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Medical and Surgical Management, and Implications for the Practicing Gastroenterologist

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Medical and Surgical Management, and Implications for the Practicing Gastroenterologist UCSF UC San Francisco Previously Published Works Title Morbid obesity-the new pandemic: medical and surgical management, and implications for the practicing gastroenterologist. Permalink https://escholarship.org/uc/item/8pw8k8v6 Journal Clinical and translational gastroenterology, 4(6) ISSN 2155-384X Authors Cello, John P Rogers, Stanley J Publication Date 2013-06-06 DOI 10.1038/ctg.2013.6 Peer reviewed eScholarship.org Powered by the California Digital Library University of California Citation: Clinical and Translational Gastroenterology (2013) 4, e35; doi:10.1038/ctg.2013.6 & 2013 the American College of Gastroenterology All rights reserved 2155-384X/13 www.nature.com/ctg CLINICAL/NARRATIVE REVIEW Morbid Obesity—The New Pandemic: Medical and Surgical Management, and Implications for the Practicing Gastroenterologist John P. Cello, MD1 and Stanley J. Rogers, MD1 The gastroenterologist, whether in academic or clinical practice, must face the reality that an increasingly large percentage of adult patients are morbidly obese. Morbid obesity is associated with significant morbidity and mortality including enhanced morbidity from cardiovascular, cerebrovascular, hepatobiliary and colonic diseases. Most of these associated diseases are actually preventable. Based on the 1991 NIH consensus conference criteria, for most patients with a body mass index (BMI ¼ weight in kilograms divided by the height in meters squared) of 40 or more, or for patients with a BMI of 35 or more and significant health complications, surgery may be the only reliable option. Currently in the United States, over 250,000 bariatric surgical procedures are being performed annually. The practicing gastroenterologist in every community, large and small, must be familiar with the various surgical procedures together with their associated anatomic changes. These changes may dramatically increase the prevalence of nutritional deficiencies and profoundly alter the clinical and endoscopic approaches to diagnosis and management. Clinical and Translational Gastroenterology (2013) 4, e35; doi:10.1038/ctg.2013.6; published online 6 June 2013 Subject Category: Clinical Review INTRODUCTION is Ztwice ideal body weight and/or 100 pounds or more overweight. Body mass index (BMI) is commonly used to Over 100 million adult Americans are currently overweight or describe the status of weight. BMI is calculated as weight in obese. It has been widely recognized by physicians, kilograms divided by the height in meters squared (m2). An insurance adjusters, nutritionists and the public at large overweight individual has a BMI between 25 and 29.9 kg/m2. that these patients are at increased risks for hypertension, Obesity is defined as a BMIZ30 kg/m2. The prevalence of type II diabetes, coronary artery disease, gallbladder hypertension is virtually linearly related to the BMI as is disease, certain cancers (colon, ovarian, breast), dyslipide- diabetes, lumbosacral spine disease, chronic cholecystitis mia, cerebral vascular disease, osteoarthritis and sleep and an excess use of five or more healthcare specialists. apnea. The pandemic in the United States and indeed around Coronary artery disease is especially prevalent among obese the globe has spread dramatically.1–5 In 1988, for example, men, with a prevalence of 44% in men over the age of 50 years there were only 19 states with an adult obesity prevalence with a BMI of 30 kg/m2 or more. of 10–14%. In 1994, however, there were 16 states with a prevalence of adult obesity of 15–19% and 34 states with 10–14% prevalence of obesity. In the year 2000, there were 22 states in which the prevalence of obesity wasZ20%, 27 MEDICAL OPTIONS states with 15–19% obesity and only 1 state with a preva- The average overall efficacy of an unsupervised rigorous lence of 10–14% obesity. In the second decade of the new weight-loss program is about 20 kg/year. Other options millennium, the reality for the gastroenterologist is that a large typically used by patients outside of medical supervision and increasing percentage of patients are obese, a disease include support groups, behavior modification, specialized that is associated with significant morbidity and mortality, and structured diets, and non-medically supervised very-low most of these associated deaths are actually preventable. The calorie diets. Commercial options cost consumers billions of problem for all of us is the extraordinary healthcare costs. dollars annually and do produce definite though transiently There are estimated between 250 and 300 billion dollars positive results. Several unorthodox methods including bulimia, annually spent on conditions directly related