Obesity’s Cutting Edge
Wednesday, July 4th, 2007By LORETTA GRANTHAM – Palm Beach Post Staff Writer  Sunday, June 24, 2007
Patients who’ve lost nearly 100 pounds are thrilled!
A new weight-loss surgery doesn’t require you to reroute your digestive system or deal with an adjustable implant. You will, however, have to give up more than three-quarters of your stomach, which is permanently removed.
But for lifelong dieter John Linehan, who dropped 100 pounds after having a sleeve gastrectomy last year, this was a triumph, not a sacrifice. A potent blow to the tyranny of an insatiable appetite.
“I don’t want people to think it’s a magic pill, but in my opinion, it’s pretty darn close,” he says. “I’m not a slave to the cravings anymore. I can eat a small amount and feel full.”
Linehan is one of nearly 200 patients who’ve had gastric sleeve surgery in the past two years at the Cleveland Clinic in Florida, a Weston research hospital that’s among a handful of bariatric centers pioneering the procedure.
The operation involves cutting off the crescent moon-shaped part of the stomach and leaving behind a tube, or “sleeve,” which can hold from about 2 ounces to 6 ounces.
Not only is food capacity shrunk from the size of a football to that of a thin banana, but there also appears to be a bonus: The stomach section that gets “tossed in the pan,” as one surgeon put it, is where ghrelin, a hormone that stimulates hunger, is produced.
This may explain, at least in part, why Linehan spends less time pondering snacks.
While the Delray Beach graphic designer, 61, is doing well out of the gate, doctors say that his chance of long-term success is unknown. That’s because most gastric sleeve studies are less than four years old.
“I’m watching the procedure closely,” says Dr. Andrew Larson, bariatric surgeon at JFK Medical Center in Atlantis. “If it really does have lasting results, I might be willing to do it. But I don’t think it’s quite ready for prime time.
“The downside is that we don’t know what’s going to happen in the long run. On the other hand, there are advantages.”
All weight-loss surgeries, doctors say, carry the risk of regain. The stomach, regardless of its post-operative size, eventually can stretch. And diet and exercise are up to the patient. Plus, early suppression of ghrelin, one of many appetite regulators, appears to ebb over time.
But bariatric surgeons, eager to boost their arsenal against obesity and related diseases, are eager to see how the sleeve stacks up.
Dr. Raul Rosenthal and his Cleveland Clinic colleague, Dr. Samuel Szomstein, have published several studies.
“Because we don’t have long-term data, we recommend this to patients with caution,” Rosenthal says. “We say, ‘Listen, there is a possibility that you may not lose what you need to lose or you may regain a considerable amount of weight.’
“But the good thing is that the sleeve leaves the door open to additional surgery if needed.”
Gastric sleeve goes solo
Sleeve gastrectomy emerged in the late 1980s as part of a procedure called the biliopancreatic diversion with duodenal switch, which limits food absorption.
And the stomach-tube technique also has been used as a first step to help severely obese patients drop pounds before gastric bypass, still considered the gold standard of bariatric surgeries.
But only in recent years has the sleeve been offered by itself — especially for adolescents, seniors and patients with health problems that limit their options — because of fewer complications. Unlike gastric bypass, it doesn’t hinder food absorption, which can cause vitamin and protein deficiencies, anemia and osteoporosis.
The Lap-Band, meanwhile, an adjustable ring placed around the top of the stomach, also allows normal digestion. But some patients don’t want (or can’t tolerate) an implanted device that may cause food to get stuck temporarily.
“The good thing about the sleeve is that it doesn’t create the complications of a bypass or require the follow-up of a band,” Rosenthal says. “You don’t need vitamins for the rest of your life, you don’t develop ulcers, and it doesn’t create dumping.”
Dumping refers to the nausea, cramps, vomiting and heart palpitations that may occur when bypass patients eat foods that are high in fat and sugar. Some people view this potential side effect as a plus because it makes you think twice before indulging.
‘Impressed by early results’
Less than two weeks ago at a national conference in San Diego, members of the American Society for Bariatric Surgery were abuzz about gastric sleeve and how it might expand treatment options.
“I think we’re all very impressed by the early results,” says Dr. Neil Hutcher, immediate past president of the group and a surgeon at Bon Secours St. Mary’s Hospital in Richmond, Va.
