Last Exit Bypass

17. December 2008

Physicians are having a tough time with morbidly obese patients. Trials with conservative therapies mostly end with an even higher weight of the patient and an increasing health risk. The ultima ratio for people with a very high BMI: The stomach bypass.

Every other German citizen is overweight. More and more people suffer from a morbid obesity with a Body Mass Index (BMI) of more than 35. They cannot expect a long life because the resulting diseases such as high blood pressure, diabetes mellitus, dyslipidemia and cancer cut their life span drastically. For this format, conservative measures do not promise a weight reduction. A stomach bypass has to be taken into consideration here. Studies in Sweden and the US show that bariatric surgeries increase the chance of survival of pathologically obese patients drastically (NEJM 2007; 357: 741-751 and 753-761). And the weight loss is still significant 10 years after the bypass surgery.

Surgical technique controversial

During surgery, a small part of the stomach is connected with a loop of the small intestine thus bypassing the rest of the stomach, the duodenum and parts of the small intestine. Afterwards amounts of food and fat digestion are reduced. Even though today the more gentle laparoscopic surgery is the “golden standard”, the surgery still remains risky and irreversible. The serviceableness but also the risks of bypass surgeries were recently verified in a review of the studies in Clinical Evidence (Clin. Evid. 2008; 01: 0604). But it was not possible to clarify which surgical technique should be preferred. The proximal bypass results in a shorter intestine passage than the distal bypass with a longer digestion. Up to now, the latter method was associated with the chances of a higher loss of weight.

Shorter is better

Swiss surgeons at the Universitätskrankenhauses Zürich (university hospital Zurich) compared both surgical techniques and decided for the proximal bypass to be more advantageous making it first choice (British Journal of Surgery 2008; 95: 1375-1379). Half of about 50 patients had received the proximal, the other half the distal bypass. The BMI of originally 46 average sank to an average of 31.7 (31 percent) in the group with the proximal surgery over a period of about 4 years. Patients with a distal stomach bypass had a decrease to 33.1 (28 percent). However, the two surgical techniques vary in operation time and hospital stay significantly and were shorter in proximal surgeries.

Concomitant diseases vanish

Independently from the surgical method, Markus Müller and his colleagues came up with impressing figures of health improvement in their recent study. According to that, 29 patients suffered from hypertension. Two years after the surgery only seven patients still had the problem which equates to 76 percent less. Diabetes mellitus type 2 sank from 19 patients to two patients – a reduction of 90 percent. Prior to the surgery, 39 patients suffered from dyslipidemia. After the surgery, only 9 patients still suffered from increased blood fats, an equal to 77 percent less. Thus the normalization of metabolism is a considerable success of the bariatric surgery.

Complications common

Those results cannot belie that stomach bypass surgeries are full of risks. Even though no patient died due to the surgery, 29 complications were noted down in 27 of the patients, eleven of the group with a proximal bypass and 16 of those with a distal bypass. This required another twelve surgeries, two thirds on patients with a distal stomach bypass. 16 of the complications were early problems showing within the first 30 days after the surgery. Here both groups were affected equally. Eight wound infections, two each internal hernia, scar stricture and pulmonary embolism, one patient with secondary hemorrhage of the stapler suture and one more patient generated an abscess. 13 cases of long-term complications appeared after 48 months, especially internal hernia and anastomosis suture strictures. One patient with a distal bypass developed heavy protein malnutrition. Those long-term complications caused nine re-surgeries and three endoscopic dilatations.

Cost absorption might take a while

Often the stomach bypass surgery is the last chance for an almost regular life. Unfortunately not every health insurance company is willing to grant the surgery solely because of the BMI. First all conservative methods have to be exploited even though it is common knowledge that those methods usually do not help morbidly obese people.

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