| | Proposal for a multidisciplinary approach to the patient with morbid obesity: The St. Franciscus Hospital Morbid Obesity ProgramReceived 19 June 2006; received in revised form 12 June 2007; accepted 28 June 2007. published online 15 January 2008. Abstract Morbid obesity is a serious disease as it is accompanied by substantial co-morbidity and mortality. The prevalence is increasing to an alarming extent, in Europe as well as in the United States. In the past few decades, bariatric surgery has developed and gained importance. It currently represents the only long-lasting therapy for this group of patients, resulting in an efficient reduction in body weight and obesity-related medical conditions, mostly cardiovascular in nature. The importance of a standardized protocol, the use of selection criteria, and a multidisciplinary approach have been stressed but not yet described in detail. Therefore, in this article, the multidisciplinary approach and the treatment protocol that have been applied in our hospital for more than 20 years are set out in a detailed manner. The application of a strict protocol may help to select and follow-up motivated patients and to organize multidisciplinary research activities. 1. Introduction  Obesity has become a worldwide epidemic and continues to increase, leading to significant morbidity and mortality [1]. The classical disorders associated with obesity are cardiovascular disease, type 2 diabetes mellitus, hypertension, lipid disorders, cancer, arthritis, and the sleep apnea syndrome [2], [3], [4]. Moreover, morbid obesity has a negative impact on the quality of life [5]. Obesity caused by an impaired balance between food intake and energy expenditure is now becoming a larger problem than undernutrition. While prevention of obesity and overweight by population-based and individual information programs is the basis of intervention, lifestyle changes with dietary counseling and stimulation of exercise constitute the first step in the treatment of obese subjects. Regrettably, a considerable number of obese patients shows a progressive increase in body weight and becomes morbidly obese [6]. Lifestyle intervention is not an efficient approach in morbidly obese subjects [6], [7]. Moreover, a reduction in caloric intake in this condition is counterbalanced by a reduction in energy expenditure [8], making the ultimate goal of losing weight in real life almost impossible. In morbidly obese subjects, the best long-lasting intervention is a surgical approach using bariatric surgery techniques [9]. Two recent meta-analyses [10], [11] and one large clinical trial [12] have described the long-term effects of bariatric surgery. Weight loss with bariatric surgery is the most effective and durable treatment for type 2 diabetes [12]. Moreover, bariatric surgery has been shown to decrease the relative risk of death in morbidly obese patients by 89% [13]. To increase the success rate and in order to diminish the complication rate of this intervention, a multidisciplinary approach is recommended. Yet, such an approach has not been described in detail before. In the present paper, we will describe the morbid obesity program that has been in operation at the Department of Internal Medicine of the St. Franciscus Hospital in Rotterdam for more than two decades [14]. It takes place in a multidisciplinary setting and may serve as a model for other institutions in the process of setting up such a program. 1.1. Non-surgical treatment of morbid obesity Obesity results from an imbalance between energy intake (eating behavior) and energy expenditure (exercise). The first line of treatment for morbid obesity involves caloric restriction, exercise, and behavioral modification. Though this strategy may be effective in some patients, the weight loss is frequently of short duration, with only 5–10% of patients maintaining the weight loss for more than a few years [15]. Pharmaceutical intervention would be the next most preferable therapy. However, the results of medical treatment with orlistat (a pancreatic and gastric inhibitor that produces 30% fat malabsorption) and sibutramine (a centrally acting monoamine uptake inhibitor that enhances satiety and possibly attenuates the fall in metabolic rate that occurs with weight loss) have been disappointing [16], [17]. Recently, rimonabant has been tested for a maximum period of 2 years; its effects on weight and cardiovascular risk factors are similar to those of the other drugs [17]. Intra-gastric balloons are associated with variable amounts of weight loss, depending upon the size of the balloon. Aside from the fact that the achieved weight loss vanishes after removal of the balloon, this procedure has undesirable side effects, including