Weight-Loss Surgery Cuts Pounds but Creates Risks by Carolyn Cosmos Curious about surgery for losing weight? If you turn to the Internet for information about ìstomach stapling,î you might come across an eye-arresting Web site spattered with stars and stripes. A red ìcrawlî streams across your screen: ìQuick scheduling of consults and gastric bypass surgery is now available,î it says. You scroll down to a picture of a bridal couple where the woman is slim and her testimonial tells a happy tale: ìI never believed that I would get married. Two years after surgery I am now married and have even modeled for magazines.î Accurate medical information is available at the siteóclick to find it. To qualify for weight-loss surgery, you must be severely overweight by at least a hundred pounds or have a body mass index of 40 or more, it says. The medical name for this condition is clinically severe or morbid obesity, and it can seriously threaten your health, contributing to the development of diabetes, high blood pressure and heart disease. If you are morbidly obese and other treatments havenít worked, surgery could very well be an option. In fact, it could save your life. ìEven so,î you may ask, ìwhat about the surgical risks? Whatís involved?î Bariatric surgeryóìbariatricî means weight lossóalways entails cutting off or closing off part of your stomach to reduce stomach size. This restriction promotes a feeling of fullness with less food. The operation, depending on the procedure you choose, can also feature cutting your small intestine in two. Your surgeon attaches the ends to new intestinal spots. Food traveling through your body now bypasses part of the stomach or part of the intestineóor both. Because the food you eat is skipping some of its typical routes and moving through your body at a faster pace, fewer calories get through to load you up with fat. This is called ìmalabsorption.î The result is that you lose weight rapidly and for a period of 18 to 24 months after the procedure. Bariatric surgery is performed as both traditional ìopenî surgery and, more recently, as a laparoscopic procedure. In laparoscopic techniques, a doctor operates through a small incision helped along by a fiber-optic tube. The tube allows a video camera to project pictures of internal organs onto a television screen. Laparoscopy features less pain and a briefer hospital stay. Risks of Bariatric Surgery Nevertheless, if all this sounds like a drastic way to diet, youíre quite right: Responsible bariatric surgeons describe this group of procedures as ìrisky.î Theyíll tell you itís majoróand certainly not cosmeticósurgery, and they should present you with a list of potentially serious complications. The red-white-and-blue Web site, however, plays them down. It tells you, ìThere is a minor chance of post-operative complications.î It shaves the surgeryís generally accepted death rate of five deaths per thousand surgery patients by understating it slightly. And it doesnít indicate that some types of bariatric surgery have higher death rates and more complications than others. This absence of adequate information is unfortunate because in some bariatric surgery situations, as in any serious surgery, things can go terribly wrong. They did for one Colorado patient, Dani Hart, who preferred not to use her real name. Hart nearly lost her life from complications following her weight-loss surgeryócomplications she said her bariatric surgeon largely ignored. Eighteen months later, plagued by chronic vomiting, malnutrition, psychological distress and newly appeared disease, she had the operation reversed at a Mayo Clinic in Scottsdale, Ariz. Her bariatric surgeon there, she said, ìgave me the best care.î In contrast, ìMy original doctor minimized the risks. I had 15 minutes with himî before the surgeryóa bypass called the Roux-en-Y procedure. ìNobody told me other options.î Hart eventually recovered but others have been less lucky. Thirteen patients have died in Fresno, Calif., hospitals since February 2000 as a result of bariatric surgery, according to a series of articles published in the Fresno Bee by Tracy Correa and Barbara Anderson in January of this year. Other causes of death, such as a heart attack, were typically listed on the Fresno death certificates, masking the apparent pattern. The mortality rate for weight-loss surgery in the United States is ìmuch higherî than the usually quoted five deaths per thousand patients, noted Herman Praszkier with the law firm of Anderson & Associates in St. Louis, Mo. He said causes for the poor statistics include inaccurate death certificates and poor physician reporting procedures. Praszkier said he has sued ìall but oneî of the half-dozen bariatric