MAY
The
American
Journal
1975
of Surgery VOLUME
129
NUMBER
5
EDITORIAL
Surgical Treatment of Obesity John M. Beal, MD, Chicago, Illinois
The surgical treatment of obesity has been the subject of numerous articles in recent years, and jejunoileal bypass is performed with increasing frequency throughout the country. The ready acceptance of this operation by many surgeons is striking. Perhaps the frequency with which obesity is encountered in our society and the fact that standard surgical technics are employed in this procedure are factors that contribute to the increasing popularity of intestinal bypass surgery. In addition, the treatment of extreme obesity by dietary restriction has been of notoriously limited success. Recently, a competent general surgeon, well qualified in gastrointestinal surgery, sought information concerning the selection of patients for jejunoileal bypass and the precise technic recommended. This inquiry was stimulated by a patient who seemed to fulfill the criteria for morbid obesity and who desired surgical therapy. The surgeon asked for this information with the objective of performing the operation himself, although he had no previous experience in this particular.field. Reprint requests should be addressed to John M. Beal. MD, Medical School, Northwestern University, 303 East Chicago Avenue, Chicago, Illinois 606 11.
Volume 129, May 1975
The selection of patients for operations for obesity has varied widely. Some clinics have performed jejunoileal bypass procedures in patients who were 5 feet, 2 inches in height and 165 pounds in weight. Others have limited the operations for obesity to patients whose weight exceeded three times the ideal weight according to life insurance tables. Despite the obvious enthusiasm of many for this therapeutic approach to obesity, there remains the basic concern about therapy that is not directed at the cause of a problem. The surgeon must produce a pathophysiologic abnormality of the gastrointestinal tract to correct a metabolic disorder that frequently is the result of a basic psychologic disorder. Furthermore, the outcome of intestinal bypass procedures is not always satisfactory. Complications and death may result from technical mishaps directly related to the intestinal anastomoses. Serious metabolic consequences are being reported, including hepatic failure, renal calculi, and hyperuricemia, the result of metabolic alterations. Diarrhea and electrolyte imbalance are well known difficulties after operation. Psychologic disturbances also may appear.
493
The surgeon is often confronted with a patient who is seeking the operation as relief from the consequences of obesity. Many of these patients hope to find a panacea that will permit unlimited intake of food without concern about weight gain. Although it is apparent that intestinal bypass operations have benefited many obese patients, unexpected and unpredictable complications occur, and the ultimate place of this procedure in the therapy of obesity is uncertain, To gain objective criteria for the selection of patients, maximal safety during the operative procedure, and careful follow-up study, it seems logical that intestinal bypass operations should be performed in carefully controlled circumstances in medical institutions where adequate numbers of patients can be treated and followed up on a continuing basis. The selection of patients probably should be made by a panel of physicians with special interests in obesity; optimally this panel would include a psychiatrist, as well as a gastroenterologist and a physician with metabolic expertise. There is a problem of more fundamental significance concerning such operations. Physicians have a responsibility to patients that the treatment proposed is sound and is a reasonable approach to the disease from which the patient is suffering. The onus placed on surgeons is often particularly difficult. Not only must the surgeon select the appropriate procedure for the problem to be treated, but
494
also he must consider the morbidity and mortality rates, which are often related to the frequency with which he performs a particular operation. This principle is emphasized in determining the need for cardiac surgery when high risk surgical procedures are involved. In order to maintain competent performance and technical expertise, the Inter-Society Commission for Heart Disease Resources has recommended that an annual case load of 200 open heart procedures should be assured to qualify a cardiac surgery center. It seems appropriate to apply similar standards to other highly technical and hazardous procedures, as well as to operations that are in a developmental stage. The goal must be to provide maximal safeguards to the patient while accurate assessment of the therapeutic results is obtained. Complicated gastrointestinal operations of high risk, such as pancreaticoduodenectomy, and procedures that are technically demanding and associated with profound physiologic consequences are not optimally performed by surgeons who use them only occasionally. Rather, complex surgical procedures of this type should be undertaken in hospitals where similar complicated operations are frequently performed and where the more sophisticated ancillary facilities are available to assess the results effectively, particularly when criteria for selection of patients and procedures are uncertain and changing.
