Christie's stomach procedure has fans, skeptics

Fernando Bonanni, a surgeon at Abington Memorial Hospital, was disappointed to hear Tuesday about Gov. Christie's choice for weight-loss surgery.

The governor admitted this week that he secretly had lap-band surgery in February.

"He couldn't have picked a worse choice, unfortunately," said Bonanni, medical director of Abington's Institute for Metabolic and Bariatric Surgery. "It's not that it's a bad surgery for everyone, but it's a bad surgery for him."

Bonanni said the procedure - installing a laparoscopic adjustable gastric band - is not ideal for "super-obese" patients like the governor. He said the band tends to work better for people who have less to lose.

While it has fewer complications at the time of surgery than other weight-loss operations, it has more later on, he said.

Bonanni said he removes about four lap bands a month.

Rohit Patel, medical director of the Center for Metabolic and Bariatric Surgery at Cooper University Hospital in Camden, was more politic. "The goal is for the patient to feel comfortable with the operation," he said, "for them to be successful with that operation with both preventing and resolving disease."

They and other obesity experts agreed that surgery is the most effective way for very heavy people to lose weight. It works far better than diet and exercise or medications.

Patients can choose among several procedures that change the size or shape of the stomach or the way food travels through the intestinal tract. They have differing complication rates, affect hunger and metabolism differently, and lead to different levels of short- and long-term weight loss. All require big changes in eating behavior.

Lap-band patients must be seen often by doctors for adjustments in the size of the band, which constricts the stomach. Patients with lap bands find it easiest to cheat on their diets.

Christie said Tuesday that his doctors told him that the lap band was the best choice for him because of his age and condition.

But lap-band surgery is becoming less popular, said Jaime Ponce, a Georgia surgeon who is president of the American Society for Metabolic and Bariatric Surgery. He said 160,0000 Americans have weight-loss surgery each year, a number that has been stable the last three years. A newer procedure, sleeve gastrectomy, is gaining ground.

Besides helping people lose weight, the society says, surgery reduces the odds that obese people will die from cancer, heart disease, or diabetes. In many cases, surgery resolves or improves Type 2 diabetes, high blood pressure, high cholesterol, and sleep apnea, the group says.

In the procedure that Christie chose, a band filled with saline is wrapped around the upper part of the stomach. This forms a small pouch that restricts food intake.

Patients feel full faster and longer, but retain normal digestion.

Other options include gastric bypass, in which the size of the stomach is greatly reduced and it is attached to the middle of the small intestine. This bypasses part of the small intestine and limits calorie absorption.

In a newer surgery, sleeve gastrectomy, the stomach is stapled vertically, reducing its size by 85 percent.

Bonanni also performs the duodenal switch, a more complex procedure that combines gastrectomy with a longer bypass. It has the best results for extremely overweight patients, but also requires constant nutritional monitoring to ensure that the patient gets enough vitamins. Ponce said it accounts for about 1 percent of weight-loss procedures.

Of the three most common approaches, lap banding has the lowest rate of major complications: 0.1 percent. That compares to 3.6 percent for gastric bypass and 2.2 percent for sleeve gastrectomy.

Still, the band can erode through the stomach or slip. Patients can suffer from heartburn, ulcers, infection, poor nutrition, and belly scarring.

Ponce said some centers have much better success rates with bands than others. They are still effective when done in patients who are committed to changing their behavior.

"The band probably works better on patients that are not that overweight, but that doesn't mean it's not going to work on Gov. Christie," he said.

Thomas Wadden, director of the Center for Weight and Eating Disorders at the University of Pennsylvania, said patients are attracted to the band because it is less invasive and is reversible, but he said about 40 percent of patients need another operation because they have regained weight or the band has slipped. Still, he said it's "a very safe procedure" that can be a "good decision for people who are severely obese."

He said patients typically lose 20 percent of their initial weight with the band and are 10 percent to 15 percent below their starting weight in five to 10 years. That compares to an initial loss of 35 percent for the bypass with a long-term loss of 25 percent. Sleeve patients lose 25 percent to 30 percent. Wadden said he had no long-term numbers for that procedure.

Bypass is far more effective than the lap band at ridding patients of diabetes.

Wadden said most people remain overweight even after the surgery and weight loss. "You can't rid yourself of these excess fat cells," he said.

Bonanni said patients can find ways to put weight back on with any of the procedures. "You can get around each and every one of these," he said. "This is not a walk in the park. It's the hardest thing you'll ever do."

Patel said the most important thing is to lose enough weight to reduce the health risks associated with obesity. "I applaud Gov. Christie's decision to address his weight," he said. "That's not always an easy issue for people to talk about and address."