Bariatric Surgery – Is It For Me?

Kenneth B. Jones, MD, FACS, ASBS, IFSO

INTRODUCTION:
Having been in bariatric surgery since before the ASBS started, I have seen lots of trends come and go, beginning with the malabsorption of the intestinal bypass, replaced by the partial restriction, partial malabsorption of the loop gastric bypass, then the Roux-en-Y, followed by the totally restrictive vertical banded gastroplasty (VBG), swinging back to the Roux-en-Y gastric bypass (RYGBP) in the mid ‘80's and then back again to the restrictive lap band (GB) in the late '90's and early 2000's.  Today, it is no wonder that patients can be confused as to what to choose between the lap band, Roux-en-Y gastric bypass, lap or open, the biliopancreatic diversion (BPD) with or without duodenal switch (DS), and more recently the "gastric sleeve"; meant to be the first stage of the BPD/DS, but it has worked so well it appears as though that will be the one and only stage for many patients.  With all the available procedures, how does one decide?

CHOOSING THE OPERATION: 
First one needs to learn all they can about the individual surgical procedures, their risks, benefits, and average long term maintained weight loss.  In general, as we go from the totally restrictive procedures of the VBG (now rarely done) and lap band, to the combination restrictive/malabsorptive RYGBP, to the totally malabsorptive BPD and BPD/DS, the benefits of long term maintained weight loss increase, but so do the risks, generally speaking.
           
In bariatric surgery, there are two short term postop serious life-threatening risks that we all need to be made aware of, that is, gastrointestinal leaks and pulmonary embolus, meaning blood clots going from the lower extremities or pelvis to the lungs, contributing to the overall mortality rate of gastric bypass of 0.5%, or 1 in 200.  However, one must realize that these data include a significant number of patients with BMI's over 60 who have hypertension, diabetes, sleep apnea syndrome, and coronary artery disease, all of which would markedly drive the risk up.  For my usual patient with a BMI of 47, the surgical risk would be markedly less, i.e., 5/3000, or 1/600, probably closer to the real world experience.
           
Another consideration is laparoscopic versus open.  Indeed, the laparoscopic approach gets the patients out of the hospital a day earlier.  In general, these procedures are considerably more expensive, carry higher risks of postoperative bleeding, leaks, and later small bowel obstruction. There is better short term excess weight loss, but long term weight loss and benefits are virtually the same. Less pain and scarring are appealing, however, in spite of the risks.

A serious consideration is that many health insurers allow a patient to have one bariatric operative procedure for the life of their individual health insurance policy, so I would advise that you choose well and take to heart the data I have presented above, particularly relative to long term weight loss, realizing that with the lap band one may have problems many years down the road, as sometimes the balloons fail, there is erosion of the band into the stomach and other reasons for the band's removal and/or conversion to RYGBP in some patients.  On the other hand, RYGBP is associated with potential malabsorption of iron, vitamin B12, folic acid, and calcium.  So if one fails to take their vitamins with iron and calcium supplements religiously every day for the rest of their lives, they will indeed become anemic and develop earlier and more severe osteoporosis, which is totally avoidable if they take their vitamins and calcium every day.  BPD and DS are similar operations to RYGBP, but there is a higher risk of protein malabsorption later in life of 2-8%.  Again, probably completely avoidable, if one merely pays attention to their protein and other dietary needs.

CHOOSING THE SURGEON:
Once you have chosen the operation you think you prefer, how does one choose a surgeon?  My first bit of advice would be to beware of ads.  These are certainly not peer reviewed, and just remember what your grandma always said, "If you have to tell people how good you are, maybe you are not as good as you think."  That is not to say that advertising is wrong today, nor those that do are not excellent surgeons.  They may very well be.  So in choosing the surgeon, check on their reputation.  Call their office and ask if they have a web site so you can check into their credentials and curriculum vitae, which will tell you whether or not they are certified by the American Board of Surgery, members of the ASBS, and the American College of Surgeons.  Ask how many cases they've done, their complication and mortality rates, and weight loss outcomes.  The ASBS "Center of Excellence" designation is probably a good recommendation itself, but there are many excellent bariatric surgeons to choose from who have excellent results, but their numbers are not such that they would qualify for this designation, as it frequently takes two or more surgeons in a locale to have enough cases to qualify.

