Bariatric and Metabolic Surgery, An Issue of Surgical Clinics

Shanu Kothari

Description

A comprehensive review of bariatric and metabolic surgery for the general surgery! Topics include: The obesity epidemic/economic impact and diabetes epidemic/economic impact, physiology of obesity/diabetes, physiology of weight loss surgery, history of bariatric surgery, laparoscopic adjustable gastric banding, sleeve gastrectomy, biliopancreatic diversion/duodenal switch, laparoscopic gastric bypass, complications of laparoscopic adjustable gastric binding, complications of laparoscopic gastric bypass, outcomes/comparative effectiveness studies, co-morbidity reduction data, economic impact of bariatric surgery, adolescent bariatric surgery, revisional bariatric surgery, the future of bariatric surgery, and more!

Sujets

• Medical
• Médecine
• Surgery

Informations

• Publié par: Saunders
• Date de parution: 28 décembre 2011
• Nombre de lectures: 0
• EAN13: 9781455712137
• Langue: English
• Poids de l'ouvrage: 1 Mo

Extrait

Surgical Clinics of North America , Vol. 91, No. 6, December 2011
ISSN: 0039-6109
doi: 10.1016/S0039-6109(11)00134-4

Contributors
Surgical Clinics of North America
Bariatric and Metabolic Surgery
GUEST EDITOR: Shanu N. Kothari, MD, FACS
Department of General and Vascular Surgery, Gundersen Lutheran Health System, 1900 South Avenue, La Crosse, WI 54601, USA
CONSULTING EDITOR: Ronald F. Martin, MD
ISSN  0039-6109
Volume 91 • Number 6 • December 2011

Contents
Cover
Contributors
Forthcoming Issues
Bariatric and Metabolic Surgery
Bariatric and Metabolic Surgery
Tipping the Balance: the Pathophysiology of Obesity and Type 2 Diabetes Mellitus
Physiology of Weight Loss Surgery
Epidemiology and Economic Impact of Obesity and Type 2 Diabetes
The Economic Costs of Obesity and the Impact of Bariatric Surgery
The History and Evolution of Bariatric Surgical Procedures
Surgical Treatment for Morbid Obesity: The Laparoscopic Roux-en-Y Gastric Bypass
Complications of Laparoscopic Roux-en-Y Gastric Bypass
Evolution of Laparoscopic Adjustable Gastric Banding
Complications of Adjustable Gastric Banding
Sleeve Gastrectomy
Biliopancreatic Diversion with Duodenal Switch
Impact of Bariatric Surgery on Comorbidities
Bariatric Surgery Outcomes
Adolescent Bariatric Surgery
Revisional Bariatric Surgery
Future Directions in Bariatric Surgery
Index
Surgical Clinics of North America , Vol. 91, No. 6, December 2011
ISSN: 0039-6109
doi: 10.1016/S0039-6109(11)00136-8

Forthcoming Issues
Surgical Clinics of North America , Vol. 91, No. 6, December 2011
ISSN: 0039-6109
doi: 10.1016/j.suc.2011.09.002

Foreword
Bariatric and Metabolic Surgery

Ronald F. Martin, MD
Department of Surgery, Marshfield Clinic, 1000 North Oak Avenue, Marshfield, WI 54449, USA
E-mail address: [e-mail]


