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Interview. Bypass, sleeve, ring: “We observe more suicides” after surgery to lose weight

Health insurance reimburses the bypass surgery and hospitalization up to 70%. (©Illustration/Adobe Stock)

In 2017, Éric had recourse to the bypass, an operation which reduces the stomach. He lost 60 pounds. Today, he regrets his choice and his pleasure in eating.

“There is a real disconnect between my mind and my body. I want to eat, but my body is too quickly saturated. I know that eating too much hurts me, but it makes the frustration more tolerable. Today, I regret the operation, “he recently explained to our editorial staff. Strasbourg news.

The 50-year-old went through a major depression and resumed his “bad” eating habits. His stomach is full as soon as he finishes his entry, so he tries to peck, without much success, and is very often nauseous.

This testimony, among others, highlights the well-identified problem of the psychological management of these operations, “because few psychologists / psychiatrists have expertise in this area, and in particular in eating disorders”, explains at news.fr the teacher Didier Quilliotfrom the multidisciplinary obesity surgery unit at the University Hospital of Nancy.

News: Bariatric surgery is experiencing a real craze in France, is it a “French” particularity?

Didier Quilliot: Since 2013, more than 40,000 patients have surgery each year, yes. There was a Covid-19 effect with fewer interventions in 2020, but it is actually between 40 and even more than 50,000 interventions that take place each year.
France is clearly one of the countries that practice bariatric surgery the most in the world if we relate to the general population and the obese population, because we are a country rather preserved by obesity for the moment.
In France, we have been operating since around 1995, so we have some perspective. And the refund plays, of course. Health insurance reimburses the bypass surgery and hospitalization up to 70%. However, the intervention can obviously only be reimbursed if the medical adviser has accepted the operation.

What are the “techniques”?

QD: The High Authority for Health (HAS) has validated three of them: the sleeve gastrectomy, the gastric bypass in Y and the gastric ring. In summary, the gastric bypass, like the sleeve gastrectomy, act essentially by reducing the feeling of hunger, by reinforcing satiation and satiety. Bypasses consist of a reduction in the size of the stomach associated with a bypass of part of the stomach and the small intestine.
As a general rule, we eat when we are hungry, but sometimes we eat for other reasons… which we often define as gluttony but which actually hide a form of compensation, or processing of our emotions.
Patients eat when they are stressed, anxious when they feel unwell, when they are unable to manage their emotions… Surgery has a braking effect, but the psychological component can persist, and that is the whole difficulty.

The General Inspectorate of Social Affairs, Igas, had pointed out in 2018 a “poor supervision” of obesity surgeries in France. Have “safeguards” been put in place since this report?

QD: You have to keep in mind that surgery is a chance. On average, with these operations, patients gain six years of life expectancy and nine years when there is diabetes…
But are we operating on the “right” patients? Surely not. Type 2 diabetics or prediabetics, patients at high risk of complications, should be the main beneficiaries. However, today, it remains difficult to convince diabetologists to consider bariatric surgery, and in particular gastric bypass, as a first-line treatment.
In France, doctors (endocrinologists, diabetologists, nutritionists) have taken a long time to get involved in bariatric surgery. Initially, probably due to a lack of evidence, a lack of skills, and investment in the field by surgeons. Multidisciplinary teams have been slow to set up and are still often insufficiently structured.

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The weak point mainly concerns psychological care?

QD: Yes, because few psychologists/psychiatrists have expertise in this area, and in particular in eating disorders.
The High Authority for Health (HAS) regularly reminds us that surgery is a second-line treatment for obesity – that is to say after failure of a well-conducted medical, nutritional, dietary and psychotherapeutic treatment for six months at one year – and concerns patients whose body mass index (BMI) is greater than or equal to 40 kg/m2, or whose BMI is greater than or equal to 35 kg/m2, associated with at least one comorbidity likely to be improved after surgery.
If successful, it helps with significant and persistent weight loss. However, this heavy act should only be carried out after a shared medical decision, with clear information on the existing techniques, their advantages and disadvantages, their consequences, the complications and the need for medical follow-up. throughout life…. But there is still work.

The risks are known, must be prevented and managed, in particular nutritional risks. And this imposes mandatory regular monitoring, which is still too poorly organized in France. Apart from the risk of deficiency, the main risks are to switch to another addiction (alcohol, drugs, substances, games, purchases, sex, etc.) or to develop other psychological disorders, such as depression, thus, we have observed three to four times more suicides following these operations. Surgery alone cannot be enough.

Obesity surgery leads to lasting weight loss with certain and visible repercussions on the daily life of obese people, but this intervention can also call them into question in the deepest part of themselves, since it goes from one on the one hand changing them physically, and on the other hand preventing them, in part from managing their discomfort through food.
The need, clearly identified, is to take care of patients in a multidisciplinary way and to insist on psychological care. Indeed, eating disorders are very often linked to old psychological traumas. It is essential to prevent any risk of relapse or compensation of the symptom of food addiction by another equally devastating.
But the lack of trained shrinks today poses a real problem.

Currently, 30% of psychiatric positions are not filled in public hospitals, according to the French Federation of Psychiatry.

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