I have tried, really tried, for years to lose weight, but now I’m 42 and at 5’4″ weigh 290 lbs. My doctor says I don’t have any hormone problem, but I have become diabetic, and he says now that I simply must lose it. I walk several times a week with a group of other heavy women, but it hasn’t done anything. What can you tell me about the stomach stapling operation?
Obesity has been in the news a great deal recently, with estimates that over 50 percent of Americans are obese, defined as a body mass index (BMI) greater than 30, and that about 1.5 million are morbidly obese, with a BMI greater than 40, (or greater than 35 if a complicating illness such as diabetes or hypertension are present). You have a BMI of 49, which is very obese.
Despite all the millions spent by Americans on weight-loss programs and products, less than 5 percent of heavy people are able to lose weight and keep it off for more than a couple of years. This is a very discouraging statistic. Even with the recently withdrawn weight-loss drugs fenfluramine and dexfenfluramine, weight-loss rarely was greater than 10 percent of body weight, and the weight was regained after the drug was stopped. The two new drugs currently approved for this purpose, orlistat (Xenical) and sibutramine (Meridia) offer no better results. It’s not surprising therefore, that the number of weight-loss surgeries, referred to as bariatric surgery, has doubled to 40,000 per year in the past few years.
Bariatric surgery was first reported in the 1950s, when procedures which simply disconnected most of the intestine from the food stream were developed. These led to severe complications, and were soon abandoned, but there are now several procedures in widespread use which avoid most of the complications, and are quite effective. Both stomach stapling and gastric bypass surgery, the other commonly done procedure in the U.S. are approved by the National Institutes of Health for the treatment of morbid obesity. You ask specifically about stomach stapling, a procedure that was popular some years ago, but is now being done less frequently in this country, although it is still popular in Europe and can be done laparoscopically, without a large abdominal incision.
Stomach stapling or banding essentially reduces the size of the stomach by putting a line of staples, or a silicone band vertically across the stomach, creating a small pouch through which the food must pass, and a large pouch that is out of the food stream. Since the small pouch will only hold a small amount of food, the person having the procedure feels full rapidly, and cannot eat as much as before. There is no malabsorbtion following this procedure since the intestine remains intact. Malabsorbtion refers to a reduction in the amount or types of nutrients that are absorbed.
Stapling has not had the best results, however. The staple line can become undone, giving the person a larger stomach pouch, the small pouch can simply stretch, and people unfortunately learn how to eat high calorie liquids like milkshakes or ice cream which pass through the pouch so easily that they don’t fill the person up. This obviously sabotages the basis for the procedure. In a Mayo Clinic series only 38 percent of the patients were able to maintain a 50 percent weight-loss after 3 years (Mayo Clinic Proceedings 2000;75:673-680). You need to lose more than 50 percent of your body weight, and keep it off permanently.
In the Mayo Clinic report and an accompanying editorial the procedure now done there, a form of gastric bypass, was described. In this procedure the stomach is divided in half vertically, leaving a small pouch large enough to hold only 2-3 tablespoons of food at one time. Although the small pouch can stretch with time, there is no possibility of the staple line opening up to create a larger pouch since the rest of the stomach is physically disconnected from the pouch. In addition, the small pouch is attached to the intestine about 150 cm downstream from the normal spot where the stomach opens into the intestine. This creates some degree of malabsorption, predominately of fat, though vitamin B12, calcium, magnesium and iron may also be poorly absorbed. In addition, since the food stream passes right into the intestine further down, it creates a side effect long recognized after stomach surgery called the “dumping syndrome”.
When a person who has had this procedure eats something that contains easily digested sugars or carbohydrates, they are absorbed into the body so rapidly that they produce nausea, weakness, sweating, faintness and often diarrhea. People rapidly learn that they cannot sabotage this procedure by drinking highly caloric liquids or eating ice cream. The Mayo Clinic report noted that after 4 years, the average weight-loss was still 63 percent of the preoperative body weight, and that 72 percent of the people operated on had maintained greater than 50 percent weight-loss. Obviously a much superior result to that with stomach stapling.
The malabsorbtion of nutrients that I mentioned was corrected with supplements. Diarrhea was common after surgery and persisted in about 22 percent after several years. This was defined as one episode of diarrhea per week or more. All the patients were able to eat normal food, although some foods caused them more difficulty than others. Heartburn and vomiting was seldom seen.
Bariatric surgery is now so common that an American Society for Bariatric Surgery has been formed and has more than 500 surgeon members. Most major medical centers have a bariatric surgery program. Insurance often refuses to cover the surgery, but that may change in the next few years as legislation mandating such coverage becomes the law in more states.
Although I and most doctors still believe that aerobic exercise and a prudent diet should be a person’s first approach to limiting weight gain or losing weight, I do recognize that for many heavy people, perhaps because of some genetic or inherited problem, this won’t work. For them, bariatric surgery may indeed be lifesaving.