WEIGHT LESS
Bariatric surgery does more than help obese people lose weight: It offers hope for a longer, healthier life.
They are simple parts of life that, for most people, need no more than a passing thought.
Bending over to tie your shoes.
Taking a seat on an airplane or sliding into a booth at a restaurant.
Finding a shirt, dress or pair of shoes that fit.
But for patients who seek help from Gary J. Anthone, M.D., associate professor of surgery at the Keck School of Medicine and director of the Bariatric Surgery Program, these can be insurmountable tasks.
Anthone’s patients suffer from morbid obesity. They usually weigh at least 100 pounds more than they should—pounds that refuse to fall off, despite diet programs, behavior modification and attempts at exercise.
For more than a decade, Anthone has heard their familiar cries for help and their common frustrations. He has seen men so overweight they could not get up out of a chair and women with huge bellies that drop down to their thighs. But Anthone and his partner Peter Crookes, M.D., also an associate professor of surgery, are able to offer them hope. Hope comes in the form of a type of bypass surgery that limits the amount of food that can be eaten and alters a basic physiological process so less fat is absorbed.
Through their weight loss surgery, almost 700 people have received another chance at a lighter life. And it is not about vanity, Anthone points out. It is about health.
“Not only are there significant complications such as diabetes and sleep apnea associated with obesity,” he says, “but morbidly obese people face discrimination and ridicule. They’re often viewed as lacking self-esteem or willpower. This is about improving quality of life.”
Obesity’s price
Unfortunately, for the 12 million Americans who are morbidly obese, it is a poorly understood disease. It is not just about eating too much, Anthone says. In part, genetics seems to dictate how an individual’s body stores energy as fat. Psychological causes for obesity are complex, but childhood emotional, sexual or physical abuse may play a role in some individuals.
While a well-planned diet and exercise can help control weight in moderately obese people, Anthone says, they have proved ineffective for the morbidly obese. Such people usually lose only 10 to 40 pounds—not nearly enough in a 300-plus-pound person to stop the diseases that accompany obesity.
And the health problems are significant.
“Having obesity surgery is not an easy decision,” Anthone says. “But there are three main reasons for a patient having an easier decision: diabetes, sleep apnea and arthritis.”
Surgery often reverses the insulin resistance that characterizes diabetes, halting a disease commonly seen in obese people. Weight loss also may end sleep apnea, a serious disorder in which patients repeatedly stop breathing during sleep. It also lightens the load on the hips, knees and lower spine.
“For many people, the fourth reason for surgery is simple,” Anthone says. “They don’t want to wait until they develop one of these problems.”
Since 1992, Anthone and Crookes have performed hundreds of bariatric operations at USC University Hospital. They now log five to six surgeries a week.
Intestinal fortitude
After finishing his surgical residency in the late 1980s, Anthone did a research fellowship at Johns Hopkins Hospital, studying how hormones help the intestines absorb nutrients from food—a natural fit with the topic of obesity.
By 1991, Tom R. DeMeester, M.D., professor and chair of the Keck School’s Department of Surgery, recruited Anthone to USC, where he initially pursued colorectal surgery. Soon afterward, Anthone met Doug Hess, M.D., a surgeon from Ohio, at a professional meeting.
Hess gave a talk on his unique approach to obesity surgery, which coincidentally was based on a procedure developed by DeMeester to remedy a form of bile-induced gastritis. Anthone became so intrigued that Hess invited him to Ohio to learn the procedure.
Over several trips, Anthone assisted with the surgeries and mastered the technique, called a distal gastric bypass with duodenal switch, or just duodenal switch, for short.
Ten years later, Anthone still performs one type of bariatric surgery: the duodenal switch.
“I currently perform this procedure because I believe it is the best one based on the impressive results I have seen,” he says. “It offers the patient a 90 percent chance of success with a minimum of side effects.”
The duodenal switch makes up about 25 percent of all gastric bypass operations, Anthone says, while a different type of gastric bypass, called the Roux-en-Y, comprises 75 percent.
Bypass basics
The duodenal switch restricts the amount a person can eat and changes the setup of the small intestine so that less fat is absorbed from food.
Surgeons remove about 75 percent of the curve of the stomach, reducing it to the size of a hot dog. In addition, they rearrange the small intestine just below the stomach’s bottom valve so that bile does not reach the intestine until the last part. Because the body can only absorb fat from consumed food when it is mixed with bile, keeping bile away from food until the last minute means less fat is absorbed.
Undigested fatty foods can irritate the colon and cause more frequent bowel movements, so duodenal switch patients often steer clear of such foods, but patients can generally eat small portions of most foods without significant side effects.
In the Roux-en-Y gastric bypass procedure, surgeons divide the top of the stomach to create a small pouch of 15 to 20 cc, about the size of a plum. They then create an isolated loop of small bowel that is 50 to 150 cm (2-5 feet) long, which is connected to the gastric pouch. The patient is limited in his oral intake because of the small size of the pouch. Food absorption is limited because the connection with the digestive juices occurs quickly. Weight loss occurs because of the small intake and the malabsorption.
Because food goes right through the stomach into the small intestine in the Roux-en-Y, these patients sometimes experience “dumping syndrome”— cramps, sweating, hot flashes and dizziness, especially after eating fatty and sugary foods.
As a whole, gastric bypasses have shown consistent results, notes Anthone: An average loss of 70 percent of excess body weight occurs within two years after surgery.
Not just surgery
Maria Harrison, clinical medical assistant, screens many of the interested patients. “Do you have a history of heart disease?” she asks. “How about depression? Diabetes? Is your family supportive?”
