Morbid obesity is recognized as a serious health problem. The costs associated with obesity are substantial; billions of dollars are spent yearly in the United States on weight reduction, and a goodly portion of that is for treatment of the many complications associated with obesity. In 1991, the second National Institutes of Health Consensus Conference, after reviewing all data, concluded that surgical therapy should be offered to severely obese patients unresponsive to medical therapy. Since that time, the surgical community has settled on the Roux-en-Y gastric bypass, usually performed laparoscopically, and the adjustable gastric banding procedure as the means of accomplishing weight reduction with the fewest complications. We hope that this theme issue will alert you to the principles and pitfalls of bariatric surgery and the newer, and perhaps more physiologic, endocrine approaches to this universal problem.
Kenneth G. MacDonald, Jr, MD, is an authority in the field who has written extensively in this area. He acquaints you with the worldwide problems of morbid obesity, its prevalence, and some of the history of its surgical remedies.
This fascinating review of past experience, by the master of bariatric surgeons, Edward E. Mason, MD, PhD, is necessary as a guide to future success with gastroplasties and is presented with attention to the details of each operative approach.
Cottam et al summarize the present and future roles of laparoscopic bariatric surgery.
This article is by O'Brien and Dixon, who have the most successful series using this technique.
Livingston and Fink describe the criteria and costs of bariatric surgery and emphasize how it improves patients' quality of life.
Cummings and Shannon delve into the physiology of appetite and the potential of endocrine approaches to weight reduction. Is this the future?
We have entered the era of genetic analysis as a means of predicting the aggressiveness of tumors. Recently, a scheme for designating breast cancers as favorable or unfavorable based on genetic material from the tumors appeared in the literature. This issue of the ARCHIVES includes a beautiful study of RET proto-oncogene mutations and their relationship to the biological aggressiveness of multiple endocrine neoplasia type 2, adding to the growing body of knowledge relating specific genotypic abnormalities with phenotypic tumor syndromes. Multivariate analysis identified an increased likelihood of advanced medullary thyroid cancer at diagnosis with increasing age and risk group (level 1, 2, or 3 mutations). Current genetic testing can detect 99% of RET mutations. Because of the importance of early intervention in the treatment of medullary thyroid cancer and of screening for pheochromocytoma, identifying mutation patterns in carriers can significantly affect clinical decision making.
The incidental pancreatic cyst periodically plaques us as surgeons. At the recent New England Surgical Society meeting, Castillo et al, drawing on their large series, set forth their concept of the management of such lesions. Because more than half these lesions are malignant or premalignant, occur in older patients, and are smaller than symptomatic cysts, they cannot be dismissed. Using all available diagnostic modalities and a 2-cm cutoff point, they propose an algorithm for managing these lesions.
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