“Medical Treatment of any Disease Process, including Obesity, Should Always be Our First Choice”

| March 1, 2017

A Message from Dr. Raul J. Rosenthal

Raul J. Rosenthal, MD, FACS, FASMBS, Clinical Editor, Bariatric Times; Chief of Staff, Professor of Surgery and Chairman, Department of General Surgery; Director of Minimally Invasive Surgery and The Bariatric and Metabolic Institute; General Surgery Residency Program Director; and Director, Fellowship in MIS and Bariatric Surgery, Cleveland Clinic Florida, Weston, Florida


Dear Friends and Readers of BT,
We start this month’s editorial with the sad news of the passing of our dear friend and colleague Dr. George Blackburn. I am thankful to Dr. Daniel Jones and Ms. Angela Saba for writing this wonderful “In Memoriam” that summarizes Dr. Blackburn’s outstanding achievements and contributions to the field of Obesity and Nutrition. George was indeed a role model to many, an innovator, and a great friend. He will be missed by all of us.

This month we also feature an interview with Dr. Sangeeta Kashyap on the five-year outcome data of the STAMPEDE (Surgical Therapy And Medications Potentially Eradicate Diabetes Efficiently) trial. Evaluating medical versus surgical treatment and comparing Roux-en-Y gastric bypass (RYGB) to laparoscopic sleeve gastrectomy (LSG), this trial clearly demonstrates the superiority of surgical treatment in patients with obesity and type 2 diabetes mellitus (T2DM). It also shows that weight loss after RYGB is superior to LSG, although when it comes to HbA1c, it seems that both are equally effective. Two questions remain to be answered: 1) What were the complications of the RYGB population vs. the ones of the LSG group?  and 2) How important is it to achieve more weight loss at the risk of increased morbidity? RYGB is an outstanding operation that has proven to be safe and efficacious, but when compared to the LSG, it has significant higher long-term morbidty.[1,2] Contrary to what many might think, LSG is a simple procedure but not an easy one. Acute complications of sleeve are among the most challenging ones for us to manage. Obesity as we know, is a predisposing factor for other serious medical conditions, such as cancer, and we should always attempt to achieve maximal weight loss to prevent these terrible complications from happening. So can we accept less weight loss at the expense of less complications? I hope that with time, we will be able to better identify which patients with metabolic syndrome are candidates for the bypass and which ones for the sleeve. I also believe that medical treatment of any disease process, including obesity, should always be our first choice.

I would like to congratulate and comment on the excellent article in this month’s installment of The Medical Student Notebook. Leith Hathout provides a thorough review on idiopathic intracranial hypertension, also known as pseudotumor cerebri. He discusses literature showing improvement of pseudotumor cerebri with bariatric surgery.

I have personally operated on a young adult woman with severe obesity with impending blindness due to pseudotumor cerebri. After gastric bypass and rapid weight loss, her eye exam normalized completely. Why did this happen? Chronic and acute elevation of intraabdominal pressure (IAP) have been a passion of mine for the last 20 years. I have published extensively on this subject and the pathophysiology, though complex, is directly related to the increased IAP that results in decreased venous return from the central nervous system (CNS) resulting in elevated intracranial pressure (ICP), release of vasopressin, and among other side effects, decreased renal function. A clear acute example of it is the abdominal compartment syndrome and a clear chronic example of it is morbid obesity and pseudotumor cerebri.

I look forward to see many of you at the annual meeting of Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) and join us in celebrating the 20 year anniversary of the Fellowship Council.

Sincerely,
Raul J. Rosenthal, MD, FACS, FASMBS

References
1.    Hutter MM, Schirmer BD, Jones DB, et al. First report from the American College of Surgeons Bariatric Surgery Center Network: laparoscopic sleeve gastrectomy has morbidity and effectiveness positioned between the band and the bypass. Ann Surg. 2011;254(3):410–420; discussion 420–422.
5.    DeMaria EJ, Pate V, Warthen M, Winegar DA. Baseline data from American Society for Metabolic and Bariatric Surgery-designated Bariatric Surgery Centers of Excellence using the Bariatric Outcomes Longitudinal Database. Surg Obes Relat Dis. 2010;6(4):347–355.

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