Obesity

What Is Obesity?

 Obesity is determined by measurement of body fat, not merely body weight. People might be over the weight limit for normal standards, but if they are very muscular with low body fat, they are not obese. Others might be normal or underweight, but still have excessive body fat. The current best single gauge for body fat is a measurement called body mass index (BMI). It is derived by multiplying a person's weight in pounds by 703 and then dividing it twice by the height in inches. For example, a woman who weighs 150 pounds and is 68 inches tall would have a BMI of 22.8. The result is graded on a scale to indicate levels of body fat. Federal guidelines define overweight as a BMI of 25 to 29.9 and obesity as a BMI of 30 or greater. Experts argue over what constitutes dangerous weight at different ages or for healthy people with no risk factors. The standard BMI guidelines do not apply to people over 74 or conditioned athletes (who may have abnormally high BMIs because of very dense muscle tissue.

What Causes Obesity?

Cultural Influences on Eating

 The age adjusted prevalence of obesity in the United States for the year 1999-2000 was an astounding 30.5% , compared with 22.9% in the years of 1988-1994 as calculated in the National Health and Nutritional Examination Survey.  Those with extreme obesity (BMI ≥ 40) now represent 4.7% of the population, as opposed to 2.9% in those earlier years.  These statistics place America number one on the list of the world’s most obese nations.  Abundant production of food, wide marketing of food of poor nutritional quality, lack if exercise, and an increasing reliance on technology to curtail energy expenditure all place Americans at higher risk for obesity.  Even foreign born citizens have an increased likelihood of obesity upon moving to the United States and adopting its lifestyle. 

Biologic Factors

Eating patterns are regulated by feeding and satiety centers located in the hypothalamus and pituitary glands of the brain that respond to signals indicating high fat stores and hunger. Substances critical in this process include glucose (sugar), insulin (a hormone that is critical in the conversion of blood sugar, or glucose, into energy), and leptin (an enzyme that signals the brain when fat stores are high and is found in high levels in obese people).    

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Genetic Factors

Genetic factors influence fat metabolism and regulate certain hormones and proteins that affect appetite and may play some part in 70% to 80% of obesity cases . A number of genetic variations are involved in making people susceptible to obesity. Inherited attributes can include the way fat is distributed, metabolic rates, changes in energy responses to over eating, food preferences, and other factors. Genetic factors may also play a direct role in some cases of very severe obesity. Although genetic abnormalities may make it harder or easier to lose weight, the prevalence of obesity has dramatically increased over the past two decades, and genes cannot have changed within that time. 

 Effects of Certain Medications

Some prescription medications contribute to weight gain, usually by increasing appetite. Such drugs include corticosteroids, antidepressants, and other psychoactive drugs. In a particularly unfortunate conflict of interest for obese individuals with type-2 diabetes, the use of insulin and insulin-stimulating drugs used to treat the condition often leads to weight gain. Although drugs usually are not the primary cause of obesity or being overweight, some people may be mistakenly tempted to stop taking their medications without their doctors' knowledge.

Medical Causes of Obesity

A number of medical conditions may contribute to being overweight: hypothyroidism, Cushing’s Disease (a rare condition caused by high levels of steroid hormones), polycystic ovarian syndrome and other rare disorders.

Who Becomes Obese?

Obesity in Adults

In men, BMI tends to increase until age 50 and then it levels off; in women, weight tends to increase until age 70 before it plateaus. Gaining some weight is inevitable with age and adding about 10 pounds to a normal base weight over time is not harmful. However, in one study, 64% of women and 73% of men between ages 50 and 60 were seriously overweight. The tendency in the US is toward an unhealthy average increase of one pound per year after age 25. This condition is made worse by the fact that muscle and bone mass decrease with age, so the fat increase is actually about one and a half pounds. This means that by age 55, the average American has added over 37 pounds of fat during the course of adulthood.

Obesity in Children

More children and adolescents are overweight in America than ever before, possibly up to 25%, according to some estimates. Like obese adults, obese children are at increased risk for high blood pressure, insulin resistance (a risk factor for diabetes), and possibly cardiovascular disease. The likelihood that a child will become obese gradually increases as a child matures. For example, although one study suggested that the weight of a toddler does not appear to influence the risk for obesity, an overweight 15-year old is 17 times more likely to be overweight as an adult than a normal-weight adolescent. 

Specific Groups at Risk

Ex-Smokers. The trend toward weight increase has followed the trend for quitting smoking. Nicotine increases the metabolic rate, and quitting, even without eating more, can cause a weight gain, which may be considerable. It is important to note that weight control is not a valid reason to smoke. People in previous centuries did not smoke cigarettes, nor were they usually obese.

Shift-Workers. A recent study found that individuals who work late shifts (between 4PM and 8AM) tend to eat more and take longer naps than day workers and are more likely to gain excess weight.

How Serious Is Obesity?

Cardiovascular Disease and Diabetes

Obesity is a risk factor for heart disease, high blood pressure, diabetes, and stroke. People who are obese have almost three times the risk for heart disease as people with normal weights. Being physically unfit adds to the risk. Studies continue to report that obesity in childhood is a strong predictor of heart disease, in one study it was a greater risk factor than a family history of heart problems. Reducing weight may eliminate this risk. 

High Blood Pressure. Hypertension is the health problem most commonly associated with obesity, and the greater the weight, the greater the risk. While hypertension carries its own serious risks for stroke and heart attack, overweight people with high blood pressure are also at increased danger for enlargement of the left heart chamber, a major risk factor for heart failure. 

Insulin Resistance and Diabetes Type 2. Obesity is strongly associated with type 2 diabetes (previously called non-insulin dependent or adult-onset diabetes). Almost 90% of type 2 diabetics are obese. Although only a minority of obese people are diabetic, researchers have blamed obesity and sedentary living for the dramatic increase in type 2 diabetes over the past years. Type 2 diabetics generally have normal or high levels of insulin, a critical hormone in the metabolism of sugar. However, they are unable to use the insulin, a condition called insulin resistance, which is now thought by many experts to be an independent risk factor for heart disease. 