gastric ulcers and erosions. Research is ongoing in order to find an effective design. As with balloon insertion, jaw wiring is only a temporarily effective measure; it carries with it the risk of massive aspiration and suffocation after vomiting and is, therefore, currently no longer considered a significant mode of treatment. At first, we required a 50% excess weight loss by dieting before surgery in our patients with morbid obesity. Yet, even with the help of a nutritionist and sometimes that of a physical therapist or psychologist, we were only able to achieve this goal in approximately 15% of the patients. Among these 15%, morbidity had already decreased considerably at the time of surgery (Table 1) [18]. 2. Multidisciplinary approach toward morbid obesity Non-surgical treatment is frequently ineffective in achieving long-lasting weight loss in morbidly obese subjects, and several explanations have been proposed for this failure. Firstly, after weight reduction, patients need fewer calories to maintain their weight than lean subjects [8]. Secondly, it has been suggested that most obese individuals are insensitive to endogenous leptin [19], which decreases faster than expected after weight reduction [20]. This relative leptin deficiency can stimulate appetite and diminish energy consumption, which also hampers long-term weight loss. Moreover, plasma ghrelin levels rise after diet-induced weight loss (but not after gastric bypass surgery), resulting in weight regain [21]. Ghrelin is an orexigenic substance secreted predominantly by the oxyntic glands in the gastric fundus after contact with food. After gastric bypass surgery (RYGB), ghrelin levels decrease because of the elimination of the relevant part of the stomach [21]. Moreover, other gut hormones, such as peptide YY (PYY) and glucagon-like-peptide-1 (GLP-1), which enhance satiation postprandially, increase after RYGB [22]. Thirdly, long-lasting adherence to lifestyle recommendations is extremely difficult [23]. Therefore, surgical gastrointestinal techniques have been developed since 1955. The rationale of surgical intervention is either to decrease the intake (“restrictive surgery”) or the absorption (“malabsorptive surgery”) of nutrients, leading to weight loss. The most common types of restrictive surgery involve the LAP-band (most popular in Europe) and vertical banded gastroplasty (Europe); malabsorptive techniques include gastric bypass (most popular in the USA) and gastric sleeve resection/duodenal switch. 3. Treatment protocol at the Saint Franciscus Gasthuis in Rotterdam 3.1. The team The selection and the preoperative and postoperative care of morbidly obese patients should be carried out by a multidisciplinary team consisting of a surgeon, an internist/gastroenterologist, a psychologist (or psychiatrist), a nutritionist, and a physical therapist [24], [25], [26], [27]. 3.2. Importance of a protocol In our opinion, it is of utmost importance to use a protocol describing selection criteria, preoperative screening, frequency of follow-up, and a timetable for the patients. Furthermore, a clear description of perioperative educational sessions for the patients and agreements about preoperative weight loss and postoperative follow-up should be written down in a signed contract with the patient. This contract does not have any juridical value, but rather serves to emphasize the joint major effort taken by patient and treating team. The main reason for preoperative screening is to rule out endocrine causes of obesity and to prevent eating misbehavior, the “out eating” of the proximal pouch capacity, causing failure of long-term weight loss. In our hospital, such a team and a strict protocol have been operational since 1978. 3.3. Selection criteria According to the recommendations of the NIH health consensus development conference statement on gastrointestinal surgery for morbid obesity in 1991, patients with a BMI above 40 kg/m2 or exceeding 35 kg/m2 with obesity-related co-morbid conditions are potential candidates for bariatric surgery if non-surgical attempts at weight reduction have failed (Table 2) [24], [27], [28].  | • Acceptable operative risks | | | • Well-informed and motivated patients | | | • Readiness to participate in treatment and long-term follow-up | | | • BMI ≥40 kg/m2 | | | • BMI≥35 kg/m2 with obesity-related co-morbid conditions, such as: | | | – Severe sleep apnea | | | – Pickwick syndrome | | | – Cardiomyopathy | | | – Severe diabetes mellitus | | | – Joint disease | | | • Failure of non-surgical attempts to lose weight | | | • Psychological suitability | | | • Exclusion of endocrine disorders (Cushing, hypothyroidism) | | | • Exclusion of severe psychological or psychiatric disorders (binge eating) | | | • Exclusion of alcohol and drug abuse | | | | |
