One of the many overlooked health problems related to weight gain and obesity is the problem of incisional hernias. Incisional hernias are a common form of the broader category of ventral hernias, meaning an abnormal bulge protruding through the muscular tendinous layer of the abdominal wall. Ventral hernias may be congenital, protruding through naturally occurring weak spots of the abdominal wall such as the umbilicus and the midline areas where muscles fuse during development. Or, ventral hernias may occur in weakened areas of the abdominal wall that occur as a result of surgery.

Surgical incision sites are closed well after surgery, but they never regain the full strength of the natural musculotendinous strength-layer of the abdominal wall. Over time the strength of the closure site reaches around 95% of its original. During the healing phase and for years to come, if significant stress is placed upon the abdominal wall then the muscles and tendons in the closure area can separate creating a weak spot or hernia through which the abdominal tissues can protrude. This is known as an incisional hernia. Such protrusions are much more likely to occur with weight gain and obesity.

Dangers Of Ventral Hernias
The problem with ventral hernias of all kinds and incisional hernias in particular, is that they can produce abdominal pain, enlarge over time, produce obstruction of the intestines and, in rare occasions create strangulation of the intestines, which can be life threatening. Strangulation occurs when the intestine becomes caught within the fibrous neck of the hernia and while entrapped becomes swollen and damaged leading to ischemia – loss of blood supply of the intestines – and dangerous infection, perforation or sepsis. This does not occur often, but it is important rationale arguing for the repair of these hernias to be done when feasible.

Repairing Incisional Hernias
In the last decade advances have been made in the repair techniques of incisional hernias. Traditionally these have been repaired with an open incision through the previous scar or over the bulge. The contents of bulging tissues are pushed back into the abdomen. The edges of the muscle or tendinous neck are sewn together if possible and then a type of synthetic mesh material is placed to further strengthen the muscle layer. In more recent years, I, and other pioneering surgeons around the country have utilized laparoscopy to repair even large and complex incisional hernias with a much less invasive technique. The laparoscopy involves placement of a camera and additional ports through small keyhole type incisions to work from the inside of the abdomen, reduce the bulging contents of the hernia back internally where they belong and create the mesh repair from the inside.

Differences in Types of Repairs of Incisional Hernias
Traditional open repairs involve the disadvantage of a larger scar that comes from open surgery. This translates into more hospital time and more recovery time in the weeks following surgery. The larger wound also creates a greater opportunity for wound infection, an especially common complication in obese individuals. Some surgeons have historically preferred the open technique because they are accustomed to this type of exposure and they try to close the muscles and tendons back together even if this occurs under tension. Open surgical repairs of ventral and incisional hernias have historically had a significant rate of recurrence of the ventral hernia over time as well as other complications stemming from the more major abdominal surgery required.
The laparoscopic or minimally invasive approach has several advantages and differences.

In a recent study by Genco and Colleagues (Surgical Endoscopy, Volume 23, pg. 1849-1853, 2009) a bariatric center compared the effectiveness of laparoscopic sleeve gastrectomy against the Bioenterics Intragastric Balloon (BIB) with twelve months of follow-up.

The mean surgical time for the sleeve gastrectomy was 120 minutes. The mean endoscopy or balloon positioning time was around 15 minutes for the BIB. Prior to surgery, the body mass index was 54.1 for the BIB group and 54.8 for the sleeve gastrectomy group. At six months follow-up time, the BMI had fallen to 46 for the BIB group and 45 for the sleeve gastrectomy group. At twelve months, the BMI for the BIB has risen to 48 kg/m² and the BMI for the sleeve gastrectomy had fallen to 43 kg/m². Eighty patients underwent the BIB procedure and 40 patients underwent the sleeve gastrectomy procedure. Failure of weight loss (defined as weight loss of less than 10%) was similar in both groups (2 out of 40 for the sleeve gastrectomy and 4 out of 80 for the BIB procedure.

