Medical and Psychosocial Factors of Weight Loss Surgery

Severe obesity is a chronic condition that is extremely difficult to treat. In some people, it can lead to life-threatening health issues such as diabetes, hypertension, stroke, and respiratory conditions. For the approximately 5% of people in the US who are severely obese, bariatric surgery to restrict food intake or interrupt the digestive process can be a safe and effective option.

James Wallace, MD, PhD, is a Medical College of Wisconsin Associate Professor of Surgery and Director of the Bariatric Surgery Program at Froedtert & the Medical College. "Those with a Body Mass Index (BMI) greater than 35 and a significant obesity-related medical condition would be good candidates for weight loss surgery," he says.

Three Categories
Dr. Wallace estimates that about half of the weight loss operations in the US are gastric bypass surgeries, about 40% are lap band surgeries, and about 10% are others.

There are three main categories of bariatric surgeries, explains Dr. Wallace. "Restrictive operations, such as the 'lap band' surgery, reduce the size of the stomach and make it difficult to eat too much. Malabsorptive operations such as the 'duodenal switch' alter the flow of food from your stomach to your intestine, causing less absorption of calories in the intestine. And a combination operation involves characteristics of both restrictive and malabsorptive procedures."

Dr. Wallace specializes in a combination surgery called the Roux-en-Y gastric bypass, the most commonly performed weight-loss surgery. A smaller stomach pouch is created by stapling or banding, so food intake is restricted. Then a Y-shaped section of the small intestine is attached to the pouch so food bypasses the duodenum (the first segment of the small intestine) and part of the jejunum (the second segment of the small intestine.) This causes reduced calorie and nutrient absorption.

Less-Common Procedures Still in Use
There are also lesser-used surgeries, says Dr. Wallace: "The duodenal switch, a malabsorptive surgery, has lower numbers in the US," he notes. In this surgery, much of the stomach remains, including part of the duodenum.

The sleeve gastrectomy is a procedure in which more than half of the stomach is removed, often as the first step in weight loss for extremely obese patients who will later undergo a duodenal switch.

In gastric pacing, typically performed as an outpatient surgery, an electronic device similar to a pacemaker is implanted in the stomach. The device produces signals that "trick" the stomach into feeling full.

"In Europe, they're still working on versions of the gastric balloon," says Dr. Wallace. Just as it sounds, this involves moving a deflated plastic balloon into the stomach and then inflating it with sterile fluids. The stomach, of course, feels full.

"The Effects of the Surgery Are Remarkable"
Weight-loss surgery is not without risks, says Dr. Wallace. Most of the surgeries are major abdominal operations requiring general anesthesia and a stay in the hospital. The standard risks of bleeding, infection, drug reaction, and cardiac problems are present, in addition to the special considerations of pulmonary complications, clotting complications, and gastrointestinal disruption. The patient's weight itself, a problem in many operations, is also an issue.

But there are many benefits to bariatric surgery, says Dr. Wallace, who has performed about 1100 gastric bypass surgeries since 1999. "When you talk about the benefits of weight loss surgery, you have to approach it from both a medical and a psychosocial standpoint," Dr. Wallace says. "The effects of the surgery are remarkable, and quite profound in all areas. Those medical conditions that are related to obesity, such as diabetes, hypertension, sleep apnea, and a long list of others, are all substantially improved by surgical weight loss."

In addition, many of Dr. Wallace's patients experience significant societal barriers and discrimination, and weight loss changes that. "While weight loss surgery is sometimes derisively referred to as cosmetic, it never is. You can't ignore the impact on your self-image when you look in the mirror and half of what you used to be looks back."

Not all patients deal with that change in a constructive way, says Dr. Wallace. "It changes who people are, and not everyone is prepared for that." To that end, the Bariatric Surgery Program has a staff in place to help patients before and after their surgery. "Everyone who comes into the program meets with a dietician, a psychologist, nurse clinicians, and advanced-practice nurses," emphasizes Dr. Wallace. "We evaluate the patients pre-operatively, coach them and support them, and teach them their new lifestyle post-operatively."

A Center of Excellence
The American Society of Metabolic & Bariatric Surgery (ASMBS) recently designated Froedtert & the Medical College's Bariatric Surgery Program a "Center of Excellence." The ASBS has very specific requirements that the hospital, the practice, and the surgeons must meet to receive this designation. The criteria for the hospital call for at least 125 surgeries to be performed annually. Appropriate equipment for patients' weight must be used in the operating rooms and hospital rooms, including larger beds, suitably-sized doorways, floor-mounted toilets, and patient lift systems.

"It's a very difficult issue," says Dr. Wallace. "If someone who weighs 500 pounds falls and can't get up, who could help that patient up? We must have the appropriate equipment." Criteria for the practice also include a multi-disciplinary approach, with support such as dieticians, physical therapists, and psychologists; as well as an office that can support the phone traffic and number of patients.

"Finally," says Dr. Wallace, "the surgeon must have sufficient experience and do at least 50 weight-loss surgeries annually; the ASBS reviews all of the surgeon's medical records for a year." Froedtert & the Medical College, the Bariatric Surgery Program, and Dr. Wallace met or surpassed all these criteria.

In addition to the honor of the designation, Centers of Excellence are the only locations where Medicare patients are guaranteed coverage for weight-loss surgeries. Previously, Medicare would not decide on patients' coverage until after their surgery was completed, but as of February 2006, Medicare has guaranteed coverage for most bariatric surgeries performed at Centers of Excellence for Medicare beneficiaries who are severely obese and have an obesity-related medical condition.

An Effective Tool
Bariatric surgery continues to be a viable option for people who are severely obese, and the number of patients having weight-loss surgeries has increased dramatically in the past decade. "I think the biggest difference between now and 20 years ago is that we are learning to better care for patients who have had weight loss operations," says Dr. Wallace.

"We understand that these operations are simply tools, and that there are certain predictable rules that will help people succeed with the operations. That's not to say that these operations are easy methods; they're not. They require fundamental changes to who people are and how they carry on their lives."

The principal work in the field, Dr. Wallace stresses, is addressing obesity as a disease. "We are increasing our understanding of how appetite is controlled and how satiety is regulated, and that's where the big breakthrough is going to be. This disease is ultimately going to be treated by medications - surgery is not the final evolution of how you take care of someone who is morbidly obese. But at present, it's the best option."

P.J. Early
HealthLink Contributing Writer

Dr. Wallace practices at the Froedtert & The Medical College of Wisconsin General Surgery Clinic.

For more information on this topic, see Dr. Wallace's HealthLink article When Nothing Else Works: Surgical Treatment of Obesity.