The Morbid Me

Scalpel-free Obesity Surgery on the Horizon

Stomach-stapling surgery to combat obesity may be done in the future with a tube inserted through the mouth, making the procedure safer than using an incision and opening the way for more people to undergo it, doctors say.  Natural orifice transendoscopic surgery, or NOTE, requires no incisions because instruments -- such as long tubes with robotic arms and staple guns -- can be inserted through the mouth and snaked down the esophagus. (Read Here)

Shedding the Skin: The Body Contouring Boom

In recent years, there has been a surge of bariatric procedures for obesity — a projected 177,600 surgeries in 2006, according to the American Society for Bariatric Surgery. With it has come another wave, a substantial rise in body contouring procedures to address the huge amounts of skin and remaining pockets of fat associated with massive weight loss. The American Society of Plastic Surgeons reports a total of more than 68,000 of these procedures in 2005, including thigh, arm and breast lifts and extended abdominoplasties and lower body lifts. Reflecting the trend, some patients are consulting with plastic surgeons before weight-loss surgery to discuss contouring options.
Procedures include:

• Extended abdominoplasty/lower body lift: 20,630, up 22 percent (from 2004)
• Thigh lift: 7,486, up 20 percent
• Upper arm lift: 8,741, up 16 percent
• Breast lift/reduction: 31,277, up 24 percent
• Total body contouring procedures: 68,134, up 22 percent
  • Source: American Society of Plastic Surgeons

(Read an article about TX woman and her Body Contouring experience here)

The Story of Surgery for Obesity

I receive so many questions about what type of bariatric surgery to choose, that I decided to do some quick research so I can point you to an “efficient and official” site with all needed information in one place. So I landed in the American Society for Bariatric Surgery and found this professional compilation of surgery techniques. It is not only easy to understand, but has all the graphics and diagrams and statistics necessary to really have a clear picture on all procedures.

As you can see, many of the procedures are not performed anymore, but it is interesting to read and learn how everything started, and why those specific techniques are no longer performed. (Read Here)

Mesh can make Weight-Loss Surgery Safer

About 25% of patients who have open gastric bypass surgery develop incisional hernias. These lead to serious complications. Holding the incision closed with a polypropylene mesh can prevent these hernias.

A small, randomized clinical trial reported today in the British Journal of Surgery studied 74 seriously obese patients who had a gastric bypass. Polypropylene mesh was used to help close the incision in 34 patients, while 36 patients received standard sutures alone.

The result was clear – none of the patients with mesh closures developed hernias, while hernias occurred in eight of those who only had sutures.

Developing a hernia is the most common reason why patients return to hospital after a gastric bypass, so finding that mesh can prevent this is important

Using the mesh did not affect any other aspect of the treatment, including the length of a patient's stay in hospital, or the overall cost of the procedure. (Read more Here)

Body Lift after Weight Loss Surgery

I just found this great website about a consumer guide to Plastic Surgery. It is well written and very informative and organized. One of the topics covered is about the “Body Lift”, also known as a belt lipectomy that improves the appearance of the abdomen, thighs, and buttocks. The operation is performed typically to remove excess skin and fat following massive weight loss.

According to the American Society of Plastic Surgeons, the four most popular body contouring procedures after massive weight loss are breast lift, upper arm lift, thigh lift, and lower body lift.

Check out this particular article here.

The Lap-Band: Less Invasive? Yes, same results? No!

Here is an interesting article about the Lap-Band procedure. Considered by many doctors as a safer, less invasive surgical option for severely obese people. Approved by the Federal Drug Administration (FDA) five years ago, the Lap-Band System is a relative newcomer in the United States.

Now, as you can read, there is a comparison with Gastric Bypass Surgery, and Dr. Paul Stanish says that in a 18 month period, the results with Lap-Band and Gastric Bypass are the same… Hmmm… Honestly, I expect to live more than 18 months after my operation. This is why it is so important to see the Weight Loss Surgery as a long term solution. It has been proven that on the long term, Gastric Bypass is more successful.

I am not saying that Lap-Band is not good. I do believe it is a good alternative if the risk factors for a full blown Gastric Bypass surgery are to high. But if you are morbidly obese, in the long term, it has been proven with much less success.

