gastric rupture—a life-threatening complication. 

The procedure also deprives care providers of the 

ability to visualize the distal stomach and duodenum. 

Restrictive procedures 

In the 1970s and 1980s, bariatric surgery was simplified 

by introduction of a number of purely restrictive 

gastric operations: gastroplasty, gastric partitioning, 

banded or ringed vertical gastroplasty (partial gastric 

partitioning at the proximal gastric segment), and 

gastric banding (placement of an adjustable or nonadjustable 

band around the stomach to create a small 

pouch) (FIGURE 4). These are the least invasive of 

bariatric procedures because the stomach is not cut or 

stapled, no anastomoses are required, and the natural 

physiologic passage of food is not altered. 

Patients who eat more than can be tolerated at one

sitting may experience vomiting, especially during the 

early postoperative period. Other complications include 

the lodging of food particles or pills within the band or 

ring, and occasional band slippage or erosion. While 

morbidity is low, weight loss also may tend to be less 

dramatic than with other forms of bariatric surgery. 

New procedures 

In the 1990s, procedures that do not rely on either malabsorption 

or restriction were introduced into bariatric 

surgery. Gastric and vagal pacing have been tested in 

animals and in preliminary human trials. 6 A hypothesis 

behind this approach is that induced gastric paresis 

and/or afferent vagal central nervous system stimulation 

will produce satiety and, as a consequence, weight loss. 

The electrical stimulation procedures are simple and 

easy to perform, but it is too early to determine their 

place in the armamentarium of bariatric surgery. 

Frequency of surgery by type 

Gastric bypass operations account for 65% of bariatric 

procedures performed worldwide, according to the 

IFSO survey. 1 The most common procedure in the 

world is laparoscopic Roux-en-Y gastric bypass (26% 

of all operations), followed by laparoscopic gastric 

banding (24%), open gastric bypass (23%), laparoscopic 

long-limb gastric bypass (9%), open long-limb gastric 

bypass (7%), vertical banded gastroplasty (5%), and 

biliopancreatic diversion/duodenal switch (5%). 

About 57% of bariatric procedures in the United 

States are performed laparoscopically, compared with 

63% worldwide. Similarly, gastric banding is performed 

less frequently than gastric bypass in the United States; 

it was not approved by the US Food and Drug 

Administration until the middle of 2001. About 20,000 

gastric bands were placed from 2001 to 2003 and 

another 40,000 were expected in 2004. 

Is there a clear winner? 

The heterogeneity of the bariatric surgery data makes it 

difficult to draw conclusions about the superiority of one 

procedure over another. Studies differ with regard to procedural 

variations, measures of weight change, and length 

of follow-up. Degree of weight loss must be balanced 

against operative risk, short- and long-term morbidity, 

and the need for later revisional surgery. Moreover, while 

later morbidity is heavily procedure-dependent, operative 

FIGURE 4 

Vertical banded 

gastroplasty 

Gastric banding 


FAMILY 

PRACTICE 

Restrictive procedures 

risk depends largely on the skill of the surgeon and may 

vary for patients undergoing the same operation. 

In the Cochrane review previously cited, 3 gastric 

bypass was associated with significantly greater weight 

loss and fewer revisions or conversions than gastroplasty, 

but also with more side effects and postoperative 

deaths. Greater weight loss, and fewer side effects and 

reoperations, occurred with adjustable gastric banding 

than with vertical banded gastroplasty. Weight loss was 

similar with open and laparoscopic procedures; however, 

the laparoscopic approach had fewer serious complications. 

Laparoscopic surgery was associated with 



TABLE 1 

Meta-analysis of changes in weight and 

obesity-related comorbidities after bariatric surgery * 

reduced blood loss, fewer intensive care unit stays, 

reduced length of hospital stay, reduced days to return 

to activities of daily living, and reduced days of return 

to work. Because all studies included in the Cochrane 

analysis had the potential for significant bias, the investigators 

cautioned that these results should be viewed as 

tentative—the relative safety and efficacy of different 

bariatric procedures remain to be determined. 

Impact on comorbidities 

The effects of bariatric surgery on obesity comorbidities 

are rapid and profound (TABLE 1). In a landmark 1995 

article, Pories et al reported achievement of long-term 


Mean change/value P Value 

Weight loss Absolute weight 40 kg

ing surgery. Gastric bypass also corrected or alleviated 

other comorbidities of morbid obesity, including hypertension, 

obstructive sleep apnea, cardiopulmonary failure, 

arthritis, and infertility. 7 

In the SOS study, incidence of diabetes was reduced 

32-fold in surgical patients relative to controls at 2 

years. At 8 years, there was still a 5-fold reduction in 

diabetes incidence. 4 Incidence of hypertension was 

reduced 2.6-fold in surgical patients relative to controls 

at 2 years. However, by 8 years the surgical patients’ 

blood pressure had reverted to control values despite 

maintenance of a 16% weight reduction. 4,8,9 

Buchwald and colleagues recently conducted a systematic 

review of published observational and interventional 

trials involving bariatric surgery. 10 A total of 134 

studies (5 randomized controlled trials, 28 nonrandomized 

controlled trials or series with comparison groups, 

and 101 uncontrolled case series) that included 22,094 

patients were analyzed to determine the impact of specific 

bariatric surgical procedures on weight loss, operative 

mortality outcome, and 4 obesity comorbidities 

(diabetes, hyperlipidemia, hypertension, and obstructive 

sleep apnea). Results are summarized in Table 1. 

For purposes of analysis, surgical procedures were 

grouped into 5 main categories: (1) gastric banding, (2) 

gastric bypass (this category consisted principally of 

Roux-en-Y variations but included all procedures with 

a gastric bypass component, such as gastroplasty with 

gastric bypass and banding with gastric bypass), (3) gastroplasty, 

(4) biliopancreatic diversion or duodenal 

switch, and (5) mixed or other. A random-effects model 

was used. Weight loss was reported as the mean percentage 

of excess weight loss; changes in absolute 

weight (kg), body mass index (BMI), and percentage of 

initial weight were also reported where appropriate. 

The baseline mean BMI for 16,944 patients was 

46.9 kg/m 2 (range, 32.3-68.8). Mean percentage of 

excess weight loss was 61.2% (95% CI, 58.1-64.4) for 

all patients. Mean percentage excess weight loss by procedure 

was: gastric banding, 47.5%; gastric bypass, 

61.6%; gastroplasty, 68.2%; biliopancreatic diversion 

or duodenal switch, 70.1%. Operative mortality in the 

first 30 days was 0.1% for the purely restrictive procedures, 

0.5% for gastric bypass, and 1.1% for biliopancreatic 

diversion or duodenal switch. 

