WebMD Live Events Transcript
Bariatric surgery is not just a fad. It's a serious, life changing procedure that is helping thousands of obese patients lose the weight necessary to improve health and lengthen their lives. What does it take to qualify for this surgery? Who should consider it? Who should not? Philip Schauer, MD, of The Cleveland Clinic answered these questions and more on July 27, 2005.
The opinions expressed herein are the guests' alone and have not been reviewed by a WebMD physician. If you have questions about your health, you should consult your personal physician. This event is meant for informational purposes only.
Welcome to WebMD Live. Our guest today is Philip Schauer, MD, from The Cleveland Clinic. He is here to discuss bariatric surgery (weight loss surgery).
Welcome Dr. Schauer. Could you tell us a little about your background and what you do?
Sure, Kate. I am currently the director of bariatric surgery at the Cleveland Clinic. I just arrived about six months ago from the University of Pittsburgh where I was for approximately ten years. I developed the bariatric surgery program there as well.
I have been involved with bariatric surgery for approximately ten years. In fact I'm currently the president elect of the American Society for Bariatric Surgery.
I also specialize in laparoscopic or minimally invasive surgery of the gastrointestinal tract. But bariatric surgery has been my primary interest for nearly a decade.
What is bariatric surgery?
What are the primary procedures involved?
Kate, there are probably 20 or 30 operations that have developed over the last 50 years to enable people to lose weight long-term. Over the past say 10-15 years, three major operations have emerged that have been shown to be both safe and effective. These operations include the gastric bypass, which is also called Roux-en-y gastric bypass.
This operation is currently the most commonly performed procedure in the United States; approximately 75% to 80% of all bariatric operations in the U.S. involve gastric bypass. It involves two things that we do to the intestinal track:
- We staple across the stomach to make a very small stomach pouch, reducing stomach volume by about 95%.
- We bypass a small portion of the upper intestinal tract. The small stomach pouch allows an individual to feel full with a small amount of food and reduces appetite. The bypass also aids weight loss by decreasing the absorption of some of the calories that are eaten.
That's the gastric bypass procedure. The average patient tends to lose about 65% to 75% of the excess weight they're carrying. So the patient that is 100 pounds overweight will typically lose 65 to 70 pounds and keep that weight off long term -- five, ten, fifteen years and beyond.
Patients who have this operation do need vitamin supplements such as iron, B12 and calcium in order to offset deficiencies that could occur after the surgery.
The second most common operation in the United States for weight loss is called gastric banding. Another term would be adjustable gastric banding. And another term commonly used would be the lap band, which is actually a specific device made by Inamed.
A lap band is an adjustable band made of silicone that is placed around the upper stomach. And it, like gastric bypass, creates a small pouch about the size of a walnut. This band is adjustable. It can be adjusted after surgery; it can be made tighter or looser by filling the band with fluid. The band is attached to its tubing -- attached to a reservoir that's placed under the skin of the abdomen. After surgery the doctor can add fluid through the skin and a port to adjust the diameter of the band that will increase weight loss.
This operation involves probably 15%-20% of the operations in the United States, and the average patient tends to lose about 50% of his or her excess weight. Basically these two are the predominant operations used today.
|"We're just beginning to understand the regulation of appetite."|
How does gastric bypass actually reduce appetite?
You know we're just beginning to understand the regulation of appetite. Appetite, meaning the desire to eat, is as complex as many other human urges we have.
We do know that there is much communication between stomach and intestines and the brain through various pathways. These can be hormonal as well as neurological. We haven't quite figured out exactly how these operations work in terms of reducing appetite, but we do know they are quite effective.
Some ideas put forth would suggest that filling the small stomach pouch stretches the small stomach, which sends signals back to the brain, telling the individual that they're full and satisfied. We call that satiety.
So we don't know exactly how these operations work. But if you ask any patient who has had gastric bypass, particularly in that first year, they will certainly tell you their appetite is much less, and they will tell you that a much smaller quantity of food fills them up and makes them feel satisfied. And that's the key. Many diets result in weight loss but still leave the individual wanting more. These operations are fundamentally different because they satisfy a patient's desires.
About the lap band: Why would you want to adjust the size of the pouch?
