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Gastric Surgery Broader Approach Needed to Successfully Treat Obesity For patients with recalcitrant obesity and accompanying medical problems, simply offering bariatric surgery is not enough, says Erik Dutson, MD, surgical director of the UCLA Center for Obesity and METabolic health (COMET). “Weight-loss surgery alone can’t be expected to bring about the desired results,” Dr. Dutson explains. “It must be accompanied by radical changes in a patient’s lifestyle, which requires education about diet and exercise both before and after surgery, as well as support groups. Medical management is also very important. The success rate for bariatric surgery is high. Approximately 85 percent of patients who undergo the Roux-en-Y gastric bypass or vertical sleeve gastrectomy (the two types of bariatric surgery offered at UCLA) experience sustained, efficacious weight loss. Nonetheless, the weight- loss strategy remains vastly underutilized. “As a field we serve less than 1 percent of patients for whom bariatric surgery is medically indicated,” Dr. Dutson says. “In many cases, patients may be fearful, or they simply see surgery as an extreme option.” The safety of bariatric surgery has significantly improved over the years, with in-hospital mortality declining from approximately 4 percent to less than 0.1 percent. While many patients continue to be wary of the risks associated with surgery, the irony is that for patients who qualify, the risk of dying from not getting surgery is significantly higher. Studies indicate that the five-year mortality rate for patients who qualify for and receive bariatric surgery is 89 percent lower than for patients who qualify but don’t pursue the operation. “The fact that it’s much safer to get the surgery than not to if you qualify isn’t intuitive to most people,” Dr. Dutson says, “so we need to get the word out.” The Roux-en-Y and the vertical sleeve gastrectomy are the two approaches used by COMET surgeons because they are the ones that can have significant metabolic effects in patients, STORY HIGHLIGHTS Dr. Dutson explains. Of the two offered at UCLA, the Roux-en-Y is considered the gold standard, particularly for the largest patients. Those who aren’t good candidates for a gastric bypass — including patients who are on chronic nonsteroidal drugs, steroids or immunosuppressive agents — tend to be steered toward the sleeve gastrectomy. Weight-loss surgery coupled with lifestyle changes offers the best results. Of the two types of bariatric surgery offered at UCLA, the Roux-en-Y is considered the gold standard. Prior to surgery, patients are seen several times by the center’s team. “Patient education is one of the critical pieces to management that has been underemphasized in the past when you look at bariatric surgery,” Dr. Dutson says. “Patients were getting these operations without any idea of how to use them. They weren’t making good food choices; they didn’t understand the difference between carbohydrates, fats and proteins; and then they couldn’t take maximum advantage of their altered anatomy and hormones.” Postoperatively, patients are placed on a strict diet while their stomachs heal, with graded alteration of the food they eat and regular visits to the center, both for continuing education and to track metabolic parameters. Research is also a major part of the center’s mission. “We now understand that the metabolic component of obesity is much more complex than we had ever thought,” Dr. Dutson says. “There is a tremendous amount that we don’t know.” Under the leadership of its medical director, Simon Beaven, MD, COMET is seeking to learn more about the role of fatty liver disease in metabolic syndrome and how to better manage patients with the condition so they don’t ultimately require liver transplantation. Some clinical trials are looking at the central nervous systems of patients who don’t benefit from bariatric surgery to see how they might differ from those in th[153]