The surgical approach to morbid obesity

Rising demand for gastric bypass procedure keeps Yale surgeon busy and looking for reinforcements.

Americans spend $33 billion annually on products and services they believe will help them lose weight. The investment is usually a bad one, as sustained weight loss remains an elusive goal in an increasingly supersized nation. According to the U.S. Surgeon General, 61 percent of American adults are overweight or obese (as are 13 percent or more of children aged 6 to 19) and face a higher risk for diabetes, heart disease and other illnesses.

This may be why Robert L. Bell, M.D., HS ’01, is one of the busiest surgeons on the Yale faculty. Recruited in 2002 after a fellowship at the University of Maryland, Bell brought with him a minimally invasive procedure known as laparascopic gastric bypass, in which the surgeon uses special instruments to create a small gastric pouch, then attaches a y-shaped limb of small bowel to form the outlet to the intestines. After surgery the patient’s appetite is sated by very small amounts of food; a 50 to 80 percent loss of excess body weight is typical. The procedure is appropriate for patients who are morbidly obese—generally 100 to 400 pounds overweight—and for whom other methods of weight loss have failed.

Similar procedures were performed occasionally at Yale, as open surgery, about 15 years ago. Doing the bypass laparoscopically, while reducing complications and discomfort for patients, is relatively rare because of the elite skill level the procedure demands, said Robert Udelsman, M.D., M.B.A., chair of the Department of Surgery, who recruited Bell to Yale. Seeing someone perform the delicate operation guided only by video images amazes students and veteran surgeons alike. Bell, said Udelsman, “is of the Star Wars generation.” Speaking at grand rounds in September, Udelsman said Bell has a six-month waiting list and may soon be joined by a second surgeon. “It may be we’ll need seven bariatric surgeons,” Udelsman said. “I don’t know.” Patient interest in the procedure has soared nationally since NBC weatherman Al Roker lost more than 100 pounds following the surgery in 2002.

Pre- and postoperative care are as crucial as the surgery itself, said Bell, and are the factors that distinguish well-run programs. Each patient must be evaluated by a psychiatrist or psychologist and a dietician before being accepted as a candidate for surgery. All of Bell’s patients are what he terms “professional dieters” who have gone the traditional diet and exercise route many times without being able to shed weight permanently.

But for Bell’s patients, losing weight is a matter of health more than appearance. “You’re not going to be a size 2,” Bell tells them. His goal is to bring their weight down enough to reduce the health risks associated with obesity. Postoperative support is equally important. With less room to accommodate food, patients need to be sure that they are using the smaller gastric pouch to get adequate nutrition; otherwise protein deficiency and other complications can result.

Hunger is not a problem. “The brain is fooled into thinking that the body is in a full state,” said Bell. Levels of the appetite-stimulating hormone ghrelin, which spikes prior to a meal and dips after a meal, stay consistently low in gastric-bypass patients. This may hold some clue as to why these patients generally avoid the “yo-yo” dieting syndrome that plagues many who try to lose weight by nonsurgical means.

Acceptance of surgical treatment for obesity is growing, but societal preconceptions about obesity linger. “It truly is the last accepted form of bigotry,” Bell said. The simplistic assumption is that obese people are overweight because they are lazy and/or they eat too much, but science increasingly belies that idea. One of Bell’s colleagues is fond of giving the bariatric surgeon some advice on dealing with patients: why don’t you just tell them to eat less?

“Of course, he’s kidding,” said Bell. “Mostly.”

—Colleen Shaddox

When it comes to defining outcomes, caregivers and patients don’t always agree

Physicians often turn to a patient’s friends or family members to make a decision on medical treatment. But a Yale study has found that seriously ill elder patients and caregivers disagreed approximately 40 percent of the time over the acceptability of outcomes such as memory loss, physical impairment and chronic pain.

According to Terri R. Fried, M.D., lead author of a paper published in the Archives of Internal Medicine in September, this is “the first study that asked how acceptable different states of health would be as a result of treatment.” Fried, an associate professor of internal medicine (geriatrics) at the School of Medicine, said caregivers may not be representing patients’ desires.

Although approximately 60 percent of patient-caregiver pairs agreed on the acceptability of severe memory loss as an outcome, about 40 percent could not agree. An outcome of chronic pain generated 35 percent disagreement, and being bed-bound evoked 43 percent disagreement. Without treatment, patients faced further decline and death. The 193 patients in the study were over age 60 and seriously ill with cancer, congestive heart failure or chronic lung disease.

According to Fried, patients and their caregivers are often in denial about the illness and try to spare each other’s feelings. The failure to discuss difficult possibilities leaves caregivers ill-prepared to make treatment decisions for seriously ill patients.

Physicians must educate the patient about the course of the illness and the decisions that need to be made, Fried said. “Most patients do have strong views about the quality of life,” she said. “We need to translate that into choices that are useful in medical decision making, and that’s what we tried to do in the study.”

—Mary Anne Chute Lynch

Et cetera

Clozapine and diabetes risk

Patients taking the antipsychotic drug clozapine have a higher-than-average chance of developing diabetes, but recent research suggests that clinicians may not be finding at-risk patients.

In a study by Michael J. Sernyak Jr., M.D., HS ’91, professor of psychiatry, a screening of 121 patients taking clozapine—none previously diagnosed with diabetes—found that 23 percent showed elevated glucose levels, a frequent precursor to diabetes. The results suggested that a patient taking clozapine should be followed closely, said Sernyak, chief of psychiatry at the VA Connecticut Healthcare System in West Haven. Sernyak said that early intervention would reduce morbidity and the high costs of the complications of diabetes. The study was funded by the Department of Veterans Affairs and reported in May in The Journal of Clinical Psychiatry.

—John Curtis

Drugs and the adolescent brain

The adolescent mind that impels teenagers to dye their hair purple and go airborne on skateboards also makes them more vulnerable to drug addiction. According to an analysis by Yale researchers of more than 140 studies in the basic and clinical neurosciences, their stage of brain development is to blame. “Several lines of evidence suggest that sociocultural aspects particular to adolescent life alone do not fully account for greater drug intake,” said R. Andrew Chambers, M.D., assistant professor of psychiatry and lead author of the study published in June in The American Journal of Psychiatry. “And while we strongly suspect that genetic factors in individuals can lower the threshold of drug exposure required for ‘tripping the switch’ from experimental to addictive drug use,” Chambers said, “here we have a phenomenon where a neurodevelopmental stage common to virtually everyone, regardless of genetic make-up, confers enhanced neurobiological vulnerability to addiction.”

—Cathy Shufro


			Originally published in Yale Medicine, Winter 2004. Copyright © 2004 Yale University School of Medicine. All rights reserved.