Phẫu Thuật Giảm Béo (Bariatric Surgery)

101. Hocking, M.P., McCoy, D.M., Vogel, S.B. et al. (1991). Antiperistaltic and
isoperistaltic intussusception associated with abnormal motility after
Roux-en-Y gastric bypass: a case report. Surgery 110: 109–112.
102. Goverman, J., Greenwald, M., Gellman, L. et al. (2004). Antiperistaltic (ret-
rograde) intussusception after Roux-en-Y gastric bypass. Am Surg 70:
67–70.
103. Duane, T.M., Wohlgemuth, S., Ruffin, K. (2000). Intussusception after
Roux-en-Y gastric bypass. Am Surg 66: 82–84.
104. Majeski, J., Fried, D. (2004). Retrograde intussusception after Roux-en-Y
gastric bypass surgery. J Am Coll Surg 199: 988–989.
105. Edwards, M.A., Grinbaum, R., Ellsmere, J. et al. (2006). Intussusception
after Roux-en-Y gastric bypass for morbid obesity: case report and literature
review of rare complication. Surg Obes Relat Dis 2: 483–489.
106. Huang, B.Y., Warshauer, D.M. (2003). Adult intussusception: diagnosis and
clinical relevance. Radiol Clin North Am 41: 1137–1151.
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Chapter 10
Sequential Treatment of Obesity
Maurizio De Luca, Luca Busetto,
Gianni Segato and Franco Favretti
Introduction
The first laparoscopic procedure was undertaken in 1990, and this new
approach was to influence the future of obesity surgery. Behind
laparoscopy there is a new philosophy consisting in the evaluation of the
risk/benefits ratio for each operation, related to the individual patient,
and at the same time, a renewed respect for anatomy and physiology. So,
the future of obesity is related to these concepts: laparoscopy, risk/
benefits ratio, respect for anatomy and physiology. In a single phrase:
quality of life.
Everybody knows that obesity is a global problem of epidemic pro-
portions and morbid obesity can at present be treated only by surgery.
There is now international agreement about the indications and con-
traindications for bariatric surgery. At the same time, despite knowledge
of physiology and hundreds of international congresses, general disagree-
ment about the choice of bariatric operation remains.
There is a grey zone in which the surgeon uses his experience, knowl-
edge and the technology of his hospital to decide the best operation for a
specific patient. So, day by day, it is becoming clear that obesity surgery
is developing a philosophy.
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Classification of Bariatric Operation
In the short history of bariatric surgery many tens of operations have been
proposed, but most of them were not carried out because of the poor effi-
cacy of the procedure, or due to concerns over serious co-morbidities.
At present, the most performed bariatric operations are:
(a)
Restrictive: vertical banded gastroplasty Mason; vertical banded gas-
troplasty MacLean; sleeve gastrectomy; gastric banding.
(b) Malabsorptive: biliopancreatic diversion Scopinaro; duodenal
switch sleeve gastrectomy;1,2 duodenal switch with gastric restriction
and preservation.3
(c)
Mixed: gastric bypass.
All the above-mentioned operations can be performed by laparoscopy,
and research and technology are opening up to surgeons the possibility
of other laparoscopic and endoscopic procedures. These new approaches
have still to be defined, and some of them need further clinical trials in
order to clarify the best indications for their use. These approaches are:
(a)
Endoscopical: intragastric balloon, endobarrier and POSE (Primary
Obesity Surgery Endoluminal);4
(b) Electrical stimulation: gastric pacing,5 vagal stimulation;6
(c)
Surgical: LAP-BAND® + duodenal switch with (‘Bandinaro’),7
functional gastric bypass,8 sleeve gastrectomy.3,5
Effectiveness/ Invasiveness of Various Operations
The scientific community has accepted that the effectiveness of bariatric
operations cannot be evaluated only in terms of weight lost. Other param-
eters should be considered. The Bariatric Analysis and Report Outcome
System (BAROS),9 for example, considers weight loss and the impact of
weight loss on co-morbidities and quality of life. It is a complete and well
standardized method.
Effectiveness is expressed in terms of percentage excess weight loss
(EWL) because almost all results are expressed in this manner in the lit-
erature. Table 1 shows the effectiveness of various surgical techniques
based on results in the literature in terms of percentage EWL.

Then, evaluating the above-mentioned procedures laparoscopically
(obviously only the intragastric balloon is performed by endoscopy) and
evaluating the invasiveness of the operations, we indicate risk values
according to the literature in Table 2.
Scoring from 0 to 4, the parameters considered in Table 2 are: general
anaesthesia, incisions and/or suture of gastro-intestinal tract, anatomical
and/or functional reversibility and morbidity.
Figure 1 evaluates both effectiveness (percentage EWL) and risk
score of various operations.
‘Operations with more effectiveness are operations with more risk’.
Undertreatment and Overtreatment
The literature illustrates the interesting similarities of any specific opera-
tion, when the general features of the patients (age, weight, BMI, weight
loss, co-morbidities) are taken into account. In particular, operations with
more effectiveness also have a higher risk.
Laparoscopic gastric banding, for example, has a huge diffusion
worldwide (300,000 implantations) with percentage EWL of 45–55 and
good results in 75–80 per cent of cases.
Evaluating these results in a different manner, we could say that the
majority of patients has a good experience with LAP-BAND®, while
Sequential Treatment of Obesity
287
Table 1.
Effectiveness (percentage EWL) of the various surgical
techniques currently available.
Risk of operation
% EWL
Intragastric Balloon (BIB)
25
Gastric Pacing
25
Lap-Band
50
Vertical Banded Gastroplasty (Mason)
55
Vertical Banded Gastroplasty (MacLean)
60
“Functional” Gastric Bypass
70
Duodenal Switch + Lap-Band (Bandinaro)
75
Gastric Bypass
75
Bilio Pancreatic Diversion
80
Duodenal Switch + Gastric Tubulisation
80

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M. De Luca et al.
Table 2.
Risk score of the various surgical techniques currently available.
General
Invasiveness
Anatomical
Functional
Operation
anesthesia
opening G.I. tract
reversibility
reversibility
Morb
Risk score
Intragastric Balloon (BIB)
0
0
0
—
0
0
Gastric Pacing
1
0
0
—
0
1
Lap-Band
1
0
0
—
1
2
Vertical Banded Gastroplasty (Mason)
1
1
—
1
2
5
Vertical Banded Gastroplasty (MacLean)
1
2
—
1
2
6
“Functional” Gastric Bypass
1
3
—
1
3
8
Duodenal Switch + Lap Band (Bandinaro)
1
3
—
1
3
8
Gastric Bypass
1
3
—
1
4
9
Bilio Pancreatic Diversion
1
4
—
1
4
10
Duodenal Switch + Gastric Tubulisation
1
4
—
1
4
10

20–25 per cent of patients has a surgical undertreatment, but in both
groups of patients, the risk score is very low (Table 2, risk score 2).
On the other hand, though, 60–70 per cent of obese patients undergo-
ing gastric bypass (Table 2, risk score 9) or biliopancreatic diversion
(Table 2, risk score 10) undergo useless overtreatment.
So, the surgeon has to decide if the patient can be treated with a mini-
mally invasive procedure (e.g. LAP-BAND®) with a failure rate of
Sequential Treatment of Obesity
289
BIB = Bioenterics Intragastric BalloonTM
GP = Gastric Electrostimulation
LAP-BANDTM = Laparoscopic Gastric Banding
VBG MASON = Vertical Banded Gastroplasty (Mason)
VBG MACLEAN = Vertical Banded Gastroplasty (MacLean)
FUNC GASTRIC BYPASS:Functional Gastric Bypass
DS + BAND = Lap-Band + Duodenal Switch (“Bandinaro”)
GASTRIC BYPASS = Gastric Bypass
BPD = Bilio Pancreatic Diversion
0
1
2
3
4
5
6
7
8
9
10
100
80
60
40
20
BIB GP
LAP
BAND
VBG
MASON
VBG
MC LEAN
FUNC.
GASTRIC
BYPASS
DS +
BAND
GASTRIC
BYPASS
BPD
DS +
SG
Figure 1.
Effectiveness (percentage EWL) and risk score of the various surgical tech-
niques currently available. BIB = BioEnterics® Intragastric Balloon BIB®; BPD =
biliopancreatic diversion; DS + BAND = duodenal switch + LAP-BAND® (‘Bandinaro’);
DS + SG = duodenal switch + sleeve gastrectomy; FGB = functional gastric bypass; GB =
gastric bypass; GP[QA2a] = gastric pacing; LAP-BAND® = laparoscopic gastric banding;
VBG MACLEAN = vertical banded gastroplasty MacLean; VBG MASON = vertical
banded gastroplasty Mason.

20–25 per cent, or with a more invasive procedure like gastric bypass
and/or biliopancreatic diversion risking an overtreatment in 60–70 per cent
of cases. For this reason the decision over which bariatric procedure to
select becomes a philosophical judgment.
Surgical Treatment of Obesity
Nowadays, and increasingly in the future, the aim of obesity surgery will
be defined in terms of quality of life.
In future we will consider the effectiveness of the approach, always
preferring the less invasive procedure. Surgical complications in obese
patients are absolutely be avoided because the management of them is
more difficult than in a normal weight patient.
The literature, for example, shows that laparoscopic gastric bypass in
patients with BMI > 60 results in about 50 per cent of peri- and post-
operative surgical complications (M. Gagner, pers. comm., 2001); in these
patients it would be useful to reduce the BMI before the gastric bypass
operation. Nowadays we can reduce the initial BMI with a less invasive
procedure, such as the insertion of an intragastric balloon (BioEnterics®
Intragastric Balloon or BIB® which is now called Orbera in our series),
which is then followed by laparoscopic gastric banding.4
In a high rate of patients (78 per cent in our experience) this sequential
treatment could be considered definitive and that a further, more invasive
operation, such as gastric bypass or biliopancreatic diversion, is useless.
For patients with a low rate of percentage EWL and/or lack of com-
pliance to the LAP-BAND® (22 per cent of patients in our experience), an
operation with more effectiveness and more risk will be indicated and
surely more justified. In this case the weight loss, even if modest, will be
useful in order to reduce peri- and post-operative complications related to
the higher BMI of the patient.
In our opinion the higher sensitivity to quality of life and risk/benefits
concepts, two important parameters already applied in every other field of
surgery, will be applied by bariatric surgeons to the sequential treatment
of obesity.
We think that in the future we will use the surgical options that we
already have today in different ways. So, at the beginning of a surgical
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treatment, we usually perform the less invasive procedure with a good
rate of effectiveness (2,245 LAP-BAND® patients in our series with
0 mortality), considering the second more invasive options (duodenal
switch with gastric preservation or ‘Bandinaro’ in our series, Scopinaro
procedure, gastric bypass or functional gastric bypass) only for patients
for whom previous less invasive surgery has not given useful results. 9,10
Please see Fig. 2.
Conclusions
The future of bariatric surgery will be characterized by:
1.
concepts of ‘quality of life’ and ‘risk/benefits’, which will influence
the scientific community more and more;
2.
the widespread use of a less invasive approach, such as laparoscopic
gastric banding, due to the less invasive procedure;
Sequential Treatment of Obesity
291
•
Digestive loop = 200 cm.
•
Common loop = 50 cm
•
Bilio-pancreatic loop = remainder of small intestine
Figure 2.
Bandinaro.

