WEIGHT LOSS SURGERY
While I was at the American Society of Bariatric Physicians’ conference, I met a surgeon from Florida, Michael Butler, who performs weight loss operations. I asked him about these surgeries, which are only recommended for people who are extremely obese. Butler motioned me toward a sixtyish blonde woman who was wearing a cowboy hat and a glittery Western-yoked shirt. “I’d like you to meet someone,” he said.
The woman was slightly fat, with loose sallow skin and a slow and uneven gait. She didn’t look too healthy. Seven and a half years ago, Butler said, he had performed her surgery. “I lost 123 pounds,” the woman told me, “And those 123 pounds are still off.” She appeared to be delighted with her results. “This is the best thing that ever happened to me,” she said.
Butler smiled quietly, proud of his work. He performs more than one hundred of these surgeries a year — at a cost to the patient of about $20,000 each — for people who are at least 100 pounds over average weight. “You really do something that changes a person’s life,” he said. “You have individuals who have been out of society, can’t work, and now you can put these people back in society, and they feel positive about themselves.”
Of all physician weight loss treatments, surgery is the most drastic. On the whole, patients are pleased with the results — at least in the first few years. One study of patients conducted three years after their surgeries showed that almost all of them would rather be deaf, blind, or have a limb amputated than go back to being as fat as they were before. But often, after those first few years, when the “honeymoon period” is over and many patients have begun to gain weight again, many wonder whether the surgery was worth it, particularly in light of the very unpleasant side effects almost all experience, as well as the serious long-term medical complications many endure. Yet weight loss surgeries are becoming more popular as obesity is being increasingly viewed by the medical establishment as a dire health problem that needs aggressive treatment with drugs and other interventions.
The 1995 report issued by the Institute of Medicine, for instance, recommended that more attention should be paid to surgery as a viable option for weight loss when all else has failed. “There is compelling evidence that comorbidities are reduced in severely obese patients who have lost weight as a result of gastric surgery,” the panel members wrote. “Therefore, it is puzzling that this treatment is not more widely used for severely obese individuals at very high risk for obesity-related morbidity and mortality.”
Weight loss surgeons, like bariatricians, are starting to push their services more aggressively. There are about 500 weight loss surgeons in the country; they perform some 25,000 procedures per year, at $20,000 apiece, for a total of $500 million a year. While the medical literature suggests performing the procedure on people who are “morbidly obese,” the half percent of the population that is more than 100 percent over desirable weight, it is being marketed more widely. Some bariatric surgeons say the procedures are appropriate for anyone who is 100 pounds overweight, even though a 230-pound woman, for instance, may not have any health risks at all associated with her weight. Bariatric surgeons use television and newspaper ads, 800 numbers, telemarketers, and sophisticated marketing techniques to target potential patients. In San Diego and other cities, weight loss surgeons advertise in local papers for large hotel seminars they hold for prospective clients.
“They used very slick sales techniques,” says Suzanne Szames, a San Diego woman who attended a seminar not long after she watched a good friend of hers slowly die from malnutrition and kidney failure several years after she had intestinal bypass weight loss surgery. The physicians, she said, began the presentation to the audience of 150 with a show of empathy and friendliness. “They said they knew diets don’t work, they knew what we’d all been through, they understood us, and they were there to help,” Szames recalls. Then they used scare tactics, telling the audience that fat people were apt to succumb to something called Sudden Death Syndrome. They described obesity as a cancer, says Szames. “They said fat was a malignancy, and like any other malignancy, it required surgery.” The rewards of the surgery were great, the surgeons said; not only would patients lose their excess weight, but their diabetes and asthma would be cured.
The surgeons didn’t mention the side effects of weight loss surgeries until audience members asked them directly, says Szames. When they were mentioned, they were usually made light of, or glossed over. One woman in the audience, she recalls, stood up and asked if weight loss surgery patients had a problem with flatulence. “Oh, yes, there’s flatulence,” one of the surgeons told her. Then he laughed. “You have to always carry air freshener.” Szames said the physicians downplayed the very real risks involved with the surgeries and emphasized the fairy-tale promise of a morbidly obese person gaining a new lease on life by losing huge amounts of weight.
