Doctors Debate Safety of Obesity Surgeries

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Doctors Debate Safety of Obesity Surgeries

By MARILYNN MARCHIONE

The Associated Press

Sunday, January 1, 2006; 9:07 PM

-- 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 long-term effects.

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 abdomen.

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 stomach.

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 ann Mallory, executive director of the bariatric

society.

" To me it is a very straightforward decision, " said Dr.

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. 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 system.

" 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

laparoscopic band. "

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. 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. "

___

On the Net:

Surgery explainer: http://win.niddk.nih.gov/publications/gastric.htm

American Society for Bariatric Surgery: http://www.asbs.org

American Obesity Association: http://www.obesity.org

The Obesity Society: http://www.naaso.org

Body Mass Index calculator:

http://www.cdc.gov/nccdphp/dnpa/bmi/calc-bmi.htm.English