Bariatric surgery becoming more accepted way of handling severe, long-term weight problems
by Cameron Steele
csteele@annistonstar.com
Aug 12, 2012 | 13000 views |  0 comments | 27 27 recommendations | email to a friend | print
Dr. Cliff Black and his team prepare for gastric sleeve surgery on a patient at Stringfellow Hospital in Anniston. (Anniston Star photo by Trent Penny)
Dr. Cliff Black and his team prepare for gastric sleeve surgery on a patient at Stringfellow Hospital in Anniston. (Anniston Star photo by Trent Penny)
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She needed a cane to hobble 15 steps from her apartment to her car.

She used a wheelchair for anything farther than that.

At 5-foot-5, Andrea Cheeks weighed 550 pounds. The Sylacauga woman couldn’t walk, couldn’t work, couldn’t shop, couldn’t leave her home without help. Couldn’t breathe sometimes. At 43, she had high blood pressure, diabetes, sleep apnea and an ulcer eating away at her leg as a result of problems with blood circulation.

She was suffering. She was going to die young, Cheeks learned from her doctors.

“My life consisted of staying home and paying bills,” Cheeks said in a recent phone interview, voice thick with tears. “Just knowing that I was not where God wanted me to be physically.”

But in May, things changed. Cheeks had part of her stomach removed in a gastric sleeve surgery at Stringfellow Memorial Hospital. Since then, she’s lost some 80 pounds and is out of her wheelchair for the first time in years. By this time next year, Cheeks’ doctor — Anniston surgeon Cliff Black — expects her to have lost 72 percent of her total body weight, or 400 pounds.

“That is just shocking — I’m still seeing this huge, excessively morbidly obese person in the mirror in my mind,” Cheeks said. “I can’t grasp that yet.”

Bariatric benefits

Many community leaders and health care experts are focused on preventative measures for obesity — a growing epidemic across the country and in Alabama in particular. But there are some who come into play at the other end of “our big problem” — when eating healthy and exercise aren’t enough and the weight gain has become life-threatening.

Bariatric, or weight-loss, surgery is something of a last-ditch effort for obese people: It treats weight issues by cutting away, rerouting or tying off parts of the stomach.

Annually, surgeons across the country perform around 220,000 bariatric surgeries each year.

Locally, between 125 and 150 people undergo surgical weight loss procedures each year. Black, the only comprehensive bariatric surgeon between Birmingham and Atlanta, performs the surgeries at Stringfellow.

Once a field surrounded with controversy — from what insurance companies should require of a person before they cover financial costs associated with the procedures to whether the benefits of surgery actually outweigh the risks — bariatric surgery has in recent years become widely recognized by health experts as a safe, effective way to curb weight and improve other obesity-related issues. Less than one-tenth of people die as a result of complications, said Dr. Brian Sabowitz.

“There’s overwhelming evidence that it makes sense to do bariatric surgery on people who need it,” said Sabowitz, who is professor of endocrinology at University of Texas, San Antonio, and Director of Metabolic and Bariatric Medicine at a San Antonio weight loss clinic.

Changing perspective

In the mid-1990s, weight-loss surgeries were rarely performed on anyone other than people suffering from a combination of obesity and diabetes, said Sabowitz, also a member of the American Society of Bariatric Physicians. People viewed bariatric surgeries either as a cosmetic procedure, health experts said, or one reserved for those who risked sudden death if some drastic measure was not taken. They also worried about complications from what Black still calls “formidable procedures.”

But as more clinical studies have demonstrated the effectiveness of the procedures and doctors have become more experienced at the laparoscopic operations, the perspective on bariatric treatment changed, according to local and national health experts. Recent studies by the New England Journal of Medicine show bariatric surgery not only helps people to permanently lose weight, but also cures type 2 diabetes, especially compared to more orthodox weight-loss routines. Similarly, the weight-loss operations have also been shown to reduce health problems with sleep apnea, hypertension, high cholesterol and heart disease, local and national medical experts say.

For severely obese people, the general rule of thumb these days is “not having the surgery is a greater risk than having surgery,” Sabowitz said. “The likelihood of you dying within the next five to 10 years is greater without surgery.”

‘Every sort of everything’

Most of Black’s patients are like Cheeks: They meet the National Institutes of Health eligibility for surgery by having body mass indexes of 40 or higher. Others have BMIs greater than 35 plus other health problems like diabetes, fatty liver disease or coronary artery disease. BMI calculates a person’s body fat based on height and weight.

“We’re dealing with people that are truly sick from their obesity,” Black said. “They are spectators not participants of their own lives.”

