When a severely obese person is told to lose weight, the prospect can be overwhelming. Changing diet alone results in slow weight loss. Exercise, which is more effective, is hard and painful. “More than anything, obese patients don’t feel good. Their joints hurt; they have sleep apnea, heartburn, and mobility limitations,” says Dr. Norbert Richardson, director of the bariatric surgery program at St. Alexis Hospital. St. Alexis does 600 bariatric surgeries a year, and Richardson reports that the benefits to patients are almost immediate.
“Younger (obese) women tend to get polycystic ovary syndrome, in which their fertility goes way down,” Richardson notes. “Weight loss surgery reverses it. Also, about 80 percent of my patients are type-2 diabetics. With gastric bypass in particular, half are off their medications before they go home, and within a month, most are completely off.” He’s referring to the three main types of bariatric procedures: gastric bypass, sleeve gastrectomy and banding.
Because of the extent of their obesity, 15 million Americans are candidates for bariatric surgery, Richardson reports. “There’s no question that long-term mortality is greatly reduced by having this surgery. Interestingly, the greatest reduction is not from its effect on chronic disease, but from fewer cancer cases, because excess weight depresses the immune system and significantly increases the risk of many cancers.” He says a bariatric practice is very rewarding because patients are so thankful to get their lives back.
Dr. Esteban Varela does minimally invasive bariatric surgery at Washington University. He prefers the sleeve gastrectomy, done through five or six tiny keyhole incisions in the abdomen. During the surgery, he creates a sleeve or a banana-shaped stomach, removing 80 percent of the organ but leaving all the connections into and out of the stomach undisturbed. Besides reducing its size and the amount of food that can be eaten at one time, the procedure eliminates most of the ghrelin, an appetite-stimulating hormone. “Several studies looking at five-year outcomes have been very favorable,” he says. “The weight loss is comparable to the gastric bypass and better than the band. There is lesser potential for nutrient malabsorption because we don’t change the connections.”
The Bariatric Surgery Center at Washington University also does gastric bypass and banding. Says Varela, “These patients have many chronic conditions and have tried everything else before they come to me. For morbidly obese patients (100 pounds or more overweight), weight loss surgery is safe and the only effective treatment. It’s also a jump-start on getting healthier. Diet and exercise initially are harder because of the impact on the joints and the lowered metabolism from yo-yo dieting. After the surgery, most people maintain and continue to lose. Of course, there are always exceptions. If you try hard enough, you can circumvent any procedure, but our patients get counseling in nutrition and exercise to encourage them to add to their successes.”
Darin Minkin, D.O., is the founder, director and bariatric surgeon at the Des Peres Hospital Bariatric Surgery Center. Surgeons there offer laparoscopic approaches for gastric bypass, sleeve gastrectomy and banding, doing about 350 procedures a year. “I do mostly the banding,” Minkin says. “It’s the safest and least invasive, and it’s reversible. There are no malabsorption issues. While patients lose more weight faster with gastric bypass, the Lap-Band is a good alternative for many. You can lose as much weight overall if you follow other program components.”
He says follow-up is crucial because periodic tightening of the band ensures success. Having the band in place restricts the amount that can be eaten at one time, but if it isn’t tight enough, the stomach empties too soon and the patient –becomes hungry again. By having the correct tightness, the band slows stomach emptying and leaves a longer feeling of fullness.
“I see patients every six to eight weeks the first year,” Minkin says. “We make sure they are feeling good, symptom-free, and following their diet and exercise program. If they are eating small amounts, losing weight and not struggling with hunger, the adjustment is fine. We do an average of four to six adjustments the first year.” One big advantage of the banding is that it’s a safe procedure that can be used even during pregnancy. Recent research indicates that too much weight gain in the first trimester is implicated in gestational diabetes. “I’ve had 10 women in my practice who have had the Lap Band while pregnant,” Minkin notes. “I work closely with their obstetricians and they do quite well.”