to obesity. purging, starvation diets or even jaw wiring are considered Obesity is by definition an excess storage of fat. The hazardous to a patient’s health. Additionally, prescription medical definition of morbid obesity is a patient whose weight pharmacological agents are available; however some of these, 1Division of Gastroenterology, Department of Medicine, University of California, San Francisco, San Francisco, California, USA Correspondence: John P. Cello, MD, Division of Gastroenterology, Department of Medicine, University of California, San Francisco, 3D-GI Unit, 1001 Potrero Avenue, San Francisco, California 94110, USA and SJ Rogers, Division of General Surgery, Department of Surgery, University of California, San Francisco, San Francisco, 521 Parnassus Avenue, Rm. C-341, Surgery, San Francisco, California 94143, USA. E-mail: [email protected] and [email protected] Received 10 January 2013; accepted 6 March 2013 Morbid Obesity—The New Pandemic Cello and Rogers 2 including thyroid derivatives and amphetamines, are not surgical options and their different benefits and potential licensed for bariatric use and should not be used. problems. Since most non-surgical programs fail in the long In general, drugs that can treat obesity work through three term, patients are becoming increasingly interested in surgery different mechanisms: appetite suppression, increased meta- as more effective and durable. Patients know these options bolism of dietary nutrients, and interference with the routine often by information accessible on the internet, and clinicians absorption of ingested nutrients.6–12 Multiple single-agent must be vigilant in keeping up to date with these options. drugs are in later stages of development, including Contrave, Bariatric surgery introduces several unique issues to the Empatic, Qnexa, and an injectable combination of leptin and practicing internist and gastroenterologist, and knowledge of pranlintide. Qnexa has recently been approved by the FDA as these must be gained to adequately address the increasing an adjunct to dietary control in patients with a BMI 30 kg/m2. proportion of the patient population who have had bariatric This is a combination of two drugs including phentermine and surgery. topiramate. An application was recently rejected by the FDA for a novel 12 drug used outside the United States called Rimonabant. It is SURGICAL OPTIONS FOR MORBID OBESITY— a selective cannabinoid receptor-1 blocker, and its major side MULTIDISCIPLINARY APPROACH NECESSARY effect is vacillating mood disorders. Unfortunately, it has only a limited efficacy with a 4–5 kg additional weight loss over that It is quite clear from past experience that patients should be achieved with a 1,500 calorie/day diet alone. carefully screened in a multidisciplinary manner before being Orlistat, currently the only approved medication for obesity, considered acceptable candidates for surgery for morbid is a pancreatic lipase inhibitor that costs about $200 per obesity. Unfortunately, limited screening may be undertaken month. Given its pharmacological mechanism of action, by the patient who seeks surgery at sites remote from the untoward side effects of steatorrhea, diarrhea, cramping and community physicians who will be ultimately caring for the flatulence are common. The overall efficacy is marginal patient. The disciplines that routinely should be involved in however. Patients only lose an additional 3–4 kg/year with providing these patients with a preoperative evaluation include Orlistat over that achieved by a 1,500 calorie/day diet alone. gastroenterology, anesthesia, cardiology, pulmonology, psy- Sibutramine, recently discontinued by order of the FDA chiatry, endocrinology and clinical nutrition. In many instances, is a monoamine reuptake inhibitor. It cost about $120 a however, few if any of these specialties have interacted with the month and had the side effects of tachycardia, hypertension, individual patient before being considered for bariatric surgery. seizures, cholelithiasis, depression and even suicide ideation. The surgical options that are currently available include Its efficacy was demonstrated to be limited also. It’s estimated those that are a) predominantly malabsorptive, those that that 4–5 kg of extra weight loss could occur over a year with are b) primarily restrictive, and c) those that have a sibutramine in addition to a 1,500 calorie/day diet. combination of malabsorptive and restrictive components. The surgical options (Figures 1–3) are as follows: NOVEL INTERVENTIONAL THERAPIES There are many novel therapies that are being investigated around the world.13–34 The most promising, currently licensed for use in much of Europe and Latin America, is the BioEnteric Intragastric Balloon, also called the BIB system. It is licensed overseas for short-term use (6 months) and it consists of an intragastric balloon
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