Ronald F. Martin, MD, Consulting Editor

The greater danger for most of us lies not in setting our aim too high and falling short; but in setting our aim too low, and achieving our mark.
— Michelangelo
It would seem to me that many of the major problems we face at all levels of society essentially involve a disagreement of how to distribute something; perhaps money, perhaps power (usually related to money), perhaps food, perhaps some natural resource such as petrochemicals or rare earth metals, or maybe even education. It doesn’t really matter where you go, people seem to disagree, often fiercely and fundamentally, about who deserves what and who should pay for it or provide it. One can see it in our local communities, or watch it on television, or go to some remote village in Iraq or valley in Afghanistan or impoverished city in the Horn of Africa. It’s all the same—people arguing and jockeying for position of control over something that is limited in availability, or at least perceived to be limited or valuable.
Then we have obesity. Actually, we have an epidemic of obesity. We have an epidemic of a disease of excess that is subsequently causing a shortage of resources—ironic, really. The contributors to this issue very nicely review the basis of this problem as well as some of its societal implications and provide a sound foundation for our current solutions such as they are. I commend any surgeon to read these reviews carefully as this is material that any surgeon, in particular any general surgeon, needs to be facile with whether she or he performs these operations or doesn’t.
From a surgical standpoint, bariatric surgery is a bit of an intellectual enigma. We take perfectly working anatomy and physiology and we derange it to a point where we hope it solves the problem of calorie intake and absorption excess. All the while hoping that the problem we create, while solving the problem we encountered, won’t overshoot the target and cause starvation or create some new problem as a result of altered anatomy, like, for example, lose endoscopic access to the foregut for future concerns.
As a person responsible for training other surgeons, bariatric surgery presents me with other dilemmas as well. No matter how much of it one does, it doesn’t help one become that much better at dealing with most other surgical problems. I can feel the backlash as I type this from some people but I’ll let them write their own opinions. I’ll grant you that one can develop better laparoscopic skills under some challenging situations and that is a plus. Also, one can see what happens when one’s best performed technical efforts go awry—also a good learning experience. But the incremental benefit for diagnosing problems and understanding pathophysiology becomes fairly minimal after managing a few patients such as these. Largely due to the successful development of these procedures and the ample supplies of candidates for them, we have created an almost assembly-line approach to bariatric operations. And while that is necessary and good for the bariatric patient, it isn’t necessarily all that useful for surgical education.
I hate to turn the conversation back to money but it is pretty near impossible not to do so. We physicians are an adaptable and creative bunch. If the people who pay us say they will reduce the unit reimbursement for something, then we crank up the utilization rates to make up for it. Then we have the “Well, if you think I am expensive, try the alternative argument.” And it’s a good argument; take, for example, renal transplant versus continued dialysis—good argument, financially. In particular regard to obesity surgery, some say these operations cost too much and some say it is cheap compared to treating diabetes and hypertension and obstructive sleep apnea and replacing joints. And both sides are right. The fact remains that we will much more likely pay for solutions to the problem of obesity than the prevention.
At this moment the big economic question facing us is, are we coming out of a recession or going into a double-dip recession? Some might even argue that there is an actual depression but I’ll leave that to the economists to argue. No matter how you classify it, money is tight and getting tighter for the foreseeable future. Many clamor that health care costs have to be cut. Well they do, but doing it now would be really pretty counterproductive. Health care is one of the few “nongovernment” sectors of the economy that didn’t tank. A ten percent reduction in health care spending all of a sudden would create an almost two percent reduction in gross domestic product: that would put huge brakes on any recovery or initiate a depression and it would further worsen the unemployment situation as most health care jobs in the United States are not readily outsourced and would mostly solely affect American workers. So while health care costs need to come back on line with reality as a percent of our total spending, especially value for costs, today just isn’t the right time for that to happen. The passion to cut health care costs makes for good politics until you actually have to tell someone what goes away.
Obesity as a disease gives us a real chance to look in the mirror and see who we are (please forgive the metaphor). It shows us how our view of this disease is markedly altered by the prism through which we look. And it tells us how we respond to incentives—both as physicians and as patients. If you make your living as a bariatric surgeon, the obesity epidemic is the job security dreamscape. If you make your living as a grocer or a restaurateur, same deal. If you are a government planner, an insurance executive, health care administrator, or a physician who plans on practicing medicine in a capitated world—it is a real nightmare scenario; a disease that increases consumption on both sides of the scales, takes a long time to grow, and doesn’t kill people quickly.
If ever there were a problem that we should look at from a pan-societal viewpoint, obesity is it: from childhood education, to food distribution, to early screening and management, to research and development into satiety and metabolism, to policy on funding and reimbursing for prevention and for treatment, and even for civil engineering and design to make our communities more conducive to human propulsion and less dependent on motorized propulsion.
As I said, it is hard to reconcile, at least for me, that in a world suffering from so much need that one of our biggest challenges is a disease of excess. My personal intellectual challenges aside, the case remains that it is true. As for us surgeons, we must once again do what we must to understand the disease and understand the role it plays and that we play in society. We must also do what we can to put ourselves out of business as much as possible with regard to obesity as we have with trauma and other diseases—realizing that we are at no risk for becoming completely unemployed as a result of our efforts to reduce the public’s need for us. I suggest that we aim for a higher goal than just becoming proficient at the technical aspects of managing obesity. We need to lead the way out of this problem altogether.
The best tool to be an effective part of the solution to any problem is always a good knowledge of the fundamentals. Dr Kothari and his colleagues have provided us with an excellent review in this issue of the Surgical Clinics of North America. Once informed, we can all decide how to proceed with that information. As always, your r