Open Access
Feature Article

What's new in weight loss management and surgery?

Open Access
Feature Article

What's new in weight loss management and surgery?

Tamara C Preda, Veronica A Preda, REGINALD V. LORD

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© animated healthcare ltd/spl/diomedia.com
© animated healthcare ltd/spl/diomedia.com
Dr Veronica Preda is a Consultant Endocrinologist at Macquarie University Hospital; and Senior Clinical Lecturer at Macquarie University, Sydney. Dr Tamara Preda is a General Surgeon at Liverpool Public Hospital, St Vincent’s and Prince of Wales Private Hospitals; and Clinical Lecturer in Surgery at the University of Notre Dame, Sydney. Professor Reginald Lord is an upper Gastrointestinal Surgeon at St Vincent’s Public and Private and Macquarie University Hospitals; and Professor and Head of Surgery at the University of Notre Dame, Sydney, NSW. Dr Veronica Preda and Professor Lord are both members of the multidisciplinary Healthy Weight Clinic at MQ Health, Macquarie University Hospital, Sydney, NSW.

Novel antiobesity procedures

It is important for GPs to be able to inform their patients that novel devices for obesity, outlined below, are neither restrictive (in the sense of decreasing oral intake) nor malabsorptive. Also, they go against the bariatric principles of healthy eating choices and modifications to diet that are the basis of durable medically meaningful weight loss management.

Intragastric balloons

Some patients who are unwilling to undergo surgery or do not meet the BMI and other criteria for surgery opt to have endoscopic placement of an intragastric balloon. The saline-filled silicone balloon within the stomach mimics gastric fullness. The treatment is temporary (six or 12 months) but may be repeated at intervals. Intragastric balloon treatment is not covered by Medicare or private health insurance and is consequently expensive. Initial weight loss should occur when used in concert with lifestyle changes, but weight regain is reported to occur in about one-third of patients after balloon removal, and weight cycling between serial procedures is common.27 

Complications include pain, nausea and halitosis, as well as less frequently gastric erosion or ulceration, and perforation, which can be fatal. The balloon may also deflate and migrate, causing a bowel obstruction. The long-term efficacy of this procedure remains unclear, and safety notices have been issued by various government agencies worldwide regarding this therapy.

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Endoscopic sleeve gastroplasty 

Endoscopic sleeve gastroplasty (also known as transoral gastroplasty) uses endoscopic suturing to create a narrow gastric lumen that is intended to replicate a now discarded operation, vertical banded gastroplasty. The long-term failure of that operation suggests that patients who undergo endoscopic gastroplasty will need to be monitored for failure of the suture line. Intake is restricted and satiety following small meals occurs. Professional societies such as the American Society for Gastrointestinal Endoscopy suggest that endoscopists performing these procedures have a system in place for enrolment and long-term follow up of patients to monitor weight loss and maintenance.

Conclusion

In patients with obesity who have comorbidities such as type 2 diabetes, bariatric surgery has been demonstrated to be superior to intensive medical therapy in managing these diseases.16 Most patients will achieve at least partial remission of comorbid diseases, and normoglycaemia off all diabetes medications is also reported in most patients, but the diseases can recur if weight is regained. Bariatric surgical management has been shown to reduce all-cause mortality (including deaths due to diabetes, cardiovascular disease and cancer) in patients with obesity.28-33 It represents a growing area of experience for patient care, with good evidence to support certain bariatric techniques for sustained weight loss and improvements in overall health. An experienced team approach, tailoring treatment to the individual patient is important. If surgery is appropriate, the risks and benefits for each patient, including the psychological effects of permanent inability to eat a normal-sized meal, need to be considered and explained. At present, sleeve gastrectomy has the best risk-to-benefit profile. Patients must commit to lifelong adherence to dietary modifications and vitamin monitoring, as deficiencies are common. 

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Overall, obesity is a complex chronic disease for which specialist weight assessment and management clinics are required for optimal care. With the emergence of new drugs, devices and surgical procedures, as well as ever increasing patient numbers, assessment by teams skilled in this area is becoming more necessary. Surgery has a definitive effective role in management. Postsurgery diligent follow up and review of patient care is essential to maintain weight loss and remission of comorbid disease.      MT  

 

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COMPETING INTERESTS: None.