Cancer

Excess weight is a strong risk factor for esophageal cancer in certain people. The increased risk may be due to a higher incidence of gastroesophageal reflux disorder (heartburn) in people who are overweight. (Obesity does not appear to be related to a higher risk for stomach cancer.) Women who are obese appear to have two to three times the risk for uterine cancer as thinner women. Obese women are also at higher risk for gallbladder cancer, and obese men are at higher risk for colon and prostate cancers. 

Muscles and Bones

Obesity places stress on bones and muscles, and overweight people are at higher risk for hernias, low back pain, and aggravation of arthritic conditions. 

Gallstones

The incidence of gallstones is significantly higher in obese women and men. The risk for stone formation is also high if a person loses weight too quickly. In people on ultra-low calorie diets, gallstones may be prevented by taking ursodeoxycholic acid (Actigall).

Reproductive and Hormonal Problems

Women who gain weight after age 18 are at higher risk for developing uterine fibroids. Abnormal amounts of body fat, either 10% to 15% too high or too low, can contribute to infertility in women. In men, obesity can contribute to reduced testosterone levels. The dangerous effects of obesity on pregnancy are multifold. They include high blood pressure, gestational diabetes (diabetes, usually temporary, that occurs during pregnancy), urinary tract infections, blood clots, prolonged labor, a higher fetal mortality rate in late stages of pregnancy, and Cesareans. 

Effects on the Lungs

Obesity is proving to be a strong risk factor for adult-onset asthma. Obesity puts people at risk for hypoxia, in which oxygen is insufficient to meet the body's needs. Obese people need to work harder to breathe and tend to have inefficient respiratory muscles and diminished lung capacity. The Pickwickian syndrome (or sleep apnea), occurs in severe obesity when lack of oxygen produces profound and chronic sleepiness and, eventually, heart failure.

People who are obese and nap tend to fall asleep faster and sleep longer during the day; at night, however, it takes them longer to fall asleep and they sleep less than people with normal weights. In an apparent vicious circle, studies have suggested that not only can obesity interfere with sleep, but that sleep problems may actually contribute to obesity. Obesity is particularly associated with sleep apnea, which occurs when the upper throat relaxes and collapses at intervals during sleep, thereby temporarily blocking the passage of air. Some people may not even know they have this condition except for vague symptoms, such as morning headache, fatigue, and irritability. Sleep apnea is associated with a higher risk of heart arrhythmias, stroke, right-sided heart failure, and car and other accidents due to daytime drowsiness. Sleep apnea may actually contribute to weight gain by depriving people of REM (rapid eye movement) sleep. 

Emotional and Social Problems

A study that followed obese adolescents for seven years found that, compared to thinner peers, overweight women completed fewer years of school, were 20% less likely to be married, and had 10% higher rates of household poverty. Overweight men were not as severely affected as women, although 11% were less likely to be married than nonobese men and their incomes were lower. Sick days, healthcare costs, and short-term disability all rise with increasing BMI values in workers. No evidence exists, however, that obese people suffer from emotional disorders, such as major depression or anxiety, to any greater degree than thinner people. Generally, depression and anxiety are caused by the weight problem and are usually resolved by weight loss.

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What Are Guidelines For Weight Treatments?

A recent study reported that nearly 29% of men and 43% of women were trying to lose weight but only 21.5% of men and 19.4% of women were using the most effective method, reducing calories and exercising at least 150 minutes a week. Extreme dieting programs can sometimes be harmful and are rarely successful over the long term. Some experts believe that it is not weight that causes the diseases associated with being overweight but the accompanying unhealthy foods and sedentary lifestyles. They point to one study, in which obese people began exercising regularly and consumed a diet rich in fruits, vegetables, and whole grains and low in fats. After only three weeks, indicators for heart disease (cholesterol and triglyceride levels, blood pressure, and insulin) had all improved although the average weight loss was less than five percent. Once a person has lost weight, long-term maintenance is usually required to ensure that healthy lifestyle habits continue. While many weight-maintenance programs last one to two years, some experts say there is no evidence that such a long duration improves outcome and they suggest that a four- to six-month program may be just as effective. 

Everyone should be warned, however, that diet failure is extremely common. To make the dieting process even more difficult, an obese person often cannot use hunger pangs as a natural signal to eat. A stomach that has been stretched by large meals will continue to signal hunger for large amounts of food until its size reduces over time with smaller meals. 

What Are Diets And Lifestyle Methods For Managing Weight?

A 1999 analysis of 2,800 individuals who had lost at least 30 pounds and maintained the weight loss for more than year reported the following: about 55% had been involved in a formal weight loss program; 20% succeeded with liquid diets; only 4.3% used medications; and 1.3% had surgery. And 81% reported that they exercised more often and more vigorously than with previous attempts.

Calorie Restriction

Calorie restriction has been the cornerstone of obesity treatment. The standard dietary recommendations for losing weight include reducing calorie intake by 500 to 1000 calories a day and having a fat intake of no more than 30% of total calories. Saturated fats should be avoided.    

Extreme diets of less than 1,100 calories carry health risks and are often followed by binging or overeating and a return to the obese state. Such diets usually have insufficient vitamins and minerals, which must then be taken as supplements. Severe dieting has unpleasant side effects (including fatigue, intolerance to cold, hair loss, gallstone formation, and menstrual irregularities) and can be dangerous. Most of the initial weight loss is in fluids and minerals; later, fat is lost, but so is muscle, which can account for more than 30% of the weight loss. It is very dangerous to be on severe diets longer than 16 weeks or to fast for more than two or three days. 