New Trend: Laparoscopic Sleeve Gastrectomy. The Gastric Sleeve

The Miami Herald has a great story on a relatively new weight-loss procedure that removes up to 75 percent of the stomach, making it resemble a tube. The so-called gastric sleeve also eliminates the portion of the stomach that produces hormones that stimulate hunger, and unlike the more common gastric bypass procedure, it does not alter the intestine. Therefore, patients don't have to worry about dumping syndrome, the forcing of undigested food into the intestine, which causes light-headedness, vomiting and diarrhea.

Important: To read the full article, you have to have a free Miami Herald account. If you do not want to subscribe, you can use this great service called BugMeNot and use the logins they provide.

All About Weight Loss Surgery

I decided to compile a little bit of everything about Weight Loss Surgery in this post, mainly because I get many emails asking the same questions, and also because it is time to put everything in one page together not only to refresh our memories, but also to remind ourselves what a great tool we have available. Enjoy!

The Problem

People with clinically severe obesity are at great medical risk of disability or premature death. High blood pressure caused by clinically severe obesity can contribute to heart attacks, congestive heart failure and stroke. Other health concerns such as sleep apnea, asthma, low-back pain, urinary stress incontinence and severe acid reflux are also a result of increased weight. Significant weight loss can often ease these conditions or reverse them completely. 

In today’s progressive medical science, surgery to promote weight loss by restricting food intake and interrupting digestive processes is an option for clinically severe obese patients, who have been unsuccessful with other weight loss treatments. 

The ideal patient for weight loss surgery

These should be patients whose body mass index, or BMI, is 40 or greater (equivalent to about 100 pounds over ideal body weight for men or 80 pounds over ideal body weight for women).

Weight loss surgery may also be an option for people with a BMI of 35 or greater who suffer from life-threatening obesity related health problems, such as diabetes, obesity-related heart disease or severe sleep apnea.

Types of surgery available

Common types of weight loss surgery include: Jejuno-ileal Bypass, Biliopancreatic Diversion and Duodenal Switch, Long Limb Roux-en-Y gastric bypass; Vertical Banded Gastroplasty, Silastic Ring Gastroplasty, Adjustable Band Gastroplasty and Roux-en-Y gastric bypass, the latter being the “preferred” choice of surgery (Roux-en-Y gastric bypass). 

According to the American Society of Bariatric Surgery (ASBS) Survey, amongst its members (surgeons), Roux-en-Y gastric bypass is by far the most often performed type of weight loss surgery with restrictive procedures accounting for less than 25% of procedures.

How is Roux-en-Y gastric bypass surgery performed?

Surgery is performed by creating a small stomach pouch (about the size of a person’s thumb, using a surgical stapler. The small stomach pouch restricts food intake by allowing only a small amount of food to be eaten at one time. Next, the small bowel is divided about two feet from the stomach. 

One end of the small intestine is brought up and attached to the stomach pouch (the gastrojejunostomy). The other end of the small intestine, still connected to the now non-functional stomach remnant, is reconnected to the intestinal tract (the jejunostomy).

As gastric bypass implies, following the surgical procedure, that food is now routed past most of the stomach and the first part of the small intestine. 

Endorsed by a 1991 consensus panel convened by the National Institutes of Health as the only effective means of inducing significant long-term weight loss for the vast majority of patients with clinically severe obesity, patients post-gastric bypass surgery have usually lost 50-70% of their excess weight (five years). 

Long before that, complications of clinically severe obesity begin to resolve. These include control of diabetes; lowered blood pressure and total cholesterol; relief from sleep apnea, severe acid reflux, and urinary stress incontinence; and eased low-back and osteoarthritis pain. Patients also report enhanced mobility and their mood and self-esteem also improve. Successful patients also slept seven hours per night on the average and 76% of patients rated their personal energy as being average or high.

Gastric Banding

According to a clinical study published on Obesity Surgery magazine (16,2006), a 10-year study of the Gastric Banding surgery for morbid obesity reveals that patients developed late complications, such as band erosion, pouch dilatation/slippage, catheter-or port-related problems. 

