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Surgical Solutions to Obesity

With: Dr. Elliot Goodman

There are a host of medical problems associated with obesity. Stroke, diabetes, heart disease, and joint problems are just a few of the known consequences, and yet nearly one quarter of American adults are obese, and this number is rising. An estimated three to five percent of adult Americans are morbidly obese. For these individuals, medical problems, in addition to social and practical problems, are a near inevitability. Fortunately for some, the battle against obesity has a surgical weapon. It's called bariatric surgery.

Below, longtime general and bariatric surgeon, Dr. Elliot Goodman of the Montefiore-Einstein Center for Weight Reduction Surgery, talks about the procedure, and its effect on the physical and emotional lives of his patients.

First, could you tell us what bariatric surgery is, and who undergoes this procedure?

Bariatric surgery is the surgical treatment of severe obesity. And when we say severe, we mean anybody who is at least a hundred pounds overweight. People who undergo bariatric surgery have generally been obese for decades, and they most often have a history of childhood obesity.

What does the surgery entail?

In the surgery, we staple the stomach to make it much smaller, and we reroute food so that it bypasses the first few feet of intestines. We actually rearrange the anatomy and the physiology of the intestinal tract.

And what does this do to the body?

Well in addition to dramatically reducing the size of the stomach, the surgery also changes the hormonal condition of the patient. You're changing their sensitivity to insulin, you're changing their metabolism of iron and calcium and other nutrients.

And a lot of things which would otherwise get absorbed don't get absorbed. There are hormonal changes induced which suppress appetite. There are hormonal changes induced which increase the body's sensitivity to insulin, because most severely obese patients are resistant to insulin, which is why so many of them are diabetic. So it's one operation that has manifold effects on body metabolism.

Does this surgery actually treat diabetes in some cases?

Absolutely. I hear stories of patients who are on three or four different medications for diabetes, and a hundred units of insulin -- which is a big daily dose of insulin -- and within a few weeks they're off. They're off the medications even before they've lost a significant amount of weight. Also, people who have very high cholesterols will often see their cholesterol dipping down to normal. So these are some of the more dramatic effects of the operation.

Coronary artery disease and high blood pressure also respond well. It's great to see patients who may be on five, ten, twelve different medications, over time say, "Well, I dropped this medication," or, "I halved this dose." Within a year or two, they may be down to the bare minimum of medications.

I imagine that the surgery may also solve some of the more structural problems in the body, like joint pain?

Absolutely. People with aches and pains or degenerative joint disease are well served by this surgery.

Could you describe the experience of one patient who has responded well to the surgery?

Sure. I operated on a woman about a year and a half ago who was about three-hundred and fifty pounds overweight, and had been obese for most of her life.

She was only in her early forties, but was so big that she had to come into the office with a walker. She was unable to sit in any of the chairs even though we have fairly heavy-duty armless chairs, and she was too heavy to weigh in our office. Our scale goes up to five hundred pounds.

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Did she describe to you her reasons for wanting the surgery?

She told me she couldn't work, couldn't fit into an armchair, and couldn't really go out anywhere. She said she could not take the bus, because she couldn't get up the stairs into the bus, or sit down in the bus. She didn't go out to shop because people would stare at her, whisper about her behind her back, or just blurt out obscenities at her.

Was bariatric surgery a last resort for her?

She'd been struggling with this for a very long time. She had tried everything else: diets, over the counter pills, and exercise, when she was younger and abler. And she had decided that if she didn't do anything at this point about her weight, having failed at everything else, her life expectancy was extremely limited. She wasn't sure whether she'd be around in a few more years. And I agreed that her weight was life-threatening.

What happened after the initial consultation?

First she was seen by our nutritionist, and then she was evaluated by one of the psychologists we use.

Why do you do a psychological evaluation?

Many reasons. A lot of patients who come in, perhaps at the suggestion of their own doctors, don't understand that this is a very big operation, and that it can occasionally go wrong, and that it can occasionally lead to complications, including death. This is not a tummy tuck, or liposuction. They need to understand the severity of the procedure, and the small chance of major complications.

Also, there are patients who may be depressed. If they are severely depressed, we'll often recommend that they defer surgery -- get the acute depression under control and then come back.

Binge eating is another problem among some of our prospective patients. They will respond to stress by eating, and will eat so much that they induce vomiting. If it persists after surgery, particularly in the early days post-surgery, binge eating can be very dangerous. After the surgery, patients have very small stomachs - approximately the size of an egg -- and if they try and stuff too much food into them, they can actually break down the surgical staples, causing a leak, which can be potentially fatal. So we need to weed these patients out.

How long, for our case study patient, did the whole testing period take?

The whole process took about six to eight weeks. After she was seen by the nutritionist and psychologist, she underwent a medical workup, just to make sure that she would be able to tolerate the operation and the anesthesia.

And the operation was successful?

Yes. The first big milestone was that we could actually weigh her. She dropped below five-hundred pounds. And then she was down to four-fifty, then four-hundred, and so on. Two or three months after her surgery, she was able to walk without the walker. Eventually she could sit down in our waiting room and get up without assistance. And her joint trouble began to subside.

She has a job now, and she's going back to school. Through the process of the operation, we were able to draw her back into the mainstream of life.

Do your patients keep in touch with you long after surgery?

Yes, the longevity of the relationship with the patients is quite remarkable. I don't think patients call their surgeons years after an operation to say, "Hey, three years ago you took out my gall bladder." But I get calls all the time from bariatric surgery patients. I bond with these people for years.

Just recently a patient called me up out of the blue and said, "You're the second person I've told that I'm pregnant." This was a patient who had been trying to get pregnant for ten years. But before the surgery she weighed three-hundred and fifty pounds, and she was essentially infertile.

Is this gratifying?

Yes. It's enormously gratifying, as a doctor, to help people reclaim aspects of their lives that they think are lost, and simple freedoms that most of us would take for granted.

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Dr. Elliot Goodman is on the medical staff of Montefiore Medical Center and the surgical faculty of the Albert Einstein College of Medicine in New York City.