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Foreword
In this Journal feature, information about a real patient is presented in stages (boldface type) to an expert clinician, who responds to the information, sharing his or her reasoning with the reader (regular type). The authors’ commentary follows.
Stage
A 41-year-old man with a weight of 159 kg and a body-mass index (BMI; the weight in kilograms divided by the square of the height in meters) of 49.1 presented for consideration of bariatric surgery. He had been morbidly obese since childhood; he had tried several commercial weight-loss programs in addition to dieting on his own but had had little long-term success.
Response
Bariatric surgical procedures are a well-established approach to the treatment of morbid obesity, offering sustainable weight loss and a reduction in the risk of conditions related to obesity. Candidacy is stratified according to BMI. Adults with a BMI of 40 or higher are potential candidates for the procedure. Patients with a BMI of 35.0 to 39.9 are generally considered to be eligible if they have at least one serious coexisting condition, such as obstructive sleep apnea, type 2 diabetes, or hypertension.
Stage
The patient had a history of hyperlipidemia and had undergone cholecystectomy. His medications included rosuvastatin and ezetimibe. He had no known drug allergies. He lived with his wife and three children and worked in information technology. He was a current smoker, with a 30-year history of one to three packs per day. He had a remote history of excessive alcohol use and had been abstinent for the past 15 years. He reported no illicit drug use. He had no known family history of gastrointestinal disorders. After consultation, he decided to undergo Roux-en-Y gastric bypass.
Response
Roux-en-Y gastric bypass is one of the most common bariatric surgical treatments for obesity. The procedure involves the creation of a small upper gastric pouch (with a capacity of approximately 30 ml), stapling of the stomach, and division of the small intestine at the proximal jejunum, with anastomosis of the distal portion (the alimentary, or Roux, limb) to the gastric pouch. The proximal end of the divided jejunum (the biliopancreatic limb) is anastomosed farther down the jejunum (Figure 1). Pancreatic and biliary secretions come into contact with food below this anastomosis, in the “common channel”...