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Surgery by itself won't be enough

It saves lives, brings long-term weight reduction and fights diabetes. But it still has complications.

June 02, 2008|Susan Brink | Times Staff Writer
  • A band is wrapped around the stomach.
A band is wrapped around the stomach. (Anne Cusack, Los Angeles…)

Throw out any thoughts that weight reduction surgery is a shortcut to svelte. The surgery, performed on about 200,000 Americans a year, is a last resort to rescue people in danger of dying early from the health consequences of their extreme obesity.

After years of question marks, studies now show the surgery saves lives, sustains long-term weight loss and combats -- maybe even reverses -- diabetes. But although it's much safer today, it still results in the death of 1 in 200 patients and can result in complications such as blood clots, hernias or bowel obstructions. Patients can end up back in the hospital to repair intestinal leaks that can lead to serious infection.

Because of these complications, a National Institutes of Health panel of experts has recommended the surgery only for people considered morbidly obese, roughly 100 pounds or more over their ideal body weight. People whose weight is that far out of control face a risk of death from diabetes or heart disease five to seven times greater than those of normal weight.

"These people don't have a lot of options," says Dr. John Morton, director of bariatric surgery at Stanford's Center for Weight Loss Surgery. "When someone is drowning, I throw them a life preserver. I don't have time to build a bridge."

About 14,000 Californians undergo weight-loss surgery each year. But according to American Society for Bariatric Surgery guidelines, more than 1 million Californians qualify medically: those with a body mass index of 40 or more, or 35 or more if they have conditions such as heart disease or diabetes.

The twin remedies to get rid of fat -- diet and exercise -- have proven ineffective for people who are vastly overweight. A cycle takes over. Weight gain leads to problems such as arthritis or difficulty breathing, which makes exercise difficult and eventually, impossible. People sit more, move less and don't burn all the calories they consume. "Once you're in the morbidly obese category, it is very, very hard to lose the weight using nonsurgical means," says Dr. Melinda Maggard Gibbons, a general surgeon and researcher at the Center for Surgical Outcomes and Quality at UCLA.

There are two main surgical options. Gastric bypass surgery diverts food from a stomach that has been reduced from the size of a football to the size of a golf ball, using surgical staples or a plastic band. The most common and successful technique is called the Roux-en-Y procedure, named for the surgeon who invented it and the resulting Y-shape of the reconfigured small intestine. The food from the tiny stomach bypasses more than half of the small intestine, where nutrients and calories are absorbed, and then heads for the large intestine, from where it's eventually excreted as waste.

Stomach-banding surgery, which is reversible, wraps a silicone belt around the stomach, drastically reducing its size, so that as little as a tablespoon of food fits at a time. Both procedures successfully result in weight loss, though more pounds come off, and quicker, with gastric bypass surgery.

"The surgery is anatomy-mandating behavioral change," Morton says. A small or bypassed stomach demands that people eat less. This leads to weight loss, which allows more freedom of movement, which makes exercise possible.

Improvements in surgical options came after years of trial and error. In the 1950s, surgeons experimented with intestinal bypass surgery, leaving the stomach intact but looping out all but about 2 feet of the intestine. People lost weight, but their guts could no longer absorb vital nutrients. Patients suffered episodes of diarrhea 10 to 15 times a day, as well as malnutrition, dehydration, kidney stones and liver problems.

So surgeons largely gave up on intestinal bypass and tried stomach stapling instead. "That had problems," says Dr. David Zingmond, professor of internal medicine at UCLA. "People could re-expand their stomachs."

It wasn't until the early 1990s that gastric bypass surgery began to help people more than it hurt them.

The new techniques have fewer nasty or life-threatening side effects, provided that patients eat small amounts and take nutritional supplements. Still, questions about the procedures' long-term results persisted until 2007, when a Swedish study in the New England Journal of Medicine seemed to settle at least some of them. Researchers followed about 2,000 obese patients who had undergone weight-loss surgery -- either gastric bypass or surgical banding -- and compared them with about 2,000 similarly obese people who didn't have surgery but were counseled in diet and exercise. After 10 years, those who had gastric bypass surgery weighed 25% less; those who had stomach-banding surgery were down about 15%. Those who got traditional diet advice lost no more than 2% of their weight.

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