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Weight-Loss Surgery
Cuts Pounds but Creates Risks
by Carolyn Cosmos
This well researched article
originally appeared in the "Washington Diplomat" in the early 2000's - I
was one of the consultants on it.
Curious about surgery for losing weight? If you turn to the Internet for
information about “stomach stapling,” you might come across an
eye-arresting Web site spattered with stars and stripes. A red “crawl”
streams across your screen: “Quick scheduling of consults and gastric
bypass surgery is now available,” it says.
You scroll down to a picture of a bridal couple where the woman is slim
and her testimonial tells a happy tale: “I never believed that I would get
married. Two years after surgery I am now married and have even modeled
for magazines.”
Accurate medical information is available at the site—click to find it. To
qualify for weight-loss surgery, you must be severely overweight by at
least a hundred pounds or have a body mass index of 40 or more, it says.
The medical name for this condition is clinically severe or morbid
obesity, and it can seriously threaten your health, contributing to the
development of diabetes, high blood pressure and heart disease. If you are
morbidly obese and other treatments haven’t worked, surgery could very
well be an option. In fact, it could save your life.
“Even so,” you may ask, “what about the surgical risks? What’s involved?”
Bariatric surgery—“bariatric” means weight loss—always entails cutting off
or closing off part of your stomach to reduce stomach size. This
restriction promotes a feeling of fullness with less food.
The operation, depending on the procedure you choose, can also feature
cutting your small intestine in two. Your surgeon attaches the ends to new
intestinal spots. Food traveling through your body now bypasses part of
the stomach or part of the intestine—or both. Because the food you eat is
skipping some of its typical routes and moving through your body at a
faster pace, fewer calories get through to load you up with fat. This is
called “malabsorption.” The result is that you lose weight rapidly and for
a period of 18 to 24 months after the procedure.
Bariatric surgery is performed as both traditional “open” surgery and,
more recently, as a laparoscopic procedure. In laparoscopic techniques, a
doctor operates through a small incision helped along by a fiber-optic
tube. The tube allows a video camera to project pictures of internal
organs onto a television screen. Laparoscopy features less pain and a
briefer hospital stay.
Risks of
Bariatric Surgery
Nevertheless, if all this sounds like a drastic way to diet, you’re quite
right: Responsible bariatric surgeons describe this group of procedures as
“risky.” They’ll tell you it’s major—and certainly not cosmetic—surgery,
and they should present you with a list of potentially serious
complications.
The red-white-and-blue Web site, however, plays them down. It tells you,
“There is a minor chance of post-operative complications.” It shaves the
surgery’s generally accepted death rate of five deaths per thousand
surgery patients by understating it slightly. And it doesn’t indicate that
some types of bariatric surgery have higher death rates and more
complications than others.
This absence of adequate information is unfortunate because in some
bariatric surgery situations, as in any serious surgery, things can go
terribly wrong.
They did for one Colorado patient, Dani Hart, who preferred not to use her
real name. Hart nearly lost her life from complications following her
weight-loss surgery—complications she said her bariatric surgeon largely
ignored.
Eighteen months later, plagued by chronic vomiting, malnutrition,
psychological distress and newly appeared disease, she had the operation
reversed at a Mayo Clinic in Scottsdale, Ariz. Her bariatric surgeon
there, she said, “gave me the best care.”
In contrast, “My original doctor minimized the risks. I had 15 minutes
with him” before the surgery—a bypass called the Roux-en-Y procedure.
“Nobody told me other options.”
Hart eventually recovered but others have been less lucky. Thirteen
patients have died in Fresno, Calif., hospitals since February 2000 as a
result of bariatric surgery, according to a series of articles published
in the Fresno Bee by Tracy Correa and Barbara Anderson in January of this
year. Other causes of death, such as a heart attack, were typically listed
on the Fresno death certificates, masking the apparent pattern.
The mortality rate for weight-loss surgery in the United States is “much
higher” than the usually quoted five deaths per thousand patients, noted
Herman Praszkier with the law firm of Anderson & Associates in St. Louis,
Mo. He said causes for the poor statistics include inaccurate death
certificates and poor physician reporting procedures.
