Weighing The Options
Bariatric surgery offers big health benefits for Georgians struggling with the effects of obesity. But it’s not a quick or easy fix.
Surgical Techniques: Dr. Michael A. Edwards, chief of the Minimally Invasive and Digestive Surgery Section at Georgia Health Sciences University in Augusta, demonstrates techniques used in bariatric surgery. With him is Nadia Butler, a member of the Georgia Health Sciences Health System Board of Directors.
Georgia Health Sciences University
Obesity is a problem of major proportions in Georgia, costing the state $2.1 billion annually either directly or indirectly for diagnostic and treatment services and reduced productivity. But for far too many Georgians, the ultimate cost of excess weight cannot be measured in dollars. An estimated 6,700 die each year from health problems attributed to obesity.
While the logical solution to excess weight is to eat less and exercise more, people who are severely obese often need something more, says Oliver Whipple, M.D., medical director of the weight-loss surgery program at Mem-orial University Medical Center in Savannah. Increasingly, many are finding the solution through the Memorial program or one of a dozen or so other bariatric surgery programs in the state.
“Bariatric surgery is not a quick fix – no easy way out,” says Dr. Whipple. “But it has been shown to improve or resolve obesity-related health problems for people who commit to surgery and lifelong lifestyle changes afterwards.”
If you or someone you know has considered bariatric surgery, there’s never been a better time to make the commitment. It is offered at many of the larger hospitals around the state, some with a decade or more experience. And as evidence of the benefits accumulates, insurance coverage for the surgery is becoming more common.
Here are important factors to take into account when considering bariatric surgery and some benefits that might be surprising.
Types of Surgery
Rather than a single procedure, bariatric surgery refers to a number of procedures de-signed to promote significant weight loss. Most centers in Georgia and throughout the U.S. perform three different types of surgery: laparoscopic gastric banding, vertical sleeve gastrectomy and gastric bypass.
Laparoscopic gastric banding, often referred to as lap band, involves the placement of a plastic band around the upper end of the stomach, which helps decrease the amount of food that it takes to feel full, says Dr. Whipple, whose eight-year-old program has performed “in the neighborhood of 900 bariatric surgeries” and is on pace to do around 300 this year alone. Gastric banding does not involve cutting or stapling the stomach itself; following surgery, the surgeon can adjust the band as needed. If complications occur, the band can be removed. It is the only one of the three weight-loss surgeries that can be reversed.
Vertical sleeve gastrectomy, also known as gastric sleeve, is similar to the band in that it is a restrictive procedure – meaning it alters the capacity of the stomach, restricting the amount of food you can eat. The procedure involves stapling off and removing a portion of the stomach so that it is narrowed like the esophagus, says Dr. Whip-ple, leaving only a chicken-egg-size pouch at the bottom.
Gastric bypass, the most complex of the three procedures, involves partitioning the upper portion of the stomach called the pouch to roughly the size of a chicken egg, then dividing the small intestine and attaching one end of the intestine to the pouch and the other a little lower on the same portion of intestine.
Unlike the other two procedures, gastric bypass gives patients two components of weight loss, says Dr. Whipple. Partitioning off the upper part of the stomach restricts the amount that can be eaten, and rerouting the small intestines decreases the absorption of calories from the food that is eaten.
“Until you mix some of the digestive enzymes from the first part of the small intestine, called the duodenum, with the food you were eating, you don’t absorb all of the calories you take in,” says Dr. Whipple. “So with the bypass, you have that decrease with absorption as well as a decrease in what’s going in.”
Choosing the best of the three surgeries is based on a number of factors, including any other health problems you have and the amount of weight you have to lose. According to guidelines established by the National Institutes of Health in 1991, anyone with a body mass index – a reliable indicator of body fatness calculated from a person’s weight and height – of 40 or greater, which corresponds to being 100 pounds or more overweight, is a candidate for bariatric surgery, says Scott Steinberg, M.D., medical director of bariatric surgery at DeKalb Medical Center in Decatur. “If they have diabetes, high blood pressure or sleep apnea, they only need a BMI of 35, about 70 pounds overweight,” he says.
