Case 25-2004 — A 49-Year-Old Woman with Severe Obesity, Diabetes, and Hypertension
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《新英格兰医药杂志》
Presentation of Case
A 49-year-old woman was evaluated at this hospital for the management of obesity. She had been overweight since childhood; at the age of 10 years she weighed 45.4 kg, at the age of 18 she weighed 88.5 kg, and throughout most of her adult life she weighed between 108.9 and 129.3 kg. She was able to lose weight on more than 10 occasions with diet and exercise but always regained it within two to three years. Dexfenfluramine was prescribed for weight loss when she was 40 years old, and she lost 11.3 kg but gained 22.6 kg after she stopped taking the drug.
Ten years earlier, diabetes mellitus had been diagnosed; it was controlled with metformin hydrochloride and glyburide. Twice within the 12 years before the evaluation, the woman had noted intermittent, sharp pain radiating down her left leg. Plain radiographs showed that there was narrowing of the disk spaces between the second and third and the third and fourth lumbar vertebrae and first-degree spondylolisthesis of the fifth lumbar vertebra. Despite several courses of physical therapy and the intermittent use of ibuprofen, intermittent pain persisted.
An episode of exertional chest pain had occurred five years before the evaluation; radionuclide scanning of the heart revealed a large anterior defect suggestive of ischemia. Coronary-artery angiography demonstrated 50 percent occlusion of one coronary artery. Aspirin and pravastatin were prescribed.
Three years earlier, treatment with insulin had been started because of inadequate control of blood glucose. At the same time, hypertension was diagnosed (blood pressure, 164/114 mm Hg), and treatment with lisinopril was started. An ophthalmologist diagnosed diabetic retinopathy. Two years earlier, the patient had reported the sensation of burning on the soles of her feet that awakened her at night. Gabapentin was prescribed. She had experienced episodes of depression intermittently for 11 years; they had been treated first with bupropion and for the past 3 years with fluoxetine.
The patient (gravida 2, para 2) had delivered both her children by cesarean section and worked as a registered nurse for a health care agency. A tonsillectomy had been performed when she was 14 years old. She was allergic to penicillin. She had been divorced for five years, and she lived with her two grown children. She had smoked 10 cigarettes per day for several years but had stopped smoking many years before her evaluation, she drank alcohol infrequently. Her brother had undergone coronary-artery bypass grafting when he was 41 years old, and her mother had died of a myocardial infarction at the age of 52. Her parents and all three of her brothers were obese. Her medications included insulin (55 U in the morning and 30 U in the evening), metformin, fluoxetine, atorvastatin, lisinopril, ibuprofen, conjugated estrogens, medroxyprogesterone acetate, a calcium supplement, aspirin, and multivitamins.
On physical examination, the patient's height was 155 cm and her weight 129.5 kg. The body-mass index (the weight in kilograms divided by the square of the height in meters) was 52. The blood pressure was 156/93 mm Hg, the heart rate 104 beats per minute, and the respiratory rate 16 breaths per minute. Examination of the lungs and heart revealed no abnormalities. The abdomen was obese and nontender, with no organomegaly. She had moderate folliculitis under a grade 2 abdominal pannus (i.e., the layer of fat covers the groin area in line with the upper-thigh crease). The distal pulses were palpable, and there was no peripheral edema. There were no focal neurologic deficits. Electrolyte levels, the results of liver-function tests, and the white-cell and platelet counts were normal. The results of other laboratory tests are shown in Table 1.
Table 1. Laboratory Values.
Discussion of Management
Dr. Janey S. Pratt: Obesity is epidemic. More than 65 million Americans, or 1 in 3, have obesity (defined as a body-mass index greater than 30), and more than 10 million have severe obesity (a body-mass index greater than 40).1,2 This patient, who had a body-mass index of 52, had severe, lifelong obesity, which was complicated by type 2 diabetes mellitus, hyperlipidemia, hypertension, depression, and low-back pain. She has been unable to sustain weight loss with the use of a variety of diets and medication. She was referred to us to explore surgical management of her obesity. Since obesity is a multifactorial, chronic disease, its treatment requires a multidisciplinary, long-term approach. Members of this patient's multidisciplinary clinical team will discuss aspects of her assessment and care.
Medical Evaluation
Dr. Lee M. Kaplan: The medical evaluation of this patient with obesity was focused on identification of the causes and complications of the excess weight and on treatment to reverse them or prevent their progression. Therapeutic decisions in a case such as this one are guided by the degree of obesity and the severity of the medical and psychological complications. For the majority of persons with obesity, a specific cause cannot be identified.2 Even when endocrine disorders such as hypothyroidism or Cushing's disease are present, they are rarely the cause of the obesity. In an increasing number of patients, the onset or exacerbation of obesity correlates with the use of medications that cause weight gain as a side effect. When I first saw this patient, she was taking insulin, which is commonly associated with weight gain, and fluoxetine, which causes weight gain in a minority of patients. However, she had been severely overweight since late childhood, before those medications were administered.
The common disorders associated with obesity can be divided into five major categories: metabolic, structural, degenerative, neoplastic, and psychological (Table 2).2 Several of them (obstructive sleep apnea, thromboembolism, and degenerative arthritis) result from both structural and metabolic dysfunction. The relationship of each complication to the body-mass index varies widely, with the risk of diabetes and other metabolic complications increasing at a body-mass index as low as 23 to 25 and the risk of anatomical complications increasing most strikingly in persons with severe obesity. Among the many complications of obesity, obstructive sleep apnea, fatty-liver disease, gastroesophageal reflux disease, fungal skin infections, and nutrient deficiencies are the most commonly undiagnosed or undertreated complications in patients presenting for care at a specialized obesity center.2 This patient had diabetes, hypertension, and hyperlipidemia. As part of the initial evaluation, a sleep study was conducted, which showed that she had sleep apnea. Although it was not among the symptoms she initially described, she later reported that she had snored and had had difficulty sleeping for many years.
Table 2. Complications of Obesity.
People with obesity have an elevated risk of all the diseases for which patients are most commonly screened: hypertension, hyperlipidemia, diabetes mellitus, and cervical, breast, prostate, and colorectal cancers. Ironically, however, several studies have shown that they are less likely to undergo screening for these disorders than are people of normal weight.1,2 In this patient, screening was complete and up to date. The strongest medical contraindications for weight-reduction surgery are severe lung disease, unstable cardiovascular disease, uncontrolled clotting disorders, portal hypertension with gastric varices, pregnancy, and ongoing substance abuse. This patient had none of these disorders.
Nutritional Evaluation
Susan Cummings: This patient's comprehensive nutrition evaluation included the assessment of anthropometric data and social, nutritional, and behavioral factors. Our objectives were to assess her risk for complications of obesity, to identify factors contributing to her obesity, if possible, and to provide baseline data to assess the outcomes of treatment.
