Physician Focus: Weight-Loss Surgery is Just the Beginning
By Rick Buckley Jr., M.D., and Mitchell Gitkind, M.D.
Ten years after then-U.S. Surgeon General Dr. Richard Carmona addressed Congress in July of 2003 on the obesity epidemic and declared it “the fastest-growing cause of disease and death in America,” obesity remains a major public health problem. Today, 36 percent of adults and 17 percent of children are considered obese according to the U.S. Centers for Disease Control and Prevention, and the American Medical Association has now recognized obesity as a disease.
Private organizations and public health agencies alike have put forth scores of programs in response – from exercise recommendations to new food pyramids to school regulations to corporate and community wellness programs – with modest results.
One approach to the obesity epidemic that is becoming increasingly in demand by patients is weight-loss surgery. Some 220,000 of these operations are being performed each year, and the number is likely to rise. It's an approach that can have multiple advantages: Besides helping obese patients shed excess pounds, weight-loss surgery can be an effective therapy for chronic illnesses associated with obesity, such as diabetes, hypertension, and sleep apnea.
The most common types of weight-loss surgery are gastric bypass, adjustable gastric banding, and sleeve gastrectomy, all of which can be done through a few small incisions – what we doctors call “minimally invasively.”
Gastric bypass, the most frequently performed procedure, makes the stomach smaller by dividing it into two parts and creating a bypass to the small intestine. The patient's “old stomach” stays in place. Sleeve gastrectomy, the newest procedure, makes the stomach smaller by removing about two-thirds of it. Both bypass and sleeve gastrectomy appear to change the way the body and the brain process signals of hunger and fullness. These surgeries can also increase “insulin sensitivity,” which improves elevated blood sugar levels in diabetic patients. Adjustable gastric banding is a procedure, by which an adjustable band, designed to reduce food intake, is placed around the upper part of the stomach. All of the operations try to make a three-ounce pouch to restrict food intake.
Which operation a patient will undergo depends on several factors, including the patient's physical condition. Each operation is safe and low risk, though the risks increase for patients who are older, heavier, and may have existing medical complications, such as heart disease. No surgery is entirely risk-free, and though the percentages of problems that can occur are small, some complications, such as leaking, obstructions, blockages, and gallbladder problems, can arise with each procedure, both at the time of the surgery and even well after the surgery.
Here's the caution: Eligible patients considering this surgery should understand it's not a quick fix. It's only one tool that providers have to reduce obesity and help people get healthy, and it represents only one step in a life-long process to attain and maintain normal weight and better health.
The first step to determine if someone is eligible for surgery is calculating body mass index (BMI), a number based on weight and height that indicates a person's body fat. Patients with a BMI of 30 are considered obese; 35 would be about 80 pounds overweight; 40 would be about 100 pounds overweight. Those with BMIs of 40 and above are the most common candidates for surgery, although patients with BMIs from 35-40 along with certain weight-related medical issues can also be appropriate.
After determining BMI, the patient begins an extensive program designed to improve diet and physical activity – critical changes needed to achieve the best possible result after surgery. The preparation process includes a team of medical specialists, incorporating the skills and expertise of a physician, dietician, psychologist, and exercise physiologist, as well as the surgeon.
Tobacco and alcohol are also concerns before surgery. A permanent commitment to quitting smoking is necessary for a safe, long-term result, and drinking is also something that must be addressed. Most successful patients never go back to drinking significant amounts of alcohol after surgery.
How successful the operation will be -? that is, how much weight a patient will lose and keep off -? will vary with the kind of operation and the patient's willingness to engage in physical exercise, eat a proper diet, and live a healthy lifestyle. But for those patients willing to make that commitment and modify their behavior – and rigorously stick to it – this approach to weight loss can have great benefits.
For more information, visit the Patients and Public page of the American Society for Metabolic and Bariatric Surgery at http://asmbs.org/ For a video discussion, visit www.physicianfocus.org/weightlosssurgery.
Rick Buckley Jr. M.D. is former chief of bariatric surgery at North Shore Medical Center in Salem, Mass., and Mitchell Gitkind, M.D., is director of the UMass Memorial Weight Center in Worcester, Mass. Physician Focus is a public service of the Massachusetts Medical Society. Readers should use their own judgment when seeking medical care and consult with their physician for treatment. Send comments to PhysicianFocus@mms.org.
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