Once drastic, now safer
Surgery has surged in popularity as a way to treat severe obesity. Today, it appears safe enough that some surgeons are testing it in children.
Most people who are tremendously obese can’t shed their weight through diet and exercise. For more than 50 years, surgeons have offered them another way: shorten or diminish the capacity of the gut.
The first operations in 1954 cut out most of the small intestine, says Dr. Sayeed Ikramuddin, the director of gastrointestinal surgery at the University of Minnesota in Minneapolis. “There were a lot of complications,” he says: people ending up malnourished or subject to diarrhea, kidney stones and liver failure.
Although the operation could be reversed if life-threatening (the unused portion of the small intestine was left in place but simply bypassed) the technique was abandoned in the late 1970s.
Next, in the late 1960s, surgeons developed “stomach stapling,” which stapled shut approximately the top third of a patient’s stomach, reducing its capacity for food. This procedure, however, also led to problems, such as a less functional, thicker-walled stomach and leakage of stomach contents. Symptoms could be halted by reversing the operation.
In current practice, surgeons choose one of three or four weight-loss surgeries based on a patient’s body mass index and whether he or she has other diseases such as diabetes. The more invasive methods have the highest risks. A study in 2004 found that the risk of dying while undergoing “banding” -- in which surgeons pinch off the stomach with a band filled with saline solution -- was about one-tenth of 1%.
The highest risk of death came with a procedure called a “duodenal switch,” in which most of the stomach is removed and what’s left is reattached near the end of the small intestine. The method is usually reserved for the “super morbidly obese,” individuals with a body mass index greater than 50 who are at high risk of diseases and reduced lifespan from their extreme body weight. People undergoing a switch have about a 1% chance of dying from the method.
What really improved safety, experts say, was the introduction, in 1994, of laparoscopic procedures into weight-loss surgery. Using lasers and cameras, surgeons make a few small incisions and perform procedures without cutting a person’s belly.
Between 1998 and 2004, the death rate of patients undergoing obesity surgery dropped 80%, according to a 2006 report by William Encinosa of the federal Agency for Healthcare Research and Quality in Rockville, Md. -- probably due to simpler surgery.
Madelyn Fernstrom, director of the University of Pittsburgh Weight Management Center, says the philosophy surrounding weight-loss surgery has helped too. “Surgery is a powerful tool, but you also have to have changes in exercise, nutrition and behavior.” Six months before an operation, individuals have to show they can maintain a more healthful lifestyle.
Researchers are continuing to develop safer methods. They are testing a balloon that can be placed in the stomach and filled with saline, taking up space that would otherwise hold food. It requires no surgery. Surgeons are also learning to thread surgical instruments through the nose or mouth and then down into the stomach, avoiding incisions.
Fernstrom says potential patients should look for hospitals certified as “Centers of Excellence” by the American Society for Bariatric Surgery, or accredited in bariatric surgery from the American College of Surgeons. “This means that these institutions have a lot of experience and the surgeons have more specialized training,” she says. “Studies show that hospitals doing more surgeries have better outcomes.”
