• How Weight-Loss Surgery Choices Are Changing

    How Weight-Loss Surgery Choices Are Changing

    Americans now prefer less-extensive sleeve gastrectomy to traditional gastric bypass.

    When it comes to weight-loss surgery in the U.S., a new procedure has taken over as first choice, the latest figures show. Sleeve gastrectomy is now more popular than gastric bypass surgery, which makes deeper changes in the digestive tract.

    In a four-year study, presented at the annual ObesityWeek conference in November, researchers looked at more than 70,000 patients who had weight-loss surgery between 2010 and 2013. Sleeve gastrectomy grew from slightly more than 9 percent of procedures in 2010 to 49 percent by 2013. Gastric bypass dropped from about 58 percent of procedures to 44 percent.

    First and foremost, weight-loss surgery is a last resort. It’s meant for obese people who’ve repeatedly tried to lose weight through diet, exercise and medications, but who can’t achieve or maintain a healthy weight, putting them at risk for a variety of serious medical conditions.

    Below, bariatric surgeons and patients talk about deciding between these top two types of major weight-loss surgery.

    Uneventful Surgery

    Wendy Harmon, 47, is happy with the sleeve gastrectomy surgery she had in July. She wanted to lose weight permanently, but without having her digestive tract realigned, as with gastric bypass.

    Sleeve gastrectomy is performed with a laparoscope, which is placed along with surgical instruments through small incisions in the abdomen. Surgeons remove up to 80 percent of the stomach, leaving a narrow gastric tube or “sleeve.” After the procedure, patients can no longer eat as much, and they feel full from far smaller food portions than they did before.

    “I’ve lost all my excess weight a few times,” Harmon says. “And it came down to – I wanted to keep it off.” The sleeve procedure seemed right for her. “I thought the smaller stomach would help me stay satisfied with smaller portions,” she says.

    It was during her medical physical to obtain a surgical referral that Harmon was diagnosed with Type 2 diabetes, a common complication of obesity. Metformin, the first-line drug for diabetes, was prescribed to control her blood sugar.

    Harmon looked into two surgical practices. While one was closer to home and more convenient, she instead chose Northwestern Memorial Hospital in downtown Chicago. She was impressed with the surgeon’s credentials and liked the program’s preoperative regimen, with a series of classes on nutrition that also encouraged a healthy overall lifestyle, including exercise.

    She says surgery was almost uneventful, and recovery went smoothly as well. And in a positive health note, she was able to stay off diabetes medication (which had been on hold after surgery) as her blood sugar levels returned to normal.

    Harmon now weighs nearly 150 pounds less than she did a year ago. The difference in her eating habits, she says, is portion size and food choices: “Because I spent a lot of my life eating very rich, sugary foods, and now I’m eating more foods that are fresh and lean and healthy.”

    Less Food/Less Hunger

    “The sleeve, just by removing the stomach, allows the patient to have less hunger,” says Dr. Jaime Ponce, director of bariatric surgery at Dalton Surgical Group in Georgia, and co-medical director at Memorial Hospital in Chattanooga, Tennessee. That, he explains, is in part because the portion of the stomach that’s removed no longer produces certain hunger-causing hormones.

    Sleeve gastrectomy can appear less daunting to patients than laparoscopic gastric bypass, says Ponce, a past president of the American Society for Metabolic and Bariatric Surgery. “The gastric bypass does involve more surgery, because it involves cutting and stapling of the stomach, and rearranging or rerouting the small bowel,” he says. “So with all that, it’s a big surgery that can carry more complications.” But sleeve gastrectomy isn’t free from side effects, either.

    Complications Can Happen

    Shaun Rattee, 27, of Warwick, Rhode Island, had a sleeve gastrectomy in October 2014. Although Rattee says he would do it again “in a heartbeat,” he still sounds a little hesitant. While he lost the weight he wanted, dropping from 409 pounds at surgery to his present 218 pounds, his experience was far from smooth.

