Gastric Bypass or Laparoscopic Gastric Band?


Gastric Bypass

When I was a very young doctor I had an enormously fat patient – in those days it was rare to be so fat – who was admitted to the hospital for a long time to try to get her to lose weight more or less by starving her. I still remember her semi-liquid form flowing over the sides of the bed. I tried to be nice and understating.

“I suppose you eat for comfort,” I said to her.

“No, dear,” she replied. “I just like the taste.”

I did no know then that she was (if I may be permitted what in the circumstances is a slightly ridiculous metaphor) the canary in the mine, and that only 40 years later many human mastodons would bestride the world, at least in America and Britain.

With this epidemic has grown a new surgical speciality: bariatric surgery, that is to say surgery to correct obesity. A paper in a recent edition of the Journal of the American Medical Association reports on the results of two types of such surgery to treat obesity, gastric bypass and laparoscopic gastric band.  (How long before a rock group calls itself the Laparoscopic Gastric Band?) The authors conglomerated the results from 10 hospitals so that the results should reflect average practice, not just the very best practice.

Gastric bypass proved to have better results all round than gastric banding, except that there were a small number of deaths immediately after surgery. But the results were distinctly variable even for the same procedure; for example, at three years after operation those who had had a gastric bypass varied between having lost 59.2 per cent of their baseline weight and having gained 0.9 per cent. Those who underwent the gastric banding varied between having lost 56.1 per cent of their original weight and having gained 12.6 per cent. On average, however, the two groups had lost 31.5 per cent and 15.9 per cent respectively of their original weights after their operations.

Most of the weight loss was within the first year after the procedures; one sub-group among the patients began to regain weight after six months, and all began to regain weight after two years. The weight they gained after two years, however, was slight by comparison with what they had lost.GetImage

Gross obesity is strongly associated with Type II diabetes. The operations ameliorated the diabetes of those who suffered from it in 67.5 percent of those who had at the time of gastric bypass and 28.6 percent of those who had it at the time of gastric banding. Gastric bypass also improved the lipid profile of 61.9 percent of patients with dyslipidamia and 27.1 percent of those who underwent gastric banding. The question that this study did not answer, however, was whether these improvements resulted in a reduced death rate of those who underwent surgery compared with those who did not. For it is always dangerous to suppose that the reduction in the risk factors for something (such as death from heart attacks or strokes) actually results in a reduction of that something itself. What stands to reason in medicine turns out often not to be so reasonable after all.

I happened to read this paper while I was in France. No one can possibly say that the French do not enjoy their food but it is perfectly obvious that the proportion of grossly obese people in the population of France is very much smaller than that in America or Britain. This was an aspect of the question of obesity that the paper did not mention. There is no possibility that surgery will improve the deplorable dietary choices of so many Americans and British.