Weight loss surgery is an increasingly popular choice for dealing with obesity. But there are risks involved, and not everyone who goes the surgery route ends up happy with the results. Surgeon and researcher Dr. Elliot Goodman joined us to discuss the issue.
Moderator: Welcome to WebMD Live, Dr. Goodman. Let’s start by discussing who is a candidate for weight loss surgery.
Goodman: The National Institutes of Health, in 1991, came up with a list of criteria with which we consider patients suitable or not suitable for weight loss surgery. These criteria were as follows:
Anybody who is 100 pounds or more above ideal body weight is a candidate for this surgery
If a patient is 85 or more pounds above ideal body weight but has medical problems related to their obesity, such as diabetes, hypertension or pulmonary or cardiac problems, they might also be candidates.
All patients should have attempted other less-invasive methods of weight loss and have failed and they also ideally should be screened by a psychologist or a psychiatrist to make sure they understand the major lifestyle changes involved in having the operation.
Moderator: What are the primary types of surgery available for weight loss?
Goodman: There are several different types of operations, but you can divide them in three:
The first type of the operation limits the size of the stomach and therefore limits how much food you can eat at any one time.
In the old days the vertical banded gastroplasty, or stomach stapling, was the main form of this type of operation. Nowadays there’s a newer form of operation called lap band, and what happens there is through the telescope you can place a plastic inflatable band around the top of the stomach to limit how much food you can eat at any one time.
The next form of operation is what they call a malabsorptive operation where you don’t limit the amount of food the stomach can take in but limit how much food the intestines can absorb. In particular, fats pass through the body and do not get absorbed.
The old fashioned operation in this category was the small bowel bypass, which was abandoned because of lots of complications. Nowadays there’s a newer form of this operation called duodenal switch, which also aims to limit how many calories you can absorb from food.
This operation has certain risks associated with it, because you don’t absorb nutrients as well and you can get into nutritional problems if you don’t take nutritional supplements and follow up with the surgeon.
The last operation is a combination of the first two types, whereby you limit the size of the stomach and additionally limit absorption from the gut into the body. An example of this operation is the gastric bypass. This is the operation that Carnie Wilson and Al Roker had, and this is the main operation for obesity in this country.
Essentially this operation is converting the size of the stomach from the size of a wine bottle to the size of an egg, and you bypass the first four or five feet of intestine.
Member question: How does the roux n-y surgery work?
Goodman: The roux n-y operation is another way of talking about the gastric bypass: It’s the same operation, limiting stomach’s size and limiting calorie absorption in the gut. Patients will lose two-thirds of their excess weight one to two years after their surgery.
Moderator: How do you decide which surgery is right for an individual?
Goodman: There are certain surgeons who prefer some operations over others. The advantage of the lap band it is less invasive than the others, and for that reason can be used in obese teenagers in whom more invasive surgery would be less preferable. The lap band, however, can easily be cheated if you eat a lot of high calorie sugary drinks. It also takes three or four years to work.
The other two operations will give patients more weight loss at a quicker speed, but have higher risks of complications because they’re bigger operations and they are rearranging the arrangement of the stomach and intestine.
The duodenal switch type of operation allows patients to eat normal portion sizes because it does not drastically reduce the size of the stomach, but it can also lead to nutritional deficiencies because only the last two feet of small intestine are still available for absorption.
Member question: How permanent is gastric bypass? Since this seems to be a relatively new procedure, do we know how it holds up over a lifetime?
Goodman: The first thing to say is a patient should consider it permanent. It is not something that can be reversed at a later date unless absolutely necessary. It was first prescribed and performed about 35 years ago and there are some very good studies that have looked at patients 10 to 15 years after surgery and have shown it to be a very effective method of weight loss even 10 to 15 years after operation.
Member question: I keep reading that gastric bypass surgery provides great benefits for obese patients with type 2 diabetes. How does the surgery help?
