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Palmer Lecture: Surgical Treatment of the Obesity Epidemic

Aurora Pryor
Aurora Pryor

The 2010 Palmer lecture was given by Aurora Pryor, Associate Professor of Surgery at Duke University Medical Center and co-Director of the Duke Metabolic and Weight Loss Surgery Program. Aurora received a biomedical and electrical engineering degree at Duke University and subsequently completed her medical and surgical training there. She is Chief of General Surgery at Durham Regional Hospital, an inventor, a teacher, and an expert in bariatric surgery.

John Angus Palmer completed the Gallie Course in General and Plastic Surgery in Toronto and fellowship training at the University of Edinborough and St Marks. He was a master surgeon, an astounding technician, a thoughtful clinician and gifted teacher. His expertise covered a very broad range of general, head and neck, endocrine and cancer surgery.

John had numerous and eclectic interests outside of surgery: his family, painting, collecting art, collecting and refinishing antiques, carving decoys, anatomy, skiing and boating, to name a few. He also mixed a mean pitcher of martinis. As a centennial project in 1967, he and his family dismantled a pioneer log house and reconstructed it near their family cottage in Dwight, Ontario. They then opened it to the public as a charming antique shop.

Lorne Rotstein

Aurora first documented the obesity epidemic in North America, then explained that there are two classes of operative treatments for obesity - restrictions and diversions. Gastric restrictions use adjustable bands or sleeve reduction to create a sensation of fullness after the residual small gastric pouch is filled. Afferent vagal fibers from the proximal stomach that remain in continuity transmit a message of satiety after only a small meal following these procedures. Combined diverting procedures involve some re-routing of the gastrointestinal tract. These procedures, including Roux -en-Y reconstruction or a duodenal switch are more complex, but offer a more reliable rate of sustained weight reduction. She favors the Roux-en-Y procedures because of the dramatic cures of diabetes - powerful evidence that is evident even a day or two after surgery. (Perioperative Safety in the Longitudinal Assessment of Bariatric Surgery, N Engl J Med 2009; 361:445-54). John Palmer performed the first bariatric surgical procedure in Canada as one of his many innovative contributions. The operation was a stapled gastric restriction procedure.

Adjustable Gastric Band
Sleeve Gastrectomy

Among the 3,500 bariatric operations performed at Duke (600 procedures per year), 17% are restrictive operations and 81% are diversions. There is a 70% long- term stable weight loss rate with the Roux-en-Y procedure. Associated with that weight loss is significant reduction in medical co-morbidities associated with obesity, such as diabetes or hypertension. Overall the 30-day mortality of primary bariatric surgery in the Duke series is 0.25%. In a large series followed at McGill University, comparing surgery with medical care in obese patients, the five year mortality is 0.68% in patients treated surgically and 6.17% with medical care alone. The benefits of surgery are striking: 76.8% complete resolution of diabetes and 86% improvement in control of diabetes. Blood pressure is reduced, hospitalizations are reduced, return to work among disabled morbidly obese Medicaid patients is 37%. Complications include anastomotic leak, thromboembolism and marginal ulcers.

Steps to reduce the risk of surgery include careful anticoagulation, preoperative weight loss and blood pressure control. All patients are treated with proton pump inhibitors, as the incidence of marginal ulcers was 4.7% in the initial series. One of the complications of restrictive operations using adjustable bands is slippage of the band in 5-10% of patients.

Food Portions 20 Years Ago vs. Today

Centers of excellence in Bariatrics are becoming more widespread in the United States; they are required by many insurance payers in order to qualify for reimbursement. A large centre such as the Duke Centre provides a stable team of caregivers including psychologists, nurse practitioners, dieticians, surgeons and dedicated operating teams. Such centres require devotion of considerable operating time and space to the program.

The University of Toronto Bariatric Program will use a more distributed hub and spoke model. There will be one central program but the operations will be distributed (New Bariatric Surgical Program Established at University of Toronto, The Surgical Spotlight, Spring 2009).

During a spirited and well-timed discussion period, Jack Langer asked about the use of bariatric surgery in children. The Duke program is just starting a paediatric program; there are important questions about the effect of the operation on development to be answered from experience.

Andy Smith asked about warning labels, analogous to those on cigarette packages. The widespread use of high fructose corn syrup in many foods and the supersizing of commercially available portions present a health hazard. Labeling has only begun to be practiced, but warning does not yet appear on packaging. Richard Reznick asked about non-surgical interventions - apparently there are endoluminal sleeves that can be introduced by gastroscopy and gastric balloons to fill the stomach. Experience with these is very preliminary.

David Urbach asked about the best way to develop a program. Aurora felt that starting with simpler operations to develop proficiency and good results had been helpful at Duke. Kyle Anstey asked about performing bariatric surgery in developmentally or cognitively impaired patients. Because of potential problems with management in the longer term, Aurora recommended that accepting these patients for surgery be delayed until the program is better developed.

Allan Okrainec asked about surgery in the elderly. Duke has no cut off, but the province of Ontario has recommended that surgery be offered only to those who are under 60 years of age. There is not yet sufficient experience to know how valuable the surgery will be in non-obese diabetics. It is interesting to note that gastric surgery, once a very significant part of general surgery practice, has been eclipsed in recent years because of effective pharmacotherapy for peptic ulcer and reflux disease. The obesity epidemic has returned gastric surgery to a prominent place in surgical practice.


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