Primer on Weight-Loss Surgery

Dear Readers,

Americans love quick fixes, especially when it’s high tech.  With something really hard like weight loss, what’s not to like about an instantaneous surgical cure?

Well, a lot. Start with:

  • This is major, major surgery that rearranges your guts forever.
  • The cure is not instantaneous. You have to have the discipline to follow a brand-new diet for the rest of your life.
  • Because most of these surgeries work by reducing your body’s ability to absorb foods, you have to pay lifelong attention to the possibility of not getting enough essential ingredients in your diet, which can mean serious disease or illness.
  • Surgically altered gastric anatomy carries with it risks of complications which are not statistically high, but are life-threatening if they ever do happen.  And they can happen any time from the day of surgery onward.

But even a skeptic like me has to acknowledge that there is a place for surgical weight loss.  And that’s the subject of this month’s newsletter: looking at the pros and cons of weight loss surgery with both eyes wide, wide open.

The Weighty Facts

According to the Centers for Disease Control and Prevention  (CDC), more than 1 in 3 American adults is considered obese, as are nearly 1 in 5 children. Obesity is the second-leading cause of preventable death, and it takes about 300,000 U.S. lives a year.

Annual health-care costs of obesity in the U.S. are nudging $150 billion; yearly medical costs of obese people are about $1,429 higher than people of normal weight. According to The Conversation, a website that analyzes and discusses recent scientific studies, obesity can reduce life expectancy by five to 20 years.

Let’s face it: Obesity can be life-threatening. High blood pressure, diabetes, cardiovascular disease, stroke, sleep apnea, arthritis, liver disease and some kinds of cancer — all these can happen with too much weight. Sometimes, a combination of dietary changes and regular exercise can help the obese lose weight. Sometimes, they’re not.

The Procedure

“Bariatric surgery for severe obesity is associated with long-term weight loss and decreased overall mortality,” according to the Journal of American Medical Association (JAMA).

But it never should be the first treatment for losing weight. It’s invasive, serious surgery that carries risks, and it doesn’t work for everyone.

Bariatric surgery is not a single procedure — the term refers to several different approaches to limiting the amount of food someone can consume and absorb.

There are four common types of weight-loss operations in the U.S. As described by the National Institutes of Health (NIH), they are:

  • adjustable gastric band (AGB);
  • Roux-en-Y gastric bypass (RYGB);
  • biliopancreatic diversion with a duodenal switch (BPD-DS);
  • vertical sleeve gastrectomy (VSG).

AGB decreases food intake by placing a small band around the top of the stomach to restrict the size of the opening from the throat to the stomach. The surgeon determines size of the opening with a circular balloon inside the band that can be inflated or deflated depending on each patient.

RYGB also decreases food intake, and affects absorption as well by causing food to go directly from the small pouch into the small intestine. So food is absorbed differently because meals bypass the stomach, duodenum and upper intestine.

BPD-DS,

or “duodenal switch,” is more complicated, with three steps. One removes a large part of the stomach — patients feel fuller sooner, so they eat less. Two, food is rerouted away from much of the small intestine, again to limit absorption. Three, bile and other digestive juices are changed, also to affect the body’s ability to digest food and absorb calories.

In removing a large part of the stomach, a “gastric sleeve” (see VSG below) is linked to a short part of the duodenum, which is linked directly to a lower part of the small intestine. So only a small part of the duodenum is left to absorb food and nutrients.

When the patient eats, food bypasses most of the duodenum. The distance between the stomach and colon is much shorter after BPD-DS, and because significantly less nutrition is absorbed, the chances are greater for long-term problems.

VSG, too, restricts food intake and decreases the amount of food used. Most of the stomach is removed, often resulting in a decrease of ghrelin, a hormone that stimulates appetite. This form of reducing hunger is perceived as somewhat more “natural” than other purely restrictive surgeries, such as AGB.

Sometimes, VSG has been performed as a first step before BPD-DS for patients who might be at higher risk of problems after more extensive surgery. But recent research indicates that some patients can lose a lot of weight with VSG alone and avoid a second procedure.

Side Effects and Risks

As with all surgery, complications can include allergic responses to anesthesia, bleeding and infection. Also, leaks can occur from where the intestines are sewn together. Some patients experience diarrhea or blood clots in the legs that can move to the lungs and heart.

The surgeon who performs the procedure also is responsible for monitoring side effects and complications.

Side effects that present a bit later can result from poor absorption of nutrients, especially for patients who don’t take the vitamins and minerals that are prescribed with every surgery. If these nutritional issues aren’t addressed promptly, there can be permanent damage to the nervous system, and the start of disease, such as pellagra (lack of vitamin B3-niacin), whose symptoms are dermatitis, diarrhea and mental disburbances; beri beri (vitamin B1-thiamine), which can cause heart failure; and kwashiorkor (lack of protein), characterized by swelling, irritability and skin ulcers.