These authors conclude that the BIB procedure is considered a preferred option for a “first step procedure” for patients with high surgical risk or for patients with high body mass index (super obese BMI greater than 50) or for patients who plan to undergo a more complex bariatric procedure.

The Bioenterics Intragastric Balloon has emerged as a valid option in treatment of morbid obesity in certain circumstances. For example, author Bufetto demonstrated that placement of the BIB as a first step reduced the subsequent risk of conversion to open surgery during the eventual bariatric surgical procedure. It also reduced the risk of intra-operative complications in “super obese” patients, those who had a body mass index over 50. (Bufetto, L., Pre-operative Weight Loss by Intragastric Balloon in Super Obese Patients Treated with Laparoscopic Gastric Banding: A Case Controlled Study, Obesity Surgery, Volume 14, pg. 671-676, 2004)

The concept of preventing diseases like diabetes, obstructive sleep apnea or hypertension usually centers around behaviors such as improved eating habits and exercise, and no doubt these are highly important for preventing weight gain related conditions.  Less commonly acknowledged is that people who need to lose 40 to 60 pounds can do so successfully before they have developed many of the most severe obesity related health conditions.  Thus, they are able to prevent disease rather than waiting until the diseases have become fully manifest and are already requiring medical treatment just to manage them.

In numerous studies, no intervention has proven more successful than weight loss surgery for achieving this drop in pounds necessary to prevent the health conditions and diseases mentioned.  The list of health conditions that are going to come along with a 50 pound weight gain is quite long and includes many problems including difficult injuries of the weight-bearing bones and joints including the spine, ankles, hips and knees, but many other conditions as well including asthma exacerbations, breathing difficulties, fatty liver infiltration (hepatic steatosis) and pre-diabetes or impaired glucose tolerance and headaches.

But weight loss surgery as a preventive treatment?  Clearly, this idea is far from an accepted notion and runs counter to most people’s notion of what preventive interventions  consist of.  Nonetheless, the data bespeaks themselves and if you or a loved one are in the range of 40 to 50 pounds overweight and have a BMI between 30 and 35, then you have to look at what interventions are likely to be most successful at helping you live a longer and healthier life (not to mention feel better and feel more energetic).  You also have to look at what you can do to prevent the onset of diabetes, which is highly likely to occur at that BMI, given enough time.  Then I think it makes sense to examine the risks associated with any intervention and invasiveness.

At our center, I have taken the approach that laparoscopic adjustable gastric banding is of such low invasiveness that it does make a great deal of sense as a disease prevention tool whereas our protocol has not included laparoscopic sleeve gastrectomy or Roux-en-Y gastric bypass surgery.  In the future this may change, but right now the risk/benefit analysis in my view favors making available the least invasive weight loss surgical option for this low BMI group of 30 to 35.

One of the challenging questions that many of us in the bariatric surgical field struggle with is trying to identify factors among the eating behaviors of prospective patients prior to surgery that might help us predict the success a patient can expect after surgery or, even better, allow some type of intervention-such as counseling or therapy of some sort- that can prove that outcome. Research studies have taken place that involve asking detailed questions about eating behavior of a large group of patients expected to undergo weight loss surgery and then compared the weight loss success afterward. For the most part, prospective studies aimed at assessing pre-operative problems such as binge eating disorder, reveal no real consistent predictors of post-surgical weight loss success. Binge eating disorder specifically is reduced markedly after laparoscopic adjustable gastric banding surgery and Roux-en-Y gastric bypass surgery. Probably because it just becomes much more difficult or impossible to consume large amounts of food in a single sitting.
In multiple prospective studies of numerous types of eating behavior disorders, including binge eating disorder, all patients experience a significant and marked weight reduction after weight loss surgery with both Roux-en-Y gastric bypass and laparoscopic adjustable gastric banding. In some programs, historically, binge eating disorder has been considered a reason to exclude people from surgery, a practice that is clearly ill-advised given the very poor success of non-surgical weight loss efforts among binge eaters.
We will explore more details of eating behavior and psychology as it relates to weight loss surgery and medical weight loss programs in other posts. The bottom line is that these eating behavior problems are common, but are not a reason to exclude someone from weight loss surgery or from medically supervised weight loss. On the contrary, they are simply characteristics to be identified and then acknowledged as deserving of more help, counseling and support.