Endocrine disorders that can cause morbid obesity, alcohol and drug abuse, and serious psychological and psychiatric disorders should be ruled out, but are rare. Furthermore, surgery should only be offered to patients who are well informed and motivated, and who have acceptable operative risks. Other arbitrary selection criteria in our hospital also include age 18–60 years and the readiness to undergo psychological screening, to attend pre- and postoperative educational sessions, and to remain under lifelong supervision. 3.4. Phases of intervention at the St. Franciscus Hospital in Rotterdam (Fig. 1) 3.4.1. Referral phase Most of our morbidly obese patients are referred by general practitioners (GPs) in the Rotterdam area. Specialists from other hospitals without morbid obesity programs also refer patients to our clinic, albeit in a smaller proportion. A minority is referred by GPs from other regions in the Netherlands. An increasing number of patients are self-referred and contact our department after having visited our webpage, which contains information about our program. Others know patients who have been treated at our center. After getting in touch with the coordinating nurse at our department, patients receive information (a pamphlet) as well as forms with specific questions regarding weight, height, medical history, and the use of medication. Subsequently, written informed consent is asked from the insurance company to include patients in the program. When this request is approved, patients are placed on a waiting list and get an appointment with the internist within 3–6 months (Fig. 1). During that period, no specific treatment is given, apart from the usual advice on physical exercise and diet. 3.4.2. Intake phase At the first screening visit, patients undergo a complete physical examination and their medical history is taken. The major task of the internist is to rule out endocrine disorders (especially hypothyroidism, Cushing's syndrome) and to screen for common obesity-related conditions. A series of additional investigations is also scheduled. These comprise: chest X-ray, electrocardiography, pulmonary function testing for hypoventilation syndrome, abdominal ultrasound for gallstones (an elective cholecystectomy can be performed at the time of gastric surgery), gastroduodenoscopy, and clinical chemistry analyses such as lipids, vitamins, and glucose. In addition, the internist conducts preoperative screening and surveillance. A (non-binding) contract is signed with the patient stating that he/she will follow the entire program, including the educational sessions both before and after the operation, and that he/she is willing to participate in the long-term follow-up program of our clinic. The only purpose of the contract is to make clear to the patient that a minimum level of motivation and adherence to the protocol, including long-term follow-up surveillance, is required. Until now, no patient has ever refused to sign the contract; however, this does not mean that every patient has adhered to it completely. Patients who are not able or willing to adhere to our protocol usually seek their own alternative. Partners are welcome to participate in the educational sessions. Since we consider bariatric surgery a non-physiological intervention with considerable mortality and morbidity risks, only the most motivated patients who are willing to adhere to a new and different lifestyle are allowed to enter our program. Agreeing to sign the contract is the first criterion for selection; the second is the obligation of the patient to lose at least 10 kg of weight before surgery. The reason for this is to test motivation and diet adherence, to improve the patient's physical condition (lifestyle: diet, physical exercise) before surgery, and to minimize surgical risks, thus creating a better starting point for the future. The patients are not referred for surgery before having lost 10 kg. This weight loss should occur within 12 months; otherwise, patients will drop out of the program. However, exceptions can be made after discussion within the multidisciplinary team. This way, not too many patients are lost; exact numbers, however, are not known. This procedure is easier than our previously used protocols, but it is not evidence-based. 