Vol. 12 •Issue 5 • Page 57
Cutting Out Obesity

Is gastric bypass surgery a miracle cure for the U.S. obesity epidemic?

By:  Marci A. Landsmann

We've all seen singer Carnie Wilson on TV, touting the benefits of bariatric surgery. She is transformed before our eyes from a size 28 to a size 6. Such dramatic images tantalize, forcing us to ask a question: Is gastric bypass surgery the answer to the growing obesity epidemic, or is it a miracle cure that's just too good to be true?

As obesity rises in this country, more people regularly wage war against the bulge. Diets succeed only to fail months later. Waistlines grow. It was a routine 54-year-old Barbara Thompson knew by heart. A college librarian and author of Weight Loss Surgery: Finding the Thin Person Hiding Inside of You, Thompson is 5 feet and 7 inches and weighed 264 pounds.

She recalls the day her physician detailed her probable success of weight loss. If she went on a traditional diet, she could expect to lose nearly 5 percent of her body weight—about 13 pounds. With the help of diet drugs, she could lose 10 percent of her body weight, or about 26 pounds. With surgery, the physician told her, she could lose between 50 percent and 80 percent of her body weight. She knew at that moment what it would take to beat her weight problem.

"I was so devastated," she says when she realized that surgery was the only way to control her weight. After one final good faith effort in dieting and yet another failure, Thompson decided to undergo surgery.

Many people who are morbidly obese (characterized by a BMI of 40 kg/m2 or roughly 100 pounds overweight) have a history of similar yo-yo diet attempts. Countless studies show that diet regimens fail to provide long-term weight control in severely obese patients.¹ One study even proved the majority of patients regain the weight they lose in five years' time. ²

Patients who are morbidly obese have a lot of incentive for wanting to shed those pounds—and it's not just for self-image. Obesity takes a toll on the body, exposing it to a host of health problems, including diabetes, digestive tract disease, cardiopulmonary problems and hyperlipidemia, to name a few. These health problems shorten life spans and compromise quality of life. ³

With these cold facts in front of her, Thompson underwent one of the most popular weight loss surgeries (as did Carnie Wilson), called Roux-en-Y gastric bypass (RGB). The RGB creates a small, stapled pouch in the stomach, making it the size of an egg. A surgeon attaches a part of the small intestine directly to the stomach pouch, effectively bypassing the lower stomach and the upper portions of the intestine. The surgery, which on average takes about two hours, restricts food intake and the amount of calories and nutrients the body absorbs, helping patients lose weight.

Successful surgeries often bring amazing results. A 400-pound person could expect to lose 100 to 150 pounds in the first nine months.⁴ And patients don't have to worry about the seesaw effect that once came with dieting. On average, patients lose 50 percent to 60 percent of their excess body weight even 10 to 14 years after surgery.⁵ In addition, patients with obesity can climb out of life-threatening health categories. Blood sugar levels come back to normal, orthopedic pain often disappears, and cholesterol levels improve.

But getting a new lease on life doesn't come without costs.

There is a significant risk when undergoing this surgery, says Dirk Rodriguez, MD, a board-certified surgeon who specializes in laparoscopic RGB in Dallas. One out of every 200 patients dies. Experts attribute this mortality rate to the high-risk patient population; often these patients are de-conditioned and present with several complicating factors. Therefore, any surgery is risky.

One in four people will experience a complication from surgery, says Dr. Rodriguez, noting that these statistics could translate into something minor or deadly. One of the most dreaded repercussions of surgery is a gastric leak (occurring about 2 percent of the time⁴), in which the pouch isn't completely sealed. Having gastric fluid leak into the stomach can cause a deadly infection.

Other complications exist as well. One out of four patients will develop hernias or wound infections.⁴ Now, however, laparoscopic surgery can reduce these complications. But it's complex.

"Laparoscopic gastric bypass surgery is probably the most difficult surgery—[to] perform," says Dr. Rodriguez, largely because a surgeon needs to cut across three tightly nestled intestinal units: the stomach, small bowel and the colon. Navigating this area with a laparoscope takes a trained eye and a lot of patience. To truly master the technique, surgeons may need to perform as many as 100 procedures, says Dr. Rodriguez.

