Bariatric surgery can seem like a miracle to patients desperate to drop pounds and to physicians looking for a treatment. Experts warn that it can be risky business for both.
Most of the stories start the same way. “You name it, I’ve done it,” one Chicagoan sums up her 30-year battle against obesity, waged through countless diet and exercise plans. As a last-ditch effort she had her stomach shrunk. In the months following her bariatric surgery—a procedure that restricts the stomach, limiting the amount of food that can be eaten—the pounds, nearly 150 of them, flew off. She was half her previous size. Also noteworthy, her chronic health problems, including hypertension, disappeared.
Thanks to such successes, demand for weight-loss operations has skyrocketed. In 2004 an estimated 140,000 Americans had bariatric surgery. In 2005 that number is expected to reach 175,000. Some 300 of those patients will come to the University of Chicago Hospitals Center for Surgical Treatment of Obesity, where John Alverdy leads a multidisciplinary team of surgeons, gastroenterologists, internists, dieticians, nurse practitioners, and clinical psychologists. The team’s breadth underscores the complexity of the condition, the procedure, and the post-operative experience.
The Centers for Disease Control and Prevention (CDC) defines obese as having an excessively high amount of body fat in relation to lean body mass. The CDC and other health agencies make the determination by calculating a person’s body mass index (BMI), body weight in kilograms divided by height in meters squared. People with a BMI of 25 to 29.9 are considered overweight; 30 to 39.9 qualifies as obese; 40 and higher—100 pounds or more overweight—is morbidly obese.
An estimated 64 percent of adults in the United States tip the scales as overweight or obese, according to the National Health and Nutrition Examination Survey. The numbers keep climbing. The percentage of obese Americans age 20 or older has increased from a reported 23 percent between 1988 and 1994 to 30.5 percent between 1999 and 2000, and morbidly obese from 2.9 percent to 4.7 percent.
The federal government tracks obesity as part of a campaign to prevent and treat it. Medical problems including arthritis, diabetes, hypertension, and sleep apnea are common among extremely overweight patients, and it’s estimated that related health care costs as much as $100 billion each year. The CDC succeeded in spotlighting obesity in March 2004 when it released a widely publicized study showing that 400,000 Americans die annually from the condition. Several months later, federal officials revealed that the number was lower because of a computation error. In January they offered a new estimate of 365,000 deaths and continued to maintain that the country has a serious fat problem. Bolstering the claim, in March a study led by University of Illinois at Chicago professor S. Jay Olshansky, AM’82, PhD’84, and reported in the New England Journal of Medicine, found that obesity may lower life expectancy.
While some critics challenge the notion of an obesity health crisis, others question the obesity label altogether. “It’s a medical construct,” argues Eric Oliver, a Chicago political scientist who is writing a book on the making of the obesity epidemic. “The evidence doesn’t really suggest that obesity is a disease.” Unlike diet and exercise, Oliver believes, weight has become a health focus because it’s measurable. “We’re taking an arbitrary point on the scale” and calling it fat. Politicians, he says, then use obesity to draw attention to social issues such as individual responsibility and corporate greed. “The messages are coinciding with a lot of prejudices Americans have about obesity.”
Doctors agree with Oliver that prejudices shape perceptions of obesity and, subsequently, ideas about weight-loss operations. “The majority of U.S. society buys into the moral model of obesity, not the medical model,” explains surgery resident Heena Santry, a Robert Wood Johnson clinical scholar studying the procedure. “As long as people think of [obesity] as a moral failure,” a result of eating too much and laziness, “then they will have a hard time accepting” its surgical treatment.
While those who see being overweight as a moral or personal failure consider the operations cosmetic, Alverdy and others view them as medical care for a disease. “There’s just no kudos for being overweight. That’s why I believe there’s a strong neurophysical drive and genetics involved that go beyond volition and will,” he says. “In America fat people [get blamed] for being fat and skinny people take the credit for being skinny. Because of that we’re convinced that we know why they’re fat—and we’re wrong. For most patients, surgery is the last resort. That’s the main crux of this argument you can’t get people to see.”