3.
some new techniques, already introduced, becoming more widespread
(e.g. Bandinaro, functional gastric bypass, sleeve gastrectomy);
4.
the intragastric balloon and gastric electrostimulation having a role in
the sequential treatment of obesity;
5.
consideration of the ‘step by step’ approach or ‘sequential treatment
of obesity’, waiting for a sure indication that a specific operation is
suitable for a specific patient.
References
1. Gagner, M., Rubino, F., Ren, C. (2000). Laparoscopic bilio-pancreatic diver-
sion with duodenal switch: technical aspects. Obes Surg 10: 317–318.
2. Marceau, P., Hould, F.S., Simard, S. et al. (1998). Biliopancreatic diversion
with duodenal switch. World J Surg 22 (9): 947–954.
3. Vassallo, C., Negri, L., Della Valle, A. et al. (1997). Bilio-pancreatic diver-
sion with transitory gastroplasty preserving duodenal bulb: 3 yr experience.
Obes Surg 7: 30–33.
4. Weiner, R., Gutberlet, L., Bockhorn, H. (1999). Preparation of extremely
obese patients for laparoscopic gastric banding by gastric balloon therapy.
Obes Surg 9(3): 261–264.
5. Shikora, S.A., Bessler, M., Fisher, B.L. et al. (2000). Laparoscopic insertion
of the implantable gastric stimulator (IGSTM): initial surgical experience.
Obes Surg 10: 315.
6. De Luca, M., Segato, G., Busetto, L. (2004). Progress in implantable gastric
stimulation. Summary of results of the European multicenter study.
Obes Surg 14: S33–S39.
7. Cadière, G.B., Favretti, F., Himpens, J. et al. (2001). Anneau gastrique et deri-
vation bilio-pancreatique par laparoscopie. J Celio-Chir 38: 33.
8. Furbetta, F., Gambinotti, G. (2002). Functional gastric bypass with an
adjustable gastric band. Obes Surg 12: 876–880.
9. Favretti, F., Cadière, G.B., Segato, G. et al. (1998). Bariatric Analysis and
Reporting Outcome System (BAROS) applied to laparoscopic gastric band-
ing patients. Obes Surg 8: 500–504.
10. Favretti, F., Segato, G., Asthon, D. et al. (2007). Laparoscopic adjustable
gastric banding in 1791 consecutive obese patients: 12-year results. Obes
Surg 17: 168–175.
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Chapter 11
Bariatric Surgery: When the Miracle
is Not Enough
Melodie K. Moorehead
Introduction
For most patients, bariatric surgery is nothing short of an earthly miracle.
Originally, bariatric surgery was intended for dangerously obese people.
Currently, bariatric surgery also benefits non-obese people challenged
with other metabolic issues, particularly diabetes. Most forms of bariatric
or metabolic surgery impact the experience people have relating to food;
as a result, it is the author’s opinion that health-related psychological sup-
port is warranted for all people undergoing such surgery. This chapter,
however, provides information that focuses on the role of psychology in a
bariatric surgery programme for people suffering with severe obesity. The
close of the chapter will highlight political actions that healthcare
providers can take to help turn the tide of obesity throughout our world.
People who have been dangerously obese for years can shed hundreds
of pounds after surgery; and often for the first time, these people feel wel-
comed by a society that had effectively shunned them all their lives.
Unfortunately, too often the weight-loss miracle alone is not enough.
Bariatric surgery, although the nexus of successful treatment, is now rec-
ognized as foremost among other measures essential for effective,
long-term treatment of morbid obesity.
New research provides compelling support for clinical and anecdotal
evidence that, despite an initial dramatic weight loss, bariatric surgery is
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M. K. Moorehead
frequently challenged by the return of patients’ former detrimental behav-
iour. Without a professionally managed long-term recovery programme
predicated on pre- and post-operative mental health care, some patients
suffer an undetected relapse, either by regaining weight or substituting
hazardous coping behaviours, such as alcoholism, drug addiction, com-
pulsive shopping or gambling. One key to widespread success after
bariatric surgery is the effort made by the entire multi-disciplinary team of
healthcare professionals. These are guided by a pathway of care intended
for a long-term recovery programme involvement with a standardized
methodology for measuring patient progress.
Increasingly, medical experts specializing in bariatric surgery are
publicly acknowledging the need for a comprehensive psychological
treatment programme managed by a mental healthcare expert trained to
work with bariatric surgery patients. Professional medical organizations
that have recognized the value of the bariatric mental health specialist
include the American Society for Metabolic and Bariatric Surgery
(ASMBS), formerly known as the American Society of Bariatric
Surgery (ASBS), the International Federation of Surgery for Obesity
(IFSO) and recently, the American College of Surgeons (ACS).
Research suggests that a professionally structured and managed recov-
ery programme is an important key to successful long term surgical results.
Typically, morbid obesity is a chronic disease shaped by years of what some
patients refer to as ‘addictive’ behaviours, and it is common to hear partici-
pants in a programme characterize themselves as ‘food addicts’. Although
surgery can help bring about life-saving weight loss, medical improvement
and a better quality of life, some patients’underlying psychological dynam-
ics can undermine even the most encouraging short-term results. The return
of deeply ingrained self-defeating attitudes can revive the destructive
behaviours that first engendered or contributed to the disease of the patient’s
morbid obesity. (It is very important to be cautious when connecting addic-
tion or addictive behaviours to morbid obesity because there is so much
discrimination, prejudice and ignorance surrounding these subjects.)
Further support for a comprehensive mental healthcare programme is
found in the increasing evidence that the disease of morbid obesity is
partially driven by psychological dynamics — affective and physiological –-
similar to those known to characterize addiction. Salient among

psychological factors is the potential of transference, a possibility that, in the
absence of a return to overeating, patients may transfer or substitute their
addictive approach to food to alcohol, substance abuse or other self-destruc-
tive behaviours.
The resurgence of life-long psychological habits can overwhelm even
the powerful hope that arises when patients experience dramatic post-
operative weight loss. Professional healthcare specialists must counsel
patients beforehand in preparation for the potential emotional impact of
surgery. Frequently, this approach helps avoid greater risk of shock and
destruction should a relapse in behaviour occur.
The author’s clinical experience suggests that the most promising
post-operative outcome is seen when each patient’s unique psychological
profile is identified and incorporated in the very structure of post-
operative care. This individualized regimen is then integrated into over-
arching guidelines of a standardized, multidisciplinary/interdisciplinary
treatment programme. Once, the value of psychological services was lim-
ited to evaluating patients for surgery and predicting who would succeed
or who would fail. This seems like a truncated view of psychological serv-
ices because the inability to predict individual human behaviour, the value
of the initial evaluation and the role of psychology, on a routine basis, has
not been fully recognized. In fact, psychological services are of critical
benefit, not only in enhancing patient compliance but also in ensuring a
significant improvement in longer term quality of life.
Although research is referenced, this chapter does not attempt a com-
prehensive review of scientific findings. The author relies on relevant
clinical data to elucidate the philosophy behind the research discussed
here and better clarify assessment and treatment. Clinical data and obser-
vations draw upon a biomedical literature review and more than twenty
years of clinical experience in the design and implementation of the psy-
chological standardized protocol articulated by the author at
ASMBS/ASBS and IFSO presentations. Hopefully, the information here
will make it easier for medical professionals, as well as patients, their
friends and loved ones, to understand and appreciate some of the chal-
lenges faced by bariatric surgery patients.
Results from a variety of bariatric procedures, including Vertical-
Banded Gastroplasty, Roux-en-Y Gastric Bypass, Adjustable Banding and
Bariatric Surgery: When the Miracle is Not Enough
295

