The doctor was blunt with the very large woman on the examining table. “By the time you’re 40, you’ll probably be dead,” he told Marsha Holloway Howell. She was 27 and a medical assistant in Birmingham, Alabama. At five-feet 11 and 313 pounds, her body mass index (BMI) was 43.6. That meant she was morbidly obese, and the “morbid” in that term is not hyperbole.
People so heavy have an amply documented host of problems: from bad feet and sleep apnea to reduced lifespans and elevated rates of a host of afflictions ranging from diabetes and high blood pressure to heart disease and sudden cardiac death. So, in what seemed like a fairly obvious decision, Howell opted for the most common weight loss surgery — the gastric bypass, also known as the Roux-en-Y, in which the guts are rearranged so the small intestines are attached to a surgically-created pouch, fashioned from a portion of the stomach.
Howell went under the knife in September 2004. The surgery went fine. Weight loss was prompt, as advertised, and she reached her target weight by the following spring. The only problem was that she started getting sick three months after the surgery. There was pain and vomiting, and it never stopped.
First came the ulcers, one after another — an affliction she never experienced before the surgery, and she never smoked and strictly followed doctor’s orders to avoid ulcer-causing over-the-counter drugs. Then came an intestinal hernia, another complication of the surgery. Her teeth kept breaking from calcium deficiency and vomiting, all byproducts of vomiting from the ulcers and “malabsorption” of nutrients caused by the surgery, which prevents the body from processing vitamins and minerals at the usual rate because of the way the guts are rearranged.
A pregnancy, three years after the surgery, was an ordeal. The child was born healthy, but a C-section delivery was complicated by a tummy tuck operation that she had a year after the surgery, resulting in a blood clot and a gaping incision that had to be left open for months after childbirth.
She was forced to quit work. She required three-times-a-week nursing care for the Wind-Vac dressing in the incision, even as she was taking care of the baby. Root canals on her brittle teeth proved ineffective, so most were pulled and she was forced to wear dentures. As her medical problems mounted so did her financial woes. She lost her house and was forced to move into an impoverished suburb of Birmingham.
In January 2010, she hit bottom. “I took every pill I had,” she recalls. It was the day her husband asked for a divorce. She was found in time, taken to the intensive care unit and then the psychiatric ward.
Howell’s hellish experience, while far from common, is a lesser-known and under-appreciated aftermath of what is widely considered to be the most effective method of treating obesity. Weight loss surgery works — the author of this article can attest to that, having had the operation in November 2010 and lost 130 pounds of excess weight and kept it off, without complications. Such results are common. A meta-analysis of 164 studies including 161,756 patients showed average loss of 67.5 percent of body weight in one year, with 94 percent seeing diabetes cured, 80 percent experiencing an end to high blood pressure, 95 percent realizing an end to sleep apnea and 72 percent saying au revoir to excess cholesterol and triglycerides. On average, bariatric patients keep half their excess weight off five years after the surgery.
But the trade-off is not death on the operating table — just one tenth of one percent of weight-loss operations — but troublesome complications, some arising years after the surgery. Studies show increased rates of substance abuse and suicide after weight-loss surgery, as patients struggle to cope with the loss of comfort foods. “The problem is the surgery is an anatomic fix for a psychological problem,” says Dr Lisa Medvetz, a bariatric surgeon and weight-loss specialist who practices in Pennsylvania and Idaho.
One nettlesome issue is that patients can have an uneventful surgery, experience no immediate complications, and then experience surgery-related issues years later. The reason is not botched surgery, for the most part, but, in the case of the gastric bypass, the anatomical changes caused by the surgery. Long-term complications can be especially daunting for patients who undergo gastric bypass, which involves physical rearrangement of the bowels.
Dr Andres J. Acosta, a gastroenterologist and bariatric surgeon at the Mayo Clinic, says that studies have shown a late-complication rate of up to 40 percent after weight-loss surgery. But he notes that those studies, which encompass even easily-treated nutritional deficiencies, were skewed by the fact that many early surgeries were riskier open incisions, before the widespread use of laparoscopic “keyhole” surgery in the 2000s.
Dr. Acosta says that new data, adjusted for the aging of the population, shows a long-term complication rate of 14 percent to 15 percent. The complication rate is particularly high, he says, for patients using the Lap-Band, a surgical device that reduces the size of the stomach to reduce appetite. Dr Acosta says that the high rate of follow-up surgeries for the Lap-Band, which he says is as high as 50 percent, and limited weight loss, is such that he has stopped installing the device.
For the thousands of people who have successfully undergone weight loss surgery — 80 percent of whom are women, according to one study — the number of reported complications are likely to increase in coming years, as more complications arise from the vast increase in the number of bariatric operations during the 2000s. Only one percent of eligible patients receive the surgery, Dr Acosta points out. “There’s definitely room for more, and the more we do, the more complications we’re going to see long term.”
The increase in surgeries was particularly dramatic in the early 2000s. Between 1998 and 2004, the annual number of bariatric surgeries in the U.S. climbed from 13,386 to 121,055. The gastric bypass was the most popular surgery until 2013, when it was surpassed by the less invasive gastric band, in which the stomach is reduced in size. By 2014 the total number of bariatric surgeries had climbed to 193,000, with 27 percent of them gastric bypass, as compared to 52 percent for the gastric band. But over the years, the gastric bypass has been dominant, with about 80 percent of all weight loss surgery over the years.