Once you have chosen your surgeon, he or she will see you in consultation, frequently with several other patients at the initial interview, take an extensive history, preparing to present the high points, emphasizing your individual co-morbidities to your health insurance carrier, and investigate whether or not this is a covered procedure.  Frequently it is not, and if you choose to pay for the procedure out of your pocket, inquire with your surgeon if he or she has a maximum liability agreement with the hospital in the event that you should have a catastrophic complication which could cost you hundreds of thousands of dollars.  This would mean that the hospital, for example, would charge you a set fee preoperatively of X dollars, and would only charge you a small limited amount more in the event that you did have complications, and write off the remainder.  This doesn't happen very often, and for that reason there is a catastrophic insurance carrier by the name of BLIS and other similar insurance carriers to remove the liability from you, the surgeon, and the hospital. Check into it.

PRE-OP PREPARATION:
While waiting on insurance approval, now is the time to get yourself in shape for the surgery.  If you smoke, stop immediately. Your history will have provided indications for preoperative evaluations by other specialists, including pulmonologists, intensivists, cardiologists, nephrologists, psychologists, etc.  We don't have good data that indicates that preoperative weight loss will reduce complications significantly, but long term maintained weight loss is a little bit better in most patients who do have a preoperative weight loss, probably due to the fact that it puts one in the category of the more serious, conscientious patients who predictably are going to work harder postoperatively because they proved they could do it preoperatively.  The weight loss will also help sleep apnea syndrome, reduce pretibial edema, and subsequently decrease the size of the liver, so it makes the surgery considerably easier for the surgeon, which makes the risk of complications much less for the patient.

FOLLOW-UP:
Postoperatively, one needs to do everything his or her surgeon recommends, which usually is getting up within a few hours after surgery and moving, which will get your bowels functioning more quickly, and significantly reduce the risk of blood clots and pulmonary embolus.  Usually your surgeon will have had a great deal of experience with whatever procedure you are having, and has followed a number of patients, so you should follow his or her advice explicitly to get the optimum results, not the least of which is to go to support group meetings.  We are continually disappointed by support group attendance, as patients frequently go to one or two postop meetings and then drop out.  I know they afford a great deal of benefit for many people, but I frequently run into patients who have been lost to follow-up for five years or more, and they have continued to do extremely well with a minimal amount of follow-up, but they are the exception, not the rule. To get optimal results, it is imperative that the patient take the responsibility for their own long term follow-up, as every program has built-in postoperative visits for a finite amount of time, and then virtually forever as necessary, the vast majority of which are pre-paid within the global surgical fee.  So follow up and continue to do what your surgeon asks you to do, and your chances of fulfilling your long term expectations will be greatly enhanced.

CONCLUSION: 
We have been doing bariatric surgery for over 50 years, and we are just now scratching the surface and barely making a dent in the public health sector with the disease of morbid obesity.  I see morbidly obese people every day who are going through life with an exterior veneer of happiness (or at least complacency) and are no doubt crying on the inside, clueless about the fact that they are DYING.  Our nonsurgical medical colleagues have been some help, but why they don't refer virtually all of their morbidly obese patients with diabetes, sleep apnea syndrome, coronary artery disease, and severe venous stasis disease to us, I will never understand.  'Diet doctors' come and go, (frequently leaving in the middle of the night), as they all fail.  Bariatric surgery is highly successful, and therefore should be supported by the entire medical profession.

Is bariatric surgery for you?  The next time you see your doctor, ask how much longer you need to take your insulin, Glucophage, Crestor, Digoxin, or Lasix, and the answer will invariably be "forever of course, unless you lose a whole lot of weight".  DUH!!

REFERENCES:
Buchwald H, Avidor Y, Braunwald E, et al.  Bariatric surgery: a systematic review and meta-analysis.  JAMA 2004 Oct 13: 292 (14): 1724-37.
Zimmerman JM, Blanc M, Mashoyen P.  Adjustable gastric banding: Experience of 2,000 cases.  Obes Surg 2006; 16: 410 (abstract).
Sweet WA.  Vertical banded gastroplasty: stable trends at weight control at 10 or more years.  Obes Surg 1994; 4: 149-152.
Jones KB, Afram JD, Benotti PN et al.  Open versus Laparoscopic Roux-en-Y Gastric Bypass: A Comparative Study of Over 25,000 Open Cases and the Major Laparoscopic Bariatric Reported Series.  Obes Surg 2006; 16: 721-27.
Capella RF.  Bowel Obstruction after Open and Laparoscopic Gastric Bypass Surgery.  J Am Coll Surg 2006; 203: 328-35.
Higa KD, Ho T, Boone KB.  Internal hernias after laparoscopic Roux-en-Y gastric bypass: incidence, treatment and prevention.  Obes Surg 2003 Jun; 13(3) 350-4.

Scopinaro N, Papadia F, Marinari GM, et al.  Biliopancreatic Diversion.  In Buchwald H, Cowan G, Pories WJ (eds.): Surgical Management of Obesity pp 239-251.  Philadelphia, Saunders Elsevier, 2007.