EXPERT > Doctor In The House

Benefits of Bariatric Surgery

By Dr. Mark Grief
Interviewed by Melissa Moniz
Wednesday - March 24, 2010
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Dr. Mark Grief
Bariatric surgeon at Kapi’olani Medical Center at Pali Momi

How has bariatric surgery evolved?

Locally, the first bariatric surgery was the vertical gastroplasty, which progressed to what is available today with the Lap-Band and Roux-en Y Gastric Bypass.

The Lap Band is an implantable device that is secured around the stomach. So the Lap Band, which is the only FDA-approved device at the present time, creates a small pouch that limits how much you can eat at one time and can be adjusted. There are other bands in development and in trials right now.

The Roux-en Y Gastric Bypass basically divides and forms a pouch in the stomach, which only can hold about 20-30 cc. And we bypass about 120 centimeters of small intestine, which hooks to that small stomach.

This produces poor absorption and a smaller stomach.

How is it determined which procedure is right for the patient?

I recommend that patients who are thinking of bariatric surgery to go over the pros and cons of each. The band is a much simpler thing to apply or put in, and recovery time is less. Its results aren’t as good as the gastric bypass, and long term hasn’t been shown to have the staying power.

So is it the choice of the patient or do the doctors recommend one?

We usually do recommend what procedure is right for the patient, and a lot of that recommendation has to do with what we call “co-morbidities.” If a patient is a diabetic, then I would strongly recommend the gastric because that procedure has better results and has actually shown patients to be off their medication shortly after the procedure. That’s really astounding. And studies show that long term (approximately two years) about 80 percent of diabetics will be off their medication.

Can you explain BMI (body mass index) and how that number determines the need for bariatric surgery?

The BMI is basically your weight divided by your height. A somewhat arbitrary decision was made years ago by the National Institutes of Health that morbid obesity is defined as a BMI over 40. A normal BMI is about 25. Basically, a 40 BMI for a 5-foot-2-inch patient would be roughly about 210 pounds. But generally the BMI for most insurance companies would have to be more than 40 before they would consider it a medical necessity. Anything less would be elective. However, that number can vary if you have a co-morbidity (and insurance companies will classify these differently) such as severe diabetes, cardiomyopathy, sleep apnea or osteoarthritis. Some would include hypertension in there, but others don’t.

Like any surgical procedure, there are risks involved. Can you talk about the risks?

I think most people are scared to undergo surgery because of the considered risks, but what I usually tell patients is that if you’re a morbidly obese patient and you don’t have anything done, then the numbers show that there are 400,000 premature deaths nationally every year because of obesity. So, if you are over-weight, there are risks involved. Having said that, the gastric bypass and the band do have risks, but as far as deaths, the numbers are fewer than one in 500 for gastric bypass and less than one in 1,000 for Lap Band.

There are possibilities of complications, such as with the band, because it’s a mechanical thing it can slip on the stomach. But with the new technique we apply, that’s usually a very low 1 percent to 2 percent chance. More serious would be blood clots in the legs if the patient isn’t moving. Complication risks increase when the BMI rate is higher. The ideal BMI rate for surgery is between 40 and 60; anything over 60, there are higher chances of complications.

Any new treatments on the horizon?

The one procedure that probably is as promising as any and is being done at different centers is the Sleeve Gastrectomy, and what that does is remove about 80 percent of the stomach, leaving a small tube where the big stomach used to be. And by removing those portions of the stomach, it also removes a hormone called ghrelin, which gives you that hunger feeling. So that level drops in those patients, so they have less hunger and a small stomach. It’s still being investigated, but I anticipate that this will be a very good alternative to the gastric bypass.