Diabetes was completely resolved in 76.8% of 

patients and resolved or improved in 86.0%. There 

FIGURE 5 


FAMILY 

PRACTICE 

Risk of mortality after bariatric surgery * 

(Kaplan Meier analysis) 

Percent surviving 

100 

90 

80 

70 

60 

50 

Surgery (n=1,035) 

Control (n=5,746) 

1 2 3 4 5 

Years 

* Relative risk vs controls, 0.11 (95% CI, 0.04-0.27) 

Adapted from Christou et al. 11 

P


FIGURE 6 

Quality of life after bariatric surgery 

Mobility 

Energy 

Pain 

Sleep 

Social 

isolation 

Emotional 

reaction 

0 

0 

0 

0 

7 

16 

13 

19 

20 

30 

33 

■ Control 

■ Surgery 

0 10 20 30 40 50 60 70 

Best Median score Worst 

Shown here are results of the Nottingham Health Profile I as completed 

by 62 patients who underwent vertical banded gastroplasty 

or Roux-en-Y gastric bypass and 20 preoperatively morbidly obese 

controls. Mean follow-up was 7 years (range, 0.5-14). Adapted 

from van Gemert et al. 13 

prising, since even a modest (eg, 10%) weight loss can 

significantly lower blood pressure. Unlike the case with 

type 2 diabetes and hyperlipidemia, the reduction in 

hypertension appeared to be independent of the type of 

surgery performed. 

Obstructive sleep apnea was resolved in 85.7% of 

patients and was resolved or improved in 83.6% of 

patients. The extracted studies showed improvements in 

oxygen saturation, decreases in arterial carbon dioxide, 

and increases in arterial oxygen content. All of these 

changes resulted primarily from the increase in 

diaphragmatic excursion brought about by reduction in 

obesity-induced intra-abdominal pressure. 

Increased life expectancy 

Given the scope of the reductions in diabetes, hyperlipidemia, 

hypertension, obstructive sleep apnea, and other 

obesity comorbidities that accompany bariatric surgery, it 

should come as no surprise that patient life expectancy is 

also increased. Christou et al recently conducted a large 

observational study to test the hypothesis that surgically 

induced weight loss reduces long-term morbidity, mortality, 

and healthcare use in patients with morbid obesity. 11 

None of the 1,035 surgery patients or 5,746 age- and gender-matched 

severely obese controls had medical conditions 

other than morbid obesity at study entry. Mean follow-up 

was 5 years (range, 1-16). Bariatric surgery (Rouxen-Y 

gastric bypass) resulted in a mean percentage excess 


63 

weight loss of 67.1% (P

have shown similar increases in employment and/or 

income after bariatric surgery. It should be noted that 

US law prohibits employment discrimination based on 

physical attributes that do not affect job performance. 

In both of the studies cited above, postoperative 

quality of life tended to decrease somewhat over the long 

term. Since HRQOL correlates with the degree of weight 

loss, this may simply reflect the well-known tendency of 

bariatric surgery patients to regain a modest portion of 

their lost weight after 2 years. In addition, it has been 

suggested that patients derive considerable psychological 

support from their postoperative visits and may experience 

an emotional downturn when those visits cease. 

At no time, however, did quality of life drop to the 

level of obese controls. Van Gemert and colleagues 

emphasized that this remained true even in patients who 

experienced significant surgical complications such as 

stoma stenosis or band erosion or disruption. Noting 

that other studies have also found surgical complications 

to be a nonissue, they commented: “The fact that 

patients with complications nevertheless experienced a 

significant improvement in quality of life compared with 

the control group highlights the severity of the mental 

and physical suffering ... before surgery. Apparently, 

these patients prefer a nonobese state with surgical complications 

over an obese state.” 13 

Matching patient and procedure 

A morbidly obese patient may be broadly matched to 

the most suitable bariatric procedure on the basis of several 

variables: 14 

1) BMI. Some bariatric procedures induce more 

weight loss than others. Patients with the highest BMIs 

may be guided to procedures that achieve the most 

weight loss (eg, biliopancreatic diversion with duodenal 

switch, long-limb Roux-en-Y gastric bypass). 

2) Age. Older patients (>40 years) may be candidates 

for the more definitive procedures (eg, biliopancreatic 

diversion, duodenal switch, and long-limb Rouxen-Y 

gastric bypass). Despite their complexity, increased 

operative risk, and long-term surgically induced morbidity, 

such procedures have a lower risk for failure and 

need for reoperation. 

3) Gender, race, and body habitus. Women may lose 

less weight after a given procedure than men. Similarly, 

African Americans and possibly Hispanics tend to lose 

less weight after a given procedure than Caucasians. 

Central (as opposed to peripheral) obesity in men and 

android (as opposed to gynecoid) obesity in women 


FAMILY 

PRACTICE 

appear to be associated with more comorbidities that 

increase operative risk. 

Patients in whom combined gender, race, and body 

habitus is ‘unfavorable’ are candidates for a more definitive 

operation. If combined status is ‘favorable,’ a simpler 

operation (eg, gastric banding) may be appropriate. 

4) Comorbidities. The patient with few serious preoperative 

comorbidities clearly has a better long-term 

prognosis than the patient with numerous serious 

comorbidities. They can be guided to a simpler, faster 

operation, despite the increased risk for subsequent revisional 

surgery. When comorbidities predict a poor longterm 

prognosis, a more definitive operation with a 

lower risk for reoperation is recommended. 

Conclusion 

Morbidly obese patients who elect to undergo bariatric 

surgery experience significant reductions not only of 

weight but also of obesity comorbidities, including diabetes, 

hyperlipidemia, hypertension, and obstructive 

sleep apnea, with resultant improved life expectancy. 

The quality of life of these patients also has been shown 

to improve. While bariatric surgical procedures differ 

with regard to degree of weight loss, short- and longterm 

morbidity, and need for revisional surgery, the data 

are difficult to interpret. Thus far, no single bariatric procedure 

has emerged as clearly superior to others. ■ 

REFERENCES 

1. Buchwald H, Williams SE. Bariatric surgery worldwide 2003. Obes Surg. 

2004;14:1157-1164. 

2. McTigue KM, Harris R, Hemphill B, Lux L, Sutton S, Bunton AJ, et al. 

Screening and interventions for obesity in adults: summary of the evidence for 

the U.S. Preventive Services Task Force. Ann Intern Med. 2003;139:933-949. 

3. Colquitt J, Clegg A, Sidhu M, Royle P. Surgery for morbid obesity (Cochrane 

Review). In: The Cochrane Library. Issue 3. Chichester, UK: John Wiley & 

Sons, Ltd; 2004. 

4. Torgerson JS, Sjöström L. The Swedish Obese Subjects (SOS) study—rationale 

and results. Int J Obes Relat Metab Disord. 2001;25(suppl 1):S2-S4. 

