Medical assistance with the ‘battle of the bulge’

FATHER TADEUSZ PACHOLCZYK warns of the risks associated with bariatric surgery . . .

Fr. Tadeusz Pacholczyk

Bariatric surgery, which often involves banding of the stomach, is a widely used procedure for treating severe obesity. An implantable “stomach pacemaker” is also poised to assist the overweight.

Many people have already benefited from these kinds of surgical interventions, enabling them to shed a great deal of weight, improve their health and get a new lease on life. At the same time, however, it’s important for us to examine such interventions from an ethical point of view. It’s not simply a matter of weight loss achieved by any means whatsoever, but a rational decision made after carefully weighing the risks, benefits and alternatives.

Bjorn Hofmann, a medical ethicist who writes about the ethical issues surrounding obesity-correction techniques notes, “Bariatric surgery is particularly interesting because it uses surgical methods to modify healthy organs, is not curative, but offers symptom relief for a condition that is considered to result from lack of self-control.”

The healthy organ that is modified is the stomach, which may be either banded or surgically modified with staples to create a small stomach pouch. This causes food to be retained in the small pouch for a longer period of time, creating a feeling of fullness, with the effect of reducing how much a person ingests at a single meal.

Like any surgical technique, bariatric surgery has risks associated with it: Mortality from the surgery itself is less than 1%, but post-surgical leakage into the abdomen or malfunction of the outlet from the stomach pouch can require further surgeries. Nearly 20% of patients experience chronic gastrointestinal symptoms. Wound infections, clot formation, vitamin deficiencies, cardio-respiratory failure, and other complications like osteoporosis can also arise.

A new device, sometimes described as a “pacemaker for the stomach,” was recently approved by the Food and Drug Administration. This rechargeable and implantable device blocks electrical nerve signals between the stomach and the brain and helps to diminish the feeling of being hungry. The small machine, along with its surgical implantation, is expected to run between $30,000 and $40,000, making it competitive with bariatric surgery.

Because the stomach pacemaker does not modify organs, some of the surgery-related complications associated with modifying or stapling the stomach are eliminated. Other surgical complications related to the insertion of the device into the abdomen have sometimes been observed, however, as well as adverse events associated with its use, like pain, nausea and vomiting.

Bariatric surgery, it should be noted, is not universally successful in terms of the underlying goal of losing weight, and some patients ultimately regain the weight they lose either through enlargement of the stomach pouch or a return to compulsive eating patterns or both. Results have been similarly mixed for patients receiving the stomach pacemaker: Some lose and keep off significant amounts of weight; others show only negligible improvements when they fail to make lifelong changes in eating habits.

Among the ethical questions that need to be considered here are: Should an expensive, invasive and potentially risky surgery be routinely used for an anomaly that might be addressed by modifications in diet and eating habits? What criteria should be met before such surgery is seriously considered? It’s also of ethical importance that physicians and surgeons not be unduly pressured by device manufacturers to use their devices.

In 1991, the National Institutes of Health developed a consensus statement on “Gastrointestinal Surgery for Severe Obesity” that offers guidance for clinical decision making. It says patients seeking therapy for the first time for their obesity should “generally be encouraged to try non-surgical treatment approaches including dietary counseling, exercise, behavior modification and support.”

These broad guidelines are intended to spark discussion on the part of patients and their medical team: How much support has an individual really received prior to looking into weight reduction surgery or stomach pacemaker insertion? The need for support is also likely to continue following surgery.

In sum, there are notable differences between such surgical interventions and traditional weight-loss techniques involving exercise and diet. With the surgical techniques, due diligence will be required both prior to and following such interventions, particularly in light of the questions about the cost-effectiveness, safety, risks and outcomes of interventional surgery for overweight patients.

REV. TADEUSZ PACHOLCZYK, PH.D., earned his doctorate in neuroscience from Yale. He is a priest of the diocese of Fall River, Mass., and serves as the director of education at The National Catholic Bioethics Center.