Quote:
HammerHead previously said:
Since you are the "Belly Doc" here is one for ya.
Gastric Bypass or LapBand  |
If you look at the data, both of these procedures are good for about 50 to 70% of excess body weight loss. However, the bellshaped distribution of results overlap and the Roux-en-Y Gastric Bypass (RGB) is slightly favored from that standpoint. This, however, is HIGHLY surgeon dependent. It turns out that different surgeons have different results with these operations and not all of it is due to surgical expertise. There are a variety of system related factors that play into it.
The LapBand requires absolutely NO gastrointestinal anastomoses (places where you sew the bowel together to direct flow). The KEY danger of any morbid obesity operation is leakage from an anastomosis. The mortality of anastomotic leak can be as high as 50%. The reason that it's so dangerous (and so much MORE dangerous than the same type of complication in a thinner person) is that one of the consequences of having spillage into the belly is often that the patient will require at least a day or two in the ICU on a ventilator after the emergency clean up operation. A morbidly obese person on a ventilator is a timebomb of further complications waiting to happen. Also, it can be very difficult to detect the presence of a leak before it starts to create havoc.
Any obesity operation is more successful in the best selected and best prepared patients. This is where the "system factors" play in. Surgery for morbid obesity is only a small component of a larger care plan that includes a tremendous amount of support from non-surgical care providers who assist the patient in a massive lifestyle change - both before the operation and afterward. People who are not going to tolerate the change well, even though they may really really want to try - need to be properly identified so that they can be properly counselled. This is why you could look at a statistical plot of weight loss for an individual surgeon who does a lot of these operations and get a completely WRONG idea of their comparative surgical skill. The measure of weight loss as an outcome tests the whole system that the surgeon is part of.
I don't do these operations, although I have some experience with them from my training. My hospital system isn't tooled up to do these, my patient population is probably not rich in people who could participate at the level necessary to benefit, and if I were to try to set some system in place that would be able to support a weight loss practice, I'd have to feed it a constant stream of patients in order for it to maintain its skill level.
Basically, for this operation, a surgeon is either IN or they're OUT. If they're IN, they better be IN 100%. There is little or no room for a part time bariatric surgeon. A surgeon who wishes to participate in bariatric surgery should probably be doing this operation more than once a week. After they are established, they should probably be doing over 100 per year. It needs to be the main thing that they do.
I have a very broad based minimally invasive surgical practice involving a variety of complex laparoscopic surgical procedures. I'm heavily involved in surgical education, teaching residents the basics of surgery, and in particular the basics of laparoscopic technique. I wouldn't be able to offer as much training for my residents if I narrowed my practice to bariatrics.
As you can tell, I've thought a lot about this! This is for good reason. Bariatric surgery WORKS. Obesity is a massive public health problem (pun intended) and surgery is the ONLY weight loss method with durable statistical results. It ameliorates a huge number of related medical issues. It quite simply saves lives. There is a lot to be said for offering this operation. I just can't justify doing it if I'm going to offer a shabby version of it because I don't do it enough or I don't do it within a sufficiently supportive system.
...bet you didn't want that much...
Bottom line RGB vs. LB:
I would offer the LB because it's safer. I'd make up the slight difference in weight loss statistics by doing it within an amazingly well conceived system of diet and excercise counselling along with support groups and social networking, to help keep people on track after surgery.
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