It’s been six years since the last obesity theme issue in the Journal of the American Medical Association. What have we learned since then? Not much. That is demonstrated mostly by the fact that the 5 original investigations that are reported here are all about obesity surgery. Then there are 9 editorials, 1 about bariatric surgery, another about the obesity theme issue and the rest are rehashing of the non-surgery, losing fight against this monster. Perhaps the theme is the fact that we should stop talking about diet and exercise as the solution to obesity – or maybe not yet. One editorial, about exercise, deserves further discusion in my next column.
So what about surgery? Recently there has been a worldwide shift from Roux-en-Y gastric bypass, which makes a small stomach and there is a bypass of part of the small intestine, to sleeve gastrectomy, that is tecnically easier and involves resection of 70% of the stomach without intestinal bypass, because the weight loss is almost as good and there are maybe slightly fewer complications at least early on after sleeve gastectomy. Laparoscopic banding has turned out badly and is no longer done. The necessity of reoperation occurred in 22% of bypass and 16% after sleeve gastrectomy. That was mostly for internal hernias in the bypass surgery patients and terrible gastroesophageal reflux disease (GERD) in the sleeve gastrectomy customers. GERD is very common in obesity anyway but it is cured by bypass surgery and made worse by sleeve gastrectomy. Otherwise both types of surgery fixed the obesity and the complications of obesity other complications got better, especially type 2 diabetes, and people die significantly less after surgery than if they just keep trying whatever else.
So we can be reassured “that the rapid switch from Roux-en-Y gastric bypass to sleeve gastrectomy in the last decade has not been a therapeutic misadventure” like adjustable gastric banding was. If you start out with a big GERD problem, however, sleeve gastrectomy may not be the best idea and more differences in weight loss and overall success could still become more evident as we watch for longer than the approximately 5 years that these studies represent.
1. JAMA January 16, 2018; 319(3):203-316.