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Saturday, October 28, 2006

Bariatric surgery, the pro's and con's: is the procedure group both an efficacious treatment plan as well as a true reduction in mortality risk

I wrote this paper for my English 112 class. Jason, yes, it's me under my pseudonym here!


Purpose:Addressing the issues of the efficacy as well as risk of bariatric surgery in a manner which is accessible to lay persons preparing to undergo bariatric surgery as well as their families. Addressing the risk as well as benefit, the evidence presented proves the case that bariatric procedures most assuredly reduce cardiac and other co morbidity risks and is beneficial as a treatment for chronic morbid obesity. This paper will address these issues from both an evidenciary standpoint as well as a personal standpoint.

I will be addressing both physiological as well as psychological issues associated with morbid obesity and it's treatment. Evidence from sources such as the American Society for Bariatric Surgery, as well as a competent body of physicians, peer reviewed, and my personal on line journal will be presented to both document the issues and make my case.

Bariatric surgery, the pro's and con's: is the procedure group both an efficacious treatment plan as well as a true reduction in mortality risk

Before my surgery, I weighed in at 581 pounds, and was more or less wheelchair bound due to the fact that I could only walk about fifty feet without experiencing crushing chest pain. I had developed Type II Diabetes, and an enlarged heart as well as non healing wounds on both legs. Within 30 days after my surgery, I was off of the insulin and all cardiac medications. I experienced immediate relief of the comorbidities and was already seeing improvement in the condition of my legs due to better blood sugar management as well as an eighty five pound weight loss in the first thirty days. The benefit was already enormous, and included an enormous reduction in the risk of early death due to these comorbidities associated with obesity.

When you see the news and the current rash of horror stories in the news media concerning the complications that can occur after bariatric surgery, you have to wonder if it is worth it or not. Based on my personal experience, it is. I had the Roux-N-Y procedure performed on me on March 11, 2005 and in the last year and a half, I have succeeded in losing and keeping 352 pounds off my body. My activity levels are off the charts and essentially, I have a new lease on life. This paper will look at the evidence presented from both points of view and present the case that bariatric surgery is beneficial and in all honesty, the only truly effective long term solution to morbid obesity in the toolbox as things currently stand.

This is not to say that the surgery is without risk. What do the risks entail, you ask? The first risk is death during the procedure. This is quite rare, fortunately. The statistics nationally are about 1 person in 200 or 0.5% of the total number of patients undergoing this procedure annually(R Jones, personal communication, March 11, 2005). I acquired this particular statistic from my surgeon, Dr. Rosemarie Jones, with Carmel Surgical Specialists during my preparation for surgery. This is about the average for the surgical discipline, incidentally.

Post surgery, the risks are quite rare. Post surgical infection, wound leakage and other post surgical complications account for approximately a 10% total mortality rate after the procedure according to the American Society for Bariatric Surgery. This rate is the combined total of all of the possible complications, incidentally. The risk is actually quite low, overall.

Why are the risks actually lower than the perception presented by the news media? When a person is preparing for bariatric surgery, the process is grueling. This is all designed, of course to minimize the risk to the patient as well as determine if the patient is a candidate both clinically and psychologically. The Roux-N-Y procedure is a radical and irreversible procedure primarily done as a laparoscopic surgery and the patient has to be able to discipline themselves to follow the diet and hydration requirements as well as activity requirements or the consequences can be disastrous. The lifestyle and dietary changes are permanent.

To explain the procedure, what happens is this: the stomach is separated into two pieces. The top section is formed into a pouch about the volume of an egg. The small intestine is severed three feet below the stomach, and the lower section is attached to the upper stomach section. The upper three feet of small intestine and remaining stomach section are rejoined an additional three feet down on the small intestine, forming a Y. The treatment was originally used for repair of stomach ulcers, but surgeons noted marked weight loss after this surgery (American Society for Bariatric Surgery, 2001). The surgery has the net effect of bypassing approximately 90- 92% of the receptors for carbohydrates and sugars, hence one aspect of the enforced weight loss.

Due to the increased mobility from this weight loss, post surgery, the patient is better able to exercise. This has many benefits, not the least of which is the increase of cardiac health. As the strength of the heart increases, the cardiac output fraction increases and the heart rate at rest decreases. In addition, the peripheral circulatory system gains in both volume of flow capability and flexibility. The blood chemistry also changes in the patient’s favor, with a net reduction if both LDL and HDL cholesterol as well as saturated fats called triglycerides. The long term net effect is to greatly decrease the chances of coronary incident or coronary artery disease. The long term effect of obesity has demonstrated a direct correlation to early mortality due to MI (Myocardial Infarction) as compared to individuals with a normal BMI (Body Mass Index) (Romero-Corral, et al, 2006). This fact, along with the immediate reduction in other comorbidities, such as diabetes and hypertension, add up to less stress on the heart and other internal organs. There are other benefits as well.

Additional benefits include the simple fact that if you weigh less, there is less stress on your skeletal system. Morbidly obese individuals are clinically far more likely to require knee and hip replacements due to excess wear on the joints. They are far more prone to spinal problems due to asymmetric stress on the spine caused by body geometry issues. These skeletal issues are a major contributor to long term disability of the morbidly obese.