5. Buchwald H. Overview of bariatric surgery. J Am Coll Surg. 2002;194:367- 

375. 

6. Buchwald H, Buchwald JN. Evolution of operative procedures for the management 

of morbid obesity 1950-2000. Obes Surg. 2002;12:705-717. 

7. Pories WJ, Swanson MS, MacDonald KG, Long SB, Morris PG, Brown BM, 

et al. Who would have thought it? An operation proves to be the most effective 

therapy for adult-onset diabetes mellitus. Ann Surg. 1995;222:339-350. 

8. Sjöström CD, Peltonen M, Sjöström L. Blood pressure and pulse pressure during 

long-term weight loss in the obese: the Swedish Obese Subjects (SOS) 

Intervention Study. Obes Res. 2001;9:188-195. 

9. Sjöström CD, Lissner L, Wedel H, Sjöström L. Reduction in incidence of diabetes, 

hypertension and lipid disturbances after intentional weight loss induced 

by bariatric surgery: the SOS Intervention Study. Obes Res. 1999;7:477-484. 

10. Buchwald H, Avidor Y, Braunwald E, Jensen MD, Pories W, Fahrbach K, 

Schoelles K. Bariatric surgery: a systematic review and meta-analysis. JAMA. 

2004;292:1724-1737. 

11. Christou NV, Sampalis JS, Liberman M, Look D, Auger S, McLean AP, et al. 

Surgery decreases long-term mortality, morbidity, and health care use in morbidly 

obese patients. Ann Surg. 2004;240:416-423. 

12. Kolotkin RL, Meter K, Williams GR. Quality of life and obesity. Obes Rev. 

2001;2:219-229. 

13. van Gemert WG, Adang EM, Greve JW, Soeters PB. Quality of life assessment 

of morbidly obese patients: effect of weight-reducing surgery. Am J Clin Nutr. 

1998;67:197-201. 

14. Buchwald H. A bariatric surgery algorithm. Obes Surg. 2002;12:733-746. 



Before and after surgery: 

The team approach to management 


Director, Center for Nutrition and Weight Management 

Geisinger Health Care System 

Danville, Pa 

Despite impressive outcomes, bariatric surgery 

remains the treatment of last resort for morbid 

obesity. Among the patients who stand to benefit 

most are those who 1) have failed attempts at medical 

and lifestyle management or have been judged as unlikely 

to succeed at them and 2) have a body mass index 

(BMI) of 40 kg/m 2 or higher or a BMI of 35 to 40 kg/m 2 

and 1 or more of the following comorbidities: diabetes, 

hypertension, obstructive sleep apnea, cardiovascular disease, 

gastroesophageal reflux disease, degenerative joint 

disease, or steatohepatitis (fatty liver) (TABLE 1). 1-3 

Amelioration of comorbidities should be the primary 

goal when contemplating surgery. Indeed, in the severely 

obese patient, surgery is the only treatment that has been 

shown to cure or ameliorate many of these chronic medical 

conditions. 

In addition to the above criteria, potential candidates 

must be well-informed about bariatric surgery, 

motivated, and have realistic expectations. Operative 

risks must be acceptable, and patients should understand 

the ways in which their lives will change after the 

operation. They also should be prepared to accept longterm 

postsurgical follow-up. 

Contraindications to bariatric surgery include 

untreated major depression or psychosis, certain personality 

disorders (eg, bipolar, schizoaffective), active 

alcohol or drug abuse, and noncompliance with preoperative 

medical, nutritional, and psychologic management. 

Weight-loss surgery is no longer denied to 

patients older than 65 years; however, surgical risks may 

outweigh benefits in patients over 70 years of age. 

Bariatric surgery in children and adolescents 

remains controversial. Inge et al noted that surgery in 

severely obese teenagers (12-18 years) with significant 


associated medical conditions (metabolic syndrome, 

diabetes, obstructive sleep apnea, reactive airway disease, 

steatohepatitis) is safe and has resulted in resolution 

of comorbidities. 4 

Bariatric surgery programs and insurance carriers 

invariably insist that patients meet some or all of the 

above conditions. However, criteria vary from region to 

region and state to state, and it is therefore recommended 

that the family physician obtain specific inclusion 

and exclusion criteria from the patient’s insurance carrier 

before making a referral for bariatric surgery. 

Preoperative evaluation and care 

A comprehensive team approach to patient management 

is advocated by most bariatric surgeons and insurance 

carriers. An ideal team includes, at a minimum, 

representatives from 4 specialties: medicine, nutrition, 

psychology/psychiatry, and surgery. 5 The team evaluates 

the patient, treats conditions that require stabilization 

before surgery, and participates in postoperative education 

and management. In addition to providing optimal 

care in each area of expertise, team members should be 

able to communicate constructive insights to help the 

patient fully appreciate the lifelong lifestyle changes 

necessitated by bariatric surgery. 

Medical evaluation. To decrease perioperative 

morbidity, the medical professional whether a family 

physician, internist, endocrinologist, gastroenterologist, 

or cardiologist should ensure optimal preoperative control 

of such common comorbid conditions as hypertension, 

hyperglycemia, dyslipidemia, liver abnormalities, 

and sleep disorders. A modest preoperative weight loss 

of 5% to 10%, which is mandatory in many bariatric

surgery programs, is an effective intervention that can 

facilitate significant improvement in many comorbidities. 

A thorough physical examination and disease-specific 

testing are also recommended. Cardiovascular 

assessment, via a stress imaging study such as echocardiography 

or nuclear imaging, should be considered in 

patients older than 50 years and in those whose obesity-related 

comorbidities (especially diabetes, hypercholesterolemia, 

and hypertension) have been present for 

more than 10 years. Administration of dobutamine or 

adenosine often is needed to achieve target heart rates in 

patients with limited mobility. 

A 12-lead EKG should be performed to assess, 

among other things, for Q-Tc interval prolongation. 

Obese patients with acquired Q-Tc interval prolongation 

have increased risk for postoperative malignant 

arrhythmias. 6 

Sleep apnea is common in the severely obese, but is 

often overlooked or misdiagnosed as depression or 

chronic fatigue syndrome. A polysomnogram or, if it is 

not available, nocturnal pulse oximetry should be 

arranged for patients with loud snoring and documented 

apneic episodes, significant daytime somnolence, 

and/or early morning headache. 

A routine workup that includes complete blood 

count, liver function studies, and disease-specific serologies 

may be augmented by additional testing, such as 

right upper quadrant ultrasound to assess for cholelithiasis 

and liver size and steatosis, stool analysis for 

Helicobacter pylori antigen, and measurement of bone 

mineral density. 