There are two main types of weight loss surgeries performed these days. Both sound a little like a bad home plumbing job. With gastroplasty or stomach stapling, most of the patient’s stomach is stapled off so that only a small pouch is still usable. The stomach becomes about five percent of its original size, and its capacity to hold food decreases a hundred-fold. Often gastroplasty is done with a band around the opening leading from the stomach pouch to the intestines, called vertical banded gastroplasty (the most common type of weight loss surgery), which keeps the stomach from distending again. With gastric bypass (the Roux-en-Y gastric bypass is the second most common surgery), the stomach is stapled, then the intestines are whacked off below the stomach and rerouted to the bottom of the stapled pouch, blocking off the rest of the stomach, the duodenum, and part of the small intestines, where food and vitamins are usually absorbed. Food goes straight from the esophagus to the tiny stomach pouch and directly into the lower part of the small intestines. Both of these procedures can usually be reversed, although that requires another surgery that is potentially more dangerous than the initial one.
With both procedures, there is a slight risk of stomach juices leaking into the abdomen, resulting in severe infection and occasionally death. Both cause severe diarrhea, awful flatulence, foul odors, pain from the staples, skin eruptions, and occasional infections. Patients vomit if they eat more than a few tablespoons of food. Those who have had their stomachs stapled often turn to bland, easily-digested foods; they often can’t tolerate meat, vegetables and fruits, and turn instead to ice creams, puddings, pastries, processed white breads, potato chips, and other unnutritious fare. The gastric bypass surgery patients can’t eat sweets because of “dumping syndrome,” where sugar passes into the small intestines too rapidly, causing dizziness, diarrhea, weakness and sweating. Because the part of their small intestines that absorbs nutrients has been blocked off, many patients develop deficiencies in iron, calcium (leading to osteoporosis), and other vitamins; it’s difficult to take enough supplements to make up for what isn’t absorbed in the intestines.
Several other long-term complications arise with weight loss surgeries. Sometimes food gets clogged in the outlet at the bottom of the stomach pouch, requiring that patients get their stomachs pumped (this happened to 22 percent of patients in one study). Others need several revisions to their surgeries, and develop painful masses of scar tissue. Sometimes these scars can end up blocking segments of the digestive tract, so stomach secretions and bile continue to enter, with nowhere to go; this requires immediate surgery. About half of weight loss surgery patients develop gallstones. Some develop cardiac arrhymmias. There is a higher suicide rate among weight loss surgery patients than there is among the morbidly obese.
Medical texts say there is an illness rate of ten percent with the surgeries, and a death rate of one percent with most weight loss surgeries. But people who oppose weight loss surgery — including the National Association to Advance Fat Acceptance (NAAFA) — say the side effects are more severe, and that the death rate from complications several years after surgery is higher. “Somewhere along the line, at five or ten years, the outcome of these surgeries is malnutrition and malabsorption,” says Marty Lipton, a San Diego NAAFA member who had a friend die after weight loss surgery. “Eventually, people’s bodies cannot keep up with it.” Usually, she says, insurance companies will cover the surgeries, but not revisions that may be needed later on when these long-term side effects develop. About ten percent of NAAFA’s members have had weight loss surgery, according to founder William Fabrey, and most gained the weight back and suffered health problems; several members have died after the surgery.
