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Western University of Health Sciences College of Osteopathic Medicine of the Pacific Pomona, Calif

To the Editor:

Gastric bypass surgery (GBS) has been shown to reduce body weight effectively,¹ and use of this procedure is markedly increasing in the United States.² As more and more patients undergo GBS, our heightened cognizance to the postsurgical care of these patients is required.

Among many medical concerns I have for post-GBS patients is an incidental finding I noticed recently during an in-depth patient review for a separate study. In examining the medical records of post-GBS patients, I observed that a rather large percentage of these patients complained of various musculoskeletal issues—most commonly, chronic back pain.

Massive weight loss can result in ptosis of the breasts and excessive laxity of the skin around the arms, back, flanks, abdomen, and proximal legs, which may be causative factors in these complaints.³ Hooper et al⁴ concluded that patients' musculoskeletal complaints significantly decrease after GBS when compared with their status before surgery. From an osteopathic perspective, it is likely that these patients develop chronic somatic dysfunctions while morbidly obese, and that although they experience dramatic improvement in their symptoms after GBS, there continue to be musculoskeletal issues secondary to the severe ptosis and weight of the excess skin.

Body contouring surgeries are available to treat these areas of ptosis^5–7 and may also help to reduce these musculoskeletal complaints. Hurwitz⁸ has recently shown that it is possible to safely help patients who have undergone massive weight loss with a single-stage surgical procedure called the total body lift (TBL), which removes sagging skin of the upper and lower body and contours these areas into a healthier-looking shape.

If the chronic nature of a patient's preoperative low back pain extends into the later postoperative period, however, he or she may benefit from osteopathic manipulative treatment (OMT). A recent meta-analysis of randomized controlled trials, which studied the efficacy of OMT for the treatment of low back pain, concluded that OMT results in a significant reduction of pain.⁹

Although I have only briefly touched on my perspective regarding this recent observation, I hope that I have motivated readers to take an interest in the musculoskeletal health of post-GBS and post-TBL patients. It would be interesting to see the results of a longitudinal study that focuses specifically on osteopathic diagnoses pre-GBS, post-GBS, and post-TBL. Additionally, a cohort study of post-GBS and post-TBL patients—divided into an OMT group and a non-OMT group—may demonstrate the efficacy of OMT in the musculoskeletal health of these types of patients.

Adding osteopathic evaluation to the care of post-GBS and -TBL patients should be considered, as these patients may have compensating spinal, muscular, and peripheral joint dysfunctions that would need adjustment to respectively promote appropriate posture, strength, and motion for their new body habitus. Such involvement of multiple disciplines of medicine ensures a well-rounded approach to patient care.

References
1. Salameh JR. Bariatric surgery: past and present. Am J Med Sci. 2006;331:194 –200.[Medline]

2. Santry HP, Gillen DL, Lauderdale DS. Trends in bariatric surgical procedures. JAMA.2005; 294:1909 –1917.[Abstract/Free Full Text]

3. Hurwitz DJ. Total Body Lift: Reshaping the Breasts, Chest, Arms, Thighs, Hips, Back, Waist, Abdomen and Knees After Weight Loss, Aging and Pregnancies. New York, NY: MDPublish.com;2005 .

4. Hooper MM, Stellato TA, Hallowell PT, Seitz BA, Moskowitz RW. Musculoskeletal findings in obese subjects before and after weight loss following bariatric surgery. Int J Obes (Lond). In press.

5. Hurwitz DJ, Agha-Mohammadi S. Postbariatric surgery breast reshaping: the spiral flap. Ann Plast Surg.2006; 56:481 –486; discussion, 486.[Medline]

6. Costa LF, Landecker A, Manta AM. Optimizing body contour in massive weight loss patients: the modified vertical abdominoplasty. Plast Reconstr Surg. 2004;114:1917 –1923; discussion 1924–1926.[Medline]

7. Strauch B, Herman C, Rohde C, Baum T. Mid-body contouring in the post-bariatric surgery patient. Plast Reconstr Surg.2006; 117:2200 –2211.[Medline]

8. Hurwitz DJ. Single-staged total body lift after massive weight loss. Ann Plast Surg.2004; 52:435 –441, discussion 441.[Medline]

9. Licciardone JC, Brimhall AK, King LN. Osteopathic manipulative treatment for low back pain: a systematic review and meta-analysis of randomized controlled trials. BMC Musculoskelet Disord.. 2005;6:43–54. Available at: http://www.biomedcentral.com/1471-2474/6/43. Accessed July 25, 2006.

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