Praszkier said he has sued “all but one” of the half-dozen bariatric
surgeons in the St. Louis area for medical malpractice or the wrongful
death of patients. All the surgeries involved the Roux-en-Y gastric
bypass, the most frequently performed bariatric procedure in the United
States. His cases also all involve what Praszkier described as inadequate
follow-up care.
The scope and seriousness of the bariatric surgery problem, if there is a
problem, is not yet clear, in part because many obese patients are so
seriously ill.
For example, Georgeann Mallory, executive director of the American Society
for Bariatric Surgery (ASBS) in Gainesville, Fla., noted that the
“mortality rate of morbidly obese diabetic patients without surgery is
four times that of morbidly obese patients after surgery.”
And a study conducted by the American Cancer Society demonstrated that the
risk of death from all causes increases substantially among overweight
people. The study was published in the New England Journal of Medicine in
1999. Various other studies over the years have consistently confirmed
that morbidly obese people die sooner and suffer more ailments than their
lean counterparts.
One difficulty in assessing the situation lies in the procedure’s
popularity: “This surgery is growing in the United States and is spreading
worldwide,” Praszkier said.
For example, the International Federation for the Surgery of Obesity (IFSO),
with headquarters in Toronto, has affiliates in Italy, Mexico, Japan, the
Czech Republic, Germany, Brazil, Austria, the United Kingdom, Spain,
Poland, Australia, New Zealand and various other locations. The major
bariatric surgery procedures have also been developed around the globe,
including procedures that originated in Sweden, Italy and the United
States.
In 1997, there were approximately 23,100 weight-loss surgeries performed
in the United States, Mallory added. The current ASBS estimate is 63,100 a
year, she said, and the numbers are going up. The bariatric Web site with
the red crawl illustrates this trend: It says it has six clinical
locations in several states where surgery can be performed, with four
brand new locations opening soon.
The growth of all types of weight-loss surgery makes it hard to track what
is happening in the field. The standard bariatric mortality statistics
“may not be accurate due to the recent explosion of interest in bariatric
surgery and the dramatic increase in the number of surgeons performing it,
especially those using the laparoscopic technique,” said bariatric surgeon
Dr. Joseph Kamelgard, assistant professor of surgery at the University of
Medicine and Dentistry of New Jersey in Newark and chair of the ASBS
Public Education Committee.
“Since the laparoscopic technique is so much more difficult during a
surgeon’s early experience, the complication rate would be expected to be
higher,” he pointed out.
Procedures
Available
There are two main categories of bariatric procedures, Kamelgard said. The
first group is called “restrictive.” A restrictive procedure simply limits
the amount of food a person takes in. “It can be done by actually stapling
the stomach, or it can be done by putting a band around it. The
restrictions don’t alter the rest of the system, but the weight loss is
typically not as good, in part because patients learn to beat the
operation and they don’t lose weight. They’ll drink milkshakes or eat ice
cream,” he said.
Two main types of restrictive procedures—gastric banding (which involves a
band) and vertical banded gastroplasty (which involves a band and
staples)—create a constricting ring at the top-end of the stomach.
According to Dr. Mervyn Deitel, executive director of the IFSO, 70 percent
of all bariatric surgeries in Europe and Australia have involved
restrictive banding. “It’s a simple method that is getting good results,”
Deitel said, adding that “80,000 bands have been implanted around the
world over 12 years.” It’s typically done laparoscopically and, Praszkier
noted, is considered safer and less likely to cause complications than
procedures that are more surgically complex.
One of the newest restrictive techniques is “adjustable banding” or use of
the “Lap-Band,” a medical device approved in June 2001 by the Food and
Drug Administration for procedures performed in the United States. It had
been deployed at earlier dates in Europe. In this approach, a band is
implanted laparoscopically. Inflated with a saline solution, it can be
adjusted after surgery in a doctor’s office through a portal under the
skin, allowing for subsequent adjustments over time.
