The miracle weight loss that isn’t

The selling of a surgery
Before Ellen Marraffino underwent gastric-bypass surgery in December 2003, she attended an information session at a hospital in Orlando, Florida, and was surprised to find a revival-like atmosphere. “They herded us like cattle into this large conference room. There were at least 100 people, all terribly desperate to lose weight,” recalls Marraffino, a 49-year-old former teacher. “They paraded the successful patients, giving them the microphone: ‘I never thought I could wear a size medium in my life, and now I’m so happy and things are wonderful!’ And everyone’s clapping. People were getting all whipped up, and the doctors were selling the surgery,” she adds.

Free seminars have proliferated around the country, as doctors, hospitals and bariatric surgical centers find new ways to promote their services. Add to this the proliferation of billboards, TV ads and websites covered in flashing before and after photos and exclamation-studded enticements, looking more like ads for personal-injury lawyers than for a risky surgery. “Is gastric-bypass surgery right for you? Click here to see if we can help you qualify!” beckons one Houston practice. Another site announces a “competitive packaged price” for gastric banding patients opting to pay out-of-pocket — a route that allows doctors to avoid dealing with insurance and ensures they’ll get paid in full, as insurance companies have strict rules about which candidates qualify and sometimes don’t cover the entire cost. Although self-payers are a small segment of patients, their numbers shot up 62 percent in a two-year span, according to a study by HealthGrades, an organization in Golden, Colorado, that rates the quality of health care providers. That’s a remarkable growth for an elective surgery averaging $25,000.

Meanwhile, the manufacturers of two competing brands of gastric bands — Allergan, which makes the Lap-Band, and Johnson & Johnson, maker of the Realize Band — have taken the unusual step of marketing a major surgery directly to consumers. In November 2006, Allergan introduced a TV campaign for the Lap-Band, and both companies have websites allowing would-be patients to watch or read testimonials from happy customers, link to loan providers before surgery and track their progress afterward. At the Johnson & Johnson site RealizeMySuccess.com, a banding patient can create a 3-D model of herself and see what she might look like after a dramatic weight loss. “It works much like the cosmetic surgery industry: It’s heavily advertised, to patients, especially to women. And there’s lip service being paid to health, but for patients the great motivator is to improve appearance,” asserts Paul Ernsberger, Ph.D., nutrition professor at Case Western Reserve University School of Medicine in Cleveland.

Neil Hutcher, M.D., a surgeon in Richmond, Virginia, who has performed more than 4,000 gastric-bypass surgeries, agrees that more emphasis should be put on bariatric surgery’s potential health benefits, pointing out that last year’s University of Utah study presented some of the strongest (although still nonrandomized) evidence yet of the surgery’s disease-fighting powers. The study, which was published in The New England Journal of Medicine, found that bypass patients were 56 percent less likely to die of coronary heart disease, 60 percent less likely to die of cancer and 92 percent less likely to die of diabetes than obese people who did not have surgery. “That should be the headline: Surgery Cures Type 2 Diabetes!” Dr. Hutcher exclaims. “This is about disease, and disease going away. To think we’re out there as pseudo-plastic surgeons, that’s totally bass-ackwards.”

Either way, more doctors are entering the field. Anyone can hang out a shingle, because there’s no official certification for bariatric surgeons and no mandatory training requirements; a surgeon who has $10,000 to spend can learn banding or bypass in a five-week “mini-fellowship.” The investment is a good one; surgeons’ fees average $1,300 to $1,800 for gastric bypass, and some bariatric surgeons offer tummy tucks and other procedures to remove excess skin, charging up to $14,000. Seeking to create some quality control, the ASMBS designates hospitals whose bariatric programs meet its standards as “Centers of Excellence,” helps sponsor yearlong hospital fellowships and has created an ethics committee. “But we’re not watchdogs; we only know what is reported to us,” admits Dr. Hutcher, a past president of ASMBS; as a voluntary society, the ASMBS wields limited power to tame the no-holds-barred feel of this burgeoning field.

Drs. Hutcher and Higa both say that some physicians and patients skimp on necessary follow-up care — such as visits with a nutritionist, gastroenterologist and psychologist — to save time and money, stay within their budget and maximize profits. “It’s daunting to some doctors how much you have to spend on the follow-up program. Not everyone’s doing what they should,” Dr. Higa says. The ASMBS has also admonished clinics for flouting the generally accepted guideline that surgical candidates must have a BMI of 40 or more, or a BMI of 35 to 39.9 plus be suffering serious obesity-related health problems; some centers advertised surgery for patients who had only 40 pounds to lose. In the worst cases, Dr. Hutcher says, doctors outright lie by making impossible guarantees in their ads. “‘Permanent weight loss.’ No such thing. ‘No risk.’ There ain’t no such animal as no risk,” he says. “If you see a doctor’s website that says these things, run like hell.”

