Weight-Loss Surgery: It's Not for Everyone

Answers to Your Questions

Scroll below for Dr. Ed Livingston's answers to your questions about weight-loss surgery

Bariatric surgery, also known as gastric bypass, has increased ten-fold over the past decade, with more than 150,000 Americans getting the procedure every year. Most insurance companies, as well as Medicare, pay for it. Most patients have successful outcomes, but there are still significant risks, and the surgery is not for everyone.

Dr. Paul Shekelle directs the Evidence-based Practice Center at the Rand Corporation. He says there's no question gastric-bypass surgery "works." Patients lose on average about 100 pounds or more, in just one year. And, in so doing, they also lower their risk of obesity-related diseases, such as hypertension, diabetes and high cholesterol.

But Shekelle worries that the surgery may be too appealing to patients who don't need it. And to surgeons who aren't expert at it.

"Just in our own newspaper in the city, you can open it up and there's ads for bariatric surgery. So this is being marketed directly to the public. The ads generally ask, 'Are you overweight? Tried everything? Consider coming to our bariatric surgery center.'"

Not All Surgery Centers are Equal

But not all bariatric surgery centers are equal, says Shekelle. Some have better results than others. These outcomes are important because complications can be significant. Dr. Ed Livingston is chief of gastrointestinal surgery at the University of Texas Southwestern Medical School. He's performed gastric bypass for the past 13 years, with extremely positive results for most patients, he says. In fact, when he first started performing the surgery, he was surprised at what he calls the "stunning" results. Patients were extremely positive and even "euphoric" about the results, he says.

But you have to remember this is surgery, Livingston warns. And there can be problems. One major complication is leaking, he says.

"We put all these parts together, and if the intestinal contents leak into the abdominal cavity, people can get infected," Livingston says. "And they have a very very difficult time recovering from that. They can be bed bound for months."

One out of every 200 patients dies as a result of the surgery. Patients can get blood clots in their legs or lungs. They can get hernias at the site of incision, as well as "dumping" syndrome, where they get physically ill, nauseous and sweaty if they eat foods high in fat or sugar.

"Patients that get gastric bypass have to know they are getting a permanent change in the way their body is going to absorb food," Shekelle says. "This means they can become bloated and gaseous with certain foods. And, because food is not completely absorbed, patients may also become deficient in certain nutrients and vitamins."

Not a Diet Substitute

While bypass surgery might be the right answer for certain severely obese individuals, it's clearly not for everyone. The surgery is more risky for those who are over 55 and suffer problems, such as hypertension and diabetes.

Shekelle also worries that people with a lower body mass index, a calculation of body fat based on height and weight, may want to get the surgery.

"Initially, it's people with a BMI of 40 or over," Shekelle says. "Then it's people with a BMI of 35 and over." Soon, it's people who aren't that overweight, but want the surgery instead of dieting, he says.

Unfortunately, Shekelle says, there may be a surgical center or doctor willing to help them do that. Bariatric specialists are now trying to figure out how to evaluate results from various surgical centers, hospitals and doctors in order to make that information public and help patients make decisions about where to get surgery, if it's decided they are good candidates for the procedure.

Q & A: Your Questions on Weight-Loss Surgery

What's the most effective type of weight-loss surgery? How do you know whether you're a good candidate? Could you end up regaining the weight? Dr. Ed Livingston, a professor of surgery at the University of Texas Southwestern Medical Center, answers these and other queries from the NPR audience, submitted after our story on gastric bypass surgery.

What is the most successful type of gastric bypass surgery? I have been scheduled for the surgery on Oct. 12, 2006, and was presented with three alternatives: laparoscopic, laparoscopic hand assist and open surgery. [Editor's note: these are three approaches for getting exposure to the stomach for the reconstruction.] I have opted for the laparoscopic hand assist.

I am also concerned about the first three months after the surgery. What is the best resource on choosing and preparing foods? — Michele DiQuattro, Quakertown, Pa.

