Doctors debate safety of obesity surgeries

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Bypass operations questioned
American doctors have preferred bypass operations because they produce faster, greater weight loss. But new research by O'Brien and others calls that into question.

Combining results on 23,638 patients in 43 published studies, they found that bypasses beat bands for the first three years but were comparable after seven years, with excess weight loss of 55 percent for bypass and 51 percent for bands.

That impressed Dr. Edward Livingston, chief of gastrointestinal surgery at the University of Texas Southwestern Medical Center and chief of bariatric surgery for the Department of Veteran's Affairs national system.

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"I really was not enthusiastic about bands until I came to Dallas from Los Angeles and saw the results from the group that I joined, which where quite good," he confessed. "What you can accomplish in a year with a gastric bypass you can accomplish in five years with a laparoscopic band."

Results would improve if Americans copied the Australians and included in the price of the band any future adjustments, Livingston said.

"A key to the success of banding procedures is the followup and working with a patient on their compliance," he said. "When they come in and they've sort of fallen off the wagon, you adjust the band. It really has an amazing effect."

Bands also appear safer for women attempting pregnancy. Several years ago in Massachusetts, a woman and her 8-month-old fetus died of complications 18 months after gastric bypass surgery. Other pregnancy-related deaths have been reported.

In contrast, another study O'Brien and colleagues presented at the obesity meeting found that pregnancy outcomes for women with stomach bands were comparable to normal-weight women, and better than for obese women without bands.

Dr. Mitchell Roslin, chief of obesity surgery at Lenox Hill Hospital in New York City, did a band operation in October for Long Islander Donna Dotzler, who weighed 279 pounds, but wants to do a more drastic surgery for her husband.

"I gave up on New Year's resolutions maybe five years ago," said Jim Dotzler, who weighs 479 pounds. "I'm a smart guy. If this were a matter of willpower, I'd have taken care of this a long time ago."

Riskier surgery
The operation Roslin has advised for him is BPD, which stands for biliopancreatic diversion, with or without a second procedure called a duodenal switch. Studies show it can cause loss of up to 80 percent of excess body weight for at least as long as 10 years afterward.

Surgeons remove three-fourths of the stomach to leave a sleeve- or banana-shaped organ that is connected to the small intestine, bypassing more of it than a standard gastric bypass does. It can be done in two operations a year apart to reduce its severity and the chances of death, which can be as high as 5 percent.

The "switch" preserves a valve that controls release of food into the intestines from the stomach. These operations account for nearly 5 percent of U.S. obesity surgeries and are growing.

On the horizon are other approaches, like vagus nerve stimulation, to control impulses to eat, and new drugs like rimonabant, which blocks a pleasure center in the brain that makes people want to munch.

"I see the future as combined therapy," with surgery, medication and other approaches used simultaneously, said Aronne, the obesity society president. "Time will tell what works out best."

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