A Practical Guide to Bariatric (Obesity) Surgery
Maintaining Your Health
on Mackinac
By Yvan Silva, M.D.

In 2001, the Surgeon General’s report noted that illness associated with obesity had cost the United States $117 billion in the previous year. This figure was close to the average annual cost associated with smoking, $150 billion, according to the Surgeon General. As a “fast-food” nation, the daily intake of calories by Americans has jumped by more than 10 percent over the past two decades. This situation is not unique to the United States. It is worldwide and increasing rapidly in the developed, and some developing, nations.

Obesity has become commonplace all over the United States. Two in three adults are now classified as overweight or obese, compared with fewer than one in four during the early 1960s. Interestingly, the general public continues to view this as a cosmetic, rather than a health, problem, while 280,000 deaths per year are now attributable to obesity, which will soon overtake smoking as the primary preventable cause of death if present trends continue. Although obesity is associated with severe morbidities, health care professionals and public health policy makers have not given this epidemic the kind of attention received by tobacco use, alcoholism, hypertension, diabetes, and high cholesterol. As a result, obesity rates continue to climb, while significant reductions in these other risk factors are being achieved.

Mortality rates in people who are morbidly obese are 12 times higher in men aged 25 to 34 years and six times higher in men aged 35 to 44 years compared to men of healthy weight of the same age. It has been observed that even modest weight loss, 10 percent to 15 percent of initial weight, usually results in improvement of multiple health-related problems. The costs pertaining to management of obesity, on a national scale, are estimated at $51.6 billion; the annual expenditure on weight reduction is more than $30 billion.

It is important to review current definitions of the terms. The basis is the Body Mass Index (BMI). BMI is calculated based on an individual’s height and weight. The weight in kilograms (2.2 pounds per kilogram) is divided by the square of the height in meters (39.37 inches per meter) = BMI. While this clearly, to almost all of us, means getting out the calculator, it is certainly worth considering. A BMI of 25 or more is considered overweight, 30 or more is considered obese, and 40 or more is morbidly obese. One other practical way to calculate BMI is to take the weight in pounds, divide it by the height in inches, squared, and then multiply that by 703. The calculator may not be necessary. The formula for BMI is easily available online and from many sources in chart form.

Bariatrics is the field of medicine that specializes in treating obesity. Because obesity is so difficult to treat in the long term, several specialties in the medical sciences have begun to come together to help people with this chronic condition. Of these, bariatric surgery – surgery for obesity – is rapidly gaining in popularity. Indeed, bariatric surgery, in appropriately selected patients, appears to be cost-effective by eliminating the need for medications and returning patients to productivity in the workplace.

The past five years has seen a soaring demand for obesity surgery and doctors and hospitals are scrambling to satisfy the escalating demands for surgery that is designed to shrink the size of the stomach of severely obese individuals. Several celebrities and public figures have publicized their own successes with surgery. Currently, the number of operations has increased to about 120,000 annually, approaching $3 billion in costs at an average of $25,000 to $30,000 per patient.

The procedure has been approved for patients at the upper end of the BMI, defined as morbid obesity, as well as those with the presence of co-morbidities such as diabetes, hypertension, arthritis, and degenerative bone and joint abnormalities. More than 10 million Americans, or about 4.7 percent of the population, are said to be eligible for this type of surgery.

Several hospitals are adding special programs for surgical management of obesity and larger beds to support those who are now being called “patients of size,” who may weigh up to 1,000 pounds. Specially designed with built-in weight scales, they can cost up to $20,000 each. Operating suites are being equipped with larger operating tables and optimal instrumentation and “bariatric centers” consisting of specially trained surgeons, teams of nutritionists, psychologists, specially trained nurses, exercise programs, and other support services are being put in place.

Health care insurers will usually cover the costs only for patients who meet a list of pre-conditions. Some require proof that patients have spent at least six months in diet and exercise programs supervised by a physician. Many patients are paying costs directly in an effort to deal with these problems urgently.

Several years ago, the only surgical procedure used, an intestinal bypass operation, provided patients with early weight loss, but the overall results were poor and the procedure fell in disrepute.