Preoperative placement of an inferior vena cava filter 

may be considered in patients with a high risk for 

deep vein thrombosis and pulmonary embolism. 7 

However, prophylactic use of such filters needs to be 

validated by prospective, randomized trials. White et al, 

for example, found that a vena cava filter did not reduce 

the incidence of pulmonary embolism and, in patients 

with previous pulmonary embolism, it was associated 

with a higher incidence of rehospitalization for venous 

thrombosis. 8 

Nutritional evaluation. A registered dietitian or 

nutritionist is instrumental in preoperative weight-loss 

counseling and, to that end, will assess food intake and 

identify eating triggers such as emotional upset. 

TABLE 1 


FAMILY 

PRACTICE 

Indications and contraindications 

for bariatric surgery 

Indications 

• BMI ≥40 kg/m 2 

• BMI ≥35 kg/m 2 and high-risk comorbidity* 

• Failed attempts at behavioral and medical therapy † 

• Motivated, psychologically stable, realistic 

expectations 

• Understanding of procedure, acceptance of 

operative risks, and commitment to lifelong 

behavioral changes 

• Commitment to long-term follow-up 

• Supportive family environment 

Contraindications 

• Unacceptable medical risks 

• Unresolved alcohol or drug abuse 

• Depression, especially involving suicidal ideation 

• Hostile, uncooperative patient and/or family 

*Cardiopulmonary conditions (eg, sleep apnea, cardiomyopathy, 

pickwickian syndrome), type 2 diabetes, joint disease, and body-size 

problems that interfere with ambulation and employment. 

† Or judged as unlikely to succeed at behavioral and medical 

approaches to weight loss. 

Adapted from NIH Consensus Development Conference Panel2 and 

Mun et al. 3 

Counseling also includes repeated review of the progressive 

dietary stages that the patient will be expected to follow 

after surgery. Postoperatively, the dietitian/nutritionist 

will monitor the patient for adequate nutrient intake. 

Psychologic/psychiatric evaluation. Assessment 

of mental status should be done by a psychologist or 

psychiatrist who is familiar with the psychologic/emotional 

abnormalities common to the morbidly obese, as 

well as the ramifications of bariatric surgery. The focus 

of the mental health examination is on eating disorders/behaviors 

(binge eating, in particular), uncontrolled 

major depression, and personality disorders. 

The mental health professional also needs to confirm 

that the patient has realistic expectations of surgery 

and fully understands and accepts the postoperative 

lifestyle and behavioral changes that will be required. 

The strength of the patient’s support network is another 

important issue, given the high rates of marital and 



TABLE 2 

Potential complications after bariatric surgery 

Malabsorptive* Combined † Restrictive ‡ 

Wound infection ✔ ✔ ✔ 

Anastomotic leak ✔ ✔ ✔ 

Stomal stenosis ✔ ✔ ✔ 

Marginal ulcer ✔ ✔ ✔ 

Pouch dilation ✔ ✔ 

Staple failure ✔ ✔ 

Band migration/erosion ✔ 

Access port complications ✔ 

Thromboembolism ✔ ✔ ✔ 

Pulmonary embolism ✔ ✔ ✔ 

Nausea/vomiting ✔ ✔ ✔ 

Gallstones ✔ ✔ ✔ 

Dumping syndrome ✔ 

Gastroesophageal reflux disease ✔ 

Nutrient deficiency ✔ ✔ 

(iron, vitamin B 12 , calcium, protein) 

* Malabsorptive: biliopancreatic diversion, biliopancreatic diversion with duodenal switch. 

† Combined: gastric bypass, which has features of both intestinal malabsorption and gastric 

restriction but relies primarily on restriction for weight loss. 

‡ Restrictive: vertical banded gastroplasty, gastric banding. 

Adapted from Buchwald et al 21 and McTigue et al. 23 

family discord that occur after bariatric surgery. 

Surgical evaluation. After the medical, nutritional, 

and mental health evaluations have been completed and 

adequate metabolic control has been achieved, the 

patient is referred to the bariatric surgeon who also 

assesses the patient’s motivation and expectations. In 

addition, the surgeon discusses the risks and benefits of 

the various surgical approaches after which the most 

appropriate technique is selected. 

Support groups. Preoperative attendance of support-group 

meetings is mandatory in most bariatric 

programs. Here patients are exposed to other preoperative 

candidates as well as to patients who have 

undergone weight-loss surgery. Direct contact with 

postoperative patients is particularly beneficial, as it 

provides firsthand accounts of successful and less 

than successful adaptation to the behavioral and 

lifestyle changes. In larger bariatric programs, separate 

support groups often are created for patients 


undergoing malabsorptive procedures 

(eg, gastric bypass) and those 

assigned to restrictive procedures (eg, 

vertical banded gastroplasty, 

adjustable lap band) to accommodate 

differences in rate of weight loss and 

behavioral changes. 

Perioperative care 

Bariatric surgery today is a relatively 

safe endeavor with short hospital 

stays, the result by and large of specific 

improvements in surgical technique 

and general improvements in the surgical 

milieu, such as anesthesia and ventilation. 

9 A standard, comprehensive 

protocol that is designed to ensure 

early ambulation, aggressive pulmonary 

toilet, adequate pain control, 

and diligent blood glucose control will 

decrease perioperative morbidity and 

shorten length of stay. Depending on 

which surgical procedure was performed, 

patients are usually discharged 

1 to 7 days after surgery. 

Therefore, immediate and frequent 

postoperative follow-up by the 

bariatric team is essential to ensure 

adequate hydration and prompt detection of early postoperative 

complications (TABLE 2). 

Postoperative care 

As with preoperative care, postoperative care of the 

bariatric surgery patient is comprehensive in nature 

and best achieved with the team approach. 

Postoperative involvement of the medical, nutritional, 

mental health, and surgical team members maximizes 

the likelihood of achieving optimal weight loss and resolution 

of comorbidities. 

Early postoperative period 

Anastomotic leak. During the early postoperative 

period (1-4 weeks), leakage from the gastrojejunal, gastroduodenal, 

or jejunojejunal anastomosis may develop 

in patients undergoing malabsorptive procedures, such as 

Roux-en-Y gastric bypass or biliopancreatic diversion 

with duodenal switch. Because it is potentially life-threat

ening, this complication has been well publicized 

Reported frequencies in large series (≥2,000 patients) 

have ranged from 3%. 10,11 

Anastomotic leaks most commonly occur during a 

surgeon’s first 75 laparoscopic bypass procedures. 12,13 

The leak usually manifests while the patient is hospitalized; 

however, signs and symptoms may not appear 

until 7 to 14 days after surgery. The primary care physician 

should, therefore, be familiar with their signs and 

symptoms. 

