As obesity surgery soars, patients weigh which method is best
By MARILYNN MARCHIONE, AP Medical Writer. Associated Press. New York:
Jan 1, 2006. pg. 1
As more people abandon New Year's resolutions to lose weight and turn
to obesity surgery, doctors are debating which type is safest and best.
And researchers are uncovering some surprising trends.
The most common method in the United States - gastric bypass, or
stomach-stapling surgery - may be riskier than once thought. Yet
surgeons still favor it for people who need to lose weight fast because
of heart damage or other serious problems.
A gentler approach favored in Europe and Australia - an adjustable
stomach band - can give long-term results that are almost as good and
with far fewer risks. It may be the best option for children or women
contemplating pregnancy, and is reversible if problems develop.
A radical operation - cutting away part of the stomach and rerouting
the intestines - is increasingly being recommended for severely obese
people. It gives maximum weight loss but also is the riskiest solution.
A large U.S. government study just got under way to compare all three options.
But regardless of which method is used, studies show an inescapable
reality: No surgery gives lasting results unless people also change
eating and exercising habits.
"The body just has many ways of compensating, even after something as
drastic as surgery," said Dr. Louis Aronne, director of the weight loss
program at Weill-Cornell Medical College.
He is president of the Obesity Society, the largest group of
specialists in bariatrics, as this field is known. The group's recent
annual conference in Vancouver featured many studies on surgery's
Obesity is a problem worldwide. About 31 percent of American adults -
61 million people - are considered obese, with a body-mass index of 30
or more. That's based on height and weight. Someone 5- foot-4 is obese
at 175 pounds; 222 does it for a 6-footer.
Federal guidelines say surgery shouldn't be considered unless someone
has tried conventional ways to shed pounds and is at least 100 pounds
over ideal weight, or has a BMI over 40, or a BMI over 35 plus a
weight-related medical problem like diabetes or high blood pressure.
More people are meeting those conditions. A decade ago, less than
10,000 such surgeries were done in the United States. That ballooned to
70,000 in 2002 and more than 170,000 in 2005, says the American Society
for Bariatric Surgery.
Doctors disagree over which is better: the most popular method,
Roux-en-Y gastric bypass, or the adjustable band, which is rapidly
gaining fans. Either can be done through a big incision, or
laparoscopically with tiny instruments passed through small cuts in the
In gastric bypass, a small pouch is stapled off from the rest of the
stomach and connected to the small intestine. People eat less because
the pouch holds little food, and they absorb fewer calories because
much of the intestine is bypassed. They must take protein and vitamin
supplements to prevent deficiencies.
The adjustable band has been available in the U.S. only since 2001 but
far longer in Europe and Australia where it is dominant. It accounted
for 17 percent of U.S. obesity procedures in 2005.
A ring is placed over the top of the stomach and inflated with saline
to tighten it and restrict how much food can enter and pass through the
Deaths from the procedure are only 0.1 percent compared to about 2
percent for gastric bypass. One recent study of Medicare patients found
deaths a year after gastric bypass as high as 3 to 5 percent.
The band's reversibility makes it a better choice for children, some doctors say.
"It's becoming more well-known and more accepted. Patients like it
because it's less invasive. It's an easier surgical procedure. It's
safer," said Georgeann Mallory, executive director of the bariatric
"To me it is a very straightforward decision," said Dr. Paul O'Brien,
director of the Centre for Obesity Research and Education at Monash
University in Melbourne, Australia. "I would strongly recommend that
the consumer consider the safest effective procedure first," which is
the band, he said.
American doctors have preferred bypass operations because they produce
faster, greater weight loss. But new research by O'Brien and others
calls that into question.
Combining results on 23,638 patients in 43 published studies, they
found that bypasses beat bands for the first three years but were
comparable after seven years, with excess weight loss of 55 percent for
bypass and 51 percent for bands.
That impressed Dr. Edward Livingston, chief of gastrointestinal surgery
at the University of Texas Southwestern Medical Center and chief of
bariatric surgery for the Department of Veteran's Affairs national
"I really was not enthusiastic about bands until I came to Dallas from
Los Angeles and saw the results from the group that I joined, which
where quite good," he confessed. "What you can accomplish in a year
with a gastric bypass you can accomplish in five years with a
Results would improve if Americans copied the Australians and included
in the price of the band any future adjustments, Livingston said.
"A key to the success of banding procedures is the followup and working
with a patient on their compliance," he said. "When they come in and
they've sort of fallen off the wagon, you adjust the band. It really
has an amazing effect."
Bands also appear safer for women attempting pregnancy. Several years
ago in Massachusetts, a woman and her 8-month-old fetus died of
complications 18 months after gastric bypass surgery. Other
pregnancy-related deaths have been reported.
In contrast, another study O'Brien and colleagues presented at the
obesity meeting found that pregnancy outcomes for women with stomach
bands were comparable to normal-weight women, and better than for obese
women without bands.
Dr. Mitchell Roslin, chief of obesity surgery at Lenox Hill Hospital in
New York City, did a band operation in October for Long Islander Donna
Dotzler, who weighed 279 pounds, but wants to do a more drastic surgery
for her husband.
"I gave up on New Year's resolutions maybe five years ago," said Jim
Dotzler, who weighs 479 pounds. "I'm a smart guy. If this were a matter
of willpower, I'd have taken care of this a long time ago."
The operation Roslin has advised for him is BPD, which stands for
biliopancreatic diversion, with or without a second procedure called a
duodenal switch. Studies show it can cause loss of up to 80 percent of
excess body weight for at least as long as 10 years afterward.
Surgeons remove three-fourths of the stomach to leave a sleeve- or
banana-shaped organ that is connected to the small intestine, bypassing
more of it than a standard gastric bypass does. It can be done in two
operations a year apart to reduce its severity and the chances of
death, which can be as high as 5 percent.
The "switch" preserves a valve that controls release of food into the
intestines from the stomach. These operations account for nearly 5
percent of U.S. obesity surgeries and are growing.
On the horizon are other approaches, like vagus nerve stimulation, to
control impulses to eat, and new drugs like rimonabant, which blocks a
pleasure center in the brain that makes people want to munch.
"I see the future as combined therapy," with surgery, medication and
other approaches used simultaneously, said Aronne, the obesity society
president. "Time will tell what works out best."
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