(October 27, 2008 - Insidermedicine) On a recent trip to Boston, we caught up with Dr. Michael Tarnoff, MD, FACS, an adjunct associate professor of Surgery at Tufts University School of Medicine. Dr. Tarnoff specializes in minimally invasive and bariatric surgery at Tufts Medical Center.

What is morbid obesity?

Morbid obesity is defined as having a BMI of 35 or above. That corresponds roughly to being 100 lbs above your ideal body weight. When you look at the comorbid health conditions that go in association with that, of which more than 60% of these patients will have, these would include high blood pressure, sleep apnea, asthma, heartburn, type 2 diabetes, and other conditions, not the least of which would include poor quality of life, and the risk of early death.

What diagnostic tests are available?

Patients considering weight loss surgery should be part of an integrated multidisciplinary program, and what is meant by that is that evaluation is not just about coming in and meeting a surgeon and getting signed up to have an operation, it is about a whole life-change and a move toward lifestyle adjustment, and that entails meeting with psychologists, it entails meeting with dieticians and nutritionists, it entails meeting with internal medicine physicians who specialize in obesity treatment, and ultimately it entails meeting with a surgeon to discuss specifically issues related to informed consent about the risks, benefits and alternatives of weight loss surgery, and everything related.

How is morbid obesity managed?

The management of morbid obesity generally includes two broad options. Clearly medical therapy is an option for just about every patient, and most patients that we see in a surgical weight loss clinic have clearly already tried and failed medical weight loss options and in fact that is one of the requirements before a patient can be considered for a weight loss operation, so surgery should never be viewed as a first line therapy. Medical options traditionally include self diets, fasting, low calorie diets which could also include liquid diets, there are pharmaceutical option in the form of two FDA approved drugs to help patients lose weight, and then there are combination therapies that entail use of all of those together. When you talk about surgical options there are two predominant ones that exist today that include laparoscopic gastric bypass surgery and laparoscopic gastric banding.

What is involved with these surgical methods?

Laparoscopic gastric banding entails placment of a silicon device around the upper aspects of the stomach (just below the point where the esophagus meets the stomach). The band is buckled (not too differently from what you might do with a belt buckle) and that establishes without the need for a stapling or division of tissue the creation of a small gastric pouch which then assists the patient by helping them to eat less. That’s connected to a small reservoir that’s implanted under the skin, under the breast bone which can then be adjusted, which again helps to augment appetite and typically result in adjustment of caloric intake in properly selected patients who follow up.

Laparoscopic gastric bypass entails the surgical creation of a small gastric pouch, typically about an ounce in size. This is done with the use of a device that divides the stomach tissue and staples the end shut, which is why this is sometimes referred to as stomach stapling (although that is a little bit too much of a simplistic view nowadays). Once the gastric pouch is created, the remainder of the operation entails division of the small intestine and then rerouting of the small intestine to drain both the pouch and the area of the excluded stomach which is now isolated from the outside environment .
It would be important when meeting with a surgeon to go through the details of this and to have an understanding of both of these procedure anatomically.

If I had a BMI of 35 or greater…

If I had a BMI of 35 or greater, and were diagnosed with morbid obesity or any of the associated comorbid health conditions, most specifically diabetes, I would overwhelmingly be concerned about my health status; I would be concerned about quality of life, and I would be concerned about longevity. There are now multiple studies that show that unless you are able to achieve a durable meaningful weight loss on your own and effectively rid yourself of obesity, that these associated medical conditions will ultimately shorten your life and adversely affect your health. So the consideration of surgery becomes reasonable when you look at a multitude of studies that have now been concluded over the last 10-20 years that show that despite the well publicized and over-stated risks of surgery, it is actually quite a viable option and that the risk of elective surgery to treat obesity and overweight conditions is actually less, from a risk perspective including mortality, than the risk of untreated obesity left alone.