Furthest along in clinical trials is a noninvasive technique called TOGA, or transoral gastroplasty. In the procedure, a surgeon inserts a flexible tube through the mouth into the stomach and then uses staples to create a pouch that limits the amount of food that can be consumed. Cedars-Sinai is one of nine medical centers testing the technique, created by a Palo Alto company called Satiety Inc. A previous small study showed that patients lost an average of almost 25 pounds after three months with no major complications reported. Long-term data aren't yet available.
"Patients feel great afterward," Nishi said. "They don't have any of the pain you have with laparoscopic [minimally invasive] surgery." He expects that, when perfected, the procedure will take one hour, and the patient can go home shortly afterward.
The most common weight-loss surgeries -- laparoscopic gastric bypass and gastric banding, which restrict stomach size so that patients feel full more quickly -- usually require one to three days in the hospital.
Mahaffey underwent a similar procedure called POSE (for Primary Obesity Surgery, Endolumenal), which is designed for people who need to lose only a moderate amount of weight.
"People 50 pounds overweight are the ones we should treat, before the problem gets worse," said the surgeon who performed the procedure, Santiago Horgan of UC San Diego.
In a noninvasive technique still in the early stages of development, a device is placed in the upper part of the small intestine to create a barrier between food and the wall of the intestines, thus mimicking the effect of gastric bypass surgery. Called the EndoBarrier, it could help patients lose weight before a more invasive weight-loss procedure or to help resolve Type 2 diabetes, of which obesity is a primary cause. The device is expected to cost about half as much as gastric banding and one-quarter as much as gastric bypass.
Growing acceptance
Lowering the cost of surgery will be key to offering an effective weight-loss option to thousands, or millions, more people, Schauer said. The costs of traditional weight-loss surgery vary widely across the nation, with an average cost in California of $52,224, according to a HealthGrades report released in July.
"Many experts believe if we get a procedure close to the $10,000 range, then we could dramatically expand both access and insurance coverage," he said.
Whether insurance companies will welcome the idea of more people receiving bariatric surgery remains to be seen.
Weight-loss surgery is now covered by insurance only for those patients who have premium benefits and a BMI of 40 or higher, or a BMI of 35 or higher with obesity-related medical problems. Standard health plans typically don't include bariatric surgery.
Surgery may be cost-effective if it cures diabetes and prevents heart disease, joint problems and other illnesses linked to obesity, Baker said. A 2008 study in the Journal of Managed Care found that insurers fully recover their costs for bariatric surgery two to four years after the procedure due to reduced health problems in the patient.
The patient pool for bariatric surgery is already beginning to widen. Insurance companies tend to follow the lead of the Centers for Medicare & Medicaid Services, and in February, the federal agency announced that it would approve payment of surgery for people with Type 2 diabetes and a BMI of at least 35.
In November, a consortium of influential medical groups, including the Obesity Society, composed of researchers who study all aspects of obesity, published a consensus statement recognizing the "legitimacy" of bariatric surgery as a dedicated treatment for some patients with Type 2 diabetes and noted that surgery may be suited for people with Type 2 diabetes who are not yet morbidly obese -- those with a BMI of 30 to 35.
"There is mounting evidence that for someone with a BMI of 30 with diabetes that is not well-controlled, surgery is a good option," Schauer said. A BMI of 30, for example, would reflect someone who is 5 foot 8 and 197 pounds.
"Surgery is grossly under-used," added Dr. John Kral, an obesity expert at State University of New York Downstate Medical Center in Brooklyn. "If these procedures prove safe enough, people are going to start having them before their eating behavior gets out of hand."
Risks remain
Nutritionists are not enthusiastic. They reject the notion that surgery should take the place of dieting and exercise.
"People with a BMI of 33, for example, don't weigh a lot," said Stern, an advisory board member for Weight Watchers International. "Is that worth the risks of surgery, the side effects, the potential for problems? I'm absolutely opposed to bariatric surgery under a certain BMI, such as 37 with co-morbidities."