3.4.3. Lifestyle intervention phase At the first visit to the internist, patients are referred to the physical therapist and dietician. The patients enter a program in which they learn how to improve their lifestyle, both with regard to eating habits and physical exercise. The dietician/nutritionist evaluates the patients' eating behavior and place of eating, the distribution of meals throughout the day, binge eating, and the influence of emotional factors on eating behavior. Finally, an individualized dietary plan is prepared together with the patient. The physical therapist assists in changing physical activities and actually teaches the patient which activities are necessary for a more healthy lifestyle. Group sessions are held twice weekly for 3 months. Quality of life seems to increase in most patients at this stage (personal observations), and group sessions appear to help as well [29] because patients can share their positive (and negative) results. Moreover, they can stimulate each other to achieve the predefined goals. After having lost 5 kg, patients are referred to the psychologist for assessment. This is necessary to identify patients with psychological or psychiatric disorders, those who need to be treated before continuing in the program, and those who should be denied surgical therapy. However, the need for psychological screening has been questioned [30]. Previous reports suggest that there is no difference in weight loss between groups with and without psychological problems [31]. Moreover, quality of life and psychological adjustment have been shown to improve after surgery regardless of the psychological profile [32], [33]. Reports on this subject are scarce. Contra-indications are serious psychological or psychiatric disorders, such as certain personality disorders, psychotic disorder, “binge-eating disorder”, and alcohol/drug abuse. In The Netherlands, a psychologist was involved in 19 of 28 hospitals performing bariatric surgery. There was limited consensus about selection criteria and postoperative psychological assessment was relatively rare [34]. 3.4.4. Target evaluation phase During this phase, patients are seen by the internist every 3–4 months. This serves to test motivation, to treat disorders detected at the intake phase, and to improve control of blood pressure or diabetes, if necessary. In the meantime, lifestyle interventions take place. As soon as patients reach the goal of 10 kg of weight loss, they are referred to the surgeon. 3.4.5. Surgical intervention phase Patients are seen by the surgeon and undergo routine preoperative screening by the anesthesiologist. Patients have to restrict to fluid intake for 2 weeks to prevent them from swallowing a piece of solid food that may obstruct the newly formed pouch. This measure may also lower the risk of anastomotic blow-out, although this has not been proven. During this period, patients receive help from the dietician and, if necessary, from the physical therapist. Patients are usually discharged 2 days after surgery (for vertical banded gastroplasty or sleeve resection) or depending on their clinical condition (gastric bypass) and are subsequently scheduled to visit the internist's outpatient clinic within 3–4 months after surgery. The surgeon makes an inventory of any former abdominal surgery that might complicate bariatric (laparoscopic) surgery and discusses the appropriate surgical option. The type of bariatric surgical technique depends on local customs and BMI: patients with a BMI between 40 and 50 frequently receive a restrictive bariatric procedure, and patients with a BMI above 50 or “sweet-eaters” receive a malabsorptive procedure [35]. Current surgical techniques (Fig. 2, A–E) include gastric restrictive procedures (laparoscopic adjustable gastric banding, hand-assisted vertical banded gastroplasty, and laparoscopic sleeve gastrectomy) and malabsorptive procedures (gastric bypass and bilio-pancreatic bypass or duodenal switch procedure). Nowadays, the procedures are mostly performed laparoscopically, resulting in lower morbidity and a shorter hospital stay [36]. Although malabsorptive procedures have more effect on weight loss, gastric restrictive procedures are most frequently used in Europe because of their simplicity, safety, and because they seldom lead to malnutrition-related complications. 3.4.6. Postoperative evaluation phase Postoperatively and yearly thereafter, a series of parameters are determined, such as vitamin B12, folic acid, ferritin, albumin and hemoglobin concentrations, but also calcium, magnesium, phosphate, glucose, lipids, and additional routine biochemical tests to track down deficiencies and remaining risk factors. 