The measurements of height, weight, and waist circumference provide an indication of a patient's risk for complications of obesity (Table 3).1,2 Calculations based on the patient's height, weight, and age are used to estimate energy expenditure (Table 4).3 This patient's weight put her at extremely high risk for complications. Her energy needs were estimated to be 2500 kcal per day to maintain her current weight, but her reported intake was approximately 3000 kcal a day — 500 kcal more than her net energy needs.
Table 3. Assessing Obesity: Body-Mass Index, Waist Circumference, and Risk of Disease.
Table 4. Estimating Energy Expenditure.
The patient's weight history and that of her family may give some indication of a genetic predisposition. In this patient, the weight history revealed that the onset of obesity was in late childhood and that her highest weight as an adult was 129.3 kg, the weight at the time of her presentation to us. Her lowest adult weight was 79.4 kg, immediately after dieting. Her dieting history included four commercial programs and many self-directed diets. She had lost as much as 38.5 kg at one time through dieting, but like many people she always regained more weight than she had lost from each diet, and she had gained more than 45.4 kg overall during adulthood. Her family history revealed obesity in both parents and three brothers.
The nutrition evaluation included a 24-hour recall of total food intake and the frequency of food intake, as well as inquiry into hunger, satiety (how frequently she experienced hunger and what made her feel satiated), and behaviors such as binge eating, grazing (eating not related to hunger), nighttime eating, eating in restaurants, and alcohol consumption. This information helped to determine the patient's usual food intake and provided an indication of the environmental influences on her eating patterns. Most of her calories were consumed at meals with large portions of calorically dense foods. She ate three meals a day but occasionally skipped lunch and had a planned snack in the midafternoon. She often ate in fast-food restaurants.
The assessment of physical activity included information about the activities of daily living, physical limitations, and structured exercise. This patient was sedentary and did not engage in a structured program of exercise because of her chronic back pain. The patient's expectations concerning ideal weight were also addressed, as were her self-efficacy (confidence in the ability to make the necessary behavioral changes), motivation, readiness for weight loss, and potential barriers to treatment. This patient's primary motivation to lose weight was to improve her overall health and well-being.
Psychological Evaluation
Dr. Deborah A. Vineberg: Psychological assessment of patients with obesity was once thought to be important in identifying the cause of the obesity, which was believed to be related to a lack of self-control or to a psychological addiction to food. The current understanding is that the most important reasons for this evaluation are to diagnose and treat psychological disorders that result from the obesity, compound the existing weight problem, or interfere with effective treatment. Pretreatment evaluation of this patient included screening for psychiatric disorders that could interfere with the management of obesity. Axis I disorders in the Diagnostic and Statistical Manual of Mental Disorders, fourth edition (psychiatric disorders that are clinical in nature,4 such as depression or anxiety) and eating disorders (such as binge eating or bulimia) can complicate medical management unless they are treated adequately. This patient reported poor self-esteem and a profound sense of inferiority that she attributed to being overweight. She reported that stressful events, including the births of her children and her divorce, had exacerbated her weight problem. At the time of her evaluation she identified her job, single parenthood, and her declining health as stressful factors in her life. At the initial evaluation her Beck Depression Inventory5 score was 19, which corresponds to mild-to-moderate depression. Obesity is strongly associated with depression. Persons over 50 years of age who are obese are twice as likely to become depressed within five years as those who are not obese,6 but when followed for five years, those who are depressed are not at increased risk of becoming obese. Thus, obesity is a risk factor for depression, but the converse is not true.
Psychological complications associated with gastric bypass are similar to those associated with other major surgical procedures; transient postoperative depression is the most frequent complication. Exacerbation of preexisting psychiatric anxiety or depression is rare, and more than 90 percent of cases of depression and 50 percent of cases of anxiety disorders improve.7 Depression before weight-loss surgery does not worsen outcomes8; in fact, one study found that patients with higher Beck Depression Inventory scores lost more weight after surgery than those with lower scores.9
This patient described neither binge eating nor inappropriate behaviors such as self-induced vomiting or the use of laxatives or diuretics. She demonstrated good insight into the psychological function of her weight, which she characterized as providing her with a sense of safety and a form of protection. She admitted to being fearful of substantial weight change, and she worried about her potential for self-sabotaging behavior. She was provided additional sessions with a psychologist to address these concerns.
The presence of an Axis II disorder (a personality disorder or mental retardation) can lead to difficulties in management or can be a contraindication to surgery and should be addressed before surgery is undertaken. This patient did not have an Axis II disorder, and she had no family history of psychiatric disorders. Thus, she did not have psychiatric contraindications to surgery.
We also discussed her personal support system, since the involvement of family or friends in medical and surgical treatment of obesity can improve the outcome.10 She reported that both her family and her friends were supportive of her efforts to lose weight.
Weight-Loss Surgery
Dr. Pratt: A clinical-team meeting of the obesity-medicine specialist, nutritionist, and psychologist concluded that this patient was a suitable candidate for bariatric, or weight-loss, surgery. The term bariatric comes from the Greek word "baros," meaning "weight," and refers to the treatment of weight disorders. Many different surgical procedures have been tried during the past 50 years, but there are three major categories in current use: restrictive operations (gastroplasties with the use of adjustable gastric bands), malabsorptive operations (biliopancreatic diversions), and gastric bypasses. Each can be performed either laparoscopically or in an open fashion. The standard types of gastric bypass do not carry the risk of clinically significant protein malnutrition that is associated with biliopancreatic-diversion procedures.
Weight-loss surgery provides the best long-term results for patients with moderate (class II) or severe (class III) obesity who have not responded to more conservative approaches.11,12 It is generally reserved for patients with a body-mass index greater than 40 or for those with a body-mass index greater than 35 whose obesity is complicated by one or more major diseases. This patient met the criteria for this approach, since she had a body-mass index of 52 and several major complications and was unable to maintain weight loss by other means.
The overall morbidity and mortality associated with gastric bypass surgery are approximately 10 percent and less than 1 percent, respectively.13,14 Early postoperative complications of laparoscopic gastric bypass surgery include wound infections (incidence, 3 percent), anastomotic leak (2 percent), bowel obstruction (2 percent), gastrointestinal hemorrhage (2 percent), and pulmonary embolus (less than 0.5 percent). Late complications include bowel obstruction (3 percent) and stomal stenosis (5 percent)13; both of these problems are more common after laparoscopic procedures than after open procedures. Although reported in less than 1 percent of cases,7 anastomotic ulcers have been one of the most common late postoperative complications in my experience. In patients who have gastric bypass surgery, there is often improvement or resolution of coexisting diseases such as diabetes,15 hypertension, hyperlipidemia, and sleep apnea,12 as well as improved quality of life.7,14 For this patient, my colleagues and I believed that the risks of continued obesity outweighed those of bariatric surgery and its potential complications.