The advantage to the lap band is that the physicians can adjust the diameter so that it's just right. If the band is made too tight, then patients will have trouble getting any food down. They may have nausea and vomiting. A previous version of gastric banding had a fixed band that would not allow adjusting, meaning the surgeon had to guess the exact diameter that worked best for that patient.
A band can also be too loose, then anything flows through it and patients have very minimal weight loss, if any. A lap band's adjustability allows the physician, after the operation, to find the -- and pardon this pun -- the sweet spot that provides the best diameter of the opening to create weight loss but not cause undesirable side effects.
Given this adjustability, why is the lap band produce less common than the gastric bypass?
A good way to look at this, Kate, is that the band has part of the components of the bypass. It has the small stomach component, the pouch, but doesn't have the bypass. So the band is two-thirds as effective as the bypass because it has just the restrictive component of the operation and not the bypass component.
What would happen if you used the restrictive component of a lap band with the bypass portion of the gastric bypass?
These two operations have not commonly been used in combination. However, there are some surgeons beginning to combine them in more of an investigational manner. Right now they are not available in wide use together, but in the future that may be a possibility.
Do you create the same size pouch for everyone during surgery? I have heard of people having a larger pouch than others and they end up gaining their weight back.
Regarding pouch size, most surgeons try to make the pouch as small as possible for that very reason. A large pouch overtime has a tendency to stretch and patients will consume more food to reach that point of being satisfied.
So most surgeons do advocate or create a relatively small pouch -- again, the size of a walnut or in medical terms, approximately 15 milliliters in volume. In general, the smaller the better.
What happens if someone has the procedure and does overeat with this small pouch?
While overeating may happen within the first few months of surgery, it's quite uncommon after because, again, patients become accustomed to their smaller stomach and their overall desire to eat a large meal is decreased, and they begin to have a strong sense of when they are full, and so they stop eating.
So the surgery is not a license to eat.
Correct. These two operations cause weight loss principally because fewer calories are consumed in the body. Now, having said that, there's another operation which I didn't talk much about, that's less commonly used in the United States -- less than 5% of the operations.
It's called mal-absorption procedure. Unlike the gastric bypass, it involves bypassing most of the intestines so that only a small quantity of calories can be absorbed by the body. So these patients have a much larger stomach and consume quite a large quantity of calories, perhaps even more than 3,000 calories a day, and still lose weight because only a small quantity is absorbed. These mal-absorption operations are very effective.
However, these operations have a much higher rate of nutritional deficiencies. These patients often have diarrhea or many loose bowel movements per day, and they may have nutritional deficiencies such as anemia, fat soluble vitamin deficiencies, and protein malnutrition. Some of these patients will require artificial nutrition through their veins for some period to replete their body of these important nutrients.
So, the mal-absorption operations allow patients to consume large quantities of calories, but there is a very dramatic decrease in absorption. Most bariatric surgeons do not recommend these operations as a first-line therapy.
I was going to ask why someone would choose that particular therapy given the problems.
|"This kind of weight loss is for people who have severe obesity."|
Well, it's all a matter of risk-benefits. The mal-absorption operations are much more -- I'd say drastic. They are even more effective than gastric bypass and lap band in terms of weight loss.
In fact, these patients tend to lose 80% of their excess weight or more. So in some very, very large patients, perhaps in the four- or five-hundred-pound category, these operations will enable them to get closer to their ideal body weight. But there's a price to pay for that.
So there may be a role for these operations for some patients, but probably for the majority who are seeking bariatric surgery the gastric bypass or lap band would be the best options.
Who is a good candidate for weight loss surgery?
First and foremost this kind of weight loss is for people who have severe obesity, which is usually defined as more than 100 pounds of excess body weight.
Usually that amount of weight is almost always associated with many other medical conditions, such as diabetes, high blood pressure, sleep apnea, elevated cholesterol, and joint problems with knees, hips, and back. So these operations are for people who have 100 pounds or more of excess weight and medical conditions related to that heavy weight; they're not for patients who want to lose 30 pounds, or people who want to get into a bikini for their vacation.
Do most insurance plans cover this type of surgery?
