Should You Bypass Obesity-Related Stomach Surgery?

The latest option for losing weight via surgically reducing stomach size: Having most of your stomach cut away and taken out by a procedure performed mostly through your mouth and down your throat. (A bit of the work is done through small slits in your abdomen.) What little is left of the stomach is then stitched up to form a mini-stomach, with the obvious result that it only takes a relatively small amount of food to fill it up. Other, more-established options for stomach surgery include the gastric bypass, a more extensive procedure in which in addition to the stomach being downsized it is also reconnected to a shorter span of intestine, cutting down on calorie absorption, and the lap band, in which much of your stomach is squeezed off by an adjustable band.

These procedures are often discussed as if they have been proven safe and effective in studies. But keep some points in mind when considering how “proven” a surgical technique is. There are (with a very few exceptions) no good, ethical ways to conduct randomized, blind trials of surgical procedures. It would be hard enough to do the randomization, in which patients are (to oversimplify a bit) randomly assigned to either a group that will receive the surgical procedure or a group that will not, because not many patients are willing to have surgical decisions made for them by the toss of a coin. But even if that issue were overcome, the real problem would be with blinding, which means patients don’t know which group they’re in. It’s not easy to get people to not know whether they’ve had surgery or not–and even if you could pull it off it’s even tougher to do it in a way that doesn’t run afoul of ethical considerations. (It’s been attempted, believe it or not, but hell was raised.) The result is that studies of newer surgical procedures are mostly observational studies, which means doctors just note how patients seem to be doing. (I’m not counting animal studies. Neither should you. No matter what researchers say, on average these studies don’t translate well to humans.) Some procedures that have been widely performed for many years get “case control” (epidemiological) studies, which look back at groups of patients who have received the treatment and compare them to groups who have not. While you can’t fully tell how trustworthy a study is just by noting what type of study it is–it’s wise to consider all medical studies at least potentially somewhat untrustworthy–as a rough generalization randomized, blind trials tend to be more trustworthy than case-control studies, and observational studies are the bottom of the barrel, though to be sure there are lots of exceptions and qualifications to this pecking order.

In short, the fact that gastric bypass, and, to a lesser extent, lap band procedures, have been found in case-control studies and many observational studies to be fairly safe and effective should not be taken very seriously. These types of studies can be subject to intense biases on both the parts of doctors and patients–they generally want the procedures to succeed, and may distort their observations and do a poor job of recording all relevant data. Researchers also typically don’t have access to all the data they need to fully analyze the situation. (For example, in the New England Journal of Medicine article I reference just above, the authors to their credit note that the study ignores the possibilities–likelihoods, I’d reckon, though the authors beg to differ–that people who had the surgery got much more or better medical attention afterward than other obese people get, and that they may have been healthier to begin with.) The procedures are a huge money-maker for surgeons, and the patients are often desperate to lose the weight and may be eager to convince themselves and others that they’ve done the right thing and that things are going to work out well. These biases, which can be and often are devastating to the reliability of medical studies, are exactly what randomized, blind studies attempt (if not always successfully) to eliminate. That’s why many surgical procedures are widely accepted as safe and effective, only to eventually prove themselves not so safe and/or less effective than other, less invasive and less risky treatments–the list includes many types of heart-related operations, back-pain-related operations, brain surgeries, and on and on.

This newest stomach-reduction procedure has been performed on one person so far. And yet surgeons just about everywhere will soon be able to perform it on anyone they deem suitable, providing nothing obviously terrible happens immediately to this one patient as a result. True, these sorts of “laparoscopic” (performed through small incisions and/or through the mouth, using a tiny camera and light to allow the surgeon to see what’s going on in there) procedures tend on average to be less risky than conventional, large-incision versions of the same surgery, but there can be reasons why they are sometimes less safe and/or less effective in some ways–for example, the restricted access and vision may result in a sloppier job of cutting or stitching, or in missing problems with bleeding.

And there are reasons to question whether the people who are getting these procedures really need them enough to justify the risks. (Though the twice-aforementioned NEJM study found that overall death rates went down for obese people who had gastric bypass surgery due to fewer deaths from heart disease, diabetes and cancer–findings that for a number of reasons I suspect may exaggerate the benefits of the procedure–around one percent died from the surgery itself shortly after the operation, and many had complications.) The people who sign up for these operations are typically obese people who have tried to lose the weight through diet and exercise but have failed, and whose health appears to be at some risk. But trying to compare the potential payoff from trying to diet and exercise to the likely benefits of surgery is a bit of a fixed contest. I’ve been studying the question of why people fail with diets and exercise, and it’s clear that the success rates would likely be much, much higher if overweight people weren’t getting such almost uniformly terrible advice about how to diet and exercise, and if their motivation to lose weight through dieting and exercise weren’t on average so low. Why is their motivation often so low? For one thing, they keep hearing from many researchers and obesity experts that they’ll probably fail with diet and exercise, and for another they’ve been led to believe that surgery provides a much easier and surer option that will provide all the same benefits of a successful diet and exercise program without any of the work–these procedures essentially are intensely marketed much the way cosmetic surgery is hawked, because they’re similarly ridiculously profitable. (Another issue is whether the success rate for dieting and exercising is really anywhere near as low as we’ve been told–but that’s a more complicated story.) Meanwhile, the success and benefits of surgical weight-loss keep getting pumped up through studies that are likely somewhat biased and otherwise flawed.

I don’t doubt there are obese people who, when the whole picture is soberly assessed, might be making a reasonable decision to undergo one of the procedures. But I suspect it’s a fraction of the number of people who are actually getting the surgeries. I was especially appalled to see a big and very well-researched and well-written cover story in the Atlantic earlier this year on the subject of obesity essentially advocate for, or at least seriously suggest the idea of, the government putting its anti-obesity money into handing out gastric bypass surgery for the obese, presumably instead of into research, education, good-nutrition programs, more-exercise initiatives and other anti-obesity public-health initiatives. The article, which for sure in many ways was terrific, more or less declared dieting and exercise to be a waste of time–a point of view which is pushed by many published medical studies relying on highly biased and flawed set-ups (as evidenced, for example, by the fact that findings from these studies widely and sometimes sharply conflict), but which flies in the face of the significant documented success rates that hundreds of real-world programs have achieved with obese people (and which has also been backed up by other published studies, for what it’s worth).

I think this sort of give-up-on-dieting-and-exercise-and-hold-out-for-surgery(-or-a-pill) thinking is dangerous, and is in fact a contributing factor to the obesity epidemic. If you’re thinking of getting some form of stomach-reduction surgery, I’d urge you to do some more research into the possible complications and into dieting and exercising options, and to discuss what you find with your doctor. And if your doctor is pushing you toward the surgery and especially if he seems biased toward it, try a second opinion from a doctor you have good reason to believe has an objective view about both diet-and-exercise programs and surgical alternatives. Many, many obese people have shed the weight and kept it off through dieting and exercise. Shouldn’t you be absolutely sure you’ve given dieting and exercise your very best shot under the right program before you have one or even two of your major organs hacked up and extensively rejiggered?

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