Bariatric surgery's benefits far outweigh risks

By Jennifer Lalibert�

In the year 2000 there were only 78 weight loss surgeries performed in Canada. That number shot up to over 1,100 just three years later. This surgical solution has become so popular that wait times are measured in years. Yet many physicians remain dubious of the procedure's merits, notes Dr Nicolas Christou, director of bariatric surgery at the McGill University Health Centre. They don't realize, he says, that bariatric surgery is about more than waistlines — it's a bona fide treatment option for obesity-associated comorbidities like hypertension, high cholesterol, sleep apnea and diabetes.

MEASURING UP
According to the National Institutes of Health, patients with a BMI above 40, or above 35 who suffer from obesity-related comorbidities, are prime candidates for surgery. But recent data presented at the annual meeting of the American Society for Bariatric Surgery suggests that diabetic patients with a BMI as low as 32 can benefit from slimming down surgically. "The longterm success rate of losing more than 20lbs in a morbidly obese patient is 2%," says Dr Chris Cobourn, program director of the Surgical Weight Loss Centre in Mississauga. "These patients have already been through every diet in the world — you have to realize it just doesn't work."

BYPASS vs BANDING
In North America, Roux-en-Y gastric bypass and adjustable gastric banding are the two most commonly performed procedures.

In gastric bypass, a walnut-sized pouch is permanently divided from the rest of the stomach and connected to the second part of the small intestine. Patients can't eat as much, and reducing the intestinal surfaces minimizes the calories absorbed from what they do eat. "Gastric bypass is the gold standard of bariatric surgery," says Dr Christou, who performs about 150 a year. Most procedures are now done laparoscopically, and patients typically lose 60-70% of their excess weight within two years. The procedure is covered by provincial healthcare plans — but patients are liable to spend five to seven years on a waiting list. "For every patient that we operate on, three or four more come in," says Dr Christou.

With adjustable gastric banding, an inflatable band is placed in the upper half of the stomach to create a small pouch. This reduces how much patients can eat at a time, but has no effect on absorption. The band can be adjusted with a simple office visit if needed, or removed entirely. "The followup is the key component to this procedure," says Dr Cobourn, who performs this bariatric procedure exclusively.

It's simpler, faster and safer than gastric bypass — the mortality rate is 1 in 2000, compared to 1 in 200 for bypass. But this newer procedure still awaits provincial coverage, so patients will have to fork up the $16,000 it costs themselves. However, wait times at Dr Cobourn's clinic are only about eight weeks, on average.

So what's the best choice for your patient? Generally speaking, Dr Christou says studies have shown that gastric bypass is the best option for the morbidly obese, while banding is likely better for those with less to lose. "You don't want to do a bypass in a person with BMI of 32 as a treatment for diabetes because the risk ratio is not appropriate," he says.

FEAR FACTOR
Up to 40% of patients who undergo bariatric surgery will see complications within six months after surgery, according to a study in August's edition of Medical Care. But, Dr Christou insists, you have to appreciate that in the grand scheme of things the benefits outweigh the sometimes nasty complications. Dumping syndrome is the most common problem — it's a condition where food moves too quickly through the small intestine, leading to vomiting, diarrhea, dizziness and sweating. "You have to consider the reduction in significant diseases — diabetes, hypertension, even some types of cancer — things that really matter, as opposed to treatment of minor complications," says Dr Christou.