Oct. 17, 2005 - Gastric bypass surgery greatly improves a person's quality of life, but it isn't a bed of roses, new studies show.
A spate of new studies gives a clearer picture of the risks and benefits of weight loss surgery. The studies also raise the question of what increasing numbers of patients mean for American society.
Three of the studies and two editorials on the issue appear in the Oct. 19 issue of The Journal of the American Medical Association (JAMA). The publication is timed for release during this week's annual meeting of the North American Association for the Study of Obesity (NAASO) in Vancouver, Canada.
Editorialist Bruce M. Wolfe, MD, professor of surgery at Oregon Health & Science University in Portland, says that despite a lot of media discussion, facts on weight loss surgery have been hard to come by.
"Being severely overweight is life threatening and associated with many related diseases," Wolfe tells WebMD. "Major weight loss is beneficial to these patients. That isn't very controversial. The primary issue is this: Can weight loss achieved by surgery be done safely, or are the risks and complications of the surgery such that this intervention should not be applied?"
Life Quality After Weight Loss Surgery
Psychologist Ronette Kolotkin, PhD, wondered whether people who undergo weight loss surgery actually benefit. She led a team that looked at three matched groups of obese people: 223 gastric bypass surgery patients, 110 people denied weight loss surgery by their insurance providers, and a comparison group of 189 people who did not seek obesity surgery.
Two years after surgery, patients averaged a 34% drop in body weight, Kolotkin reported at the NAASO meeting. Those denied surgery managed to lose 6.2% of their body weight, and those who did not seek surgery got 0.6% heavier.
All of the study subjects filled out quality-of-life questionnaires at the beginning and end of the study. Nearly all the surgery patients -- 98% of them -- reported meaningful increases in their quality of life. This was true for only 46% of those denied surgery and for only 30% of the comparison group.
"After gastric bypass surgery, people describe dramatic, life-altering changes. They feel like they have gotten their lives back," Kolotkin tells WebMD. "They feel vastly more able to have good quality of life and are not so focused on health and weight. They have more energy. They feel better day to day. They feel more productive at work, more sexy, more like going out and being with people and being physically active."
The difference may have been even greater than the study measured. Kolotkin says surgery patients told her that before surgery, they hadn't fully realized the impact their obesity had on their lives.
"People -- the obese themselves as well as others -- are not aware of how much quality of life is impacted by obesity," Kolotkin says. "They are often surprised when they fill out these questionnaires and realize they are suffering many ways in terms of their weight."
Early Death After Weight Loss Surgery
It bears repeating: Obesity is a very serious health problem. And gastric bypass surgery is a very serious surgery.
Death is one possible outcome. Which patients run the highest risk of this worst of all possible adverse events? Clues come from the JAMA paper by David R. Flum, MD, MPH, of the University of Washington in Seattle, and colleagues.
Flum's team looked at the 16,155 Medicare patients who underwent weight loss surgery from 1997 to 2002. Medicare won't pay for this procedure unless a person is ruled to be fully disabled by obesity. That means these patients have a higher burden of disease than the average obese person, notes editorialist Wolfe.
Even so, the numbers are sobering:
- Overall, 2% of patients died within 30 days of weight loss surgery. Within 90 days, 2.8% died. Within a year, 4.6% died.
- Men were much more likely to die than women: 3.7% vs. 1.5% within 30 days of weight loss surgery; 4.8% vs. 2.1% within 90 days; and 7.5% vs. 3.7% within 1 year.
- Patients aged 75 and older were five times more likely to die within 90 days than those aged 65-74.
- Surgeons with less experience and fewer weight loss surgeries under their belt were 1.6 times more likely to have a patient die within 90 days.
"The Flum paper identifies populations with a higher mortality risk if they undergo weight loss surgery," Wolfe says. "These risks are advanced age, male gender, and lower volume of [weight loss] surgery done by the surgeon and the medical center in question."