The most sensitive signs of anastomotic leak are sustained 

tachycardia of >120 bpm. 14 Additional signs and 

symptoms include fever, shoulder pain (usually in the 

left), abdominal pain, shortness of breath, and respiratory 

rate of >22 bpm, increased thirst, and hypotension. 

When an anastomotic leak is suspected, the recommended 

workup includes a barium swallow or CT scan 

with contrast, complete blood count with differential, 

comprehensive metabolic panel, and chest X-rays (posterior-anterior 

and lateral). 

If diagnosed early, the leak can be managed conservatively 

without long-term sequelae in most cases. Early 

management typically involves total parenteral nutrition 

(NPO) and antibiotic therapy. Percutaneous 

drainage of any collection may be warranted to prevent 

abscess formation. In the unstable patient, surgical reexploration 

with repair, drainage, and G-tube placement 

may be indicated. 

Pulmonary embolism. In contrast to the anastomotic 

leak, pulmonary embolism is not widely publicized 

as a cause of death after bariatric surgery; nevertheless, 

it may be the most frequent cause of operative 

mortality (1-30 days). All patients are at risk for deep 

venous thrombosis/pulmonary embolism (DVT/PE) 

regardless of the procedure performed. Hence, aggressive 

prophylaxis is warranted. 15 

Definitive data on the incidence of pulmonary 

embolism after bariatric surgery are lacking; estimates 

place it at 2% to 4%. In a retrospective study of 

DVT/PE prophylaxis by Miller and Rovito, the 30-day 

incidence of pulmonary embolism was 1.2%. 15 

An effective prophylactic treatment regimen for 

DVT/PE consists of low-molecular-weight heparin 

administered intraoperatively and twice a day until discharge, 

lower extremity compression devices, and early 

ambulation. As mentioned, preoperative placement of 


FAMILY 

PRACTICE 

an inferior vena cava filter is an option in high-risk 

patients, such as those with a history of DVT/PE, clotting 

disorders, or significant venous stasis. 7 As with 

anastomotic leak, DVT/PE can occur as late as 2 weeks 

after surgery, so familiarity with the signs and symptoms 

is important. 

Nausea and vomiting. Intermittent nausea and 

vomiting often occur soon after bariatric surgery. The 

complication is by no means life-threatening but can be 

frustrating for the patient and primary care physician. 

Causes of nausea include dehydration, pain medication, 

administration of vitamins, pouch size, and eating too 

quickly, eating too much, or not chewing adequately. 

Patients who are unable to keep down fluids and solids 

for a 24-hour period should be evaluated for possible 

obstruction and/or dehydration. 

Nausea typically responds to rehydration and 

antiemetic medication administered orally, per rectum, 

or intravenously. Repeated administration of intravenous 

fluid may be necessary. 

Patients who are also vomiting need to be given 

thiamine/folate and a multiple vitamin in the intravenous 

infusion to prevent thiamine deficiency and 

Wernicke’s encephalopathy. The latter may occur after 

any gastric surgery. Often, administration of thiamine 

alone immediately alleviates nausea and vomiting. 

Repeated vomiting may cause pouch swelling and 

anastomotic narrowing, which, in turn, may exacerbate 

nausea and vomiting. In addition, pouch size and 

the angle of the anastomosis into the jejunum can contribute 

to emesis. In rare instances, total parenteral 

nutrition may be necessary until the patient can tolerate 

adequate oral feeding. 

Wound complications. Wound infection or cellulitis 

occurs in 5% to 20% of patients who undergo an 

open procedure. Management often requires no more 

than opening the incision and local packing. An extended 

course of antibiotic therapy may not be necessary. 

Other early complications. Diarrhea is frequent 

after bariatric surgery and may be caused by new onset 

(often temporary) lactose intolerance, which can be 

resolved with ezymatic therapy or withdrawal of dairy 

products. Other causes of diarrhea include occult ingestion 

of sugar contained in prescription and over-the- 



TABLE 3 

Selected medications that should be avoided 

after malabsorptive procedures 

Nonsteroidal antiinflammatory 

drugs 

Advil (ibuprofen) 

Aleve (naproxen) 

Anaprox (naproxen) 

Ansaid (flurbiprofen) 

Azolid (phenylbutazone) 

Bextra (valdecoxib) 

Butazolidin 

(phenylbutazone) 

Celebrex (celecoxib) 

Clinoril (sulindac) 

Dolobid (diflunisal) 

Excedrin IB (ibuprofen) 

Feldene (piroxicam) 

Ibuprin (ibuprofen) 

Indocin (indomethacin) 

Lodine (etodolac) 

Meclomen 

(meclofenamate) 

Midol IB (ibuprofen) 

Motrin (ibuprofen) 

Motrin-IB (ibuprofen) 

Nalfon (fenoprofen) 

Naprosyn (naproxen) 

Nuprin (ibuprofen) 

Orudis (ketoprofen) 

Oruvail (ketoprofen) 

Pamprin-IB (ibuprofen) 

Ponstel (mefenamic acid) 

Rexolate 

(sodium thiosalicylate) 

Tandearil 

(oxyphenbutazone) 

Tolectin (tolmetin) 

Voltaren (diclofenac) 

Barbiturate 

Fiorinal (butalbital/aspirin/caffeine) 

Salicylates 

Amigesic (salsalate) 

Anacin (aspirin) 

Arthropan 

(choline salicylate) 

Ascriptin 

(buffered aspirin) 

Aspirin (aspirin) 

Aspirtab (aspirin) 

Bufferin 

(buffered aspirin) 

Disalcid (salsalate) 

Ecotrin (aspirin) 

Uracel 

(sodium salicylate) 

Analgesics 

Darvon (propoxyphene) 

Equagesic 

(meprobamate/aspirin) 

Micrainin 

(meprobamate/aspirin) 

Percodan 

(oxycodone/aspirin) 

Marcolide antibiotics 

Biaxin (clarithromycin) 

E-Mycin (erythromycin) 

Eryped (erythromycin) 

Erythrocin (erythromycin) 

Robimycin (erythromycin) 

Zithromax (azithromycin) 

Tetracycline antibiotics 

Brodspec (tetracycline) 

Panmycin (tetracycline) 

Sumycin (tetracycline) 

Tetracap (tetracycline) 

Ketolide antibiotic 

Ketek (telithromycin) 

counter drugs, malabsorption or dumping syndrome, 

and Clostridium difficile colitis. 

More common than diarrhea, however, is constipation, 

which results from the high protein intake, 

decreased fruit and vegetable intake, and administration 

of narcotic pain medication after surgery. 

Metabolic management. Aggressive metabolic and 

medication management is crucial in all patients during 


the early postoperative period. Insulin requirements fall 

significantly immediately after weight-loss surgery, and 

other medications need to be reduced in dosage or withdrawn. 