Major re-operation was required and the mean EWL (excess weight loss) at five years was 58.5% in patients with the band still in place. The study concludes that Gastric Banding appeared promising during the first few years after its introduction, but results worsen over time, despite improvements in the operative technique and material. 

Each year adds 3-4% to the major complication rate, which contributes to the total failure rate. With a nearly 40% five-year failure rate, and a 43% seven-year success rate (EWL>50%), Gastric Banding should no longer be considered as the procedure of choice for obesity. 

Patient’s psycho-social impact comparison between Gastric Bypass and Gastric Banding

A patient who has undergone the Roux-en-Y gastric bypass would be able to “eat better-solid food”, as compared to a patient with Gastric Banding. Due to the smaller stomach size post-surgery of the Roux-en-Y gastric bypass patient, he/she will automatically feel satiety at each meal time, thus promoting weight loss by ingesting less calories. 

In comparison, a patient who has undergone Gastric Banding would need to ingest “almost totally blended food”, due to the restricted stomach. Otherwise, it is recommended that the Gastric Banding patient ensure that food is “chewed thoroughly” in order to avoid “choking or a stuck sensation” in the stomach. 

Gastric Banding patients would need to have discipline or otherwise need to train themselves to be very “strong-willed” in following a regimented diet, in order for successful weight loss.

Deciding whether Roux-en-Y Gastric Bypass Surgery is the right surgery for you

All prospective patients must undergo a thorough pre-screening medical work-up, including a psychological profile. Patients must understand the seriousness of gastric-bypass surgery and its risks. They should have tried and failed conservative medically supervised approaches. 

Patients must understand the implications of a mandatory lifelong commitment. Potential patients with a history of substance abuse or major psychiatric problems are usually excluded as gastric-bypass candidates. Although precise details vary, all surgeons have an elaborate system of ensuring that informed patient consent is obtained prior to surgery.

Specialized facilities

The gastric-bypass surgical process is generally performed and managed by a medical team that specializes in bariatric surgery. 

Bariatric surgeons typically have surgical privileges at institutions with dedicated facilities equipped to meet the needs of the obese patient. These facilities require specific instruments for the bariatric surgeons, particularly when performing laparoscopic procedures.

Gastric Bypass Might Be Better Than Lap-Band

Extremely obese patients undergoing weight-loss surgery may do better with a procedure that bypasses part of the intestine rather undergoing a banding procedure that creates a small pouch in the stomach, according to a new study released Monday.

Researchers at the State University of New York, Health Science Center of Brooklyn and Lutheran Medical Center, also in Brooklyn, N.Y., looked at two commonly performed types of bariatric surgery in 106 patients who underwent the procedures between February 2001 and June 2004. The study appears in the July edition of the Archives of Surgery.

Sixty patients received a so-called Lap-Band device through a laparoscopic procedure which allows surgeons - through a small incision near the stomach - to place a silicone band around the stomach dividing it into two smaller compartments. The device is designed to restrict food intake and make patients feel full sooner than those with a full-sized stomach.

Forty-three patients underwent another type of procedure known as the laparoscopic Roux-en-Y Gastric Bypass, which involves sectioning off a small portion of the stomach into a pouch that bypasses the first part of the small intestine and connects directly to the lower portions, reducing the amount of calories absorbed by the body from food.

Overall, researchers found patients undergoing the laparoscopic bypass surgery had fewer long-term complications, lost more weight and had larger improvements in other co-morbidities, such as high blood pressure and diabetes, than patients who underwent the lap-band procedure.

The better outcomes of patients undergoing the bypass procedure is likely the result of better compliance among those patients rather than a particular problem with the lap-band. He said the lap-band can allow patients to cheat and consume more calories through liquids because they can still pass fairly easily through the small stomach.

For the band to be successful it requires significant will power, discipline and compliance.

Patients in the study were considered "super" morbidly obese and had body mass indexes of 50 or greater. On average patients in the study weighed roughly 340 pounds before surgery.

Patients undergoing the lap-band procedure were hospitalized for less time with an average of 1.8 days compared with 3.5 days for patients undergoing the bypass procedure. Short-term complications were statistically similar between the two groups.