Low-Fat and High-Fiber Diets

Recent studies have indicated that it is high fat intake, rather than high consumption of sugar, that is the primary culprit in dietary weight gain. Some studies suggest that replacing foods high in fats with low-fat complex carbohydrates (fruits, vegetables, and whole grains) may even be more effective than calorie counting, particularly in maintaining weight loss. People on low fat diets should consume a wide variety of foods and take a multivitamin if appropriate. Some fat in a diet is essential. It should be derived from plant oils and fish, however, and not from saturated fat from animal products or trans-fatty acids from hydrogenated (hardened) oils.

Fat Substitutes. Fat substitutes added to commercial foods or used in baking deliver some of the same desirable qualities of fat but do not add as many calories. Some replacers, such as the cellulose gel Avicel, Carrageenan (made from seaweed) guar gum, and gum arabic have been used for decades in many commercial foods and are generally recognized as safe. A recent synthetic fat, olestra, passes from the body without leaving behind any calories from fat. There have been reports of cramps and mild to severe diarrhea after eating food containing olestra. Olestra also depletes the body of vitamins A, K, D, and E and important disease-fighting nutrients found in dark colored fruits and vegetables. 

Fiber. All healthy diets should be high in fiber, which is an important weight loss-factor. It interferes with absorption of fat and protein and, along with the nutrients found in high-fiber foods, may reduce the risk for heart disease, diabetes, digestive disorders, and certain cancers. Fiber is found only in plants. For weight loss, insoluble fiber (found in wheat bran, whole grains, seeds, and fruit and vegetable peels) is most effective. Soluble fiber (found in dried beans, oat bran, barley, apples, citrus fruits, and potatoes), however, has important benefits for the heart.

Sugar and Sugar Substitutes. A number of artificial sweeteners are available, including saccharin, aspartame (Nutra-Sweet), acesulfame K (Sweet One), and sucralose (Splenda). Sucralose usually leaves no bitter aftertaste as others do, and unlike most other artificial sweeteners, it works well in baking. Although contrary to previous concerns, there appear to be no health hazards involved with artificial sugar.

High Protein Diets

High-protein low-carbohydrate diets have become popular again. Although a high-protein diet will lead to quick weight loss, its health benefits are dubious. One byproduct of this diet is the release of substances called ketones, which can cause nausea, lightheadedness, and bad breath. Such high-protein diets may also be high in fat and low in fiber-rich and healthful whole grains, fresh fruits, and vegetables. Such high-protein diets also often result in carbohydrate binges. On the positive side, one 1999 study found that participants on a fat-reduction diet (30% of total calories) who chose protein-rich foods (25% of total daily calories) over carbohydrates reduced weight significantly. Choosing more proteins may have led them to choose lean meats and fat-free dairy products, which in turn helped keep fat-intake down. Another study found that a so-called ketone diet, which is high in protein and very low in fats and carbohydrates can be a safe and effective weight loss regimen for dangerously obese adolescents if they are carefully monitored by a health professional. 

Exercise

The dangers from obesity are not simply from being overweight; being unfit increases the existing health hazards significantly. Because obesity is so often related to heart and other diseases, anyone who is overweight must discuss their exercise program with a physician before starting. Most experts recommend building up to 45 to 60 minutes a day of mostly aerobic exercise, such as hiking, brisk walking, or energetic dancing. Some studies have suggested that for both exercise adherence and total weight loss, frequent exercise sessions as short as 10 minutes in duration may be the most successful program for obese people. Although even vigorous workouts do not immediately burn great numbers of calories, the metabolism remains elevated after exercise, and the more strenuous the exercise, the longer the metabolism continuous to burn calories before returning to its resting level. This state of elevated metabolism can last for as little as a few minutes after light exercise to as long as several hours after prolonged or heavy exercise. Although the calories lost during the post-exercise period are not high, over time they may count significantly for maintaining a healthy weight. Included in any regimen should be resistance, or strength, training performed two or three times a week, which is excellent for maintaining or even building muscle as fat is lost.

Cognitive-Behavioral Therapy

The goal of cognitive-behavioral therapy is to change the daily patterns associated with eating; it is very useful for preventing relapse after initial weight loss. The patient first records in a diary all activity related to eating patterns, including the times of day, length of

meal, emotional states, companions, and, of course, the kind and amounts of food eaten. (Patients tend to underreport their dietary intake, but it is still a good method for increasing their awareness of eating patterns.) The therapist and the patient review the diary for setting realistic goals and identifying patterns that the patient can change. 

Reducing Television and Video Activities

An important 1999 study on elementary school children reported that children whose television viewing time was restricted over a school year and who did not eat in front of the television had healthier weights compared to their television-

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watching peers regardless of diet and physical activity. This is a small but significant study pointing to a major factor in the current obesity epidemic and a possible simple method for managing weight in children (and possibly in adults).

What Are Non-Dietary Measures Used To Treat Excess Weight?

Drugs used for weight loss are generally called anorexiants. All the drugs that are potentially effective when used appropriately and with additional weight loss measures, including exercise and behavioral modification. The long term effects of most of these medications have not been established. Most lose their effectiveness over time, thus requiring increased dosage, and they can be addictive and dangerous. None of these drugs deals with the underlying problems that may be causing obesity. Unless specifically instructed by a physician, people should use non-drug methods for losing weight. Except under rare circumstances, pregnant or nursing women should never take diet medications of any sort, including herbal and over-the-counter remedies.

Over-the-Counter Drugs and Herbal Remedies

People must be cautious when using any weight-loss medications, including over-the counter diet pills and herbal or so-called natural remedies. Over-the-counter diet pills that contain phenylpropanolamine (Acutrim, Dexatrim) effectively suppress the appetite, but have been known to cause severe high blood pressure and stroke if taken in doses of 75 mg or higher in the immediate-release form. A number of over-the-counter remedies (Herbal Phen-Fen, PhenTrim, Phen-Cal, Xenadrine) contain ephedrine, derived from the ephedra (also known as Ma Huang) herb. Ephedrine is actually a component in adrenaline and can cause a number of side effects, include infrequent cases of severe effects (rapid heart beat, high blood pressure, psychosis, and seizures). 