In patients who were receiving preoperative 

antidiabetic therapy, oral glycemic agents should be 

replaced with sliding-scale, short-acting insulin. 

Similarly, antihypertensive medications should be 

reduced in dosage or discontinued and diuretics should 

be withheld. Antilipid agents also should be held during 

the early postoperative period, given their tendency to 

produce nausea in some patients. 

Essential medications should be administered in 

regular-release rather than sustained-release formulations 

to offset the altered gastrointestinal absorption 

that occurs after malabsorptive procedures. 

Moreover, patient tolerance of medications can be 

improved by crushing the tablets or giving a liquid 

formulation of the drug during the first 4 postoperative 

weeks. By the fifth week, bisecting the tablets is 

usually sufficient. 

Late postoperative period 

The most common late complications seen after Rouxen-Y 

gastric bypass are gallstones, stomal stenosis, and 

marginal ulcers. 16 Gallstones often develop after rapid 

weight loss, be it surgically or nonsurgically induced, 

For this reason, some surgeons opt for prophylactic 

cholecystectomy at the time of surgery. When 

cholelithiasis is documented on preoperative ultrasound 

or palpated intraoperatively, simultaneous 

cholecystectomy probably is warranted. 

Marginal ulcers and stomal stenosis occur in 10% 

of gastric bypass patients. Chronic use of aspirin, nonsteroidal 

anti-inflammatory agents, and some other 

medications has been associated with significantly 

increased risk for these complications. Therefore, the 

agents listed in TABLE 3 should be avoided after malabsorptive 

procedures. Marginal ulcers respond to 

treatment with proton pump inhibitors and stenosis of 

the gastrojejunostomy is readily dilated by an experienced 

endoscopist. 

Nutritional management 

Immediately after surgery, patients are placed on a 

sugar-free, clear-liquid diet, from which they progress 

slowly, as tolerated, to a prudent low-fat diet. Most 

comprehensive bariatric surgery programs have estab-

lished a series of specific diets 

with recommended stages of 

progression (TABLE 4). A 

variety of commercial supplements 

designed specifically 

for bariatric surgery patients’ 

postoperative needs contain 

the required vitamins, minerals, 

and protein and offer 

some convenience for postoperative 

nutrition. These formulations 

usually obviate the 

need for additional vitamin 

supplementation and its 

attendant risk of nausea. 

As mentioned, the most 

frequent cause of postoperative 

emesis is eating too quickly 

or too much or not chewing 

adequately. Patients should 

consume small frequent meals 

throughout the day and should 

not drink fluids for at least 1 

hour after eating. When fluids 

are permitted, carbonated beverages 

should be avoided. 

Patients with recurrent vomiting 

are at risk for pouch 

swelling and edema and 

should temporarily go back to 

clear- or full-liquid diet until 

symptoms abate. 

Dumping syndrome may 

occur in patients who undergo 

a combined restrictive/ 

malabsorptive procedure such 

as the Roux-en-Y gastric 

bypass. Dumping is the 

jejunum’s response to the 

rapid introduction of a large 

amount of undigested carbohydrate. 

Enteroglucagon and 

other gastrointestinal hormones 

cause an influx of fluid 

into the lumen of the small 

intestine, which is usually fol- 

TABLE 4 


FAMILY 

PRACTICE 

Recommended dietary stages after gastric bypass surgery 

STAGE 1: Water and sugar-free clear liquids 

Begin: 1 day after surgery Duration: 1 day 

Diet: 3 fluid oz (90 cc) of regular bouillon or diet Jell-O ® per meal, plus 3-5 oz of 

water or decarbonated (flat) diet ginger ale per hour between meals. Fluid intake 

should not exceed 8 oz/hour 

Fluid Goal: 32 oz/day (1 qt) 

STAGE 2: High-protein liquid supplements primarily 

Begin: 2 days after surgery or 24 hours after stage 1 was begun Duration: 4 weeks 

Diet: 8 oz of high-protein liquid supplement 2-3 times a day plus stage 1 beverages 

Fluid Goal: 48-64 oz/day Protein Goal: 60 gm/day minimum 

• Keep a food diary to track protein and fluid intake. 

STAGE 3: Soft-protein foods 

Begin: 4 weeks after surgery Duration: 4 weeks 

Diet: 3 oz of soft foods (no fruits, vegetables, or starchy foods) 3 times a day 

plus stage 1 beverages 


• Eat slowly; no more than 1 oz every 10 minutes. 

• If you feel full, stop eating; otherwise, vomiting can occur. 

• Continuous overeating will stretch your new pouch. 

• Do not consume foods and beverages at the same time. 

Wait 30 minutes before eating and another 60 minutes after 

eating before drinking fluids. 

• Avoid cold or hot liquids and foods that are high in sugar or fat; 

they cause dumping syndrome. 

• Continue food diary to track protein and fluid intake. 

STAGE 4: Low-fat, low-sugar foods 

Begin: Approximately 8 weeks after surgery Duration: Lifelong 

Diet: Use the Food Pyramid as a guide. Every day, try to eat 6 oz of meat or 

high-protein foods, 2 cups of milk products, 2-3 servings of grains or starch, 

2 servings of vegetables, and 2-3 servings of fruit. 


• Gradually introduce new foods to your diet 1 at a time. Go slowly 

with fresh fruits and vegetables. 

• If a food is not tolerated, wait 2-4 weeks before reintroducing it. 

• Consume protein at each meal. 

• Take at least 30-60 minutes to consume a typical meal, which should 

fit on a dish no larger than a salad plate. 

• Continue to keep a food diary to ensure adequate protein and 

fluid intake. 



TABLE 5 

Nutrient supplementation after gastric bypass surgery 

Recommended 

dosage Comments 

Iron 40-65 mg/day • 2 chewable multiple vitamin (with iron) 

tablets daily for the first month, then 

• 1 prenatal multiple vitamin or 2 

regular multiple vitamin (with iron) 

tablets daily 

Vitamin B 12 350 mcg/day • An additional 1,000 mcg IM every 1-3 

sublingually months, if necessary 

Folate 800-1,000 • Most multiple vitamin tablets contain 

mcg/day recommended dosage 

Calcium + Calcium: 1,200- • Calcium citrate preferred over calcium 

Vitamin D 1,500 mg/day carbonate, which is malabsorbed after 

Vitamin D: gastric bypass 

1,600 IU/day 

lowed by runny nose, excessive salivation, nausea, 

tachycardia, syncope or presyncope, vomiting, and 

diarrhea. 17 The small bowel gradually adapts to the 

anatomic changes of surgery, and dumping syndrome 

usually resolves in 6 to 12 months. Although uncomfortable, 

the syndrome provides valuable negative 

reinforcement for patients to avoid concentrated 

sweets and carbohydrates. 

