The psychological effects of gastric bands and stomach stapling - Times Online

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From The Times

July 12, 2008

The psychological effects of gastric bands and stomach stapling

Slimming by surgical procedures are increasingly popular but the underlying emotional problems are harder to shed than the pounds

Having your stomach reduced does not resolve the need in your brain.

JOHN NAISH

Stomach-shrinking operations have captured the headlines recently, with the post-operative death in June of 29-year-old Suzanne Murphy, who wanted to lose weight so she could play with her young son, and the daytime-TV star Fern Britton's earlier admission that her dramatic weight loss was due to a gastric band rather than willpower. But amid the arguments about vanity and surgical safety, one of the most crucial dangers is ignored - the huge psychiatric toll of these operations.

The numbers having NHS stomach surgery leapt by 41 per cent between 2006 and 2007. Parliamentary figures show that there were 3,459 such operations last year, up from 2,448 the year before, but the total does not include the soaring number of private procedures performed in Britain and abroad. The most common operations in Britain are gastric banding and the Roux-en-Y gastric bypass (see box).

But amid the rush to slim by scalpel, doctors and patients are ignoring the fact that it isn't an easy cheat. While thousands of people do benefit, one operation in five fails because of a patient's significant psychological problems - the problems that led to their obesity - remaining unaddressed. The alarming way that many of these failures manifest themselves as binge-eating, severe depression, suicide or addictions is making experts increasingly sceptical.

Guidelines on who should have surgery

Guidelines by the National Institute for Health and Clinical Excellence (NICE) recognise this potential for difficulties. They state that patients with psychological contraindications should not be considered for stomach surgery. But clinicians say this is often ignored. The story of the 19st (121kg) Suzanne Murphy, who died after suffering a huge reaction to stomach-stapling surgery at Huddersfield Royal Infirmary, seems to exemplify this.

Sheila Connor, Murphy's sister, says that they both developed weight problems very young when they started comfort eating after their father died. She says that Murphy was bulimic before she became pregnant five years ago, and her weight had plummeted to 5st. After her son was born her weight spiralled, but she was never given proper psychiatric help for problems with food. "She was only given slimming pills, but whenever she got down to a certain weight, the problems kicked in," says Connor. Then Murphy had the ill-fated surgery.

John Morgan, a consultant psychiatrist at the Yorkshire Centre for Eating Disorders, began tracking obesity-surgery patients at St George's Hospital, South London, nine years ago. "Since then we have been turning out follow-up studies saying that psychological issues are powerful predictors of postoperative results. About a quarter to a fifth of patients who have surgery have bad outcomes, particularly if they have a history of binge eating, bulimia, depression or anorexia.

"If you are eating because of a need in your brain rather than a need for stomach satiety signals, having your stomach reduced is not going to solve that," he says. "In fact, having your stomach reduced will mean that you can't placate yourself in your usual way, so you can keep resolutely eating until you effectively reverse the operation by displacing the stomach band or creating a pouch in your intestines."

Patients cheat by liquidising food

A report in Pulse, the newspaper for doctors, highlights a problem called "soft calorie" syndrome, where patients cheat by consuming semi-liquid food that passes through the gut restriction. Nutritionists report stratagems such as melting Mars bars and liquidising McDonald's meals.

American psychologists have discovered how significant numbers of surgery patients become alcoholics, binge-shoppers or sex addicts. Melodie Moorehead, of the JFK Medical Centre in Atlantis, Florida, calls the problem "addiction transfer". She reports in the stomach-stapling journal Bariatric Times that people who have attributed all their problems to being overweight can suddenly realise that their emotional difficulties are not as easily shed as their excess pounds. Many of the patients become obese because they are compulsive eaters. When the eating stops, they develop another compulsion.

New research indicates that the neurological causes of compulsive eating may be similar to those of other self-destructive addictions such as cocaine addiction and alcoholism. Other studies suggest that obesity may protect against other addictions. A survey of 9,125 adults in the Archives of General Psychiatry found that obese people are 25 per cent less likely to abuse drugs. In 2004, Florida University researchers published a study of 298 women showing that obese women drink less alcohol than average. The researchers suggest that food and alcohol trigger the same reward sites in the brain.

Morgan adds: "There is also something we call multi-impulsive eating disorder, which affects a minority of patients who not only overeat, but also cut themselves or take drugs or alcohol, because their instability of personality leads them to do these things when faced with difficult emotions. Frankly, addressing these psychological problems can be necessary, but it's barely sufficient on its own. Obesity surgery basically involves retraining someone's behaviour, and that can take years." This is often ignored, he says. "Booming demand means that services are being developed that are like plastic surgery. But it's just not like breast augmentation.