Because weight loss is generally fastest and most pronounced with gastric bypass, Dr. Whipple almost always recommends it for patients who need to lose the most weight. “If I have a patient who comes to see me and they have a BMI of greater than 60, I feel like bypass without a doubt is a better choice for them, because that indicates they are probably carrying close to 200 excess pounds of body weight; and a bypass is going to give you the quickest, most predictable, most substantial weight loss of the three,” says Dr. Whipple. Gastric bypass is also the most effective against weight-related health problems, particularly type 2 diabetes, he says.
For people with less weight to lose, Dr. Whipple recommends either the lap band or sleeve, each of which has its own benefits. For example, the sleeve is the most tolerant of nonsteroidal anti-inflammatory drugs (NSAIDs), such as ibuprofen (Advil, Motrin) or naproxen (Aleve, Naprosyn), which people with inflammatory problems such as arthritis often take to help relieve pain and inflammation. He also recommends the sleeve for people who have scar tissue from previous surgery involving the abdomen that would make surgery involving the small intestine more difficult.
People with the least amount of weight to lose may opt for the lap band, which generally produces less weight loss than a bypass or sleeve, but is also the safest and easiest to reverse. “For a lot of patients, that gives them a little comfort to know that it can come out if there is a problem with it,” says Dr. Whipple.
Ultimately, the choice of surgery lies largely with the individual patient, says Dr. Whipple. “A lot of it to me is the patient’s comfort level. I want to make sure the patient is comfortable with the surgery they are choosing,” he says. “If there is something about one or the other that they are not comfortable with, I want to know what that is – if there is something I can do to help them feel better about it, by explaining it better, I certainly want to do that. I am going to tell them if there is one part of their medical history that pushes to-ward one or other, but I am going to let them know that I almost always [prefer] a decision that we come to jointly.”
Rewards and Risks
Regardless of the type of surgery you choose, the payoff can be great. “I would say that [for] all of the medical issues or conditions that are weight-related, we will see some significant improvement in potentially all of them and resolution of a lot of them,” says Michael A. Edwards, M.D., chief of the Minimally Invasive and Digestive Surgery Section at Georgia Health Sciences University in Augusta.
Research has documented improvement in problems including osteo-arthritis, hypertension, high blood lipid levels, obstructive sleep apnea and other risk factors in heart disease. Research out of Emory University even suggests gastric bypass can reverse some damage to the heart related to obesity.
But perhaps the best-documented and most dramatic benefit of gastric bypass is its effect on type 2 diabetes. “We don’t know the exact mechanism yet, but when you divert the flow of the food that you eat away from the duodenum, that has a very dramatic and immediate impact,” says Dr. Whipple.
“We know that if you have had type 2 diabetes for less than seven years, you have a strong chance of coming off all medications. You can have a complete remission of diabetes,” says Dr. Stein-berg, whose center has performed more than 2,000 weight loss surgical procedures over its 10-year history. In fact, he says, endocrinologists are starting to recommend gastric bypass for patients with uncontrolled diabetes even if they do not meet the BMI requirements for the surgery; at present, guidelines do not support its use in those circumstances.
Along with its benefits, bariatric surgery carries the medical risks inherent with all surgeries, such as bleeding, infection, blood clots and adverse reactions to anesthesia. But prospective patients should also be aware of some unexpected psychological risks of surgery, including sabotage from jealous spouses who would prefer to keep them heavy; unaccustomed – and unwelcome – attention; and a problem called transfer addiction, in which an addiction to food is transferred to another substance or habit.
“When you have the surgery and it drastically affects the amount of food you can eat, people with addictive personalities seek out a new addiction,” says Dr. Whipple. “This is easier to manage if you are aware of it ahead of time and are careful so you don’t end up with an alcohol or drug problem.”
Cost is a factor with any surgery, but if you’re considering bariatric surgery, it is particularly important that you check your insurance coverage. While coverage is becoming more common, not all insurance covers bariatric surgery – including The State Health Benefit Plan (SHBP), which provides health insurance coverage to state employees, school system employees, retirees and their dependents. It dropped bariatric surgery last year in an effort to reduce costs. But as the benefits and long-term cost savings from surgery are demonstrated, the number of insurers who cover the procedures is increasing. And failure to cover it is shortsighted, say proponents.