Laparoscopic Roux-en-Y gastric bypass was recommended, because this procedure is associated with the best long-term outcomes.14,16 This operation includes a restrictive procedure and a short-limb gastroduodenal bypass (Figure 1). It does not result in protein-calorie malabsorption, but it appears to induce neurohumoral effects that result in decreased hunger, accelerated postprandial satiety, and diminished emotion-based or reward-based eating.2 The physiological and molecular mechanisms of these effects remain poorly understood.
Figure 1. Roux-en-Y Gastric Bypass Surgery.
This operation includes a restrictive procedure, creating a small proximal gastric pouch, followed by the creation of a jejunojejunostomy in a "Y" configuration to allow an end of the jejunum to be brought up and anastomosed to this proximal pouch.
In the current case, preparation for surgery involved the full multidisciplinary team. The preoperative nutrition program included an individual session of nutrition counseling with a dietitian and a group education session to familiarize the patient with the postoperative diet protocol. The diet to be followed after gastric bypass surgery is advanced in a staged approach (Table 5). Psychological counseling was instituted to assist the patient in making the behavioral changes that would be required after surgery. The preoperative medical evaluation included a thorough assessment of the operative risks and the need for perioperative management of coexisting diseases, with discussion among the obesity-medicine physician, anesthesiologist, and surgeon to optimize her care.
Table 5. Protocol for Diet after Gastric Bypass Surgery.
The operation took about three hours. The surgical team first gained access by placing two 12-mm ports and three 5-mm ports through the abdominal wall in the upper abdomen — one for a camera, one for the liver retractor, one for stapling devices, and the other two for graspers to manipulate the stomach and intestines. The stomach was first divided by staplers across the cardia, creating a 30-ml proximal gastric pouch (Video Clip 1 in the Supplementary Appendix, available with the full text of this article at www.nejm.org). We then created a 100-cm Roux limb by dividing the intestines, stapling a jejunojejunostomy (Video Clip 2 in the Supplementary Appendix), and passing the limb behind the colon and stomach (Video Clip 3 in the Supplementary Appendix). Finally, this limb was stitched to the pouch in a double-layer anastomosis 1.5 cm in diameter (Video Clip 4 in the Supplementary Appendix). Because the liver appeared fatty, a wedge-biopsy specimen of the liver was obtained. Postoperatively, an amidotrizoic acid (Gastrografin) swallow examination confirmed that the gastrojejunal anastomosis was intact and without leak. The patient was discharged on the third hospital day while following a stage 1 diet (Table 5).
Pathological Discussion
Dr. Fiona Graeme-Cook: The specimen obtained by liver biopsy revealed hepatocellular steatosis with a very few foci of ballooning degeneration; the portal tracts showed slight proliferation of the bile ductules with minimal chronic inflammatory infiltrate (Figure 2A). Glycogenated hepatocellular nuclei were scattered. These findings are consistent with the presence of nonalcoholic fatty liver disease, without evidence of steatohepatitis, fibrosis, or cirrhosis.
Figure 2. Liver-Biopsy Specimen (Hematoxylin and Eosin).
Hepatocellular steatosis with small-droplet and large-droplet fat is apparent, with glycogenated nuclei (Panel A, arrows). Panel B shows a liver-biopsy specimen from another patient with nonalcoholic steatohepatitis, with steatosis, ballooning degeneration, and portal and lobular mononuclear infiltrates.
In the presence of insulin resistance, high levels of circulating insulin lead to high levels of free fatty acids within the liver, increasing the synthesis of triglycerides. Although the mechanism is not completely understood, hepatocytes accumulate fat, manifested as hepatocellular steatosis. This is the most common finding in the liver in patients with severe obesity, present in more than 75 percent of cases. The additional feature of glycogenated nuclei is also a marker for insulin resistance and hyperglycemia. Steatohepatitis may complicate steatosis, possibly as a result of excessive -oxidation of fatty acids by hepatocellular mitochondria. The resultant oxidative stress is thought to lead to peroxidation of lipids, resulting in hepatocyte necrosis, an influx of mononuclear inflammatory cells, and eventually, fibrosis and cirrhosis (Figure 2B). 17,18
Discussion of Outcome
Dr. Kaplan: During the early postoperative period, the patient's most prominent symptom was constipation, which was probably a result of mild dehydration. The mobilization of stored fat by lipolysis consumes prodigious amounts of water, and fluid requirements are high during the first several months after surgery. During the first few weeks, patients are closely monitored for dehydration, which may be manifested as constipation, lethargy, or light-headedness. The use of diuretics or other antihypertensive agents often must be reduced or stopped altogether in the immediate postoperative period. This patient's blood pressure remained normal, and the lisinopril was discontinued without adverse effect. Her blood sugar levels became normal within two days after surgery, despite the discontinuation of insulin and metformin. This rapid improvement in insulin sensitivity within several days after surgery is typical, and many patients require little or no therapy for their diabetes during this time. To avert potentially life-threatening hypoglycemic episodes, her blood glucose levels were monitored frequently and insulin and sulfonylureas were avoided.
Ten days after surgery, she had lost 9.1 kg. Three months after the operation, she was eating three meals and two snacks daily and had lost 27.2 kg. Six months after surgery, she had lost 37.2 kg and was eating most foods without having symptoms. Participation in postoperative programs of nutrition education and cognitive behavioral therapy appears to minimize both short-term complications related to nutritional issues and subsequent weight gain.10,11 Beginning six months after surgery, the patient participated in a monthly program for surgical support and education, which provides ongoing support and counseling. Her weight decreased by 54.4 kg, to 70.3 kg, during the first 12 months after surgery. Excess skin with ptosis in the lower abdomen was treated with abdominoplasty 15 months after the weight-loss surgery. She later regained approximately 4.5 kg, and her weight then stabilized at 74.8 kg for the next year.
Nutritional Outcome
Two years after surgery, the patient's body-mass index was 30, down from 52, and her energy expenditure was estimated to be about 1800 kcal per day, down from 2500 kcal per day. She ate three meals a day and did not routinely eat snacks. She experienced satiety with half-normal portions of food, and her hunger returned about five hours after each meal. She tolerated all types of food, although she avoided concentrated carbohydrates at the beginning of each meal as a way of preventing the dumping syndrome (i.e., rapid gastric emptying). She did not have any change in her food preferences. She walked 4.8 km a day and reported enjoying exercise for the first time.
Medical Outcome
Two years after surgery, the patient's diabetes improved but did not completely resolve. She no longer required insulin, and her metformin dose decreased from 850 mg taken three times daily to 500 mg taken twice daily. Her levels of hemoglobin A1c and urinary microalbumin fell (Table 1). Her diabetic retinopathy did not progress. Her sleep apnea, hypertension, and folliculitis resolved. Her lumbar back pain and sciatica improved substantially. Her hyperlipidemia remained well controlled with the use of a lower dose of atorvastatin than she was taking before the surgery, and there was no progression of her coronary artery disease.