3.4.7. Long-term follow-up phase and educational sessions The prospective, controlled Swedish Obese Subjects Study (SOS) reported long-term weight loss 10 years after bariatric surgery (13.2–25%, depending on the surgical technique used; 641 patients), whereas the control group (627 patients) showed a weight increase of 1.6% [12]. All risk factors that were elevated at baseline, except for hypercholesterolemia, improved in the surgical group [12]. Jazet et al. [37] recently showed that following laparoscopic adjustable silicone gastric banding, BMI decreased from 44.5±0.9 kg/m2 (mean±SEM) preoperatively to 32.0±0.8 kg/m2 5.2±0.3 years after surgery. Unexpectedly, the cardiovascular risk profile was significantly better than that of the BMI-matched control group [37]. Quality of life has been shown to improve 1 [38] to 2 [39] years after (laparoscopic) gastric banding, even though most of the patients still had considerable overweight [38], [39]. Our patients signed a contract during the intake phase and remain under lifelong supervision; in the first few years, every 3–6 months, and thereafter every year. Apart from asking about complaints (eating problems, vomiting, etc.), laboratory programs similar to the pre- and postoperative evaluations are performed on a regular basis. Educational and supportive lifestyle sessions are also planned during the first year postoperatively. In our group of patients, we performed follow-up investigations 16–20 years after bariatric surgery in 92 gastric bypass (GB) and 48 vertical banded gastroplasty (VBG) patients. Preliminary data show that the mean weight at the time of follow-up was similar to that at the time of surgery, which means an excess weight loss of 50% (which was originally required in our clinic). Morbidity comprised mainly nutritional deficiencies and gastrointestinal problems, but also direct postoperative complications. All complications occurred somewhat more often in the GB group, including revision surgery. Absolute mortality was 5 (3 early and 2 late) in the GB group and 1 (late) in the VBG group, mostly in the early years [unpublished results]. In our opinion, the procedure – as described above – helps to select the right (and motivated) patients to undergo bariatric surgery. They should understand that the procedure is non-physiological and demanding but that, at present, no other long-lasting therapies are available. 3.5. Costs In The Netherlands, bariatric surgery is reimbursed by the health insurance companies if the patients are selected in the right way. It has been stated that bariatric surgery can be cost-effective before the 4th year of follow-up [27]. Reimbursement of the costs of plastic surgery after bariatric procedures, however, may sometimes be problematic and may differ per insurance company. 3.6. Research If a strict protocol is being followed with respect to selection and follow-up investigations, data from all patients will be available for research purposes. This is important because still too little is known about these kinds of patients and procedures. Long-term follow-up data are badly needed, and careful recording of complications is necessary for quality control. 4. Conclusion Bariatric surgery evolved over the second half of the 20th century. Even though the ideal procedure has yet to be devised, surgery remains the only effective treatment for sustained, significant weight loss in the morbidly obese. Prospective, controlled, clinical trials with long-term follow-up, such as the SOS [12], are strongly needed to determine which (laparoscopic) techniques will yield optimal outcomes in terms of both absolute weight loss and improvement in obesity-related medical disorders. The application of a strict protocol is advantageous in terms of selection and follow-up of motivated patients, but also to learn more about this difficult to treat patient group. As surgery has thus far not been shown to be the optimal solution, long-term success will most likely come from ongoing research aimed at disclosing the genetic factors involved in obesity and by the closely linked development of anti-obesity drugs. 5. 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[39]. [39]Champault A, Duwat O, Polliand C, Rizk N, Champault GG. Quality of life after laparoscopic gastric banding. Prospective study (152 cases) with a follow-up of 2 years. Surg Laparosc Endosc Percutan Tech. 2006;16:131–136. MEDLINE a Department of Internal Medicine, Center for Diabetes and Cardiovascular Risk Management, St. Franciscus Gasthuis, Rotterdam, The Netherlands b Department of GI-Surgery, St. Franciscus Gasthuis, Rotterdam, The Netherlands c Department of Medical Psychology, St. Franciscus Gasthuis, Rotterdam, The Netherlands  Corresponding author. Department of Internal Medicine, Center for Diabetes and Cardiovascular Risk Management, St. Franciscus Gasthuis, Kleiweg 500, 3045 PM Rotterdam, The Netherlands. Tel.: +31 10 4616094; fax: +31 10 4612692.
PII: S0953-6205(07)00355-X doi:10.1016/j.ejim.2007.06.015 © 2008 European Federation of Internal Medicine. Published by Elsevier Inc. All rights reserved. | |
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