Melissa Walton-Shirley, MD

Disclosures

November 15, 2017

I'm a skeptic when it comes to gastric-bypass surgery. I suspect I always will be, but I must admit that I was struck by the science presented here at American Heart Association (AHA) 2017 Scientific Sessions. The GATEWAY study is the first single-center, open-label, randomized, controlled trial of Roux-en-Y gastric bypass plus medical therapy or medical therapy alone. It examined whether the number of blood-pressure meds could be reduced by 30% or more in the postsurgical period. GATEWAY met its end point, and then some.

In the early days of gastric-bypass surgery, I saw my fair share of acute complications including wound dehiscence, infection, and MI, but thankfully not death. I saw one patient develop rapidly progressive and fatal aplastic anemia, but with no obvious link to the procedure. In the latter years, I've seen similar complications than in the earlier days, albeit at lower levels, but only at the hands of the inexperienced. 

It is in part because of the known complications of bariatric surgery that I encourage patients at their first visit to go back to the lifestyle drawing board.  Most of them have never been given good information on nutrition. They've often never heard of the DASH or Mediterranean diet. They can't tell me the difference between a carb or a fat. They think fruit juice is a fruit. They don't think to include their sweet tea and colas in their calorie and carb counts. One patient once lamented, "I can't lose weight on this diet." After examining her food diary, I announced: "There is good news and bad news. The bad news is you are correct, you are not losing weight. But the good news is that you aren't on the diet." She was drinking 400 carbs per day in the form of 16-oz colas and eating biscuits, sausage, and gravy for breakfast. In other words, patients who are earnestly trying to lose weight or aim to reverse their hypertension or diabetes deserve a chance with good dietary and sodium content information before they go under the knife.

For those who don't succeed despite all efforts at education, today's GATEWAY data represent a potential safe harbor. The complication rates were low. The first-year safety and efficacy data were excellent. Gastric-bypass surgery may just be that opportunity to regain all the secondary losses they suffered from their obesity, including health and happiness.

The GATEWAY trial design was surprising at the outset by studying gastric-bypass outcomes in patients at the lower end of the obesity scale by American standards (BMI of 30–39 kg/m2). Furthermore, it was interesting that blood-pressure lowering preceded dramatic weight loss, with most surgery patients cutting their blood-pressure meds at 30 days postop. At 1-year follow-up, some had stopped their meds all altogether.

It remains to be seen what will happen to these patients at 5 years. Will vitamin B12 and iron deficiencies induce illness? Will other undetected nutrition deficiencies increase their risk of chronic illness? Will their weight loss be sustainable and their normotensive state durable? How much can we extrapolate from a trial of 100 surgical patients—can we expect the same results in those with BMIs above 40 kg/m2?

The GATEWAY data caused me to think that I might have been a bit too hard on gastric bypass as an option and too soft on the procedure as a recommendation. I'll reserve judgment, however, until the 5-year outcomes are reported. Meanwhile, I might just push back a little less on a plan for my patient to undergo gastric bypass . . . perhaps just a little less.

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