Another interesting study (The Influence of Eating Behavior and Eating Pathology on Weight Loss After Gastric Restriction Operations, Obesity Surgery, Pg. 684; Volume 15, 2005, Ramona Burgner and Colleagues) examined whether abnormal eating behaviors including binge eating, grazing, bulimia, sweet eating and loss of control/over-eating, were all examined. In this European study that included patients undergoing banding type restrictive surgery, pre-surgical eating behavior disorders were not predictive of weight loss results. Interestingly, abnormal eating behaviors after surgery were predictive of results to some degree.
What this means is yet another study provides evidence that even very detailed, rigorous and scientific assessments of eating behaviors and abnormalities prior to weight loss surgery fail to offer meaningful predictions of the degree of success after weight loss surgery. In fact, as in other studies, all of the patients with eating disorders and eating behavior problems still lose weight and succeed with weight loss surgery. The weight loss surgery results are even more strikingly successful when one considers how unsuccessful non-surgical weight loss programs have been for these patients.

Free Lap-Band surgery coming in January. As some of you may have heard, our practice has decided to offer a free Lap-Band to a patient and is holding a contest to choose the winner. The contest will begin airing on the radio in January on Sunny 106.9.
I have agreed to donate my time and expertise to the contest winner and will help follow that person for the long term. Hopefully whoever the contest winner is will be very successful in losing every single pound of excess weight and achieve their ultimate weight loss goal!

Historically, bariatric surgeons and weight loss surgical centers have focused on the purely medical aspects of losing weight with bariatric surgery. Fairly quickly, in the history of gastric bypass surgery and Lap-Band surgery, it became clear that major medical benefits were occurring: namely the resolution of serious obesity related diseases of diabetes, hypertension, obstructive sleep apnea, hyperlipidemia, hepatic steatosis and more. Despite this very compelling health data and medical studies showing increased life expectancy and health measures, only a very small percentage of people suffering with these health conditions and morbid obesity currently avail themselves to bariatic surgery as a treatment.
Today, however, we may be seeing the beginnings of a new rationale being articulated by people seeking weight loss surgery at an earlier stage of this process, before they have developed some of the serious health consequences of weight gain. The reasons articulated, especially among people seeking out-patient laparoscopic adjustable gastric banding with the Realize Band or Lap-Band, have to do with feeling better, becoming more energetic, preventing health problems, and, yes, looking better.
Certainly, the numbers of people who might consider out-patient weight loss surgery for these types of reasons is expected to vastly exceed those whose motivation is purely medical. Does out-patient weight loss surgery in-fact deliver on these goals? We will explore this a bit further in future pieces, but the answer is by-and-large, yes. The vast majority of people do indeed experience all of the above and report a higher quality of life, greater energy level and improved satisfaction with their own appearance. As physicians, we have historically viewed these goals or achievements with less importance than the purely medical ones that revolve around disease processes, but our patients may see it otherwise.