Many so-called natural remedies are being promoted for weight loss. Some can be dangerous and few have been tested. Chitosan, a dietary fiber from shell fish does prevent a little fat from being absorbed in the intestine, but limited studies have not found that it contributes to weight loss. Garcinia (also called mangosteen) is a tropical fruit containing hydroxycitric acid, which is claimed to burn fat. Although theoretically promising, to date no well-conducted study has reported significant weight loss with the chemical. Many dietary herbal teas contain laxatives, which can cause gastrointestinal distress, and, if overused, may lead to chronic pain, constipation, and dependency. In rare cases, dehydration and death have occurred. Some laxative substances found in teas include senna, aloe, buckthorn, rhubarb root, cascara, and castor oil. Some fiber supplements containing guar gum have also caused obstruction of the gastrointestinal tract. Dietary remedies that list the ingredient plantain may contain digitalis, a powerful chemical that affects the heart. (This should not be confused with the harmless banana-like plant also called plantain.)

Orlistat

Orlistat (Xenical) can help about one third of obese patients with modest weight loss, and can assist in long term maintenance of weight loss. It reduces the body's absorption of fat from foods, thereby reducing weight and cholesterol. Orlistat blocks the action of lipase, an enzyme in the intestine that breaks down fat. It does not increase serotonin but it makes it work effectively, and it is a stimulant. Studies have found that at the end of the first year orlistat users achieve an average of 5% to 10% drop in body weight. The drug can cause gastrointestinal problems and may interfere with absorption of the fat-soluble vitamins A, D, and E and other important nutrients.

Serotonin-Releasing Anorexiants

Serotonin-releasing anorexiants increase the availability of serotonin, a chemical in the brain that prevents depression and reduces calorie consumption.  

Amphetamines

The amphetamines dextroamphetamine (Dexedrine), methamphetamine (Desoxyn), and phenmetrazine (Pleudin) were used most often in the past but are no longer prescribed for weight loss. These drugs elevate mood and produce some modest weight loss over the short term, but present serious risks of addiction, agitation, and insomnia. 

Liposuction. Liposuction does get rid of fat cells in specific areas, such as the thighs, buttocks, or knees, and weight gain generally occurs more in other locations after the operation. The pain after the operation can be severe and often the skin does not contract, resulting in a flabby look. Ultrasound liposuction is being tested, which uses a thin wand that vibrates fatty tissue at high speed until it breaks down and liquefies. Fat is then removed with pressure suction. The procedure may be able to remove large volumes of fat, including fat in areas ordinarily hard to reach using standard liposuction techniques. Complications include burns from the vibrators.

Surgery

Surgical procedures may be appropriate for some dangerously obese people. Experts recommend surgery only for those whose BMI is over 40 and if the percentage of ideal weight is over 180%, and then only if they have not succeeded in losing weight through other methods. Those with a BMI of 35 and significant health consequences of obesity are also candidates for weight reduction surgery.  Advanced techniques using a less invasive procedure known as laparoscopy, however, may increase the number of candidates for obesity surgery. 

Gastric Bypass. Gastric by-pass blocks off most of the stomach by stapling a part of the stomach closed (Roux-en-Y gastric bypass procedure).  This limits the amount of food that a person can consume. In addition, a variable length of small intestine is bypassed, so that one does not absorb as many consumed calories.  This is termed malabsorption. Most people lose about two-thirds of excess weight within two years. Many diseases associated with obesity improve (e.g., diabetes, high blood pressure, sleep apnea, joint pain, and incontinence). Vomiting is the most common side effect. The so-called dumping syndrome is a common unpleasant side effect that occurs when food waste moves too quickly through the intestine. Symptoms include nausea, weakness, sweating, and faintness (particularly after eating sweets.) Complications include problems along the staple line, obstruction, and over-expansion of the pouch. There is a risk for anemia and supplements of folate and vitamin B12 may be required. There is also a risk for bone loss and osteoporosis. Between 10% and 20% of

patients need follow-up operations to correct complications. Mortality rates of 1.5% have been reported. (This is still less than the risk of dying from severe obesity, however.) Patients must still develop a healthy life style after the operation and failure can occur if people cheat the procedure by eating frequent small meals of liquid or soft foods. Follow-up must be life long. In the late 1990’s surgeons began performing the gastric bypass procedure using laparoscopic techniques.  The advantages of performing the surgery in this manner are: a considerably smaller incision and therefore improved cosmetic result, less postoperative pain, and a significantly shorter hospital stay. This procedure is still relatively new, and although many surgeons have done large numbers with excellent results, there are many others who perform the procedure with little or no prior experience.   

Laparoscopic Adjustable Gastric Band (Lap-Band)

LAGB was introduced in the mid 1990’s and uses an FDA approved device to create restriction of  the stomach.  With this  procedure, a silicone band with an adjustable balloon is placed around the upper portion of the stomach.  A metal "port” which is  attached to the Band via a long tube, is  placed under the skin.  By injecting or  removing fluid through  the port, the balloon will increase or decrease in  tightness.  The more fluid, the tighter the band and the less one will be able to eat as the upper stomach takes  on a restricted “pouch” shape.  Follow up is extremely important as the success of the procedure rests in frequent adjustments  in balloon size.  Currently the Lap-Band device is  approved for use for 15 years, after which point it should be  removed. 

Weight loss does not reach the levels one can achieve with GB.

 Bariatric operations are more successful when combined with a healthy diet, routine low impact aerobic exercise, and follow up visits with your surgeon.  Support group attendance has also been shown to improve long term weight loss following bariatric surgery.

What is the thyroid gland?

The thyroid gland sits in the middle of the neck over the trachea.  Sometimes it can be felt when one swallows and the gland moves up and down.  It is responsible for production of some very important hormones know as thyroid hormones.  These effect many different organs and organ functions including: changes in body temperature, function of the heart, blood pressure, metabolism, functions of the brain, growth and development, as well as many other less well defined areas.