a clinical trial of Gastric Stimulator cases comprise the main body of the
supporting data. The psychological sequelae of depression and destructive
or addictive behaviours focus primarily on stress that is triggered by social
factors, plus the patient’s unique psychological characteristics. This
includes the nature and extent of patient coping skills, as well as behav-
iours frequently observed in morbidly/super-obese people. The
psychological impressions presented here are taken from direct practice or
reflect collaborative research efforts over the last decade.
Bariatric Surgery is a Behavioural Surgery Too
Before discussing a basic recovery programme protocol that promotes a
hopeful attitude in bariatric surgery patients, it is useful to describe in
more detail the characteristics of this special patient population. Again,
each recovery programme must be tailored to the individual, but to some
extent, observed generalizations can be useful. Patients presenting for
bariatric surgery are apt to be courageous, brave and complex. Often they
have demonstrated the willpower to endure such humiliating treatments as
jaw wiring and demanding regimes of self-imposed starvation diets in
their efforts to control their obesity. Yet they can also be deeply troubled
individuals suffering from negative family influences exacerbated by bru-
tal social pressures. Additionally, profound alienation and addictive
behaviours interact in complex and pernicious ways, making an integrated
long-term psychological component essential within the multidiscipli-
nary/interdisciplinary team approach for sustaining success after surgery.
Bariatric surgery patients are a self-selecting minority among the count-
less people who might benefit from this procedure. Those who undergo
bariatric surgery typically respond afterward with a powerful resurgence
of hope as body weight falls away in the first period of recovery. The con-
cept of recovery is a useful model in the work we, as healthcare
specialists, do. Unfortunately, as specialists we recognize that the insidi-
ous disease of obesity cannot be cured by surgery alone. Thus, the concept
of recovery work helps reduce the understandable yet defeating ‘magical
thinking’ that some people often attribute to bariatric surgery.
Furthermore, the basic concept of recovery empowers patients to address
their involvement in the ongoing process of healing, and relinquish their
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false belief that surgery will do all the work. This sudden emotional
rebirth taps into a wellspring of inner strength, often facilitating their
commitment to a long-term psychologically oriented post-operative pro-
gramme. Conversely, the persistence of denial after surgery quickly
becomes a contributing factor to the disease, sometimes initiating a return
to familiar counter-productive behaviours. This is one important reason
why all the members of the team must share the philosophy and reinforce
it to their patients. Literature reflects the clinical recognition that there is
no archetypal obese personality. However, there are important similarities
among obese patients, and these shared characteristics permit important
generalizations for structuring treatment programmes for a variety of
patients and surgical procedures. But over-generalization can be detri-
mental. Professionals cannot forget that each patient’s unique
psychological profile is a major factor in individual pre/post-operative
planning.
Research and clinical experience suggests that the psychological
dynamics of the morbidly/super-obese patient differ significantly from
those observed among people who are less severely overweight or not
overweight. While findings indicate that bariatric surgery patients are no
more likely to suffer from serious conditions such as bipolar disorder or
schizophrenia, affective disorders are more predictable, and increased
intensity of conditions occurs as body mass index rises.
Emotional disorders such as depression and anxiety, and symptoms of
somatization and the defence mechanisms of denial, distrust and loneli-
ness occur with greater frequency among the morbidly obese. Some
studies have reported that up to 95 per cent of morbidly obese patients
described depressive symptoms matching those in the Diagnostic and
Statistical Manual of Mental Disorder (DSM IV).1 This is a startling num-
ber, especially since denial or other self-defence mechanisms frequently
prevent patients from recognizing and reporting any signs of depression.
My European colleague, Elisabeth Ardelt-Gattinger PhD, and I have
identified two potent factors affecting the beliefs, attitudes and behaviours of
severely obese and super-obese individuals seeking surgical treatment. For
those interested in greater detail and the history of this line of discussion,
please refer to and the two-part article by
Moorehead and Alexander.2,3 Briefly, while validating the Moorehead–Ardelt
Bariatric Surgery: When the Miracle is Not Enough
297

Quality of Life Questionnaire4 (MA II) and researching what we call the
addiction component contributing to the disease of obesity, we confirmed the
presence of the self-descriptive ‘craving’ and ‘inability to control’ factors.
These correspond to two of the three factors described in the well
known ‘Three Factor Eating Inventory’5 developed by American psy-
chiatrists and psychologists, Drs Albert Stunkard and Samuel
Messick. The factors that they call ‘hunger’ and ‘disinhibition’ are
consistently similar to our own ‘craving’ and ‘inability-to-control’. In
both cases these factors speak to patients’ feelings about being hun-
gry and about a perceived inability to resist the sight or tempting
smells of food.
The real surprise was the absence of a correlation between the ‘crav-
ing’ and ‘inability to control’ factors, and Stunkard and Messick’s third
factor, ‘cognitive restraint’. This indicated to us that for the
morbidly/super-obese patient seeking surgery, experiencing ‘craving’ and
‘inability to control’ food consumption was an affective reaction — a
response to their feelings, and emotions, rather than rational, cognitive
thought processes.
The comparative ineffectiveness of conscious, cognitive efforts may
explain why attempts to control eating behaviour through ‘will’ alone
often fail. Such failure invariably exacerbates patients’ psychological dis-
tress. The healthcare professional needs to make it clear to patients that all
those dramatic vows to reform were doomed before given voice simply
because conscious mental processes are not really in control here.
Understanding even this much may allow patients, some for the first time,
to stop blaming themselves for ‘lack of willpower’ or ‘failing to face real-
ity’. Such self-accusations are commonplace and are apt to deepen
patients’ shame for having failed to control deadly obesity ‘on their own’.
Similarly, acknowledging the limitations of conscious resolutions may
relieve patients of shame for ‘taking the easy way out’ by choosing sur-
gery. For that matter, the surgical route may not seem all that easy after
the patient and family members realize that it implies a lifetime commit-
ment to a rigorous recovery support programme.
Reduction or removal of shame is highly desirable when working
with the severely/super-obese person. We need to understand the matura-
tion and development of our patients in order to appreciate how their
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M. K. Moorehead

thoughts can trigger dangerously negative thought processes in the affec-
tive response system of the brain.
Many of our bariatric surgery patients have been obese since child-
hood and it is commonly known that obese children receive less attention
and affection from caregivers, parents and teachers than do their leaner
siblings and friends. Studies also suggest that obese children easily learn
to dislike or even hate themselves because of the cultural prejudice and
discrimination linked to severe obesity.
Research conducted by Stunkard and Wadden6 underscored this self-
hatred. In their study, they showed young children silhouettes of an obese
child and asked them to describe the person portrayed by the image. The
subjects described the child represented by the silhouette as ‘lazy, dirty,
stupid, ugly, cheats and liars.’ Then drawings of children of various
weights and disfigurements were shown to a variety of audiences, both
adult and children. The audience, including obese people, rated the draw-
ing of the obese child ‘least likeable’.
We also know from research that the highest depression scores on pre-
surgery, written psychological tests come from adults who have been
obese since early childhood. Scores decrease somewhat among those who
became obese in middle childhood and adolescence. The lowest depres-
sion scores were found among those who were adults at the onset of
obesity. Interestingly, this stair-step of test results also occurs in prelimi-
nary findings on ‘addiction factor’ or ‘inability to control’ scales currently
under investigation.
Consistently high depression scores coincide with a high frequency of
reports of childhood abuse among obese patients. Research gathered and
analysed, then reported at professional international bariatric conferences,
identifies that fully two thirds of gastric-bypass patients report early child-
hood abuse. Further, a third of these same patients stated that they grew
up in, or currently reside in a household permeated with alcoholism.
Add to this complex psychological background a credible genetic
component, and it becomes clear that surgery alone cannot address the
multiple contributing factors of this disease. Bariatric surgery is a behav-
ioural surgery.
Although the psychological genesis of obesity varies, many patients
typically develop in childhood (some in their pre-verbal state of
Bariatric Surgery: When the Miracle is Not Enough
299

development) what might be usefully described as a negative ‘diet of
thoughts’. Self-defeating mental refrains (‘I’m not good enough, not lov-
able enough, not deserving enough of attention to meet my needs, etc.’)
can starve even the staunchest heart. Such psychological deprivation must
be supplanted by a solid sense of inner fulfilment or, as I call it, psycho-
logical satiety, if the patient is to succeed beyond initial weight loss
following bariatric surgery.
As soon as possible, patients must be fully apprised of the psycho-
logical hurdles that are intimately bound into this kind of surgical
procedure, and be fully aware of the issues related to why eating for rea-
sons other than physical hunger must be confronted early on. Literature
is beginning to point out that pro-active transformational coping skills
typically must be learned and actively practised if they are to replace eat-
ing as a way to manage chronic or acute stress.
Among the most pressing issues is a discussion of patients’ motives
for eating. Many pre-operative bariatric patients report that they eat for
reasons other than physical hunger or a visceral need for satiety. Patients
must quickly come to terms with the fact that weight loss, and more
importantly weight loss maintenance, requires a lifetime commitment to
all recovery programme guidelines. From the start, prospective patients
are wise to understand that this means acknowledging and taking respon-
sibility for their decisions, choices and lifestyle behaviours while also
being reassured that neither perfectionism nor flawless adherence to
guidelines are the desired behaviours.
Identifying negative self-fulfilling prophecies, e.g. ‘I am not good
enough, worthy enough ... etc.’, or inability to put into place natural
human legitimate rights such as, ‘I have the right to put myself first some-
times or I have the right to say no without losing your love’ are among the
initial tasks for the mental health care professional. It is best to start this
process before surgery and it is also an integral part of the post-operative
programme. Fortunately, teaching the patient how to acquire a ‘taste’ for
a healthier diet of thoughts can help derail such self-defeating mantras.
In an integrated, multidisciplinary/interdisciplinary team, patients
receive psychological support during each follow-up visit to the sur-
geon’s office, yet the preponderance of the mental health professional’s
job occurs in the period of time preceding surgery, when patients are
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highly motivated, and just after surgery — the time when the patient can
be most vulnerable and receptive to supportive behavioural and concep-
tual changes. The optimal time to come to terms with obesity’s most
powerful psychological currents is between the first preoperative psy-
chological evaluation and the first eighteen months immediately after
surgery. The bariatric team has an opportunity to help patients address
their most repetitious psychological issues at this time. Challenged
patients who have not learned alternative, healthy ways of coping with
stress are at risk of returning to a pre-operative, regressive style of eat-
ing. Often patients must learn new ways to manage their feelings, as well
as the changing demands of ongoing relationships. Counter-productive
hunger behaviours are apt to resurface even though patients’ newly con-
structed bodies may report feeling physical satiety. Ultimately, cognitive
recognition of the consequences of regressive coping behaviours does
not deter patients as long as underlying emotional issues remain intact.
Before surgery, the patient gains a cognitive understanding of the
need to find new ways to feel ‘full or satisfied’. After surgery, guided by
the mental health professional on the recovery team, the patient must learn
how to satisfy the need for emotional, psychological satiety by means
other than food consumption. The successful bariatric patient may
develop a motto such as, ‘I eat to live, rather than, I live to eat’. Such max-
ims become part of the healthy ‘diet of thoughts’, a key ingredient for a
successful long-term recovery programme.
Initial patient evaluations include a section that offers psycho-
education and post-operative objectives focused on an action-oriented
replacement of negative thoughts or behaviours with more appropriate
positive ones. Clearly, this requires the skill and commitment of a well-
trained mental health care professional. In this way, the mental health
specialist provides a valuable role not only to the patients, but also to the
integrated team whose time is thereby freed from this needed focus, which
in turn helps them address other necessary medical issues often faced by
bariatric patients.
The healing psychological milieu most helpful to bariatric surgery
patients and their loved ones is dynamic in nature, founded on relationship
and rapport. Cognitive, affective, behavioural, somatic and even spiritual
methods (medical hypnosis, desensitization, relaxation/breathing and
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301

