Is gastric bypass becoming the new nose job?
Bariatric surgery, once a secret last resort of the rich, may not yet be as uncontroversial as getting a bit shaved off the top, but doctors say it ought to be -- not as a cosmetic procedure, but because it saves lives.
"It should be," says Dr. Michael Snyder, president of the Bariatric Surgery Program at Rose Medical Center in Denver. "Not to be flippant, but obesity-related disease is the number two cause of preventable disease in the United States."
The number of patients is certainly climbing. According to the American Society for Metabolic & Bariatric Surgery, more than 200,000 operations were performed in 2007. And Snyder says the number of bariatric patients has doubled in the past four years.
There is an extended family of seven, all former patients of Snyder's, that seem to illustrate the success of the operation made popular by the likes of Al Roker, Carnie Wilson and Star Jones.
Frank Espinosa, 57, says he lost 147 pounds after having gastric bypass surgery in 2003. His 38-year-old daughter Tanya had her surgery on the same day and went from 205 pounds to a barely-there 124 pounds, though she says she's gained most of it back due to stress.
But Tanya's mother-in-law, Clara, 59, seems to have lost 130 of her 270 pounds for good. And Frank's wife Pam, 56, is now only 148, down from the 215 pounds she carried around until her 2004 surgery.
Dee and Nancy Dreiling, ages 52 and 60, are Pam's cousins. Together they've lost a total of nearly 230 pounds. Ron Kohler, another cousin of Pam's, weighed 358 pounds in 2006. He's since dropped more than 100 pounds.
The Espinosas and their extended family may be doing well as a whole, but how safe is stomach-stapling?
A mortality-cause study published last year in the journal Archives of Surgery seems to indicate that while gastric bypass improves the health of many, there could be a darker side.
The study, which looked at 16,683 deceased bariatric patients in Pennsylvania, found that a large number died from coronary heart disease and, oddly enough, suicide and accidents.
It comes as no surprise to surgeons that the No. 1 cause of death among patients would be prove to be heart disease, as that is the No. 1 killer of Americans in general.
"We already know that morbidly obese people are at a higher risk for coronary disease and many other medical conditions," says Dr. Anita Courcoulas, director of Minimally Invasive Bariatric & General Surgery at the University of Pittsburgh Medical Center. "We know these people have advanced coronary disease, so it's not surprising that many of them died from that underlying cause."
To bring the numbers down, all surgical practices should emphasize solid and comprehensive pre-screening and after-care, says Dr. Alexander Abkin, a laparoscopic bariatric surgeon in Floram Park, N.J.
Patients over 50 should always be seen by a cardiologist, for example. Those with compromised hearts may be poor candidates, and a reputable practice will not operate on such a candidate.
But what about suicide and accidents? According to Snyder, bariatric patients have a 58 percent higher risk of suicide and accidents than does the general population.
It's a bit of a puzzle for researchers, but one that reinforces the importance of psychological pre-screening, says Abkin.
"You can't just staple someone's stomach and send them on their merry way," he says.
It's a puzzle that Snyder -- who says he also puts his patients through a rigorous pre-screening process -- has given some thought.
When it comes to the increased risk of accidents, he says, that may be due to the increased mobility of people who drop large amounts of weight. As can be seen in the accompanying slide show of the Espinosa extended family, losing weight can inspire people to try new, and inherently risky, activities.
"This suggestion of perhaps increased risk for suicide and/or risk-taking behavior needs to be explored with further clinical studies," Courcoulas said in an email. But in the absence of such data, experts can be asked to speculate.
Even with intensive psychological screening, Snyder says, it may be that in some prospective patients there is a difficult to detect "psychological element" that makes some people more prone to fatal depression.
Having gastric bypass surgery means changing your entire lifestyle forever, he says, and it is no easy task to determine who is mentally strong enough to commit to such a change.
Frank Espinosa says that Snyder had him commit to losing 25 pounds on his own before he could have the surgery.
"It was a test," Espinosa says. "He wanted to see if I had what it takes to stick to the eating program."
Gastric bypass patients, whose stomachs are surgically reduced to the size of an egg, are only able to eat the tiniest of meals. If they attempt to eat more, they will initially experience sickness and vomiting, but if they continue to try and eat like they did before, or even like a normal person, their stomachs will eventually stretch.
"Some people think it's a fix. It's not. It's just a tool," Espinosa says. "It works if you use it correctly and respect it. It's a miracle to me. My life has totally changed."
The grandfather, who says he used to have a hard time making it up a flight of stairs, is planning to take his son-in-law, son, and two grandsons to Canada on a 28-mile backpacking trip through the wilderness.
Yet not all patients are as grounded and determined as Espinosa, and those are the ones surgeons say they must be on the lookout for. In order to understand why a comparatively large percentage of bariatric patients try to commit suicide, it is first necessary to examine the population, Snyder says.
"I look at simple things like depression," he says. "Eighty-nine percent of my patients have depression when they come in. After, the number drops to 25 percent -- about the same as the general population."
Out of that quarter, some will choose to take their own lives, but doctors are not sure why.
One possible answer, says Snyder, is that those people are unable to adjust to their new identity.
"You and I and everyone have built our lives on a bunch of tenets of who we are, including what our bodies look like," Snyder says. "After surgery, that changes very quickly."
Another reason may have to do with unrealistic expectations. In Espinosa's case, his life was indeed completely turned around by simply losing weight. But other patients may have more complicated problems to deal with.
Snyder says that when you "spend your whole life struggling with weight, as humans we want everything to be instantly cured and that's not going to happen."
He says patients should take advantage of the services most reputable bariatric practices have in place post-surgery.
Abkin says he's found group therapy a valuable tool, as long as it's run by qualified behavioral therapists, and not simply by other patients.
"Long-term success depends on this," he says. "People have issues that led them to become overweight, and if those underlying issues are not addressed there could be problems."
Snyder says that in addition to therapy he offers patients closed online chatrooms, but that he's often surprised by how many patients fail to take advantage of these support tools.
"Frank said it best, when he talked about the surgery as being a tool," Snyder says. "It's like a snowblower. It's only going to get you out of your driveway if you gas it up and use it. And if you misuse it, it can cause harm."
Yet in spite of the risks the latest studies, published in the New England Journal of Medicine, show that bariatric surgery is not only relatively safe, but that it saves lives. Some surgeons are quick to point out that for that reason, it cannot be put in the same category as a nose job.
But when it comes to society's acceptance of the procedure and of people who have it performed, perhaps the comparison will stand.