WHAT CAN YOU EXPECT FROM
WEIGHT LOSS SURGERY
"As a result of WLS, I'm not thin but I'm not obese either.
I can take a walk without huffing and puffing, and I can
get down on the floor and play with my children."
MaryAnn W, 29, 274 lbs pre-op; 149 lbs 4 years post-op
"My life has really changed because of my WLS. One of my biggest pleasures is now shoe shopping. Before the surgery, my feet were so swollen that I had to wear sneakers all the time. The other day, I bought a pair of high heels for the first time in ten years."
Tanisha K, 36, 344 lbs pre-op; 217 lbs 19 months post-op
"Little things have changed, and that's what really
makes a difference in my life. I don't have to ask for
seat belt extenders when I flyand that's great."
Bill P, 44, 329 lbs; 177 lbs 5 years post-op
Effect of Weight Loss Surgery on Quality of Life
Surgical results should be analyzed from two perspectives. Traditionally, the medical profession has viewed the results of any therapy in terms of "efficacy"how the specific problem or disease has been affected by the treatment. For example, how well did the treatment lower the blood sugar in people with diabetes or the blood pressure in patients with hypertension. The better the disease can be controlled or cured, the more effective the treatment. The same would hold true for weight loss.
However, during the past decade, emphasis has been given to analyzing the results of treatments from the patient's perspective. Medical science is beginning to examine how patients feel about the treatments they have undergone, separately from how a particular treatment affects the "numbers" (blood sugar, blood pressure, cholesterol level, etc). This new focus on the "effectiveness" of medical treatments is referred to as "quality of life" or "medical outcomes research" and it is particularly relevant to patients considering WLS. For example, we know that even modest amounts of weight loss (5 or 10 percent) can result in improvements in many obesity-related medical conditions, such as diabetes, high blood pressure or high cholesterol.
Imagine two individuals, both women who are 5 feet tall and weigh 300 lbs., with a BMI of 50. These women have diabetes, high blood pressure and high cholesterol and each takes the same medications. The first woman goes on an aggressive, medically supervised diet and loses 50 pounds in 6 months. After 1½ years, she has kept 40 pounds off. Although her final weight is 260 lbs, she is able to dispense with all of her medications. The second woman undergoes WLS and loses 140 lbs after 1½ years. Her weight is now 160 lbs and she too no longer takes any medications. Which woman do you think is happier with her result? If we analyzed this only from the perspective of "efficacy", the treatments would be equivalent because they had the same effect on the measured parameters, the levels of blood sugar, blood pressure and cholesterol, and both resulted in elimination of the need for medications. However, if we factor in the "effectiveness" of the treatment on her overall health and quality of life, the results would be quite different. The second woman is probably more satisfied from the patient's perspective because she has lost an additional 120 lbs and can now shop in regular stores, sit in chairs without difficulty and is more readily accepted by her co-workers. More and more, the results of medical treatments are being evaluated using "quality of life" indicators as well as traditional measures of efficacy, and this is also true in the analysis of the results of WLS.
Effect of Weight Loss Surgery on Medical Parameters
"I had to quit my job as a school bus driver because I had such severe sleep apnea. After my surgery, that problem was cured.
I got a better joband life is looking good."
Tony S, 52, 523 lbs pre-op; 316 lbs 22 months post-op.
"Nobody understands why, but people who have gastric bypasses get the added bonus of having their diabetes cured. I went into the hospital taking insulin, and when I was discharged,
I threw my insulin in the trash."
Lorraine G, 48, 286 lbs pre-op; 154 lbs, 18 months post-op.
"My osteoarthritis wasn't cured after my WLS; but, because I weighed so much lessit eased some of the pressure on my joints. Surely, I'm not perfect, but I feel much better than I did before."
Stephanie V, 47, 311 lbs pre-op; 214 lbs 3 ½ years post-op.
Weight Loss
Weight loss is the primary factor of concern to most patients considering WLS and the ultimate determinant of success. In the bariatric surgery community, success has been defined as the loss of at least 50 percent of excess body weight (EBW). The weight is usually lost most rapidly during the first 6 months after surgery, and then it begins to taper off and reaches a plateau after about 1½ -2 years. In general, malabsorptive procedures result in the greatest weight loss, and restrictive procedures in the least.