What is a thyroidectomy?

A thyroidectomy is a procedure in which the surgeon removes all or part of the thyroid gland.

When is it used?

A thyroidectomy may be performed when you have an overactive thyroid gland, thyroid nodules, or cancerous cells in your thyroid gland. 

Overactive thyroid gland (hyperthyroidism)

An overactive thyroid gland can be caused by many processes.  Graves disease, and toxic nodules (either single or multiple), are conditions which may be amenable to surgical management. Surgery is sometimes the best treatment for these conditions.  Symptoms of hyperthyroidism include: heat intolerance, thirst, weight loss, increased appetite, palpitations, and tremor.  Some patients develop a goiter (an enlarging gland visible in the neck), and changes to the skin and hair.

Graves Disease

Graves disease, which affects mostly young females (see Gail Devers below), is known as an autoimmune disease.  In other words one’s own body produces antibodies which are detrimental to the thyroid gland. 

This can result in symptoms of hyperthyroidism (see above) as well as protrusion of the eyes, and swelling of the legs.  Thyroid suppressing drugs,

Single Toxic nodule

Otherwise benign nodules may occasionally produce enough thyroid hormones to cause hyperthyroid symptoms.  In these cases, surgery is sometimes chosen to alleviate symptoms.

Toxic multinodular goiter

Usually developing in women over the age of 50, and in a previously large but not hyperfunctioning gland, this condition is particularly well treated by surgery.  It is characterized by multiple nodules, each of which produce above normal levels of thyroid hormone.

Thyroid nodules

Thyroid nodules are tumors, most of which are benign, but some of which are malignant and invasive cancers. These tumors are treatable and increase in frequency with age. They are more common in women. Nodules are an enlargement of the thyroid gland that can often be felt by your physician at the time of physical examination. In patients with a history of prior radiation treatment to the neck, either near the thyroid gland or near a gland called the thymus (such radiation treatment was popular in past decades, although it is no longer used), the risk of nodules is high. These nodules tend to develop long after the treatment.

In patients who are at high risk but in whom no nodules are felt, other tests are used to identify the presence of nodular change in the thyroid gland. A biopsy of the nodule with a needle may be undertaken if there is any question of the diagnosis.

When a thyroid nodule is biopsied with a needle and the diagnosis is a malignant tumor, the treatment is removal of the tumor, usually by total removal of the gland. For nodules that are not malignant, surgery is only necessary if the nodules are causing pressure on surrounding tissues.  Occasionally the biopsy of the nodule yields inconclusive results, in which case either another biopsy or surgery is recommended depending on individual variables.

Thyroid cancer 

Occasionally nodules detected by oneself, or by a physician, contain cancerous cells. Unchecked, these cells multiply and spread to other parts of the body.  Surgery offers the only potential for cure of thyroid cancer and 

 therefore a surgeon should be involved in the treatment at the earliest possible juncture.  Following surgery, other forms of treatment (radioactive iodine for example) are instituted for additional benefit.

 What is Minimally Invasive Video Assited Thyroidectomy (MIVAT)?

 Yes, the thyroid gland can be removed using laparoscopic techniques.  Not many surgeons perform this type of surgery as it requires experience with thyroidectomy as well as skill with laparoscopic techniques.  The traditional incision for removal of the thyroid gland involves a horizontal cut of 5 to 9 inches in the mid neck.  Using the MIVAT technique, the incision is reducted to 1 to 3 centimeters.  Certain patients are not candidates for this minimally invasive approach, as the gland must not be too large, as in some large goiters, or have too large of a nodule, as in nodules of greater than 4cm.

What is the parathyroid gland?

There are actually four glands located on or adjacent to the thyroid gland.  Because of some embryologic variability, one or more of these glands can sometimes be located in other areas, such as in the thyroid gland, anywhere in the neck, or even the middle part of the chest cavity known as the mediastinum.  Rarely a person has more or less than the usual four glands.

The parathyroid glands are responsible for the regulation of calcium in the blood.  Depending on how much one takes in their diet, and gets rid of through the urine, the glands produce variable amounts of a hormone called appropriately parathyroid hormone.

Parathyroid hormone has a wide variety of effects on bone, the gastrointestinal tract, and the kidneys to retain calcium in the blood.  Phosphorus is also regulated by the parathyroid gland.

What is a parathyroidectomy?

A parathyroidectomy is a procedure in which the surgeon removes part or all of your parathyroid glands.

When is it used?

The parathyroid glands help control the levels of calcium and phosphorus in the blood with a hormone called parathyroid hormone. Abnormal cells or cancer may cause an elevated parathyroid hormone level, which in turn elevates the calcium level, sometimes to dangerous levels. A problem with one or all of the parathyroid glands used to be detected after a person complained of muscle weakness, or persistent abdominal pains in association with the development of  kidney stones, decreased alertness, stomach ulcers, or decreased bone strength.  With the current day common use of routine blood work for annual physical exams or for the investigation of other medical problems, dysfunction of the parathyroid glands is detected by an elevated calcium level.  When this type of problem is detected, surgery is required to remove one or several of the glands.

An alternative is to choose not to have treatment, recognizing the risks of your condition. You should ask your primary care doctor  or endocrinologist about these choices.

What is hyperparathyroidism?

When there is an excess of parathyroid hormone.

What are frequent signs and symptoms of hyperparathyroidism?

Often there are none and its presence may be discovered as part of routine blood screening. When there are symptoms, they may include:

Severe flank pain caused by kidney stones, chronic low-back pain caused by bone softening, easy bone fractures caused by decreased calcium in the bones, upper abdominal pain caused by a peptic ulcer or pancreatitis, and fatigue, or depression.

What are the causes of hyperparathyroidism?

