Taking It Off: The Benefits of Bariatric Surgery

Kimberly Brennan’s goal was to see her youngest daughter turn 18. And to wear a skirt. And to go on the rides at Six Flags. At 44, the registered nurse and mother of two weighed 240 pounds—100 pounds more than the ideal weight for a woman standing 5-foot-5. Her knees hurt, her hips hurt, she couldn’t cross her legs, apnea interrupted her sleep and she was pre-diabetic.

It was her daughter’s 13th birthday in 2012 that finally convinced Brennan to undergo gastric bypass surgery. “As mothers, we think, I can’t let anything happen to me till my kids are 18,” she says. “When Emma turned 13, I thought, If I don’t do something, I’m not going to be here when she turns 18.”

At a news conference in May of this year, Governor Chris Christie described a similar motivation for the Lap-Band gastrectomy he underwent in February at Manhattan’s NYU Langone Medical Center under the care of Dr. George Fielding. “People in public life have the same concerns people in private life have,” Christie told reporters. “Just because I have a public office and I have some measure of notoriety doesn’t mean that my feelings about my family and my concerns about their future are any different than yours.”

Brennan and the governor are among the roughly 4,000 New Jersey residents—and more than 200,000 Americans—who elect to undergo weight-loss, or bariatric, surgery each year. Bariatric procedures rose in the United States—from 16,200 in 1992 to more than 200,000 in 2009, while the rate of obesity increased from 25 percent of the United States population in 1994 to 36 percent in 2010, according to the Centers for Disease Control.

The first weight-loss surgeries—called jejunoileal bypass surgeries—were performed in the 1950s, according to the American Society for Metabolic and Bariatric Surgery. The procedure, in which a large section of the small intestine was bypassed, is no longer performed due to a high rate of complications.

Gastric bypass was introduced in the 1960s. As use of the procedure has increased, so too has its safety—thanks to the advent and refinement of laparoscopic techniques. Today, most bariatric procedures—there are four typically practiced variations—are performed with a laparoscope, a thin, fiber-optic tube that is inserted through a small abdominal incision.

Nevertheless, a number of highly publicized deaths, including five fatalities at a group of California clinics from 2009 to 2011, and accounts of celebrities, like the singer Carnie Wilson, who regained weight after surgery, have raised concerns about the procedure.

Dr. Robert Kushner, past president of the nonprofit Obesity Society, acknowledges that the surgery has potential risks such as hernia, intestinal obstruction and malabsorption of nutrients. But he also sounds a warning heard from all bariatric surgeons that the surgery is not effective in the long term without permanent lifestyle changes.

“Eating is something that’s very meaningful for us,” says Kushner, “and bariatric surgery fundamentally changes what and how you’re going to eat for the rest of your life.” More than most other surgical procedures, bariatric surgery requires a lifetime of assiduous follow-up. Most surgeons will tell you that the patient who understands that—and carefully follows the program required after surgery—is far more likely to enjoy a successful outcome.

What’s So Good About It?
For severely obese adults who have tried and failed to lose weight, or have regained weight after a diet, bariatric surgery may represent the last, best chance at a longer, healthier life. That’s because obesity isn’t just an aesthetic problem; it also has major health implications, most notably the risk of type 2 diabetes.

“There’s a straight-line correlation: When your weight goes up, your risk of diabetes goes up,” says Dr. Michael Bilof, a bariatric surgeon with offices in Millburn and Toms River. The obese are also at greater risk for hypertension, sleep apnea (a chronic breathing disorder that disrupts sleep), arthritis, infertility, heart disease and some cancers.

By itself, weight loss can lower the risk of all these ailments. But with bariatric surgery, “there’s a tremendous resolution of comorbidities, including apnea, high blood pressure and diabetes—that’s why we do the operations,” says Dr. Frank Borao, a bariatric surgeon in Eatontown. In fact, two procedures, gastric bypass and sleeve gastrectomy, can actually resolve or significantly alleviate type-2 diabetes before weight loss has occurred. Though there’s no consensus on why this occurs, both procedures appear to induce metabolic changes that help the body regulate glucose more effectively.

