Surgery that cuts fat lengthens life

The Baltimore Sun

Growing numbers of obese people are opting for weight-loss surgery - once a risky last-resort procedure for the very fat - and new research suggests it is saving lives.

Two studies being published today in The New England Journal of Medicine show that patients who choose surgery to drop their extra pounds can restore some of the life expectancy that obesity shortens. One of the studies, on American patients, shows that seven years after their gastric bypass operations, death from diabetes decreased 92 percent, from cancer 60 percent and from coronary artery disease 56 percent.

"It's much safer to undergo the surgery than do nothing," said Dr. Thomas H. Magnuson, director of the Johns Hopkins Center for Bariatric Surgery, who was not involved in the study.

Some obesity researchers are suggesting that the data show the surgery is so safe and the consequences of not having it so dire that more patients - lighter patients - should be eligible for it.

Other weight-loss doctors - those who do not focus on surgery in their practices - are afraid that too many people might opt for the operation, which is still not completely without risk, instead of committing to diet and exercise programs.

There's less debate when it comes to the morbidly obese. For them, "the only effective long-term treatment is surgery," said study author Dr. Ted D. Adams, who researches the genetics of obesity at the University of Utah School of Medicine.

Doctors have long known that losing weight can improve quality of life and reduce the incidence of some diseases, but these are the first large-scale studies to show that weight loss through surgery really prolongs life.

Logically, Adams said, the assumption would be that it is not the surgery itself that is the life-saver, but the weight loss, 100 pounds or more in many cases. But, he said, in practice that does not hold. In 80 percent of diabetic patients, for example, the symptoms are resolved within weeks of surgery - long before most of the weight is lost, he said.

"It's intriguing to me that there are perhaps biochemical or other physiological mechanisms related to the surgery aside from weight loss that may be improving the health of the patient," Adams said.

Obesity is being called an epidemic in medical circles. Nearly one-third of American adults are now considered obese; another third are overweight. About 15 million are morbidly obese, weighing 100 pounds or more over what is optimal. Children aren't immune either. Doctors are seeing children with high blood pressure, Type 2 diabetes, even arthritis - diseases previously rare in patients so young.

With obesity on the rise, the number of bariatric surgeries performed in the United States has risen exponentially in the past decade, more than doubling from 2002 to 2005, according to the National Institutes of Health. An estimated 180,000 surgeries were performed last year, according to the American Society for Metabolic and Bariatric Surgery.

The surgery is much less risky today. Once done openly with added risks of infection, it is now primarily laparoscopic. In the second New England Journal study, involving Swedish patients, 0.25 percent died within 90 days of the procedure, compared with 0.10 percent of those in the control group. By contrast, the death rate in the 1970s and 1980s was as many as one in five, according to researchers.

Dr. Terrence M. Fullum, medical director of the Upper Chesapeake Bariatric Surgery Center in Havre de Grace, said complication rates used to be 25 percent to 40 percent. Now that the surgery is less invasive, complication rates are just 3 percent. He said he has lost three patients in 1,500 cases, and "I anticipate never having another death. We have really evolved."

In the American study, the only instance in which death rates were higher in surgery patients than in a control group of severely obese patients was when patients died from causes other than disease, such as accidents or suicides.

Adams said he isn't sure of the exact reason for that.

It could be that people who lose extensive amounts of weight become more active and then have more accidents as a result. He said other studies have shown an increase of chemical dependence in surgery patients. Also, he said, some see weight-loss surgery as an answer to their psychological concerns, believing that if they lose weight, then they will be happy. It doesn't always work out that way.

In the study, he and his team recommend further research into better methods of evaluating candidates for surgery "including the possible need for psychological evaluation and psychiatric treatment before surgery, and aggressive follow-up after surgery."

In 1991, the National Institutes of Health set guidelines for eligibility for the surgery - people with body mass indexes of 40 or higher or those with BMIs of 35 or higher, with other health problems. Dr. George A. Bray, an obesity researcher at Louisiana State University, said he thinks the NIH should take a look at whether those guidelines are out of date and whether people with lower BMIs - obese is 30 or higher - should be able to get the surgery.

Dr. David R. Flum, a bariatric surgeon at the University of Washington, Seattle, said he would be satisfied if the people who are already eligible for the surgery were getting it. "Right now, it's the insurance lottery," he said.

Some private insurers cover it; sometimes Medicaid covers it. But there are insurance companies that don't pay, he said.

Caelie Haines, 38, weighed 316 pounds on Aug. 8, 2006, when she went in for gastric bypass at the University of Maryland Medical Center. One year later, she weighs 167 pounds. She is down 16 dress sizes to a size 10, feels "wonderful" and regularly works out at a gym.

She didn't go into the decision to have surgery lightly - she has a 13-year-old daughter who needs her single mom - but she knew her blood pressure was high, her knees hurt and she had trouble breathing.

"I just felt like I had to do this," said Haines, a writer for the University of Maryland School of Medicine's Web site.

Still, the surgery isn't a cure-all. Patients of gastric bypass, which involves stapling off most of the stomach and then circumventing the parts of the digestive system where most food absorption occurs, must change their eating habits completely. They can eat only small amounts of food. They must take supplements to prevent vitamin deficiencies.

Some patients don't lose 70 percent of their excess weight, which is the average. They might ignore the cues their body is giving them by eating too much and expanding their newly shrunken stomachs. Some of the most food-addicted have been known to melt ice cream and drink it, defeating much of the purpose of the operation.

"I don't want people to get the impression that the surgery is the answer. Surgery is a tool and it's a darn good tool, but if they don't learn to eat in the proper fashion, we'll still see failures and these people will regain the weight," said Dr. Denise E. Bruner, who runs a medical weight-loss practice in Arlington, Va.

"People have got to understand the whole picture. Obesity's a serious disease and needs to be seriously treated [but] to say there is only one answer is misleading. We live in a society of immediate gratification - just cut and dice me up and that's the end of it."

Said Dr. Lawrence J. Cheskin, director of the Johns Hopkins Weight Management Center: "Many people are able to lose weight without resorting to the extra risk of surgery."

Bariatric surgeons disagree. They say their patients have tried and failed to lose weight. They say that if a 400-pound man loses 10 percent of his body weight through dieting, he still weighs 360 pounds and is at risk for many life-threatening complications.

"Surgery is not the panacea for all problems," said Dr. Kelvin Higa, president of the American Society for Metabolic and Bariatric Surgery. "This should be the last resort, but what other treatments do we have that even come close? That's the problem. We don't have any alternatives to treating this disease.

"If you don't treat it, you die. This disease is a killer."

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