The unadvertised complications
Operating on the obese always presents major challenges. “One of the first tenets you’re taught as a surgical trainee is to fear fat,” Dr. Hutcher says, in part because it crowds the organs and makes it hard to see. Twenty-two percent of bariatric-surgery patients experienced complications before they even left the hospital, findings in the journal Medical Care reveal. Those problems ranged from the life-threatening — such as infection and respiratory failure — to milder complications such as vomiting and diarrhea. And a 2005 Journal of the American Medical Association study found that 20 percent of gastric-bypass patients were rehospitalized the year after surgery, sometimes for follow-up operations. (Those same patients’ hospitalization rate averaged 8 percent in the year before the procedure.) “It’s those additional surgeries you worry about, because there’s a significantly increased risk in repeat operations,” largely due to internal scarring, points out Mass General’s Dr. Kaplan.

In September 2006, 37-year-old Jennifer Ahrendt of Jacksonville, Florida, was one year post-op, having shed an astonishing 200 pounds, when she was struck to the floor by a bolt of pain. “It was excruciating, right in the center of my breastbone and straight through to my back,” Ahrendt remembers. “It felt like everything inside me had ruptured.” A trip to the emergency room revealed Ahrendt had gallstones — a condition shown to strike about 40 percent of gastric-bypass patients — and would need another surgery to remove them. Ironically, gallstones are a sign of weight loss success, because rapid weight loss crystallizes cholesterol in the gallbladder, forming hard deposits. They are so common that many bariatric surgeons remove the gallbladder during the initial surgery. After all, bypass surgery makes that organ irrelevant: Its job is to store bile, whose destination — the first portion of the small intestine — has been wiped off the anatomical map.

Gallbladder flare-ups are the least of a patient’s post-op worries. Bowel obstructions, a risk in any surgery, are an especially serious danger for those who have gastric bypass. “What you have then is a blind loop: The intestine is obstructed in one direction and partitioned in the other direction, so there’s no exit,” Dr. Higa explains. “If they don’t get surgery within 12 hours, the bowel could dilate and explode,” potentially killing them.

Tammy Cormier of Mamou, Louisiana, found that out the hard way. In October 2003, doctors diagnosed a bowel obstruction after Cormier developed the worst pain of her life. “It was worse than childbirth,” she remembers. Doctors knocked her out and wheeled her into surgery to resolve the problem. But a month later, Cormier was out to dinner with friends when she again cried out in stomach-clutching agony. In the hospital, tests revealed another bowel obstruction. The last thing she remembers is being rushed into surgery. She woke up three days later in intensive care, hooked up to a ventilator. Cormier recalls, “It was traumatic, one of the most horrible experiences of my life,” leaving emotional scars so deep that recently, while on a Caribbean cruise for her honeymoon, a cramp in her side brought on a full-blown panic attack. “All I could think about was ending up back on that ventilator,” she says.

Because gastric bypass rearranges the digestive tract, it’s unsurprising that patients can find themselves rife with gastrointestinal complaints. Eighty-five percent of people who have gastric bypass experience “dumping syndrome,” when sugary, undigested foods empty directly into the small intestine, causing nausea, light-headedness, cramping and gas. And then there are the true GI disasters, such as the horror Dana Boulware went through. Almost immediately after her banding procedure in January 2003, Boulware started having trouble keeping food down.

“It was like surgically induced bulimia,” says Boulware, a 46-year-old data entry specialist in Houston. “No matter how small a bite I took, no matter how much I chewed, I would feel it just sitting there — a pain in my chest like a heart attack. Then it would come right up.” She managed to tough it out for 20 months because, she says, her surgeon urged her to stick with it, continually telling her to chew her food more thoroughly. Finally, when Boulware’s esophagus felt scarred from vomiting and the enamel had worn off her teeth, a second surgeon advised removing the band. Boulware readily agreed — “I think I would have taken it out myself if I had known how,” she says. Still, she considers herself lucky. Boulware’s best friend had a similarly unhappy gastric-band experience but was determined to give surgery another try. In September 2005, her friend underwent a duodenal switch — a relatively uncommon form of weight loss surgery that involves removing a large portion of the stomach and bypassing a significant section of the small intestine — and developed a leak in her bowel. She died days later of sepsis.

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