Bariatric Surgery Safer than Ever
When Dr. Daniel B. Jones was doing his surgical training at Washington University in St. Louis in the late 1990s, surgeons who performed gastric bypass procedures were considered by some of his peers to be renegades on the fringe.
Dr. Daniel B. Jones
He remembers many gastric bypass patients returning to the hospital with seroma, hernias, and other postoperative complications. "We never really saw the people who were doing well," recalled Dr. Jones, who now heads the section of minimally invasive surgery at Beth Israel Deaconess Medical Center, Boston. "A lot has changed since then."
Thanks in large part to the development of accreditation programs by the American College of Surgeons’ Bariatric Surgery Center Network and by the American Society for Metabolic and Bariatric Surgery (ASMBS), the current standards for performing bariatric surgery are more rigorous than ever. High-volume centers "may have two or three surgeons at a site, with dedicated floors where the nurses are keyed in and looking for complications when they arise so they can be addressed early," said Dr. Jones, a member of the ACS Bariatric Surgery Center Network Advisory Committee. "We have better equipment for doing intubations, for anesthesia, better instruments for operating – all these things have evolved to make bariatric surgery a lot safer than it was even 10 years ago. While we still have some questions about the physiology and the mechanisms involved in how these operations work, we have a very good understanding of the technical aspects of doing these operations and the complications, and how to prevent and treat them. In Massachusetts, for instance, use of accreditation programs has reduced mortality to a fraction of what it was just 5 or 7 years ago."
A study based on National Inpatient Sample data found that the national annual rate of bariatric surgery increased nearly sixfold between 1990 and 2000, from 2.4 to 14.1 per 100,000 adults (Surg. Endosc. 2005;19:616-20). The use of gastric bypass procedures increased more than ninefold during the same time period (from 1.4 to 13.1 per 100,000 adults).
According to the ASMBS, an estimated 15 million people in the United States are morbidly obese. About 220,000 Americans underwent bariatric surgery in 2009. The risk of death from the procedure is about 0.1%, down from about 0.4% between 1990 and 2000.
"I think we’re leveling off on the number of operations our surgeons and hospitals can address, yet our obesity problem continues to rise," observed Dr. Jones, who also is professor of surgery at Harvard Medical School, Boston. "It’s really important that we start thinking about how to prevent the problem as opposed to how to manage it after it occurs."
He credits the laparoscope for revolutionizing bariatric surgery in the late 1990s, though initial acceptance was slow. In fact, being overweight was once considered a contraindication to laparoscopy. "That all turned upside down," Dr. Jones said. "The bariatric surgeons at the time knew that obese persons would most benefit from laparoscopy. An incision on a larger patient is very big, because you have to get through all the fat, down into the fascia and to the target. Whereas someone might do a 10-cm incision on a thin person, that same incision might be 50 cm on an obese patient. But the poke holes of laparoscopy are the same small size."
Dr. Jones discussed the most common bariatric surgery procedures being performed today:
• Roux-en-Y. Commonly referred to as gastric bypass, this procedure involves reducing the stomach from the size of a football to the size of a golf ball. The smaller stomach is then attached to the ileum, bypassing about 60% of the small intestine. "While there can be long-term complications, such as B12, calcium, iron, and folate deficiency if there is not a nutritionist involved in follow-up, for the most part it’s reasonably safe," he said. "You’re going to achieve loss of 50%-70% of your extra body weight. So if you’re 100 pounds overweight, on average you’re going to lose 50-70 of those pounds. If you’re 200 pounds overweight, you might lose 100-plus pounds."
Dr. Jones generally performs open gastric bypass in patients who weigh more than 350 pounds because the visualization is better and he believes this procedure is safer for a person of that size. "Other surgeons modify their technique a bit to offset the fact that people are bigger," he said.
He reserves laparoscopic gastric bypass for patients who weigh less than 350 pounds because it generally produces less scarring and a shorter hospital stay – usually 1-2 days versus up to a 3-day stay in patients undergoing an open procedure. "When I came to Boston, people would say, ‘laparoscopic gastric bypass is not known, not proven,’ " Dr. Jones said. "That was only 8 years ago. Now, surgeons ask, ‘why would you ever do the open approach in this patient population?’ I’ve parked in the middle of that debate for a long time."
