Bypass only for morbidly obese

Doctor's warning: It won't work for everyone

Dr. John Brems, professor of surgery at Loyola University Medical Center in Maywood, does liver transplants. That's where he gets the most satisfaction.

  But 4 1/2 years ago, he decided to branch out into bariatric surgery. Bariatrics is the study of obesity and its treatment. Many of his liver patients could have kept their own livers, if it wasn't for their obesity.

  "I thought maybe I'd do a couple a month, but now it's three or four a week," he said. "It's really taken off. And it's very gratifying to do as well."

  Last year, he performed 98 Roux-en-Y gastric bypass surgeries. In 2000, he performed 85. This year, he's already done more than 90, and predicts he'll have done close to 200 before the year is out.

  "I didn't expect to be doing so many. I never thought it would take off like this," he said. "People just continue to come in, and it's gratifying to see them back afterward, almost as gratifying as doing liver transplants, because they lose so much weight, they're healthy and they feel good about themselves."

  There are two main types of gastroplasty surgeries: the Roux-en-Y gastric bypass, which is what Michele Lester had, and the vertical banded gastroplasty.

  "The Roux-en-Y is the only one I do, and I do it for a couple of reasons," Brems said. "There's the gastric banding, where you band the stomach. It's a restrictive operation that makes the stomach pouch smaller so the patient fills up faster. But then stomach stretches and they gain it back. They don't work.

  "The Roux-en-Y is a staple across. It divides the stomach, leaving a small gastric pouch that holds a tablespoon of fluid. We hook the gastric pouch to the small bowel, and when they eat, it fills up quickly. Food bypasses the foregut, the upper G.I. tract," he said. "If they eat sweets, it goes through them and they feel sick immediately, so it encourages them to avoid sweets. It tends to cure diabetes almost immediately, before weight loss even begins. It's a surgical cure for the type of diabetes these patients get."

  The good thing about the surgery is that it is durable, promoting long-term healthy eating habits.

  "The problem with diets is, they work very well as long as you stay on it," he said. "But it's very demoralizing if they lose 100 pounds, then six months later gain it back plus 20. With this operation, they lose weight, they lose the diabetes, their high blood pressure goes down, and they maintain the weight loss. That's the big plus."

Near-perfect success

  His success rate with the surgery is "99 percent-plus" when it comes to patients losing weight. In fact, out of the 400-plus people he's performed the surgery on, only one person did not lose weight.

  "It's very hard to defeat this operation. It forces you to stick to a certain way of eating," he said. "There are very few complications. The complication rate — from a minor wound infection to something major — is 6 percent."

  There are, of course, risks involved.

  "It is major surgery. I do it through an open incision, not laparoscopically," he said. "The major risk is infection or abscess, because we're cutting into the bowel and the stomach. That occurs 1 percent of the time. The second is because of their size, they can get blood clots in their legs while they're on the operating table that can travel to the lungs and kill them.

  None of his patients have died, however.

  "When I do the operation, the patients understand they can die from it. The third complication, there could be bleeding because the liver and the spleen are so close to the stomach, but that's rare. The last is they could get a hernia later on, and incisional hernia where things pull apart and need repair."

  Brems said the surgery will help chronic snackers: the ones who sit in front of the TV eating chips and the sweet eater.

  "This cures the sweet eater, eating sweets will give them diarrhea, so they tend to avoid sweets," Brems said. "The non-sweet eater, it helps because the stomach fills up quick. The opening between the pouch and the small bowel is very small, potato chips won't go through, they'll get stuck. So they have to really slow down and eat."

  People can still eat potato chips, but slowly to avoid a back-up, which can cause hours of discomfort before it is digested.

  The benefits of the surgery are obvious. People lose weight and become healthy, and in most cases, Brems said, they no longer view food as a crutch. They can eat almost anything they want, but just a few ounces of it. They could have a full Thanksgiving dinner by only taking a teaspoon of everything.

  "It forces them to change their lifestyle and stick to a certain diet," he said. "Once they lose weight, they want to exercise, they want to do good things for their bodies. Their self-esteem is better, they feel better about themselves, they have more energy, they're exercising — everything falls into place. It's a cascade effect."

  Although he gets a lot of satisfaction from the surgery and recommends it for people who are morbidly obese, he's disturbed that it could be seen as a cure-all for anyone who wants to shed that spare tire, especially young people.

  "I won't do it on anyone under 21," he said. "Now we're seeing patients who are not that overweight or teen-agers wanting it. It's not basically an excuse for not exercising or maintaining a healthy lifestyle. I'm a little worried that people are thinking this is the easy way out. It should only be done on people who are morbidly obese. If you weigh 400 pounds, there's no way you can go on a diet and keep it off. The operation is intended for someone like Michele, not for a 16-year-old who weighs 180 pounds but could easily get out and lose that weight."

  Women who elect to have the surgery can still become pregnant afterward with relatively low risk to the fetus, Brems said.

  The surgery is permanent. It can be reversed, in rare circumstances, but it is very dangerous to do so, he said.

  Most patients level off with their weight loss within two to three years, after losing on the average of 30 to 40 percent of their preoperative weight. The stomach can be stretched by chronically forcing it and overfeeding it, defeating the purpose of the operation. High-calorie foods, which will likely cause diarrhea and stomach cramping, will still cause weight gain, again defeating the purpose of the operation.

Risks

  According to information found on the Johns Hopkins Bayview Medical Center's Web site, gastric bypass carries risks of bleeding, infection in the incision, bowel blockage caused by scar tissue, hernia through the incision, rejection of sutures and adverse reactions to general anesthesia.

  For this procedure in particular, the most serious potential risk is leakage of fluid from the stomach or intestines, which may result in abdominal infection and the need for a second operation. There is also a small possibility of injury to the spleen, which may have to be removed if bleeding cannot be controlled.

  Pulling out of the staples is a smaller, less immediate risk.

  Patients may not lose the desired weight after surgery and some may lose weight too quickly, requiring nutritional supplements. According to the Web site, 10 to 15 patients per one hundred people who undergo this procedure will experience some complications. Death may occur from complications in one to two patients per one hundred. In general, the more serious complications are rare and the more common ones are avoidable or treatable.