surgeons in the St. Louis area for medical malpractice or the wrongful death of patients. All the surgeries involved the Roux-en-Y gastric bypass, the most frequently performed bariatric procedure in the United States. His cases also all involve what Praszkier described as inadequate follow-up care. The scope and seriousness of the bariatric surgery problem, if there is a problem, is not yet clear, in part because many obese patients are so seriously ill. For example, Georgeann Mallory, executive director of the American Society for Bariatric Surgery (ASBS) in Gainesville, Fla., noted that the ìmortality rate of morbidly obese diabetic patients without surgery is four times that of morbidly obese patients after surgery.î And a study conducted by the American Cancer Society demonstrated that the risk of death from all causes increases substantially among overweight people. The study was published in the New England Journal of Medicine in 1999. Various other studies over the years have consistently confirmed that morbidly obese people die sooner and suffer more ailments than their lean counterparts. One difficulty in assessing the situation lies in the procedureís popularity: ìThis surgery is growing in the United States and is spreading worldwide,î Praszkier said. For example, the International Federation for the Surgery of Obesity (IFSO), with headquarters in Toronto, has affiliates in Italy, Mexico, Japan, the Czech Republic, Germany, Brazil, Austria, the United Kingdom, Spain, Poland, Australia, New Zealand and various other locations. The major bariatric surgery procedures have also been developed around the globe, including procedures that originated in Sweden, Italy and the United States. In 1997, there were approximately 23,100 weight-loss surgeries performed in the United States, Mallory added. The current ASBS estimate is 63,100 a year, she said, and the numbers are going up. The bariatric Web site with the red crawl illustrates this trend: It says it has six clinical locations in several states where surgery can be performed, with four brand new locations opening soon. The growth of all types of weight-loss surgery makes it hard to track what is happening in the field. The standard bariatric mortality statistics ìmay not be accurate due to the recent explosion of interest in bariatric surgery and the dramatic increase in the number of surgeons performing it, especially those using the laparoscopic technique,î said bariatric surgeon Dr. Joseph Kamelgard, assistant professor of surgery at the University of Medicine and Dentistry of New Jersey in Newark and chair of the ASBS Public Education Committee. ìSince the laparoscopic technique is so much more difficult during a surgeonís early experience, the complication rate would be expected to be higher,î he pointed out. Procedures Available There are two main categories of bariatric procedures, Kamelgard said. The first group is called ìrestrictive.î A restrictive procedure simply limits the amount of food a person takes in. ìIt can be done by actually stapling the stomach, or it can be done by putting a band around it. The restrictions donít alter the rest of the system, but the weight loss is typically not as good, in part because patients learn to beat the operation and they donít lose weight. Theyíll drink milkshakes or eat ice cream,î he said. Two main types of restrictive proceduresógastric banding (which involves a band) and vertical banded gastroplasty (which involves a band and staples)ócreate a constricting ring at the top-end of the stomach. According to Dr. Mervyn Deitel, executive director of the IFSO, 70 percent of all bariatric surgeries in Europe and Australia have involved restrictive banding. ìItís a simple method that is getting good results,î Deitel said, adding that ì80,000 bands have been implanted around the world over 12 years.î Itís typically done laparoscopically and, Praszkier noted, is considered safer and les s likely to cause complications than procedures that are more surgically complex. One of the newest restrictive techniques is ìadjustable bandingî or use of the ìLap-Band,î a medical device approved in June 2001 by the Food and Drug Administration for procedures performed in the United States. It had been deployed at earlier dates in Europe. In this approach, a band is implanted laparoscopically. Inflated with a saline solution, it can be adjusted after surgery in a doctorís office through a portal under the skin, allowing for subsequent adjustments over time. A second major bariatric technique, Kamelgard added, is termed ìmalabsorptive,î which involves changing the intestinal pathway for digested food. Here, most of the stomach, the duodenum and other segments