This is probably our biggest challenge in the field right now. After several years of very good results from medical studies, there is a tremendous demand for bariatric surgery in this country, and we all know that obesity is increasing at an alarming rate.
Unfortunately, some insurance companies have actually withdrawn coverage for bariatric surgery. For example, in the state of Florida there is no insurance coverage for bariatric surgery anymore.
There are many other states where insurance companies are threatening to pull out. Why this is happening is not quite clear. Certainly the operation does cost money and has increased costs for insurance companies in the short term.
However, there's also a payback: the improvement in health often reduces the medical bills for many of these patients so that the operation actually pays for itself after three to five years. Nevertheless, it is a fact insurance companies are pulling out of coverage, making it very difficult for patients to seek the surgery.
Patients with severe obesity often have or will develop type 2 diabetes. Diabetes is one of the most common medical conditions attributed to severe obesity. Bariatric surgery very recently has been shown to be extremely effective at not only improving but in the majority of cases completely curing type 2 diabetes.
There was no other more effective long-term therapy for diabetes than bariatric surgery in patients with obesity. So I'm a strong advocate for bariatric surgery in diabetic patients.
The second part of the question had to do with pregnancy. Both the gastric bypass and lap band operations can certainly be performed in young women who want to get pregnant at some time in their life. With the gastric bypass we strongly encourage that for the year following the operation, they take measures not to become pregnant.
This is primarily because of the very rapid weight loss that occurs in those first few months after surgery. If a woman were to get pregnant during that time, it would make managing the pregnancy quite challenging, for obvious reasons.
But beyond that one year, when the patient's weight has stabilized, becoming pregnant is not a problem. In fact, I've had scores of women who I've operated on, five, eight years ago, who have had children after they had gastric bypass surgery. And both they and the babies have done quite well.
One advantage of the lap band procedure is that it is adjustable, so if a woman were to get pregnant even within a few months after surgery, all the fluid from the band could be removed. She would eat, you know, totally normally as she had before the surgery. And after delivering the baby, the band can be tightened up again. That's one big advantage of the adjustability of the lap band.
My advice is be evaluated for bariatric surgery. Diabetes would probably resolve and there's no reason why you could not become pregnant sometime after the operation.
Given that your nutritional intake is reduced with gastric bypass, would this affect breast milk and its value to the baby?
Although it is true that the quantity of food intake after gastric bypass is reduced, it still is very adequate to maintain a normal, healthy weight.
Most patients after gastric bypass will consume 1300 to 1500 calories a day and can certainly intake enough protein and nutrients to stay healthy, including breast-feeding. I've had several patients in my practice who have breast-fed relatively normally after gastric bypass surgery.
What time frame are we talking about from surgery to seeing a real effect on type 2 diabetes?
Almost immediate. In a study that we published in 2003 at the University of Pittsburgh, one-third of our patients had normal blood sugar when they left the hospital. So even before there is dramatic weight loss, gastric bypass operation can have dramatic effect. It's quite amazing.
|"Weight loss of 20 or even 30 pounds per month is not rare."|
And for the other two-thirds the improvement happens over the ensuing months, such that by within a year after the operation for the gastric bypass, 83% of patients have resolution of their diabetes.
And for the lap band, it's similarly effective. Approximately 65% of patients have resolution of their diabetes within a year after the lap band procedure.
How much does a pouch stretch over time?
If the pouch is made relatively small initially, there should be minimal stretching. Most surgeons will make a pouch that's quite small, approximately 15 milliliters, or the size of a walnut. So it has minimal capacity to stretch.
There can be weight gain, though, after any bariatric operation. And over time, if you follow patients 10, 15, 20 years, some will gain back some weight. On average it's usually about 10% or less.
So in other words, if a patient has 100 pounds of excess weight and loses 75 pounds in the first two years, over the next ten years they may gain back ten or 15 pounds. That's a typical scenario.
Does the age of the patient when they have the initially surgery effect the percentage they're likely to lose and how much they are likely to regain?
There does not appear to be an association between the patient's age and how much weight they lose or the potential for regaining of weight.
I'll add that many elderly patients can qualify for bariatric surgery. Our experience includes patients in their 60s and even in their 70s may qualify for surgery if they are in relatively good health to withstand a major operation.
