When Dr. Daniel B. Jones was doing his surgical training at Washington University in St. Louis in the late 1990s, surgeons who performed gastric bypass procedures were considered by some of his peers to be renegades on the fringe.
Dr. Daniel B. Jones
He remembers many gastric bypass patients returning to the hospital with seroma, hernias, and other postoperative complications. "We never really saw the people who were doing well," recalled Dr. Jones, who now heads the section of minimally invasive surgery at Beth Israel Deaconess Medical Center, Boston. "A lot has changed since then."
Thanks in large part to the development of accreditation programs by the American College of Surgeons’ Bariatric Surgery Center Network and by the American Society for Metabolic and Bariatric Surgery (ASMBS), the current standards for performing bariatric surgery are more rigorous than ever. High-volume centers "may have two or three surgeons at a site, with dedicated floors where the nurses are keyed in and looking for complications when they arise so they can be addressed early," said Dr. Jones, a member of the ACS Bariatric Surgery Center Network Advisory Committee. "We have better equipment for doing intubations, for anesthesia, better instruments for operating – all these things have evolved to make bariatric surgery a lot safer than it was even 10 years ago. While we still have some questions about the physiology and the mechanisms involved in how these operations work, we have a very good understanding of the technical aspects of doing these operations and the complications, and how to prevent and treat them. In Massachusetts, for instance, use of accreditation programs has reduced mortality to a fraction of what it was just 5 or 7 years ago."
A study based on National Inpatient Sample data found that the national annual rate of bariatric surgery increased nearly sixfold between 1990 and 2000, from 2.4 to 14.1 per 100,000 adults (Surg. Endosc. 2005;19:616-20). The use of gastric bypass procedures increased more than ninefold during the same time period (from 1.4 to 13.1 per 100,000 adults).
According to the ASMBS, an estimated 15 million people in the United States are morbidly obese. About 220,000 Americans underwent bariatric surgery in 2009. The risk of death from the procedure is about 0.1%, down from about 0.4% between 1990 and 2000.
"I think we’re leveling off on the number of operations our surgeons and hospitals can address, yet our obesity problem continues to rise," observed Dr. Jones, who also is professor of surgery at Harvard Medical School, Boston. "It’s really important that we start thinking about how to prevent the problem as opposed to how to manage it after it occurs."
He credits the laparoscope for revolutionizing bariatric surgery in the late 1990s, though initial acceptance was slow. In fact, being overweight was once considered a contraindication to laparoscopy. "That all turned upside down," Dr. Jones said. "The bariatric surgeons at the time knew that obese persons would most benefit from laparoscopy. An incision on a larger patient is very big, because you have to get through all the fat, down into the fascia and to the target. Whereas someone might do a 10-cm incision on a thin person, that same incision might be 50 cm on an obese patient. But the poke holes of laparoscopy are the same small size."
Dr. Jones discussed the most common bariatric surgery procedures being performed today:
• Roux-en-Y. Commonly referred to as gastric bypass, this procedure involves reducing the stomach from the size of a football to the size of a golf ball. The smaller stomach is then attached to the ileum, bypassing about 60% of the small intestine. "While there can be long-term complications, such as B12, calcium, iron, and folate deficiency if there is not a nutritionist involved in follow-up, for the most part it’s reasonably safe," he said. "You’re going to achieve loss of 50%-70% of your extra body weight. So if you’re 100 pounds overweight, on average you’re going to lose 50-70 of those pounds. If you’re 200 pounds overweight, you might lose 100-plus pounds."
Dr. Jones generally performs open gastric bypass in patients who weigh more than 350 pounds because the visualization is better and he believes this procedure is safer for a person of that size. "Other surgeons modify their technique a bit to offset the fact that people are bigger," he said.
He reserves laparoscopic gastric bypass for patients who weigh less than 350 pounds because it generally produces less scarring and a shorter hospital stay – usually 1-2 days versus up to a 3-day stay in patients undergoing an open procedure. "When I came to Boston, people would say, ‘laparoscopic gastric bypass is not known, not proven,’ " Dr. Jones said. "That was only 8 years ago. Now, surgeons ask, ‘why would you ever do the open approach in this patient population?’ I’ve parked in the middle of that debate for a long time."