body therapies) can be tailored to patients’ maturational needs. Given the
nature of modern culture, patients’ personal history, their strengths and
distress (e.g. stigmatization and isolation) and the consequent specific
maturational needs, all therapeutic exchanges can provide a full range of
potential interventions to be used for effective treatment. An effective
mental health specialist will be familiar with a wide range of therapeutic
methodologies; however, a key element becomes the purposeful use of
authentic empathy and genuine warmth in the doctor/patient exchange.
This requires the conscious planning and implementation of a ‘good par-
ent’transferential treatment environment. Responding in what is known in
psychology as an anaclitic response, or a ‘good parent’ manner, rather
than in a reactive authoritative fashion, will evidence a more useful
approach with this particular patient population. Throughout the
programme, a strong structural consistency in a multidisciplinary/
interdisciplinary learning model will contribute to positive healing since
some patients may attempt a necessary and needed recapitulation of their
original family dynamics. A good bariatric programme will provide an
environment where emotional healing can take place in every setting and
discipline visited.
A Holistic Approach to Bariatric Surgery:
Recovery Managed by Healthcare Specialists
A brief overview of the role and benefits of bariatric surgery psychology
includes a description of a holistic approach to treatment and the crucial
role played by the professional mental health specialist within the context
of a multidisciplinary or interdisciplinary team.
The current literature review of bariatric surgical outcomes, where a
broad spectrum of care was implemented, shows an admirable record of
short-term success and some successful long-term outcomes. True suc-
cesses deserve full marks. But what constitutes success? For that matter,
do patients and bariatric teams define success or failure in the same way?
These questions will be addressed shortly. Right now I would like to
express what I consider a ‘Best Practice of Care Model’ that drives posi-
tive long-term outcomes and delivers services to bariatric surgery patients
and their loved ones.
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Throughout my professional travels, I have had privileged exposure
to the emotional aspect of care provided within bariatric programmes par-
ticularly in the United Sates, Brazil, Europe and Japan. The emotional
support provided to patients within these programmes has included,
among other important medical services, the education of patients before
surgery. This includes attentive and positive support offered both pre- and
post-operatively by talented, often over-worked nurses and nutritionists,
along with routine visits by the surgeons’ or physicians’ assistant at vari-
ous prescribed intervals of time. Additionally, medical personnel within
the programme may provide referrals for psychological evaluations or,
when needed, suggest individual psychological treatment outside of the
programme. Fortunately, our bariatric community has increasingly seen
more hospitals and surgically based programmes provide in-house psy-
chological evaluations and brief ongoing psychoeducational and
behavioural support, on both a pre- and post-operative basis.
Unfortunately, this improving model of care is not universal.
Throughout the world, treatment before and after bariatric surgery still
varies widely. So do long-term outcome results. Even when recovery is
carefully monitored using a standardized method of measuring patient
progress, the full value of a professionally designed psychological recov-
ery programme is yet to be fully appreciated. Well planned programmes
need to be administered by a multidisciplinary/interdisciplinary team that
includes at least one professional mental health care specialist.
The concept of a team approach is crucial, and we have primarily used
a multidisciplinary model of care. A multidisciplinary team programme
may have all the necessary team players involved in the basic care of the
surgical patients, yet all team members primarily work in ways independ-
ent from each other, and perhaps communicate by written reports or
progress/chart notes in the medical record or even have brief telephone
conferences for more urgent matters. I have worked in this multidiscipli-
nary manner with several wonderful bariatric surgeons; however, it is my
experience that all parties involved are served to a higher degree in an
integrated interdisciplinary programme of care. I suggest that this inter-
disciplinary team model be regarded as a gold standard toward which we
strive. This model, when implemented with good leadership, provides the
optimal recovery methodology and environment to work, while providing
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303

services that offer observable standards and results for measuring
patients’ values through communication.
Communication and superior co-ordination of care distinguishes this
team approach. While pre-surgery preparation and post-surgical recovery
are typically monitored by a variety of medical specialists, a designated pro-
fessional manager or director can aid this team approach. This specialist,
whether identified as a manager, director or coordinator, ensures that the
different service providers develop a shared understanding of each patient
and their goals and coordinate an agreed-upon plan of care. This individ-
ual coordinates and directs the unified team while maintaining fiscally
sound business practices and functioning as the liaison to head administra-
tors and Chief Executive Officer of the hospital or clinic. Each specialist has
an essential role, and each reinforces the team’s overall shared care goals to
support the patient. Team members are aware of and emphasize to patients
the inter-connectedness among the different clinical specialties — surgery,
nursing, physical activity, nutrition and psychology — all members of the
team including the patient, pulling together in the same direction and under
one roof.
Psychologists are well suited to the advanced specialty training and
delivery of services to the bariatric surgery patient population, though psy-
chiatrists, psychiatric nurses and social workers have also proved invaluable
to a comprehensive programme. Key characteristics of a skilled mental
health specialist include empathy, authenticity, passion, willingness to learn
and a solid understanding for the needs of the severely obese people seek-
ing surgical intervention, and their loved ones.
Paramount is the specialist’s ability to reflect deeply and to inventory
meticulously his/her prejudices regarding this insidious disease. Above
all, professionals must never pathologize their patients. Clinical inter-
views routinely show that many patients attempt twenty or more diet
programmes before seeking bariatric surgery. Such strength of character
may bode well for a commitment to a lifelong health maintenance pro-
gramme that is properly administered by a sensitive team. However,
clinical interviews also reveal quite honestly that many patients do not
attempt earnest weight loss efforts before seeking bariatric surgery, or that
when they do the effort is often short-lived and entered into without con-
viction. These people often foster a hidden belief that surgery will stop
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them from eating indefinitely, while finally bringing a sense of satisfac-
tion and fulfilment to life. So while it is paramount to guard against
personal prejudice, it is also essential not to attempt being politically
correct by holding an erroneous belief that all bariatric patients are pio-
neering and courageous. Philosophically, to reverse a well-documented,
long-standing trend of medical prejudice found against obese people, it
might be useful to highlight and hold in mind a basic common
denominator often identified in the motivation of bariatric candidates.
Even for people who hold unrealistic expectations of surgery, core desires
are to: prevent premature death, improve his/her medical condition and
increase quality of life.
By recognizing through effective psychological evaluations those
patients who might be unconsciously seeking the ‘magic’ of surgery, the
team can focus on the underlying healthy motives for an improved life,
while providing the needed adjuncts to surgery. This approach may help
patients take greater responsibility in preparing realistically for their
needed lifestyle changes. Pre-surgery classes for groups of bariatric sur-
gery patients may further demystify the medical procedure and promote
awareness of the value of building stress management skills and altering
personal perceptions. Teaching people to feel empowered as they experi-
ence greater control of their lives will soften the changes in their
relationship to food after surgery. Helping establish and strengthen
patients’ positive inner perceptions of themselves is of vital importance to
‘changing the diet of thoughts’ or inner dialogue to minimize self-
sabotage and foster sustainable success following bariatric surgery.
Establishing a Three-Stage Psychoeducational
Recovery Programme
Within the treatment team, the psychological professional must address a
variety of issues recognized as common to many bariatric surgery patients
before surgery, immediately following surgery and in the recovery years
thereafter. One goal the author holds, that is yet to be an accepted norm of
treatment, is to offer ongoing pre- and post-operative psycho-educational
support. This level of attention can take different forms depending on how
busy a particular practice is or on the degree of resources and personnel
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305

available. It has been reported that patients are often not motivated to
attend their pre-surgery psychoeducational class, even when it is manda-
tory. For this plan to be viable and workable, in the real world, it would
have to meet patients’ true needs and the team would have to completely
buy into its value. It is also recognized that healthcare professionals are
sometimes called away on emergencies. To minimize any potential harm
due to the interruption of routine care protocols, the following three con-
ceptualized stages of programme care are offered as a flexible, best
practice care recovery model:
1.
The initial psychological, mental health or psycho-educational evalu-
ation: specialized assessment tools and preoperative psychological
recommendations may be offered that might advance the patient’s
safety and the efficacy of bariatric surgery;
2.
In-hospital psychological support surrounding the surgical event: a
wonderful means for enhancing the development of the therapeutic
alliance because it helps people feel special and cared about during a
very vulnerable time. After surgery, the psychological health care spe-
cialist’s role changes somewhat from largely assessment and
educational to one of active leadership, encouragement and support;
3.
Over the course of the author’s career this third step of specialized
care has taken the form of routine brief (5–20 minute) post-operative
follow-up sessions occurring directly in the surgeon’s office or surgi-
cal programme’s centre. Support may also take other forms such as
offering six group classes before surgery, or several time limited
one-on-one sessions after surgery, with the flexibility to include loved
ones in any session. A comparatively new concept for high-volume
practices is Shared Medical Appointments (SMAs). (Similar material
may be provided in a different format of care.)7 SMAs have been
shown to offer patients and their loved ones prompt access to medical
care. These ongoing contacts, regardless of the modality, are con-
tained within the parameters of the full programme. They help keep
patients ever mindful of their responsibility to alter their lifestyle,
avoid behavioural choices that may interfere with healthy priorities,
and practice stress management skills to improve self-care. Support
group facilitation would be another duty of the mental healthcare
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specialist. Having a provider who specializes in group-process
dynamics is another invaluable way of improving patient compliance,
encouraging programme attendance and helping patients stay on
track. The above duties, when provided by the programme’s mental
health specialist, provide cost-effective services and save the time and
energy of other team members. The other members of the interdisci-
plinary team are thereby freed to attend to other important matters of
aftercare that are within their particular specialty. Under one roof, all
these services become a routine for follow-up care as patients report
to their surgeon or bariatric centre.
After a period of time, as strictly medical/surgical interventions and
concerns fade, the psychologically oriented programme that enhances
relationship development between patients and service providers will
promote motivation for long-term follow-up, which can be the main-
stay of recovery. In this type of setting, if need arises for a more intense
form of psychological intervention, the clinical health-related, mental
health specialist can provide referrals for individual, group or family
psychotherapy.
A more detailed review of the three-stage system reveals that the first
step focuses on both pre-surgical screening services for peri-operative
psychological planning purposes and the development of adequate
pre/post-operative psychosocial therapeutic support services. From the
start, the mental healthcare professional creates an enduring climate of
emotional healing. The principal goal is to facilitate patient cooperation
and adjustment to long-range treatment goals. Further, the programme
enhances sustainable quality-of-life modifications tailored to each
patient’s psychological characteristics, emotional vulnerability and
detected obstacles or social withdrawal tendencies.
Before surgery, the programme emphasizes identifying patient’s
behaviours and attitudes that may lead to old behavioural habits. These
habits often act as obstacles to the patient’s identified goals. Once our
patients become aware of the obstacles, positive choices that promote
transforming old habits into new behaviours can be made. Ironically,
though bariatric surgery is not, as some wags say, brain surgery, with this
kind of mental health service in place, the desired bio/psycho/social
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307