Women of childbearing age who undergo gastric bypass should avoid pregnancy in the first 2 years after surgery "because they’re going to compete nutritionally with the growing fetus," he said. And patients should keep postoperative alcohol consumption in check. "If you drink half a glass of wine after gastric bypass surgery, you may be legally drunk because alcohol gets absorbed so fast in the reconfiguration of the stomach," he explained. "It may also be easier to get addicted to alcohol after the surgery because the levels get so high so fast. Alcohol needs to be on the back burner if you’re thinking about gastric bypass surgery."
According to the ASMBS, the gastric bypass procedure costs between $14,000 and $26,000, but Dr. Jones puts the cost of this and other weight loss procedures in the range of $30,000.
• Laparoscopic adjustable gastric banding (LAGB). In this procedure, surgeons place a silicone band filled with saline around the upper part of the stomach, creating a small pouch which causes restriction. The band can be tightened or loosened through a port.
Ideal candidates include patients with a body mass index of 40 kg/m2 or more, or those with a BMI of 35 kg/m2 plus a serious medical conditions such as diabetes that might improve with weight loss.
"The band operation itself is not that difficult to perform, yet you’re still around some real estate," said Dr. Jones, coauthor with Dr. Mark J. Watson of the "Lap-Band Companion" handbook (Woodbury, Conn.: Cin?-Med Inc., 2007), which is intended for patients. "There’s the esophagus, the aorta, the stomach, and the diaphragm. There are plenty of opportunities for very serious, life-threatening complications. The band is deceptively simple, but there is plenty of room for problems. Many severely overweight people who come to us have other significant comorbid conditions: coronary artery disease, hypertension, sleep apnea. All of these things may put patients at very high risk for heart attacks or respiratory arrest, or [deep vein thrombosis]."
Slippage ranks as the most common reason for needing to remove bands. Dr. Jones tells patients that there is a 40% chance that their band may need to be repaired, revised, or removed at some point in their lives. "That band may be there forever, or it may come out because they have prolapse and it’s in the wrong spot, or maybe they had an appendicitis and the band was getting infected," he said. "The things I see the most are breakdowns in the tubing or hub from, say, a needle stick during the port adjustment. Early on, a port can flip over, and long term, these bands can get out of position."
On Dec. 3, 2010, the Food and Drug Administration’s Gastroenterology and Urology Devices Panel recommended the use of the Lap-Band procedure for people who don’t meet the clinical criteria for obesity. Allergan Inc., which makes the device, proposed that the Lap-Band adjustable gastric banding system be approved for weight reduction in people aged 18 years and over with no comorbidities and a BMI of at least 35 kg/m2, or a BMI of at least 30 kg/m2 and one or more comorbid conditions. Eight out of 10 FDA panel members agreed that there was "reasonable assurance" that the device was safe and effective for this population.
Such patients may find it difficult to convince their health insurers to pay for the operation in the near future. "[Insurance companies are] probably going to hang tight at BMIs of 35-40 kg/m2. It may be that a BMI of 30-35 kg/m2 is going to be a cash-pay cost."
Patients who undergo LAGB generally go home by noon the next day. Dr. Jones believes an overnight stay for these patients is advisable, whereas most gastric bypass patients leave the hospital on the second or third day. Because more cutting and connections are involved with that procedure, there are more opportunities for leaks, stenosis, or bleeding, he noted.
• Sleeve gastrectomy. During this procedure, surgeons remove about 85% of the fundus and body of the stomach, creating a vertical sleeve that restricts the amount of food that can be consumed. The operation is generally reserved for patients who cannot tolerate LAGB or gastric bypass. As an example, Dr. Jones cited a patient whose size rendered him unable to roll over. "He was getting a hernia eroding through his belly button, so he had the beginnings of infection, so I didn’t want to put in a Lap-Band. He wasn’t a candidate for the bypass because he couldn’t tolerate the fluid shifts we might expect during the procedure. We did the sleeve procedure, and he lost 200 pounds."
Most insurance companies have been slow to cover sleeve gastrectomy, and often patients must pay for the procedure. In Massachusetts, for example, insurance companies require proof that the band or bypass can’t be done, according to Dr. Jones.
An ASMBS position statement about sleeve gastrectomy noted that there are few published studies about the long-term outcomes of the procedure beyond 5 years (Surg. Obes. Relat. Dis. 2010;6:1-5). "Such long-term data might or might not ultimately confirm that the procedure should remain in the category of a staged treatment intervention," the statement reads.
Some surgeons are applying single-port surgery to sleeve procedures and to LAGB, "but I think that is pretty investigational in terms of technique," Dr. Jones said. "I suspect that the complication profile of these techniques will be more, but we don’t know how much more."