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Featured Commentary

The online formats of SRGS include access to What You Should Know (WYSK): commentaries on articles published recently in top medical journals. These commentaries, written by practicing surgeons and other medical experts, focus on the strengths and weaknesses of the research, as well as on the articles' contributions in advancing the field of surgery.

Below is a sample of one of the commentaries published in the current edition of WYSK.


Adams T, Davidson L, Litwin S, et al. Weight and Metabolic Outcomes 12 Years after Gastric Bypass. N Engl J Med. 2017;377:1143–1155.

Commentary by: Raul Rosenthal, MD, FACS

We commend the authors for an excellent, pivotal report that highlights the benefits of bariatric-metabolic procedures that result in remission of comorbidities associated with severe obesity. In previous reports, Adams et al, reported that bariatric-metabolic procedures result in decreased long-term mortality when compared to matched subjects that opted not to undergo bariatric surgery.1 In this report, the group presents 12-year follow-up results of an observational and prospective study of severely obese subjects that underwent Roux-en-Y gastric bypass (RYGB) and assessed the remission of associated metabolic syndrome (MS), as well as maintenance of weight loss (WL). A total of 1,156 patients with severe obesity were divided into three groups: 418 patients who sought and underwent RYGB (surgery group), 417 patients who sought but did not undergo surgery (non-surgery group 1) primarily due to lack of insurance coverage, and 321 patients who did not seek surgery (non-surgery group 2).

The authors performed clinical examinations at baseline and at 2 years, 6 years, and 12 years to evaluate the presence or remission of type 2 diabetes mellitus (DM), hypertension, and dyslipidemia. At 12 years, the authors reported that the group that underwent RYGB had a significant higher remission of DM (51 percent of the subjects) when compared to the non-surgical groups. In addition, although not significant, the surgical group demonstrated a higher remission or improvement of MS. Also, the surgical group’s WL at 12 years was significantly higher, with -35kg excess weight loss (EWL), when compared to the non-surgery groups, whose EWL was -2.9 kg at 12 years. The authors demonstrated the long-term durability of WL and effective remission and prevention of DM, hypertension, and dyslipidemia in severely obese subjects after RYGB when compared to a non-surgical group of patients.

This study is relevant for many reasons. First, it is not written by a group of bariatric surgeons, which reduces the potential for bias in conclusions. Second, it shows the excellent long-term maintenance of WL and remission of comorbidities after RYGB. The latter becomes a paramount finding because bariatric literature is generally deficient in reporting long-term follow-up. The reason for this phenomenon is the high percentage of patients that move out of state, lose their insurance coverage, and are unable to see their treating physicians. It is also important to highlight the significant number of patients that, despite being good candidates for RYGB, were unable to benefit from bariatric surgery due to lack of insurance coverage. Finally, of note is the large number (n=321) of patients that chose not to undergo bariatric surgery despite its record of being effective and amongst the safest surgical procedures being performed in surgery worldwide.2 Most of these patients either fear surgery or, despite being severely obese, are in denial and do not see themselves as surgical candidates.3 In summary, the authors have to be congratulated for an outstanding and critical contribution to the body of bariatric-metabolic surgical literature.

References

  1. Adams TD, Gress RE, Smith SC, et al. Long-term mortality after gastric bypass surgery. N Engl J Med. 2007;357:753–61.
  2. Pories WJ, Swanson MS,MacDonald KG et al. Who would have thought it? An operation proves to be the most effective therapy for adult-onset diabetes mellitus. Ann Surg. 1995;222(3):339–50; discussion 350–2. Free Full Text
  3. Alfonso BB, Rosenthal RJ, Li KM, et al. Perceived barriers to bariatric surgery among morbidly obese patients. Surg Obes Relat Dis. 2010;6(1):16–21.