“There are several things that can be said pretty clearly now. The operation is safe, and there probably will be fewer potential negative side effects when compared with the gastric bypass.
“But we’ve seen operations that are restrictive in nature show early good results and then deteriorate. We really have to be very careful and go through an extensive review process.”
A Cleveland Clinic study published in the January/February edition of Bariatric Times showed that the mean percentage of excess weight loss six months after gastric sleeve was 53 percent, on par with gastric bypass.
In other words, most patients drop about half of the pounds they need to lose within six months. But keeping it off remains to be seen.
Case in point: Linehan has regained about 10 pounds.
“It probably wouldn’t have happened had I been exercising,” he admits, quipping that his rowing machine makes a nice clothes rack. “I know I need to stay active to keep the weight off.”
Rosenthal, meanwhile, says that when it comes to bariatric surgery, the scale is just part of the story. Treating obesity-linked diseases is the other.
“Obviously, if you do surgery, a patient will lose weight and solve related problems,” he explains.
“But what we’re seeing with gastric bypass is that three days after surgery, diabetes is gone — even before weight loss has started. We believe that the sleeve may have similar results.
“We haven’t figured out exactly how everything works together, but we’re making major progress not only in weight loss but in curing diabetes, hypertension and high cholesterol.”
A family history of diabetes was one reason why Susan Welborn of Jupiter sought weight-loss surgery for her son, Matt Luongo, who’d hit 289 pounds by age 12.
“I contacted numerous bariatric surgeons, but nobody would do it because of his age,” she says. “They’d say, ‘Come back when he’s 18.’
“It was very frustrating because he was the size of an adult, and he continued to gain weight no matter what we tried. I worried that once he hit puberty, the problem would get even worse.”
Rosenthal agreed to evaluate the boy and, with the approval of Matt’s pediatrician, performed a sleeve gastrectomy April 17, 2006.
Explains the surgeon: “I was reluctant to do a bypass because I didn’t want him to have trouble absorbing vitamins and minerals while he was still growing. And I didn’t want to do a Lap-Band on a child because of adjustments and needles.”
(A needle is used to inject saline into a port under the skin of the abdomen when tightening or loosening the band.)
The high school freshman, now 13, since has lost 79 pounds and gained self-esteem, even hoping to try out for football.
He’s among the youngest weight-loss surgery patients in the country, but the number of 12- to 19-year-olds going under the knife has tripled in recent years, according to a hospital study published in the Archives of Pediatrics & Adolescent Medicine in March.
“Surgery should always be a last resort,” Rosenthal says. “And for a child, the very, very, very last resort.
“Unfortunately, our country is the world champion of childhood obesity with about 32 percent of our kids being overweight. As surgeons, we have to be ready to deal with the major medical problems, like Type 2 diabetes, that are already showing up as part of this epidemic.”
Moving toward the mainstream
Recovery after gastric sleeve, which is performed through tiny incisions in the abdomen instead of through an open procedure, is relatively quick.
Matt, for instance, only missed a week of school. And Linehan jokes that he was so pain free he thought Rosenthal hadn’t done anything.
Both endured a liquid diet immediately after surgery, easing their way up from clear broth to puréed chicken to regular food, albeit in small portions, after a few weeks.
But all surgery is risky, and although the sleeve is less internally complex than gastric bypass, leaks and bleeding can occur along the staple line where the stomach is severed.
Research presented at the bariatric conference in San Diego, however, shows that sleeve gastrectomy, which takes about 90 minutes in the operating room, is generally safe and, at least in the short term, effective in helping quell appetite and combat obesity.
“There are upcoming papers that have five-year data, so we’re getting tantalizingly close to being able to make a statement on intermediate efficacy,” Hutcher says.
In other words, surgeons will know more tomorrow — and in the days to come — about how gastric sleeve measures up in America’s waistline war.
But for Matt Luongo’s mom, Susan Welborn, it’s enough to know that she’s given her son a chance at a normal life starting in high school, not decades after a host of health problems have taken their toll.
“Before he’d come home, and all he wanted to do was play video games,” she says. “He didn’t want to go to the beach, he didn’t want to hang out with friends. Now he’s willing to go out and do things.
“I remind him that having surgery is just the beginning, a way to take the edge off the hunger. He knows that the rest of it is up to him.”
Staff researcher Melanie Mena contributed to this story.