The effectiveness of the operation comes from the final reconstruction of the stomach and small intestine, not the approach to doing it. Roux-en-Y gastric bypass – named for the surgeon who devised the technique and the "y" shape of the small intestine's reconfiguration — is the safest, most effective operation. In terms of weight loss and control of medical complications from obesity, outcomes are the same from open surgery with a six-inch incision, and laparoscopic surgery. Even the surgical complications are not too different: Complications that are avoided by the laparoscopic operation are traded for others that are more common with laparoscopic gastric bypass.

For the second part of your question, I'd recommend finding a dietician — your surgeon should have a recommendation — and talking to other patients who have been through this surgery.

Is laparoscopic adjustable gastric banding ("lap-band") as good as gastric bypass? I'm told it is as effective and has a shorter recuperation than bypass surgery. — Michael Travis, Warren, Mich.

Recovery is easier after lap-band procedures — placing an inflatable band around the stomach that can be reduced in size to restrict eating. Lap bands, however, may not be as effective. Lap bands require a great deal of patient compliance with diet as well as with visits to the physician. With gastric bypass, most people lose weight no matter what they do, because the physiological response after the operation makes them physically ill if they eat fattening foods. With gastric banding, patients can still eat fattening foods, so it takes a lot of patient buy-in. Weight loss is very slow with the band; It may take 5 years to achieve the degree of weight loss with a band that one observes a year after a bypass.

Is the surgery reversible? — Laurel Paul, Auburn Calif.

Roux-en-Y gastric bypass operations should not be considered reversible. The parts of the stomach and small intestine can be put together again but their function will never be quite the same. Most likely, important nerves that regulate the stomach’s function are cut during these operations.

Lap bands are reversible by removing the band. There is little consequence.

My concern is if I decide to have the surgery, I might gain all the weight back. I read somewhere there could be a weight gain of 10 percent to 30 percent of the initial weight loss. Is it possible to gain 100 percent of it back? — Elaine Moheet, Shelton, Conn.

This can happen but not often. Following a gastric bypass, patients usually will reach their lowest weight one year following the operation. Between years 1 and 5 some weight is regained but the patient's weight tends to stabilize after 5 years. Long-term results for lap bands in U.S. patients are not known.

What are the long-term issues that occur when having a Roux-en-Y gastric bypass surgery? I've heard that absorption of nutrients decreases. — Barbara Kinback, Lake Jackson, Texas

Reduction in nutrient absorption following a Roux-en-Y gastric bypass is fairly minimal. The major problem comes from iron and vitamin B12. These are poorly absorbed and need to be supplemented. Calcium absorption is reduced and needs supplementation. A primary care physician should conduct annual checks of basic nutritional measures.

I was intrigued to hear ghrelin mentioned in the news story about bariatric surgery. I had read about this appetite-producing hormone years ago. Is there any research being done on weight control through ghrelin regulation? — Wendy Smith, Camp Hill, Pa.

Ghrelin is a hormone secreted by the stomach that induces appetite. Studies looking to see if ghrelin is affected by gastric bypass are very inconsistent. Based on currently available information, no one can conclude that ghrelin is involved in the gastric bypass effect on eating. The exact mechanisms by which gastric bypass work remain unknown.

There is research investigating ghrelin and many other substances as potential medical treatments for obesity. Unfortunately, none appear very promising at the current time.

Drug development for obesity treatment has proved frustrating. Eating is a basic, fundamental behavior absolutely required for survival. Consequently, animals have evolved multiple redundant mechanisms to ensure that they seek and consume food. When a drug blocks one pathway, there always seems to be another that crops up to drive eating behaviors. Of the approximately 200 drugs being developed for obesity treatment, all appear to have relatively modest, short-term weight-loss effects.

Does the stomach stretch again over time, or does it remain at a ½-ounce size? — Andrew Long, Columbia, Pa.

Over time, stretching of the stomach may occur. No one has clearly documented that this really happens. It is known that weight loss is not related to pouch size or the size of the connection between the stomach and small intestine. It has been clearly shown that subsequent operations to reduce the size of large pouches or make the connection smaller do not result in further weight loss.

