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I copied this article from a web site recommended on the DS authorization

site. I thought it was well written and worth a read.

Pam

http://www.sifersmd.medem.com

(Written by Dr. Sifers for IPA Newsletter)

The National Institute of Health in the early 1990' s recognized the complete

failure of medical management of obese patients and

strongly encouraged bariatric surgery for persons with a BMI of 40 or

greater, or of 35 or greater with significant associated medical problems.

They also concluded that bariatric surgery for patients with a BMI of 50 or

greater is mandatory. The big question is not if surgery is indicated in

these patients, but which procedure is best.

There are basically two types of procedures to surgically treat morbid

obesity. Historically and currently in the United States, restrictive

procedures (i.e. l-oz. Gastric pouch with small gastric outlet) are the most

common. These include Mason Shunt, Vertical Banded Gastroplasty, Roux-en-Y

Gastric Bypass and Gastric Banding (adjustable/inflatable). These procedures

do result in significant weight loss, however they also cause drastic

lifestyle changes and frequently fail after ten years, requiring

re-operation. If the procedure is successful, the patient will never enjoy

eating and will always be limited from a large diet to very small amounts of

solid food.

The second type of bariatric surgery involves moderate gastric

restriction combined with partial malabsorption. These procedures include

Biliopancreatic Diversion (BPD) and Duodenal Switch (BPD/DS). These two

procedures have been done in Europe and

Canada for twenty years and in the United States for about five years.

They work by causing near-total malabsorption of fat and significant

malabsorption of protein and complex carbohydrates. They also

require careful medical follow-up for twelve to eighteen months to avoid

malnutrition complications. However, this is easily medically managed.

After twenty years of participating with gastric restrictive procedures

including Mason shunts, VBG's, and Roux-en-Y gastric stapling, I have

been extremely impressed with the medical and psychological advantages of the

BPD-type procedures. I originally did not fully

appreciate these advantages, however we have completed just over 100* of

these since late August of 2000. These patients are followed on a monthly

basis and, in my opinion, have far more superior medical and psychological

outcomes. The medical advantages are significant. The BPD results in complete

cure of type II diabetes and returned cholesterol and

triglyceride levels to normal within one month. The Biliopancreatic

Diversion is the only bariatric procedure to have a proven twenty-year

follow-up with limited weight regain. It results in 90-95% loss of excess

body weight within eighteen months of surgery.

The FDA has recently approved adjustable and inflatable Lap Band

procedures, after considerable controversy. These are very simple

operations, basically involving solid or inflatable bands placed just distal

of the esophagogastric junction. Although simple and easily performed

laparoscopically, in my opinion this is the worst and most

dangerous form of bariatric surgery. The twelve to eighteen month excess body

weight is only 35-40%. No long-term statistics are available, but the

expected slippage and gastric erosion rate may be very worrisome.

No bariatric surgical procedure is fool proof. All involve significant

risk and complication rates, and depend heavily on strict patient

compliance. The odds of any patient with a BMI greater than 40 losing 100

pounds and maintaining that loss for three years is less than 1% on any form

of medical management. For BPD patients, the odds exceed 95%.

After twenty years, loss of excess body weight for BPD patients ranges

from 75-90%. Roux-en-Y gastroplasty (most-common restrictive procedure) does

result in short-term weight loss (75-90% loss of excess body weight), which

is nearly equivalent to the BPD. However, long-term studies show the

Roux-en-Y bypass after 14 years to only provide 49% excess body weight loss.

In other words, those procedures will usually be temporary and require

re-operation in about ten years.

Despite the risks of bariatric surgery, almost all insurance companies will

cover most of the patient's cost. They have correctly

calculated that the costs of bariatric surgery are far less than the future

costs of failed medical management for morbid obesity.

There is no question that obesity is a major medical problem in the United

States. The normal BMI range is 19-25. The range of obesity is 25-40. Morbid

obesity is defined as a BMI at or above 40. There are 97 million Americans

age 20 or greater classified as obese, or 55% of the adult population. Ten

million Americans are morbidly obese, or 5% of the population. Morbidly obese

patients have a mortality rate 1200% higher than the same age person of

normal weight. Any patient with BMI of 40 or greater has a proven significant

increase in risk of coronary heart disease, type II diabetes, stroke,

significant bone and joint disease, sleep apnea, cancer, and a host of other

medical problems. All of these problems are weight-related and correctable

with significant maintained weight reduction.

As I stated before, I have been pleasantly impressed with the success of the

Biliopancreatic Diversion procedure. We are currently accepting new patients

who are interested in this procedure, and should any physician require more

information about the BPD, we would be happy to provide it.

The IPA DOC Newsletter, Aug 2001*

BY: Sifers. M.D.. F.A.C.S.

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