Weighing the Risks
More than ever, obese patients are turning to gastric bypass surgery. The results can be striking, but it's not a slam-dunk
This summer, Sherrianne Swartz plans to do something that most people take for granted: ride a roller coaster with her teenage son. It's not fear that has kept Swartz, 36, on the ground for the better part of a decade--but fat. At over 400 pounds, she has been too big to fit into the seat. Until now, that is. Barely 16 months after gastric bypass surgery, which reduced her stomach to the size of a hard-boiled egg, Swartz has shed 185 pounds. And the other wild ride that she began at age 10 with her first diet is finally coming to an end. "I tried every diet and every diet pill there was," says Swartz, a customer service representative for an insurance firm who lives in Independence, Ky. "I'd go up and down and lose it and gain it; nothing was successful."
Swartz's story, which also included bouts with type 2 diabetes, high blood pressure, sleep apnea, and other potentially fatal complications from obesity, is becoming all too commonplace. It's no wonder. About two thirds of the American population is overweight, and roughly 30 percent of them are officially obese--defined as having a body mass index, or BMI, of 30 or more (5 foot 6; 186 pounds, for example). Some 9 million adults, in fact, carry an extra 100 pounds or more and are considered morbidly obese (a BMI of at least 40), the prime candidates for bariatric surgery.
In addition to medical problems, quality of life for many severely obese patients is virtually nonexistent. "I love to garden, but I had to stop," says Rhonda Waller, a Cincinnati office manager who has weighed as much as 300 pounds and recently had a knee replacement brought on by her extreme weight. "I can't get down on my knees, because I'll never get back up," says Waller, who is scheduled for gastric bypass surgery this month. Then there are the logistical issues--not being able to squeeze into a restaurant booth or buckle a seat belt--the chronic exhaustion, and the humiliation and public scorn.
Despite triumphant tales on reality shows of weight loss without drugs or surgery, most seriously overweight people stand a better chance of appearing on American Idol than they do of logging a triple-digit weight loss and keeping it off. "Diet, exercise, and behavior modification alone with people who are 100 pounds or more overweight has been a uniform failure," says Neil Hutcher, president of the American Society for Bariatric Surgery.
Last resort. With few options, doctors and patients are increasingly turning to gastric bypass surgery as a lifesaver and often as a last resort. In 1995, just 20,000 weight-loss operations were performed in the United States. Last year, there were 170,000, according to the ASBS. The most common procedure is the Roux-en-Y, which involves drastically shrinking the size of the stomach and rerouting the small intestine to reduce calorie absorption. The surgery has been thrust into the spotlight by celebrity patients, such as the Today show's Al Roker, Idol's Randy Jackson, and singer Carnie Wilson. The ability to perform the operation laparoscopically has also upped its popularity. With Medicare now expanding its coverage of the procedure, not to mention full-throttle marketing of the surgery, the number of bypass recipients is certain to grow.
The results can be impressive: Patients typically lose 100 pounds or more the first year when their appetites are almost nonexistent, for reasons doctors can't quite explain. Hypertension and troubles related to joints improve dramatically, and 85 percent of people who have diabetes before surgery see blood sugar levels return to normal. The transformation can't be overstated. "Before the surgery, I couldn't take 10 steps without having to rest," says Swartz. "I couldn't clean the house, bring in the groceries, or do much of anything but sit on the couch. That's all over now."
But the surgery is risky and can be deadly, facts that can get lost in the din of doctors and hospitals pitching the operations like the latest fad diet. Short-term death rates range between 1 and 2 percent. In the past three years, patient deaths have prompted several hospitals to suspend or revamp their weight-loss surgery programs, and some insurers have stopped paying for the operation. Iowa Methodist Medical Center in Des Moines, for instance, halted bariatric surgery in late 2004 after seven patient deaths. The program was reinstated in January with tougher standards for surgeons, who must perform at least 100 weight-loss operations to qualify, and stricter guidelines for patients, who must be both morbidly obese and suffering from a serious obesity-related illness.
Concerns among the medical profession about the risks and rapid growth of the surgery are increasing. "These mom and pop shops are opening up, performing risky procedures, and leaving patients with a lot of complications," says Craig Albanese, head of pediatric surgery at Lucile Packard Children's Hospital at Stanford University. In the first federal study of its kind, the National Institute of Diabetes and Digestive and Kidney Diseases recently began a four-year study of the operation at six medical centers. "Hospitals developed programs for bariatric surgery before there had been explicit review of what makes it safe, what are the criteria for surgeons to do it safely, and who are the right patients for the procedure," says Paula Griswold, executive director of the Massachusetts Coalition for the Prevention of Medical Errors. "There's more recognition now of what needs to be done, but even more is still needed."
