Wide Use of Weight-Loss Surgery

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After spending the majority of her 48 years trying to slim down, Veronica Mahaffey was still 50 pounds overweight - not morbidly obese but still far from the size she wanted. Worried about her health, she called a San Diego weight-loss surgery clinic last spring and asked for help.

She was told no.

At 185 pounds and with a body mass index of 28, the mother of four was not heavy enough to meet medical guidelines or insurance company qualifications for weight-loss surgery. Those require a BMI of at least 40, or 35 for people with a related medical problem such as diabetes or sleep apnea.

"People would say, 'You look fine.' But I couldn't get into normal-size clothing. That's not fine," said Mahaffey, of California.

Ultimately, she got the surgery through a clinical trial of one of several new weight-loss procedures. Now 10 pounds from her goal weight of 135, Mahaffey said she looks better, feels better and is confident she'll no longer have to fight her weight.

Her experience may soon be shared by thousands of Americans.

Traditionally limited to dangerously heavy individuals, weight-loss surgery is undergoing technical advances and becoming an option for moderately obese patients. Physicians who perform the procedures say it's a form of early intervention that can help prevent medical problems, such as diabetes, associated with carrying significant excess weight.

But other health professionals are concerned, citing the potential for complications and high costs.

"If you're looking at the numbers of people who are obese - that's a third of the population," said Dr. Robert Kushner, a professor at Northwestern University's Feinberg School of Medicine. "It's unimaginable even thinking about providing invasive procedures to a group this large.

" Obesity is a public health crisis that is not going to be solved by surgical interventions."

Nutritionists also are not enthusiastic. They reject the notion that surgery should take the place of dieting and exercise.

The problem is that nothing has worked so far in slowing the nation's alarming rise in obesity. A New England Journal of Medicine study published last month concluded that obesity rates soon will negate life-span gains achieved through declining smoking rates.

The American Society for Metabolic & Bariatric Surgery argues that surgery should be a bigger part of the solution.

Technological innovations may help make that possible by turning some surgeries into a one-hour, incisionless procedure - making them more attractive to moderately overweight adults like Mahaffey, overweight and obese teenagers, and normal-weight people with difficult-to-control diabetes. Several new procedures are in human clinical trials.

Already, bariatric surgery rates have doubled in six years, to 220,000 procedures in 2008, according to the bariatric surgery society.

Depending on the type of surgery used, patients can lose 50 percent or more of their excess body weight and maintain that loss for as long as 10 years after surgery. Other research has found that bariatric surgery cures Type 2 diabetes in a majority of patients studied, as well as improving symptoms related to sleep apnea and heart disease, such as high cholesterol and blood pressure.

In comparison, recent studies on long-term use of weight-loss medications show a typical weight loss of 5 to 22 pounds over one year.

But even the simplest surgical procedures are not without risks. The most common weight-loss surgeries -- gastric bypass and gastric banding - restrict stomach size so patients feel full faster. Afterward, 19 percent of patients experience dumping syndrome, which is involuntary vomiting or defecation, according to the federal Agency for Healthcare Research and Quality. Complication rates involving ulcers, wound problems, hemorrhage, deep-vein thrombosis, heart attacks and strokes range from 2.4 percent to 0.1 percent.

"None of these procedures is benign," said Dr. Blandine Laferrere, a diabetes expert at Columbia University College of Physicians and Surgeons in New York.

Experts are seeking ways to decrease the risks.

"Investigators are working on ways to make these operations more effective, safer, less invasive and lower-cost," said Dr. Philip Schauer, director of the Bariatric and Metabolic Institute at the Cleveland Clinic.

Furthest along in clinical trials is an incisionless technique called TOGA, or transoral gastroplasty. A surgeon inserts a flexible tube through the mouth into the stomach and then uses staples to create a pouch that limits the amount of food that can be consumed.

Some surgeons are adopting a wait-and-see attitude on such procedures until longer-term data are available. "These approaches are still experimental, and we don't know yet how successful they will be," said Dr. Jonathan Myers, director of bariatric surgery at Rush University Medical Center in Chicago.

Mahaffey underwent a procedure called POSE, or primary obesity surgery, endolumenal, designed for people who need to lose only a moderate amount of weight.

In another incisionless technique still in the early stages of development, a device is placed in the upper part of the small intestine to create a barrier between food and the wall of the intestines, mimicking the effect of gastric bypass surgery. The device is expected to cost about half as much as gastric banding and one-quarter as much as gastric bypass.

Lowering the cost of surgery will be key to offering an effective weight-loss option to thousands, or millions, more people, Schauer said. The costs of traditional weight-loss surgery vary widely, with average costs ranging from $13,000 to more than $50,000, depending on the type of procedure and the area where it's performed.

Whether insurance companies will welcome the idea of more people receiving bariatric surgery remains to be seen. Weight-loss surgery is now covered by insurance only for those patients who have premium benefits and a BMI of 40 or higher, or a BMI of 35 or higher with obesity-related medical problems. Standard health plans typically don't include coverage of bariatric surgery.

However, insurance companies tend to follow the lead of the Centers for Medicare & Medicaid Services, and last February the federal agency announced that it would approve payment of surgery for people with Type 2 diabetes and a BMI of at least 35.

In November, a consortium of influential medical groups published a consensus statement recognizing the "legitimacy" of bariatric surgery as a treatment for some patients with Type 2 diabetes and noted that surgery may be suited for people with Type 2 diabetes who are not yet morbidly obese - those with a BMI of 30 to 35.

"I see many patients with BMIs in the low 30s who aren't going to make it much longer," said Kushner, of Northwestern. "If we could get that person to take off 30 or 40 pounds long-term, that would make a tremendous difference."

"There is probably a subset of patient with BMIs under 35 - those with diabetes, metabolic syndrome, hypertension, severe sleep apnea - who would benefit substantially from some sort of (surgical) intervention," said Dr. Eric Hungness, a bariatric surgeon at Northwestern Memorial Hospital. The Chicago medical center is offering surgeries to patients who fit that description on a case-by-case basis, he said.

Nearby, at a surgery center at 900 N. Michigan Ave., Myers estimates he has performed more than two dozen lap-band stomach surgeries on patients with BMIs of 30 to 35 in the last several years. More have conditions such as diabetes, high blood pressure or high cholesterol and all pay for the operations themselves.

"This isn't a quick fix or an easy fix," he warned, noting that people have to permanently change their eating, drinking and exercise habits for the procedures to achieve expected weight-loss gains.

Dr. John Baker, president of the bariatric surgery society, said that for people with a BMI of 25 to 30, which is considered overweight but not obese, diet and exercise changes should still be the treatment of choice.

"Even people who have surgery still have to focus on those things," he said. "You have to change your lifestyle and habits for any weight-loss program."

Copyright © 2014, Los Angeles Times
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