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Mal Fobi’s Corner

Should a bariatric surgeon perform the procedure requested by the patient?

Currently there are many operations in the armamentarium of the bariatric metabolic surgeon and we also have a better understanding of how these operations effect their outcome.

Should a bariatric surgeon perform the procedure requested by the patient?

I am often asked this question.

I have always taken this to be a push back by surgeons who claim they did an operation because that is what the patient wanted. This is usually in response to the question “Why did you choose that particular operation for the patient?”

I remember asking quite a few surgeons in the eighties and nineties why they did a gastroplasty (gastric stapling) instead of the gastric bypass? Then the question became why the adjustable band in the late nineties and early 2000 and currently why they do a sleeve gastrectomy?

The article was authored by Mathias A. L. (MAL) Fobi - MD FACS, FICS, FACN, a clinical professor of surgery at SAIMS JIO University and the Director of clinical Research and Training at Mohak Bariatric and Robotic Surgery Center in Indore, India. He was the Medical Director and Chief Surgeon at the Center for Surgical treatment of Obesity in Los Angeles from 1979 to 2016. He is a past President of the California chapter of the ASMBS, past President of the ASMBS Foundation, past President of IFSO and past Chair of the Board of Trustees of IFSO

What is common to these procedures is that more than 50% of them were/are by surgeons who could/can do only one type of bariatric operation. Any surgeon can perform the operation.  These are deceitfully easy operations to perform though not that easy to perform correctly and safely. Also since the procedures are technically easy to perform, surgeons can perform many cases daily.

Let us put this in the perspective of usual medical practice. Apart from cosmetic surgery, it is not customary for a patient to go to a surgeon and request a particular operation? Admittedly, currently most medical information is readily available on the Internet for those who can take the time to read and extract good information. In that case a well-informed patient should be able to request a particular operation.  Otherwise, a bariatric metabolic surgeon (a surgeon specialized in bariatric metabolic surgery who can perform various bariatric metabolic operations including revision operations) is best placed to recommend the operation of choice for a particular patient based on the patients condition.

We, bariatric metabolic surgeons, understand the disease obesity a little better now than when obesity surgery was introduced. Currently there are many operations in the armamentarium of the bariatric metabolic surgeon and we also have a better understanding of how these operations effect their outcome.

In addition, we know more not only about the effectiveness but also the duration of the effectiveness of the operations. Last, and most importantly, we now have good information on some of the inherent side effects of the operations.

This brings us to algorithm in the field of bariatric metabolic surgery. This is only possible if a bariatric surgeon can perform a variety of operations or at least the most common varieties such as sleeve gastrectomy, gastric bypass (long limb, distal or banded) one anastomosis gastric bypass and biliopancreatic diversion with a duodenal switch. Unfortunately, any surgeon who can do laparoscopic surgery is free to call himself a bariatric metabolic surgeon and there is not much anyone can do about it. It is a free wide world. (Legislation without ability to enforce is not very helpful.)  In addition, people afflicted with unhealthy weight are desperate, and thus, very susceptible to unsubstantiated claims.

Should a bariatric metabolic surgeon perform the procedure requested by the patient?

Yes, if the surgeon can perform the operation technically correctly and safely.

BUT

The patient must be a candidate for a bariatric metabolic procedure.

The patient must show an understanding that obesity is a multifactorial chronic disease.

The patient must understand that any treatment is to control the obesity not cure it.

The patient must understand that since the human body has a tremendous ability to adapt there is a high probability for a secondary operation sometime in the follow up period

AND

The surgeon must have discussed the various options available for treating the patient and agrees with the choice of the operation requested by the patient.

In addition to the above, the patient must show an understanding that:

  • The bariatric operation requested is a tool that has to be used judiciously by the patient for the chance to attain weight loss and weight loss maintenance.
  • That even if the operation is done optimally and the patient follows the guidelines strictly, there is no guarantee that the patient will lose and maintain the weight loss.
  • That even if the operation is done optimally and the patient follows the guidelines strictly, there are adverse effects (complications) that can occur and that some complications can only be corrected by another operation.
  • That even if the operation is done optimally and the patient follows the guidelines strictly the operation has un towards outcomes that the patient must learn to live with in exchange for the benefits from the operations.

No, if the surgeon does not know how to perform the operation correctly, technically and safely or does not have the support and equipment to manage a patient with the operation. In that case, the surgeon should refer the patient to a center where the procedure can be performed correctly and safely

No, if the surgeon does not perform the operation requested because it is not an accepted procedure in the state or country where the surgeon practices or

If it is not a safe operation for treating obesity.

What if the surgeon can perform the operation requested but does not think it is the best operation for the patient?

The answer depends on what the surgeon’s decision is based on, effectiveness of the operation or contraindication to the operation.

Yes, if the surgeon thinks there is a more effective operation, but the operation requested is not as effective but has no increased risk above the operation the surgeon would recommend. The patient should be so informed.

No, if after a detailed informed consent, the surgeon thinks the risk of the operation far outweighs its benefit i.e.,

  • A patient with <30% cardiac ejection fraction requesting a BPD-DS
  • A patient with grade C esophagitis requesting a sleeve gastrectomy
  • A patient with a strong history of gastric cancer requesting a gastric bypass leaving a remnant stomach in place.
  • A patient with unrealistic expectations of the operation

The surgeon should recommend the patient seek a second opinion and consider an alternate procedure.

What if a surgeon only performs one type of bariatric operation?

Ideally, if that is the operation the surgeon can perform, he/she should not be performing bariatric metabolic surgery. However, if forced by circumstance,

such a surgeon should perform that operation only in a case where the operation is the best option otherwise refer the patient to a center where the best option for the patient is performed.

A bariatric metabolic surgeon should be able to perform a variety of bariatric metabolic operations technically correctly and safely. The surgeon should have a well-equipped facility with the support of a multi-disciplinary team. A bariatric surgeon should be able to offer a bariatric surgery candidate the best option based on the patient’s condition. At this time there is no one operation that is optimal for all candidates for bariatric metabolic operations.

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