medical changes can occur, giving the lie to this long-standing joke
because the brain must change too. That is why it is paramount for us to
accept that in part, bariatric surgery is a behavioural surgery. A harmful
‘diet of thoughts’ must be supplanted with a new way of thinking. This is
not an easy task. The opposition is nothing less than chronic psychologi-
cal co-morbidity. To overcome old habits and achieve behavioural and
attitudinal changes, we must approach patients with comprehensive and
pragmatic psychological programmes of care. Unsurprisingly, the best
post-operative care begins with pre-operative care.
All members of the treatment team must understand that even mak-
ing the decision to have bariatric surgery is transformational. For most
patients, their mental health evaluation is the first chance they have to
tell ‘their story’ fully to attentive listeners. And the team must be atten-
tive because the weight-related challenges and losses endured while
coming to this transformational decision can later be a source
of strength for building upon much-needed future decisions and actions
that will support overall recovery. Thus, the opportunity to detail one’s
history in a safe, non-judgmental environment with the support of
an understanding specialist can be a pivotal step in the process of help-
ing the patient let go of a life-long history of personal shame and
self-blame.
Therefore, the initial evaluation is formulated on a broad psycho-
educational model rather a narrower, traditional clinical psychological or
psychiatric evaluation. In this context, the evaluation provides valuable
patient education while simultaneously serving as a consultation to the
bariatric surgeon and other team members. This evaluation is, for the
entire team, more useful than the standard red light/green light checklist
before surgery. An immediate advantage of the more detailed psycho-
educational evaluation is the enhancement of the entire team’s under-
standing of the patient’s needs, strengths and vulnerabilities. With this
added detail, team members can help put in place a safety net to address
potential specific post-operative adjustment difficulties.
When the team plans ahead to address life events, issues and symp-
toms known to undermine a patient’s efforts to comply with needed
protocols, it collectively exerts a positive effect on post-operative adjust-
ments. Items likely to arise from a thorough pre-surgery evaluation that
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can sound an alarm for potential postoperative patient adjustment issues
may include:
•
A chaotic or unstable lifestyle;
•
Active bulimia nervosa;
•
Dangerous or non-compliant behaviour in psychiatric or medical
treatment;
•
Active substance abuse/compulsive gambling;
•
Untreated psychiatric symptoms or symptoms not stabilized by
medication;
•
Suicide attempts or psychiatric hospitalizations within the previous
twelve months;
•
Unresolved/untreated childhood abuse or neglect.
When such impediments are identified, the mental health specialist is
more alert to specific behaviours and is better prepared to direct the
patient to services necessary to reduce or stabilize problematic symptoms.
The three most common services I have found valuable to refer to in prob-
lems such as the examples described above include a psychiatric referral
for psychotropic medication evaluation or review, a recommendation for
pre-surgical psychotherapeutic alliance (therapy) with a mental health
specialist outside of the surgical programme and the ‘Alanon Family
Group’. Alanon is a wonderful worldwide fellowship and resource that
can be utilized in order to help patients or those whose lives have been
negatively impacted by a loved one or friend’s alcohol or drug usage. This
programme is free of charge and offers valuable opportunities for build-
ing stress management skills to people in need.
Additionally, it is essential for the surgical programme’s mental health
specialist to understand the surgeon and team’s philosophy and expecta-
tions. For example, if a surgeon prefers only minimal post-operative
involvement, the specialist will design a programme to compensate for
less medical follow-up. If the patient has been described before surgery as
having serious psychiatric conditions known to thwart recovery, the men-
tal health specialist must adjust the recovery programme accordingly.
Surgeons may choose to proceed with surgery even when a compre-
hensive pre-surgical evaluation indicates only a modest chance of
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309

long-term success. Pre-surgical conditions I have encountered that, at
times, evidenced a complicated recovery include: severe (non-psychotic)
depressions (particularly where there was a history of childhood abuse
without therapeutic attention), untreated anxiety conditions or attention
deficit disorders that become interruptive to life, active substance abuse or
dependency, post-traumatic shock disorder, schizophrenia and what was
once known as multiple personality disorder not properly managed or sta-
bilized with appropriate medications and treatment, bipolar disorder with
or without psychotic episodes also not stabilized and extreme body image
distortion/severe eating disorders. Though seen infrequently in surgical
candidates, even these worrisome conditions do not necessarily preclude
success. Rather, these more serious circumstances require increased team
awareness of the specific dynamics of the individual’s mental processes.
I have had the opportunity to provide consultations to such patients for
surgeons before full preoperative services were fully in place. While at
times these cases can be managed with great difficulty postoperatively, it
has been my experience that implementing pre-operative recommenda-
tions often provides the extra help some people need to safely undergo
bariatric surgery, and increases their chances for improved medical con-
ditions and a better quality of life. Team members need to apply a
psychodynamic understanding within their sub-specialty, so that the pos-
sibility for providing a safe, therapeutic environment for the patient’s
life-long success increases.
Incorporating a patient’s particular psychological dynamic into each
subspecialty on the recovery team begins with the rejection of a morbid
obesity stereotype. Patients may present similar symptoms, but the psy-
chological healthcare specialist must make sure that all professionals
focus on the individual being interviewed. No team member can be per-
mitted to lapse into prejudice; patients are hyper-sensitive to adverse first
impressions. An inadvertent slip before surgery is likely to increase the
risk of post-operative iatrogenic complications.
By rejecting stereotypes, the professional builds a bridge of empathy
to the individual with targeted clinical pathways for specialized service
delivery. It is at this juncture that the team psychologist, in consultation
with team members, can refine and enrich the contributions of each team
specialist, enabling him/her to provide the most efficacious care.
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The Initial Psychoeducational Interview
With the aid of other dedicated colleagues, a comprehensive paper was
created on this topic and is available from the ASMBS.8 The ASMBS
paper expounds further on the various aspects of a pre-surgery mental
health evaluation that can be covered by the mental health specialist, as
well as considerations for the choice and use of psychological instru-
ments. (For those interested in obtaining a copy of the nine-page skeleton
work sheet used and created by members of my office simply visit our
website, Drmoorehead.com.)
Briefly, the pre-surgery evaluation is a comprehensive, structured
psychological and educationally oriented clinical interview. The goal is to
collect a thorough psychosocial history of the individual, including his/her
perception of past and present family life. Among items of special inter-
est is the body-weight history with specific emphasis on the patient’s
psychological relationship to food, dieting and frustration-tolerance. A
weight history assessment includes an evaluation of the patient’s family
weight and food-use rules and patterns.
The clinical evaluation measures the level and depth of psychological
functioning for each surgical candidate, including emotional stamina, ego
strength, defence and personality structure, intact coping strategies,
characteristic cognitive and behavioural patterns, reasoning styles/
problem-solving methods, body image and self-esteem profiles. Medical and
psychological co-factors, including pertinent psychiatric history, early abuse
history, chemical substance abuse or dependency issues are also important,
as is a description of the existing social support for each patient.
Also of diagnostic relevance are an assessment of the patient’s ad hoc
problem-solving skills, a mental status exam and an evaluation of the
patient’s typical pain management thresholds. The assessment and evalu-
ation of each patient’s suggestibility should be conducted with an eye to
pain-management training. The initial interview needs also to delineate
the patient’s motivation for, and understanding of the details of surgery
and the after-care regimen.
When structured as a psycho-educational model, the interview pro-
vides patients with a detailed understanding of some of the dramatic
changes that may lie ahead. While improvement in quality of life is a
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311

reasonable expectation following surgery, altering consequences may
also include:
•
Radical and unexpected changes in the dynamics of important rela-
tionships (workplace or domestic);
•
Spiking in pre-operative depression or anxiety as patients lose the
ability to turn to food for emotional comfort;
•
Potential for substitution of food with another form of destructive
behaviour such as smoking, excessive alcoholic consumption, shop-
ping leading to financial difficulties, gambling etc. (what the mass
media refers to as ‘transfer of addiction’).9
Thorough pre-surgery education and evaluation are the main compo-
nents of securing psychological informed consent. In the course of the
evaluation, patients can gain a clearer understanding of the victories and
challenges that some people encounter before, during and after bariatric
surgery. Psychologically informed consent is essential for helping prevent
the patient from feeling overwhelmed, neglected or deprived after
surgery–feelings that can undermine programme involvement.
Additionally, the evaluation process itself can be of therapeutic value. The
mental health professional can address the patient’s immediate fears, while
establishing a rapport through the use of didactics with combined empathic
treatment.
This initial face-to-face contact cannot be underestimated.
Professionals specializing in the surgical treatment of severely/
super-obese patients often agree that many who struggle with the disease
of morbid obesity experience predictably similar forms of acute and
chronic psychological distress. While the rapid changes that come with
surgery are most frequently welcomed, they can also easily topple a frag-
ile personality. When the dramatic body weight reduction following
surgery is considered in light of the extreme, pre-treatment psychological
stressors described by some patients, it becomes abundantly clear that
post-surgical attitudinal changes and behavioural modifications can desta-
bilize some patient’s fragile ego status.
Moreover, readily apparent radical changes may serve as precipitants
to a period of even more pronounced psychological vulnerability. It is
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important to remember that bariatric surgery, unlike gall bladder surgery,
often changes the way people cope with their feelings. Bariatric surgery
most often takes away or interrupts the way some people deal with life–by
eating, eating and eating. Many patients go into surgery excited for this
change. Others are fearful of the change, and some do not come to the
awareness until after the surgery. Ironically, the direct experience of this
potent change is sometimes experienced as a profound loss. The point is
that when we threaten or take away a coping mechanism, we foster vul-
nerability that causes some patients to experience a regressed state of
emotion. During this brief window of time, when the regressed psycho-
logical maturation level is evidenced, there is definitive indication for
hand-in-hand psychological care concurrent with the surgical interven-
tion. The vast majority of the world’s bariatric programmes do not offer
this service. Our programmes will improve as we do.
When evaluating any candidate for weight-loss surgery, it is important
to remember that the disease of morbid or severe obesity kills and/or sub-
stantially reduces the quality of life of the afflicted, and dramatically,
often adversely, affects the lives of their loved ones. Because a lifelong
transformation is at stake, as well as the very life of the patient, the eval-
uator must never lose sight of the two purposes of the pre-surgery
interview: educating the patient and providing the surgeon and team
members with a comprehensive report on the patient’s underlying
strengths and challenges.
In this respect, it may be instructive to liken the mental health spe-
cialist in the bariatric arena to the child custody evaluator in a divorce
proceeding. While the judge or attorneys may want the psychologist to
determine which parent might provide better care, the decision is a legal
matter that lies with a higher authority. As such, it falls to the judge; the
custody evaluator merely advises. Similarly, before surgery an in-depth
evaluation can assist the surgeon in appreciating patient psychosocial
dynamics so that the surgeon, as head of the team, can make a more
informed medical/surgical determination for a particular patient regarding
the appropriateness of surgery and weighing potential surgical benefits
against possible psychological challenges. Ultimately, just as the judge
decides matters of law, the surgeon remains responsible for surgical deci-
sions concerning patient care.
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313

