Weight Loss Surgery Makes Life Better for Obese
Gastric Bypass Boosts Mental, Physical Health -- but Complications Common
By Daniel DeNoon
WebMD Medical News
Reviewed By Louise Chang, MD
on Tuesday, October 18, 2005
Oct. 17, 2005 - Gastric bypass surgery greatly improves a person's quality of
life, but it isn't a bed of roses, new studies show.
A spate of new studies gives a clearer picture of the
risks and benefits of weight
loss
surgery. The studies also raise the question of what increasing
numbers of patients mean for American society.
Three of the studies and two editorials on the issue appear in the Oct. 19
issue of The Journal of the American Medical Association (JAMA). The
publication is timed for release during this week's annual meeting of the North
American Association for the Study of Obesity (NAASO) in Vancouver, Canada.
Editorialist Bruce M. Wolfe, MD, professor of surgery at Oregon Health &
Science University in Portland, says that despite a lot of media discussion,
facts on weight loss surgery have been hard to come by.
"Being severely overweight is life threatening and associated with many
related diseases," Wolfe tells WebMD. "Major weight loss is beneficial to these
patients. That isn't very controversial. The primary issue is this: Can weight
loss achieved by surgery be done safely, or are the risks and complications of
the surgery such that this intervention should not be applied?"
Life Quality After Weight Loss Surgery
Psychologist Ronette Kolotkin, PhD, wondered whether people who undergo
weight loss surgery actually benefit. She led a team that looked at three
matched groups of obese people: 223 gastric bypass surgery patients, 110 people
denied weight loss surgery by their insurance providers, and a comparison group
of 189 people who did not seek obesity surgery.
Two years after surgery, patients averaged a 34% drop in body weight,
Kolotkin reported at the NAASO meeting. Those denied surgery managed to lose
6.2% of their body weight, and those who did not seek surgery got 0.6% heavier.
All of the study subjects filled out quality-of-life questionnaires at the
beginning and end of the study. Nearly all the surgery patients -- 98% of them
-- reported meaningful increases in their quality of life. This was true for
only 46% of those denied surgery and for only 30% of the comparison group.
"After gastric bypass surgery, people describe dramatic, life-altering
changes. They feel like they have gotten their lives back," Kolotkin tells WebMD.
"They feel vastly more able to have good quality of life and are not so focused
on health and weight. They have more energy. They feel better day to day. They
feel more productive at work, more sexy, more like going out and being with
people and being physically active."
The difference may have been even greater than the study measured. Kolotkin
says surgery patients told her that before surgery, they hadn't fully realized
the impact their obesity had on their lives.
"People -- the obese themselves as well as others -- are not aware of how
much quality of life is impacted by obesity," Kolotkin says. "They are often
surprised when they fill out these questionnaires and realize they are suffering
many ways in terms of their weight."
Early Death After Weight Loss Surgery
It bears repeating: Obesity is a very serious health problem. And gastric
bypass surgery is a very serious surgery.
Death is one possible outcome. Which patients run the highest risk of this
worst of all possible adverse events? Clues come from the JAMA paper by
David R. Flum, MD, MPH, of the University of Washington in Seattle, and
colleagues.
Flum's team looked at the 16,155 Medicare patients who underwent weight loss
surgery from 1997 to 2002. Medicare won't pay for this procedure unless a person
is ruled to be fully disabled by obesity. That means these patients have a
higher burden of disease than the average obese person, notes editorialist
Wolfe.
Even so, the numbers are sobering:
- Overall, 2% of patients died within 30 days of weight
loss surgery. Within 90 days, 2.8% died. Within a year, 4.6% died.
- Men were much more likely to die than women: 3.7% vs.
1.5% within 30 days of weight loss surgery; 4.8% vs. 2.1% within 90 days; and
7.5% vs. 3.7% within 1 year.
- Patients aged 75 and older were five times more
likely to die within 90 days than those aged 65-74.
- Surgeons with less experience and fewer weight loss surgeries under
their belt were 1.6 times more likely to have a patient die within 90 days.
"The Flum paper identifies populations with a higher mortality risk if they
undergo weight loss surgery," Wolfe says. "These risks are advanced age, male
gender, and lower volume of [weight loss] surgery done by the surgeon and the
medical center in question."
What about patients who aren't Medicare beneficiaries? David S. Zingmond, MD,
PhD, and colleagues at the UCLA Center for Surgical Outcomes and Quality looked
at California patients. Overall, less than 1% of patients died within one year
of surgery.
Complications After Weight Loss Surgery
Death isn't the only bad thing that can happen after gastric bypass surgery.
There can also be surgical complications. How often do these occur? Zingmond's
team looked at this.
They looked at records on the more than 60,000 California patients from 1995
to 2004 who underwent what is now the most common weight loss surgery: the
Roux-en-Y gastric bypass.