“If you break a bone,” says Bilof, “we operate on your bone and your bone gets better; if your gall bladder is inflamed, we operate on your gall bladder and it gets better. But when we do bariatric surgery on your stomach, your diabetes gets better, your sleep apnea gets better, your hypertension gets better, your risk of heart disease goes down. It’s the only surgery I’m aware of that will treat multiple problems.”

It’s Not a Silver Bullet
It’s easy to understand the attraction of bariatric surgery. As anyone who has tried to lose weight can attest, dieting is hard and, even when it’s successful, the results can be short-lived. And for the seriously obese, dieting is even more challenging, given the sheer number of pounds they need to shed. But while weight-loss surgery promises, and often delivers, spectacular results, it can also be as demanding and disappointing as dieting—and despite improved safety, it is considerably riskier.

A 2005 report from the New Jersey Department of Health notes that bariatric surgery could “result in serious medical problems including complications and death.” That, of course, is true of virtually all surgeries. In fact, as the report makes clear, the risk of mortality from bariatric procedures for most patients under 70 is quite low. But studies show that the best outcomes derive from procedures performed by highly experienced surgeons, and at hospitals that do a high volume—100 or more—of the surgeries annually. A 2004 study from the University of Washington, for example, showed that the risk of dying within 30 days of the surgery fell from 1 chance in 50 to as little as 1 in 500 with an extremely practiced surgeon.

Though each type of bariatric procedure carries its own risks, the surgery in general poses potential problems—and challenges. One of them is the very real risk of vitamin and mineral deficiencies caused by a decreased volume of food intake and, after some procedures, a decreased ability to absorb nutrients. A Mayo Clinic study indicated that gastric bypass surgery, which affects the body’s ability to take in nutrients like vitamin D and calcium, can lead to osteoporosis.

But for many patients, the most serious challenge of the surgery is the commitment required. “Surgery is the beginning of the journey,” says Kushner. Post surgery, patients face a lifetime of carefully monitoring what they eat and following up with their surgeons to check for complications. “Because you’re eating a small amount of food—about 800 calories a day—it’s very important to eat healthfully, especially food that’s high in protein and fiber,” says Dr. Hans Schmidt, division chief of bariatric surgery at Hackensack University Medical Center. Additionally, he says, patients must exercise regularly, take nutritional supplements and follow up religiously with their doctors.

Who Qualifies?
In general, candidates for bariatric surgery must have tried and failed to lose weight via conventional means and must have a body mass index (BMI) of 40 or higher, or 35 or higher with comorbidities like diabetes, hypertension or severe sleep apnea. (For Lap-Band surgery, BMI can be as low as 30 with comorbitidities.)
Cost, of course, is another consideration. Nationwide, the price of the surgery ranges from $11,500 to $26,000, according to the American Society for Metabolic and Bariatric Surgery. The operation is covered by Medicare and two-thirds of the country’s large employers (many large companies fund their own health insurance), though “there are more and more insurance exclusions,” says Bilof. He hopes that the American Medical Association’s recognition of obesity as a disease earlier this year will convince insurers to increase coverage.

How It Works
The most commonly performed procedure today is the Roux-en-Y gastric bypass, which creates a golf ball-sized pouch from a small section of the stomach and connects the pouch to the middle portion of the small intestine. This allows food to bypass part of the stomach and the upper portion of the small intestine, where the majority of calories and nutrients are normally absorbed. “The bypass is the gold standard,” says Schmidt. “It probably offers the greatest amount of weight loss, and the most reliable weight loss—meaning that everybody who has the procedure loses a lot of weight.”

Gerry Marrone, a Middletown resident who underwent Roux-en-Y gastric bypass surgery in 2005, lost 110 pounds, going from 335 to 215. After regaining 30 pounds, he stabilized at around 245.

On average, patients drop 60 percent of their excess body weight with gastric bypass. It is also highly effective at resolving type 2 diabetes. But the procedure permanently changes not just the size of the stomach, but also the function of the small intestine. Risks include intestinal blockage, hernia and ulcer.

Increasingly popular is vertical sleeve gastrectomy, in which the stomach is reduced by about 85 percent. This surgery not only curtails the amount a patient can eat, but also reduces hunger by removing the section of the stomach responsible for the production of the appetite-stimulating hormone ghrelin. Like bypass, it also leads to an early resolution of type 2 diabetes. Dr. Karl Strom, a surgeon at the Center for Advanced Bariatric Surgery in Glen Ridge, calls the procedure “very, very effective.” What’s more, he notes, “it doesn’t have the long-term complications of bypass.” Because the surgery is relatively new, data on complications is scarce, but known risks include stomach ulcer and obstruction.