With complications from the surge in bariatric surgeries surfacing, the anecdotal evidence of late complications is starting to mount. A kind of clearinghouse and online support group for people so afflicted is a closed Facebook group called How Gastric Bypass Ruined My Life, which Howell co-administers. Its 2200-odd members consist largely of people, almost entirely women, who found that gastric bypass and the Lap-Band have turned their lives into sheer misery. Doctors like Medvetz and curious but as-yet healthy bariatric patients also drop by — to learn, and be terrified. Unlike other, far larger bariatric-surgery online groups, which emphasize body transformations and common side effects of drastic weight loss such as hair loss, Howell’s group dwells on the horror of major medical problems dropping in out of the blue.
When people say the surgery ruined their lives, they may be exaggerating. Samantha Lamont-nelthorpe is not.
Her gastric bypass surgery came at the age of 34, in 1999. She was 5-feet-nine and 300 pounds. The weight came off fast, as promised — 120 pounds in the first year. Her life was great. She enrolled her no-longer-morbidly-obese self in medical school in Ontario, where she lives. All fine. Until 2004. Her appetite vanished. She started “losing weight and losing weight,” she recalls. She wound up semi-conscious on her bathroom floor.
It was a small bowel obstruction, a recognized complication from the surgery. Dr Acosta notes that such issues arise from all surgeries involving the intestines, and gastric bypass “is not an exception.” The bypass surgery caused adhesions — scar tissue. These can result in a life-threatening blockage. “Any time go into the abdominal cavity and mess with the gut you’re likely to have adhesions,” Dr. Lamont-nelthorpe, now a physician, points out. As a doctor, she is perfectly aware of what would have happened had the blockage not been cleared fast enough. She’d be dead.
But the bowel obstruction was minor compared to what followed four years later. It came out of nowhere in 2008, nine years after the surgery. She’d feel fine until about two hours after eating. And then, suddenly she’d crave sugar. If not satisfied, she’d pass out. “You literally find yourself going from being perfectly fine to being unconscious in a matter of minutes,” she says. Dr. Lamont-nelthorpe had come down with a particularly scary complication of the surgery called postprandial hypoglycemia.
As noted, gastric bypass can has a miraculous effect on diabetes, curing it as soon as the patient is wheeled out of the operating room. That’s apparently because the surgery has an effect on the insulin-regulation mechanism. That’s great if you’re a diabetic or have high blood sugar. But, in some patients, the surgery causes hypoglycemia in patients who are not diabetic.
In Dr Lamont-nelthorpe’s case, the condition is so dangerous that she has “hypoglycemic” tattooed on her wrist, in lieu of a medic-alert bracelet. Her blood sugar level has been recorded at as low as 17 (normal is 80). The Mayo Clinic has conducted research into post-operative hypoglycemia, and such a rare form of hypoglycemia is found in only 0.2 percent of patients, Dr. Acosta points out. [tweaked wording – gw] It is, he says, manageable by medication and various surgical procedures, and by no means incurable. Still, Dr Medvetz, who has never encountered the severe form that plagues Dr Lamont-nelthorpe, says that she’s found milder hypoglycemia complications among 10- to 15 percent of people who have had gastric bypass.
Indeed, most complications of the surgery are manageable — but that is small solace for the patients who have them. Adele Thermes, a program manager for adults with disabilities in Eau Claire, Wisconsin, had her operation in 2009, when she was 38. It was a smashing success. She’s 5-feet-three, weighed 242 pounds at the surgery, and hoped to reduce to cut her weight in half. She did. It worked.
The problem is that it continued to be a smashing success far too long. It was such a smashing success that it became a nightmare. The weight loss, which usually stops after a year or so, never stopped. Her metabolism went into overdrive and stayed there. Her description of her symptoms sounds like something from the classic 1950s sci-fi flick, The Incredible Shrinking Man. Only it really happened — and that was just one complication of the operation.
Thermes required multiple operations in the years that followed, directly because of the gastric bypass. Her gallbladder had to be removed (gallbladder complications, caused by the severe weight loss, are a recognized aftermath of the surgery). Then the site of the gallbladder operation ruptured and required further surgery. Her small intestines collapsed into her large intestines like an old-fashioned telescope, known as an intussusception, which had to be surgically corrected. She had hernias, another recognized long-term complication, and, most recently, a perforated ulcer, all painful, dangerous and requiring emergency surgery. She also suffers from sporadic ileus, in which her bowels simply stop working, resulting in stool impaction.
The silver lining, if you can call it that, is that Thermes has no problem keeping her weight down. Indeed, she has to work to keep it up. Howell, who struggles with osteoporosis caused by calcium deficiency, has given up trying to lose weight. She is 230 pounds now and okay with it. She’s more focused on keeping her bones from breaking — she has broken her ankle eight times since the surgery. She’s had three back surgeries. In all, she’s required fifteen operations since the bariatric surgery. Thermes has had seven operations since the bypass surgery, though offhand she could only name six. All are kind of jumbled in the Hades of her memory.
Howell has considered having the operation reversed, but there is a possibility that her intestines might shut down entirely, which would mean she would have to be fed via a feeding tube for the rest of her life.
“They say the surgery is life-changing,” she says ruefully, “and they mean it.”