Weight Loss Surgery for Obesity

Bariatric surgery as a quick fix for obesity in men

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The first weight loss surgery Garrick Pedersen underwent nearly killed him.

Doctors placed an elastic band around Pedersen's stomach just below the esophagus to restrict how much food he could eat. Pedersen, who weighed close to 300 pounds, began to lose weight almost immediately after the surgery.

"I was overjoyed," says Pedersen, 52, a lawyer in the San Francisco Bay area. "I felt better. I looked better." What's more, very small portions of food left him feeling full.

Then came trouble. Pedersen felt sharp abdominal pains and was rushed into surgery. The band around his stomach had slipped, threatening to cut off circulation. Had he waited much longer, he could have died. The band was safely removed, but Pedersen began to regain weight quickly.

"I was devastated," he remembers. "It wasn't just a matter of wanting not to be fat, though that certainly mattered to me. There are serious health problems associated with being obese, which I was. And I already had many of them. I was being treated for diabetes. My hips and my knees were deteriorating. My blood pressure was too high. Being obese was almost certainly going to cut my life short. And when you have two young kids, that's a hard thing to think about."

So, less than a year later Pedersen was back in the hospital, undergoing another weight loss operation. This time, surgeons bypassed a large section of his stomach and eliminated a stretch of his intestines, an operation called gastric bypass. Three months after the second operation, Pedersen has lost more than 45 pounds, enough that people stop him on the street to say how great he looks.

Weight loss surgery: Drastic solutions to a drastic problem

Pedersen is hardly alone in resorting to drastic weight loss surgery to shed pounds. More and more severely overweight and obese people are turning to bariatric surgery, as these weight loss procedures are called. According to a 2005 report published in the Journal of the American Medical Association, the number of bariatric operations increased sevenfold in just five years-from 13,365 operations in 1998 to 102,177 in 2003. Survey results also show a steep climb in the number of men opting for weight loss surgery.

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Since surgical approaches to treat obesity were first undertaken in the 1970s, they've been controversial. If the problem is that obese people eat too much, chopping away parts of their stomachs and intestines to get them to eat less seems an extreme solution.

"But the fact is, dieting and other lifestyle interventions simply don't work very well for most people," says Edward Livingston, MD, a surgeon at Southwestern Medical School in Dallas and head of bariatric surgery for the nation's Veterans Affairs system. "And for people who are obese, they almost always fail." To keep prescribing treatments that have been shown repeatedly to fail is simply bad medicine, he insists.

In truth, early attempts at weight loss surgery didn't work all that well either. They carried serious risks of infection and death. But now, surgeons have refined two basic approaches, experts say, gastric banding and gastric bypass surgery, which offer better results with far fewer complications than earlier procedures.

Weight loss surgery: Band versus bypass

The simplest type of weight loss surgery, gastric banding, involves placing a band around the upper part of the stomach, which creates a small pouch. The operation restricts the amount of food that can be digested, making people feel full with much smaller portions.

In the second and more complicated procedure, gastric bypass surgery, the surgeon creates a small pouch out of the stomach and directly connects the pouch to the large intestine. In most cases part of the large intestine is also removed. Because a large stretch of the digestive tract that normally absorbs food is bypassed, patients absorb fewer calories from the food they eat.

For men, weighing the risks and benefits of these two types of weight loss surgery is especially thorny. "Men in general experience more complications from bariatric surgery than women," Livingston explains, "probably in part because they carry more abdominal fat than women, so the operation is more difficult to perform. "But men also suffer more complications as a result of obesity than women, so they stand to benefit more by losing weight."

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Gastric banding is the safer of the two weight loss surgeries. The operation is typically performed as "belly-button surgery," performed through a small opening in the abdomen, a procedure called laparoscopic surgery. Unfortunately, for severely obese patients the results are often disappointing. "After gastric banding, weight loss is typically slow, and many patients end up losing only a relatively small percentage of body weight," explains Livingston. Because the pouch that's formed by inserting the band can expand if people eat too much food, some patients end up regaining the weight they've lost.

