50y ears in adults. The techniques have varied, and today mainly four methods
are used; gastric banding with fixed or variable band (GB), gastric bypass
(GBP) and vertical banded gastroplasty (VBG). The techniques are schematically
presented in figure 1. All these methods can today be performed by laparoscopic
surgery [1, 2] and the risk of postsurgical complications is low [3–5].
Regarding two other types of surgery, bileo-pancreatic bypass and duodenal
switch, the information is more limited and it is also possible that the side effects
are more pronounced [6–10]. Jejuno-ileal as well as other types of intestinal
bypass procedures are not currently in use due to severe side effects [11].
Bariatric surgery is the only method by which a long-standing and pronounced
weight reduction has been obtained in a large number of obese patients
[4, 12–14]. In the Swedish ongoing SOS study, the long-term effects of surgery
are compared with low-energetic conventional treatment. The control group is
not randomized. This weakness is compensated by a large number of patients
enrolled. The incidence of diabetes was dramatically reduced in the bariatric
surgery group. Furthermore, there was also pronounced reduction of hypertriglyceridemia
and increased levels of HDL-cholesterol [15]. The prevalence
of hypertension was initially reduced in the bariatric surgery group, but at
follow-up after 8 years there was no significant difference between the groups
[14]. However, of major importance is that the quality of life was considerably
increased both after 2 and 4 years follow-up [16, 17] and there was a
correlation between the degree of weight reduction and health-related quality
of life.
The complication rates in the SOS-study are low taken into consideration
that most of the patients were not healthy at the time of the operation. The
post-surgery mortality was 0.25% [3, 5]. 12% of the first 1,164 patients in the
surgery group were re-operated within 4 years of follow-up. The reasons were
poor weight reduction or technical complications. The frequency of re-operations
was highest in the GB group [5].
The positive results have led to a booming demand for bariatric surgery in
many countries, above all in the United States. Between 2001and 2003 the
number of bariatric procedures in the United States is expected to rise from
50,000 to 120,000 per year [18]. In children and adolescents no controlled or
prospective studies are published. However, there are approximately 200 cases
presented in five follow-up reports [19–23]. The quality of the reports as well as
the follow-up time varied considerably. The age of the subjects varied between
8 and 20 years and all subjects were extremely obese. The negative side effects
presented were gallstones (a well-known problem associated with the weight
reduction per se) and anemia. In one study two deaths were reported [21]. No
one seemed to be directly related to the surgery intervention, but rather to the
morbid obesity.
Most of the patients seem to have considerable improvement of quality
of life and health at follow-up. In one study 100% were positive to the
surgery [22] and in another 85% [19]. All signs of severe obesity co-morbidity
disappeared in one [20] and in another study oxygenation was markedly
improved in subjects with sleep apnea syndrome [21]. However, it has to be
emphasized that these case presentations do not satisfy any reasonable
requirements. The results were in many cases based on telephone interviews,
or questionnaires sent by post and only on a few occasions clinical examinations.
Despite these concerns the results are surprisingly positive and stress
the need of prospective studies including careful medical and psychological
examinations.
There are many ethical problems involved if bariatric surgery is considered
for childhood obesity. For all children surgical restriction of food intake is also
a restriction on the personal integrity. Children with mental retardation, e.g.
Prader-Willi syndrome or subjects with eating disorders or children with hypothalamic
obesity are all patients who cannot handle food intake and they should
not be exposed to bariatric surgery. The least invasive surgical method is gastric
banding and the band is also relatively easy to remove. On the other hand,
gastric banding is the bariatric procedure, which is marred by most problems
and seems also to be least effective. Furthermore, gastric banding does not
encourage healthy eating habits as high energy density liquids and sweets are
well tolerated. Gastric bypass is the method, which seems to be most favorable
when both effect on weight loss and negative side effects are considered.
However, it is an extensive operation and for children with a long life
expectancy it can be questioned whether it is ethically justified. It is to be hoped
that within ten years more potent anti-obesity drugs are available and an active
conservative treatment is maybe preferable in most cases of childhood obesity.
In subgroups of children and adolescents with severe otherwise untreatable
obesity life expectancy and quality of life are so severely affected that it may
well be ethically justified to try surgical treatment. This should preferentially be
done in controlled clinical trials.
0 komentar:
Posting Komentar