Shrinking Waistlines Though gastric bypass is still a mainstay for dramatic weight loss, new, less-invasive procedures are gaining a place at the table.

By Christine Stutz



Susan Hess struggled with excess weight her entire adult life, and six years ago her endocrinologist gave her an ultimatum she couldn’t ignore.

“You will never be able to lose a significant amount of weight without doing something drastic,” she told her. “You might be able to lose 10 pounds on your own, but you need to lose a lot more than that.”

Hess’ diabetes had progressed to the point where she needed an insulin pump for daily injections. She’d had a cardiac ablation to treat her worsening heart problems, which had forced her to retire from her job as a registered nurse at the Upper Chesapeake Medical Center. She suffered from severe back and knee pain that made it difficult to walk.

“I had tried all different kinds of diets, and I’m not a big exercise person. Plus, it’s next to impossible to lose weight when you’re on insulin,” says Hess, a Fallston resident who was 67 at the time.

When her doctor suggested gastric bypass, a surgical procedure that changes the way the stomach and small intestine handle food, Hess didn’t think long before saying yes. On a cold day in January 2011, she headed to Sinai Hospital to have the outpatient procedure performed by Dr. Christina Li, a bariatric surgeon with LifeBridge Health.

“It was a snap,” says Hess. Over the next nine months she lost 90 pounds, dropping from 250 pounds to 160 pounds, from a size 2X to a size 12. And she hasn’t gained the weight back. “My weight hasn’t varied by more than a pound each year,” she says happily.

Like Hess, an increasing number of Americans who are struggling with obesity are looking for weight-loss solutions beyond diet, exercise and medication. They are motivated not just by a desire to look and feel better—but in many cases to address life-threatening health problems such as cardiovascular disease, hypertension, Type 2 diabetes and sleep apnea.

Gastric bypass was one of the first surgical procedures developed to help the very obese achieve rapid weight loss. Begun in the early 1990s and refined several times since, it remains the most popular, accounting for about 80 percent of all weight loss surgeries in the United States.

But over the last several years, the weight-loss arsenal has dramatically expanded as new noninvasive options have come online, proving both popular and effective. The latest procedures don’t require any surgical incisions in the body. Instead, a tube is inserted into the throat to make adjustments to the stomach that result in fairly rapid weight loss.

“Until recently, there hasn’t been anything in between medical therapies and traditional bariatric surgery. That’s where endoscopic weight-loss surgery comes in,” says Dr. Vivek Kumbhari, director of bariatric endoscopy at Johns Hopkins Medicine, who runs the Johns Hopkins Concierge Weight Loss Program. What all of these new approaches have in common, Kumbhari says, is that they are fairly quick, cause minimal pain, leave no scars and are reversible.

Rebecca Johnson (not her real name), a 36-year-old health care professional in Baltimore, was planning to start a family. But in order to have a healthy pregnancy she knew she needed to drop her excess weight. Her target goal: lose 85 pounds.

“I really needed a jump-start to get headed in the right direction, so I started exploring my options,” she says. Gastric bypass was not an option for her. “I was concerned that it was just too permanent, in terms of cutting your stomach down.”

With gastric bypass, a surgeon surgically divides the stomach into a small pouch (about the size of a walnut) and a larger one, and then connects the small pouch to a part of the small intestine that is slightly farther down. With the smaller stomach, people feel full much more quickly and eat less. And because food bypasses the duodenum in the small intestine, fewer calories and nutrients are absorbed.

“When I learned about the gastric balloon, I thought, ‘This might be just what I need.’ It’s less invasive and it’s not permanent so I wouldn’t be modifying my body,” says Johnson.

With this approach, a silicone balloon is inserted through the throat and into the stomach during a 20-minute procedure.

Because the balloon occupies space, you eat less at mealtimes. The balloon also slows the stomach-emptying process so you feel less hungry between meals. The balloon is removed after about six months. Patients connect with a medical team—composed of dietitians, behavioral psychologists and exercise physiologists—before and after the procedure, for up to a year, to ensure they have the tools they need to make the weight loss stick.

According to physicians, the balloon technique produces a loss of about 25 percent of excess body weight, mostly within eight weeks of the procedure. LifeBridge Health’s Li has found that patients can expect to lose approximately 20 to 60 pounds with this approach.

“Some patients are struggling to lose weight before an event, or before elective surgery. This is a great noninvasive way to do that,” says Li, who heads up the Minimally Invasive Surgery program at Northwest Hospital.