The
American
Journal
1975
of Surgery VOLUME
129
NUMBER
5
EDITORIAL
Surgical Treatment of Obesity John M. Beal, MD, Chicago, Illinois
The surgical treatment of obesity has been the subject of numerous articles in recent years, and jejunoileal bypass is performed with increasing frequency throughout the country. The ready acceptance of this operation by many surgeons is striking. Perhaps the frequency with which obesity is encountered in our society and the fact that standard surgical technics are employed in this procedure are factors that contribute to the increasing popularity of intestinal bypass surgery. In addition, the treatment of extreme obesity by dietary restriction has been of notoriously limited success. Recently, a competent general surgeon, well qualified in gastrointestinal surgery, sought information concerning the selection of patients for jejunoileal bypass and the precise technic recommended. This inquiry was stimulated by a patient who seemed to fulfill the criteria for morbid obesity and who desired surgical therapy. The surgeon asked for this information with the objective of performing the operation himself, although he had no previous experience in this particular.field. Reprint requests should be addressed to John M. Beal. MD, Medical School, Northwestern University, 303 East Chicago Avenue, Chicago, Illinois 606 11.
Volume 129, May 1975
The selection of patients for operations for obesity has varied widely. Some clinics have performed jejunoileal bypass procedures in patients who were 5 feet, 2 inches in height and 165 pounds in weight. Others have limited the operations for obesity to patients whose weight exceeded three times the ideal weight according to life insurance tables. Despite the obvious enthusiasm of many for this therapeutic approach to obesity, there remains the basic concern about therapy that is not directed at the cause of a problem. The surgeon must produce a pathophysiologic abnormality of the gastrointestinal tract to correct a metabolic disorder that frequently is the result of a basic psychologic disorder. Furthermore, the outcome of intestinal bypass procedures is not always satisfactory. Complications and death may result from technical mishaps directly related to the intestinal anastomoses. Serious metabolic consequences are being reported, including hepatic failure, renal calculi, and hyperuricemia, the result of metabolic alterations. Diarrhea and electrolyte imbalance are well known difficulties after operation. Psychologic disturbances also may appear.
493
The surgeon is often confronted with a patient who is seeking the operation as relief from the consequences of obesity. Many of these patients hope to find a panacea that will permit unlimited intake of food without concern about weight gain. Although it is apparent that intestinal bypass operations have benefited many obese patients, unexpected and unpredictable complications occur, and the ultimate place of this procedure in the therapy of obesity is uncertain, To gain objective criteria for the selection of patients, maximal safety during the operative procedure, and careful follow-up study, it seems logical that intestinal bypass operations should be performed in carefully controlled circumstances in medical institutions where adequate numbers of patients can be treated and followed up on a continuing basis. The selection of patients probably should be made by a panel of physicians with special interests in obesity; optimally this panel would include a psychiatrist, as well as a gastroenterologist and a physician with metabolic expertise. There is a problem of more fundamental significance concerning such operations. Physicians have a responsibility to patients that the treatment proposed is sound and is a reasonable approach to the disease from which the patient is suffering. The onus placed on surgeons is often particularly difficult. Not only must the surgeon select the appropriate procedure for the problem to be treated, but
494
also he must consider the morbidity and mortality rates, which are often related to the frequency with which he performs a particular operation. This principle is emphasized in determining the need for cardiac surgery when high risk surgical procedures are involved. In order to maintain competent performance and technical expertise, the Inter-Society Commission for Heart Disease Resources has recommended that an annual case load of 200 open heart procedures should be assured to qualify a cardiac surgery center. It seems appropriate to apply similar standards to other highly technical and hazardous procedures, as well as to operations that are in a developmental stage. The goal must be to provide maximal safeguards to the patient while accurate assessment of the therapeutic results is obtained. Complicated gastrointestinal operations of high risk, such as pancreaticoduodenectomy, and procedures that are technically demanding and associated with profound physiologic consequences are not optimally performed by surgeons who use them only occasionally. Rather, complex surgical procedures of this type should be undertaken in hospitals where similar complicated operations are frequently performed and where the more sophisticated ancillary facilities are available to assess the results effectively, particularly when criteria for selection of patients and procedures are uncertain and changing.
