New lives for morbidly obese patients

“Bariatric surgery is much safer and much more regimented than it used to be,” says Dr. Michael A. Snyder of Denver Bariatrics. “The results are phenomenal in treating weight problems and the conditions that accompany them. Not treating weight issues aggressively if a patient has high blood pressure really means not fully treating the high blood pressure.”

Patients often feel frustrated because their doctors want them to try yet another diet. Some primary care doctors may not be giving bariatric surgery proper recognition and recommending it to their patients for consideration, Dr. Snyder says. That may be because they are basing their decision on out-of-date information.

Two types of bariatric surgery are commonly performed today: Roux-en-Y gastric bypass, in which the surgeon creates a small stomach pouch and attaches it directly to the intestine, bypassing much of the stomach and the first part of the small intestine; and Lap-Band, in which the surgeon places an adjustable band around the stomach. After both procedures, patients feel full after eating a very small meal of 1 to 2 ounces of food.

Gastric bypass surgery

The Roux-en-Y procedure, which has been performed in hundreds of thousands of patients since the 1960s, is the gold standard in terms of safety and effectiveness, Dr. Snyder says. It is performed either laparoscopically (through a small incision) or as an open procedure with a full incision. Risks and results are similar with both procedures.

“In my practice, the average loss for laparoscopic gastric bypass is 82 percent excess body weight by one year,” he says. Studies have shown a slight regain with gastric bypass; after three to five years, average weight loss is about 75 percent.

During the first year after bypass, 80 percent of the weight loss results from surgery and 20 percent from compliance with the patient’s program, Dr. Snyder says. In the second year, the percentages reverse, with only 20 percent of weight loss resulting from surgery and 80 percent from the patient’s efforts.

Gastric bypass requires a lifetime commitment and is irreversible.

“With gastric bypass, what you leave the OR with is what you’ve got FOREVER,” Dr. Snyder says. Because of the bowel rerouting, for most patients, simple carbohydrates will be difficult to tolerate.

Gastric bypass carries risks associated with bowel division and reconnection, such as leakage and staple-line problems.

Lap-Band procedure

Approved by the FDA about five years ago, the Lap-Band has exploded in popularity, Dr. Snyder says. In this procedure, the surgeon places a band around the upper stomach, producing an hourglass shape and a narrow, adjustable outlet. The goal is to manage the rate at which food travels through the stomach and create a feeling of satiety with smaller meals that fill the small upper stomach.

The Lap-Band produces an average one-year loss of 52 percent of excess body weight, and weight loss progresses statistically for three years following surgery.
“We expect about 75 percent excess weight loss by three years,” Dr. Snyder says.
Both gastric bypass and gastric banding are major, abdominal surgeries that carry all attendant risks, Dr. Snyder says.

The risks associated with Lap-Band procedures include slippage and, rarely, erosion.
“The risks with the Lap-Band are less because the magnitude of the surgery is smaller,” Dr. Snyder says.

Making life changes

“Early on with gastric bypass, you lose weight seemingly no matter what,” he says. “That’s very exciting; then there is a plateau phase where the work kicks in. With the Lap-Band, you have to do the work from the beginning to get results. Ultimately both require work.”

Patients must not only adjust to new eating and exercise regimens; they also must change how they view themselves

“Emotionally, someone who has been morbidly obese most of their life has to deal with their own image and society’s treatment of them. People often say, ‘I don’t know what it’s like to live not being a fat person. A lot of people finally seem to be able to live as the person they really are.

Prior to surgery, “many patients of mine are not spending notable amounts of time and energy thinking about who they are and want to be,” he says. “After surgery, it is all about living life to your fullest potential. It is not about ‘getting by’ and ‘getting through the day.’ There is no more room for excuses: ‘I can’t do this’ or ‘They don’t like me because of my weight.’

“This reality is hard for some who have spent much of their lives with significant weight issues. All of life is not defined by your weight, and this newfound responsibility is difficult for many. This is where support from me, my office staff, support groups and one’s own internal support network comes into play.”

Who should consider bariatric surgery?

Candidates for bariatric surgery include people who have:

  • A Body Mass Index of 40, or 35 with associated problems such as depression, diabetes, fatigue, gastroesophageal reflux disease (GERD), heart disease, coronary artery disease, elevated blood fats, high blood pressure, joint pain, menstrual and/or fertility issues, or sleep disorders including sleep apnea and urinary stress incontinence
  • Failed in previous weight loss attempts
  • No medical problems that would make surgery too hazardous 
  • Not abused drugs or alcohol for at least one year
  • Quit or never smoked, or are willing to quit in anticipation of surgery. Surgical risks are greatly increased with smoking.
  • Committed to making permanent life changes. “One does not ‘try’ bariatric surgery,” Dr. Snyder says. “It is a huge commitment on the level of getting married and having children. It will have lifelong implications and has to be viewed as such.” In addition, “people have to somewhat have their act together. This cannot be an act of desperation. It takes work to succeed; this is a tool that is only as effective as the person using it. Patients must be aware that they must make diet and exercise changes, have support in the home and in life, and be compliant with medical follow-up for life.”
  • A personal desire to have surgery. One cannot do this “for someone else.”


Choosing a bariatric surgeon

Bariatric surgery is best done by an experienced specialist in a comprehensive program, Dr. Snyder says.

He recommends that people thinking about bariatric surgery consider the following:

  • Look for a specialist associated with an SRC-certified Center Of Excellence. The commitment and work to get this certification is notable and ensures that an objective body has found the program to be safe, humane and results-oriented. (For information about Centers of Excellence, visit asbs.org)
  • The surgeon should have a team composed of pulmonary/critical care medical specialists, psychiatric professionals, gastroenterologists, cardiologist and anesthesiologists. A full medical/pulmonary, psychiatric and laboratory work-up should be required for all patients.
  • The focus should be less on the procedures and more on the program, ensuring that all patients have access to adequate education and follow-up for life. 
  • Support groups supervised by the program should be made available to all patients before and after surgery, and supervised by the program. “I am a firm believer in support groups,” Dr. Snyder says. “Support groups provide a venue for people to hear about and discuss the realities of bariatric surgery and living with it. What, for example, do you do at Christmas dinner? What do you say when people stop noticing you have lost a lot of weight? How does a wife deal with a husband who doesn’t like it when she wants to go out now?”
  • The program needs to be transparent with access to patients and referring doctors about its surgical volume, results and safety record and program components. “If they can’t give that data, don’t assume they’re safe,” Dr. Snyder says. “All good programs have regular educational seminars where they present this information to the public.”