Benign tumors of one of the parathyroid glands. Enlargement of all of the glands due to chronic kidney disease. Recent illness, especially endocrine disorders. Medical history of rickets or vitamin-D deficiency. Kidney failure. Use of laxatives. Use of digitalis. Female over age 50.

Preventive Measures

No specific preventive measures.

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Expected Outcomes

Most causes of hyperparathyroidism are curable with surgery.  Relief of symptoms is variable, but the relentless progression to possible complications (see below) is halted.

Possible complications without surgery.

Cataracts, kidney damage, peptic ulcer, pancreatitis, psychosis, and bone loss are the most common possible complications with unabated hyperparathyroidism.

What is the treatment of hyperparathyroidism?

General measures.

Diagnostic tests include laboratory studies of blood and urine, X-rays of bones, CT or MRI scan, and ultra-sound. Surgery to remove all abnormal parathyroid tissue usually cures the condition. Normally the remaining parathyroid tissue is sufficient to produce enough hormone. If it isn't, you may require treatment for underactive parathyroid (hypoparathyroidism). Sometimes, in mild cases, therapies other than surgery may be recommended. They consist of forcing fluids, limiting dietary intake of calcium, or forced diuresis to get rid of excess calcium.  Long term hazards may stem from the non surgical management of this condition. Treatment may be necessary to correct any underlying disorder causing the hyperparathyroidism.

Medications

Diuretics to force sodium and calcium excretion are usually only required with severely elevated calcium levels.  Don't take antacids that contain calcium. Estrogens for postmenopausal females may be prescribed.

Activity

Follow medical advice about returning to normal activities following surgery.

Diet

Drink extra water to prevent kidney stones. Limit calcium-containing foods, such as milk and cheese. A special diet may be recommended as part of your treatment.

How do I prepare for a parathyroidectomy?

You may have a special xray called a Sestamibi scan, or a CAT scan or ultrasound to determine the exact location of the abnormal gland or glands prior to surgery.  This allows for easier localization of the gland during surgery, a smaller incision, and less likelihood of damaging the remaining normal glands.

Not every surgeon uses this approach, preferring instead to explore all glands at the time of surgery.  Ask your surgeon if he or she uses the minimally invasive approach as it reduces the size of the incision as well as the potential for complications from the surgery.

Plan for your care and recovery after the operation. Allow for time to rest and try to find people to help you with your day-to-day duties.

Follow any instructions your surgeon may give you. Eat a light meal, such as soup or salad, the night before the procedure. Do not eat or drink anything after midnight and the morning before the procedure. Do not even drink coffee, tea, or water.

What happens after the procedure?         

Most patients go home the same day depending on your condition. You will have a small scar in the front of your neck.

Ask your surgeon what other steps you should take and when you should come back for a checkup.

What are the benefits of this procedure?

You will no longer have the problem of abnormal cells or cancer in the parathyroid glands.

What are the risks associated with this procedure?

There are some risks when you have general anesthesia. Discuss these risks with your doctor. The laryngeal nerves may be injured. These nerves allow you to speak normally. If they are damaged, the damage may be temporary or permanent, and your voice may be hoarse. The original problem will persist if another gland elsewhere in the body is overactive. Your wound may bleed and require attention. It may also become infected. You may experience postoperative hypoparathyroidism (inadequate parathyroid function) including weakness, muscle spasm, and cardiac irregularities. If there was cancer, not all of it may be removed and it may grow back.

You should ask your doctor how these risks apply to you

Laparoscopic Adrenalectomy

What are the adrenal glands?

The adrenal glands are two small glands located atop the kidneys which produce several essential hormones including cortisol, aldosterone, and various sex hormones. 

When is adrenalectomy indicated?

Adrenalectomy is indicated when various benign tumors are present.  These tumors may be detected on routine study for other conditions (the so called incidentaloma, as they are incidentally discovered), or they may be symptomatic.  Symptomatic tumors are usually of the functional variety.  That is they produce one of the normal adrenal hormones in excessive amounts.  Examples include the pheochromocytoma, aldosteronoma, cortisol producing adenoma, and sex steroid producing tumor.

The functional tumors should be removed because of potentially dangerous symptomatology.  Pheochromocytomas produce excessive amounts of glucocorticoids which can result in hypertension (sometimes to dangerous levels), headache, sweating, heart palpitations, abdominal pain, anxiety, and weakness. 

The previously mentioned incidentaloma is most often benign if less than six centimeters in size, but if greater than six centimeters has at least a 15% chance of being malignant.  Therefore these tumors also require removal with adrenalectomy.

Other malignant tumors that may benefit from adrenalectomy are those that have spread from other sites, namely the lung, bone, kidney, and skin.

How is the adrenal gland evaluated?

Patients with tumors fortuitously  first diagnosed by ultrasound or CT scan performed for other reasons should most often undergo blood and urine testing to determine if the tumor is functional.  There may be a need for an MRI as well, to better help identify the tumor.

The role of fine-needle aspiration cytology is limited to the evaluation of potentially metastatic tumors, and can be dangerous if the tumor is a pheochromocytoma (sometimes triggering hypertensive emergencies).

How is the adrenal gland removed?

Before 1992, conventional open methods of adrenalectomy included the anterior

transabdominal approach, the posterior retroperitoneal approach (lumbar), the flank approach, and the lateral transthoracic (thoracoabdominal) approach. However, these are large incisions which can lead to several potential postoperative complications, increased pain, and a longer hospital stay.  The technique of laparoscopic adrenalectomy was introduced in 1992, and it has become the preferred approach.

Laparoscopic adrenalectomy in experienced hands has a very low rate of complications.  Bleeding has been shown to be less than with the open method.  Also, the incidence of postoperative infections like wound infections and pneumonia is less.

Some conditions may preclude the safe removal of the adrenal gland by the laparoscopic method.

Cholecystectomy

What is a the gallbladder?