One in 200 die? This sounds like a huge number for elective surgery. Is this a misprint? — Kyle Robbins, Rome, N.Y.

No — the mortality rate for bariatric operations ranges from 0.2 to 1.8 percent. This relates to the patient's risk for complications. Surgery on obese individuals is inherently high-risk. Many of the complications that cause postoperative death are not related specifically to bariatric surgery; rather, they are a function of obesity. For example, one of the most common causes of postoperative death is pulmonary embolus — blood clot in the lung. These can occur in obese patients from any type of surgery they have.

The risks vary with the patient. Very large older men have a much higher risk of complications than relatively healthy, smaller women.

Although 1 in 200 or 0.5 percent seems high, death rates of 5 percent following heart operations are not unusual.

Should gastric bypass be prescribed by a doctor who does not perform the surgery but will refer the patient to someone else? I worry that going first to the doctor who might perform such surgery would lead automatically to being eligible for the surgery even though such a case might not be the right candidate. — Darlene Whitten, Denton, Texas

There are no assurances regarding the bias of the physician you talk to. Some nonsurgeons are completely opposed to these procedures and are blinded to any potential benefits. On the other hand, there are nonsurgeons who refer patients for surgery and are not very aware of the risks for that particular patient.

Yes, some surgeons may aggressively recruit patients. Others, however, may be extremely conservative in terms of accepting patients based on prior bad experiences with bariatric surgery complications.

The best bet is to find a physician who has no financial stake in the procedure. That may prove difficult, but such surgeons can be found in large HMO’s or group practices, in academic medical centers, and at government hospitals such as the VA. Another approach is to get multiple opinions.

I was curious if there is some sort of evaluation procedure/ranking of certified bariatric surgeons. And how might one evaluate the results of a specific surgeon/clinic? Is the norm based on weight lost, number of infections, number of deaths or some other criteria? Has anyone actually assessed the quality of specialist surgeons and clinics in this field and, if so, is such information available to the public. — Brian Chabowski, East Lansing, Mich.

Quality is an elusive concept. It is difficult to know the quality of the program or its surgeons. One cannot assess quality or complication rates or deaths because high-quality programs may also be those that selectively take care of the highest-risk patients. There are some initiatives in place attempting to measure quality of care for bariatric surgery, but none are tested and, as of yet, none appear reliable. No one really knows how to assess quality of care for bariatric surgery.

High-quality surgeons are most likely those who have performed hundreds of gastric bypass operations. And they should be open and willing to discuss their outcomes, good and bad.

The people who know the best about the caliber of bariatric surgeons are the nurses who work in the operating room. You can also ask the physicians you trust. Talk to your internist. An internist might be able to say, "I've sent patients to a certain doctor and they've done well — or poorly." Surgeons who themselves do not perform the surgery may also know: It is likely they will have taken care of the complications of those bypass surgeons who may not be very adept at these procedures.

What is the position of the American College of Obstetrics and Gynecology (ACOG) and American Society for Bariatric Surgery regarding gastric bypass surgery and pregnancy? How much data has been collected on pregnancy complications and outcomes after gastric bypass and lap banding procedures? — Pamela Anderson, Lexington, Ky.

I cannot speak in reference to these organizations but women should not get pregnant in the first year following weight-loss surgery. After that, pregnancy is not a problem but requires close nutritional monitoring. There is some data regarding pregnancy but not extensive amounts. What exists suggests that it is safer to be pregnant following surgically induced weight loss than being pregnant while obese.

If bariatric surgery is only recommended for people with a body mass index [BMI] above 40, what is the recommended approach for people with BMI around 35 who have tried changing habits without much success? — Gabriel Waxemberg, Sylvania, Ohio

Current recommendations allow for bariatric surgery if there are significant obesity-related medical conditions for those with BMI ranging between 35 and 40. I have seen a number of patients in this weight category who underwent surgery develop substantial problems relating to excessive weight loss. More studies are needed before clear recommendations can be given regarding the safety/efficacy profile for patients with BMI less than 40.

Dr. Ed Livingston is a professor of surgery at the University of Texas Southwestern Medical Center.

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