Sleeve Gastrectomy is Technically Simple, Requires Minimal Follow Up, and Results in Negligible Long-term Complications— What More Can We Ask For?

| May 16, 2012

Dear Readers of Bariatric Times:

This month we share with you reviews and comments from Drs. Ed Mason and Walter Pories on the recent studies published in the New England Journal of Medicine (NEJM).[1,2] These prospective, randomized, controlled studies demonstrated that bariatric surgery in combination with medical therapy is far superior to medical therapy alone when treating patients’ type 2 diabetes mellitus (T2DM) associated with obesity. What seemed to be a well-kept secret or denied evidence for the last 50 years, has finally been validated. What I found most interesting from both publications, is that all three procedures—Roux-en-Y gastric bypass (RYGB), biliopancreatic diversion with duendenal switch (BPDDS), and laparoscopic sleeve gastrectomy (LSG)—were equally efficient in controling patients’ T2DM. I cannot resist highlighting that SG was one of the procedures tested because if we compare the complexity of the surgery, the difficult follow up, and the potential for long-term morbidity, SG is by far the best of these procedures. SG is technically simple, requires minimal follow up, and results in negligible long-term complications. What more can we ask for? I always mention Ed Mason’s personal comments to me: “we need to look for a procedure that doesn’t create new problems and does not require so much follow up.” I cherish so much Pories’s anecdotes on Carrell, Jacobeus, and Max Plank as well as Mason’s comment that Theodor Billroth was the first metabolic surgeon that we had in human history.

Jennifer Traub RD, CNSC, presents an interesting column “Taste changes after bariatric surgery: What to do when your patients cannot stand the taste of their Food.” If we could find a medication that could make bread, French fries, and chocolate taste like raw onions, that would also help us lose some weight, wouldn’t it? All these hormonal, metabolic, and neurologic changes that result from baraitric procedures are so intriguing. I have seen 30 years of psoriasis and chronic renal failure disappear in patients as well and I still don’t understand how and why. Traub’s article discussing understanding the consequences and how to treat this common side effect of bariatric surgery is one you must read and share with your patients.

I just returned from the 81st Australasian Royal College of Surgeons scientific congress in Kuala Lumpur, Malaysia. After sharing two magnificent days with our bariatric surgeon colleagues of the Asian Pacific Region, I realized how embedded the banding culture is in that part of the world. Would anyone in the United States place a second band in a patient who had an erosion and band removal and came back for weight regain? They would. It seems that SG is slowly gaining in popularity, but they are still dealing with complications related to the learning curve, and I believe it will take another couple of years until they can get rid of the witch spell. Kudos to John Jorgenson, MD, for an outstanding conference.

Also in this issue, Drs. Lee Kaplan, Randy Seeley, and Jason Harris present the third installment of the Metabolic Applied Research Strategy (MARS) Initiative Series. I learned a lot about MARS while listening to Seeley’s presentation in Kuala Lumpur. So far, we have received very positive feedback from readers on this series on metabolic research.

In this month’s Surgical Pearls: Techniques in Bariatric Surgery, Drs. Alfons Pomp and Amanda Powers provide instruction on how a mesenteric defect should be closed after an antecolic gastric bypass. I fully agree with the authors’ statement, “ We believe there are patient benefits if the mesenteric defect is properly closed.” Indeed , if you choose to close them, then do it right. The problem is that you have to be an excellent surgeon to do so. Recent reports from master surgeons with internal hernia (IH) rates of 16 percent tell us that the learning curve is steep, and whether you try to close them or not, patients will still have internal hernias through mesenteric defects. I also completely agree with the authors’ conclusions that the diagnosis of IH is a difficult one and missing one can result in catastrophic consequences. I will never forget Dr. Harvey Sugerman’s description of “a patient that comes to your office with excruciating crampy periumbilical pain that irradiates to the back” as being patognomonic of IH. At Cleveland Clinic Florida, we adopted a more insistent attitude to gastric bypass patients that come to our emergency room and office with recurrent abdominal pain—“diagnostic laparoscopy.” What is interesting to observe in those cases we relaparoscoped is that, in the majority of cases, the defects that were left open at the time of the primary procedure closed spontaneously.

This month’s installment of the American Society for Metabolic and Bariatric Surgery (ASMBS) News and Update by Dr. Robin Blackstone is also a must read as it answers many important questions on accreditation process changes. Also, do not miss the first open forum taking place on Friday, June 22, 2012, at the annual ASMBS clinical congress in San Diego, California.

A while ago, Dr. Daniel Jones and I thought about getting medical students familiar and involved with the obesity disease. Based on Dan’s idea, we are launching a new column entitled “The Mentored Student Clinical Casebook.” In the first edition of this column, Raaj Mehta presents an outstanding paper on perceptions of obesity—another must read. If you work with medical students and they are interested in writing about basic topics related to the obesity disease, encourage them to do so. Become a mentor in helping humankind learn and understand the devastating consequences of the obesity disease. I am sure you will love this new column and this month’s issue of BT as a whole.

I take this opportunity to wish all moms a happy Mother’s Day and all families a restful memorial day weekend. I look forward to seeing all of you at the annual ASMBS clinical congress in San Diego.

Sincerely,
Raul J. Rosenthal, MD, FACS
Editor, Bariatric Times

References
1.    Schauer PR, Kashyap SR, Wolski K, et al. Bariatric surgery versus intensive medical therapy in obese patients with diabetes. N Engl J Med. 2012; 366:1567–1576. 2.
2.    Mingrone G, Panunzi S, De Gaetano A, et al. Bariatric surgery versus conventional medical therapy for type 2 diabetes. N Engl J Med. 2012;366:1577–1585.

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