How can we know when we have lost all that we're going to lose?
Within the first few months after gastric bypass there's rapid weight loss. Weight loss on the order of 20 or even 30 pounds per month is not rare. As time goes on, certainly beyond one year after surgery, the weight loss definitely slows down.
Most patients will reach their new baseline weight somewhere between one-and-a-half to two years after surgery. This can also be affected by the activity level of the patient. Most bariatric surgeons strongly advocate patients be involved in an exercise program; regular exercise can dramatically add to the weight loss achieved by the gastric bypass.
Your weight loss will likely decrease over the next several months. But you can certainly impact your weight loss by actively being involved in a regular exercise program as well as being very judicious on what and how you eat.
How does a doctor decide which procedure is the right one for you?
The choice of the operation will differ among bariatric surgeons. Both operations, I believe, are effective and relatively safe, but there are differences that may be more or less appealing to individuals. In our program at The Cleveland Clinic, we try to educate our patients and involve them in that decision.
What are the risks involved in these surgeries?
It is true these operations can have dramatic benefits to patients by decreasing weight, improving their quality of life, and in some cases even improving their life span. However, even though we can usually do these operations with laparoscopic surgery, they are still major operations, so complications can occur. In the hands of an experienced surgeon and an experienced medical center, these complications can usually be kept at a very low rate.
But one must expect that complications are possible when having this surgery, just like any patient who is contemplating heart surgery or other major intestinal surgery or even gallbladder surgery. It's important for the patients to understand that there certainly is a risk, but there's also a significant risk of severe obesity.
Severe obesity over time usually results in many severe medical conditions which can be life threatening, such as diabetes. So there's also a risk of death if a patient does not have surgery and allows their severe medical conditions to worsen over time.
What is the overall risk of death from this operation? Across the country, mortality rates of 1% or less are considered reasonable. How does that compare with other major surgery? Well, heart surgery has a mortality rate of 5%. Colon surgery has a mortality rate of 5%. So there are many other major operations with mortality rates much higher than bariatric surgery.
What are recovery types like for these surgeries?
If the operations are done with laparoscopic technique, that is with small incisions, most patients have a very rapid recovery.
In our hands at The Cleveland Clinic, gastric bypass surgery means usually a two-day stay in the hospital and then approximately two weeks off of work. With the lap band it's even less. One night in the hospital, and then back to work in seven to 10 days.
I'm not near The Cleveland Clinic. How would I go about finding the right kind of doctor to do this?
I highly recommend you find a surgeon and a hospital that has demonstrated a track record with bariatric surgery. It's a highly specialized field and it's clear that the best results are achieved by surgeons in hospitals that have experience in this area.
|"Are costs for the surgery coming down?"|
One way to find that information would be to go to the American Society of Bariatric Surgery web site (www.asbs.org). Listed there are members -- surgeon members -- of the society, according to the state and town they live in.
That's one good way to find that information. Very soon there will be fairly detailed credentialing information available about bariatric centers in your region, probably within the next one to two years, and many hospitals will be required to have accreditation to perform bariatric surgery.
Are costs for the surgery coming down as a result of higher volume of procedures performed?
I think so. There is information recently published in the medical literature showing that the high-volume centers tend to have lower costs, in part because the results are better and they have lower complications. So I think it is true, we are seeing some of the costs come down a bit because of this.
We're also seeing, though, very high-risk patients seeking the surgery. These are patients who unfortunately had obesity for many, many years and have already compromised heart and lungs and are severely high risk. These folks obviously will have higher costs because it will require more intensive therapy during their hospital stay.
What kind of therapy?
For example some patients who already have severe heart disease or severe lung disease as a consequence of obesity may require a stay in an intensive care unit after surgery. That's quite expensive. And if they are in the intensive care unit for several days, that cost goes way up.
Some folks require special tests prior to surgery to determine if they are in good enough health to withstand an operation. Some folks will require treatment of their conditions prior to surgery to optimize their health, to make the operation as safe as possible.
We have a question here asking how common is abdominal hernia following gastric bypass surgery?