Because surgery is the central element of the entire transformation
from obesity to manageable weight, some have questioned whether there
is a meaningful role for psychology during the hospital stay and subse-
quent outpatient medical follow-up visits. I would urge that psychological
support at every stage is invaluable, and I know that many of my peers
share this view, favouring active involvement that helps patients manage
the emotional stress, behavioural transitions and even physical demands
that often arise during and after bariatric surgery. This provides an excel-
lent opportunity for healing and nurturing the spirit of our patients during
the dramatic weight loss process.
It is no small accomplishment for the patient to plan and arrange for
surgery; however, the full psychological impact of entering the hospital,
enduring surgery and facing the challenges of successful recovery are an
altogether distinct experience that requires consideration. Most patients
readily grasp the basic science of their surgery, but what they face after-
ward, often in silence, is unknown territory. After surgery they must cope
with the frequently frightening uncertainties that accompany behavioural
and lifestyle changes, including learning an entirely different way to feel
about and approach food. Moreover, to an extraordinary degree, some
people in support group settings talk about their new relationship to food
as comparable to an ex-smoker’s memories of nicotine or a former
addict’s cold flame for drugs.
Post-surgical support must be immediate. As a member of a larger,
multi-disciplinary/interdisciplinary outpatient team, the mental health
specialist can contribute a great deal even when medical concerns take
precedence. This includes follow-up exams or ‘fills’, for adjustable band
surgery patients. Though the purpose of the office visit is largely medical,
the mental health professional can provide counsel and comfort for
patients, which in turn enhances further participation in their programme,
as patients learn and practice new coping and behavioural skills. As part
of a coordinated team effort, such services and expertise greatly improve
the patient’s chances of implementing the positive behaviours necessary
to achieve lifelong success.
Creating this kind of positive period of time before surgery can pro-
vide a ‘golden window of opportunity’ period of time after surgery.
During this ‘honeymoon’time, patients experience their maximum weight
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M. K. Moorehead

reduction, which makes them motivated and receptive to overriding even
deeply ingrained behaviours with new, life-affirming ideas and actions.
Providing skills-building activities such as positive affirmation work and
structured progressive relaxation can be particularly effective during these
phases of time when patients are preparing to discover or are rediscover-
ing their new bodies, in effect, their new self. This is the best time to
systematically supplant the morbid ‘diet of thoughts’. Familiar negative
thoughts now must give way to behaviours and thoughts that reinforce
life-saving, long-lasting behaviours, transferring from a pleasant honey-
moon experience to a health satisfying marriage with their surgery.
Clearly, this is not solely about giving up the lifelong habit of turning to
food for comfort. A well designed recovery programme also shows patients
how to acknowledge, appreciate, and take ownership of all the positive
changes that have occurred: ‘I am good enough. I am loveable. I deserve the
attention I need’. At every step along the way, the mental health specialist
assists patients in making the smoothest transition possible to their new life.
And for virtually every bariatric surgery patient, the resulting weight loss
resolve, improvement of medical condition and enhancement in quality of
life may also be regarded as a medical resurrection.
In addition to the above range of psychological and mental health
services, the bariatric support group is a crucial component of the patient’s
psychological and emotional journey toward full recovery. For many,
these meetings provide patients with their first opportunities to free them-
selves from a profound social and emotional isolation and become a
valued member of a community of hope. It is quite common for our
patients to feel misunderstood and even blamed for seeking bariatric sur-
gery, which is frequently and erroneously viewed as the ‘easy way out’.
The support group confronts these hurtful misconceptions head-on, and
supplants them with well-deserved praise for embracing the difficult and
varied challenges that can arise before and after surgery.
In light of many patients’ histories of despair, discrimination, hope-
lessness, depression and anxiety, the overarching theme of the support
group raises feelings of personal life-transformation and pride in accom-
plishment. So pervasive is this sense of a second chance at life that many
bariatric surgery patients declare that they now have two birthdays — the
day of their birth and the day of their surgery.
Bariatric Surgery: When the Miracle is Not Enough
315

What is it about the concept of rebirth that makes it such a common
theme among these patients? The answer becomes evident when
patients share their life stories and the changes resulting from surgery
and group support. Abusive relationships end as patients no longer
accept victimization; diabetes, chronic debilitating pain and other life-
threatening conditions disappear; parents become more actively
engaged in their children’s development; infertile couples give birth to
long-dreamed-of babies. Many mundane daily activities become small
celebrations of a new life. Patients find they are suddenly comfortable
in public seating, walk easily down store aisles, and attract no more
attention than anyone else in public forums. Many discover new job
prospects and entirely new economic or social opportunities.
Exhilarated patients admit they are so pleased with their success that if
needed, they would undergo the surgery again. Even patients who expe-
rience significant complications and setbacks after bariatric surgery say
they would do it again ‘in a heartbeat’.
The healing process comes full circle when support group members
take the added therapeutic step of comforting and counselling others who
are considering or preparing for bariatric surgery. This service by group
members gives prospective patients a valuable opportunity to interact
with those for whom surgery was successful. Plus, the pre-operative
patient can meet people in several different stages of recovery. This
becomes an especially effective tool for managing patient expectations
and reducing anxiety. Interactions with other group members can become
a key component of informed psychological consent.
Another significant role of the support group involves encouragement
and education after surgery. Patients often experience a rise in self-esteem
just from ‘giving back’ to the group by sharing their personal stories of
triumph and tribulation. By trusting and sharing their experiences in a
group, people can learn that slips or lapses in following programme pro-
tocols do not have to end in collapse or failure. Meetings provide
opportunities to learn how to handle feelings in new ways other than turn-
ing to food. They can help individuals understand that while it is natural
to fear the regaining of weight, the power to sustain their weight loss is
always within their grasp.
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M. K. Moorehead

What is the Value of Speaking the Same Language
in Outcomes?
How can we ensure that a programme is really working to help patients
succeed and feel successful? After all, psychological wellbeing can be
greatly impacted by perceived success or failure. For that matter, what
determines success or failure? How can we, as a worldwide bariatric com-
munity, help patients re-define what it means to be successful or to have
failed after bariatric surgery, rather than simply reading numbers on a
scale? How can bariatric programmes improve the reporting and compar-
ing of outcomes by including the patient’s input in the process? How can
we come together universally to report our findings in meaningful ways,
particularly as we speak so many different languages?
A reliable, standardized easy method for measuring patient progress
is a key to understanding success for any widely applicable recovery pro-
gramme. The Bariatric Analysis and Report Outcome System (BAROS),
described and published in 1998 (Oria and Moorehead10) is such a tool.
BAROS, in an effort to respond to the 1991 National Institute of Heath
Consensus report, organizes acknowledged definitions and stages of
recovery into three categories to create a concise, clear accounting of an
individual’s progress.
As recovery proceeds, the healthcare professional continues to meas-
ure and chronicle progress using the BAROS system. BAROS provides
objective definitions and standards for measuring recovery, including per-
centage of excess weight loss, improvement in co-morbidities related to
obesity and patient perceived quality-of-life as measured by The
Moorehead–Ardelt Quality of Life Questionnaire II (MA II).11
Briefly, BAROS defines five outcome groups–failure, fair, good, very
good and excellent–by results on a scoring table that adds or subtracts
points for percentage of excess weight loss, changes in medical conditions
and QOL ratings (Fig. 1).
To assess quality of life before and after treatment, BAROS incorpo-
rates the MA II (Fig. 2), also designed for independent use, specifically to
address self-esteem, physical activity, social life, work conditions, sexual
activity and relationship to food. The one-page questionnaire uses simple
Bariatric Surgery: When the Miracle is Not Enough
317

318
M. K. Moorehead
Figure 1.
Moorehead–Ardelt quality of life questionnaire.
Please make a check in the box provided to show your answer.
1. Usually I Feel...
Very BadlyAbout
Very Good About
Myself
Myself
2. I Enjoy Physical Activities...
Not At All
Very Much
3. I Have Satisfactory Social Contacts...
None
Very Many
4. I Am Able to Work...
Not At All
Very Much
5. The Pleasure I get Out Of Sex Is...
Not At All
Very Much
6. The Way I Approach Food Is...
I Live to Eat
I Eat to Live
MOOREHEAD - ARDELT QUALITY OF LIFE QUESTIONNAIRE
SELF ESTEEM, AND ACTIVITY LEVELS
Melodie K. Moorehead, Ph. D., Bariatric Surgery Clinical Psychologist, 1201 E. Broward Blvd., Ft. Lauderdale, FL 33301.
Elizabeth Ardelt, Ph. D., Institute fŸr Psychologic, UniversitŠt Salzburg.
MOOREHEAD - ARDELT QUALITY OF LIFE QUESTIONNAIRE
SELF ESTEEM, AND ACTIVITY LEVELS
Copyright 1997 M.K. MOOREHEAD, Ph.D. (954) 524-5244
(
((
(
(
(

Bariatric Surgery: When the Miracle is Not Enough
319
Figure 2.
MA QoLQ II self esteem and activity levels scoring key.