The JIB (jejuno-ileal bypass), which is no longer performed, resulted in weight loss of approximately 80 percent of EBW. The PBD and DS (bilio-pancreatic diversion and duodenal switch) are almost as good in that regard, with weight losses approximating 70 to 80 percent of excess body weight. After RYGB (Roux-en-Y gastric bypass) patients typically lose between 50 and 75 percent of their excess body, while after VBG (vertical banded gastroplasty), they tend to lose between 40 and 60 percent of excess body weight. Early results of the adjustable lap banding procedures are comparable to VBG, however most of the data comes from European studies in which the long-term follow-up has been poor. These results are summarized in Table 7-1.
Weight Regain
Data on weight regain parallels that on weight loss (Table 5-1). The malabsorptive procedures, JIB, BPD and DS, have the best results, with less than a 10 percent regain after 5 years and 10 years. RYGB is slightly less durable, with most studies reporting weight regain between 10 and 15 percent after 5 years, which continues as long as 15 years after surgery. VBG is less effective, with weight regain commonly as high as 25 to 40 percent after 5 years. Long-term data on gastric banding is not available as yet, but one can safely assume that it will be no better, and probably worse, than VBG.
___________________________________________________________
Table 7-1: Weight Loss and Regain After Various Weight Loss Surgery Procedures
JIB
BPD DSRYGBVBGGastric Banding
Percent Excess
Body Weight Lost 8070-80 50-75 40-6040-60
Percent Weight Regained <10<10 10-15 25-40Unknown
___________________________________________________________
Potentially Life-Threatening Co-Morbid Conditions
Weight loss by any means often results in considerable improvement or complete resolution of most obesity-related medical conditions. The degree of change is not necessarily related to the amount of weight loss. Improvement refers to a reduced requirement for treatment whereas complete resolution implies cure, with no further treatment required.
Type II diabetes: The effect of surgery (RYGB) on the course of Type II diabetes is most dramatic. Studies by Dr. Walter Pories and colleagues from the East Carolina University involving hundreds of patients have shown marked improvement in the biochemical abnormalities associated with diabetes. Within days of surgery, these investigators observed a return of fasting blood sugar levels to normal, lower blood levels of insulin (which is usually elevated because of the body's resistance to insulin), and most patients were able to be discharged from the hospital no longer needing insulin. The speed with which these improvements occurred suggest that they are not related to weight loss, since the amount of weight lost within the first few days of surgery is minimal.
Hypertension: Hypertension improves or completely resolves with weight loss in the vast majority of patients, with people taking lower doses of blood pressure medication or no medication at all.
Hyperlipidemia: In most individuals, weight loss typically results in significant improvement in cholesterol and lipid abnormalities.
Cardiovascular disease: Although long-term data on the risk of heart attack or stroke are not available, it seems reasonable to assume that elimination or reduction of predisposing factors for cardiovascular disease (diabetes, hypertension, lipid abnormalities) will reduce the overall cardiovascular risk.
Obstructive sleep apnea - obesity hypoventilation syndrome (Pickwickian Syndrome): Marked improvement in sleep abnormalities after weight loss occurs in most people, with almost half experiencing complete resolution.
Liver disease: Weight loss usually results in improvement in liver function and a decrease in fat deposits.
Cancer: It is unclear whether or not this risk decreases with weight loss.
The effect of surgery on several potentially life-threatening co-morbid conditions is summarized in Table 7-2.
____________________________________________________________________________
Table 7-2: Effect of Weight Loss Surgery on Obesity-Related Co-Morbid Conditions
Co-Morbid Condition ImprovedCompletely Resolved
Type II diabetes 93 percent89 percent
Hypertension 90 percent66 percent
Abnormal Blood Lipids 85 percent70 percent
Sleep Apnea 72 percent40 percent
____________________________________________________________________________
Life-style Limiting Conditions
Weight loss also results in relief or improvement in most of these conditions as well, which often have a dramatic impact on people's lives.
Osteoarthritis: Weight loss relieves considerable strain on the lower back, hips, knees, and ankles. Patients often experience improved mobility and decreased requirements for anti-inflammatory or analgesic medications, allowing them to increase their activity level and productivity.
Gallstones: Rapid weight loss by any method is associated with an increased risk of gallstones. After WLS, this incidence is approximately 25 percent. In the past few years, a drug, ursodiol (Actigal), has become available which can reduce the risk to less than 5 percent.