"There are some good centres in the UK that focus on comprehensive treatment to address both mind and body issues. But there are many more where people don't really know what they are doing. I would like to see services be given minimum standards before they can start operating. There needs to be access to eating disorder experts and budgets for the significant minority who need postoperative support."

Samantha Scholtz, who gives NHS patients pre-surgical psychiatric assessments at the Imperial Weight Centre, Charing Cross Hospital, West London, cautions that post-surgical support is often lacking. "The first few weeks after the operation, people are very emotional.The effects of the surgery, not being able to eat, and losing weight all cause depression and anxiety. Six months down the line, more depression arises. Often this is because their expectations have not been met. The body image is often not great. There is a lot of loose skin and it is cosmetically not a good operation. But sometimes it is sold that way."

Scholtz, the lead author of a study in Obesity Surgery on postoperative complications in 37 patients, adds that suicides right after surgery go up. "You have to prepare people to have realistic expectations. The benefits are primarily for their physical health, diabetes and blood pressure, but not body image. Obesity surgery is good for certain people. But they need the right follow-up and support."

Around the country, patients have similar difficulties. At the MSN online gastric bypass support group, "Calavandrial", from Hull, had an operation five months ago and has lost 4st. But she feels thatshe is getting a "raw deal in the postoperative phase", and adds: "I'd have liked some counselling for my 'inner food fiend'. My doctor refuses to support what he calls 'experimental surgery' and my surgeon has retired with no replacement. To say this situation is getting me down is putting it mildly."

In similar vein, "Stamperlou", on the Mini-Mins support forum, reports: "The surgeon gave me a card for a support group on the web that I could never access and a flyer for some group meetings that were held 20 miles away."

Complaints such as this are particularly disturbing in the light of research underlining the importance of postoperative support. A report last year in Surgery for Obesity and Related Diseases says that support groups can make a significant impact on weight loss, especially after six months when the rate of loss from surgery normally begins to decline.

But no matter whether support is given or not, there is strong evidence that unless patients are properly screened, long-term failure rates are far higher than surgeons tend to admit. In a study of 317 gastric-banding patients, by the Hôpital du Chablais, in Switzerland, investigators found that, after seven years less than half the operations could be called a success. The 2006 study, in Obesity Surgery, concluded that gastric banding "should no longer be considered as the procedure of choice for obesity. Until reliable selection criteria for patients at low risk for long-term complications are developed, other longer-lasting procedures should be used."

Backlog of 60,000 patients, say doctors

This caution has fallen on deaf ears. Now that bariatric surgery has been approved as effective by NICE, NHS primary-care commissioning groups have an obligation to fund it. And enthusiastic proponents want to see many more operations as soon as possible. The British Obesity Surgery Society, for example, claims that there is a backlog of about 60,000 patients needing a gastric bypass - and more NHS surgical training and resources are needed to catch up.

The British Obesity Surgery Patients Association describes the growth rate in NHS-funded bariatric surgery operations as "woefully inadequate". But given the psychiatric evidence, it may be wiser to consider carefully the long-term emotional fallout from all these operations - and to develop effective ways of preventing it before weighing in with even more.

Weightloss surgery - the facts

In the 1950s, doctors in America reslised that ulcer patients and cancer survivors often shed pounds after having parts of their stomachs removed.

Surgeons in Minnesota began to experiment with operations that were designed solely for weight loss. Their early approaches have been abandoned because they proved too risky, but refinements have led to the most common weight-loss surgery techniques - gastric bypass and gastric banding.

The gastric bypass

The Roux-en-Y gastric bypass, or gastric bypass for short, includes stapling off a golfball-sized pouch from the rest of the stomach. The small intestines are re-routed so that food no longer passes through the upper portion of the gut. Patients can't eat as much because their stomachs are smaller, and fewer calories are absorbed because food doesn't remain in the intestines for as long.

Gastric banding

Weight loss is less rapid with this reversible procedure. An adjustable silicone band is fitted around the upper part of the stomach to create a pouch. This fills quickly with food, which passes slowly into the rest of the stomach. Patients can eat only small meals and they feel fuller sooner. The band can be tightened or loosened by injecting or removing fluid from a balloon on its inside surface. Injecting fluid tightens the band; removing fluid loosens it. Both procedures are done through an access port under the skin.

Other types of operation

Other versions of bariatric surgery are carried out sparingly, including operations to staple the stomach or to remove a large portion permanently (sleeve gastrectomy).

Risks

Some are common to any surgery, such as infections or blood clots in the lungs. Others - including bowel obstructions and leaks in the new connections - are related directly to gastric bypass surgery.