In one longer-term study, in 1993, Norwegian researchers looked at 174 cases of vertical banded gastroplasties (the surgery that reduces the stomach size without bypassing the intestines), following patients who had the operations for five years. They found higher rates of complications and deaths than are reported in shorter-term studies. During the first month, twenty-five patients reported complications, including severe wound infections, perforation of the stomach, peritonitis (inflammation of the abdominal cavity due to bacteria leaking from the stomach), and blood clots in the veins and in the lung. One patient died of widespread infection and multi-organ failure. Those numbers are in keeping with most statistics on the risks of weight loss surgery. But after five years, there were 60 cases of severe complications. Twenty-six patients had to be re-operated on, half of them because they had continual vomiting. Fifteen had developed hernias where the incisions were, and four patients died (one death was unrelated). Fewer than half had kept their weight off at or below 30 percent of the desirable weight. Many had regained weight because the stomach pouch eventually expands. After the study was completed, the researchers changed their minds about gastric surgery; their “early optimistic view” become a more “realistic one,” and they suggested that weight loss surgery isn’t the final solution to obesity.
In 1989, an American Medical Association panel of surgeons and gastroenterologists — not obesity experts, like the Institute of Medicine panel — was divided on the question of whether weight loss surgeries should be considered safe and effective. Half thought that neither of the main techniques used in weight loss surgery — stomach stapling or stapling plus intestinal bypass — had established its safety or effectiveness.
Many people who have had weight loss surgery have come to regret their decision. Karen Smith, a 40-year old Albuquerque woman who heads NAAFA’s Weight Loss Surgery Survivors group, underwent a jejunoileal bypass — a surgery, now rarely performed, where most of the small intestine is bypassed, leaving it floating, unattached at one end, inside the body — when she was 26 years old and about 375 pounds. She lost 90 pounds after the surgery, down to 285 pounds. After five years, her body adjusted to its shortened intestines, and she regained all the weight. The side effects, however, have stayed with her. She has 15-20 bowel movements a day, many of which she can’t control. She has to always carry an extra change of clothing with her in case she had an accident. Because the food she eats is improperly digested, her stools have a terribly foul odor. One government office where she worked set up a special cleaning task force to try to identify the source of the tremendously bad smell on her floor. “It was me,” she says. “It was terribly embarrassing.”
Because of her bowel problem, Smith can no longer exercise, and, formerly socially active, she often avoids people. “They said if I had surgery I would lose weight and do all the things I could never do because I was fat,” she says. “Instead, I didn’t lose weight and I can’t do any of the things that kept me healthy before.” Smith lost most of her hair from nutritional deficiency, she had kidney stones, and a bacterial overgrowth at the shunt end of the useless portion of her intestines caused an arthritis-like syndrome in her body. She tried to lose weight by dieting, but gained weight even on Weight Watchers. “It isn’t fair; I have only 18” of intestines, and I can’t lose weight,” she says. She has since given up dieting and slowly lost weight to 300 pounds, where it has stabilized for some years. “I lost more weight by giving up dieting than by weight loss surgery,” she says.
In the past few years, Smith, a former minister, has devoted much of her time to counseling people who are considering weight loss surgery. “I knew the surgery would kill me some day,” she says. “I had to face that, and do what I could to tell people.” She tries to provide people with information about the risks of surgery. “I was angry that I wasn’t given all the details of my surgery,” she says. “Everyone should have enough information to make an informed decision. Doctors overemphasize the dangers of obesity, and minimize the risks and side effects of surgery.”
Smith gives people who call her — some 400 prospective patients a year — statistics on weight loss surgery that she has gleaned from medical journals. Ten percent of patients, she tells them, don’t lose any weight at all. People who are morbidly obese — one hundred to two hundred pounds overweight — have a 39% chance of getting down to 130% of their ideal body weight. Super-obese patients, those more than 200 pounds overweight, have only an 8% chance of getting down to that “success” point. After about five years, seventy percent of patients regain all the weight. One in ten loses the weight and keeps it off. “Everyone goes into it with the hope that they’ll be one of the lucky ten percent,” says Smith.
Despite her efforts, Smith says she rarely talks people out of having the surgery. She knows how difficult it is to be extremely obese in this culture, and she understands their intense desire to lose weight when nothing else has helped them. Instead of changing their minds, many callers get angry with her. “They tell me,” she says, “you’re taking away our dream.”
© Laura Fraser