The gallbladder is a sac like organ cradled beneath the liver and charged with the storage of bile.  Bile is produced by the liver for the digestion of the fats in our diet.  When the fats reach the duodenum, the gallbladder is triggered through hormonal messengers to contract.  This releases the bile into the intestinal tract to mix with food.

What are gallstones?

In some people, crystals of cholesterol or bile pigment, which are normally dissolved in the bile, form stones.  These stones may remain in the gallbladder causing no urgent trouble.  However, in others, these stones travel down the bile ducts (the system of tubes which connect the liver and gallbladder to the intestines), obstructing them and causing a variety of problems.

What are the symptoms of gallstone disease?

Symptoms of gallstones usually occur soon after eating a fatty meal.  The stimulation of the gallbladder causes small stones to be pushed into the bile ducts along with bile.  If these stones temporarily obstruct the bile ducts, symptoms are produced.  One might experience only bloating and vague "gas pains", while others might experience sharp pain which rises to a peak over several hours then subsides.

If the stones become lodged further on in the bile ducts, one may develop inflammation and infection of the duct itself (termed cholangitis), or of the pancreas (pancreatitis).  Each of these is also a potentially fatal problem if untreated.  Symptoms may include the aforementioned as well as jaundice (a yellowing of the skin), and confusion.

Who is at risk for gallstone disease?

Gallstones tend to affect females more than males, women who have experienced multiple pregnancies, are overweight, and in their forties.

These people tend to form stones largely composed of cholesterol.  Others with certain inherited diseases or acquired parasitic infections (usually not seen in the United States) form stones composed of bile pigment.

Who would require removal of their gallbladder?

Not all persons with gallstones require removal of their gallbladder.  Those with symptoms however, even if mild, ought to have their gallbladder removed (termed cholecystectomy) in order to avoid the potential for serious, even fatal infections.

Therefore, persons with symptomatic cholelithiasis (stones in the gallbladder producing symptoms), choledocholithiasis (stones in the bile duct), cholangitis, or gallstone pancreatitis (inflammation of the pancreas caused by an obstructing gallstone) should have their gallbladders removed.

Other conditions merit removal of the gallbladder as well.  Diabetics, because of an increased risk of serious infections, should most likely have their gallbladder removed if it contains stones.  Those with calcium deposits or polyps in or on the gallbladder wall should also undergo cholecystectomy to remove a potential cancer of the gallbladder.

How is the gallbladder removed?

Most cholecystectomies should be performed laparoscopically.  Laparoscopic removal of the gallbladder is one of the oldest and safest of the laparoscopic procedures, and can be performed well by many surgeons.  The procedure has a low complication rate and usually results in complete resolution of symptoms and prevention of future complications of untreated gallstones.

Not every patient can safely undergo the laparoscopic procedure.  Multiple previous surgeries, an extremely inflamed gallbladder, and unusual anatomy are some of the potential reasons.

Laparoscopic Antireflux Surgery

What is gastroesophageal reflux disease and heartburn?

Gastroesophageal reflux disease (GERD) is a condition in which the acids from the stomach move backward into the esophagus (an action called reflux). Reflux occurs if the muscular actions in the esophagus or other protective mechanisms fail.
 

What causes gastroesophageal reflux disease?

Anyone can have mild and temporary heartburn caused by overeating acidic foods. This is especially true when bending over, taking a nap, or engaging in lifting after a large meal high in fatty, acidic foods. Persistent gastroesophageal reflux disease (GERD), however, may be due to various conditions, including abnormal biologic or structural factors.

Malfunction of the Lower Esophageal Sphincter (LES) Muscles: The band of muscle tissue called lower esophageal sphincter (LES) is responsible for closing and opening the lower end of the esophagus and is essential for maintaining a pressure barrier against contents from the stomach.  If it weakens and loses tone, the LES cannot close up completely after food

empties into the stomach. In such cases, acid from the stomach backs up into the esophagus. Many drugs, foods, and alcohol can lower the pressure of the LES.

Abnormalities in the Esophagus:

Motility Abnormalities. Problems in spontaneous muscle action ( peristalsis) in the esophagus commonly occur in GERD, although it is not clear if such occurrences are a cause or result of long-term effects of GERD.

Adult-Ringed Esophagus. This condition is characterized by an esophagus with multiple rings and persistent trouble with swallowing (including getting food stuck in the esophagus). It occurs mostly in men.

Hiatal Hernia:

The hiatus is a small hole in the diaphragm through which the esophagus passes into the stomach. It normally fits very snugly, but it may weaken and enlarge. When this happens, part of the stomach muscles may protrude into it producing a condition called hiatal hernia . It is very common, occurring in over half of people over 60 years old, and is rarely serious. Until recent years, it was commonly believed that most cases of persistent heartburn were caused by a hiatal hernia. Hiatal hernia may impair LES muscle function. Studies have failed to confirm evidence, however, that it is a common cause of GERD, although its presence may increase GERD symptoms in patients with both conditions.

    normal                   hiatal hernia

Genetic Factors: Studies suggest an inherited risk exists in many cases of GERD, possibly because of inherited muscular or structural problems in stomach or esophagus. Genetic factors may especially play a strong role in susceptibility to Barrett's esophagus, a precancerous condition caused by very severe gastroesophageal reflux.

Asthma: The relationship between asthma and gastroesophageal reflux is unclear (see my article “Gastric Asthma).  Asthma may trigger reflux, or reflux may be a cause of asthma.  Some authorities suggest that in a high proportion of persons with atypical asthma, symptoms are actually caused by gastroesophageal reflux.

Drugs that Increase the Risk for GERD: Nonsteroidal anti-inflammatory drugs (NSAIDs), calcium channel blockers (used to treat high blood pressure and angina), anticholinergics (used in drugs that treat urinary tract disorders, allergies, and glaucoma), beta adrenergic agonists (used for asthma and obstructive lung diseases), dopamine (used in Parkinson's disease), bisphosphonates (used to treat osteoporosis), sedatives, antibiotics, potassium, or iron pills.