    A leak from the sleeve, one of the procedure’s major complications, sent Rattee back to surgery within a few days. He eventually had a small tube, called a stent, inserted via his throat. “That made me nonstop puke for right around six weeks until I got it removed,” he says. “I couldn’t swallow anything.” He was in and out of the hospital during that time and continues to suffer from acid reflux.

    Rattee began considering weight-loss surgery at 25, and chose sleeve gastrectomy after a talk with his wife. “I really wanted to keep at least a part of my stomach,” he says. He hoped to avoid nutritional deficiencies, which occur more frequently with gastric bypass.

    Other than being overweight, Rattee says he was “pretty healthy” without medical complications. “That’s why I chose to get the surgery done at 26,” he says. “So I could avoid long-term effects on my body [like] diabetes. Because that does run in my family.”

    Rattee, who had his procedure at the Roger Williams Medical Center, in Providence, Rhode Island, is satisfied with his current weight. He works out two or three times a week, getting in at least an hour of cardio at the gym. He no longer craves sugar and sticks to a high-protein diet.

    Gastric Bypass Pluses

    Dr. Philip Schauer, director of the Bariatric and Metabolic Institute at the Cleveland Clinic, is a co-author of the study on national weight-loss surgery trends. Gastric bypass is still very popular, he says, and offers certain advantages, including greater weight loss.

    “One metric is called ‘excess weight loss,'” Schauer says. For instance, someone who is 100 pounds overweight and loses 70 pounds would have lost 70 percent of their excess weight. “An average result with a gastric bypass would be about 75 to 85 percent excess weight loss,” he says. “[With] a sleeve gastrectomy, an average result would be 60 to 65 percent.”

    For obese people with diabetes, “the gastric bypass is a particularly good operation,” says Schauer, who is also a past president of ASMBS. “The actual bypass of the intestine seems to have an additional effect that improves diabetes, independent of the weight loss.”

    Contrary to the overall trend, gastric bypass rose in popularity among bariatric patients with Type 2 diabetes, while sleeve gastrectomy rates dipped among those patients.

    Bypass or Sleeve?

    Several factors play into which option is preferable for patients, Schauer says. The sleeve procedure is shorter, lasting about an hour, versus two hours for gastric bypass. “[Sleeve gastrectomy] is a little bit less stressful of an operation because of that,” he says. “So perhaps [for] patients who are older, in their 60s or their 70s, it’s a more gentle procedure.”

    Risk of complications is slightly lower for older patients who have the sleeve procedure, Schauer says, and that also holds true for patients with major medical conditions, like heart failure. “Another area we tend to use the sleeve is in folks who are obese, but just mildly obese,” he says. “So folks who need to lose, say, 50 to 80 pounds. It works pretty well there.”

    Recovery is similar for both procedures, Schauer says. “They’re both done with laparoscopic surgery [and] almost the same type of incisions,” he says. For patients in their 20s to 50s, he says, the difference in surgery duration doesn’t have much effect.

    One unpleasant but generally avoidable side effect of gastric bypass is known as dumping, in which food dumps too quickly into the small intestine from the stomach, causing abdominal symptoms like diarrhea. Schauer says most patients can avoid nausea or dumping by staying away from foods that are rich in sugar or fat, like a bowlful of ice cream.

    Choosing a Surgery Center

    It’s important to have bariatric surgery done in a center with specially trained staff, the right-size equipment and surgical instruments for larger patients, expertise in reducing and recognizing complications (like blood clots), and the ability to rescue patients who get into trouble, Ponce says. He strongly recommends seeking a center recognized by the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program.

    He points to a 2012 study that found significantly lower in-hospital death rates of 0.06 percent in accredited bariatric surgery centers versus 0.21 percent (which is still low) in non-accredited centers. Patients in accredited centers also had shorter lengths of stay and lower costs. You can visit the American College of Surgeons website to search for accredited bariatric surgery centers in your area.

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