http://www.cnn.com/2009/HEALTH/07/29/health.weight.loss.surgery/

Weight-loss surgery safe, but sleep apnea increases risk

Story Highlights
* Study: Bariatric surgery in skilled hands is safer than first thought
* Out of 4,776 patients, only 4.3 percent experienced a serious
complication
* Sleep apnea, severe obesity, history of blood clots, and walking limits
raise risk

By Heather Mayer
Weight-loss surgery isn't risk-free, but a new study suggests that in the
hands of a skilled surgeon, it may be safer than previously thought.
However, some people -- including those with sleep apnea or a history of
blood clots -- are more likely to have problems with surgery than others,
according to a study published this week in the New England Journal of
Medicine.

"The overall conclusion that we reached is that bariatric-surgery safety is
actually quite good," said Dr. Bruce Wolfe, a professor of surgery at the
Oregon Health and Science University.

In the past, bariatric procedures have been associated with death rates of
2 to 3 percent and complication rates of up to 24 percent. However, the
obesity epidemic is fueling a rise in such surgeries, prompting concerns
about their safety. In 2005, 171,000 people underwent bariatric surgery,
more than 10 times the number that had the procedure in 1994.

To assess the safety of such operations, Wolfe and his colleagues looked at
4,776 patients in the first month after having a bariatric procedure. They
found that 4.3 percent of patients had a serious problem, such as a blood
clot or needing another operation, and 0.3 percent, or 15 patients, died
within a month after surgery -- a complication rate similar to other types
of surgery.

Four main factors seemed to increase the risk of complications, including
sleep apnea, severe obesity, a history of blood clots, and an inability to
walk at least 200 feet prior to surgery. Health.com: 10 easy food swaps cut
cholesterol, not Taste

Sleep apnea is a common disorder in the obese (about half of the patients
in the study had the condition). Excess weight in the neck region can
contribute to sleep apnea, which is characterized by snoring and the
collapse of the upper airway during sleep, sometimes hundreds of times a
night.

Sleep apnea causes sleepers to snort and gasp for breath and is associated
with high blood pressure, vascular changes, and a greater risk of heart
disease. "We assume (the effects) are related to why it is a surgical
risk," Wolfe says.

Surgeons at Brigham and Women's Hospital, in Boston, Massachusetts, have
been performing bariatric surgery with good results since 1995, said Dr.
Malcolm Robinson, an assistant professor of surgery at Harvard Medical
School, who practices at the hospital and wrote an editorial accompanying
the study. "As the art of bariatric surgery has evolved, it's become safer,
and this study is proof of that evolution," he said.

Even with the risks of an operation factored in, bariatric surgery can be a
lifesaver, particularly for people who are very obese. Such patients are at
high risk of death due to obesity-related illnesses, such as heart disease
and type 2 diabetes. Such surgery is recommended only for those with a body
mass index greater than 40, which would be 248 pounds or more for someone
who is 5 feet 6 inches. If other health problems, such as diabetes, are
present, surgery may be recommended for someone with a BMI of 35 or higher
(217 pounds or more for someone who is 5 feet 6 inches). Health.com: The
slimming power of mint

"[Research suggests that] surgery increases survival and makes people live
longer, even taking into account mortalities," said Wolfe.

The patients in the new study were treated between 2005 and 2007 at 10
centers with a large volume of bariatric procedures. In all, 33 highly
skilled surgeons, who were certified by the Longitudinal Assessment of
Bariatric Surgery Consortium, conducted the operations. Robinson says that
the study's low complication rate might not be the standard at all centers.

Plus, the study could not determine if one type of bariatric procedure was
better than the others. Most of the patients had one of three procedures:
an open Roux-en-Y, in which a small pouch is created that bypasses the
stomach and attaches to the upper intestine; a Roux-en-Y conducted
laparoscopically, in which a camera, light, and instruments are threaded
through a small incision; or laparoscopic adjustable gastric banding, in
which an adjustable band is wrapped around the stomach to create a small
pouch, which then empties into the larger portion of the stomach.

The death rate was 2.1 percent with the open Roux-en-Y and 0.2 percent with
the laparoscopic version. (Some patients who underwent the open Roux-en-Y
had health factors that put them at greater risk for complications.) There
were no deaths associated with laparoscopic adjustable gastric banding.

Some doctors avoid using the adjustable band procedure because they think
it needs to be adjusted or removed too often, and because they believe the
weight-loss results aren't as strong, according to Robinson. Others prefer
it, saying it's safer and just as successful in terms of pounds lost.

Wolfe says he doesn't recommend one gastric procedure over the other.
However, patients at a higher risk for complications may be advised to
choose a lower-risk procedure like banding, he said. Health.com: Cut up to
900 calories with simple substitutions

Even though the complications from bariatric surgery are rare and usually
reparable, patients can take certain precautions to ensure an even safer
recovery.

Patients who have experienced blood clots prior to the surgery were more
prone to having them again, regardless of the kind of operation, said
Wolfe. He said that the increased risk of complications in patients who
were so heavy they couldn't walk was not surprising.

"It's believed to be important that after surgery, patients walk around to
reduce blood clots," Wolfe said. "But if a person is unable, they
presumably are at a higher risk for blood clots."

Patients should lose some weight before surgery because it can lower the
risk of complications, experts agree. "That goes along with our finding
that the very highest weights or severity of obesity is associated with
greatest risk," said Wolfe. Health.com: How crash diets, like the master
cleanse, harm your health and heart

He recommends losing 10 percent of one's body weight before surgery to help
speed recovery. "[But] a low BMI didn't automatically mean the complication
rate is lower," he cautioned. "Other factors are involved."

When choosing a hospital for the surgery, experts recommend considering the
center's expertise, equipment, dietary program, nonphysician health-care
providers, and the anesthesiologists' skill and experience (it is harder to
administer anesthesia to heavier patients).

The researchers plan to follow 2,400 patients for several years after
surgery to determine the long-term complications and benefits of the
different procedures.