A deficiency of micronutrients is common after gastric bypass surgery. We regularly assessed the patient's levels of iron, calcium, vitamin B12, vitamin D, and vitamin K. Iron deficiency developed approximately 10 months after surgery (Table 1). It was treated successfully with oral ferrous bisglycinate and polysaccharide iron supplementation. Before surgery, she had been found to have a vitamin B12 deficiency, which occurs in a small number of patients with obesity who have followed many diet programs. Intranasal vitamin B12 supplementation was begun before the operation and was continued afterward, and two years later she had normal levels of vitamin B12 (Table 1). Secondary hyperparathyroidism from malabsorption of calcium and vitamin D occurs in more than 60 percent of patients after gastric bypass. Metabolic bone disease is common and must be screened for and treated. This patient took prophylactic supplementation with an oral calcium preparation (1000 mg of elemental calcium per day), and her levels of calcium, vitamin D, and parathyroid hormone have remained normal.
Psychological Outcome
Six weeks after the operation, the patient recognized feelings of loss related to being unable to overindulge in food. She commented, "You fixed my stomach, but I need to fix my head," alluding to the need to focus on psychological triggers for eating that could no longer be satisfied by food. Twelve weeks after surgery, she reported feeling "great." She was excited about her increased energy, and the Beck Depression Inventory score fell to 3, within the range of minimal depressive symptoms, and it remained at that level thereafter. She stopped taking fluoxetine.
Two and a half years after the gastric bypass surgery, both her self-confidence and her self-esteem have increased. She is more assertive in her relationships, with positive results.
Dr. Pratt: This case illustrates the importance of a multidisciplinary team that includes an obesity-medicine specialist, a nutritionist, a psychologist, and a surgeon to ensure optimal medical and psychological results from weight-loss surgery.1,10,19 Although this patient was able to initiate exercise on her own, it is important to include a physical therapist or trainer when needed. Although her obesity was not cured, since her body-mass index remained elevated (at 30), the team viewed this case as having a successful outcome.
Dr. A. Benedict Cosimi (Surgery): How would you assess whether the patient's psychological issues were solved or complicated by the surgery? This patient considered her weight a protective shield. How did she feel when this shield disappeared?
Dr. Vineberg: Instead of using the weight as a protection, she worked to establish appropriate boundaries with people in her life, so that she could maintain appropriate emotional distance that did not depend on the physical or emotional distance caused by her size.
Dr. Kaplan: It is not clear whether the protection that she felt the excess weight provided was a primary or a secondary event. If you are shunned in society because of obesity, you may then use the weight as an excuse not to interact with people.
Dr. Carlos Fernández-del Castillo (Surgery): The adjustable gastric band has been approved by the Food and Drug Administration for use in the United States. I anticipate that its application is an easier operation than bypass. Why was it not used here?
Dr. Pratt: The early experience with the adjustable gastric band in the United States showed a high rate of reoperation,20 and definitive studies of long-term outcomes are not yet available. To achieve an optimal outcome, the band has to be adjusted every two to six months by the addition or removal of saline. This dependence on frequent follow-up visits suggests that success with this procedure may be more dependent on voluntary behavior than the success observed after gastric bypass.
Dr. Jay Vacanti (Pediatric Surgery): Can you comment on the use of surgery in the management of pediatric obesity?
Dr. Pratt: Obesity in adolescents is being treated surgically in several centers around the country, including the Weight Center.21 Although the pediatric program here focuses primarily on behavioral and medical approaches, gastric bypass surgery has been used to treat a few teenagers with severe obesity and obesity with medical complications, such as type 2 diabetes mellitus or obstructive sleep apnea, who have not been responsive to other interventions. Recent studies have shown that resolution of diabetes is most likely in patients who have had it for less than five years, so waiting to perform surgery in children with type 2 diabetes may be more dangerous in the long term than performing the surgery.22
Source Information
From the Weight Center (J.S.P., S.C., D.A.V., L.M.K.), and the Departments of Surgery (J.S.P.), Psychiatry (D.A.V.), Pathology (F.G.-C.), and Medicine (Gastrointestinal Unit) (L.M.K.), Massachusetts General Hospital; and the Departments of Surgery (J.S.P.), Psychiatry (D.A.V.), Pathology (F.G.-C.), and Medicine (L.M.K.), Harvard Medical School.
References
Clinical guidelines on the identification, evaluation, and treatment of overweight and obesity in adults: the evidence report. Obes Res 1998;6:Suppl 2:51S-209S.
Kaplan LM. Body weight regulation and obesity. J Gastrointest Surg 2003;7:443-451.
Harris JA, Benedict FG. A biometric study of basal metabolism in man. Washington D.C.: Carnegie Institute of Washington, 1919.
Diagnostic and statistical manual of mental disorders, 4th ed.: DSM-IV. Washington, D.C.: American Psychiatric Association, 1994.
Beck A, Steer R. Manual for revised Beck Depression Inventory. San Antonio, Tex.: Psychological Corporation, 1987.
Roberts RE, Deleger S, Strawbridge WJ, Kaplan GA. Prospective association between obesity and depression: evidence from the Alameda County Study. Int J Obes Relat Metab Disord 2003;27:514-521.
Schauer PR, Ikramuddin S, Gourash W, Ramanathan R, Luketich J. Outcomes after laparoscopic Roux-en-Y gastric bypass for morbid obesity. Ann Surg 2000;232:515-529.
Dymek MP, le Grange D, Neven K, Alverdy J. Quality of life and psychosocial adjustment in patients after Roux-en-Y gastric bypass: a brief report. Obes Surg 2001;11:32-39.
Averbukh Y, Heshka S, El-Shoreya H, et al. Depression score predicts weight loss following Roux-en-Y gastric bypass. Obes Surg 2003;13:833-836.
Balsiger BM, Murr MM, Poggio JL, Sarr MG. Bariatric surgery: surgery for weight control in patients with morbid obesity. Med Clin North Am 2000;84:477-489.
Brolin R. Update: NIH consensus conference: gastrointestinal surgery for severe obesity. Nutrition 1996;12:403-404.
Brolin R. Bariatric surgery and long-term control of morbid obesity. JAMA 2002;288:2793-2796.
Podnos YD, Jimenez JC, Wilson SE, Stevens CM, Nguyen NT. Complications after laparoscopic gastric bypass: a review of 3464 cases. Arch Surg 2003;138:957-961.
Nguyen NT, Goldman C, Rosenquist CJ, et al. Laparoscopic versus open gastric bypass: a randomized study of outcomes, quality of life, and costs. Ann Surg 2001;234:279-291.