Increasingly, more people are approaching their weight loss efforts with a preventive attitude. Today in my clinic I saw two people who represented what I think is the future for forward thinking people and their doctors. Each of them was significantly overweight with a body mass index between 30 and 40, but neither of them had severe health problems from their overweight or obesity. Yet, that is.
The first patient, a thirty-three year old female whose mom has type 2 diabetes knows that she is committed to losing weight, but has just not had the right tools and knows also that if she is not able to lose the weight, her mother’s health problems will become her own. As she described it to me, there really is no reason for her to wait until she develops type 2 diabetes or hypertension or any of the other obesity related health problems before she moves forward with an aggressive weight loss program. In her case she wishes to undergo Lap-Band surgery and I believe she will be quite successful with it.
The other patient, a forty-one year old male, was told by his doctor he has a condition known as “pre-diabetes”. He wasn’t exactly sure what this meant or if it was even important, but it sounded ominous. I discussed with him the definition of pre-diabetes and we talked about his glucose tolerance test, which showed his body is unable to handle a challenge of ingested oral glucose. This means he has the high likely-hood of progressing to type 2 diabetes, which will require medications. It means that while his blood sugars are not typically out of range, if he eats and has a significant carbohydrate load then the blood sugars to rise into abnormal territory.
By some estimates, seventy-million Americans have pre-diabetes and most of them will progress to type 2 diabetes in their lifetime. Most of these people are also overweight or obese. As this gentleman stated, “Why wait for the diagnosis of full-blown diabetes”.

I saw a patient today who has battled with depression intermittently throughout her life and also struggled with obesity. She wonders if the two are related, but also about how she will manage the depression after her weight loss surgery. Is it still possible to take medications should she need them? Might her depression improve if she undergoes weight loss surgery?
Interestingly, the research on depression and obesity shows it is a two way street: depression leads to more obesity, but obesity itself exacerbates depression. It makes sense, if we think about it. Depressive feelings can lead to overeating and loss of motivation to exercise. Likewise, obesity can lead to feelings of lower self-esteem and lower one’s mood.
Research also indicates some people do experience improvement in their depression after weight loss surgery.
Similar data exists about non-surgical weight loss. Of course it is hard to separate out which comes first, better feelings of self-esteem and higher motivation that lead to successful weight loss or some improvements in weight, leading to better body image and some improvement in mood. Ultimately, this chicken and egg question may be difficult to answer, and the most important advice is to seize the day and to work very hard on both problems. By this, I mean that if you struggle with depressed mood then seek help immediately including psychological counseling and visiting with health professionals who may offer effective antidepressant medications and recommend mood elevating activities like exercise. Likewise, if you are overweight or obese, don’t let another day go by without working on this problem too. Seek professional help. Follow the strategies and tips outlined here and in my books and you will benefit with lower weight and an improved mood.
For my patient today, I also let her know that antidepressant medications can be taken and absorbed after Roux-en-Y gastric bypass surgery. We do believe it is best to change from any extending release formulations (for example Effexor XR) to the standard release formulations that usually must be taken two to three times a day rather than only once a day.
Like so many complex facets of human health, depression and obesity are closely linked. One affects the other, but more importantly one is improved by improving the other

It is not uncommon for me to hear questions along the lines of:
“Will Having Weight Loss Surgery Guarantee That I Won’t Regain the Weight?”
or
“If weight loss surgery is so effective, why do some people need revision weight loss surgery?”

A recent large clinical study found that 89% of people maintained their weight loss after bariatric surgery over an eight-to-ten year time frame. That still leaves at least 11% of people regaining significant weight, and with well over 200,000 procedures performed every year, those with weight re-gain represent a large number of people.

At least five studies, three of them with large samples, have demonstrated a dramatic improvement in life expectancy and reduction in disease over many years among groups of people studied who underwent weight-loss surgery, as compared to people who did not.

But the surgery is far from perfect or a magic cure-all. The same temptations and drives, stresses and human behaviors are still at work, and can lead to weight re-gain in this high carb, high-calorie environment in which we live. Bariatric centers and surgeons have continued to look for ways to help people who re-gain weight.

Some of the new technology to shrink stretched pouches may offer hope to people who have re-gained weight. But my own view is that these attempts to improve, or “revise” the original surgery work best when offered in conjunction with education, coaching, support groups, counseling and a program of physical activity to change the whole way in which a person approaches eating and activity. Clearly the secrets to long term weight loss success lie in making sustained life changes in one’s approach to food and activity levels. Revision procedures can often help, but they represent only a part of the solution to this complex and challenging problem.