Adjustable gastric banding
is poorly understood in Canada
Visual courtesy of Allergan
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While we've made great strides
in treating obesity's co-morbidities — diabetes,
hypertension and sleep apnea, among others — the
medical community has lagged in combatting the problem
itself. The numbers speak for themselves: from 1995
to 2005, 28.6% of Canadians gained weight while a mere
6.7% slimmed down. One out of six Canadians of normal
weight (BMI 18.5-25) in 1995 was overweight (BMI 25-30)
a decade later.
But all the time and money being
poured into managing obesity-related diseases could
easily be recouped by re-educating GPs and their patients
about how to shed the pounds in the first place —
well before those problems ever crop up, says Dr Chris
Cobourn, a Mississauga surgeon. And despite what you
may firmly believe, the solution isn't always urging
them to live a healthier, more active lifestyle. Odds
are they've already tried that, and failed. Scary as
it may sound, Dr Cobourn says the best solution may
very well be the most drastic — surgery.
GUT
REACTION
Dr Cobourn specializes in adjustable laparoscopic stomach
banding, a type of weight-loss surgery that has been
slow to catch on in Canada.
"There's an immediate [negative]
reaction, even though most physicians don't understand
the difference between the different procedures," he
says. "Some GPs don't even want to hear about it —
they think any surgical approach to obesity is too risky.
We have to overcome that bias."
Dr Cobourn insists that the biggest
risk of all lies in failing to consider all the available
options. The co-morbidities of obesity are severe: a
landmark American study published in the journal Annals
of Internal Medicine in 2003 found that obese patients'
life expectancies were 7.1 years shorter for women and
5.8 years shorter for men.
 THE
BIG SQUEEZE
Adjustable gastric banding is drastically different
from gastric bypass surgery, or stomach stapling —
a fact little known among Canadian doctors and the public,
according to Dr Cobourn.
During an outpatient laparoscopic
procedure, an inflatable loop is placed around the upper
portion of the stomach, effectively reducing the stomach's
capacity by up to 90% or more. According to the rate
of weight loss — the goal is about two pounds per
week — and the patient's ability to eat enough
to maintain proper nutrition, the band can be adjusted
as needed during a simple visit to a doctor's office.
A port is placed subcutaneously in the abdomen to allow
injection of saline through tubing to the band, or to
remove the solution to loosen it. And the surgery is
reversible; the band can be removed relatively easily.
The procedure, which has not yet
been approved for public reimbursement in Canada (it
has received the go-ahead from many European and American
insurers) can be used for patients with a BMI of 35
or greater, or 30-35 if they've already developed co-morbidities
like hypertension or diabetes.
Compared to gastric bypass, Dr
Cobourn says, adjustable gastric banding is safer and
at least as effective. A half-dozen or so studies, tracking
a total of thousands of surgeries, have shown that a
patient who undergoes gastric banding can expect to
lose up to 50-60% of excess weight within several years,
and that the weight-loss is sustainable, as opposed
to the "yo-yo" dieting that's seen so often in obese
patients.
Dr Cobourn performs 97% of his
surgeries on an outpatient basis, maintains a 99% follow-up
rate, and boasts a total of just 11 adverse events over
the course of 441 consecutive patients over 24 months
— none of which resulted in deaths.
THE
PRICE TO PAY
So if adjustable gastric band-ing is so great, why aren't
more GPs referring their patients for consultations
with surgeons who can provide it? Several reasons, according
to Dr Cobourn, not the least of which is the cost.
Gastric banding doesn't come at
a bargain. The whole process — from consultation
through the surgery to five years of follow-up —
will set patients back $16,000 at Dr Cobourn's clinic.
Without public or private insurance coverage available,
the price alone could turn patients and doctors away.
But as Toronto FP Dr David Satok put it, "The reality
is that when somebody is morbidly obese, we have to
get over the discomfort of talking about money." Like
many of his colleagues, Dr Satok admits he knew little
about gastric banding, but after learning about the
procedure from Dr Cobourn, he's now considering recommending
it to his obese patients.
Dr Cobourn also points out that
the cost of commercial diet programs, prescription drugs
and gym memberships can mount, potentially reaching
an even greater total over the course of years or decades
of failed attempts to lose weight.
TOUCHY
SUBJECT
"Obesity remains the last socially acceptable prejudice,"
says Dr Cobourn. "Patients consider it an insult if
a GP suggests surgery, they think their physician is
calling them fat and, well, they are — and they
need surgery."
It may not be an easy thing to
discuss: gastric surgery is often seen as the last resort
for patients who've failed to lose weight on their own.
But the reality is that most of them cannot sustain
weight loss with just diet and exercise. "The longterm
success rate of losing more than 20lbs in a morbidly
obese patient is 2%," Dr Cobourn says.
The bottom line is they can't do
it alone — they need your help — and you have
to have all the facts yourself to give it to them. "The
missing link in obesity treatment is primary care professionals,"
admits Dr Vansen Lee of Willowdale, ON, another FP who's
recently learned about gastric banding from Dr Cobourn.
"If we can overcome our preconceptions, we can teach
the public better. If we don't understand it well, the
patients won't either." Dr Satok agrees. "We have to
do a better job at medical education," he says.
LINGERING
FEARS
The popularity of stomach-stapling surgeries reached
its peak in the 1980s — and the subsequent years
of pain and complications for its patients convinced
many in both the public and in medical circles of the
dangers associated with gastric surgery. The problem
of perception remains: many continue to regard any gastric
surgery as highly suspect. The remedy may have to start
with a change in the way family doctors talk to their
patients.
"People have preconceived notions
about surgery for obesity," says Dr Lee. "They're really
scared — 'Oh, that must be stapling or liposuction,'
they say — but if you present it as a new management
tool for obesity, you will get a better reception."
Dr Satok agrees: "Very few will consider surgery because
of fear, but one of the things we have to do is be aware
of the medical risks of morbid obesity and balance that
with the procedure's risks."
That's not to say that the concerns
about adopting adjustable gastric banding too enthusiastically
aren't legitimate. "The fact of the matter is we are
talking about a fairly small number of surgeries done
so far," says Dr Satok. He says he intends to learn
more about the pros and cons before he starts recommending
the procedure.
"We need more user information
and experience," says Dr Lee, who nevertheless plans
to discuss it with some of his patients. "It's very
important that GPs aren't afraid to talk about it."
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