What about patients who aren't Medicare beneficiaries? David S. Zingmond, MD, PhD, and colleagues at the UCLA Center for Surgical Outcomes and Quality looked at California patients. Overall, less than 1% of patients died within one year of surgery.
Complications After Weight Loss Surgery
Death isn't the only bad thing that can happen after gastric bypass surgery. There can also be surgical complications. How often do these occur? Zingmond's team looked at this.
They looked at records on the more than 60,000 California patients from 1995 to 2004 who underwent what is now the most common weight loss surgery: the Roux-en-Y gastric bypass.
The first thing Zingmond and colleagues found was that many more people are having the surgery than ever before. Of the 60,000 patients who underwent the operation in the 10-year study period, 11,659 had the operation in 2004 alone.
The second thing they found was that the operation often has complications. Obese people have many health problems associated with being obese and end up in the hospital more often than normal-weight people. In the year before gastric bypass surgery, nearly 10% of patients had been admitted to the hospital.
"In the first year after surgery, about 20% get admitted -- about double the baseline rate," Zingmond tells WebMD. "It never gets back down to 10% in first three years after surgery. So we see an increase in rates of hospitalization."
Before surgery, most patients were hospitalized for obesity-related problems. After surgery, most patients were hospitalized for problems arising from the surgery itself in the first two years. "What it really comes down to is for potential patients -- at the time of surgery, not after -- to think about what they are willing to put up with after surgery," Zingmond says. "Other researchers have done the analyses and found that the benefits far outweigh the risks for appropriate patients. But people who are overweight will be more likely to be readmitted to hospital in the first three years after the procedure. They should be prepared for this."
Zingmond is quick to point out that laparoscopic weight loss surgery -- a new, minimally invasive technique -- results in far fewer complications. Wolfe agrees and estimates that two out of three weight loss surgeries today use the laparoscopic technique.
Yet nobody yet knows the long-term consequences of offering weight loss surgery to ever larger numbers of patients.
"We know the surgery results in weight loss, lower cholesterol, and resolution of diabetes," Zingmond says. "But we don't know about the changes to the gastrointestinal tract and whether, over a lifetime, this has some impact. We're still looking at what happens."
Surgery the Best Treatment for Morbid Obesity?
Despite the risk of death and other complications, weight loss surgery attracts increasing numbers of patients. The JAMA report by University of Chicago researcher Heena P. Santry, MD, and colleagues chronicles the trend.
From 1998 to 2002, Santry's team finds the estimated number of weight loss surgeries in the U.S. increased from 13,365 to 72,177. As the number of surgeries increased, the rate of complications went down.
Why the increase? Despite the huge number of diet books sold each year, relatively few morbidly obese people manage to lose -- and keep off -- significant amounts of weight.
Weight loss surgery, Santry and colleagues write, "remains the only durable option for weight loss in the morbidly obese." Yet in the U.S., less than 1% of such people undergo weight loss surgery in any given year.
"What is up with that?" Wolfe asks. "There is concern about risk and there are negative perceptions that arise from poor results of operations that have been tried and failed in the past. I believe that risk of complication is the single greatest explanation of why the number of patients is relatively small. As that improves, demand will accelerate quite substantially."
Yet Santry's data reveal a major disparity. Obesity is most common in people with low incomes. Yet weight loss surgery is most common among higher-income people.
"There is still the widespread perception that instead of a disease, obesity is just people's misbehavior and they are not deserving of treatment," Wolfe says. "An unresolved question is to what extent does cost justify withholding access to a treatment. If it is the best treatment for a medical condition, the cost is a problem -- but we cannot deny patients just because it is expensive to give them the proper treatment for their condition. How to sort that out in the long term is a question."
Zingmond says it's a question we'll have to answer in a hurry. He notes that in California alone, as many as a million people qualify for weight loss surgery.
"Multiply by 10 or 15 for the whole country," he says. "We need, as a society, to address this rationally. Can we send everyone who is overweight to surgery? That is the debate we are having now. Each state Medicare program is making these decisions. California does allow it -- and the wait list is long."