With record U.S. obesity rates and newly expanded Food and Drug Administration eligibility criteria for Lap-Band surgery, more and more Americans may be mulling the possibility of going beyond diet and exercise to tackle their weight and the medical problems that come with it.
Those deciding on the surgical route face the often-baffling choice of which procedure is for them. Although there are some broad guidelines, experts say, the final choice comes down to what both patient and doctor are comfortable with.
"It's very hard to scientifically answer the question" of which procedure is right for a patient, said Dr. Mitchell Roslin, chief of bariatric surgery at Northern Westchester Hospital in Mt. Kisco, N.Y. "Every time you answer the question, you are getting somebody's personal bias."
Adds Dr. Theodore Khalili of the Khalili Center for Bariatric Care in Beverly Hills: "We don't make the decision for the patient. We present the risks and benefits and let the patient decide."
Here are some facts to consider in deciding whether to have weight-loss (bariatric) surgery — and then which procedure to pick. There are four main options:
• Roux-en-Y, or gastric bypass surgery: The surgeon creates a small pouch in the stomach to restrict food intake and bypasses part of the intestine to restrict food absorption, connecting the remainder to the pouch.
• Banding: An inflatable silicon band is attached to the upper part of the stomach, then inflated with silicon solution to restrict food intake. Two commercial products are available: the Lap-Band (Allergan Inc. of Irvine) and the Realize Band (Ethicon Endo-Surgery Inc. of Cincinnati).
• Gastric sleeve: The stomach is stapled to convert it into a long, narrow tube with about only 20% to 30% of its normal volume, to restrict food intake.
• Duodenal switch or biliopancreatic diversion: The intestines are rerouted to create a very short path for nutrient absorption. The patient takes in only about 20% of the calories and nutrients in food.
"There are arguments to be made for all of the procedures," Roslin said; the choice depends on what the patient needs.
The gold-standard procedure against which others are measured is laparoscopic Roux-en-Y bypass. "It has the longest history and has tremendous impact with very low mortality and morbidity if done in a center of excellence," said Dr. Namir Katkhouda, director of bariatric surgery at USC's Keck School of Medicine.
More than half of the estimated annual 220,000 bariatric surgeries in the U.S. are gastric bypasses, mostly by laparoscopy. The surgical complication rate is about the same as for having a gallbladder removed, Katkhouda said.
Patients typically lose about 70% to 80% of their excess weight in the 12 to 18 months after surgery, a drop of about 20 points in body mass index (BMI), said Dr. Scott Cunneen, director of bariatric surgery at Cedars-Sinai Medical Center. About 85% have their Type 2 diabetes resolved and can stop taking most diabetes medications within days or weeks after surgery. Long-term complications can include intestinal blockage and malabsorption of vitamins and essential nutrients.
Banding accounts for about 40% of bariatric surgeries. Many patients prefer it because "they want less complications or they don't want their 'plumbing' changed," said Dr. Peter LePort, medical director of the MemorialCare Center for Obesity at Orange Coast Memorial Medical Center in Fountain Valley. Patients typically lose about 50% of excess weight over two to three years, about 10 BMI points. About 65% resolve their Type 2 diabetes, but only after substantial weight loss.
Though banding has fewer initial complications, it has more in the long run, making the complication rate about the same as for bypass. In about 5% to 10% of cases, the band moves out of position, causing an obstruction and necessitating a reoperation, Khalili said. It may erode through the stomach wall, requiring surgical repair. The band or the port used to refill it may break, which doesn't cause injury but may necessitate a reoperation.
By some estimates, LePort said, as many as a quarter of patients who get the band have it removed within 10 years, due to problems or because they don't like it.
Gastric sleeves were originally combined with the duodenal switch for use on extremely obese patients. But many felt they were losing enough weight with the sleeve alone and it became a stand-alone procedure that is very popular in Europe.
The chief problem is the long staple-line used to narrow the stomach, Khalili said. The smaller the stomach is made, the more effective the procedure — but the greater the pressure on the staples from eating. This raises the risk of leakage of stomach contents into the abdomen, which can cause severe infections, he said.
The gastric sleeve is generally viewed as midway between banding and gastric bypasses for both weight loss and resolving diabetes. It accounts for about 5% of bariatric procedures, but insurance companies began paying for the procedure at the end of 2010. Roslin predicts the proportion will grow to 30% in the next few years because the gastric sleeve has fewer complications than banding and doesn't require surgery on the intestines.
Most surgeons reserve the duodenal switch (about 5% of bariatric surgeries) only for the most obese — and many prefer not to do it at all. It gives the greatest weight loss, at least 85% of excess weight, and a 90% to 95% resolution of diabetes.
But the surgery is complicated and time-consuming, and it also brings the highest risk of malnutrition. Patients frequently suffer from significant diarrhea and flatulence. "The advantage is not enough better to justify taking those risks," Khalili said.