Washington Post Lap Band Article

jla78 · July 22, 2003

Pretty good article...http://www.washingtonpost.com/wp-dyn/articles/A25474-2003Jul21.html?nav=hptoc_h

A Kinder Cut?

Obese Patients Weigh Safety, Effectiveness, Lifestyle Issues of Lap Band, Bypass Surgeries

By Sandra G. Boodman

Washington Post Staff Writer

Tuesday, July 22, 2003; Page HE01

After his weight ballooned to 285 pounds, John Bischoff, a veteran of failed diet and exercise programs, figured he had no alternative to a gastric bypass that would permanently shrink his stomach. His internist suggested it. A surgeon told him the operation might alleviate his hypertension and lower his worrisome cholesterol level as well as his weight. The retired America Online executive was about to schedule the surgery when he mentioned it to his daughter, a nurse practitioner.

"She looked at me like, 'What, are you crazy?' " recalled Bischoff, 56, who lives in Loudoun County. "She said it was radical surgery, life-altering, and there's no reversing it." Bischoff's daughter instead suggested a new, less invasive and reversible weight-loss operation called adjustable laparoscopic banding, which restricts food intake without cutting or stapling the stomach or permanently rerouting the intestines, as does bypass surgery.

That appealed to Bischoff, who had the "lap band" surgery six weeks ago at Reston Hospital. Surgeon Eric D. Pinnar made a series of one-inch cuts in Bischoff's abdomen, through which he inserted an inflatable hollow silicone band around the top of Bischoff's stomach. The band reconfigured the organ into an hourglass shape, drastically shrinking the top. This serves a dual purpose: It limits the quantity of food Bischoff can eat and quickly triggers a feeling of fullness that lasts for several hours.

Four hours after the 60-minute procedure, Bischoff was walking around his hospital room. The next day he went home. A week later he was back on the golf course. So far he has lost about 22 pounds, at a rate of one to three pounds per week, the amount Pinnar recommends.

"I think this surgery is a great option," said Bischoff, who said he has suffered no complications, isn't hungry and eats a fraction of what he used to. "The big thing for me is that it's controllable." Bischoff said he was willing to trade the possibility of lesser weight loss for the band's adjustability.

As Bischoff loses weight, the device can be periodically tightened or loosened to allow more or less food to pass through it. Adjustments are made by controlling the amount of saline Pinnar inserts into itthrough a portal implanted under the skin of Bischoff's abdomen. The port is connected to the band by a slender plastic tube.

In the two years since it was approved by the Food and Drug Administration (FDA), the adjustable band, widely used in Europe and Australia, has emerged as a kinder, gentler -- and less effective -- alternative to gastric bypass. Although bypass patients usually lose more weight rapidly -- sometimes a pound a day -- the operation carries a higher risk of death and permanent complications than the band.

The reason lies in the nature of the gastric bypass procedure: The most common operation, known as the Roux-en-Y, not only reduces the amount of food that can be eaten, but also causes significant malabsorption of calories and nutrients. Malabsorption places patients at greater risk of anemia, osteoporosis and bone disease, problems that can usually be prevented by taking high doses of Vitamins. About 20 percent of bypass patients also require further surgery to correct complications, which can be life-threatening; the mortality rate from bypass is estimated to be about 1 percent. The mortality rate after the band is roughly 0.1 to 0.2 percent.

Some band-related complications can be reversed by removal of the device, which requires another operation. An FDA official said manufacturer Inamed has reported seven deaths and 97 serious injuries associated with the band between 1999 and 2002. An Inamed official said that about 15,000 U.S. patients have received bands. Recipients include television personality Sharon Osbourne, singer Ann Wilson of Heart and actor Brian Dennehy.

Whether the lap band will become popular enough to compete with gastric bypass surgery remains to be seen, particularly because bypass operations are increasingly being performed laparoscopically rather than through a single large incision, enabling patients to recover more quickly with less pain.

Both band and bypass procedures are recommended by federal health officials only for selected patients who are morbidly obese: those approximately 100 pounds or more above their healthy weight. That description fits nearly 5 percent of American adults.

A Growth Industry

In the past two years, the number of Americans turning to weight loss, or bariatric, surgery has skyrocketed. The American Society for Bariatric Surgery, the trade association for weight loss surgeons, estimates that 103,000 Americans, most of them women, will undergo obesity surgery this year, compared with approximately 40,000 in 2001. This explosive growth reflects the accelerating epidemic of obesity, which affects more than 25 percent of the U.S. population coupled with growing media coverage of the problem and of celebrities' surgeries (most recently the laparoscopic gastric bypass performed on "Today" show weatherman Al Roker). It's also spurred by the lack of viable long-term weight-loss alternatives for the morbidly obese.