MacDonald KG Jr, Long SD, Swanson MS, et al. The gastric bypass operation reduces the progression and mortality of non-insulin-dependent diabetes mellitus. J Gastrointest Surg 1997;1:213-220.
Jones KB Jr. Bariatric surgery -- where do we go from here? Int Surg 2004;89:51-57.
McCullough A. Update on nonalcoholic fatty liver disease. J Clin Gastroenterol 2002;34:255-262.
Neuschwander-Tetri BA, Caldwell SH. Nonalcoholic steatohepatitis: summary of an AASLD Single Topic Conference. Hepatology 2003;37:1202-1219.
Blackburn GL, Greenberg I. Multidisciplinary approach to adult obesity therapy. Int J Obes 1978;2:133-142.
Ren CJ, Horgan S, Ponce J, et al. US experience with the LAP-BAND system. Am J Surg 2002;184:46S-50S.
Sugerman HJ, Sugerman EL, DeMaria EJ, et al. Bariatric surgery for severely obese adolescents. J Gastrointest Surg 2003;7:102-108.
Schauer PR, Burguera B, Ikramuddin S, et al. Effect of laparoscopic Roux-en-Y gastric bypass on type 2 diabetes mellitus. Ann Surg 2003;238:467-485.
Related Letters:
Case 25-2004: A Woman with Severe Obesity, Diabetes, and Hypertension
Padwal R., Podgorski G. P., Pratt J. S., Kaplan L. M.(Janey S. Pratt, M.D., Sus)
A 49-year-old woman was evaluated at this hospital for the management of obesity. She had been overweight since childhood; at the age of 10 years she weighed 45.4 kg, at the age of 18 she weighed 88.5 kg, and throughout most of her adult life she weighed between 108.9 and 129.3 kg. She was able to lose weight on more than 10 occasions with diet and exercise but always regained it within two to three years. Dexfenfluramine was prescribed for weight loss when she was 40 years old, and she lost 11.3 kg but gained 22.6 kg after she stopped taking the drug.
Ten years earlier, diabetes mellitus had been diagnosed; it was controlled with metformin hydrochloride and glyburide. Twice within the 12 years before the evaluation, the woman had noted intermittent, sharp pain radiating down her left leg. Plain radiographs showed that there was narrowing of the disk spaces between the second and third and the third and fourth lumbar vertebrae and first-degree spondylolisthesis of the fifth lumbar vertebra. Despite several courses of physical therapy and the intermittent use of ibuprofen, intermittent pain persisted.
An episode of exertional chest pain had occurred five years before the evaluation; radionuclide scanning of the heart revealed a large anterior defect suggestive of ischemia. Coronary-artery angiography demonstrated 50 percent occlusion of one coronary artery. Aspirin and pravastatin were prescribed.
Three years earlier, treatment with insulin had been started because of inadequate control of blood glucose. At the same time, hypertension was diagnosed (blood pressure, 164/114 mm Hg), and treatment with lisinopril was started. An ophthalmologist diagnosed diabetic retinopathy. Two years earlier, the patient had reported the sensation of burning on the soles of her feet that awakened her at night. Gabapentin was prescribed. She had experienced episodes of depression intermittently for 11 years; they had been treated first with bupropion and for the past 3 years with fluoxetine.
The patient (gravida 2, para 2) had delivered both her children by cesarean section and worked as a registered nurse for a health care agency. A tonsillectomy had been performed when she was 14 years old. She was allergic to penicillin. She had been divorced for five years, and she lived with her two grown children. She had smoked 10 cigarettes per day for several years but had stopped smoking many years before her evaluation, she drank alcohol infrequently. Her brother had undergone coronary-artery bypass grafting when he was 41 years old, and her mother had died of a myocardial infarction at the age of 52. Her parents and all three of her brothers were obese. Her medications included insulin (55 U in the morning and 30 U in the evening), metformin, fluoxetine, atorvastatin, lisinopril, ibuprofen, conjugated estrogens, medroxyprogesterone acetate, a calcium supplement, aspirin, and multivitamins.
On physical examination, the patient's height was 155 cm and her weight 129.5 kg. The body-mass index (the weight in kilograms divided by the square of the height in meters) was 52. The blood pressure was 156/93 mm Hg, the heart rate 104 beats per minute, and the respiratory rate 16 breaths per minute. Examination of the lungs and heart revealed no abnormalities. The abdomen was obese and nontender, with no organomegaly. She had moderate folliculitis under a grade 2 abdominal pannus (i.e., the layer of fat covers the groin area in line with the upper-thigh crease). The distal pulses were palpable, and there was no peripheral edema. There were no focal neurologic deficits. Electrolyte levels, the results of liver-function tests, and the white-cell and platelet counts were normal. The results of other laboratory tests are shown in Table 1.
Table 1. Laboratory Values.
Discussion of Management
Dr. Janey S. Pratt: Obesity is epidemic. More than 65 million Americans, or 1 in 3, have obesity (defined as a body-mass index greater than 30), and more than 10 million have severe obesity (a body-mass index greater than 40).1,2 This patient, who had a body-mass index of 52, had severe, lifelong obesity, which was complicated by type 2 diabetes mellitus, hyperlipidemia, hypertension, depression, and low-back pain. She has been unable to sustain weight loss with the use of a variety of diets and medication. She was referred to us to explore surgical management of her obesity. Since obesity is a multifactorial, chronic disease, its treatment requires a multidisciplinary, long-term approach. Members of this patient's multidisciplinary clinical team will discuss aspects of her assessment and care.
Medical Evaluation
Dr. Lee M. Kaplan: The medical evaluation of this patient with obesity was focused on identification of the causes and complications of the excess weight and on treatment to reverse them or prevent their progression. Therapeutic decisions in a case such as this one are guided by the degree of obesity and the severity of the medical and psychological complications. For the majority of persons with obesity, a specific cause cannot be identified.2 Even when endocrine disorders such as hypothyroidism or Cushing's disease are present, they are rarely the cause of the obesity. In an increasing number of patients, the onset or exacerbation of obesity correlates with the use of medications that cause weight gain as a side effect. When I first saw this patient, she was taking insulin, which is commonly associated with weight gain, and fluoxetine, which causes weight gain in a minority of patients. However, she had been severely overweight since late childhood, before those medications were administered.
The common disorders associated with obesity can be divided into five major categories: metabolic, structural, degenerative, neoplastic, and psychological (Table 2).2 Several of them (obstructive sleep apnea, thromboembolism, and degenerative arthritis) result from both structural and metabolic dysfunction. The relationship of each complication to the body-mass index varies widely, with the risk of diabetes and other metabolic complications increasing at a body-mass index as low as 23 to 25 and the risk of anatomical complications increasing most strikingly in persons with severe obesity. Among the many complications of obesity, obstructive sleep apnea, fatty-liver disease, gastroesophageal reflux disease, fungal skin infections, and nutrient deficiencies are the most commonly undiagnosed or undertreated complications in patients presenting for care at a specialized obesity center.2 This patient had diabetes, hypertension, and hyperlipidemia. As part of the initial evaluation, a sleep study was conducted, which showed that she had sleep apnea. Although it was not among the symptoms she initially described, she later reported that she had snored and had had difficulty sleeping for many years.