Patients often suffer post-surgical complications, some of them life threatening. The most common ones include bleeding, blood clots, bowel obstructions, hernias, and severe infections. Studies have shown that 10 to 20 percent of patients need additional surgery for such complications. Sandy Pierce, who went from 302 pounds to 126 pounds after gastric bypass surgery in 2001, knows that all too well. She has had eight surgeries in five years to deal with bowel obstructions and hernias. Last year, after her weight dropped to 104 pounds, Pierce had her bypass surgery reversed, but her stomach wouldn't function properly. She also has endured numerous problems stemming from vitamin deficiencies. "The first two years were great, but then the problems began, and they never stopped," says Pierce, 42, who is no longer able to work and depends on a feeding tube. Although Pierce, who had an "open" gastric bypass rather than the less invasive and less risky laparoscopic procedure, is an extreme example, she is not an isolated case. "There are bad outcomes," says Trace Curry, a bariatric surgeon and director of the Deaconess Hospital Surgical Weight Loss Center in Cincinnati. "But for every bad gastric bypass story, there are 1,000 good ones."
Even success takes a lot of work. Patients can eat only small amounts of food at a time, and they must maintain a lifelong regimen of vitamins and proper nutrition to stay healthy. Nearly 30 percent of patients develop nutritional deficiencies that lead to conditions like anemia and bone loss.
Even those who eat right may be winning only half the battle. "There are tons of reasons that people eat, and nutrition is low on the list," says Mitchell Roslin, chief of the obesity surgical program at Lenox Hill Hospital in New York. Take Rhonda Redman, a Los Angeles boutique owner who had gastric bypass surgery in 2004. Redman, 49, almost delayed her operation, which is preceded by fasting, after having such a bad day the day before that only a cheeseburger could take away the pain. "It's been harder to deal with some emotional issues since the surgery, because I can't turn to food," says Redman, who has lost more than 100 pounds.
With that in mind, prospective patients are required to undergo counseling so they don't return to their same habits. This is especially true for teenagers, whose ranks among bypass patients are growing. At Lucile Packard, where there is a three-month waiting list to enter the clinic, teens who are candidates for bariatric surgery (a BMI of at least 40 and one severe obesity-related illness) must participate in a six-month program that includes behavior modification, physical therapy, and psychiatric evaluation before they ever meet a surgeon. "We're militant about changing kids' behavior and lifestyle before I get near them," says Albanese.
But patients may find that old eating habits do return. While large portions are not an option, steady grazing or high-calorie foods can put the pounds back on quickly. As patients are reminded: "An M&M a minute adds up." In fact, the average patient, a 5-foot-4 woman at 275 pounds, weighs about 190 pounds three years after the operation. Lighter but still obese. "The surgery is just a tool," says Curry. "It's not a magic cure."
Get in line. You'd never know that from listening to the sales pitches. With an obesity epidemic and doctors eager to cash in on a procedure that can cost upwards of $30,000, bypasses are being marketed like new cars. Small hospitals and independent weight-loss centers are moving aggressively into gastric bypass. Earlier this year, one New York surgeon promised a free operation to the first 10 qualified candidates to show up at the Times Square Brewery on New Year's Day. By 5 a.m., dozens of obese people lined the sidewalk. Dominick Artuso, a bariatric surgeon at the Community Hospital at Dobbs Ferry in Westchester County, N.Y., said he did it to help people whose insurance wouldn't cover the surgery. The publicity, however, was "not a bad thing," says Artuso. "My administrators were smiling from ear to ear."
Weight-loss operations are challenging even for the most-skilled surgeons, since patients are often high-risk cases because of diabetes or heart or lung problems. To master a gastric bypass, a surgeon needs to perform it at least 100 times, according to the ASBS, whose own ranks of active doctors have grown from 367 in 2000 to more than 1,600 this year. Yet virtually any surgeon can hang out a shingle. As a result, ASBS plans to identify "centers of excellence,''facilities that track patient outcomes for a minimum of five years, require that doctors perform at least 125 procedures, offer ongoing physician education, and are fully equipped for life-threatening emergencies.
In the meantime, some obese patients are opting for a newer, safer route to thinness: gastric banding. The band works like a rubber band, tying off a small section of the stomach. It is inserted through small incisions in the abdomen, and there is no cutting, stapling, or intestinal rerouting, reducing the risk of complications. The band can be adjusted by a saline injection through a port in the abdomen under the skin and is removable. The band is not yet approved by the Food and Drug Administration for teenagers, but doctors believe that it may be the diet of the future. "Weight loss is much slower than with gastric bypass, but after five years the results are about the same," says Curry.
Ultimately, most doctors believe that curing obesity will be a combination of pills and devices like gastric bands. In the meantime, bypass and banding may be the only solutions for a population that desperately needs to tighten its belt.
This story appears in the March 27, 2006 print edition of U.S. News & World Report.