The first thing Zingmond and colleagues found was that many more people are
having the surgery than ever before. Of the 60,000 patients who underwent the
operation in the 10-year study period, 11,659 had the operation in 2004 alone.
The second thing they found was that the operation often has complications.
Obese people have many health problems associated with being obese and end up in
the hospital more often than normal-weight people. In the year before gastric
bypass surgery, nearly 10% of patients had been admitted to the hospital.
"In the first year after surgery, about 20% get admitted -- about double the
baseline rate," Zingmond tells WebMD. "It never gets back down to 10% in first
three years after surgery. So we see an increase in rates of hospitalization."
Before surgery, most patients were hospitalized for obesity-related problems.
After surgery, most patients were hospitalized for problems arising from the
surgery itself in the first two years. "What it really comes down to is for
potential patients -- at the time of surgery, not after -- to think about what
they are willing to put up with after surgery," Zingmond says. "Other
researchers have done the analyses and found that the benefits far outweigh the
risks for appropriate patients. But people who are overweight will be more
likely to be readmitted to hospital in the first three years after the
procedure. They should be prepared for this."
Zingmond is quick to point out that laparoscopic weight loss surgery -- a
new, minimally invasive technique -- results in far fewer complications. Wolfe
agrees and estimates that two out of three weight loss surgeries today use the
laparoscopic technique.
Yet nobody yet knows the long-term consequences of offering weight loss
surgery to ever larger numbers of patients.
"We know the surgery results in weight loss, lower cholesterol, and
resolution of diabetes," Zingmond says. "But we don't know about the changes to
the gastrointestinal tract and whether, over a lifetime, this has some impact.
We're still looking at what happens."
Surgery the Best Treatment for Morbid Obesity?
Despite the risk of death and other complications, weight loss surgery
attracts increasing numbers of patients. The JAMA report by University
of Chicago researcher Heena P. Santry, MD, and colleagues chronicles the trend.
From 1998 to 2002, Santry's team finds the estimated number of weight loss
surgeries in the U.S. increased from 13,365 to 72,177. As the number of
surgeries increased, the rate of complications went down.
Why the increase? Despite the huge number of diet books sold each year,
relatively few morbidly obese people manage to lose -- and keep off --
significant amounts of weight.
Weight loss surgery, Santry and colleagues write, "remains the only durable
option for weight loss in the morbidly obese." Yet in the U.S., less than 1% of
such people undergo weight loss surgery in any given year.
"What is up with that?" Wolfe asks. "There is concern about risk and there
are negative perceptions that arise from poor results of operations that have
been tried and failed in the past. I believe that risk of complication is the
single greatest explanation of why the number of patients is relatively small.
As that improves, demand will accelerate quite substantially."
Yet Santry's data reveal a major disparity. Obesity is most common in people
with low incomes. Yet weight loss surgery is most common among higher-income
people.
"There is still the widespread perception that instead of a disease, obesity
is just people's misbehavior and they are not deserving of treatment," Wolfe
says. "An unresolved question is to what extent does cost justify withholding
access to a treatment. If it is the best treatment for a medical condition, the
cost is a problem -- but we cannot deny patients just because it is expensive to
give them the proper treatment for their condition. How to sort that out in the
long term is a question."
Zingmond says it's a question we'll have to answer in a hurry. He notes that
in California alone, as many as a million people qualify for weight loss
surgery.
"Multiply by 10 or 15 for the whole country," he says. "We need, as a
society, to address this rationally. Can we send everyone who is overweight to
surgery? That is the debate we are having now. Each state Medicare program is
making these decisions. California does allow it -- and the wait list is long."
SOURCES: North American Association for the
Study of Obesity (NAASO) Annual Meeting, Vancouver, Canada, Oct. 15-19, 2005.
Flum, D.R. The Journal of the American Medical Association, Oct. 19,
2005; vol 294: pp 1903-1908. Santry, H.P. The Journal of the American
Medical Association, Oct. 19, 2005; vol 294: pp 1909-1917. Zingmond, D.S.
The Journal of the American Medical Association, Oct. 19, 2005; vol
294: pp 1918-1924. Courcoulas, A.P. and Flum, D.R. The Journal of the
American Medical Association, Oct. 19, 2005; vol 294: pp 1957-1960. Wolfe,
B.M. and Morton, J.M. The Journal of the American Medical Association,
Oct. 19, 2005; vol 294: pp 1960-1963. Bruce M. Wolfe, MD, professor of surgery,
Oregon Health & Science University, Portland. David S. Zingmond, MD, PhD,
assistant professor of medicine, UCLA. Ronette Kolotkin, PhD, clinical
psychologist, Obesity and Quality of Life Consulting, and adjunct assistant
professor, Duke University, Durham, N.C.
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