Gastroesophageal reflux: Heartburn usually resolves quickly with weight loss. In addition, regardless of its effect on weight, RYGB is an effective anti-reflux operation because it prevents the stomach acid from refluxing back into the esophagus.
Urinary stress incontinence: Symptoms of urinary stress incontinence are among the first to resolve with even modest degrees of weight loss.
Venous disease: Mild symptoms of venous disease, such as varicose veins or transient leg swelling, can improve with weight loss. Unfortunately, patients with chronic venous disease or massive leg swelling often have permanent changes in their veins and skin by the time they are treated.
Menstrual irregularity and infertility: Ovulation, and hence menstrual periods, will often resume with weight loss. Consequently, many women who have had problems with infertility are able to conceive. There have been numerous reports of women having normal pregnancies after WLS, although it is recommended that birth control be used during the weight loss period.
Depression and social stigmatization: Numerous studies now document improvement in the symptoms of depression and low self-esteem after significant weight loss.
Effect of Weight Loss Surgery on Quality of Life Measures
"I was missing so many days from work from obesity related illnesses,
that I was terrified of losing my job.
Now I only have to stay home when I have a cold."
Patrick O'C, 55, 366 lbs pre-op; 204 lbs 2 ½ years post-op.
"I have to buy a dress for my daughter's wedding and I'm not dreading it. When my son got married, I wore a size 26now I fit nicely into a 16. I'm not a model, but I will make an attractive mother of the bride."
Sylvia F, 49, 286 lbs pre-op; 193 lbs, 4 years post-op.
"Six months after my surgery I was able to fit comfortably behind the wheel of my car. That makes a tremendous difference in my life."
Barbara M, 34, 314 lbs pre-op; 188 lbs, 20 months post-op.
Information is accumulating concerning improvements in the quality of life of patients following WLS. Most of the results are positive. My colleague, Patricia Choban M.D., and I published two of the first reports in the United States studying patients who underwent RYGB. Patients completed a standardized questionnaire called Short Form-36 (SF-36), before surgery and at different time points subsequently.
The SF-36 consists of 36 questions in 8 categories: physical activity, social functioning, physical and emotional factors in role activities, bodily pain, general mental health, vitality, and general health perceptions, in which the patient grades his or her health in order to provide an assessment of overall health status. This questionnaire has been completed by thousands of patients nationwide, and is widely used throughout the health care system. Before surgery, patient responses were considerably below national norms in all of the areas assessed, indicating that their obesity severely compromised their health and limited their lives. Postoperatively, the patients showed a consistent improvement in their health status, to levels that either matched, or even exceeded the average.
These results reflect the positive effect that successful WLS has on patient's lives. Several studies in Europe have also documented marked improvement in quality of life, depression, and unemployment after WLS. These findings indicate that many of the psychological challenges confronted by severely overweight people are due to their weight, and not vice versa.
One of the more dramatic studies evaluating quality of life examined the negative effects of severe obesity compared to the positive effects of weight loss. Patients who had successful WLS were asked to compare their suffering from morbid obesity with several other conditions such as diabetes, dyslexia, legal blindness or having a leg amputated, combined with a normal weight. The patients overwhelmingly preferred to be normal weight with another disability than to be morbidly obese. When asked if they would accept several million dollars to remain morbidly obese, none chose the money over the opportunity to become normal weight.
Louis Martin, M.D. of Louisiana State University, has documented that as many as 40 percent of patients who were receiving public assistance at the time of surgery were able to return to work after successful WLS. In Sweden, the Swedish Obesity Study (SOS) is currently comparing the long-term effects of surgical and standard non-surgical treatments in the largest prospective clinical trial of its kind in the world. Initial reports from the SOS have demonstrated the superiority of the surgical approach in all parameters, including medical outcomes and quality of life measures. The results of the SOS have also shown that surgery is cost effective; the operation pays for itself within 3 years as patients spend fewer health care dollars on treatment of obesity-related medical problems and miss less time at work.
WLS is not magic nor a panacea for all of life's problems. Researchers have documented that many patients will return to their baseline, preoperative psychological profile several years after successful weight loss. These findings suggest that the psychological or social problems confronting obese individuals have multiple causes. Weight loss cannot improve an abusive marriage or make a "lousy" boss nicer.
However, examining all of the available information about WLS, balancing its risks, benefits, results and costs, it is undeniable that it is the safest and most effective treatment for patients with clinically severe or morbid obesity.