Johnson had her procedure performed with Kumbhari at Johns Hopkins in April 2016. “It was very fast and seamless,” she says, “though there was some adapting those first few weeks as I figured out how much food and fluid I could take in without overdoing it.”

Thanks to nutritional counseling, she lost seven pounds on her own before the balloon was inserted. She lost 61 more pounds with the balloon in place.

“This is just what I needed,” says Johnson. “I’ve given up soda and am eating lots more protein, fruits and vegetables, and I now have a good sense of reasonable portions,” she says. Johnson is also exercising regularly, following a regimen mapped out by her exercise physiologist at the Johns Hopkins Weight Management Center, whose experts provide support to patients in the concierge program.

With the balloon now removed, Johnson is confident she’ll be able to drop another 17 pounds to reach her target goal. And she’s in a much healthier place to start trying to get pregnant. “It’s been a tremendous transformation,” she says. “I have more energy and I’m sleeping much better.”

The gastric balloon is not the only tool in the endoscopy toolbox. In another endoscopic procedure, called sleeve gastroplasty, the stomach is stitched into a tube shape to reduce its volume by 70 percent. Patients can expect to lose about half of their excess weight—usually around 50 to 70 pounds—following this potentially reversible procedure, according to Johns Hopkins’ Kumbhari.

A more drastic procedure, known as aspiration therapy, involves inserting a port in the stomach, and attaching an aspiration tube to the port, usually for one year. After meals, patients use the device to empty a portion of the contents of their stomach into the toilet, thereby preventing the body from absorbing those calories—often about one-third of what was ingested. Those using aspiration therapy can expect to lose about 40 percent of their excess poundage, or around 60 pounds in the first year. Kumbhari says about 70 percent of his patients are so pleased with the results that they continue using the tube past the first year.

Gastric Botox is an approach with admittedly short-term results, but it can help jumpstart a weight loss program. In this procedure, botulinum toxin is injected into the stomach lining during endoscopy, paralyzing the smooth muscle and slowing the digestive process. This helps patients feel full more quickly and thus eat less. Because the effects start to wear off after three months, patients can expect more modest results in terms of pounds lost, around 12 to 16 pounds on average.

Patients don’t need to be significantly overweight to qualify for these endoscopic procedures: Most typically have a body mass index between 30 and 40. On the down side, these procedures are generally are not covered by medical insurance, and cost anywhere from $7,500 to $20,000, which includes many months of follow-up care.

“It was a significant investment for my husband and me,” says Johnson. “It’s not worth your while if you are just looking for a quick fix and are not willing to put in the work to make a life change.”

Although there is a lot of excitement about the new endoscopic approaches, Dr. Mark D. Kligman, a bariatric surgeon at the University of Maryland Medical Center (UMMC), has been slow to get on the bandwagon, arguing that they produce only modest outcomes. As director the Center for Weight Management and Wellness at UMMC, Kligman almost exclusively recommends the gastric bypass and gastric sleeve surgery. With the latter procedure, more than half of the stomach is surgically removed, leaving a thin vertical “sleeve” that is the shape of a banana.

“In the past five years, we have gone sleeve-heavy,” Kligman says, “but we still do more bypasses than sleeves.” Bypass is a better option for patients with diabetes, he says, and it’s superior for individuals with reflux, which can be exacerbated by the sleeve.

While all of these interventions provide a great kick-start to weight loss, physicians agree the key is for patients to make lifestyle changes and maintain those good habits to keep the weight off. That’s why nutritional and behavioral counseling are part of every treatment package. “The surgery is only the beginning,” says Li. “It’s all about keeping the weight off.”

As anyone who has ever dieted can attest, relapsing to old habits is more the rule than the exception, and the pounds have a way of creeping back on. The same risk applies following these medical procedures. “The way surgery should be looked at is as a tool to learn new habits,” says Kligman.

“I have patients who have lost 200 pounds and kept it off for 10 years or more,” Li says. “I love hearing how they have transformed themselves and their lives.”

Susan Hess is one of those success stories. Six years after her gastric bypass surgery, she’s seen dramatic improvement in her health. She’s ditched her insulin pump and now needs only daily medication for her diabetes. Her cardiac issues have disappeared, and she no longer struggles with back and knee pain.

“I garden in the summer and try to go swimming every day,” says Hess, now 73. “Last summer, my husband and I visited Berlin, Germany, and we walked and walked and walked. I feel so good.”

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