The surgeries are expensive — they can cost anywhere between $18,000 and $35,000, according to the online consumer guide for bariatric surgery. Most insurance carriers cover the majority of those costs for people who meet National Institutes of Health guidelines for the surgery, Sabowitz said, albeit only after patients have also jumped through other hoops first, such as trying other weight loss programs and meeting regularly with their primary physicians for six months.

Cheeks had to take these steps and others like it, she said, before Medicaid covered her gastric sleeve operation.

The Sylacauga woman said she has been overweight or obese her entire life. She never took care of herself, she said, because from the time she was 11, her focus was her late sister, who had cerebral palsy.

By the time Cheeks graduated high school, she already weighed 300 pounds. She didn’t have time to exercise, she said. When she realized she needed to, she couldn’t because of her weight.

Dieting never seemed to work, either.

“I tried every other source of weight loss, from diet shakes to starvation, everything sort of everything,” she said, crying. Health experts say Cheeks’ story is a familiar one: Most of the people who end up on Black’s operating table physically cannot exercise — cannot lose significant weight from dieting.

“Asking a morbidly obese person to just push away from the table and start exercising more is like asking a young woman to stop having her period,” Sabowitz said.

Different surgeries, different results

On a recent morning in the Stringfellow hospital operating room, Black and his physician’s assistant Lauren Waltz move with careful precision. The OR is dark save for the bright surgery lamps that illuminate the small incisions on the patient’s stomach, thin laparoscopic tools plugging each hole in the skin.

The technicalities of the gastric sleeve procedure are viewable on television screens above the patient’s shoulders. Waltz uses a pincer-like tool to stretch the stomach as Black snips part of it away. He staples the new, smaller stomach closed as he goes. Forty-five quiet, undramatic minutes pass before a nurse snaps the lights on, and Waltz holds one of the incisions open for Black to extract the stomach portion for discarding.

Gastric sleeve surgery is one of the three most common bariatric procedures, and one of the most effective operations, according to experts and several national studies.

It involves the removal of the greater curvature of the stomach — and, as a result, the removal of the enzyme that sparks hunger urges, as well, Black said.

He noted that successful sleeve procedures result in a 75 to 100 percent loss of the patient’s excess body weight.

“Patients typically lose one pound a day early on after gastric bypass or gastric sleeve procedures,” Black said.

Gastric bypass surgery is similar to the sleeve process, except it involves an extra step of rerouting the intestines to bypass part of the stomach. “And basically, patients have to lose that, because they already have one foot in the grave when they come to me,” Black said.

The reason bypass and sleeve procedures work so well is because they cut out that hunger hormone, Sabowitz said. The patient’s stomach — and therefore capacity to eat — is smaller, but the hunger pangs are gone, too.

“After you have surgery, the hunger gets better, and they are going to lose weight,” Sabowitz said. “Any strategy for weight loss that requires a person to not eat if they are hungry is guaranteed to fail.”

Reservations about the band

For that reason, surgeons like Black and experts like Sabowitz aren’t nearly as supportive of the gastric band operation as they are of other bariatric surgeries.

The band involves tying off part of the stomach, thereby restricting the amount of food a person can eat without getting sick. But it doesn’t cut out that key hunger hormone, health care officials said. It’s also the surgery with the highest complication rate: Black said he routinely has to take out bands that are causing problems with vomiting, infection, leakage or reflux.

At the San Antonio clinic where Sabowitz works, surgeons have taken out twice as many bands this year as they removed in 2011, he said.

“And this year, we’ve put in none,” he said.

Born again

For the first time in her life, Cheeks has hope about her future, about her health. She can tell the ulcer on her leg is receding. Since her surgery in May, she no longer needs medication for cholesterol or high blood pressure. She doesn’t pack her wheelchair when she goes out anymore, because she knows she needs practice walking, getting stronger.

“It’s just amazing how everything just started to correct itself,” she said. “I believe I was reborn on May 16, 2012.”

Sabowitz noted that many people who undergo bariatric surgery will gain back some of the weight they originally lose. But rarely, he said, do they reach the morbid obesity levels they found themselves at prior to surgery. Cheeks is now looking forward to her six-month checkup with Black, waiting for the moment when she’ll step on the scale with pride.

She’s eager to start exercising, go shopping. To take a walk in a park. Sit in her church pew without pain.

“I got my life back,” Cheeks said.

Star staff writer Cameron Steele: 256-235-3562.






WARNING: The following multimedia elements feature graphic footage and photos

In the OR: Gastric Sleeve Surgery (WARNING: Graphic Footage) from Anniston Star on Vimeo.









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