Laparoscopic gastric banding, also known as Lap-Band surgery, involves the placement of a silicone band around the upper portion of the stomach to create a small pouch, which significantly decreases the amount a patient can eat. The band is connected to a port, which enables the surgeon to tighten the band over time.

While the surgery is reversible and carries the fewest risks of all bariatric procedures, “it’s probably the least reliable for weight loss,” says Schmidt. (Forty percent of excess body weight is average.) To lose weight, patients have to be extremely committed since, Schmidt notes, “it’s easy to cheat by eating food that’s high in calories.” In addition, unlike other bariatric surgeries, the procedure does nothing to alter appetite. That means many patients find themselves regaining lost weight. Risks include ulcer and slippage of the band, which can block the outlet to the stomach. And Strom notes that, in some patients, doctors are unable to create an optimal circumference for the band—neither too tight nor too loose—known as the “green zone,” a problem that can hinder weight loss. These negatives may explain the results of a 2011 study published in Archives of Surgery showing that almost half of all Lap-Band patients eventually have the device removed.

A number of surgeons have suggested that Lap-Banding was the wrong choice for Christie. “From my perspective, the band is only appropriate for a small subset of patients: generally young, otherwise healthy people who don’t need to lose more than 150 pounds,” says Bilof. Christie, he notes, probably needs to lose more than 200 pounds.

According to the governor, he was in excellent health before the procedure. But diabetic patients may not see much improvement in the disease after Lap-Banding. It’s too early to call the results of Christie’s surgery, and he’s been noticeably reticent about it since his earlier revelations, though a photo taken in August on the campaign trail reveals a significantly slimmer governor. In the end, his success, may hinge on the ability to stick to a demanding regimen.

The fourth option, biliopancreatic diversion with duodenal switch, is a relatively rare procedure that’s generally recommended for patients who are either severely diabetic or who, like Christie, would benefit from losing 200-plus pounds. It’s performed by removing part of the stomach, then connecting the upper portion of the small intestine (the duodenum) to the lower portion, bypassing the middle.

Losses after duodenal switch can be as high as 80 percent of excess body weight, and the average reduction in type 2 diabetes is 99.7 percent. But with the impressive results come some serious risks, including intestinal obstruction and severe long-term nutritional deficiencies.

Life after Surgery
The key to sustainable weight loss isn’t so much the surgery as what happens afterward, and that includes faithful follow-up. For Bilof, it’s simple: “The patients who follow up do better.” Regular checkups can catch potential complications, and they help patients stay on task—an important consideration given that roughly half of all gastric-bypass patients regain some of the weight they have lost after two years. “People think they’re smarter than their bodies,” Marrone says, “but it doesn’t work that way. I have to make decisions every day about what I’m going to put in my mouth.”

Doctors and patients stress the importance of support from family and friends, as well as professionals including nutritionists, counselors and the surgeon. There are also support groups of fellow patients.

Kimberly Brennan may be the perfect example of a committed patient. She lost 100 pounds within 10 months of gastric bypass, and another seven after that; she now tilts the scales at 133. To keep the weight off, she has become an ardent runner. Not only has she completed two marathons, five half marathons and an ultra-marathon of 31 miles, she also started a nonprofit running clinic at Robert Wood Johnson University Hospital in New Brunswick, where she teaches her own method of low-impact running dubbed the Kimmy Shuffle.

“Nothing about my life is the same,” she says. “I can cross my legs, and I’m elated every time I put on a skirt.”

In August, Brennan actually took her daughter to Six Flags. After trying all the rides—including the scream-inducing variety—Brennan realized something she had forgotten during her decades-long struggle with obesity: She really hates those rides.

Still, Brennan views her newfound ability to get on those rides—not to mention the resolution of her joint pain, sleep apnea and pre-diabetes—as a testament to the surgery and her “hardheaded” commitment to it.

“Never in my life,” she says, “have I been so able bodied.”

Leslie Garisto Pfaff is a longtime contributor on health, education and other topics.