Gone are the days when weight-loss surgery was used only for the morbidly obese — people who are at least 100 pounds over their ideal weight.
That's because even for less severely overweight people who can't keep the pounds off through conventional means, this surgery can be the most effective way to banish certain serious health conditions.
"If you are diabetic and overweight and your blood sugar is not under good control with standard treatment and medication, surgery is your best option," said Dr. Michel Murr, professor of surgery at USF Health and director of surgery at Tampa General Hospital.
Murr said for years, bariatric surgeons have seen Type 2 diabetes disappear practically overnight in patients who have gastric bypass surgery. "We see it in a day or two after surgery. It's so dramatic that sometimes we don't believe it," said Murr.
It's believed that the surgery brings about an almost immediate change in gastrointestinal hormones, which corrects diabetes before any significant weight loss has occurred.
"Once you divert food away from the stomach and into the small bowel, insulin production increases, insulin resistance decreases and major organs become more responsive to insulin," said Murr.
The gold standard for weight loss in the severely obese has long been gastric bypass surgery. Sometimes called stomach stapling, the procedure permanently closes off part of the stomach, creating a smaller pouch. It also changes the way food is digested and the way calories and nutrition are absorbed by the body.
Another surgery, vertical sleeve gastrectomy, changes the size and shape of the stomach, so it looks like a banana and holds less food. But it doesn't change digestion or the way nutrients are absorbed.
Gastric banding has been used widely in the U.S. for about 10 years. Most popular are the Lap-Band and Realize brands. Both are removable, adjustable devices placed around the top of the stomach and filled with saline, causing the band to tighten and create a smaller stomach pouch that holds less food.
While Type 2 diabetes corrects in about 95 percent of bypass patients shortly after surgery, it may take several months and considerable weight loss in a sleeve or band patient.
"The band doesn't change the way hormones talk to the body,'' Murr said. "Gastric bypass does."
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All the procedures are performed under general anesthesia, often laparoscopically through small punctures in the abdomen. Gastric bypass usually requires a couple of days in the hospital; banding allows you to go home the same day or after just one night in the hospital. Adjustments to the bands, made as weight is lost, are usually performed every few months in a doctor's office and take only a few minutes.
Weight loss with gastric bypass is typically faster than with banding — 100 pounds in 3 to 5 months versus a year with a gastric band.
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None of these procedures are magic bullets, and they're certainly not solely for cosmetic purposes. First off, they carry risks like any surgery, such as bleeding and infection. And although newer techniques have lessened long-term issues, patients have reported significant problems with absorbing nutrients and have had serious digestive issues.
Plenty of people with a surgically shrunken stomach have regained weight — and their health problems — after not following their new regimen scrupulously. That's why bariatric surgery patients are encouraged and even required to work with dietary, exercise, and behavior modification experts and attend support groups.
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Regardless of the procedure chosen, most programs tell their patients not to expect to reach their ideal body weight. Murr says gastric bypass patients who are 100 pounds overweight can expect to lose about 65 percent of their excess weight. According to the Lap-Band and Realize websites, gastric band patients can expect to lose 43 to 47 percent of their excess weight.
It's not impossible to lose all the excess weight, but years of experience and data indicate that it doesn't happen for most patients. And doctors like Murr say that as long as conditions like diabetes are kept under control, the surgery has been a success.
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The benefits of surgical weight loss don't stop with eradicating diabetes. In many patients sleep apnea resolves, blood pressure normalizes, high cholesterol and triglycerides plummet and fatty liver disease not associated with alcoholism fades away. Other medical conditions that are likely to improve include acid reflux or GERD, incontinence, degenerative joint disease, polycystic ovary syndrome and other causes of infertility, migraine headaches, depression and asthma.
That's why most bariatric surgeons no longer consider themselves simply weight loss specialists.
"Our focus today is on what we call metabolic surgery for the resolution and treatment of diabetes and other conditions associated with being overweight," said Murr.
Earlier this year, the FDA approved use of the Lap-Band in less overweight patients, those with a body mass index as low as 30 (a BMI between 19 and 24 is normal), if they also have at least one other metabolic disease or co-morbidity, like diabetes or high blood pressure.
"We don't need to let patients get morbidly obese to get treatment," said Dr. Tiffany Jessee, bariatric medical director for the Carillon Surgery Center. Several years ago she stopped performing gastric bypass surgery to devote her practice to gastric banding.
"You don't have to push a patient to a more radical procedure to resolve their co-morbidities,'' she said. "You need to lose about 30 percent of the weight to improve co-morbidities. The band will do that."
But for patients with a BMI greater than 50, Murr recommends gastric bypass, both to immediately resolve diabetes and also because he thinks it's a more proven procedure.
"I know with bypass they will lose 60 to 65 percent of their weight ... and I know that the weight loss is sustainable over time.''
Irene Maher can be reached at firstname.lastname@example.org.