drawings to represent the patients’ choices among perceived degrees of
change, and points are awarded to the responses that help determine the
score. BAROS also accounts for complications and re-operative surgery.
Points are merely deducted from the final tally of the scoring, thus avoid-
ing the controversy of considering re-operations as failures.
BAROS analyses outcomes in a simple, objective, unbiased and evi-
dence-based fashion. While it is not a perfect system, it helps provide a
common understandable language for our international community.
Additionally, it can be adapted to evaluate other forms of medical inter-
vention for the control of obesity. This method merits further
consideration by all international organizations seeking an adoption of
standards that will measure the success and impact of bariatric treatments
and will provide the comparison of results among surgical series.
Standardized outcomes measuring the three fields identified in BAROS
also help bring quantitative support to qualitative terms, such as success and
failure. This can help patients broaden their view of what constitutes success
while reducing their fear of weight regain. Used in this context, BAROS can
be valuable, clinically, for helping patients remain accountable.
Quantification of specific changes and results on the Improvement of
Co-morbidities and QoL sections of BAROS can be used to provide reas-
surance to patients returning to their surgeons by providing concrete
evidence that helps to decrease feelings of shame and anxiety and reduce
their sense of ‘failure’ simply because they gained some weight.
Standardized outcomes that quantify a range of success very well could
demonstrate a ‘good’or ‘fair’result even when there is weight gain after sur-
gery. Objective measurements of quality-of-life-improvement and resolve of
co-morbidities may well maintain their high scoring value even with weight
regain! One value for speaking a standardized language regarding outcome
measures is that we can better help our patients and our programmes.
Discussion
Bariatric surgery continues to be on the rise worldwide. One thing we can
all agree on is that there is still much to be learned about the disease of
obesity. Research is warranted and currently under way that demonstrates
the need for evidenced-based practice (EBP) in healthcare. Fortunately,
the field of bariatric surgery psychology is growing strong in the face of
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M. K. Moorehead

the advancing problem of morbid/super-obesity. The participation of
major medical and internationally recognized academic institutions will
help to determine scientifically what specialized bariatric mental health
services are needed in every comprehensive bariatric surgery programme.
These services can help patients build and strengthen healthy coping skills
while advancing their legitimate rights. EBP involves a process of clinical
decision-making based on research, clinical expertise, patient preferences
and characteristics. They are trans-disciplinary and promote a lifelong
learning process. While empirically supported treatments are a driving
force of EBP, they must not be reduced to such. We as helping profes-
sionals must also be free to act as creators, acting within the scope of our
licences and expertise while engaging patients in the shared decision mak-
ing process.12 Helping to change the patient’s inner ‘diet of thoughts’,
accompanied by progressive relaxation for stress management, can sup-
plant regressive coping behaviours that often leave bariatric surgery
patients vulnerable.13
Beyond working directly with patients and their loved ones, develop-
ment of a superstructure for cost-effective psychological practice
standards that responds specifically to the needs of bariatric surgery
patients is another area worthy of research. Such inquiry must lead to the
development of sound clinical pathways aimed to increase patient cooper-
ation that maximizes successful weight reduction and quality of life while
minimizing the litigious impact often seen in bariatric surgery.
Acting as political change agents, bariatric healthcare providers all
over the world have an opportunity and responsibility to provide leader-
ship in this ever-shrinking planet by participating in venues that focus on
prevention of obesity. An example of this occurred in May 2007 when
major stakeholders gathered in Washington DC.14 More than 100 leaders
from the public health, academic, industry and government communities
came together to discuss and identify a common list of urgent federal pol-
icy actions needed to reverse the American obesity epidemic. Six
recommendations were identified as essential policy changes to be made,
and were provided in a report offered to Congressional leaders in
Washington DC. This agenda promises to become the central platform for
the newly formed Collaborative Campaign to End Obesity (CCEO),
through which leaders and advocates can work together to reduce obesity
in North America. Helping to facilitate this gathering and establishing a
Bariatric Surgery: When the Miracle is Not Enough
321

common agenda proved immediately fruitful and focused on three
primary core panel areas:
•
Promoting active lifestyles;
•
Promoting better nutrition;
•
Change in the health care sector.
Six identified policies changes were offered to Congress that can be
translated quickly into ‘critical and realizable’ actions:
1.
Expand coverage for prevention, diagnosis and effective treatments of
obesity;
2.
Increase federal support for research services focused on obesity;
3.
Ensure that all foods in schools meet the Dietary Guidelines for
Americans. See
4.
Reduce the marketing of unhealthy foods and increase the marketing
of healthy, culturally relevant foods;
5.
Increase physical activity in schools;
6.
Create a built environment that supports physically active lifestyles.
For the complete report go to:
I close this chapter with a remark made to me by a patient many years
ago that remains relevant in our discussion regarding the role and value of
psychological services in a bariatric programme:
‘I know that for me, obesity surgery probably saved my life and most
definitely improved the physical quality of my life. At the same time,
I believe that the vast majority of patients who need obesity surgery
have psychological/emotional issues, such as low self-esteem that need
to be addressed and would benefit from psychological counselling and
intervention. I believe that the psychological intervention is just as
important as every incision, pouch, suture, band or staple.’
Acknowledgements
I would like to give my appreciation to Drs Nadey S. Hakim, Franco
Favretti and Gianni Segato, for the opportunity to offer my talents and
322
M. K. Moorehead

views regarding perspectives held on the subjects discussed in the chapter.
I honour the relationships with Drs Norman Samuels and Emanuel Hell
for inviting me into the field of bariatric surgery and introducing me to
the worldwide community. Recognition is given to Drs Elisabeth
Ardelt-Gattinger, Cynthia Buffington, Florence Kaslow and Cynthia
Alexander for enduring stimulation and vitality to my career. Gratitude is
acknowledged to my former business colleagues, Drs Joan M. DiGregorio
and Michael S. Parish, and to William C. Banks, formerly of Money
Magazine, for his outstanding and extensive editing efforts. Lastly, I
would like to simply thank Mr and Mrs Maurice and Joyce Williams, my
Mom and Dad, for their undying support and understanding. Happy 80th
Birthday Mom and Dad!
References
1. American Psychiatric Association (1994). Diagnostic and Statistical Manual of
Mental Disorders, 4th ed., American Psychiatric Association, Washington, DC.
2. Moorehead, M.K., Alexander, C.L. (2007). Transfer of addiction and consid-
erations for preventive measures in bariatric surgery, Part 1. Bariatric Times
4(1): 22–25.
3. Moorehead, M.K., Alexander, C.L. (2007). Transfer of addiction and consid-
erations for preventive measures in bariatric surgery, Part 2. Bariatric Times
4(4): 18–21.
4. Moorehead, M.K., Ardelt-Gattinger, E., Lechner, H. et al. (2003). The vali-
dation of the Moorehead-Ardelt Quality of Life Questionnaire II. Obes Surg
13: 684–692.
5. Stunkard, A.J., Messick, S. (1986). Eating Inventory Manual, The
Psychological Corporation, Toronto.
6. Stunkard, A.J., Wadden, T.A. (1992). Psychological aspects of human obe-
sity. In: Bjorntorp P., Brodoff B.N. (eds). Human Obesity: General Aspects,
pp. 352–358, Lippincott, Philadelphia.
7. Kaidar-Person, O., Wong Swartz, E., Lefkowitz, M. et al. (2006). Shared
medical appointments: new concept for high-volume follow-up for bariatric
patients. Surg Obes Relat Dis 2: 509–512.
8. LeMont, D., Moorehead, M.K., Parish, M.S. et al. (2004). Suggestions for
the Pre-Surgical Psychological Assessment of Bariatric Surgery Candidates,
American Society for Bariatric Surgery, Gainsville, Florida, USA.
Bariatric Surgery: When the Miracle is Not Enough
323

9. The new science of addiction: emergence of alcoholism after weight-loss
surgery offers clues to roots of dependency. (July 18, 2006). The Wall Street
Journal, D1–3.
10. Oria, H.E., Moorehead, M.K. (1998). Bariatric Analysis and Reporting
Outcome System (BAROS). Obes Surg 8: 487–499.
11. Moorehead, M.K., Ardelt-Gattinger, E., Lechner, H. et al. (2003). The vali-
dation of the Moorehead–Ardelt Quality of Life Questionnaire II. Obes Surg
13: 684–692.
12. Spring, B. (2007). Evidence-based practice in clinical psychology: what it is,
why it matters; what you need to know. J Clin Psychol 63: 611–631.
13. The Gift and the Tool©: A Personal Guide for a Lifelong Journey. A two-CD
audio set for those living with the disease of severe/super obesity.
Dramatically presented, it is a complete emotional guide for the bariatric
surgery patient and their loved ones. CD 1 is an inspirational presentation
helping to promote psychological informed consent. CD 2 contains a combi-
nation of relaxation techniques and positive affirmations to help prepare
patients for surgery, the surgery itself and for facing life and its challenges
after surgery. Also included are five Quality of Life Questionnaires that will
help measure progress from pre-surgery, to recovery and to maintenance.
Melodie K. Moorehead PhD (Drmoorehead.com).
14. National Summit on Obesity Policy, 8–9 May 2007, Ronald Reagan
Building & International Trade Center. Sponsored by Johnson & Johnson
and Discovery, coordinated by Venn Strategies.
15. Accessed 31 March 2010.
Suggested Reading
DiGregorio, J.M., Moorehead, M.K. (1994). The psychology of the bariatric
surgery patients: a clinical report. Obes Surg 4: 361–369.
Al-anon (1995). How Al-anon Works for Families and Friends of Alcoholics,
Al-anon Family Group Headquarters Inc., Virginia Beach, Virginia, USA.
Kleiner, K.D., Gold, M.S., Frost-Pineda, K. et al. (2004). Body mass index and
alcohol use. J Addict Dis 23: 105–118.
Kolotkin, R.L., Crosby, R.D., Pendelton, R. et al. (2003). Health-related quality
of life in patients seeking gastric bypass surgery vs. non-treatment-seeking
controls. Obes Surg 13: 371–377.
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Maddi, S.R., Fox, S.R., Khoshaba, D.M. et al. (2001). Reduction I psychopathol-
ogy following bariatric surgery for morbid obesity. Obes Surg 11: 680–685.
Mahoney, M.J. (2003). Constructive Psychotherapy: A Practical Guide, Guilford
Press, New York.
Moorehead, M.K., Ardelt-Gattinger, E., Lechner, H. et al. (2003). The validation
of the Moorehead–Ardelt quality of life questionnaire II. Obes Surg 13:
684–692.
Sogg, S., Mori, D. (2004). The Boston interview for gastric bypass: determining
the psychological suitability of surgical candidates. Obes Surg 14: 370–380.
Stunkard, A.J., Wadden, T.A. (1992). Psychological aspects of human obesity. In:
Bjorntorp P., Brodoff B.N. (eds). Human Obesity: General Aspects,
pp. 352–358, Lippincott, Philadelphia.
Oria, H.E., Moorehead, M.K. (1998). Bariatric Analysis and Reporting Outcome
System (BAROS). Obes Surg 8: 487–499.
Wadden, T.A., Sarwer, D.B., Arnold, M.E. et al. (2000). Psychosocial status of
severely obese patients before and after bariatric surgery. Prob Gen Surg 17:
13–22.
Wadden, T.A., Stunkard, A.J. (eds.) (2002). Handbook of Obesity Treatment,
Guilford Press, New York.
Wang, G.J., Volkow, N.D., Thanos, P.K. et al. (2004). Similarity between obesity
and drug addiction as assessed by neurofunctional imaging: a concept
review. J Addict Dis 23: 39–53.
Wolf, A.M., Falcone, A.R., Kortner, B. et al. (2000). BAROS: an effective sys-
tem to evaluate the results of patients after bariatric surgery. Obes Surg 10:
445–450.
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Chapter 12
Effects of Bariatric Surgery on
Co-Morbidities
Sebastiaan Van Cauwenberge and Bruno Dillemans
Introduction
Much has been written about the medical conditions that are associated
with morbid obesity and their response to bariatric surgery. Diabetes,
hypertension, hypercholesterolemia and obstructive sleep apnoea are
among the commonly reported co-morbid conditions which tend to
improve significantly or resolve completely following weight loss surgery.
This chapter gives an overview of the positive effects of bariatric sur-
gery on the previously mentioned co-morbidities. It will focus on
adjustable gastric banding (AGB), Roux-en-Y gastric bypass (RYGB) and
biliopancreatic diversion/duodenal switch (BPD/DS). We describe in detail
the evidence of their beneficial properties on those various co-morbid con-
ditions based on the current available literature.
Other co-morbidities such as gastro-oesophageal reflux disease
(GORD), musculoskeletal problems and polycystic ovary syndrome will
also be discussed. At the end of the chapter, the quality of life changes
after bariatric surgery will be reviewed.
Hypertension
One of the most frequent complications of obesity is hypertension.1
Hypertension is a risk factor for cardiovascular disease and stroke. It has
327