Other Causes of GERD: Weakened peristaltic movement in the esophagus may contribute to GERD. If the mucous membrane is impaired, even a normal amount of acid can harm the esophagus. Pressure on the abdomen caused by obesity and also wearing tight clothing can contribute to acid-backing up into the esophagus.

Who gets gastroesophageal reflux?

Studies suggest that between 21% and 59% of Americans suffer heartburn or regurgitation during any given year. Only 20% of people with such symptoms seek help.  People of all ages are susceptible to GERD. Elderly people with GERD tend to have a more serious condition than younger people.

Risk Factors for Heartburn, GERD, or Both:

Eating-Pattern Risk Factors. Anyone who eats a heavy meal, particularly if one subsequently lies on the back or bends over from the waist, is at risk for an attack of heartburn. Anyone who snacks at bedtime is at high risk for heartburn.

Pregnant Women. Pregnant women are particularly vulnerable to heartburn in their third trimester as the growing uterus puts increasing pressure on the stomach. Heartburn in such cases is often resistant to dietary interventions and even antacids.

Obesity. Studies suggest that obesity increases acid in the esophagus, thereby significantly increasing the risk of GERD. Evidence is weak, however. One study reported no association between excess weight at any age and the presence or severity of GERD symptoms.

People with Respiratory Diseases. People with asthma are at very high risk for GERD. A study also indicated that patients with chronic obstructive pulmonary diseases (e.g., emphysema or chronic bronchitis) were more likely to have GERD.

Smokers. Some studies have reported a high incidence of GERD in smokers. Smoking may reduce LES muscle function, increase acid secretion, and impair protective mucus membranes. Smoking reduces salivation, which helps neutralize acid. Whether it is the smoke, nicotine, or both that triggers GERD is not clear.

Alcohol. Alcohol has mixed effects on GERD. It relaxes the LES muscles and, in high amounts, may irritate the mucous membrane of the esophagus. All alcoholic beverages increase

 stomach acid levels. A combination of heavy alcohol use and smoking even increases the risk for esophageal cancer.  

What are the symptoms of gastroesophageal reflux?

Common Symptoms:

Heartburn. Heartburn is the primary symptom of gastroesophageal reflux. It is a burning sensation that radiates up from the stomach to the chest and throat. Heartburn is most likely to occur after a heavy meal, while bending over or lifting, or when lying down.

Dyspepsia. Up to half of GERD patients have dyspepsia, a syndrome consisting of pain and discomfort in the upper abdomen, fullness in the stomach, and nausea after eating.

Regurgitation. Regurgitation is the feeling of acid backing up in the throat. Sometimes acid regurgitates as far as the mouth and be experienced as a "wet burp." Uncommonly, it may come out forcefully as vomit.

Less Common Symptoms:

Many patients with GERD do not experience heartburn or regurgitation. Instead symptoms may appear in other locations.

Chest Sensations or Pain. Patients may have the sensation that food is trapped behind the   breast bone. Chest pain is a common symptom of GERD. It is very important to differentiate it from chest pain caused by heart conditions, such as angina and heart attack.

Symptoms in the Throat. Less commonly, GERD may produce symptoms that occur in the throat: Acid laryngitis (a condition that includes hoarseness, dry cough, the sensation of having a

lump in the throat, and the need to repeatedly clear the throat), dysphagia (trouble swallowing), chronic sore throat, or persistent hiccoughs.

Coughing and Respiratory Symptoms. Asthmatic symptoms like coughing and wheezing may occur. In fact, in one study, GERD alone accounted for 41.1% of cases of chronic cough in nonsmoking patients. The incidence was even higher when GERD and asthma were combined.

Chronic Nausea and Vomiting. Nausea that persists for weeks or even months and is not attributable to a common cause of stomach upset may be a symptom of acid reflux. In rare cases, vomiting can occur as often as once a day. All other causes of chronic nausea and vomiting should be ruled out, including ulcers, stomach cancer, obstruction, and pancreas or gallbladder disorders.

How serious is gastroesophageal reflux?

Nearly everyone has an attack of heartburn at some point in their lives. In the vast majority of cases the condition is temporary and mild causing only transient discomfort.

If patients develop persistent gastroesophageal reflux disease with frequent relapses, and it remains untreated, serious complications can develop over time. Such complications can include the following: ulcers, severe narrowing ( stricture) of the esophagus, erosion of the lining of the esophagus, precancerous changes in the cells of the esophagus, and problems in other areas, including the teeth, throat, and airways leading to the lungs.

Older people are at higher risk for complications from persistent GERD.  

Bleeding:

In very severe cases, the patient may detect dark-colored, tarry stools (indicating the presence of blood) or vomit blood, particularly if ulcers have developed in the esophagus. This is a sign of severe damage and requires immediate attention.

Sometimes long-term bleeding can result in iron deficiency anemia and may sometimes even require emergency transfusions. This condition can occur without heartburn or other warning symptoms, or even obvious blood in the stools.

Barrett's Esophagus: A minority of patients with persistent GERD are at risk for Barrett's esophagus. This condition results in abnormal cellular changes in the esophagus that puts a patient at risk for cancer.

Asthma and Other Respiratory Disorders: Asthma. Asthma and GERD often occur together. Studies report that reflux disorder coincides with between 32% and 80% of asthma cases. Theories for the causal connection between GERD and asthma are included in my article “Gastric Asthma”.

Other Respiratory and Airway Conditions. Current studies indicate an association between GERD and various upper respiratory problems that occur in the sinuses, ear and nasal passages, nasal passages, and airways of the lung. People with GERD appear to have an above-average risk for chronic bronchitis, chronic  sinusitis, emphysema, pulmonary fibrosis (lung scarring), and recurrent pneumonia. If a person inhales fluid from the esophagus (aspirates) into the lungs, serious pneumonia can occur. It is not yet  known whether treatment of GERD would also reduce the risk for these respiratory conditions. </