Goodman: The interesting thing is that a patient with diabetes who may be on several different tablets to control blood sugar and/or may be on large doses of insulin to control their blood sugar, typically can get off their medications or reduce their insulin doses days after surgery, even before any significant weight loss has occurred.
In our own laboratory we have shown when you reduce the number of calories an individual consumes, such as in the early phase after a gastric bypass operation, the body’s sensitivity to insulin suddenly increases, and this enables the patient to control their own blood sugar without having to rely on insulin injections. We have found that over 95 percent of diabetes patients either have their diabetes completely cured or significantly improved.
Moderator: So for a person with diabetes undergoing this procedure, it would be important to work with their endocrinologist and dietician before and after surgery?
Goodman: Yes, both. Particularly for patients on high insulin doses it’s very important to follow up with medical doctors or endocrinologists so that insulin doses are adjusted as time goes on, and so the blood glucose doesn’t go too low because of changes of calorie intake after surgery.
Member question: I am interested in the diet following weight loss surgery. What is recommended?
Goodman: The important thing to say is that each surgeon has his own way of doing things, and that no one way is right or wrong. All I can say is that the way I advance my patient’s diets after surgery is as follows:
A clear liquid diet of juice, Jell-O, and water for the first week after surgery.
For two or three weeks after that, a pureed diet, avoiding anything with too much sugar or fat. This can include oatmeal, mashed potato, thicker soups, and even a little scrambled egg.
After that two- or three-week period they can advance to a diet of soft solids, where fish, chicken, vegetables, and fruits can be included where they are well cooked (except the fruit), cut into small pieces, chewed very well and in small portions. Patients should eat four or five meals a day. In this third stage of the diet they can only eat 3 or 4 ounces at a time, but as time goes on they can eat 4 or 5 ounces at a time.
Member question: It sounds great, but what are the risks for each procedure?
Goodman: Good question. The first thing to say is that it is very important that patients who undergo this surgery after very careful consideration and they should have been through extensive evaluation by their surgeon, by a nutritionist, and by a psychologist.
The risks of the bigger operations include:
- Death from complications. This occurs one in 100 to one in 200 patients.
- Leaks where the stomach or intestine is cut and stapled together
- Blood clots in the legs or the lungs
- Wound infections
- Obstruction after surgery
With the lap band there’s a much smaller risk of complications, since it is less invasive, but it’s also less invasive and slower to work.
Member question: Are there any guarantees that weight loss surgery works?
Goodman: Since surgery is an art, so they say, and not a science, there are never any guarantees. However, the statistics show that on average you can expect to lose between 50 and 75 percent of your excess weight with any of these operations, if the surgeon does his job and the patient does his or her job. By that I mean the patient has to eat well, take any nutritional supplements that are required after surgery, and the patient exercises after the operation.
Member question: If people go back to eating like they did before the surgery, gradually stretching out the pouch, won’t they end up back where they started?
Goodman: It is possible to beat all of these operations if you overeat or if you eat the wrong sorts of food. In about 1 or 2 percent of patients after the gastric bypass the staples used to divide the stomach can actually unzip, and then the food goes through the old route through the rest of the stomach. If this happens patients will regain weight. So it is possible to cheat these operations, yes.
Member question: You said that counseling was important before the surgery. Should patients continue counseling after surgery?
Goodman: I think it’s very important for all patients to continue to seek nutritional counseling after surgery.
In terms of mental health, I have recently done a study looking at around 70 patients who underwent the gastric bypass operation. We sent them a mental health questionnaire about a year and a half after the operation. We came up with interesting results. We found about a quarter of the patients before surgery had symptoms of depression and 50 percent had elements of an eating disorder, such as binge eating or night eating.
Sixteen months after surgery, although the eating disorders were almost 100 percent cured, the depression remained in 25 percent of patients. It looks as if this operation is not necessarily a cure for depression in the overweight, and it may be that taking away food from individuals who use food as an emotional support may on the one hand lead to weight reduction, improvements in blood pressure, high cholesterol, and curing of diabetes, but on the other hand the withdrawal of that emotional support given to the individual by food can lead to psychological stresses in itself.
