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Laparoscopic gastric bypass successful for many morbidly obese patients

Obesity is a complex, chronic disease. The causes are unclear. Evidence suggests it often has more than a single cause—genetic, environmental, psychological, cultural/social and metabolic factors all play a part.

What influences obesity?
The hypothalamus, a region of the brain that controls an immense number of bodily functions, including food intake, sends out hunger signals when you restrict your eating. If you eat until you're full, the hypothalamus sends signals to make you feel full. For reasons we don't fully understand, some individuals are resistant to the hypothalamus signals of fullness.

There are also subtle genetic defects we don't fully understand that make some of us susceptible to obesity. And, unfortunately, once a person gets morbidly obese, he or she doesn't need to overeat to maintain weight at that level because very heavy people are also very inactive.

Diseases associated with morbid obesity
Many people with a BMI of 40 have other diseases, often of the cardiovascular system, including high blood pressure and loss of heart muscle function. They may have some degenerative joint disease from the mechanical stress of carrying all that weight, which may lead to arthritis in the knees and ankles. Diabetes is the most serious and most frequent associated disease we see with morbid obesity.

Who should consider surgery?
In my practice, I basically follow the NIH guidelines. A person should have a BMI of greater than 40, which averages about 80 pounds overweight for a man and 100 pounds for a woman. If a patient suffers from sleep apnea, diabetes, hypertension, I would consider a patient for surgery with a BMI of 35 or higher.

I require that individuals try multiple diets for at least a year before considering surgery, and I have devised a diet-history questionnaire so I can evaluate the success or failure with diets. I look at how much weight was lost with each diet and how long the weight stayed off. Almost all morbidly obese people have dieted off and on their whole lives with no lasting success.

In general, I consider people between the ages of 18 and 55, although I am somewhat flexible depending on the individual situation of each patient. I might consider an adolescent, but I would rarely consider someone under age 14. Also, obese elderly people have many serious health conditions and are usually at too high a risk for surgery.

Mental health screening
All my patients must undergo a preoperative mental health visit to screen them for psychological disorders, to assess their eating patterns and to determine if they have the coping skills and support systems necessary to do well with surgery. I refer my patients to the Yale Center for Eating and Weight Disorders, where the staff is very experienced in assessing individuals with severe weight problems. If, for example, a patient has serious chronic depression that's not being treated, we might decide surgery is not a good option until the psychological illness is under control.

The surgery in a nutshell
During the surgery I convert the patient's stomach to the size of a toddler's stomach using the Roux-Y approach. I do minimally invasive surgery with a laparoscope, which requires only four 5-millimeter incisions and two 12-millimeter incisions. I use a stapling device and attach the downstream intestine to the small stomach pouch.

The operative time is related to the size of the patient. Those with a BMI of 40 usually take 2-1/2 hours, but each step takes longer with bigger patients. My largest patient was 530 pounds with a BMI of 74, and that surgery took about five hours. Patients usually require two to three days of hospitalization. Older individuals with bad degenerative bone disease may take longer because of back pain.

The risk of complications from this kind of surgery is very low. Two percent of patients experience some leakage from the site where the stomach and intestine are attached. Most of them will heal on their own with proper treatment. To safeguard against leakage, I take an extra half hour during surgery to test for leaks. If there are any, I put in extra stitches in the affected area. People who have open bypass surgeries have about a 25 percent risk of wound infection and about a 25 percent chance of developing a hernia in the incision, but these risks are virtually eliminated in patients who are treated laparoscopically.

Pulmonary complications such as pneumonia are also reduced with minimally invasive surgery. Patients who have open surgery often experience shallow breathing because of postoperative pain, which increases their risk of pneumonia. Those who have the smaller surgery can breath normally postoperatively.

Patients who have had the minimally invasive technique report much higher quality of life when compared to patients who underwent the open technique. They experience less pain, and they're able to return to normal activities sooner.

Diet after surgery
After surgery, patients are on a liquid diet for two weeks and solid food is introduced gradually. After two weeks, I go over the restricted diet with them very carefully. Each patient has visited with a dietitian before surgery so they are aware of the changes they'll need to make in their eating habits.

Patients who overeat after surgery often experience severe nausea and vomiting. If they have fresh suture lines, they are in danger of pulling stitches out, and if they keep overeating, they can stretch their stomach.

Patients are asked to keep a food diary and at well-defined postoperative intervals, I meet with them to evaluate their progress. Once patients have begun to lose substantial amounts of weight, they're able to begin exercising and can work up to a 1,000 calorie a day diet. Postoperatively patients will need to take three nutritional supplements: iron, calcium and vitamin B-12.

Success rates
Patients lose a lot of weight quickly. A 400-pound individual could expect to lose 100 to 150 pounds in the first nine months. Many patients plateau at this point and losing weight then becomes more gradual and requires the patient to eat carefully and exercise. Often around this time many patients require some plastic surgery to cut away the loose flap of skin resulting from the weight loss.

We tell all patients the surgery is nonreversible. This surgery is a lifelong commitment to change; it's not a temporary quick fix, and anyone who enters into it with the intention of getting it reversed shouldn't have the surgery to begin with. Reversal attempts would require open, high-risk surgery.

Gastric bypass is very effective in the long-term cure or improvement of associated diseases such as sleep apnea, diabetes and hypertension. Heart pump function improves and the progression of heart disease slows. Degenerative bone disease and arthritis usually improve, and they do not progress at the rate they would if surgery were not performed.

Dr. Bell is an assistant professor at the Yale University School of Medicine and director of bariatric surgery at Yale-New Haven Hospital.