One of the many benefits of the laparoscopic surgery with the small incisions is that the rate of hernia formation is extremely low. Those patients who have open bariatric surgery, that is with a large incision, usually from the breast bone down to near the naval, have a much greater risk of having a hernia.
This is because their large weight pulls on the incision, leading to a hernia in approximately 20% of patients. So two out of ten patients will get a hernia after open surgery. It's fairly common. However, hernia surgery today can be very effective at resolving or curing this hernia.
How long does it take for the insurance company to decide "yes or no" in coverage of bariatric surgery?
There are many different insurance companies throughout the country. It's been my understanding that each company has their own policy regarding who they believe is suitable to have bariatric surgery, and they have their own process for approving a surgery.
I have seen some companies respond rapidly -- within a few days of the application. I've also seen some companies take weeks if not months to make that decision.
Can exercise tighten up the excess skin left after surgery, or is it just an inevitable result?
How much excess skin a patient has after weight loss is entirely dependent upon how large they are before surgery. For example, a person that needs to lose 100 pounds after surgery may have only minimal loose skin and may not desire or need to have any plastic surgery.
Patients that lose 200 pounds, however, almost always have redundant skin, either in the abdomen or under the arms or around the thighs. Patients that have excess skin certainly qualify for plastic surgery.
Essentially a new specialty within plastic surgery has developed as a result of bariatric surgery. But again, the challenge is for patients to get funding for these procedures. Most insurance companies will not cover plastic surgery.
You can imagine if many insurance companies don't cover bariatric surgery, they are certainly not going to cover plastic surgery. So it's usually up to the patient to pay for these operations and the plastic surgery on their own.
Now, sometimes they can get coverage by the insurance company if they are considered medically necessary. For example, if it's abdominal excess skin and it's causing infections or hygiene problems.
Can you look in your crystal ball and tell us what you see for bariatric surgery?
It's quite exciting. In the immediate future, what I see is improved results across the country due to improved training of surgeons and hospitals. Right now there are many excellent centers that offer bariatric surgery with very good outcomes. However, results vary dramatically.
So I see in the next five years standards being established that will enable virtually any patient to go to a center within a reasonable distance from their home and have high-quality surgery. We're not quite there yet, but that is within the next five years.
The other exciting area is that these operations are going to become even less invasive. It's very likely that the bariatric operations will be performed without incisions. Yes, without incisions. Some of these operations will be performed through the mouth with an endoscopy procedure. This will dramatically reduce the pain and recovery and perhaps allows patients to go home the same day and go back to work the day after the procedure. That's probably five or ten years away.
|"Although obesity is a severe problem, there is therapy that is quite effective."|
I must also say, although I'm a surgeon, I'm very interested in any therapy that improves long-term weight loss. And there is no doubt that some time, perhaps a decade or so from now, there will be medication that is much more effective than what we have today. The medications we have today include Meridia and Xenical and unfortunately they are not very effective long term.
Anybody out there who has severe obesity and has major medical conditions, my advice would be to not wait in the hope that a magic pill comes by in the next year or two. That's probably a decade or so away. Right now only bariatric surgery has predictable long-term results.
Dr. Schauer, do you have any final comments for us?
I think our audience and the American public needs to clearly understand that obesity is a severe disease that is increasing at an alarming rate and is causing dramatic ill effects to our society and the health of the average American.
Currently surgery is the only effective therapy that consistently results in long-term significant weight loss. There are two operations, gastric bypass and lap band, that are relatively safe and effective.
These operations are not without risks, but in general, the risk of the operation is much less, for many people, than the long-term risk of severe obesity. Any patient interested in seeking surgery, I would highly encourage that they do their home work and research and identify a highly qualified, skilled surgeon, and a team of physician and health care workers who work at that bariatric center, to provide them with the support that is essential for long-term success.
Although obesity is a severe problem, there is therapy that is quite effective. Hopefully over the next several years, high quality bariatric surgery programs will be much more broadly available to the public. I wish all the audience members and listeners today the best of luck in seeking their solution to severe obesity.
Our thanks to Dr. Philip Schauer from the Cleveland Clinic. For more information, please visit The Cleveland Clinic bariatric surgery center at www.clevelandclinic.org/bariatric surgery.
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