Longer-term problems include strictures (narrowing where the intestine was joined) and hernias (part of an organ bulging through a weak area of muscle). The latter can be from the incision, and is a weakness protruding from the abdominal wall’s connective tissue. It can cause a blockage in the bowel. An internal hernia occurs when the small bowel is displaced into pockets in the lining of the abdomen. The pockets form when the intestines are sewn together. Internal hernias are more dangerous than incisional hernias, but all bowel blockages are serious.

Duodenal switch has particular risk for long-term problems, includinganemia (abnormally low red blood cells) and osteoporosis (loss of bone mass that can make bones brittle).

Then there are psychological side effects. Some patients need post-operative emotional support to help them adjust to the changes in body image and personal relationships that occur with a different body shape.

See also my backgrounder on avoiding malpractice with weight-loss surgery.

The Best Candidates

Bariatric surgery is not about a more pleasing figure; it’s about saving lives. Candidates aren’t merely overweight, they are obese, as defined by their BMI-body mass index. As described in my previous newsletter, that’s a calculation derived from a person’s height and weight. For most people a healthy BMI is below 25; overweight is between 25 and 29.9, and anything over 30 is obese.

But you really have to be morbidly obese, with a BMI of at least 35 to 40, to qualify for surgery in the minds of most responsible doctors. And surgery is usually offered to those between 35 and 40 only if they also have another serious health issue like type 2 diabetes. Some medical professionals believe it should be considered for people with BMIs between 30 and 35, but that’s controversial.

To calculate your BMI, link here to the CDC’s body mass calculator.

But losing only 5% to 10% of your body weight can improve your health significantly, especially if accomplished not only with diet, but exercise. For someone who weighs 250 pounds, that’s a loss of only 12.5 to 25 pounds. If lifestyle changes can achieve that, a sustained such program can probably achieve even more loss, without risking the downside of invasive, often irreversible surgery.

Like most invasive procedures, bariatric surgery is expensive — on average, it costs $20,000 to $25,000. Medical insurance coverage varies by state and insurance provider, and often is denied if other measures haven’t been tried first. It’s more likely to be covered if:

  • the patient has at least one health problem linked to obesity;
  • the procedure is suitable for the patient’s medical condition;
  • approved surgeons and facilities are involved.

Homework You Need to Do

If you are a candidate for bariatric surgery, you must ensure your surgeon has experience in the specific procedure recommended for you. Check to see if he or she is a member of the American Society for Metabolic & Bariatric Surgery, or the American Society of Bariatric Physicians. Ask how many of these procedures he or she has performed. Research the hospital’s record for procedures as well, and its adverse outcomes and readmissions within 30 days of discharge.

Find out more at the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program.

If any provider, surgeon or facility, is reluctant to provide information, it’s a signal to go elsewhere.

Surgery Is Only the First Step

In addition to your medical profile, the biggest consideration for whether or not to have bariatric surgery is if you can manage the post-op regimen required to remain healthy and sustain weight loss. As explained in “Life After Bariatric Surgery,” from the University of California, San Francisco Medical Center, “Weight-loss surgery is not a cure for obesity, but rather a tool to help you lose weight to live a healthier, longer and more fulfilling life. Success depends on your ability to follow guidelines for diet, exercise and lifestyle changes.”

In addition to vitamins and minerals, patients usually must take medication, at least for a while. And you will be advised not to take some kinds of medicine. Your diet will be restricted, at least for a while, and you’ll be expected to follow guidelines:

  • Eat slowly and chew small bites of food thoroughly.
  • Avoid rice, bread, raw vegetables, fresh fruits, and meats that are not easily chewed such as pork and steak. Ground meats usually are tolerated better.
  • With soft and solid foods, take only three bites at one sitting, then wait a minimum of 20 minutes before eating more.
  • Eat balanced meals with small portions.
  • Avoid the use of drinking straws and carbonated beverages, chewing gum and ice because they can introduce too much air into your pouch and cause discomfort.
  • Avoid sugar, sugar-containing foods and beverages, concentrated sweets and fruit juices

Most likely, you will be given an exercise prescription, and guidance for psychological counseling. Both programs might require some adjustment.

The whole process of losing weight — from determining treatment options to surgery, recovery and maintenance — requires a huge commitment in the long term. Following a proper procedure under expert guidance and monitoring can improve the quality of life immeasurably.

Here’s to a healthy 2014!

Sincerely,
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Patrick Malone
Patrick Malone & Associates