It is a mere fraction of the extensive evaluation needed before surgery. Patients are first asked to attend an informational seminar. Then they meet with the surgeon to discuss their history. If they are interested, they must call back and undergo tests to evaluate their heart and lung function. They usually wait a minimum of two months before having surgery, giving them time to reconsider their decision.
Patients also undergo preoperative psychological testing. Some patients may not be suitable candidates for weight loss surgery: those with a history of depression or childhood abuse may experience post-surgical depression, while those with a history of chemical dependency have a higher risk of relapse or non-compliance with the strict follow-up necessary after the surgery.
In addition, Anthone recommends that some patients have plastic surgery in advance to remove excess belly skin and fat. Removing this excess before the surgery reduces the physical challenge for the patient during recovery. Susan Downey, M.D., associate professor of clinical surgery, performs plastic surgery to re-contour patients’ bodies and give them more self-confidence and a better body image after the obesity surgery. Not only does she remove excess abdominal skin, but she can also restore breast shape and remove extra tissue from the arms and legs.
Harrison says many patients do not realize how challenging recovery can be. “Not only do people feel lousy,” she says, “but they lose the joy of eating, and must adjust to that.”
Anthone and Crookes require patients to make follow-up visits on a regular basis. Patients also see a dietitian, get advice on supplements and medication and get blood tests. Patients attend support groups, and are referred for counseling if they need help.
“Follow-up is so important,” Anthone says. “I don’t just say good-bye to a patient after the surgery. I keep seeing the patient for years to make sure they are doing well.”
Some patients use the visits to tell of their successes. “This is the best thing that ever happened to me,” proclaims Brenda, one of Anthone’s patients, during her visit three months after surgery. “I’m very tired but very happy. I weighed 353 pounds before the surgery and I’m now at 296. And I’m still losing.”
Adds Anthone, “For both patient and physician, this surgery is a commitment to a better life.” n
For more information about gastric bypass surgery, or to learn more about The Doctors of USC, call 1-800-USC-CARE (1-800-872-2273).
From Laparoscopy to Lap-band: New Technology for Obesity Surgery
USC minimally invasive surgeons recently performed their first laparoscopic bariatric surgery at USC University Hospital.
After more than seven months of planning, practice and patience, Namir Katkhouda, M.D., completed a complex Roux-en-Y gastric bypass without a long incision. Instead, he performed the surgery using slender instruments and a tiny camera, or scope, threaded through small cuts in the skin.
In minimally invasive procedures, patients experience smaller scars, quicker recovery time and less pain than in open procedures.
Katkhouda, professor of surgery and director of the Department of Surgery’s laparoscopy program, honed his technique by observing surgeries, consulting with pioneering colleagues in the United States and Europe, reviewing publications, taking an American Bariatric Society course and practicing in his lab.
“This is an incredible surgery on the complexity scale of laparoscopic procedures,” says Katkhouda. He is a laparoscopic leader, pioneering the technique in operations and teaching other surgeons. He has written books on laparoscopy, and designed instruments used in the procedures.
In the laparoscopic bariatric procedure, Katkhouda performs a Roux-en-Y. He makes five small incisions and threads a tiny camera into the abdomen. He inserts long tools through tubes placed into the incisions, and watches the organs on a screen as he operates.
Katkhouda creates a 150 cm segment of the small intestine and sutures it to the tiny gastric pouch that he creates using laparoscopic techniques The small intestine absorbs nutrients from food, but with less intestine, the body absorbs fewer calories.
He resects much of the stomach, leaving it a small pouch about the size of a plum and sealing it with tiny sutures before reconnecting it with the intestine. That restricts food intake.
Patient Tony Matta left USC University Hospital just three days after his laparoscopic bariatric surgery, sooner than the four-to-six-day recovery time that typifies open procedures.
Matta went back to work 10 days after surgery. Six weeks after surgery, the once-320-pound Matta had dropped 47 pounds, reversed his diabetes and lowered his blood pressure to normal. He lost the drive to eat, resumed normal sleep patterns and bucked his depression.
Katkhouda is excited about the surgery’s potential but warns that only surgeons with proven laproscopic skills should perform the surgery. He expects that in the coming years, surgeons will offer weight loss solutions to morbidly obese patients tailored to their unique needs. For now, he will continue to perform the laparoscopic Roux-en-Y, but does not exclude—with improvement of the technique and instrumentation—that the duodenal switch could be offered laparoscopically.
“In the coming years, there will be an operation for each situation,” Katkhouda says. Understanding each patient’s history and eating habits—whether sweet-eater, snacker or binge eater, for example—can guide choices.
And as society has accepted morbid obesity as a serious problem, attempts to combat obesity have grown.
Witness the Lap-band.
First standardized in the 1990s in Belgium and Italy, the laparoscopic adjustable gastric banding procedure squeezes closed the upper part of the stomach with an inflatable belt. Patients quickly feel full after eating a little.
“Over the past seven years in Europe, thousands of Lap-bands have been placed,” Katkhouda says. “And now they can place a band in one hour, with a one-day hospital stay, and through only three small incisions. This does not mean that this operation is devoid of risks; careful patient selection and technique is required.”
Only recently approved in the U.S. by the Food and Drug Administration, the Lap-band can be inflated or deflated through a catheter under the skin. Surgery can be reversed by removing the band, says Katkhouda, one of the few surgeons in Los Angeles approved to offer the procedure.
“While the laparoscopic gastric bypass is good for the average morbidly obese patient, the Lap-band may help those who are morbidly obese and under 20 years old,” he says. “It also is an option for those over 60, or at high risk for complications.”
Katkhouda agrees with his colleagues that obesity treatment does not end when the patient leaves the hospital. “These patients have a radical change in their lives,” Katkhouda observes. “Without food for comfort, depression sets in. Support groups and nutritional counseling are key.“
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