Expert Advice BariatricSurgery

October 25, 2007|By Holly Selby

An estimated 66 percent of adults in the United States are overweight or obese, according to the Centers for Disease Control and Prevention. Although doctors recommend that those who wish to lose weight first try to do so through dieting, exercise, behavior therapy and anti-obesity drugs, an increasing number of people are turning to surgery when these steps fail.

In 2006, for example, about 150,000 patients in the United States underwent what is known as bariatric surgery, says Michael Schweitzer, director of minimally invasive bariatric surgery at Johns Hopkins Bayview Medical Center. That number is up from about 14,000 patients in 2003.

What is bariatric surgery?

Bariatric surgery is surgery for the morbidly obese and is aimed at addressing medical problems, [which can include diabetes, heart disease and severe sleep apnea], related to obesity and decreasing the patient's weight to a safe weight.

Who should consider bariatric surgery?

A patient who qualifies for this kind of surgery must have a BMI [body mass index, which is calculated using a person's height and weight] of 40 or more. That is about 100 pounds overweight for a man and about 80 pounds overweight for a woman. Or the patient must have a BMI of 35 and have an obesity-related disease such as diabetes, heart disease or sleep apnea.

The surgery is for patients who have tried and failed at diets in the past, who have a good support network of family or friends and who are psychologically prepared.

If a patient, for example, is going through enormous life upheavals, acute depression or a divorce, this is not a good time to get this surgery.

Could you describe the surgery?

The three bariatric surgeries most commonly done in the United States are known as the Roux-en-Y gastric bypass [or gastric bypass], the adjustable gastric band, and the duodenal switch with biliopancreatic bypass.

The first - Roux-en-Y gastric bypass - we usually do laparoscopically. It entails dividing the stomach into a very small upper pouch that is less than the size of an egg. We then divide the intestine so that we can bring an isolated segment of the intestine up to that small pouch.

Therefore, the food will bypass the rest of the stomach and the first part of the intestine. This makes the patient feel full after eating a small amount of food.

The second type of surgery, the adjustable gastric band, involves a silicone band with a balloon on the inside that goes around the top of the stomach. We inflate the balloon with saline and squeeze the stomach. This slows the passage of food to the rest of the stomach and causes the patient to feel satiated after eating a small amount of food.

And the third technique?

That is called the duodenal switch with biliopancreatic diversion. This involves taking out the lateral part of the stomach and rearranging the intestines so that there are only about 100 centimeters of intestine in which the food mixes with bile and pancreatic juices for digestion. This decreases the amount of calories the body absorbs.

What kind of preparation does a patient considering the surgery receive?

The approach is multidisciplinary. You meet with the surgeon. You meet with the dietitian who goes over the post-op diet and the vitamins and so on that you will need. You also meet with a mental health professional who will evaluate you and provide information to you if you need extra support.

At Hopkins, the psychiatrist runs an eating disorder group to help patients who will have extra needs after the surgery. We also have informational sessions and support group meetings for the patients.

What are the complications?

A possible complication obviously is death. In a center of excellence for bariatrics, the mortality rates are very low. At Hopkins, the rate is less than 0.5 percent.

The most serious complications are a leak of stomach or intestinal fluids, which can cause a severe infection inside the abdomen or a blood clot that goes to the heart and lungs. At Johns Hopkins, this happens in less than 1 percent of cases.

After gastric bypass surgery, one side effect - and we surgeons look at it as a good thing - is called "dumping." With this side effect, you may experience abdominal pain and your heart may race after a high-sugar meal or food, so it keeps you from eating sweets, which is a good thing. It is listed as a complication, but we surgeons see it as a positive side effect.

How long does it take to recover from these surgeries?

Most patients are back to work in two weeks after laparoscopic surgery and up to six weeks if they undergo open surgery. All of the procedures can be done laparoscopically.

Immediately after surgery, the patients are placed on a special diet for about a month that is low on solid food. After that, they are taught to fill up their smaller stomachs with protein first and healthy carbs to make them feel full on lower quantities of food. And they are taught not to drink while they eat and to avoid high-sugar foods.

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