Table 2. Complications of Obesity.
People with obesity have an elevated risk of all the diseases for which patients are most commonly screened: hypertension, hyperlipidemia, diabetes mellitus, and cervical, breast, prostate, and colorectal cancers. Ironically, however, several studies have shown that they are less likely to undergo screening for these disorders than are people of normal weight.1,2 In this patient, screening was complete and up to date. The strongest medical contraindications for weight-reduction surgery are severe lung disease, unstable cardiovascular disease, uncontrolled clotting disorders, portal hypertension with gastric varices, pregnancy, and ongoing substance abuse. This patient had none of these disorders.
Nutritional Evaluation
Susan Cummings: This patient's comprehensive nutrition evaluation included the assessment of anthropometric data and social, nutritional, and behavioral factors. Our objectives were to assess her risk for complications of obesity, to identify factors contributing to her obesity, if possible, and to provide baseline data to assess the outcomes of treatment.
The measurements of height, weight, and waist circumference provide an indication of a patient's risk for complications of obesity (Table 3).1,2 Calculations based on the patient's height, weight, and age are used to estimate energy expenditure (Table 4).3 This patient's weight put her at extremely high risk for complications. Her energy needs were estimated to be 2500 kcal per day to maintain her current weight, but her reported intake was approximately 3000 kcal a day — 500 kcal more than her net energy needs.
Table 3. Assessing Obesity: Body-Mass Index, Waist Circumference, and Risk of Disease.
Table 4. Estimating Energy Expenditure.
The patient's weight history and that of her family may give some indication of a genetic predisposition. In this patient, the weight history revealed that the onset of obesity was in late childhood and that her highest weight as an adult was 129.3 kg, the weight at the time of her presentation to us. Her lowest adult weight was 79.4 kg, immediately after dieting. Her dieting history included four commercial programs and many self-directed diets. She had lost as much as 38.5 kg at one time through dieting, but like many people she always regained more weight than she had lost from each diet, and she had gained more than 45.4 kg overall during adulthood. Her family history revealed obesity in both parents and three brothers.
The nutrition evaluation included a 24-hour recall of total food intake and the frequency of food intake, as well as inquiry into hunger, satiety (how frequently she experienced hunger and what made her feel satiated), and behaviors such as binge eating, grazing (eating not related to hunger), nighttime eating, eating in restaurants, and alcohol consumption. This information helped to determine the patient's usual food intake and provided an indication of the environmental influences on her eating patterns. Most of her calories were consumed at meals with large portions of calorically dense foods. She ate three meals a day but occasionally skipped lunch and had a planned snack in the midafternoon. She often ate in fast-food restaurants.
The assessment of physical activity included information about the activities of daily living, physical limitations, and structured exercise. This patient was sedentary and did not engage in a structured program of exercise because of her chronic back pain. The patient's expectations concerning ideal weight were also addressed, as were her self-efficacy (confidence in the ability to make the necessary behavioral changes), motivation, readiness for weight loss, and potential barriers to treatment. This patient's primary motivation to lose weight was to improve her overall health and well-being.
Psychological Evaluation
Dr. Deborah A. Vineberg: Psychological assessment of patients with obesity was once thought to be important in identifying the cause of the obesity, which was believed to be related to a lack of self-control or to a psychological addiction to food. The current understanding is that the most important reasons for this evaluation are to diagnose and treat psychological disorders that result from the obesity, compound the existing weight problem, or interfere with effective treatment. Pretreatment evaluation of this patient included screening for psychiatric disorders that could interfere with the management of obesity. Axis I disorders in the Diagnostic and Statistical Manual of Mental Disorders, fourth edition (psychiatric disorders that are clinical in nature,4 such as depression or anxiety) and eating disorders (such as binge eating or bulimia) can complicate medical management unless they are treated adequately. This patient reported poor self-esteem and a profound sense of inferiority that she attributed to being overweight. She reported that stressful events, including the births of her children and her divorce, had exacerbated her weight problem. At the time of her evaluation she identified her job, single parenthood, and her declining health as stressful factors in her life. At the initial evaluation her Beck Depression Inventory5 score was 19, which corresponds to mild-to-moderate depression. Obesity is strongly associated with depression. Persons over 50 years of age who are obese are twice as likely to become depressed within five years as those who are not obese,6 but when followed for five years, those who are depressed are not at increased risk of becoming obese. Thus, obesity is a risk factor for depression, but the converse is not true.
Psychological complications associated with gastric bypass are similar to those associated with other major surgical procedures; transient postoperative depression is the most frequent complication. Exacerbation of preexisting psychiatric anxiety or depression is rare, and more than 90 percent of cases of depression and 50 percent of cases of anxiety disorders improve.7 Depression before weight-loss surgery does not worsen outcomes8; in fact, one study found that patients with higher Beck Depression Inventory scores lost more weight after surgery than those with lower scores.9
This patient described neither binge eating nor inappropriate behaviors such as self-induced vomiting or the use of laxatives or diuretics. She demonstrated good insight into the psychological function of her weight, which she characterized as providing her with a sense of safety and a form of protection. She admitted to being fearful of substantial weight change, and she worried about her potential for self-sabotaging behavior. She was provided additional sessions with a psychologist to address these concerns.
The presence of an Axis II disorder (a personality disorder or mental retardation) can lead to difficulties in management or can be a contraindication to surgery and should be addressed before surgery is undertaken. This patient did not have an Axis II disorder, and she had no family history of psychiatric disorders. Thus, she did not have psychiatric contraindications to surgery.
We also discussed her personal support system, since the involvement of family or friends in medical and surgical treatment of obesity can improve the outcome.10 She reported that both her family and her friends were supportive of her efforts to lose weight.
Weight-Loss Surgery
Dr. Pratt: A clinical-team meeting of the obesity-medicine specialist, nutritionist, and psychologist concluded that this patient was a suitable candidate for bariatric, or weight-loss, surgery. The term bariatric comes from the Greek word "baros," meaning "weight," and refers to the treatment of weight disorders. Many different surgical procedures have been tried during the past 50 years, but there are three major categories in current use: restrictive operations (gastroplasties with the use of adjustable gastric bands), malabsorptive operations (biliopancreatic diversions), and gastric bypasses. Each can be performed either laparoscopically or in an open fashion. The standard types of gastric bypass do not carry the risk of clinically significant protein malnutrition that is associated with biliopancreatic-diversion procedures.
