More obese Americans are choosing to have surgical procedures to help them lose weight. In fact, the number of obesity surgeries in the U.S. has quadrupled since 2000 to 171,000 cases in 2005 from about 40,000 cases in 2000. And the numbers keep increasing. Obesity surgery includes several procedures: stomach stapling, stomach banding, gastric bypass and combinations of these procedures. The idea of having surgery is to limit how much patients can eat, so that they’ll consume fewer calories. Since obesity surgery is one of the few weight-loss services covered by health insurance, many people who need to lose 100 pounds or more consider it as a weight-loss option.
Ongoing research, particularly in the last 10 years, continues to make big strides in providing safer and more effective obesity surgery techniques to optimize long-term weight loss. Non-surgical techniques are also being explored. The intragastric balloon procedure, for example, entails inserting a balloon filled with saline water in the stomach. The balloon floats freely in the stomach, taking up space and enhancing the sense of fullness. It can remain in place for up to six months, after which time it is deflated through another brief procedure and removed.
But remember, if you’re obese, surgery isn’t a magic bullet. Even though obesity surgery limits a patient’s daily caloric intake, she must still be committed to monitoring her eating habits and increasing her physical activity, if she wants to achieve long-term success. Given all the publicity about medical procedures to combat obesity, I wanted to take a closer look at the surgery procedures available and who is best suited for them.
Who is a good candidate for surgery?
We are continuously reminded that Americans are getting fatter, but only about five to 10 percent of the population is considered to be severely obese. Only those who are severely or morbidly obese (someone who has to lose about 100 pounds) should consider obesity surgery. You can gauge whether you’re a good candidate for it based on a weight index called BMI (body mass index). BMI looks at your body weight and height and links it to your health risk. You meet the criteria for surgery if your BMI is 40 or more, or 35 or more if you have illnesses related to your weight, such as high blood pressure and diabetes.
To find your BMI, you can ask your doctor, search for a BMI chart, or even calculate it yourself. Here's an easy way to determine your BMI:
- Take you weight in pounds and multiply by 703. Divide this number by your height in inches.Finally, divide this number again by your height in inches.
- BMI isn't the only criteria, though — a total commitment to long-term lifestyle changes and dedication to positive health habits are also a must.
What kinds of surgery are currently used to treat obesity?
There are several types of surgical techniques available to help reduce your caloric intake. These can be based on:
- Restriction: the stomach is made smaller.
- Malabsorption: less food and calories are absorbed during digestion.
- Combined procedures: the stomach is made smaller and there’s some mild absorption of calories.
- Staged procedures: sequential surgeries, where restriction is performed first, and then there’s a second malabsorption procedure.
What are the specific procedures?The surgeries can be performed with a large abdominal incision (called “open”) or with small, Band-Aid-sized incisions (called “minimally-invasive” or “laparoscopic”). The operations are the same, regardless of the incision type. Here are the operations currently available:
- Many people are familiar with this technique, commonly known as “stomach stapling.” This is one of the oldest tools and uses restriction only. It is usually discouraged, though, since weight loss is hugely variable afterwards and often there’s complete weight regain within the first few years after surgery.
- This technique restricts the size of the stomach. It involves placing a large band around the stomach, which can be tightened as needed, and doesn't require the stomach to be cut. The band can actually be removed if needed. Weight loss with this procedure is slow and steady, reaching its maximum about two years after the surgery. Lifelong surgical follow-ups are necessary to adjust the band for the long-term success of this surgery, and it is believed that this will also enhance lifestyle changes.
- Often referred to as the “gold standard” for obesity surgery, this operation, also simply called gastric bypass surgery, creates a small stomach pouch that is about the size of an egg and physically separate from the rest of the stomach. At the same time, a part of the intestine that normally absorbs calories is “bypassed,” allowing less food to be retained by the body. This means that both fewer calories are consumed (due to the small stomach size) and digested (because of the rerouting of intestines). Weight loss is relatively rapid with this surgery — you can lose 100 pounds or more within nine to 12 months, with a maximum loss expected by 18 to 24 months.
Who can help determine if you're a good candidate?
Only a surgeon trained to perform obesity surgeries can determine your candidacy and the best surgical strategy for you, even if you believe that you are a good candidate and prefer a particular operation. Look for a surgeon and hospital that is accredited by the American Society of Bariatric Surgery (ASBS). This is an important designation to look out for to ensure that you get comprehensive care — before and after surgery. The University of Pittsburgh Medical Center is one of many in the United States that is accredited. You should be able to find a program near you.
What is new on the surgery horizon?
There continue to be more advances in the field of obesity surgery, with more options and techniques developing for future clinical use. Here are some on the horizon:
- Sometimes considered to be a non-surgical treatment, because it does not involve incisions, this procedure is performed by either a gastroenterologist or a surgeon. A deflated balloon is inserted into the stomach (patients are under light anesthesia for about 20 to 30 minutes), which is then filled with sterile salt water. The balloon floats freely in the stomach, taking up space and enhancing the sense of fullness. It can remain in place for up to six months, after which time it is deflated through another brief procedure and removed.
The balloon is available in other countries, and, in fact, one of my center’s programs at our UPMC sister hospital in Palermo, Italy, has already had great success with it. This new development should be coming to the U.S. soon, as the FDA has approved the balloon for future testing, deeming it safe to investigate further. - While in its very early stages, some kinds of obesity surgery can be done with a specially designed instrument that enters the stomach through the esophagus. This surgery is an area of great interest and research.
We may also see future techniques that use not only minimally-invasive techniques (such as Band-Aid-size incisions), but also non-invasive procedures. These may involve doctors using modified instruments that will let them enter the stomach from the mouth, reducing the need for surgical incisions for some procedures.
Dr. Fernstrom’s Bottom Line: Obesity surgery is a much-needed tool for many patients struggling with severe obesity. If you think you might need obesity surgery, first talk with your primary care doctor and then make sure you seek a program with ASBS (American Society of Bariatric Surgery) certification.
Madelyn Fernstrom, Ph.D., CNS,is the founder and director of the An associate professor of psychiatry, epidemiology, and surgery at the University of Pittsburgh School of Medicine, Fernstrom is also a board-certified nutrition specialist from theAmerican College of Nutrition.
PLEASE NOTE: The information in this column should not be construed as providing specific medical advice, but rather to offer readers information to better understand their lives and health. It is not intended to provide an alternative to professional treatment or to replace the services of a physician.