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Nutrition & Weight Control


The Facts About Obesity Surgery

About 5% of Americans are 100 or more pounds overweight, and based on current obesity trends, the numbers are likely to increase. People carrying this much excess weight are 2 to 3 times more likely to die prematurely than people of average weight. They are also frequently plagued by chronic medical problems, including heart disease, diabetes, and osteoarthritis, and their quality of life often suffers owing to a variety of problems, including impaired mobility, breathing difficulty, depression, and a poor self-image.

Expanding Numbers

Bariatric surgery, from the Greek baros for weight and iatreia for medical treatment, can help severely obese people lose weight and keep it off by reducing the size of the stomach and, sometimes, bypassing a portion of the small intestine. The number of Americans who have had bariatric surgery has increased dramatically during the last decade. According to the American Society of Bariatric Surgeons, about 16,000 such procedures were performed in 1992 compared with about 63,000 last year. Singer Carney Wilson, celebrity Sharon Osbourne, comedian Roseanne Barr, “Today” show weatherman Al Roker, and New York Congressman Jerry Nadler are among the public figures who have slimmed down in recent years with the help of a bariatric procedure.

The increased popularity of bariatric surgery can be attributed to a variety of factors, including the national obesity epidemic, improved surgical techniques, and publicity surrounding celebrities who undergo bariatric procedures. In addition, a greater understanding of the serious—and expensive—health risks associated with obesity has persuaded many insurance companies to provide coverage. The payoffs are improved health, longer and better quality life, and lower lifetime health care costs. However, bariatric surgery is not a magic bullet. Serious complications are possible and there may be some unwanted lifestyle implications.

A Smaller Stomach

Bariatric surgery has been performed in various guises since the 1960s. Today there are three major, much refined approaches: vertical banded gastroplasty, gastric bypass, and adjustable gastric banding. In each procedure, the surgeon creates a small pouch that receives food. Thus, patients who undergo a bariatric procedure eat less because they feel full sooner. Gastric bypass is associated with the most weight loss since it also reduces calorie absorption. Adjustable gastric banding is the newest procedure. Performed in the United States since 2001, it is the only bariatric procedure that can be reversed with relative ease. The cost of bariatric surgery ranges from about $20,000 to $50,000.

“Gastric bypass is the procedure we use most here at Hopkins,” says Thomas Magnuson, M.D., Chief of General Surgery at the Johns Hopkins Bayview Medical Center. “Vertical banded gastroplasty is rarely performed owing to the possibility of longterm complications and weight gain. Adjustable gastric banding is rarely performed because most insurance companies consider it experimental and therefore not reimbursable.” The criteria used to determine which procedure is best for a given patient have not been established. Dr. Magnuson and colleagues hope to soon perform randomized studies to answer this question.

Gastric bypass surgery is executed through an open incision and takes less than 2 hours. But hospitalization for several days and intensive postsurgical care are necessary, largely because all obese patients are vulnerable to complications after any major operation. Home recuperation takes at least a month. Short-term complications include lung collapse (atelectasis), blood clots in the legs (which can break off and travel to the lungs, causing a pulmonary embolism), wound infection, and fluid collection in the abdomen. Long-term complications include reopening of the stomach pouch, breakdown of the materials used to secure internal structures, leakage of stomach juices into the abdomen, the formation of scar tissue (which can prevent food from exiting the stomach), and development of an abdominal hernia.

In some instances, laparoscopy (a technique which inserts specially designed instruments into the abdomen through several small incisions) can be used instead of open surgery for gastric bypass. However, laparoscopic gastric bypass is still experimental. Laparoscopy shortens recovery time and decreases the likelihood of certain complications, such as wound healing problems. “But this comes at the expense of higher rates of leakage, internal hernias, and bowel obstruction,” Dr. Magnuson says. “About 80% to 90% of gastric bypasses in the United States are still performed through an open abdominal incision and this should be considered the gold standard.”

Who Is a Candidate?

Because of the risks associated with gastric bypass and other bariatric procedures, bariatric surgery is appropriate primarily for people under age 60 who are morbidly obese—at least 100 pounds overweight (a body mass index, or BMI, of 40 or more)—and have been unable to control their weight through aggressive dieting. Surgery may also be considered for people who are slightly less obese (a BMI of between 35 and 40) if they have serious obesity-related medical problems, such as sleep apnea (temporary breathing disruption during sleep) or severe diabetes. Musculoskeletal, neurologic, or body-size problems that interfere with daily functioning could also tip the scales in favor of surgery.

A recent study of 1,067 patients who underwent gastric bypass reported in the Annals of Surgery found that extremely obese men were at highest risk for life-threatening complications. Older patients had about the same rate of complications as younger ones, but they were more likely to die. Blood clots, though infrequent, were the most common cause of death. In this study, factors that are normally thought to increase surgical risk, such as diabetes and a history of smoking, were not associated with a higher risk of complications or death. The mortality rate was 3% for men and 0.8% for women.

A study in Obesity Surgery warns that psychological problems are common among people who are contemplating bariatric surgery. In a study of 115 surgical candidates, researchers at Montefiore Medical Center in New York City found that 70% had a current or past psychological problem, usually depression or an anxiety disorder. The lifetime prevalence of depression was 56%, compared with 17% for the general population. Anxiety disorders were present at the time of the interview in 17% of patients. Such problems can affect expectations, the decision about whether to proceed with surgery, and how well patients do afterward.

The New You

Weight is shed gradually over a year or more. Although patients may not ultimately slim down to their ideal weight, they usually lose a dramatic amount of weight and are pleased with the result. Excess skin may appear around the abdomen, upper arms, and other areas. Some patients undergo cosmetic surgery to remove it.

There is also a dramatic change in eating habits. The newly created pouch can accommodate only a few tablespoons of food at first and about 5 oz after a year. Thus, people who have undergone gastric bypass must eat several light meals a day rather than a few larger ones. Consuming even a little extra food during a meal can be extremely uncomfortable. Over time, however, internal tissues may continue to stretch, which can permit more food to be eaten and could lead to weight gain. Inadequately chewed food can also prompt discomfort.

Because gastric bypass reduces nutrient absorption as well as calorie absorption, about 30% of patients develop anemia, which can be prevented with supplements. Nausea and/or vomiting after eating sweet foods (dumping) is another frequent problem. Dumping can be prevented by avoiding sweet foods. Some patients experience heartburn or vomiting after eating other types of foods. These problems can often be mitigated by avoiding the foods that seem to trigger them.

Exercise should become routine, and lifelong medical, nutritional, and psychological follow-up care is essential.

For More Information
The American Society for Bariatric Surgery
Gainesville, FL 32607

From The Johns Hopkins Medical Letter: Health After 50, May 2004


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