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Crucial Concerns When Considering a Bypass

March 06, 2000|From Washington Post

Don't even think about it if you're just overweight, not severely obese.

Although there is growing acceptance in the medical community that surgery is an appropriate last-ditch treatment for severe obesity, many experts caution that no one with a body mass index (BMI) of less than 40, or less than 35 with a life-threatening condition, should consider it.

Anyone contemplating surgery also should be highly motivated to make permanent dietary changes, be willing to stick to a rigid and off-putting eating regimen for months--or years--and have tried less invasive methods of weight loss. Children and adolescents should not have surgery because the operation has only been studied in adults, according to the National Institutes of Health.

Here are some other suggestions for potential candidates, culled from the NIH and the American Society for Bariatric Surgery:

* Carefully consider the risks. Gastric bypass is major abdominal surgery and involves rearrangement of the gastrointestinal tract. The death rate from the procedure is about 3 per 1,000 patients; serious complications include blood clots, internal hemorrhage, stroke and infection from an abdominal leak. Although the operation can be undone, reversal is considered to be more dangerous than the original procedure. After reversal, it is likely that the digestive tract will not function as it did before bypass surgery.

* Insist on experience. Choose a surgeon who is board-certified and has done hundreds of Roux-en-Y gastric bypass or vertical banded gastroplasty operations. Ask about the doctor's complication and re-operation rates. Ten percent to 20% of patients require additional surgery to correct complications. A rate above 20% is a red flag.

* Be prepared for more surgery. Gallstones are common, and many patients may need to have their gallbladders removed. Bypass operations also result in the formation of scar tissue, which can cause a bowel obstruction that may occur years after surgery. This is a potentially fatal complication that must be treated promptly. Patients who lose a lot of weight often need plastic surgery to remove folds of hanging skin. Insurance companies typically consider this to be a cosmetic procedure and most won't pay for it.

* Get ready to take vitamins--lots of them. Anemia, osteoporosis and other nutritional deficiencies are common after surgery because the duodenum, the portion of the intestine that absorbs iron and calcium, is bypassed. Many patients also suffer hair loss. These problems may be offset by taking extra calcium and vitamins and eating enough protein.

* Do some research. Make sure the surgeon offers a comprehensive program that includes nutritional counseling and psychological support. Attend support group meetings and talk with patients who've had surgery. Ask the doctor for names of people who've had serious complications, and talk with them. Avoid a doctor who seems most interested in selling the surgery or one who tells you that diet and exercise don't work.

* Understand the procedure. Think very carefully about having an operation other than a standard Roux-en-Y gastric bypass or vertical banded gastroplasty. These two procedures have received the most scientific scrutiny, although vertical banded gastroplasty is performed less frequently these days because of its high failure rate. Some doctors recommend the biliopancreatic diversion, an extensive gastric bypass in which parts of the stomach are removed, but only for people who are several hundred pounds overweight.

Laparascopic surgery, which involves making several small holes in the abdomen rather than one foot-long vertical incision, is controversial and should be considered experimental.

* Decide whether eating is more important than being thinner. Do not consider surgery if your need to eat--or choice of foods--is more important than losing weight. Some patients adjust to the rigors of the new regimen with relative ease, while others become very depressed and find it enormously difficult.

* Don't expect nirvana. Being thinner--or even thin--will not solve your problems, although psychologists and surgeons say that many obese patients believe it will.

"People continue to struggle with family relationships, depression, their relationship with food and their body image," psychologist Maria Z. Cohn said.

* Take your time. Don't be seduced by celebrity testimonials, slick Web sites or friends who extol the glories of surgery.

"You cannot make this decision in haste," Cohn said. "It's life-changing, and there's really no going back."

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