Although Safe, Gastric Bypass Surgery Still Carries RisksDec 22, 2003 | The Advertiser At 27, Jeremy Martinez of Espanole, N.M., weighed 334 pounds. He was suffering from some of the complications of obesity, including sleep apnea, a potentially fatal sleep disorder.
Unable to lose the weight on his own, Martinez joined the nearly 103,000 Americans each year who choose to undergo the weight loss surgery known as a gastric bypass.
But, unlike the majority of bypass patients, Martinez, who had traveled to Los Angeles in September for the surgery, encountered problems that wouldn’t go away. Since the surgery, the father of three has been bedridden, unable to keep any food down. Martinez spent four weeks in the intensive care unit of his local hospital after he began having problems, including seizures.
He was sent home with a tube running through his nose and a PICC line, short for peripherally inserted cardiac catheter, going into the blood vessels near his heart.
On Nov. 24, Martinez had emergency surgery to reverse the bypass, after he began having seizures again.
Although doctors say the surgery is safe, there are some risks.
And, although the incidence of major problems is small, the list of potential complications is long. The risks during surgery include leaks in the intestine, life-threatening pulmonary embolisms and too-small openings called stomach stenosis. Estimates for the risk of death from gastric bypass surgery range from one in 350 to one in 200, depending on the source. Even when the surgery goes right, long-term risks may include gall bladder problems, hair loss, osteoporosis and other conditions associated with malnutrition.
A degree of risk
“As soon as I got home,” Martinez said, “I knew something was wrong.”
He suffered from severe nausea and vomiting from the outset.
Nausea is to be expected after the surgery, the experts say, but this and other minor problems resolve themselves within weeks, as the body gets used to the smaller stomach.
“About three weeks after that, I started having fainting spells and seizures,” said the vocational school teacher. “I would go to my regular doctor and he would correspond with the doctors who did the bypass and they would say there was nothing wrong.”
About a month ago, after repeated trips to the emergency room, Martinez’s wife, Tammy, took him to a Santa Fe, N.M., hospital, where a CT scan and upper GI series revealed the problem.
His stomach was almost completely closed off.
In about two months, Martinez has lost 50 pounds.
The problem is not uncommon, said Lafayette surgeon Dr. Uyen Chu.
“We’ve had some complications with stomach stenosis, where the opening from the stomach to the intestine becomes narrowed so food can’t pass through to the pouch and you throw up all the time. We go in with a balloon and stretch it out.”
In Martinez’s case, however, the opening was too small even for a balloon to pass through, he said.
Martinez’s doctors estimated that he would not be strong enough for corrective surgery until January, but the schedule had to be accelerated because of the seizures.
Defining the complications
While most of the news about gastric bypass surgery extols its almost miraculous results, there is little emphasis on the small percentage of bad outcomes.
“The early complication rate is about 15 to 20 percent,” Chu said. “The late complication rate is about 5 percent and the re-operation rate is about 2 or 3 percent.”
Complications sometimes depend on the surgeon performing the operation, said Dr. Thomas Borland, who has been doing weight-loss surgery since the 1980s. The more experienced the surgeon, the smaller risk of complications.
“The main complication that kills patients is pulmonary embolism,” Borland said.
The embolisms are blood clots in the extremities that break free and lodge in the lungs.
Even when the surgery goes right, Borland and Chu emphasize that the patient and doctor must be committed to lifelong follow-up care.
Vitamin deficiencies are a natural outcome, which allows only a very small amount of food into the tiny stomach pouch, and, in the case of the Roux-en-Y procedure, eliminates about 18 inches of the small intestine, and causes malabsorption of the food that does get through.
Gastric bypass patients also are cautioned to avoid becoming pregnant for at least 16 months after the surgery, Borland said.
“Some will suffer some malnutrition,” Borland said, “but the majority will have normal babies.”
Reversing the surgery
While most problems associated with the surgery can be overcome with time and care, there are still cases such as that of Martinez.
“I think it doesn’t happen often, only in about 1 percent of patients,” said Houston surgeon Dr. Adam Naaman, one of only a few physicians in the United States qualified to revise or reverse the surgery.
Naaman has done more than 250 operations to repair or reverse the procedure since 1985.
Naaman said some people simply cannot tolerate the surgery.
“As a matter of fact, I saw a lady who came from California. She had the surgery a year ago and lost 100 pounds, but can’t eat anything, because it hurts.”
While the public doesn’t often hear such negative reports, Dani Hart, author of “I Want to Live: Gastric Bypass Reversal,” hears it all the time.
Her own surgery in 2000 left her with symptoms including chronic vomiting, shaking, malnutrition, heart palpitations, muscle weakness, hypoglycemia, lactose intolerance, hair loss and eventually, osteoporosis.
“By the time I had the (reversal) I was in the beginning stages of organ failure,” Hart said.
Her doctors were unsympathetic, Hart said. “They said I was overeating, but when I had the reversal, they found the ring inverted itself when the food went down, so the food would come out.”
Hart added that she had lived on broth and puréed soup for a year and a half, until Dr. James B. Swain of the Scottsdale, Ariz., branch of the Mayo Clinic reversed the surgery in March 2002.
Her experience has prompted Hart to become a resource for others.
“People are so desperate for help,” Hart said. “The problem is trying to find someone who will take them.”
Finding a surgeon
Reversing the surgery is a concept new to the medical community, Naaman said.
“I think it takes years of doing (the surgery) to develop the expertise and confidence to do a revision or reversal. And some surgeons don’t know some of these can be revised or reversed.”
Naaman made a presentation to a meeting of the American College of Surgeons in September on how to revise some of the procedures.
Naaman, whose patients come from around the country, has no official statistics on how many surgeons do reversals.
“It’s very hard to say,” he said. “I hear many times of people who are quite well known, but yet, their patients come and tell me their surgeon won’t do a reversal.”
Even those who do reverse the surgery often have certain requirements, including patients who want the reversal done for the “wrong reasons.”
Naaman doesn’t see it that way.
“We offer psychological help and dietary help, but a very small number of them feel they would rather be the way they were, so we reverse the surgery. It’s their stomach.
“It’s not an issue of fault; it’s an issue of it’s not the surgery for them. There are very few things in life that are perfect.”
Finding a surgeon to reverse the procedure is only one of the hurdles, Hart said. Paying for it is the other. The cost for the reversal can be as much as the $20,000-to-$45,000 price tag for the original surgery more if the complications are severe. And insurance companies are often reluctant to cover reversals.
“The insurance companies need a medical necessity,” Hart said. “You’d better be pretty sick.”