Bariatric surgery is not a permanent fix to obesity, but there are newfound benefits
Weight-loss surgery can be life changing when diet and exercise fall short. The field of bariatric surgery has undergone its own transformation in recent years, with new techniques and discoveries that not only help people shed pounds, but control, and even reverse, certain diseases.
With two-thirds of the United States adult population overweight or obese, more and more are turning to bariatric surgery. In 1990, there were 16,000 bariatric procedures performed in the United States while today, there are closer to 200,000 annually, according to the American Society for Metabolic and Bariatric Surgery.
Obesity is a major problem in Chicago, with 64.2 percent of adults in the metropolitan area overweight or obese, higher than the national average, according to the Centers for Disease Control and Prevention.
The single greatest development in bariatric surgery over the past decade has been minimally invasive or laparoscopic techniques, says Dr. Robert F. Kushner, medical director of the Center for Lifestyle Medicine at Northwestern Memorial Hospital. “It changed the face of bariatric surgery by making it more acceptable to patients. They spend less time in the hospital, less time away from work and have fewer complications like infections and hernias.”
The types of procedures have evolved, too. While the most common procedures are gastric bypass, gastric banding and duodenal switch, one that’s increasingly popular is the gastric sleeve. In this procedure, surgeons remove 80 percent of the stomach laparoscopically and create a small, sleeve-shaped pouch to reduce the stomach’s capacity. In the process, surgeons are removing cells in the gastrointestinal tract that produce ghrelin, an appetite-producing hormone. When the level of ghrelin is reduced, patients feel full before they normally would.
A milestone revelation is how bariatric surgery affects people with diabetes. “We have a much deeper understanding of how certain procedures affect the gastrointestinal hormones that affect the release of insulin and how blood sugar is handled,” says Kushner. Some study results have been so compelling—a recent study showed that 80 percent of patients who underwent bariatric surgery had complete reversal of their Type 2 diabetes—that the medical community debates whether to recommend surgery for those with a body mass index (BMI) lower than 35, the standard threshold for performing surgery in people with diabetes.
Studies show that surgery has an effect on diabetic patients at least over the first year or two, according to Kushner. “We’re less sure about what happens to diabetes five to 10 years out. Are there complications that weren’t apparent over the first two years? The short-term answer is, yes. It does improve diabetes, but what is the likelihood it will reappear?”
Mark Lingner* had gastric bypass surgery in December 2003 and has successfully kept off 110 pounds. He was on insulin therapy for his diabetes before surgery and has been in remission ever since.
“I was a walking time bomb,” says Lingner, an innovation consultant living in Chicago, who is no longer considered diabetic. “I had diabetes, high blood pressure, nerve neuropathy.
“Now I play racquetball five times a week. I walk two to three miles a day and watch what I eat. I see my general practitioner every three months. I can shop in the regular men’s department, walk up stairs and race luxury sports cars.”
People often ask whether bariatric surgery is a permanent fix. Can you gain the weight back?
On average, most people regain about 15 percent to 20 percent of their maximum weight loss, says Kushner. “We don’t have a good understanding of who will maintain their weight loss and who will regain. Most studies show that as time goes on, average weight loss starts to diminish. There are some people who gain it all back. Many of them don’t come back for follow-up care.”
One thing’s certain. Keeping the weight off after surgery requires a healthy diet, physical activity, and psychological and behavioral support.
“We follow patients as long as they are able and willing to come in,” Kushner says. “Obesity is a chronic long-term condition that is never cured, only controlled.”
This long-term strategy is being put into place at Loyola University Health System. Dr. Bipand Chand came to Loyola from the Cleveland Clinic in April to launch its new comprehensive obesity program. The Loyola Center for Metabolic Surgery and Bariatric Care is focused on establishing long-term partnerships with patients to optimize their success.
Over the past decade, Loyola had a successful medical weight-loss program at Gottlieb Memorial Hospital, offering medical supervision, nutritional consultation, supervised exercise and behavior modification.
Chand has expanded this program by adding a surgical component. “We offer the full spectrum of obesity care,” he says. “Some individuals will be better suited to medical intervention while others will benefit from surgery.”
Loyola has assembled a team of experts that includes nutritionists, psychologists, exercise physiologists and bariatric surgeons. Because obesity is associated with other illnesses, there are experts in sleep apnea, cardiology, gastrointestinal issues and pulmonary medicine.
“We realize it’s not going to be a simple surgical solution,” says Chand. “These patients have suffered with this disease for many decades. It took a fairly long time to get to this point, and patients need some type of therapy after.”
Chand and his colleagues target medical conditions associated with obesity, such as diabetes, heart disease and liver disease, that can be improved with intervention. “If you can target those medical illnesses, patients will significantly lower their overall use of medications and their cancer risk and also improve their longevity.”
Bariatric surgery is not an option for everyone. “Close to 1,000 cases come through our door each year, but we only operate on 300 cases annually,” says Dr. Subhashini Ayloo, director of bariatric surgery at the University of Illinois Hospital and Health Sciences System. Only some patients are good surgical candidates while others may choose medically supervised weight loss.
“There must be a commitment from patient[s] that they are doing everything they need to do in terms of healthy food choices, decreasing portion size and dedicating themselves to activity and behavioral changes that would lead them to be more successful,” Ayloo says. “Diets don’t work. What needs to happen is lifestyle change.”
*Name has been changed at the request of the patient
Published in Chicago Health Summer/Fall 2012