A second major bariatric technique, Kamelgard added, is termed “malabsorptive,”
which involves changing the intestinal pathway for digested food. Here,
most of the stomach, the duodenum and other segments of the small
intestine are bypassed. The Roux-en-Y gastric bypass (RGB) is a common
type of gastric bypass procedure in which the stomach is completely
stapled shut, and a Y-shaped section of the small intestine is attached to
the small stapled stomach pouch to allow food to bypass the duodenum and
the first portion of the jejunum directly into an altered intestinal
segment.
“Biliopancreatic diversion” (BPD), or extensive gastric bypass, and the
“duodenal switch” (DS) are more complicated versions of malabsorptive
techniques and can be done traditionally or through the use of a
laparoscope. Both involve permanently removing major portions of the
stomach. In the BPD, three-quarters of the stomach is cut away. The
remaining stomach pouch is then diverted to the final segment of the small
intestine, bypassing the duodenum and the jejunum.
“They are very effective in weight loss but have a number of side
effects,” Kamelgard noted. With malabsorptive procedures, patients may not
get enough iron, calcium or vitamins, and, in some cases, they may risk
insufficient protein and fat intake.
The more extensive the bypass operation, the greater the chance for risks.
In addition to nutritional deficiencies, risks include pouch stretching,
band erosion, breakdown of staple lines, leakage of stomach contents,
nausea and diarrhea. According to the National Institutes of Health, 10 to
20 percent of patients who have weight-loss operations require follow-up
operations to correct complications, and nearly 30 percent of patients
develop nutritional deficiencies such as anemia, osteoporosis and
metabolic bone disease, though these can be avoided if vitamin and mineral
intakes are maintained.
Preferred procedures vary from country to country, Deitel said. “In
Canada, not much bariatric surgery is being done. In Latin America,
they’re probably doing equally the band procedures and the gastric bypass
or the duodenal switch. In Australia, it’s more likely to be gastric
banding, with a small group doing vertical gastroplasty.”
Addressing laparoscopic trends, Deitel said that although 70 percent of
surgeries are being done laparoscopically in Europe and Australia, the
current figure is 50 percent for the United States—although the U.S.
percentage stood at 4 percent only five years ago. “Younger, newer
surgeons are tending to do it,” he pointed out.
The newest and still experimental approach to bariatric surgery, still in
clinical trials, Kamelgard said, involves electrical stimulation devices.
In this procedure, a surgeon inserts an electrode in or near the stomach.
“It’s a device like a pacemaker. The stimulation gives the patient a sense
of satiety” or fullness and satisfaction, Kamelgard said.
For more information, you may visit the IFSO’s international Web site at
www.obesity-online.com/ifso or the Web site of the American Society for
Bariatric Surgery at www.asbs.org. For additional medical illustrations on
gastric bypass procedures, please visit www.laparoscopy.com/obesity/roux.html.
Carolyn Cosmos is a freelance writer in Washington, D.C.
How to Obtain
Good Bariatric Care
In addition to being well informed, there are a number of steps a
potential patient can take to protect himself or herself while exploring
bariatric options, experts say. The single most important step is checking
a surgeon’s training, experience and approach to
follow-up care.
A bariatric surgeon will be board-certified in general surgery, said
bariatric surgeon Dr. Joseph Kamelgard. There is no board certification
for this specialty. It doesn’t exist. However, bariatric training and
experience in surgery for weight loss are important because the surgery
can be complex and difficult.
With laparoscopic surgery, technical laparoscopic skill is important, but
it’s also important that the surgeon have a background in bariatrics. The
American Society for Bariatric Surgery (ASBS) recommends that physicians
using laparoscopic techniques in weight-loss surgery have experience in
open bariatric surgery as well, Kamelgard noted. They also need knowledge
of pre-care and post-operative care.
The quality of post-operative care can be critical to surgery success and
weight loss, as well as to heading off or managing side effects and
complications. You should have access to experts in nutrition and mental
health and to other needed providers, and the access should entail more
than an occasional consultation over the phone.
Taking responsibility for your own follow-up regimen is also part of the
equation for bariatric success. ASBS emphasizes that “obesity is a chronic
disease [and] frequent and long-term contact with your surgeon and regular
follow-up visits are very important for a good outcome.”
—Carolyn Cosmos |