Psychologic follow-up 

After surgery, patients need early and frequent contact 

with a psychologist or psychiatrist to address such 

issues as adjustment to behavioral and dietary 

changes, depression, marital/family discord, poor selfimage/esteem, 

and impaired coping mechanisms). 

Continued participation in support groups is beneficial 

and recommended. Many online support groups 

and chat rooms have appeared recently. Visiting such 

sites (eg, Association for Morbid Obesity Support at 

www.obesityhelp.com/morbid obesity/index.html) 

may help to reinforce goals of the bariatric program. 

Medical management 

Patients who have undergone a malabsorptive procedure 

require lifelong supplementation with vitamins and 


minerals, iron, vitamin B 12, 

and calcium with vitamin D 

(TABLE 5). 18 Gastric bypass 

patients should receive 40 to 

65 mg/day of iron, which 

can be obtained from most 

prescription prenatal vitamin 

supplements. Additional iron 

may be warranted, especially 

in menstruating women. 

Folate deficiency is rare 

after malabsorptive procedures. 

The recommended 

800 to 1,000 mcg/day of 

folate is generally contained 

in over-the-counter multiple 

vitamins. 

Vitamin B 12 deficiency 

occurs in about one-third of 

patients after malabsorptive 

surgery. An average dose of 

350 mcg/day of sublingual B 12 is recommended. 

Intramuscular injections of 1,000 mcg of B 12 every 1 

to 3 months may be warranted in some patients. 

Calcium with vitamin D is an important supplement 

that is often overlooked in gastric bypass 

patients. Calcium absorption, which occurs in the 

duodenum, is bypassed by the procedure, placing 

these patients at increased risk for osteoporosis. 

Calcium citrate (1,200-1,500 mg/day along with 

1,600 IU of vitamin D) is preferred over calcium carbonate. 

The pouch of gastric bypass patients contains 

fewer than the normal number of parietal cells, resulting 

in decreased acid secretion and accelerated 

absorption of calcium carbonate. 

Deficiencies of these essential nutrients can cause 

significant neurologic and metabolic disorders; therefore, 

annual serologic testing and measurement of 

bone mineral density is recommended. In patients 

with significant steatohepatitis or fibrosis at the time 

of surgery, a liver biopsy performed 12 to 24 months 

postoperatively will help assess progression or regression 

of disease. Similarly, follow-up polysomnogram 

should be considered to ensure resolution of obstructive 

sleep apnea. 

The ramifications of altered gut absorption for 

drug dosing extend well beyond the early postopera-

tive period. Adequate absorption of medication 

should be held in question at least until the jejunum 

has fully adapted surgical alterations. Measurement 

of blood drug levels may be necessary, particularly in 

patients receiving antiseizure, thyroid replacement, or 

antipsychotic medications, and dosages adjusted to 

achieve required therapeutic levels. In some cases, 

placement of a G-tube at the time of surgery is warranted 

to ensure adequate drug levels. 

Pregnancy should be avoided for 12 to 18 months 

after surgery. The altered absorption of essential nutrients 

and rapid weight loss confer an increased risk for 

neural tube defects and other perinatal complications. 

19,20 As with all medications, therapeutic blood levels 

of oral birth control pills cannot be assumed and 

additional birth control (eg, barrier methods, patches, 

or intramuscular injection) is necessary. 

Realistic expectations 

Weight loss after bariatric surgery ranges from 30% to 

90% of excess body-weight loss depending on the procedure 

performed. Even more important is amelioration 

of obesity-related comorbidities. A comprehensive 

meta-analysis by Buchwald et al showed that HbA 1c 

reverted to normal in 77% of patients with preoperative 

diabetes, blood pressure decreased to normal in 62% of 

patients, and obstructive sleep apnea resolved in 86%. 21 

A more detailed discussion of this study can be found 

on page 15. 

In a survey of 100 gastric bypass patients, some of 

whom had been followed for 20 years, Cook and 

Edwards found that patients with the most successful 

outcomes adhered to a strict regimen. The regimen 

included eating 5 small meals a day to avoid hunger, 

avoiding fluids for the first hour after eating, a daily 

intake of 60 oz of noncarbonated calorie-free beverages 

supplemented with calcium and vitamin B 12, sleeping an 

average of 7 hours a night, exercising 2.5 hours a week, 

and weighing themselves at least once a week. 22 

Summary 

Bariatric surgery can be a major effective component of 

comprehensive team management of morbid obesity, pro- 


FAMILY 

PRACTICE 

vided that the family physician gives serious consideration 

to both the bariatric program and surgical procedure. 

The family physician can be an integral member of 

the bariatric team who initiates patient selection, makes a 

referral to a program that includes medical, nutritional, 

psychologic, and surgical interventions, and participates 

in pre- and postoperative management. ■ 

REFERENCES 

1. Steinbrook R. Surgery for severe obesity. N Engl J Med. 2004;350:1075- 

1079. 

2. NIH Consensus Development Conference Panel. Gastrointestinal surgery 

for severe obesity. Ann Intern Med. 1991;115:956-961. 

3. Mun EC, Blackburn GL, Matthews JB. Current status of medical and surgical 

therapy for obesity. Gastroenterology. 2001;120:669-681. 

4. Inge TH, Krebs NF, Garcia VF, et al. Bariatric surgery for severely overweight 

adolescents: concerns and recommendations. Pediatrics. 

2004;114:217-223. 

5. Kushner RF. Roadmaps for clinical practice: Case Studies in Disease 

Prevention and Health Promotion. Assessment and Management of Adult 

Obesity: A Primer for Physicians (Booklet 7: Surgical Management). 

Chicago, Ill: American Medical Association; 2003. 

6. Papaioannou A, Michaloudis D, Fraidakis O, et al. Effects of weight loss on 

QTc interval in morbidly obese patients. Obes Surg. 2003;13:869-873. 

7. Ferrell A, Byrne T, Robison J. Placement of inferior vena cava filters in 

bariatric surgical patients: possible indications and technical considerations. 

Obes Surg. 2004;14:738-743. 

8. White RH, Zhou H, Kim J, Romano PS. A population-based study of the 

effectiveness in inferior vena cava filter use among patients with venous 

thromboembolism. Arch Intern Med. 2000;160:2033-2041. 

9. Christou N, Sampalis J, Liberman M, et al. Surgery decreases long term 

mortality, and health care in morbidly obese patients. Ann Surg. 

2004;240:416-424. 

10. Torgerson JS, Sjöström L. The Swedish Obese Subjects (SOS) study—rationale 

and results. Int J Obes Relat Metab Disord. 2001;25(suppl 1):S2-S4. 