The first case of weight-loss surgery, a jejuno-ileal bypass, was reported in 1954; doctors joined the upper and lower parts of the patient’s small intestine, bypassing a large segment of the small bowel, the chief site of nutrient absorption. The operation had side effects—severe diarrhea, mineral and electrolyte imbalance, liver disease—and is no longer recommended. A handful of procedures have taken its place, all based on limiting food intake by reducing how much the stomach can hold and in some cases limiting calorie intake by circumventing part of the small intestine.
Chicago’s obesity surgeons perform two operations and will soon offer a third. In roux-en-y gastric bypass, doctors staple off a large section of the stomach, which normally holds 1,000 milliliters, leaving a miniature pouch with a total volume of about 15 milliliters, or one tablespoon. They also reroute the small bowel, creating a Y-shaped loop, so that food bypasses the leftover stomach and the first segment of the intestine, or duodenum. Rather than downsizing the stomach with staples, the biliopancreatic diversion with duodenal switch—duodenal switch for short—involves removing about three-quarters of the stomach. At the same time, surgeons rearrange the small intestine, relegating digestion to its final segment. The third procedure, gastric banding, places a soft plastic band around the stomach, creating a tiny pouch and restricting food from entering the rest of the way. The band is adjustable so the size of the opening can be changed. Approved by the U.S. government in 2001, the surgery is popular in Europe and Australia.
The three operations, all reversible, can be performed as open procedures by making a large incision in the abdomen or laparoscopically by making a small incision and inserting a camera that displays the surgical area on video monitors. The less-invasive laparoscopic technique—used in the majority of Chicago surgeries—causes less pain and fewer complications such as wound infections. It also requires a shorter recovery time.
In every scenario the operation’s aftermath spells big changes not only in weight but also in nutritional habits. Patients must eat small amounts, and slowly—about 4 ounces over a half hour—four to six times a day. They can’t drink 30 minutes before, during, or after a meal. At each sitting they need large quantities of protein and fewer carbohydrates. Carbonated beverages are off-limits, caffeine and alcohol cut back. They must take vitamins for life. Following the new diet requires a complete turnabout, although the surgery itself eases the learning curve. “There’s mechanical restriction to the amount of food you can take,” Alverdy explains. Patients not only can stomach less food, but they also don’t feel like eating. For the first year, he says, “people actually feel almost a physiologic, not just mechanic, aversion to food.”
As a result a patient stands to lose 100 pounds or more relatively quickly, shedding most of the weight 18 to 24 months after the operation, according to the American Society for Bariatric Surgery (ASBS), an association of weight-loss surgeons formed in 1983. In turn, related medical problems such as diabetes can improve and even disappear, doctors report. Because the procedure limits food intake, however, eating too much or too fast can be painful and can cause vomiting. When food passes too rapidly through the system, dumping—feeling queasy and sweaty, sometimes with diarrhea—can occur. In cases of overeating the stomach pouch can stretch or tear; staples can pop out. Nutritional deficiencies and psychological issues also must be monitored, according to the ASBS. Major complications can include gastrointestinal leaks, bleeding, and death.
Even with the negatives, Alverdy’s surgical calendar stays full. Some patients are referred by their physicians; others show up on their own. Applicants are more likely to be women than men—studies show that from 75 to 90 percent of patients nationwide are female. They come into his office, telling him, “People say I’m lazy,” and, “Women think I’m crazy because I can’t lose weight.” Alverdy, a smiley, fit 52-year-old, seems like their last hope.
Interested in nutrition, he began performing bariatric surgery around 1989 and is mostly self-trained. “Not too many people in the Chicago area were doing it,” he recalls, “and there seemed to be a need.” The obesity center kept growing and in 1998 added laparoscopic procedures. In fact, Alverdy’s team was the first in the region to perform gastric bypass laparoscopically, and in the Midwest it’s now the only team doing so with duodenal switch. As more patients queued up, three years ago surgeon Vivek Prachand came on board. Alverdy himself performs about four operations a week—some laparoscopic, others open, depending on the case.
