Consider bariatric surgery first for severely obese women
I stopped wasting time with lifestyle fixes and drugs that don’t work for these patients. You should, too.
Which procedures, for which patients?
Restrictive procedures, such as vertical banded gastroplasty and laparoscopic adjustable gastric banding, are typically associated with fewer surgical complications and more gradual and less ultimate weight loss than malabsorptive procedures, such as jejunoileal bypass, biliopancreatic diversion, and duodenal switch.
The Roux-en-Y gastric bypass is a combined restrictive operation (the small gastric pouch limits oral intake) and malabsorptive operation (small-bowel reconfiguration increases dumping physiology and malabsorption).
The adjustable gastric band has an internal, inflatable balloon that can be adjusted through an abdominal port to a greater or lesser degree of constriction. For a woman with this procedure who becomes pregnant, constriction can be lessened to increase nutritional intake.
What about complications?
Complications of bariatric surgery vary with patients’ comorbidities, the technical skill and experience of the surgical team, and the type of procedure. Thirtyday operative mortality rates have been estimated at approximately 0.1% for restrictive procedures; 0.5% for gastric bypass; and 1.1% for biliopancreatic diversion and for duodenal switch.7 About 15% of patients who undergo laparoscopic adjustable gastric banding require a second operation for complications such as stomal obstruction, band erosion, band slippage, port mal-function, esophagitis, and infection.8
Many patients develop nausea and vomiting after bariatric surgery; if nausea and vomiting are accompanied by fever or severe abdominal pain, the patient should be thoroughly evaluated for a surgical emergency, such as bowel obstruction.
The most common nutritional abnormalities in patients who undergo bariatric surgery are iron, vitamin B12, folate, and thiamine deficiencies.
Pregnant women. Pregnancy should be avoided for 12 to 18 months, or until weight loss reaches a plateau, in any woman who has undergone gastric banding. Several pregnant women died after bariatric surgery because intervention was delayed during a developing surgical emergency, such as bowel obstruction.9
Don’t delay! This epidemic has major health impacts
Obesity in the obstetric population is associated with an increased rate of gestational diabetes, preeclampsia, congenital malformations, macrosomia, and cesarean section. In the gynecologic population, obesity is associated with an increased rate of fibroids, endometrial cancer, breast cancer, polycystic ovary syndrome, and infertility.
Behavioral therapy and medical therapy are unlikely to cure a patient who is severely obese. Again: I urge you to stop wasting your time with ineffective interventions for your patients whose BMI tops 40! Refer them to a bariatric surgery center instead, and reap the rewards.