of the small intestine are bypassed. The Roux-en-Y gastric bypass (RGB) is a common type of gastric bypass procedure in which the stomach is completely stapled shut, and a Y-shaped section of the small intestine is attached to the small stapled stomach pouch to allow food to bypass the duodenum and the first portion of the jejunum directly into an altered intestinal segment. ìBiliopancreatic diversionî (BPD), or extensive gastric bypass, and the ìduodenal switchî (DS) are more complicated versions of malabsorptive techniques and can be done traditionally or through the use of a laparoscope. Both involve permanently removing major portions of the stomach. In the BPD, three-quarters of the stomach is cut away. The remaining stomach pouch is then diverted to the final segment of the small intestine, bypassing the duodenum and the jejunum. ìThey are very effective in weight loss but have a number of side effects,î Kamelgard noted. With malabsorptive procedures, patients may not get enough iron, calcium or vitamins, and, in some cases, they may risk insufficient protein and fat intake. The more extensive the bypass operation, the greater the chance for risks. In addition to nutritional deficiencies, risks include pouch stretching, band erosion, breakdown of staple lines, leakage of stomach contents, nausea and diarrhea. According to the National Institutes of Health, 10 to 20 percent of patients who have weight-loss operations require follow-up operations to correct complications, and nearly 30 percent of patients develop nutritional deficiencies such as anemia, osteoporosis and metabolic bone disease, though these can be avoided if vitamin and mineral intakes are maintained. Preferred procedures vary from country to country, Deitel said. ìIn Canada, not much bariatric surgery is being done. In Latin America, theyíre probably doing equally the band procedures and the gastric bypass or the duodenal switch. In Australia, itís more likely to be gastric banding, with a small group doing vertical gastroplasty.î Addressing laparoscopic trends, Deitel said that although 70 percent of surgeries are being done laparoscopically in Europe and Australia, the current figure is 50 percent for the United Statesóalthough the U.S. percentage stood at 4 percent only five years ago. ìYounger, newer surgeons are tending to do it,î he pointed out. The newest and still experimental approach to bariatric surgery, still in clinical trials, Kamelgard said, involves electrical stimulation devices. In this procedure, a surgeon inserts an electrode in or near the stomach. ìItís a device like a pacemaker. The stimulation gives the patient a sense of satietyî or fullness and satisfaction, Kamelgard said. For more information, you may visit the IFSOís international Web site at www.obesity-online.com/ifso or the Web site of the American Society for Bariatric Surgery at www.asbs.org. For additional medical illustrations on gastric bypass procedures, please visit www.laparoscopy.com/obesity/roux.html. Carolyn Cosmos is a freelance writer in Washington, D.C. How to Obtain Good Bariatric Care In addition to being well informed, there are a number of steps a potential patient can take to protect himself or herself while exploring bariatric options, experts say. The single most important step is checking a surgeonís training, experience and approach to follow-up care. A bariatric surgeon will be board-certified in general surgery, said bariatric surgeon Dr. Joseph Kamelgard. There is no board certification for this specialty. It doesnít exist. However, bariatric training and experience in surgery for weight loss are important because the surgery can be complex and difficult. With laparoscopic surgery, technical laparoscopic skill is important, but itís also important that the surgeon have a background in bariatrics. The American Society for Bariatric Surgery (ASBS) recommends that physicians using laparoscopic techniques in weight-loss surgery have experience in open bariatric surgery as well, Kamelgard noted. They also need knowledge of pre-care and post-operative care. The quality of post-operative care can be critical to surgery success and weight loss, as well as to heading off or managing side effects and complications. You should have access to experts in nutrition and mental health and to other needed providers, and the access should entail more than an occasional consultation over the phone. Taking responsibility for your own follow-up regimen is also part of the equation for bariatric success. ASBS emphasizes that ìobesity is a chronic disease [and] frequent and long-term contact with your surgeon and regular follow-up visits are very important for a good outcome.î óCarolyn Cosmos