Member question: Is it possible to undergo weight loss surgery discreetly? By this I mean can one have it done quickly with little recovery time in order to not draw attention to ones self? Of course, the weight loss afterwards will be noticeable! But if one wants to go “on a vacation” from work and return quickly, can it be done?
Goodman: Yes, it can. Many people go back to work after only a week or two weeks, and if it comes up about surgery then, they can talk about having abdominal surgery or gallbladder surgery, since the gallbladder is often removed as part of the procedure.
One other thing to say is that it is very important to have good emotional support from friends and family for best results after this operation. So while it may be a good thing to be discreet at work, I think it is very important to be open with people at home so they can give you all the support they can, particularly if complications arise.
Member question: How is gall bladder function affected by gastric bypass surgery?
Goodman: Any time somebody loses weight rapidly, even with medication or Weight Watchers, the bile that is stored in the gallbladder becomes thick and can form stones. There is therefore a one in three chance that patients may develop gallstones after weight loss surgery. This incidence can be reduced if patients take medication after obesity surgery to help the bile dissolve.
Despite the three out of 10 patients who may form gall stones after surgery we find that only a few of these patients have symptoms related to their gall stones, and so therefore only a few end up requiring gall bladder surgery after they’ve had a gastric bypass or similar procedure.
Member question: Can I have the surgery if I have hepatitis C?
Goodman: I have done a lot of patients with hepatitis C, so as long as your liver function is good, I personally think there is no problem with a hepatitis C-positive patient undergoing obesity surgery without complications.
Moderator: Are there any contraindications for this surgery?
Goodman: I’ve operated on HIV patients with good control of their HIV disease and who show good compliance with nutritional and treatment needs related to their HIV disease. If they have obvious AIDS or their immune system is depressed or they show poor compliance with their HIV medication or nutrition, then I would not do the operation.
I would also consider untreatable coronary artery disease a reason not to operate, and similarly anybody with active cancer should not have the operation.
Lastly, certain patients with severe psychiatric conditions, particularly psychotic disorders, who do not show good self-control, would be poor candidates.
Member question: How long after surgery do you have to wait to become pregnant?
Goodman: I would wait at least one year; however, we have had several patients who have gotten pregnant before that and have successfully carried their pregnancies. Obesity is related to infertility and we’ve had some very nice stories of patients who have been infertile for 10 or 15 years, have lost 100, 150 pounds, and have then become pregnant.
Similarly, since fertility increases after weight loss surgery, it is more important to consider adequate contraception if you do not want to become pregnant.
Member question: What can a patient do to insure an adequate intake of nutrients following surgery?
Goodman: It is quite clear that most of us eat far more calories a day than we need to. If a year or so after surgery a patient is taking in 1,200 to 1,400 calories a day, 60 grams of protein a day, and taking vitamins, iron, and calcium, then they should have no problems, in terms of maintaining a good nutritional condition.
Member question: If one were more than 100 pounds overweight, would insurance cover this kind of surgery?
Goodman: Each insurance company is different, and many policies may have fine print excluding surgery. However, I would say if certain basic criteria are met, even if it involves a lot of paperwork, 90 percent of patients should be able to have the surgery performed and have their insurance cover it.
Moderator: Before we wrap it up for today, do you have any final comments for us, Dr. Goodman?
Goodman: All I have to say, for further information, look at my web site, which is www.shedweight.com, and if you have any questions you can email me via that web site and I’ll be more than happy to answer the questions.
Moderator: Thanks to Dr. Elliot Goodman, for sharing his expertise on weight loss surgery with us today. For more information, visit our message boards and check out our numerous articles and archived Live Event transcripts on WebMD.
WebMD content is provided to MSNBC by the editorial staff of WebMD. The MSNBC editorial staff does not participate in the creation of WebMD content and is not responsible for WebMD content. Remember that editorial content is never a substitute for a visit to a health care professional.