Medical Risks of Bariatric Surgery

The newest clinician to treat obesity is the surgeon. Although Bariatric procedures can have startling short-term benefits for obese patients and their medical co-morbidities, there's not much reliable data about the long term risks of surgery. I have written frequently about the difficult road to curb overeating and binging, and the decision to have drastic surgery can be liberating. It feels like the magic cure after years of struggle. But the surgeon, without sufficient knowledge of the life and trials of the obese person, typically is not equipped to assess suitability of the patient or inform patients of the real risks of surgery. Instead, they paint a rosy picture of weight loss without any reality check at all and proceed accordingly.

Unlike all other interventions for binging and overeating, surgery is permanent. The goal is to create a physical impediment that will stop someone from eating too much. The surgeon can explain the various procedures and risks during the surgery well, such as the possibility of infection or the risks of anesthesia, but has little knowledge of what happens afterwards. Much of the pre-screening is completed during a psychological evaluation which appears to be a part of the pre-op checklist rather than weeding out patients who shouldn't move forward. The only true impediment is cost, largely based on insurance coverage. After that, almost anyone who meets criteria can have it done.

Changing the anatomy of the gastrointestinal tract has significant medical consequences. This post will not thoroughly review the risks but rather point out some important things to consider. The long term effects of Bariatric surgery are still largely unknown.

After surgery, a much smaller amount of food enters the digestive system, by design. The body adapts by slowing down digestion in response to the decreased need. Over a long period of time, slowed digestion is no longer an adaptation but a permanent change called gastroparesis or delayed gastric emptying. The symptoms are chronic indigestion, limited diet and abdominal pain and, in its severe form, can be debilitating with minimal effective treatment. This condition can lead to permanent gastrointestinal disability.

Medical science is still learning about the complicated interplay between hormones in hunger and digestion. There is a lot of current research into endocrine involvement in the gastrointestinal system to devise weight loss medications. Some Bariatric surgeries take out parts of the stomach that produce these hormones. Since doctors don't know the exact mechanism of hormones in digestion, no one knows what long-term effects low levels of digestive hormones may have.

Bariatric surgery also affects absorption of nutrients, vitamins and minerals in the stomach and small intestines, yet once again it's not clear how or why this happens. Years after surgery patients can have rare deficiencies of micronutrients that humans need in very small quantities of for our bodies to function. Since its so uncommon to see signs of these deficiencies in today's world, most doctors don't check these blood tests and the syndrome goes undiagnosed.

In addition, Bariatric surgery is not a cure for eating disorders. People who binge or manage emotions by overeating find that the drive to use a behavior can outwit any physical impediment. It's too easy for people who have had one of these surgeries to adapt their symptoms and find themselves trapped again but having also undergone an ineffective, painful procedure. A thorough psychological screening needs to identify patients with eating disorders and direct them for treatment before even considering surgery.

It's telling about the current reaction to the obesity epidemic that as drastic an option as surgery is so popular. The misdirection in advertising by agribusiness, the processed food industry and the diet industry has successfully placed blame on the individual. Even the government believes the solution to this public health issue is education and individual choice despite growing evidence that we are powerless to resist the current world of delectable food. All signs erroneously place the blame squarely on the individual. Diets are ineffective and medications supposedly in the pipeline, so for many surgery appears to be the best alternative. The medical literature of the consequences of Bariatric surgery can't slow down the growth of this branch of the health care industry. 

It strikes me that only another part of the medical field can inform the public about these risky surgeries. Doctors only sporadically see patients with severe consequences of surgery because there are no sub-specialists at this point. The surgeries are still new enough that medicine doesn't yet have enough evidence to challenge such a radical approach to obesity. Pooling data among clinicians, a difficult task without centralized medical records, would be very effective. The hope is that the medical system will recognize the risk of Bariatric surgery and respond appropriately in the very near future. 

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