Weight-loss surgery provides the best long-term results for patients with moderate (class II) or severe (class III) obesity who have not responded to more conservative approaches.11,12 It is generally reserved for patients with a body-mass index greater than 40 or for those with a body-mass index greater than 35 whose obesity is complicated by one or more major diseases. This patient met the criteria for this approach, since she had a body-mass index of 52 and several major complications and was unable to maintain weight loss by other means.
The overall morbidity and mortality associated with gastric bypass surgery are approximately 10 percent and less than 1 percent, respectively.13,14 Early postoperative complications of laparoscopic gastric bypass surgery include wound infections (incidence, 3 percent), anastomotic leak (2 percent), bowel obstruction (2 percent), gastrointestinal hemorrhage (2 percent), and pulmonary embolus (less than 0.5 percent). Late complications include bowel obstruction (3 percent) and stomal stenosis (5 percent)13; both of these problems are more common after laparoscopic procedures than after open procedures. Although reported in less than 1 percent of cases,7 anastomotic ulcers have been one of the most common late postoperative complications in my experience. In patients who have gastric bypass surgery, there is often improvement or resolution of coexisting diseases such as diabetes,15 hypertension, hyperlipidemia, and sleep apnea,12 as well as improved quality of life.7,14 For this patient, my colleagues and I believed that the risks of continued obesity outweighed those of bariatric surgery and its potential complications.
Laparoscopic Roux-en-Y gastric bypass was recommended, because this procedure is associated with the best long-term outcomes.14,16 This operation includes a restrictive procedure and a short-limb gastroduodenal bypass (Figure 1). It does not result in protein-calorie malabsorption, but it appears to induce neurohumoral effects that result in decreased hunger, accelerated postprandial satiety, and diminished emotion-based or reward-based eating.2 The physiological and molecular mechanisms of these effects remain poorly understood.
Figure 1. Roux-en-Y Gastric Bypass Surgery.
This operation includes a restrictive procedure, creating a small proximal gastric pouch, followed by the creation of a jejunojejunostomy in a "Y" configuration to allow an end of the jejunum to be brought up and anastomosed to this proximal pouch.
In the current case, preparation for surgery involved the full multidisciplinary team. The preoperative nutrition program included an individual session of nutrition counseling with a dietitian and a group education session to familiarize the patient with the postoperative diet protocol. The diet to be followed after gastric bypass surgery is advanced in a staged approach (Table 5). Psychological counseling was instituted to assist the patient in making the behavioral changes that would be required after surgery. The preoperative medical evaluation included a thorough assessment of the operative risks and the need for perioperative management of coexisting diseases, with discussion among the obesity-medicine physician, anesthesiologist, and surgeon to optimize her care.
Table 5. Protocol for Diet after Gastric Bypass Surgery.
The operation took about three hours. The surgical team first gained access by placing two 12-mm ports and three 5-mm ports through the abdominal wall in the upper abdomen — one for a camera, one for the liver retractor, one for stapling devices, and the other two for graspers to manipulate the stomach and intestines. The stomach was first divided by staplers across the cardia, creating a 30-ml proximal gastric pouch (Video Clip 1 in the Supplementary Appendix, available with the full text of this article at www.nejm.org). We then created a 100-cm Roux limb by dividing the intestines, stapling a jejunojejunostomy (Video Clip 2 in the Supplementary Appendix), and passing the limb behind the colon and stomach (Video Clip 3 in the Supplementary Appendix). Finally, this limb was stitched to the pouch in a double-layer anastomosis 1.5 cm in diameter (Video Clip 4 in the Supplementary Appendix). Because the liver appeared fatty, a wedge-biopsy specimen of the liver was obtained. Postoperatively, an amidotrizoic acid (Gastrografin) swallow examination confirmed that the gastrojejunal anastomosis was intact and without leak. The patient was discharged on the third hospital day while following a stage 1 diet (Table 5).
Pathological Discussion
Dr. Fiona Graeme-Cook: The specimen obtained by liver biopsy revealed hepatocellular steatosis with a very few foci of ballooning degeneration; the portal tracts showed slight proliferation of the bile ductules with minimal chronic inflammatory infiltrate (Figure 2A). Glycogenated hepatocellular nuclei were scattered. These findings are consistent with the presence of nonalcoholic fatty liver disease, without evidence of steatohepatitis, fibrosis, or cirrhosis.
Figure 2. Liver-Biopsy Specimen (Hematoxylin and Eosin).
Hepatocellular steatosis with small-droplet and large-droplet fat is apparent, with glycogenated nuclei (Panel A, arrows). Panel B shows a liver-biopsy specimen from another patient with nonalcoholic steatohepatitis, with steatosis, ballooning degeneration, and portal and lobular mononuclear infiltrates.
In the presence of insulin resistance, high levels of circulating insulin lead to high levels of free fatty acids within the liver, increasing the synthesis of triglycerides. Although the mechanism is not completely understood, hepatocytes accumulate fat, manifested as hepatocellular steatosis. This is the most common finding in the liver in patients with severe obesity, present in more than 75 percent of cases. The additional feature of glycogenated nuclei is also a marker for insulin resistance and hyperglycemia. Steatohepatitis may complicate steatosis, possibly as a result of excessive -oxidation of fatty acids by hepatocellular mitochondria. The resultant oxidative stress is thought to lead to peroxidation of lipids, resulting in hepatocyte necrosis, an influx of mononuclear inflammatory cells, and eventually, fibrosis and cirrhosis (Figure 2B). 17,18
Discussion of Outcome
Dr. Kaplan: During the early postoperative period, the patient's most prominent symptom was constipation, which was probably a result of mild dehydration. The mobilization of stored fat by lipolysis consumes prodigious amounts of water, and fluid requirements are high during the first several months after surgery. During the first few weeks, patients are closely monitored for dehydration, which may be manifested as constipation, lethargy, or light-headedness. The use of diuretics or other antihypertensive agents often must be reduced or stopped altogether in the immediate postoperative period. This patient's blood pressure remained normal, and the lisinopril was discontinued without adverse effect. Her blood sugar levels became normal within two days after surgery, despite the discontinuation of insulin and metformin. This rapid improvement in insulin sensitivity within several days after surgery is typical, and many patients require little or no therapy for their diabetes during this time. To avert potentially life-threatening hypoglycemic episodes, her blood glucose levels were monitored frequently and insulin and sulfonylureas were avoided.
Ten days after surgery, she had lost 9.1 kg. Three months after the operation, she was eating three meals and two snacks daily and had lost 27.2 kg. Six months after surgery, she had lost 37.2 kg and was eating most foods without having symptoms. Participation in postoperative programs of nutrition education and cognitive behavioral therapy appears to minimize both short-term complications related to nutritional issues and subsequent weight gain.10,11 Beginning six months after surgery, the patient participated in a monthly program for surgical support and education, which provides ongoing support and counseling. Her weight decreased by 54.4 kg, to 70.3 kg, during the first 12 months after surgery. Excess skin with ptosis in the lower abdomen was treated with abdominoplasty 15 months after the weight-loss surgery. She later regained approximately 4.5 kg, and her weight then stabilized at 74.8 kg for the next year.