There is also growing evidence that surgery works: A recent analysis by the Cochrane Review, a respected British collaborative that disseminates research about the safety and efficacy of medical practices, examined 18 clinical trials involving nearly 1,900 morbidly obese patients. The group found that bypass surgery resulted in greater weight loss and more improvement in health problems like type 2 diabetes than conventional diet and exercise programs.

But which surgery works best for what kind of patient? And what are the long-term risks and benefits? So far no one knows. The National Institutes of Health (NIH) is poised to fund a $15 million program in which investigators at several medical centers will spend five years attempting to answer these and related questions.

"Hopefully at the end of this we'll have some answers," said Susan Yanovski, executive director of the National Task Force for the Prevention and Treatment of Obesity at the National Institute of Diabetes and Digestive and Kidney Diseases, the NIH branch overseeing the effort.

Hospitals aren't waiting for answers. Many are attempting to capitalize on the extraordinary growth potential of bariatric surgery, which Health Care Strategic Management, an industry newsletter, has characterized as "a real moneymaker for a hospital that does it right."

Many are recruiting surgeons and racing to add obesity surgery programs to lure patients, whose procedures are increasingly being reimbursed by insurance. Also at stake is the most lucrative quarry: the self-pay patient like Bischoff, who spent $15,000 of his own money after his insurance company refused to cover lap band surgery, which it and other insurers have deemed experimental.

Months-long waiting lists, particularly for bypass surgery, are common, because fewer than 1,000 surgeons nationally are believed to be performing gastric bypass. Michael A. Schweitzer, a bariatric surgeon at Johns Hopkins Hospital, says he is so busy he is booked for the next year.

"I would say the demand for surgery has increased logarithmically," said Arlington surgeon Hazem Elariny, who said he performed the Washington area's first laparoscopic gastric bypass at Fairfax Hospital several years ago. "A lot of it is due to patient interest in the minimally invasive laparoscopic approach."

Minimal Invasion

Although patients are seeking out doctors who perform gastric bypass laparoscopically, there's a dearth of evidence to show that laparoscopy is superior -- and widespread agreement that it makes a difficult operation even tougher to perform.

"This is very, very hard surgery," said New York laparoscopic surgeon Christine J. Ren, an assistant professor of surgery at New York University School of Medicine. Ren, who has performed more than 300 laparoscopic bypasses, noted that proficiency varies widely. "There are surgeons who are used to doing open procedures who are going to a weekend course, doing it on a pig and then operating on people," she said.

Laparoscopic training is now usually part of residency training for surgeons, and advanced skills can be acquired during a one-year post-residency fellowship. But most doctors older than about 45 typically have little or no training in laparoscopic techniques, which require a surgeon to manipulate special instruments inserted in small incisions along with a tiny camera. Images from the camera are projected on a monitor the surgeon watches during the operation rather than peering into an incision.

There is little dispute that the learning curve for laparoscopic bypass is steep. A recent study of 188 University of Massachusetts Medical Center patients published in the Archives of Surgery found a significant decrease in complications after 120 procedures. That conclusion was echoed by Swiss researchers who recommended that "only surgeons with extensive experience in advanced laparoscopy as well as bariatric surgery should attempt this procedure."

With the Band

It's much easier to achieve proficiency in lap band surgery. An official of Inamed, the California company that makes the only approved device on the market (a second band is in clinical trials) estimated that it takes about 25 procedures to become proficient.

The cost of the band and gastric bypass are roughly equivalent, doctors say, although the latter often requires a longer hospitalization.

Although surgeons agree that band surgery is easier and probably safer than bypass, it tends to be less successful: Most band patients lose much less weight. One reason may be that the device requires recipients to confront those twin demons of weight loss: diet and exercise. Patients who don't do both will gain weight. And many scientists believe that bypass operations trigger hormonal changes beneficial to weight loss, a hypothesis NIH researchers will be studying.

In the FDA clinical trials, 299 band patients lost an average of 36 percent of their excess weight, about half the amount that bypass patients lose. Seven percent of band patients lost no weight and some even got fatter.

"You can defeat this operation with high-calorie liquids such as milk shakes," said Reston surgeon Eric Pinnar, one of the few Washington area surgeons who performs only lap band surgery for weight loss because he regards it as less risky than bypass. "This really focuses patients on what they're eating."