Gastric bypass surgery, on the other hand, is more complicated and carries more risks, including infection, blood clots, and leakage where the stomach and intestine are surgically connected. Because the surgery interferes with absorption, especially of calcium and iron, there is also a lifetime risk of anemia and other nutritional deficiencies.

But bypass surgery is far more effective than banding. Studies show that obese patients can expect to lose up to 2/3 of their body weight. Weight loss usually occurs rapidly. And gastric bypass patients are much more likely than those receiving gastric bands to keep the weight off.

Obesity-related medical problems also vanish with surprising speed. "In diabetic patients, signs of diabetes often resolve immediately after surgery," says Livingston. High blood pressure and high cholesterol improve dramatically. Hip and knee pain are dramatically eased as weight is reduced. Sleep apnea, another serious health risk associated with obesity, also resolves as patients lose fat from around their necks, says Livingston.

A 2007 study by physicians at St. Elizabeth Health Center and Northeastern Ohio Universities College of Medicine bears him out. The researchers followed 400 patients who had undergone gastric bypass surgery. High blood pressure, cholesterol, diabetes, sleep apnea, asthma, and reflux disease had improved or completely resolved in 80% to 100% of these patients after an average of a year. Arthritis, back and joint pain, and depression also had improved, although not as dramatically.

Choosing weight loss surgery

An estimated 5% of the adult U.S. population is severely obese, with a BMI over 40. Far more than that are obese or severely overweight and suffer risk factors associated with excess body weight. Many could benefit from bariatric surgery.

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Yet despite the growing number of people turning to weight loss surgery, only a very small percentage of dangerously overweight Americans opt for the operations-fewer than 1%, according to recent surveys.

That shouldn't be surprising. The decision to tie off or entirely remove a large part of your stomach and upper intestines isn't an easy one. After the operation, patients must take specially formulated vitamin and mineral supplements for the rest of their life to prevent malnutrition. Gastric bypass surgery also may cause a condition called "dumping," when food, especially sugary food, passes too quickly through the system. It causes symptoms like nausea, bloating, abdominal pain, weakness, sweating, and diarrhea. After the surgery patients must also be careful to eat very small portions and chew carefully.

And there's always the risk of complications. A 2005 study found that the rate of hospitalizations for obese patients almost tripled in the year following gastric bypass surgery.

The benefits of weight loss surgery

Despite these risks, experts say, evidence suggests the procedures are becoming safer and more effective. "While the number of bariatric surgery procedures has increased almost tenfold [from 1998 to 2003], the length of stay and complications have declined and inpatient mortality remained stable," write Bruce M. Wolfe, MD, and John M. Morton, MD, MPH, in a recent editorial in the Journal of the American Medical Association. Mortality stands at between 0.1% and 0.2%, a remarkably low figure for any complicated surgical procedure, says Livingston.

For Garrick Pedersen, the risks were well worth taking, even after his first attempt went dangerously wrong. "Frankly, I feel great. I have more energy. My hips and knees don't hurt like they did. The diabetes is gone," he says. "I'm able to walk and even work out at the gym much longer than before."

If he eats too much, or too quickly, Pedersen can feel pretty uncomfortable for a while. But, he says, after years of going on and off diets and exercise plans, losing weight and gaining it back again, that's a small price to pay to be able to look in the mirror and like what he sees.

WebMD Feature Reviewed by Jonathan L Gelfand, MD on /2, 07

Sources

SOURCES: Santry et al, Journal of the American Medical Association, October 19, 2005: pp 1909-1917. Wolfe and Morton, Journal of the American Medical Association, Oct 19, 2005: p 1960. Peluso et al, Nutrition Clinical Practice, Feb 2007. Zigmond et al, JAMA, Oct 19, 2005. Edward Livingston, MD, Southwestern Medical School, Dallas, Texas. National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK): "Gastrointestinal Surgery for Severe Obesity."

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