Although he’s sympathetic to their plight, prospective patients need more than a sob story to make it onto his operating table. For starters, they must meet certain criteria, including a BMI greater than 40 or between 35 and 40 with major obesity-related medical problems; some problems, however, are considered too dangerous for the surgery—for example, heart or lung conditions that preclude having anesthesia. Prospective candidates must have failed previous attempts at weight loss in a medically supervised program. They also must have a stable psychological profile and fulfill dietary requirements, including taking a multiple-choice nutrition test.
Then there’s the matter of money. At Chicago the procedure costs about $50,000, and not all insurance providers cover it (a few patients pay out of pocket). Public assistance is available, and in October the federal Centers for Medicare & Medicaid Services removed language in its coverage manual stating that obesity is not an illness. The move allows subscribers to apply for reimbursement for related treatments, although obesity itself remains uncovered.
After meeting the qualifying requirements, candidates are evaluated by Chicago’s obesity center team. First they have a group session with two or three other prospective patients, the staff nurse, program coordinator, and Alverdy or Prachand. A complete history and physical are taken. Then they undergo a psychological evaluation and are interviewed by a dietician, who has them keep food logs. The process results in three ten-point scores.
The marks, tallied by a surgeon, a psychologist, and a dietician, are compared at a weekly meeting also attended by a nurse and the program coordinator. Numbers dominate the conversation. “Forty-nine, 5 feet 9 inches, 351 pounds, BMI 52.28,” Alverdy lists off a candidate’s stats at the start of a session. But reaching a decision is more than mathematics; there’s talk of motivation, psychopathology, and nutritional know-how. “He says he’s been overweight since birth. Has tried Weight Watchers, South Beach, Atkins.” The psychologist raises concern over a potential drinking problem; the dietician worries about the food available at his job. Following some discussion, Alverdy declares, “OK, he’s good to go.”
The team works its way through ten more medical folders. Among the mix is a 20-something with end-stage renal failure. Alverdy really wants to help this one. “We don’t get people to quit smoking. We treat their lung cancer,” he argues, drawing a common analogy made by weight-loss surgeons. “It just goes to show we treat symptoms, not disease.” Not on his watch: he sees obesity as the disease here and plans to address it. Another patient wins approval. In fact, each candidate gets the green light that day and will be scheduled for surgery, although Alverdy says that the center’s overall rejection rate is one in five. Complicated cases do pass through. Two patients have histories of major depression and suicide attempts. The psychologist flags them so they get extra attention along the way; one will need a letter from a social worker. Another candidate has a learning disability and will require one-on-one nutritional training, the dietician decides. When it comes to picking patients, Alverdy admits, “There are no strict guidelines.”
There also are no sure results. In a phone survey of bariatric surgeons Santry found that “not being able to predict ahead of time who will do well” remains an obstacle to securing successful outcomes. “There is no comprehensive registry,” national correspondent Robert Steinbrook writes in the March 11, 2004, New England Journal of Medicine. “Thus, it is difficult to obtain accurate data about the specific rates of serious complications and death that can be anticipated—and that may occur even with excellent care. Postoperative mortality is thought to range from as low as 0.1 percent to as high as 1 to 2 percent.” The Chicago obesity center’s mortality rate has been 0.5 percent over the past 15 years, according to Alverdy. Even successful cases can face setbacks down the road. Some people need cosmetic surgery to fix loose skin after having shed so many pounds. And five years later 25 percent of patients, Santry says, regain the lost weight, or even more.