But not always. Because the band does not cause malabsorption or a related phenomenon called the "dumping syndrome" -- an extremely unpleasant reaction that includes nausea, sweating, fainting and diarrhea that most bypass patients experience if they eat sugar -- it's not hard for band recipients to revert to their old bad habits, especially if they love sweets. Ice cream, soda and chocolate slide easily through the band without triggering an aversive reaction. bread and other carbohydrates tend to be harder to digest and can cause reflux or regurgitation.

And while band-related complications tend to be less serious, they are common. Although the band is intended to be permanent, 25 percent of patients in the FDA trial had the device removed, often because of side effects, which 89 percent of patients experienced. These include abdominal pain, nausea and vomiting, and heartburn.

Some surgeons say that recent refinements in technique may decrease the rate of complications but others predict that inferior weight loss will limit the procedure's popularity.

Ren, who has done 450 band operations, said she tells patients that the device is a tool, not a panacea "A lot depends on the patient's motivation," she said. "I tell patients, 'You're going to get where you want by making healthy food choices and exercising. That's a lot easier to do when you're not hungry.' "

"I think the lap band is a good operation for the right patient," said Schweitzer, an assistant professor of surgery at the Johns Hopkins University School of Medicine who has done 50 band procedures and more than 500 laparoscopic bypasses. "For most patients, gastric bypass is the best procedure," particularly those who crave sugar or have a body mass index (BMI), a ratio of height and weight, above 50. (A woman who is 5 feet 5 inches tall and weighs 300 pounds would have a BMI of 50.)

Aimee Lindquist, 23, of Fairfax said she chose the band over bypass because she worried the latter might be too drastic if she wanted to become pregnant.

Since her surgery four months ago, Lindquist has lost half of the 80 pounds she hopes to lose. "The best thing is that I'm no longer obsessed with my weight. I take it as it comes," she said.

Her biggest adjustment has been slowing the pace of her eating. A typical dinner, which currently consists of about half of a Lean Cuisine meal, now takes her about 30 minutes to eat because she must chew her food so thoroughly. If she doesn't, she will probably throw up.

Daryl Newhouse, 42, of Gaithersburg said she knew the band wouldn't work for her because she craves sweets. She said she spent several months researching various surgeries and chose laparoscopic over open bypass "because I thought the risks were lower and the recovery period was faster."

Newhouse, who said she weighed 125 pounds when she graduated from college, gained about 10 pounds annually over the next 20 years. A veteran yo-yo dieter, she carried 320 pounds on her 5-foot-10 frame when she underwent surgery in April 2002.

"I was definitely a sugar addict," said Newhouse, an editor at legal publisher Lexis-Nexis who felt she needed the negative reinforcement the dumping syndrome has periodically provided.

So far, she said, she has lost 125 pounds. Newhouse said she would like to lose 20 more and get down to 170, a weight she considers her ideal.

Her only complication has been hair loss, which occurred six months after surgery and has stopped. She no longer suffers from type 2 diabetes, hypertension, stress incontinence, arthritis or sleep apnea, all of which plagued her before her operation. Her life now, she said, is immeasurably better.

Most days she takes four-mile walks with her dog, something that would have been a physical impossibility a year ago. "Even my dog has lost 20 pounds," she said.

Bischoff said he is looking forward to getting down to 210 pounds, which is what he weighed when he was discharged from the Marine Corps several decades ago. "I want to be around to see my grandchildren grow up," he said.

Alexandra · July 22, 2003

That's an interesting article, thanks for posting it.

I didn't know that about Brian Dennehy! He's one of my favorite actors, partly because he's always impressed me as being very intelligent. Now I know he is!!

--Alexandra

sassyangelic1 · July 24, 2003

IMO, although it was a well written article... I think the author could have done more extensive research. I was unhappy with her boast of things the woman with the bypass had rid herself of....her meds...high blood pressure...things like that.......and the comment about the woman with the band.....didnt really state anything positive. They could have focused on that with the band our losses are healthier over time....and that our window of opportunity really never closes.....Hopefully the next articles actually are played fairly between the surgeries.

ToothFairyRDH · July 30, 2003

Sassy:

I agree. This article was some what similar to the one I posted the link for (Those Darn Newspapers: Miami Herald). I am displeased with the fact that these articles continue to state that the outcome is "less effective" than bypass. Studies have shown that the end weight loss is the same as bypass, the loss is just done at a much healthier rate with no Vitamin & nutrient (malabsorption) issues. I just wish these reporters would actually do some good research and find out the current facts before they say incorrect info about a "tool" that could be so useful & valuable to sooooo many. With articles like these, no wonder insurance companies wont cover the procedure...if it does not work, why put in the money? But the good thing is that so many have the opportunity to find out what the band can really offer....I hope to be there some day!

Thanks~Dawn (preband, still researching)