328
S. Van Cauwenberge and B. Dillemans
long been known that even a modest reduction in body weight (10 per cent)
will help reduce blood pressure (BP).2 However, in the Swedish Obese
Subjects (SOS) study no long term difference was observed in the fre-
quency of hypertension between the operated patients and obese controls,
due to long-term increase in hypertension prevalence irrespective of
weight changes.3
Pathogenesis of hypertension in obesity
Obesity-induced hypertension has multiple potential etiologic pathways,
the most well established being increased renal sodium reabsorption with
impaired pressure natriuresis via (1) activation of the renin-angiotensin
system; (2) stimulation of the sympathetic nervous system; and (3) altered
intrarenal physical forces.4 When the metabolic syndrome is present,
insulin resistance and hyperinsulinemia may contribute to hypertension
through diverse mechanisms.5 The sleep apnoea syndrome is an additional
contributing factor to the development of hypertension in a subgroup of
obese patients. Activation of the sympathetic nervous system, enhanced
aldosterone levels, and increased levels of endothelin by repeated
episodes of hypoxia are thought to be responsible in part for the elevation
in BP in this disorder.6,7
Effects of RYGB on hypertension
Weight loss is the best means to reduce obesity-related hypertension.4 The
diet-induced decline in BP was assessed in a 2008 meta-analysis of 38 ran-
domized controlled trials that found a mean fall in BP of 6.3/3.4 mmHg
with weight loss diets.8 RYGB surgery is not only one of the most effec-
tive methods for obesity treatment, but it also exerts the most significant
effect on obesity-related co-morbidities such as hypertension resolving it
in some 60 per cent9 of patients while improving control in others.10–15
Furthermore, the normal diurnal variation in BP which is lost in obese
hypertension is restored after RYGB.16 Weight loss associated with RYGB
substantially improves and/or resolves hypertension in the majority of
patients. In a study, 95 obese patients with documented hypertension and
being treated with antihypertensive medication(s) underwent RYGB. The

mean systolic BP decreased significantly from 140 ± 17 mmHg preoper-
atively to 120 ± 18 mmHg at 12 months (p < 0.01). The mean diastolic BP
also significantly decreased from 80 ± 11 mmHg preoperatively to
71 ± 8 mmHg at 12 months (p < 0.01). At 12 months follow-up,
44 (46 per cent) patients had complete resolution of hypertension while
18 (19 per cent) patients had improvement. Patients with complete reso-
lution had a shorter duration of disease as compared to patients without
resolution (53 versus 95 months, respectively, p = 0.01).17 Carson et al.
evaluated the relationship between weight loss and BP in patients with
diastolic hypertension who had RYGB surgery for morbid obesity. They
concluded that postoperative weight loss in patients undergoing RYGB
surgery was associated with resolution or improvement of diastolic hyper-
tension in approximately 70 per cent of cases. Resolution or improvement
of hypertension occurred more often in patients with a lower postopera-
tive body mass index.10
Ahmed et al. analysed 89 women and 11 men who underwent RYGB,
and monitored their BP monitored for one year. There was an 85 per cent
follow-up rate with mean percentage excess body weight loss of 60.
Reductions in systolic (9 mmHg) and diastolic (7 mmHg) BP measure-
ments were seen as early as week one postoperatively and maintained for
the duration of 12 months (p < 0.05). Furthermore, postoperative usage of
antihypertensive medication was reduced to a third of preoperative use.
This early impact on BP occurs before any significant weight loss is
achieved, thereby suggesting a hormonal mechanism that may be
involved for the changes observed.18
Even super-obese patients experience significant improvements in
co-morbidities and quality of life after RYGB even if their BMI remains
> 35 kg/m². Patients who had undergone RYGB and who had a preopera-
tive BMI > 50 kg/m² and postoperative BMI > 5 kg/m² were identified.
The records of 120 patients were reviewed for the presence of diabetes,
hypertension, hyperlipidemia and gastro-oesophageal reflux disease. The
average preoperative and postoperative BMI was 63.2 and 43.7 kg/m². Of
the 120 patients, 77 responded to the survey. In the preoperative group,
the rate of diabetes, hypertension was 50.8 per cent. Postoperatively
62.3 per cent of patients had been cured of their hypertension. The change
in the incidence of hypertension was significant at p = 0.037.19
Effects of Bariatric Surgery on Co-Morbidities
329

Effects of AGB on hypertension
Forty hypertensive and 55 normotensive obese subjects were studied
under basal conditions and again one year after significant weight loss
obtained through AGB. BP decreased in hypertensive subjects, with a
concordant decrease in PRA and supine aldosterone levels, not observed
in normotensive patients.20
Brancantisano et al. prospectively analysed 838 consecutive morbidly
obese patients who underwent AGB. After a median follow-up of 13 months
(range 6–36 months), resolution and/or improvement of hypertension was
67 per cent.21 Weiner reports similar results on 954 patients with improve-
ment or resolution of hypertension in 50 per cent of the hypertensive
patients.22 In a retrospective study on 454 patients with a mean follow-up of
30 months, hypertension was present in 73.4 per cent of the patients. After
AGB, hypertension markedly improved in 74.9 per cent of these patients.23
In a study of 88 patients with hypertension followed for 12 months after
AGB placement, 59 per cent had normal BP (without any treatment) and a
further 33 per cent had improved BP control with less therapy.24 AGB can
also play a role in the primary prevention of arterial hypertension.25
Effects of BPD on hypertension
In the well-known meta-analysis of Buchwald et al. hypertension
improved or resolved in 91.8 per cent of the evaluated patients after
BPD/DS.9 Scopinaro followed 312 patients who underwent BPD.
Hypertension was present in 86 per cent of the diabetic obese patients
before BPD. A significant reduction of the frequency of hypertension fol-
lowing the operation was observed. At one year after the operation
(follow-up on 305 patients) 50 per cent of the operated patients showed a
normal arterial pressure. The percentage of normal values rose to
64 per cent at five years and to 74 per cent at ten years (follow-up on
243 patients).26 Similar results were reported by Adami et al. 27,28 BPD was
more effective than AGB on BMI, on almost all cardiovascular parame-
ters and on cholesterol, although not on triglyceride and blood glucose.
Disappearance of diabetes, hypertension and metabolic syndrome was
similar with BPD and with AGB, and no new cases were observed.29
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S. Van Cauwenberge and B. Dillemans

Obstructive Sleep Apnoea
Prevalence and pathophysiology of obstructive
sleep apnoea in obesity
Obstructive sleep apnoea is a common chronic disease in Western society
whose prevalence is estimated at two per cent of women and four per cent
of men in the general population.30
Obstructive sleep apnoea–hypopnea syndrome (OSA) involves
recurring episodes of total obstruction (apnoea) or partial obstruction
(hypopnea) of airways during sleep. OSA is defined by an apnoea-
hypopnea index (AHI) of five or more episodes per hour associated
with daytime somnolence.31 Definite risk factors for OSA include obesity
and craniofacial or upper airway soft tissue abnormalities, while potential
risk factors include heredity, smoking and nasal congestion.32,33 Among
these, obesity is one of the strongest sleep apnoea risk factors. Mild to
moderate obesity has been associated with markedly increased sleep
apnoea prevalence. In severe obesity (BMI > 40 kg/m2), the prevalence of
sleep apnoea was estimated to vary between 40 and 90 per cent, and the
severity of sleep apnoea was generally greater than that found in leaner
clinical populations.34
Although it is clear that obesity is a key risk factor for the develop-
ment of OSA and modest reductions in weight lead to improvement in
OSA severity, the physiological mechanisms remain less than certain.
Deposition of fat around the pharyngeal airway is likely to increase the
collapsibility of the pharyngeal airway. Fat deposition around the
abdomen leads to reductions in functional residual capacity, which would
be predicted to reduce lung volume tethering effects on the upper airway.
Low lung volumes are also associated with diminished oxygen stores,
which would contribute to ventilatory control instability (high loop gain).
Finally, obesity has been associated with functional impairment in upper
airway muscles.35
Nasal continuous positive airway pressure (CPAP) is the primary
form of treatment of OSA. The concept is to deliver positive pressure
through a nasal mask to the pharynx, thereby creating a pneumatic stent.
Excessive daytime sleepiness is reversed, and the cardiopulmonary seque-
lae are eliminated with nasal CPAP.36
Effects of Bariatric Surgery on Co-Morbidities
331