Dueling Docs

Most stomach-stapling patients lose 3/4 of their extra weight within 12 months. However, complications will strike a quarter of people who have the surgery and one in every 200 will die from it.
02/16/2009 05:12am ET | Updated November 17, 2011
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The Issue

Stomach-stapling to lose weight

The Facts

At just nine years old Ron Morelli weighed 200 pounds. By the time he was an adult, the 6-ft tall businessman from Lyon, Michigan had ballooned to nearly 500 pounds. Desperate to slim down, he had his GI tract rearranged in a stomach-stapling procedure which was meant to keep him thin for life. No such luck. This season, Ron, weighing in at 420 pounds, is competing alongside his hefty teenage son Mike on NBC's hit reality show, The Biggest Loser, where gargantuan contestants submit to a grueling and public starve-and-sweat spectacle for a shot at a $250,000 prize and the crowning but dubious moniker: the biggest loser. For them, losing weight is all about diet, deprivation and intense exercise under the giddy lights of the camera.

But many doctors advocate stomach surgery for folks like Ron, who, in the unforgiving jargon of dietary science, are morbidly obese, meaning a Body Mass Index of at least 40 or about 100 pounds overweight. More than 200,000 people underwent stomach surgery last year, up ten-fold since 1995.

Is the slimming surgery worth it? The most popular bariatric surgery these days is a procedure called gastric bypass surgery in which doctors seal off most of the stomach by stapling it, leaving just a small pouch at the top. Then they reroute a portion of the small intestine so that food bypasses most of the stomach and intestine. The result is a teeny tummy in which only small amounts of food are digested and still smaller amounts of nutrients are absorbed.

Patients end up eating spoonfuls rather than platefuls -- and drop pounds fast. Most lose three-quarters of their extra weight within 12 months of the surgery. But not without risk. A quarter of people who have the surgery will suffer complications and one in every two hundred will die from it. Considering that about 15 million Americans are morbidly obese, does surgery make sense?

Two doctors debate the issue: Christine Ren, MD, Associate Professor of Surgery at New York University School of Medicine and Scott Kahan, staff physician with George Washington University Weight Management Program.

The Debate

Dr. Christine Ren

In Dr. Ren's view, the surgical approach to weight loss has a far better chance of succeeding than the cutting down calories and increasing exercise. "It's like telling people to go on macrobiotic diet or do meditation or yoga, because that can work. It may, but there has never been science to prove that diet and exercise help individuals with 100 lbs. to lose. What it shows is that the likelihood of keeping the weight off for more than 2 years is less than 5%. With just diet and exercise, you have a greater chance of surviving a brain tumor than staying slim."

"This operation is not the same as plastic surgery," says Dr. Ren. "The goal is not to transform someone who is a size 22 down to a size 4 simply because they don't like the way they look," Instead, says Ren, the surgery is primarily a treatment for serious, life-threatening medical problems that invariably crop up when you're more than 100 pounds overweight. "People really benefit from the surgery. They benefit by achieving a large amount of weight loss, usually sustained for the rest of their lives and they get rid of their diabetes, high blood pressure and lower their risk of heart disease and premature death." As for losing the pounds, says Ren "The cosmetic effect of looking thin is a side effect of the operation."

Right after surgery, patients can typically eat only about 500 calories a day, often throwing up food if they overdo it or if they don't chew food properly. Ren explains that this occurs because in the rearranged digestive tract, undigested food enters the small intestine, causing upset. But she stresses that the "surgery takes away the feeling of deprivation so patients don't miss many foods." However because their bodies can't absorb most nutrients, gastric bypass patients will need supplements. "It's true that individuals will have to take vitamin pills every day for the rest of their lives, particularly iron and calcium. Patients need to be educated on the types of vitamins and supplements they need to be taking."

The irony of gastric bypass surgery is that with their high blood pressure, high cholesterol and a host of other risk factors, obese patients are among the worst candidates for surgery, yet they are the ones who can benefit from it the most. Says Ren: "That's why you have to expect that there's going to be a complication rate after the surgery. It is major surgery where individuals can die and can have major complications. But the benefits that are incurred by the vast majority of individuals who do not die or have no complications are overwhelming."

Dr. Scott Kahan

"I disagree. I have many, many patients who lose a significant amount of weight and keep it off for years. There's no physiological reason that people cannot lose weight through diet and exercise and maintain it," says Kahan. "Yes, it's true that people can and do gain weight back, but they gain it back after gastric bypass surgery, too." (Just ask Biggest Loser contestant Ron Morelli) "With the surgery, people gain it back - maybe not as much and not as quickly as with a strict diet alone, but they can gain it back. In either case, you're still talking about a lifelong commitment to diet and exercise."

"At the heart of this question is a risk/benefit question. If we are talking about people who are 450 pounds, near death and with monumental social problems, then, yes, this is a reasonable procedure.

"But, what bothers me is that because the media hypes this surgery, we're seeing more and more patients who aren't quite 100 pounds overweight and who are gaining weight in order to make themselves surgical candidates and get the procedure covered by insurance."

Kahan also points out that you don't have to lose massive amount of weight to see a health benefit. "There is now good evidence that engaging in healthy behaviors like physical activity, and improving the quality of foods you eat, even in the absence of significant weight loss, can dramatically improve health and disease risk. You don't have to look like Brad Pitt or Angelina Jolie to be healthy. Losing just 10% of your body weight can have a huge effect on your health, especially with regard to reducing the risk of diabetes."

"For the really overweight, there are often very severe psychiatric underpinnings related to their weight. Eating is a coping mechanism. It's one thing to work this through over time, it's another thing to snap your fingers and that mechanism that you relied on for years is now gone. These patients wake up from the surgery and they can't eat like they used to. Just like that, they've had their coping mechanism taken away."

There are also irreversible side effects of surgery which patients may not be prepared for. "With their GI tract altered, patients can end up with excessively loud bowel sounds that they have to live with. It's also very common to have severe diarrhea for the long-term."

"This is surgery that is meant to be a malabsorptive procedure. That means that yes, you don't absorb the same amount of calories you used to, but you also don't absorb the same amount of nutrients. You don't even absorb medicine the same way - and that will have to be recalibrated. You can take supplements, but there are nutrients you are missing that we don't even know about. How can we offer patients supplements for nutrients we haven't even named yet? That's the real risk, the risk that nutritional deficiencies will be a lifelong possibility with this surgery. The good surgeons will have to work with patients very closely, before and after treatment."