So who makes a good candidate? The National Institutes of Health, which last held a consensus conference on bariatric surgery in 1991, recommends that it “be considered only for well-informed and motivated patients in whom the operative risks are acceptable.” Opinions vary, however, on what’s acceptable. Some surgeons operate on teens; others, including Alverdy, do not. “Right now bariatric surgeons can do what they want,” Santry says. The Chicago obesity center, as part of its multidisciplinary approach, follows patients for years post-operatively. The ASBS similarly recommends: “The patient should be able to participate in treatment and long term follow-up. Some patients with manifest psychopathology that jeopardizes an informed consent and cooperation with long term follow-up may need to be excluded.”
For the patient, the hard work begins when the operation’s over. Just ask Mary Kohrman Hayes, 52. “There’s almost this sense that you didn’t have anything to do with it,” Kohrman Hayes says 13 months after her surgery. “I think the biggest misconception is that it’s the easy way out.” For decades she had struggled to lose weight, as had her husband Michael Kohrman, a Hospitals neurologist. “I was hypertensive,” she says. “There’s a lot of diabetes in my family. Arthritis was getting to me.” Her internist suggested surgery, but initially she wasn’t sold on the idea. “There’s an underlying element of feeling like you’re a failure if you can’t deal with it yourself.” Then her brother, who’s morbidly obese, had heart failure. He survived, but the episode got Kohrman Hayes thinking, “If he died it would be tragic. If I died it would be devastating for a whole family.” The Kohrmans have three young children; pictures of the brood decorate Michael’s office walls. “That was the wake-up call. I saw that path [and thought], I don’t want to get there.”
So at 278 pounds, Kohrman Hayes, who’s 5 feet 8 inches tall, put her faith in Prachand. About four months after their initial meeting she had surgery. The duodenal switch took two hours, and she went home three days later. Impressed, Kohrman, 293 pounds and six feet tall, decided to follow suit. Unlike his wife, who’d had surgery before, he “had a virgin abdomen.” That was about to change. His August 2004 operation lasted eight hours; scarring from a childhood burst appendix caused unforeseen complications. Afterward, “I couldn’t keep anything down.” It turned out his stomach, which is larger than most, became twisted at the bottom, causing blockage. It would take two more procedures to set things right.
Husband and wife both had to make everyday adjustments. “The hardest thing the first three months is learning to eat,” Kohrman Hayes explains. “There’s clearly pain and discomfort.” Instead of having three big meals, “you eat all day long.” Getting enough protein also is tough, Kohrman points out, gesturing to a box of Protein Plus Carb Select bars on a shelf near his desk. As the pounds came off, they dealt with other differences. “The change in body image was a big change for me,” she says. “I have never been this thin. I was 180 as a senior in high school. I see myself reflected in the window, I do a double take. It takes time to adjust to that.” Kohrman, 49, had his own defining moment: “Being looked up and down at a dinner party. That happened to me for the first time in my life.” Kohrman Hayes adds that people’s reactions aren’t always easy to digest. Comments from friends and acquaintances such as “Check her out in those blue jeans” and “Are you OK?” didn’t sit well at first.
Kohrman Hayes now weighs 150 pounds, a level she has maintained since August. Her hypertension drugs are a thing of the past. Wearing a stylish cardigan, she describes a recent trip the couple took sans kids. “It was weird. When you sit down in the airplane you have all this space,” she laughs. Her husband weighs only 186 pounds these days. “Right now I vomit about once a week,” he says. “Otherwise, I’m feeling great.”
Although satisfied with their results, the couple doesn’t think the procedure is for everyone. “I would not recommend the surgery,” Kohrman Hayes says. “I would say, look at the surgery, go to a medical center, see an expert. You have to go to the experts. I worry about all of the ‘weight-loss’ centers that are sending people through like cattle. This is a big surgery.”
Chicago’s obesity doctors are a few among hundreds nationwide. The number of practicing surgeons belonging to the ASBS has increased from 258 in 1998 to 1,400 today. With big profits at stake, patients turned down by one center can easily find another door to knock on. A quick Google search for obesity produces numerous offers. “See if you’re a potential client, help in getting insurance coverage, www.gastric-bypass-center.com,” one sponsored link suggests. “It’s a real mixed-bag out there,” Alverdy observes. “There are legitimate Web sites and pretty hucksteristic Web sites.” The field, as a whole, is unregulated. Its cosmetic and commercial aspects, critics say, feed into the American culture of instant gratification and instant millions.