Nutritional Outcome
Two years after surgery, the patient's body-mass index was 30, down from 52, and her energy expenditure was estimated to be about 1800 kcal per day, down from 2500 kcal per day. She ate three meals a day and did not routinely eat snacks. She experienced satiety with half-normal portions of food, and her hunger returned about five hours after each meal. She tolerated all types of food, although she avoided concentrated carbohydrates at the beginning of each meal as a way of preventing the dumping syndrome (i.e., rapid gastric emptying). She did not have any change in her food preferences. She walked 4.8 km a day and reported enjoying exercise for the first time.
Medical Outcome
Two years after surgery, the patient's diabetes improved but did not completely resolve. She no longer required insulin, and her metformin dose decreased from 850 mg taken three times daily to 500 mg taken twice daily. Her levels of hemoglobin A1c and urinary microalbumin fell (Table 1). Her diabetic retinopathy did not progress. Her sleep apnea, hypertension, and folliculitis resolved. Her lumbar back pain and sciatica improved substantially. Her hyperlipidemia remained well controlled with the use of a lower dose of atorvastatin than she was taking before the surgery, and there was no progression of her coronary artery disease.
A deficiency of micronutrients is common after gastric bypass surgery. We regularly assessed the patient's levels of iron, calcium, vitamin B12, vitamin D, and vitamin K. Iron deficiency developed approximately 10 months after surgery (Table 1). It was treated successfully with oral ferrous bisglycinate and polysaccharide iron supplementation. Before surgery, she had been found to have a vitamin B12 deficiency, which occurs in a small number of patients with obesity who have followed many diet programs. Intranasal vitamin B12 supplementation was begun before the operation and was continued afterward, and two years later she had normal levels of vitamin B12 (Table 1). Secondary hyperparathyroidism from malabsorption of calcium and vitamin D occurs in more than 60 percent of patients after gastric bypass. Metabolic bone disease is common and must be screened for and treated. This patient took prophylactic supplementation with an oral calcium preparation (1000 mg of elemental calcium per day), and her levels of calcium, vitamin D, and parathyroid hormone have remained normal.
Psychological Outcome
Six weeks after the operation, the patient recognized feelings of loss related to being unable to overindulge in food. She commented, "You fixed my stomach, but I need to fix my head," alluding to the need to focus on psychological triggers for eating that could no longer be satisfied by food. Twelve weeks after surgery, she reported feeling "great." She was excited about her increased energy, and the Beck Depression Inventory score fell to 3, within the range of minimal depressive symptoms, and it remained at that level thereafter. She stopped taking fluoxetine.
Two and a half years after the gastric bypass surgery, both her self-confidence and her self-esteem have increased. She is more assertive in her relationships, with positive results.
Dr. Pratt: This case illustrates the importance of a multidisciplinary team that includes an obesity-medicine specialist, a nutritionist, a psychologist, and a surgeon to ensure optimal medical and psychological results from weight-loss surgery.1,10,19 Although this patient was able to initiate exercise on her own, it is important to include a physical therapist or trainer when needed. Although her obesity was not cured, since her body-mass index remained elevated (at 30), the team viewed this case as having a successful outcome.
Dr. A. Benedict Cosimi (Surgery): How would you assess whether the patient's psychological issues were solved or complicated by the surgery? This patient considered her weight a protective shield. How did she feel when this shield disappeared?
Dr. Vineberg: Instead of using the weight as a protection, she worked to establish appropriate boundaries with people in her life, so that she could maintain appropriate emotional distance that did not depend on the physical or emotional distance caused by her size.
Dr. Kaplan: It is not clear whether the protection that she felt the excess weight provided was a primary or a secondary event. If you are shunned in society because of obesity, you may then use the weight as an excuse not to interact with people.
Dr. Carlos Fernández-del Castillo (Surgery): The adjustable gastric band has been approved by the Food and Drug Administration for use in the United States. I anticipate that its application is an easier operation than bypass. Why was it not used here?
Dr. Pratt: The early experience with the adjustable gastric band in the United States showed a high rate of reoperation,20 and definitive studies of long-term outcomes are not yet available. To achieve an optimal outcome, the band has to be adjusted every two to six months by the addition or removal of saline. This dependence on frequent follow-up visits suggests that success with this procedure may be more dependent on voluntary behavior than the success observed after gastric bypass.
Dr. Jay Vacanti (Pediatric Surgery): Can you comment on the use of surgery in the management of pediatric obesity?
Dr. Pratt: Obesity in adolescents is being treated surgically in several centers around the country, including the Weight Center.21 Although the pediatric program here focuses primarily on behavioral and medical approaches, gastric bypass surgery has been used to treat a few teenagers with severe obesity and obesity with medical complications, such as type 2 diabetes mellitus or obstructive sleep apnea, who have not been responsive to other interventions. Recent studies have shown that resolution of diabetes is most likely in patients who have had it for less than five years, so waiting to perform surgery in children with type 2 diabetes may be more dangerous in the long term than performing the surgery.22
Source Information
From the Weight Center (J.S.P., S.C., D.A.V., L.M.K.), and the Departments of Surgery (J.S.P.), Psychiatry (D.A.V.), Pathology (F.G.-C.), and Medicine (Gastrointestinal Unit) (L.M.K.), Massachusetts General Hospital; and the Departments of Surgery (J.S.P.), Psychiatry (D.A.V.), Pathology (F.G.-C.), and Medicine (L.M.K.), Harvard Medical School.
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Nguyen NT, Goldman C, Rosenquist CJ, et al. Laparoscopic versus open gastric bypass: a randomized study of outcomes, quality of life, and costs. Ann Surg 2001;234:279-291.
MacDonald KG Jr, Long SD, Swanson MS, et al. The gastric bypass operation reduces the progression and mortality of non-insulin-dependent diabetes mellitus. J Gastrointest Surg 1997;1:213-220.
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Ren CJ, Horgan S, Ponce J, et al. US experience with the LAP-BAND system. Am J Surg 2002;184:46S-50S.
Sugerman HJ, Sugerman EL, DeMaria EJ, et al. Bariatric surgery for severely obese adolescents. J Gastrointest Surg 2003;7:102-108.
Schauer PR, Burguera B, Ikramuddin S, et al. Effect of laparoscopic Roux-en-Y gastric bypass on type 2 diabetes mellitus. Ann Surg 2003;238:467-485.
Related Letters:
Case 25-2004: A Woman with Severe Obesity, Diabetes, and Hypertension
Padwal R., Podgorski G. P., Pratt J. S., Kaplan L. M.(Janey S. Pratt, M.D., Sus)