Surgery recommended for obesity only in the most severe cases

Q: I have been overweight all my life. My weight is now over 300 pounds and my blood sugar is high. I have managed to lose some weight with just about every possible type of treatment, but the pounds always come back. Years ago my doctor told me that surgical treatment for obesity was possible, but unsafe. What is the present story on surgery for obesity?

A: Recently, a panel sponsored by the National Institutes of Health concluded that certain types of surgery on the intestinal tract can be an effective choice for the treatment of severe obesity that has not responded to other forms of therapy.

The initial type of surgery for obesity, a partial bypass of the small intestine, was abandoned because of the high frequency of serious complications. Considerable experience has now been gained with two forms of surgery involving the stomach rather than the intestine. Both create a small stomach pouch that fills quickly and creates a feeling of fullness. Even with those newer types of surgery, about 10 percent of patients have complications in the immediate postoperative period. Most frequent are respiratory problems and wound infections. Most serious are blood clots in the legs and leaks of stomach contents from the gastrointestinal tract into the peritoneal (abdominal) cavity. The operative death rate is low -- about 0.1 percent. Some patients have complications that may require another operation.

The panel did not advocate surgery "as the sole means of treatment" for severe obesity or recommend it for all patients. They said surgery should only be considered in individuals who are morbidly obese or those whose obesity is less severe but is associated with complications that are life-threatening.

While there is no universally accepted definition of morbid obesity, people who are 100 pounds or 160 percent above their ideal body weight are generally considered to have morbid obesity. Life-threatening complications of morbid obesity include diabetes mellitus, severe sleep apnea, Pickwickian syndrome (chronic suppression of normal respiration, characterized most notably by inappropriate sleeping), and cardiomyopathy (an abnormality of the heart muscle). In addition, the panel recommended that surgery should be limited to "well-informed and motivated adult patients with acceptable operative risks."

The health benefits of the major weight loss following successful surgery include relief of sleep apnea and Pickwickian syndrome, improvement or disappearance of diabetes, lower blood pressure and a correction of serum lipid abnormalities.

Dr. Margolis is professor of medicine and biological chemistry at the Johns Hopkins School of Medicine and associate dean for faculty affairs at the school.