“When people look at the cost of bariatric surgery, they look at the upfront costs,” says Dr. Edwards. “But long-term, there is significant cost savings to any business that provides insurance to employees. When you have someone actually have surgery and have those medications resolved or significantly improved, that can significantly improve long-term costs with less medication, fewer physician visits, less time away from work and lost productivity.”
“There are studies showing from a provider’s standpoint it takes two years to recoup your investment from surgery,” says Dr. Whipple. “After two years, the money spent on the surgery is earned back by the insurance company in savings from medical visits, medication costs, etc.”
If you don’t have coverage, ask if the medical center you’re considering offers a special cash price. Memorial, for example, has negotiated cash package prices that cover the surgery, hospital stay and associated costs at roughly $13,500 for the lap band, $18,000 for the gastric sleeve and $23,000 for the gastric bypass.
The Center and Surgeon
As with any other surgery, your best chances of success with bariatric surgery are at a center that performs a high volume of surgery, says DeKalb Medical’s Dr. Steinberg. “A lot of our patients drive five or six hours from around Georgia and adjoining states because they want to go to a specialized center for their surgery.”
Surgeons performing bariatric procedures should be fellowship trained – meaning they have received specialty training beyond their surgical residency – and board-certified in bariatric surgery. The center itself should take a multidisciplinary approach to treatment, offering the services of a dietitian and mental health professional and support groups. If a center does not have these professionals on staff, it should offer referrals, because, in the long run, the surgeon is one of the least important professionals in the sur-gery’s success, says Dr. Edwards.
“It is a lifelong change for the patient who decides to undertake surgery,” he says. “If they are committed to this lifelong change, we should be able to commit to them.”
Commitment to Success
The surgery itself is fairly easy for most people, says Dr. Steinberg. Lap band surgery takes about 30 minutes, and patients can go home the same day. Gastric sleeve and gastric bypass take about 45 minutes to an hour and require an overnight hospital stay, he says.
The vast majority of bariatric surgeries are performed laparoscopically, which means smaller incisions, less pain, fewer complications with infections and shorter recovery time, says Dr. Edwards, who with his partner Brian Lane, M.D., has performed between 2,000 and 2,500 bariatric surgeries.
While the surgery itself is easy, the commitment to make it work isn’t, says Dr. Whipple. “The surgery is a fixed event on a fixed day. It is adapting to the surgery in a positive manner that is difficult and makes for the healthy lifelong changes.
“It’s the best tool we have to take off this amount of weight and keep it off, but it’s just that – a tool. It’s not a ‘You do this and you don’t have to worry about your weight again,’” he says. “Unfortunately, like everything else in life, it is not that simple. It is an excellent tool to help you reset your weight, but the surgery can’t keep you at that weight. It is the habit changes and lifestyle changes that keep you there.”
Undergoing bariatric surgery requires a long-term commitment to follow-up and lifestyle changes, which some centers require patients to make formal. “We ask our patients to sign an agreement that they are going to follow up for at least 10 years,” says Dr. Edwards. Those who fail to follow up do not do as well as those who are conscientious about the follow-up. “We believe whole-heartedly that follow-up – not with the surgeon, but with the bariatric nurse, our medical staff, psychologist and other staff – is the key to success.”
Do Your Homework
If you think you are interested in pursuing bariatric surgery, do your homework. “Some people come to us who have spent hours on the Internet reviewing bariatric surgery, have been to a support group, maybe have a loved one who had the surgery and frankly know more than I do,” says Christian Lemmon, Ph.D., a clinical psychologist who meets with and assesses all prospective bariatric surgery patients at Georgia Health Sciences Medical Center. “Then we have other folks come in here and I’ll say, ‘Why are you considering surgery?’ and they’ll say, ‘My doctor told me I needed it.’ Then I ask if they know what it involves and they say, ‘No, not really.’
“I don’t want someone like that to have surgery because it requires such a huge lifestyle change,” says Lemmon, who specializes in assessing and treating eating disorders. “You have to follow a strict diet regimen or you could hurt yourself, and, of course, you have to be physically active. I just need them to know what they are getting themselves into.”
All bariatric programs offer informational and Q&A sessions for people considering surgery. Dr. Whipple recommends all prospective patients attend one – or more – of those sessions. “I tell them come to one of my presentations. If you are still not sure, come back next month and listen to it again,” he says. “I want you more prepared for this than any other medical procedure you have done before.”