However, long-term complications, or those that occurred after 30 days or longer, were more common in the lap-band group with 78% of patients experiencing complications compared to 28% in the bypass group. The most common long-term complication was vomiting and dehydration.

The study also showed that 15 patients with the lap-band needed follow up surgery compared to three in the bypass group. The lap-band can be adjusted after initial surgery to be made larger or smaller. Patients in the study were followed for an average of 16.2 months.

Patients who underwent the bypass had an average BMI decrease of 26.5 compared with 9.8 in the lap-band group, however researchers said both procedures produced "satisfactory" amounts of weight loss.

All patients reported fewer co-morbidities after surgery, but the decrease was more pronounced in gastric bypass patients. For example, rates of diabetes dropped to zero from 17.4% before surgery in the bypass group. Rates of diabetes in the lap-band group fell to 11% from 18.3% before surgery.

The typical gastric surgery patient has a pre-surgery BMI of 40. Some patients with BMIs of 35 or more are also considered good surgery candidates if they have another problem linked to being overweight like diabetes.

Although the study focused on patients with BMIs of 50 or greater, patients do better with a bypass rather than a lap-band. However, not every patient is a good candidate for a gastric bypass - for instance, those with certain liver problems, as well as those who've had stomach ulcers - and they might need a lap-band or similar device.

Gastric band works better than 500-calorie Diet

Although it is not the WLS method I prefer, a new study shows that Adjustable Gastric Band has a better long term weight loss success rate than a super low 500 calorie diet. Those findings where just published by the “Annals of Internal Medicine”.

Here is the report by Nanci Hellmich, USA TODAY:

Adjustable gastric banding is much more effective long-term than a very low-calorie diet for people who are about 50 pounds overweight, a study shows.

Medical guidelines support this surgical procedure — which puts a band around the top of stomach to create a feeling of fullness — in patients who are extremely obese, about 100 or more pounds over a healthy weight, or those who are almost as overweight and have serious medical conditions, such as type 2 diabetes.

Researchers at Monash University Medical School in Melbourne, Australia, recruited 80 patients who were on average 52 pounds over a healthy weight. Half had the laparoscopic adjustable gastric band surgery.

The other half followed a medical program that included a variety of strategies such as a very-low-calorie diet (500 calories a day) with liquid meal replacements, prescription weight-loss medication and behavioral therapies.

• After six months, both the surgery patients and the low-calorie dieters lost an average of 14% of their starting weight.
• After two years, the gastric band patients lost 22% of their starting weight. That was about 87% of their excess weight, or roughly 45 pounds. They also showed marked improvement in their health and quality of life.
• At the end of two years, the dieters had regained much of their lost weight but were still 5.5% below their starting weight. They had lost 22% of their excess weight, or about 12 pounds.

Researchers are still analyzing the weight-loss data. "I'm very happy that the gastric band patients are continuing to maintain their weight loss," says lead author Paul O'Brien, director of the university's Centre for Obesity Research and Education. Since the study, he received grants from INAMED Health, maker of the LAP-BAND System.

In this study, the surgery was as safe as the diet program, but O'Brien notes the procedure does carry risks, and some may need follow-up procedures, such as readjusting the band position. The surgery costs $14,000 to $18,000 in the USA, he says.

Insurance companies vary widely in coverage of gastric banding or gastric bypass, a more complex surgery that creates a much smaller stomach and rearranges the small intestine. Average cost: $26,000. Under certain conditions, Medicare covers both surgeries.

Many surgeons in the USA use gastric bypass because bypass patients lose more weight overall and lose it faster, says Neil Hutcher, president of the American Society for Bariatric Surgery and a surgeon in Richmond, Va.

Thomas Wadden, an obesity expert at the University of Pennsylvania School of Medicine in Philadelphia, says gastric banding "is a very effective procedure, but it's not a rational, cost-effective solution to the epidemic of obesity."

"Because we have limited health care dollars, we have to decide how best to invest them. Are we going to provide bariatric surgery for a relatively small number of people or instead invest in the prevention of obesity so our children hopefully won't need this surgery?"