By Susan Brink, Los Angeles Times
Throw out any thoughts that weight-reduction surgery is a shortcut to svelte. The surgery, performed on about 200,000 Americans a year, is a last resort to rescue people in danger of dying early from the consequences of obesity.
After years of question marks, studies now show the surgery saves lives, sustains long-term weight loss and combats -- maybe even reverses -- diabetes. But it still results in the death of 1 in 200 patients and can result in complications such as blood clots, hernias, bowel obstructions or intestinal leaks that can lead to infection.
Because of these complications, National Institutes of Health experts recommend the surgery only for people considered morbidly obese, roughly 100 pounds or more over ideal body weight. They face a risk of death from diabetes or heart disease five to seven times greater than people of normal weight.
"These people don't have a lot of options," says Dr. John Morton, director of bariatric surgery at Stanford's Center for Weight Loss Surgery in California. "When someone is drowning, I throw them a life preserver. I don't have time to build a bridge."
About 14,000 Californians undergo weight-loss surgery each year. According to the American Society for Bariatric Surgery, more than 1 million Californians qualify: those with a body mass index of 40 or more, or 35 or more if they have heart disease or diabetes.
The twin remedies to get rid of fat -- diet and exercise -- are ineffective for people who are vastly overweight. Weight gain leads to arthritis or difficulty breathing, which makes exercise difficult and, eventually, impossible. People sit more, move less and don't burn all the calories they consume.
"Once you're in the morbidly obese category, it is very, very hard to lose the weight using nonsurgical means," says Dr. Melinda Maggard Gibbons, a general surgeon and researcher at the Center for Surgical Outcomes and Quality at the University of California, Los Angeles.
There are two main surgical options. Gastric bypass surgery reduces the stomach from the size of a football to the size of a golf ball using surgical staples or a plastic band.
The most common and successful technique is called the "Roux-en-Y procedure," named for the surgeon who invented it and the resulting reconfigured small intestine. Food from the tiny stomach bypasses more than half of the small intestine, where nutrients and calories are absorbed, and heads for the large intestine, from where it's eventually excreted as waste.
Stomach-banding surgery, which is reversible, wraps a silicone belt around the stomach, reducing its size so that as little as a tablespoon of food fits at a time. Both procedures successfully result in weight loss, although more pounds come off, and quicker, with gastric bypass surgery.
"The surgery is anatomy-mandating behavioral change," Morton says.
A small or bypassed stomach demands that people eat less. This leads to weight loss, which allows more freedom of movement, which makes exercise possible.
Improvements in surgical options came after years of trial and error. In the 1950s, surgeons experimented with intestinal bypass surgery, leaving the stomach intact but looping out all but about two feet of the intestine. People lost weight, but their guts could not absorb nutrients. Patients suffered diarrhea 10 to 15 times a day, as well as malnutrition, dehydration, kidney stones and liver problems.Surgeons largely gave up on intestinal bypass and tried stomach stapling instead.
"That had problems," says Dr. David Zingmond, professor of internal medicine at UCLA. "People could re-expand their stomachs."
By the 1990s, gastric bypass surgery finally helped people more than it hurt them. The new techniques have fewer side effects, provided that patients eat small amounts and take nutritional supplements.
Still, questions about the procedures' long-term results persisted until 2007, when a Swedish study in the New England Journal of Medicine settled some of them.
Researchers followed about 2,000 obese patients who had undergone weight-loss surgery -- gastric bypass or surgical banding -- and compared them with about 2,000 similarly obese people who didn't have surgery but were counseled in diet and exercise. After 10 years, those who had bypass surgery weighed 25 percent less; those who had stomach-banding were down about 15 percent. Those who got traditional diet advice lost no more than 2 percent of their weight.
People normally lose a lot of weight at first, then regain some of it. This study showed that a significant amount of weight stayed off -- and for the first time showed that long-term weight loss, even when people remain overweight, is enough to save lives.
There were 129 deaths in the diet-only group, mostly from weight-related heart disease and cancer. The 101 deaths in the surgery group were also largely from heart disease and cancer, although there were half the number of heart attack deaths as for those in the diet group, and fewer deaths in all but one category. That exception was infection, possibly a result of the surgery. Twelve people who had surgery died of infection, compared with three in the diet group. Even more remarkable to scientists is the finding that both major types of weight-loss surgery can reverse diabetes.
In 2004, a review of 130 studies of more than 22,000 patients in the Journal of the American Medical Association found that many diabetics who have gastric bypass surgery are cured of diabetes, often within days.
"It's a striking benefit," Morton says. "They're off insulin and medication 82 percent of the time."
A January study in the same journal showed similar results for stomach-banding surgery, although the result can take up to a year. Researchers aren't sure why surgery reverses diabetes but speculate that it results in a change in the hormones related to diabetes.
Paul Shekelle, director of the Santa Monica, Calif.-based Rand Corp.'s evidence-based practice center, which conducts health-care reviews, said the Swedish study convinced him that bypass surgery does save lives. But he's concerned that too many people see surgery as an easy solution to a difficult problem.
"You've got to make sure that patients understand that this is not like getting your knee repaired," he says. "This is going to make your life different."
Patients won't eat sugar any more, not without risking diarrhea, gas, bloating and cramping. They won't eat large amounts of anything, ever.
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