When Nothing Else Works: Surgical Treatment of Obesity

Obesity has reached epidemic proportions in the United States. The National Health and Nutrition Examination Survey (NHANES) published by the National Institutes of Health indicate that 97 million of us are overweight or obese.

“The problem keeps getting worse,” says US Department of Health and Human Services Secretary Tommy G. Thompson. “We’ve seen virtually a doubling in the number of obese persons over the past two decades and this has profound health implications. Obesity increases a person’s risk for a number of serious conditions, including diabetes, heart disease, stroke, high blood pressure, and some types of cancer.”

For severely obese people – those more than 100 pounds overweight – losing a significant amount of weight and keeping it off in the long term is especially difficult. Methods such as behavior modification, diet and exercise, and medications have not been shown effective in achieving significant long-term weight loss. Many people who have repeatedly and consistently made unsuccessful efforts to reduce their weight come to consider the option of gastric bypass surgery.

Surgical Procedures
Surgeons at Froedtert & Medical College specialize in laparoscopic (also known minimally-invasive) gastric bypass techniques, although they also offer traditional open surgery based on the needs of the individual.

The surgical procedure performed is called the Roux-en-Y Gastric Bypass. In a laparoscopic approach, a telescoping device and instruments are placed through six small (1/2-inch) incisions. In an open approach, an incision is made from below the breastbone to the belly button. With either approach a small stomach pouch is created, approximately one ounce in size; the small intestine is separated and reconnected to the new pouch to allow food to empty. The lower part of the stomach is bypassed but digestive juices, bile and stomach acid flow normally.

With this method, there is very little interference with normal absorption of food. Instead, the operation works by reducing food intake and feelings of hunger. Patients tend to experience a rapid sense of fullness, typically without hunger. Because their “new stomach” is so much smaller, they experience fullness after eating a small amount of food.

Criteria for Surgery
You could be a candidate for surgery if you meet the following criteria:

• Body Mass Index (BMI) greater than 40 or more than 100 pounds overweight. (Calculate your BMI.)
• BMI of 35 with serious obesity-related health problems (heart problems, diabetes, sleep apnea, musculoskeletal problems, or a body size that interferes with employment).
• Failed non-surgical attempts at weight loss such as supervised diet programs or prescription diet medications.
• Evaluation by an experienced surgeon and considered a good surgical risk for obesity surgery.

Results
Most people who undergo a gastric bypass can expect to lose 60-80% of their excess body weight. Approximately 2/3 of this weight is lost in the first year and most patients continue to lose weight up to two years after surgery. On average, patients keep more than 60% of their excess body weight off 15 years after surgery. This weight loss can significantly improve the health problems related to severe obesity.

Within a few days of surgery, people who have obesity-related heartburn usually experience relief from symptoms. Likewise, those who experience urine leakage or incontinence when laughing, sneezing, or coughing may see dramatic improvement after weight loss.

Within about a month after surgery, when the first 25-30 pounds are lost, patients begin to experience relief of pain from musculoskeletal problems such as low back pain and arthritis. Unfortunately if the patient has already experienced significant nerve irritation or structural damage, weight loss may not reverse the symptoms.

Many people with Type 2 diabetes find that their blood sugar levels return to normal after surgery and they can stop or decrease their diabetes medications, including insulin. This reduces or eliminates the potential for tissue damage and other complications caused by diabetes.

Because severe obesity is related to breathing difficulties, gastric bypass surgery improves breathing ability and exercise tolerance. Daily activities, such as walking and climbing stairs, become much easier. Patients also see a dramatic relief of snoring and sleep apnea.

Within three months of surgery, at least 70% of patients who are taking medication to control high blood pressure are able to stop all medications and maintain a normal blood pressure. When medications are still necessary, doses are lowered. Also within three months, more than 80% of patients will develop normal cholesterol levels.

Short-Term and Long-Term Issues
By eating a healthy diet and using the proper vitamin and mineral supplements, nutritional problems are quite rare following the Roux Y Gastric Bypass. The body must receive enough protein to maintain itself; so patients need to eat protein-containing foods with each meal. Because the amount of food consumed is limited following surgery, patients need to take daily vitamin and mineral supplements.

Because of the drastically reduced size of the stomach, patients who continue to eat after feeling full will vomit. Red meats, which are not well tolerated, can also cause vomiting and have to be avoided for at least 3-4 months following surgery. Eating sweets, fruit juices and some dressings, particularly on an empty stomach, might cause light-headedness, profuse sweating, a rapid heart rate and other symptoms. Milk and milk products might be more difficult to digest unless dairy digestive products (such as Lactaid) are used. Because less roughage is consumed, constipation can become a problem, but this can be treated with a stool softener.

Temporary hair loss may occur during the phase of rapid weight loss; this symptom will resolve when nutrition and weight stabilize. Higher protein intake and a zinc supplement might be helpful. Since the body prefers to burn muscle rather than fat during rapid weight loss, muscle mass may decrease. At least 20 minutes of daily aerobic activity and improving upper body strength is recommended. Exercise may also enhance fat burning and hasten weight loss as well as improve mood and sense of well-being.

Severely overweight women who are infertile should use contraception following surgery because weight loss may quickly improve fertility. It is important to avoid pregnancy during the phase of rapid weight loss.

A Team Approach
In addition to the surgeons who perform the gastric bypass procedure, the Froedtert & Medical College bariatric surgery team includes two psychologists, a registered dietitian, physical therapists, two nurse practitioners, and the nursing staff on a surgical unit dedicated to the post-operative care of gastric bypass patients. This team of experts assists patients both before and after surgery to learn how to adapt to new ways of eating. In addition, the team provides a five-year follow-up program designed to improve patients’ success and prevent any metabolic complications.

Gastric bypass surgery isn’t for everyone, but it can improve and enhance the lives of well-informed and motivated surgical candidates. The surgery and the program of care provided by the multidisciplinary bariatrics team provides each person with a set of tools that, used appropriately, will result in significant long-term weight loss and, quite often, a new outlook on life.

James R. Wallace, MD, PhD
Assistant Professor of Surgery, Medical College of Wisconsin
Director, Bariatric Surgery Program and Surgeon, Froedtert & Medical College

Attila Nakeeb, MD
Assistant Professor of Surgery, Medical College of Wisconsin
Surgeon, Froedtert & Medical College Surgery

William J. Schulte, MD
Retired Professor of Surgery, Medical College of Wisconsin

Deborah A. Andris, MSN, APNP
Nurse Practitioner of Surgery, Medical College of Wisconsin Nurse Practitioner, Froedtert & Medical College Surgery

Theresa C. Brosnan, MSN
Nurse Practitioner of Surgery, Medical College of Wisconsin
Nurse Practitioner, Froedtert & Medical College Surgery

For more information on this topic, see the HealthLink articles US Obesity at an All-Time High, Medical Management of Obesity, and Surgeon General Asks Communities To Address Obesity.

MCW Health News presents up-to-date information on patient care and medical research by the physicians of the Medical College of Wisconsin.