Over the past decade, there have been marked improvements in the design of surgical procedures and with improvements in the team concept of patient management, bariatric surgery is now accepted as a strong and viable option for many patients with morbid obesity. Along with the expertise of specialists in internal medicine, gastroenterology, nutrition, and psychology, the pre- and post-surgical team approach, and continuing support group interaction, it is becoming increasingly popular with overweight Americans. It is further enhanced by the media attention to success stories.

Patient selection is important. Patients with severe untreated mental disorders such as depression and those with eating disorders are not good candidates for surgery. Patients have to be prepared to make drastic changes in their lifestyles. Counseling is an important part of the management plan. Surgical weight reduction is usually recommended to patients with a BMI of 40 or more, or 35 for those with medical complications.

Three types of operative procedures are currently being done. A relative newcomer in the field is called laparoscopic gastric banding. The abdomen is entered with a laparoscope and a restrictive band is applied to the upper stomach, limiting its capacity to one to two ounces. This minimally invasive procedure has the advantage of rapid recovery and easy reversibility. It is gaining rapidly in popularity, although long-term results are not yet available. A second procedure also greatly reduces the size of the stomach pouch without changes in the small intestine. Commonly referred to as a gastric bypass, it involves the application of staples across the upper stomach, limiting capacity. An outlet to the pouch is provided by joining a limb of small intestine to the pouch. These gastric pouches are fashioned to two ounces or less, allowing ingestion of very small amounts of solid food.

The third option, commonly called the Roux-en-Y (named after Cesar Roux, a long-ago Swiss surgeon) is also popular. It reduces the size of the stomach to a volume of about two tablespoons, narrows the passage between the stomach and the small intestine, and bypasses a long, measured section of the small intestine where the food is absorbed. The restructuring of the small intestine results in the form of a Y-shaped structure, one arm of which carries the digestive juices and the other carries food. The combination of restriction and malabsorption has proved more effective in producing long-term weight loss. Proper nutrition needs to be maintained because of the malabsorptive component and potential malnutrition. This procedure is usually preferred for patients with super-morbid obesity, with a BMI in excess of 40, 45, or more.

Success is measured as maintenance of weight loss of 50 percent or more of excess weight for up to 10 years. The Roux-en-Y operation has a long term success rate to 90 percent when combined with intensive counseling, support and nutritional education, and compliance.

There are problems emerging from this rapid expansion. The learning curve of the surgeon and the number of operations of this type performed do relate to the results. Some experts argue that a surgeon needs to do at least 100 cases before mastering the technique. While this seems overly stated, it is important to know that any surgeon can perform weight-loss surgery if the hospital will allow it, and although there are professional groups that recommend selection criteria, the guidelines are not binding. While the costs for the surgery can be $25,000 to $30,000, they can skyrocket if serious complications occur. Within 30 days of surgery, a common period to determine mortality rates, the death rate at one large university medical center was 1.9 percent. Statistics showed that patients were 4.7 times more likely to die during the surgeon’s first 19 procedures than after the surgeon has gained more experience.

Like any major surgery, there are risks. The most common complications include bleeding, blood clots, bowel obstruction, hernias, and infections from leaks into the abdomen from sites where the stomach pouch and intestine has been cut and joined or sealed surgically. According to the National Institutes of Health, 10 to 20 percent of patients require additional surgery for such complications and nearly 30 percent develop nutritional deficiencies that lead to chronic conditions like anemia and bone loss.

The benefits can be profound. In addition to long term weight control, surgery can result in excellent improvement and in some cases, reversal of Type 2 diabetes, improved blood lipid levels and heart function, correction of breathing problems like sleep apnea, reduction of high blood pressure, and musculo-skeletal ailments. Many patients are able to return to their jobs, exercise regularly, and live active social lives. Sexual interest often returns and there are the important emotional benefits, including improved self-image and self-esteem and correction of depression.

Today, bariatric surgery is definitely an option for certain individuals with morbid obesity. Improvements in the quality of life and lower health care costs, reversal of disabilities, and the risk of premature death are important considerations. Bariatric surgery is an important and thriving specialty in health care.

Dr. Silva is a professor of surgery at Wayne State University and a resident of Woodbluff on Mackinac Island.