“It’s a growth industry,” political scientist Oliver says. Seeing an opportunity, “a lot of general surgeons have specialized. It’s really one of the most commercialized aspects of surgery other than plastic surgery.” Doctors entering the bariatric field, considered a sub-interest of general surgery, are prepared through those residency programs and continuing-education classes. The ASBS has issued guidelines for granting surgical privileges, including the documentation of successful outcomes, but notes that the recommendations “are specifically not intended to establish a local, regional, or national standard of care for any bariatric surgical procedure.” In fact, there is no official certification or mandatory training despite the unique nutritional and psychological dimensions.
With few roadblocks, weight-loss centers are popping up across the country—and they are cashing in. “Some of these people are evangelical in their approach,” Alverdy says. “They’re wrong about everyone needing surgery.” Some experts in the field, Santry notes, are even pushing to have the BMI threshold decreased from 35 to 32. “It’s more profitable for them to operate on ‘thinner’ people because there’s less likelihood of medical complication,” Oliver explains. “You can find a co-morbidity,” a major obesity-related medical problem, “on almost anyone with a BMI of 30 or above. The lower they can reduce the threshold of what’s considered obese, the greater they can expand their practice.”
With increasing options and no specific credential to check, selecting a doctor can seem like a game of chance. The nonprofit Surgical Review Corporation has launched a program to identify centers of excellence. A committee of bariatric surgeons will recommend provisional status. Qualified centers can then apply for full approval within two years. A decision is made following a site visit and a review of outcomes. The University’s obesity center has applied.
In 2003 NIH funded the Longitudinal Assessment of Bariatric Surgery to research the burgeoning procedures. The effort, receiving $3 million annually for five years, involves analyzing the risks and benefits of weight-loss operations and developing a database to house patient information. Doctors at the Hospitals also are doing longitudinal studies on the side effects. At the ASBS’s annual meeting this summer in Florida, topics to be explored include bariatric-health issues and tracking outcomes. “There are several task forces,” Alverdy says. “We would hope that clinical trials…would define who should get what procedure, that the scientific method would actually regulate the market.”
For patients desperate to conquer obesity, the stakes couldn’t be higher. “In the absence of any cultural understanding on this, they’re willing to risk death and a lifetime of impairment to overcome the stigma,” Oliver declares. “You can’t eat, you can’t enjoy food. I think there are a lot of hidden costs that aren’t necessarily apparent. In many ways, I think it’s more an indictment of our culture than the profit-seeking doctors.”
Stakes are also high for the doctors. Some hospitals and insurance companies, wary of malpractice suits, are pulling the plug. Iowa Methodist Medical Center announced in September that it was suspending its bariatric-surgery program following several deaths. High mortality rates in Massachusetts prompted that state’s public-health department to convene an expert panel to review the situation and make recommendations.
Still in development, a drug that mimics the physiologic effects of surgically shrinking the stomach could also cut back the number of operations. Alverdy predicts “there will be a pill in the next five years.” For now, Oliver favors classifying bariatric surgery as cosmetic, a suggestion weight-loss doctors decry. Alverdy puts it this way: “The surgery is not cosmetic because if you’re 100 pounds overweight you have reduced longevity, increased health problems, higher cost to your employer to insure you, higher cost to the health community, and decreased productivity at work. Your quality of life stinks.”
His patients agree. There’s nothing fun about taking up more than one seat on an airplane or being the only mom at mother-daughter dance class who needs the support of a chair to get off the ground. Even worse is the arthritis, the sleep apnea, the hypertension. Half the woman she used to be and finally living the life most thin, healthy people take for granted, Kohrman Hayes is convinced: “You don’t do this for vanity issues.”