Another contributor to the co morbidity chain in the chronically morbidly obese is sleep apnea. This is a respiratory issue where the patient frequently stops breathing for a period of time multiple times per night. The respiration cycle stops until the blood oxygen saturation drops far enough to trigger the gasp reflex to restart the breathing. This has several long term effects on the body.

The first of these is simple anoxia. This is chronically low blood oxygen saturation. This puts enormous stress on every structure in the body on a cellular level. It also has the net effect of reducing the metabolism, which slows the body’s ability to heal, as well as the ability to even produce energy on the cellular level by shortening the body’s ability to utilize the Kreb Cycle (Oxidative Phosphorilosis) to produce energy. The Kreb, or Citric Acid Cycle is how the body processes nutrients to produce ATP in the high energy metabolism and requires oxygen. This is the basic stuff of life, how your cells remain functional (Shier, Butler, and Lewis, 2004). This reduces the patient’s endurance for exercise and further increases the tendency to obesity as well as reinforcing the low blood oxygenation due to reduced pulmonary capacity in relation to the body mass. This condition is called pulmonary insufficiency, and it is also a major co morbidity. It contributes to muscle damage and weakness, in both skeletal and cardiac muscles.

Sleep apnea is a major contributor to the condition known as an enlarged heart. With an apnea patient, one of the long term effects is a specific enlargement of the right ventricle of the heart, causing impaired cardiac output fraction and reduced capability to circulate the blood. This factor alone is one of the greatest causes of death outside of congestive heart failure or myocardial infarction. The reduction in body mass after the surgery greatly reduces or eliminates these problems. Sleep apnea has been documented by multiple studies as being caused by obesity and the reduction of body mass in most cases reduces or eliminates this entirely.

Another aspect of the complications caused by obesity is impaired kidney function, resulting from the combination of failure to get a full sleep cycle and a net reduction of the production of the controlling hormones that regulate the kidneys. This reduces the output of the kidneys, which also contributes to the associated congestive heart failure due to this reduced output. This causes a pooling of fluid in the thoracic cavity, reducing the efficiency of the heart and simultaneously reducing lung capacity. The reduced lung capacity contributes to the oxygenation problems, which increases the congestive heart failure, which reduces the kidney efficiency and the reduced lung capacity and additional mass contribute to worsening sleep apnea....I think you see the cycle.

In combination with the physical comorbidities, there is an associated deepening depression that goes with morbid obesity. This tends to contribute to eating more, due to the combination of seratonin imbalance and “comfort” eating. The depression is actually a symptom of the loss of control of your life as the weight gets more and more debilitating. The comfort eating is quite often a manifestation of the only issue of your life that you can control. This leads into another vicious circle, the heavier you get, the less control you have over your life, so you eat more. In addition there are other psychological factors

A Prime example of this would be the issue of guilt. You feel guilty for being so large. This is another area where comfort eating comes in. Eating stimulates hormones and endorphins. These neurochemicals make you feel better, temporarily at least. Then the guilt kicks in and you eat, feel better and feel guilty again. There is a sense of learned helplessness associated with the condition. The combination of physical and psychological issues is both devastating and lethal when you look at it from a long term survival perspective. To better understand the situation, there is a blogsite called The Amazing Shrinking Man (Leonard,2006), which addresses the long view, both before and after bariatric surgery,. This is my on line journal and it shows the progression, both the good and the bad, warts and all.

In addition to just performing surgery, there is a program of cognitive-behavioral therapy through education, group support and dietary training specific for post surgical life. This is provided free as aftercare and is available for the rest of your life. Your life is going to be far more rewarding, and far longer with the surgery than without it.

To summarize, the evidence clearly demonstrates that the risk of mortality during the surgery or from post surgical complications are greatly outweighed by the potential benefit. The associated risks of morbid obesity, whether through a psychological derivation, or physiological, are most assuredly life shortening in a drastic manner at best. Bariatric surgery is currently the only tool that has long term results in weight management and has fewer risks than a pharmacological approach (American Society for Bariatric Surgery, 2001). It has far greater efficacy than dieting, which contributes to weight issues and co morbidity due to weight swings caused by failure of the diet. Surgery shouldn't be considered as a first option, though. It should not be ruled out though, due to it's proven benefit and long term success rate.


Lopez-Jiminez, F, Bhatia, S, Collazo-Clavel, M, Sarr, M, & Somers, V (2005).

Safety and efficacy of bariatric surgery in patients with coronary artery disease..

Mayo Clinic Proceedings. 80, 1157-1162.

Karmali, AuthorS, & Shaffer, E (2005). The battleagainst the obesity epidemic:

is bariatric surgery the perfect weapon. Clinical and Investigative Medicine. 28, 147-156.

Romero-Corral, A, Montori, V, Somers, V, Korinek, J, Thomas, R, & Allison, T, Mookadam, F, Lopez-Jiminez, F (2006). Association of bodyweight with total mortality and with cardiovascular events in coronary artery disease: a systematic view of cohort studies. 368, 666- 678.

American Society for Bariatric Surgery, (November 29, 2001).

American Society for Bariatric Surgery. Retrieved October 6, 2006, from Rational for the surgical treatment of morbid obesity. Web site: http://www.asbs.org/html/rationale/rationale.html

Shier, D., Butler, J., & Lewis, R (2004). Holes Human Anatomy and Physiology,

10th Edition. Boston, Ma.: McGraw Hill.

© 2006 T Leonard

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