Critique

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Cost-benefit analyses of treatments for obesity are lacking (14). For non-surgical treatments this is expected since such treatments are unable to provide durable, truly long-term weight loss allowing such analyses. A few studies have attempted to perform econometric analyses of anti-obesity surgery focusing on employment status, consumption of medical services and sick-leave, while others have attempted to assess global changes in quality of life (15). In general, the outcomes are extremely favorable for surgical treatment of severe obesity, but there are some serious limitations in the representativity of the populations and the scope of the studies.

The short-term success brought about by the relative safety and ease of performing anti-obesity operations laparoscopically and the lure of the burgeoning market of candidates for such surgery pose serious threats to this field. Just as was the case with intestinal bypass operations in the 1960s and 1970s, when any reasonably technically competent, enterprising surgeon performed them without any knowledge of or desire for managing the sequelae of the operation, there is now a recruitment of 'handymen' willing to demonstrate their technical proficiency in the belief that others will step in to take care of the specific needs of such patients. Unfortunately, there are no such 'others'. Internists, whether endocrinologists, nutritionists, gastroenterologists or generalists, have no interest in taking care of these 'surgical' cases. Indeed, many view the surgeons as (well-paid) competitors in this market, and would rather see them fail than recognize this as an opportunity to improve the quality of care for these patients.

It is tragic that the internists' focus on the development of new drugs (16), and the surgeons' lack of understanding of the importance of behavioral modification, patient selection, and psycho-dynamics for the outcome of gastric restrictive operations stand in the way of progress in this field. Entrenched, often adversarial positions encumber the necessary interdisciplinary collaborations that might otherwise improve the treatment of severely obese patients.

Most surgeons performing bariatric surgery, whether newcomers to the field or seasoned veterans, are committed to one type of procedure: gastric restriction for the newcomers and gastrointestinal bypass for the veterans. The arguments over 'gold standard', procedure-of-choice or even standard of care embody an anti-intellectual and hazardous failure to recognize the complexity of the disease of obesity and the need to individualize. The complexity goes beyond the advances in molecular genetics and cell biology, which as yet have not translated into clinical practice or improved patient satisfaction. Unfortunately many surgeons engaged in treating obesity do not seem to have realized that this surgery is not simply a technical exercise but rather a behavioral intervention requiring patient education (9), not just 'informed consent'. Furthermore, patient selection requires more refinement than has been brought to bear by practitioners of the behavioral sciences (17).

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