11. Fernandez AZ Jr, De Maria EJ, Tichansky DS et al. Experience with over 

3,000 open and laparoscopic bariatric procedures: multivariate analysis of 

factors relalted to leak and resultant mortality. Surg Endosc. 2004;18: 

193-197. 

12. Schauer PR, Ikramuddin S, Hamad G, et al. The learning curve for laparoscopic 

Roux-en-Y gastric bypass in 100 cases. Surg Endosc. 2003;17: 

212-215. 

13. Nguyen N, Rivers R, Wolfe B. Factors associated with operative outcomes 

in laparoscopic gastric bypass. J Am Coll Surg. 2003;197:548-557. 

14. Hamilton EC, Sims TL, Hamilton TT, Mullican MA, Jones DB, Provost DA. 

Clinical predictors of leak after laparoscopic Roux-en-Y gastric bypass for 

morbid obesity. Surg Endosc. 2003;17:679-684. 

15. Miller MT, Rovito PF. An approach to venous thromboembolism prophylaxis 

in laparoscopic Roux-en-Y gastric bypass surgery. Obes Surg. 

2004;14:731-737. 

16. Nguyen N, Rivers R, Wolf B. Early gastrointestinal hemorrhage after 

laparoscopic gastric bypass surgery. Obes Surg. 2003;13:62-65. 

17. Kellum J, Kuemmerle J, O'Dorisio T, et al. Gastrointestinal hormone 

responses to meals before and after gastric bypass and vertical banded gastroplasty. 

Ann Surg. 1990;211:763-770. 

18. Elliot K. Nutritional considerations after bariatric surgery. Crit Care Nurs 

Q. 2003;26:133-138. 

19. Wittgrove A, Jester L, Wittgrove P, et al. Pregnancy following gastric bypass 

for morbid obesity. Obes Surg. 1998;8:461-466. 

20. Moore KA, Ouyang DW, Whang EE. Maternal and fetal deaths after gastric 

bypass surgery for obesity. N Engl J Med. 2004;351:721-722. 

21. Buchwald H, Avidor Y, Braunwald E, et al. Bariatric surgery: a systematic 

review and meta-analysis. JAMA. 2004;292:1724-1737. 

22. Cook C, Edwards C. Successful habits of long-term gastric bypass patients. 

Obes Surg. 1999;9:80-82. 

23. McTigue KM, Harris R, Hemphill B, et al. Screening and interventions for 

obesity in adults: summary of the evidence for the U.S. Preventive Services 

Task Force. Ann Intern Med. 2003;139:933-949. 



CME posttest | Answer form 

To receive CME credit for this activity, please visit www.jfponline.com where you can take the online posttest and receive credit. If 

you do not have Internet access, please complete the test below by circling the correct answer to each of the questions. Send your 

test with the completed registration form and program evaluation (on page 27) to: Office of CME, University of Cincinnati, PO Box 

670567, Cincinnati, OH 45267; Fax (513) 558-1708. 

1. What percentage of adults in the United States 

are obese? 

a. 19% 

b. 31% 

c. 43% 

d. 52% 

2. Which of the following bariatric surgical procedures 

is no longer used in the United States? 

a. Long-limb Roux-en-Y gastric bypass 

b. Vertical banded gastroplasty 

c. Biliopancreatic diversion 

d. Jejunoileal bypass 

3. The most commonly used bariatric surgical procedure is 

a. Laparoscopic Roux-en-Y gastric bypass 

b. Open Roux-en-Y gastric bypass 

c. Laparoscopic gastric banding 

d. Open gastric banding 

4. Which of the following statements about nonsurgical 

treatments for obesity is true? 

a. Maximum average weight losses range 

from 6 to 12 kg 

b. Noncompliance rates are about 50% 

c. Relapse rates approach 75% 

d. All of the above 

5. Which of the following antiobesity agents should be 

administered with caution in patients with hypertension? 

a. Sibutramine 

b. Orlistat 

c. All of the above 

d. None of the above 

6. Which of the following is a contraindication for 

bariatric surgery? 

a. Age 68 years 

b. Severe hypertension 

c. Schizoaffective disorder 

d. None of the above 


7. Gastric banding’s beneficial effects on weight and 

preoperative comorbidities have made it the best surgical 

solution for morbid obesity. 

a. True 

b. False 

8. A minimal 4-specialty team that manages bariatric 

surgery patients should include a 

a. Nutritionist 

b. Physical therapist 

c. Diabetologist 

d. Cardiologist 

9. According to the Buchwald meta-analysis, how many 

patients experience resolution of diabetes, hypertension, 

and/or hyperlipidemia after bariatric surgery? 

a. 50% to 60% 

b. 60% to 70% 

c. 70% to 80% 

d. 80% to 90% 

10. Nausea and vomiting after bariatric surgery may be 

caused by 

a. Dumping syndrome 

b. Vitamin supplements 

c. Inadequate mastication of food 

d. All of the above 

11. On average, how much does systolic blood pressure 

decrease when an obese patient loses 2 kg of 

weight? 

a. 0.6 mm Hg 

b. 0.8 mm Hg 

c. 1.0 mm Hg 

d. 1.2 mm Hg 

12. Aspirin should be avoided by patients who have 

undergone gastric banding. 

a. True 

b. False

Registration form (please print) 

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Program Evaluation 

Please circle the letter that best reflects your agreement with the statements below, using the following scale: 

a. Strongly disagree b. Disagree c. Agree d. Strongly agree e. Does not apply 


FAMILY 

PRACTICE 

1. The program objectives were fully met. 

2. The quality of the educational process (presentation 

a b c d e 

and information) was satisfactory and appropriate. a b c d e 

3. The educational activity has enhanced my professional effectiveness and improved my ability to: 

a. Treat/manage patients a b c d e 

b. Communicate with patients a b c d e 

c. Manage my medical practice 

4. The information presented was without promotional or 

a b c d e 

commercial bias. a b c d e 

5. The program level was appropriate. 

6. I intend to change my clinical practice as a result of 

a b c d e 

the information presented in this CME program. 

7. Suggestions regarding this material, or recommendations for future presentations: 

a b c d e 

For the Physician’s Recognition Award, you can claim only the time you 

actually spent on this educational activity. This cannot exceed the 

2.5 credits designated as the maximum allowable for this supplement. 

HOURS: MINUTES: 

ACTUAL TIME SPENT ON THIS ACTIVITY 

❚ To receive CME credit, return this page with your 

completed posttest (on page 26) to: 

Office of CME, University of Cincinnati, PO Box 670567, 

Cincinnati, OH 45267 

Fax: 513.558.1708 Tel: 513.558.7350 


A supplement to 


FAMILY 

PRACTICE 






surgery

Management of morbid obesity - The Journal of Family Practice

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