After the surgery, patients must conform to a new lifestyle, including frequent medical follow-up. Right after surgery, patients will be on a liquid diet for two weeks, with solid food being introduced gradually. Because patients have a smaller stomach, they will never be able to "cheat" on diets. If they eat an ice cream dessert, they could experience a symptom called "dumping," which temporarily produces nausea, vomiting, dizziness and sweating. Therefore, patients need to painstakingly monitor what they eat. (They generally will feel full after eating a meal comparable to half a sandwich and a small salad.)

The surgery also causes nutritional deficits because it bypasses parts of the stomach and intestine that absorb nutrients from food. Patients will need to take iron, calcium and B-12 supplements for the rest of their lives.

In addition, they will need to exercise to reap the full effects of surgery.

"Increasing muscle mass is the most effective thing patients can to do to lose weight," says Milton Owens, MD, medical director for the Coastal Center for Obesity, Orange, Calif. This surgeon, who has performed more than 1,500 gastric bypasses, recommends starting with the upper body, where there is the most chance for muscle gain.

Dr. Owens refers his patients to a physical therapist before and after surgery. This person often teaches them about gradually incorporating exercise into their lives.

Michael Dionne, PT, owner of Choice Physical Therapy in Gainesville, Ga., jokes that physical therapists may actually lose their patient base because the weight loss surgery often heals orthopedic problems and existing health conditions. Dionne, who nationally educates health care providers about the intricacies of treating bariatric populations, sees a place for physical therapists in caring for these patients post-operatively. Ideally, he sees many hospitals incorporating these patients into their cardiac III rehab programs.

He also notes the importance of being aware of the delicate nature of patients with obesity. Any period of inactivity can cause unexpected muscle weakness—and falls. Patients of size, therefore, must be treated with caution.

Even with the risks of the surgery, an estimated 90,000 people will undergo knife or laparoscope to shed their pounds nationwide this year.⁶ This is double the amount of people who underwent surgery in 2002.⁶

Most surgeons believe the procedure should be reserved for people whose weight is out of control. Many people, faced with an onslaught of other health problems, accept the risks.

"There's a lot of prejudice against any kind of surgery for these types of patients, but you are trading one risk for another," says Dr. Owens, alluding to numerous health problems obese patients often experience.

The NIH published guidelines to set parameters for the patient selection, emphasizing the importance of screening.⁵ According to the guidelines, patients must have a BMI of 40 and must have tried and failed at dieting for at least a year. Surgeons also can consider patients with a BMI of 35, if these patients have other health risks, such as life-threatening cardiopulmonary problems, joint disease and severe diabetes. The NIH also recommends patients undergo mental health screening.

The surgery, which costs between $20,000 and $25,000, is sometimes covered by insurance—provided the person meets the NIH guidelines.⁵ But many insurance companies still systematically deny the surgery for morbidly obese patients, says Dr. Owens.

No matter who pays, the field continues to expand. Revenue from this surgery was projected to reach $1.8 billion nationwide last year alone.⁶ That number was expected to increase an additional 60 percent to 70 percent this year.⁶

Nearly 800 surgeons perform gastric bypass surgery, according to the American Society of Bariatric Surgery, a medical organization that educates and researches information about bariatric surgery. These surgeons can hardly meet the demand as waiting lists grow. Just ask Dr. Owens, who started doing this surgery in 1987.

"When I got into this surgery, my colleagues looked at me as if I was an obstetrician performing abortions," he recalls. "But now, many of my colleagues are asking me what they should do to open up their offices."

For Thompson, who wears a size 8 and lost 125 pounds, it's not about monetary cost. It's about reaching up for a book at work without flinching in pain. It's about enjoying 18 holes of golf instead of four. She sees fewer barriers and horizons of possibility.

"People need to understand it's a health issue," she says. "If your only chance at beating a health problem is having surgery, then absolutely have that surgery. This is not about cosmetics. It's about life."

For a list of references, go to www.ADVANCE.forDR.com and click on the references tool bar.

Marci A. Landsmann is associate editor.

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