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.
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
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.
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
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,
were the most common cause of death. In this study, factors
that are normally thought to increase surgical risk, such as
and a history of smoking, were not associated with a higher
risk of complications or death. The mortality rate was 3% for
and 0.8% for women.
A study in Obesity Surgery warns that psychological
problems are common among people who are contemplating bariatric
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
present at the time of the interview in 17% of patients.
can affect expectations, the decision about whether to proceed
with surgery, and how well patients do afterward.
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
There is also a dramatic change in eating habits.
The newly created pouch can accommodate only a few tablespoons
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
a meal can be extremely uncomfortable. Over time, however,
internal tissues may continue to stretch, which can
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
can be prevented with supplements. Nausea and/or vomiting
after eating sweet foods (dumping) is another frequent
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
seem to trigger them.
Exercise should become routine, and lifelong
medical, nutritional, and psychological follow-up care is essential.
For More Information
Society for Bariatric Surgery
Gainesville, FL 32607
From The Johns Hopkins
Medical Letter: Health After 50, May 2004