Archive for the ‘Weight Loss Surgery’ Category

CHOOSING AMONGST WEIGHT LOSS SURGERY OPTIONS, WHY IS IT SO COMPLICATED?

Saturday, September 17th, 2011

You would think these surgeons and weight loss experts would simplify matters and devise one procedure and one standard diet program that worked the best.  Plain and simple, here is the one that works the best, sign up and you can these are the results you can expect.

Unfortunately, it has not worked out to be nearly so simple.  Instead, the surgical approaches have moved toward recognition of a few principals and have also shifted from the types of operations performed.  However, there are still several operations that appear very viable as contenders for the “best” procedure and advocates of each one continue to point to data showing its success.

Over time, we have seen that the science tells us a few important principals:

  1. The surgery works best when combined with a comprehensive program.
  2. Protein or meal replacement shakes are appetite suppressing and probably represent the second best tool we have in the battle against excess weight.
  3. Going totally without surgery yields a very, very small percentage success rate when the BMI has crept over 30-35.  (It doesn’t mean well shouldn’t try!)

The operations performed however have become perhaps somewhat more confusing for the consumer or the patient who is seeking medical help.  Over time, the surgery has shifted largely away from more invasive, open surgery toward less invasive, laparoscopic or minimally invasive surgery through keyhole incisions.  It has shifted from long hospital stays and intensive post-operative treatments and management of complications to outpatient surgery or very short hospital stays after a minimally invasive procedure.  And finally, the operations themselves have changed.  The surgery that was most successful forty years ago was an operation that involved bypassing a large percentage of the small intestine, the portion of the intestine that absorbs nutrients.  Other “mal-absorptive” operations were also very successful, but lead to long term complications such as vitamin deficiencies and deficiencies of iron and other nutrients.  So the most successful surgery has now shifted towards ones that focus most of the attention on the stomach and reduce our appetite, decrease our hunger, decrease portion sizes and may offer a small amount of mal-absorption.

Today, four operations deserve mention as being truly minimally invasive, involving minimal hospital stay and being highly successful with very few complications (especially relative to older procedures).  The four procedures I consider viable today as highly successful weight loss surgical procedures are:

  1. Laparoscopic adjustable gastric band or LAP-BAND.
  2. Laparoscopic Roux-en-Y gastric bypass or gastric bypass.
  3. Laparoscopic sleeve gastrectomy.
  4. Laparoscopic “mini” gastric bypass or “loop” gastric bypass

Each of the procedures has its pros and cons, but the bottom line is that the properly motivated person who is engaged in a long term plan with a diet plan that emphasizes proper vitamins, minerals and proteins, the use of protein shakes and regular exercise (let’s hear it for the walking club!) is highly likely to result in terrific success with long term weight loss, better health and a greater sense of energy and wellbeing.

ANOTHER SHORT TERM STUDY ON BARIATRIC SURGERY

Thursday, March 24th, 2011

Numerous short term studies report to show the benefit of one procedure over others, and usually the more invasive procedure demonstrates higher “success”.  This reflects the fact that the less invasive LAP-BAND procedure is shown to have a much slower weight loss curve, typically approaching or equaling the overall weight loss of gastric bypass surgery after thirty-six to forty-eight months.  Another recent study falls along these lines.

From my alma mater, UCSF, comes a new study examining the results of gastric bypass when compared to LAP-BAND surgery in 200 morbidly obese patients.  Complications rates were similar, but the weight loss results were better for gastric bypass and re-operation rates were lower for gastric bypass.  However the follow-up was only for one year.  It was already previously known that the LAP-BAND procedure will take three to five years to reach the approximate level of weight loss usually seen within twelve to eighteen months after gastric bypass surgery.

So do these short term studies contribute anything further to the current knowledge base?  Probably not.  What we already know is that minimally invasive weight loss surgery, when performed in the hands of highly experienced surgeons, has very low risk and complication rates.  Laparoscopic Roux-en-Y gastric bypass surgery is highly effective and has low complication rates in the hands of such high volume surgeons.  That the weight loss results are greater at the end of one year when compared to LAP-BAND is not new information.

Yet short term weight loss success is not to be discounted as an import achievement either. For many of my patients, achieving a one-year weight loss target is critical to avoiding an irreversible slide to poorer health or even death. For some people the difference between 18 and 36 months to reach a goal weight is highly significant, and in others it is not as important.

SHOULD THE FDA APPROVE LAP-BAND FOR LOW BMI?

Monday, December 27th, 2010

The FDA Advisory Committee, which recently agreed to review the current criteria that Allergan Corporation and physicians and hospitals may use to promote the laparoscopic adjustable gastric band will soon be deciding to broaden these criteria.  Until now, the LAP-BAND has been approved under FDA guidelines for people with a body mass index of 35 and greater if an obesity related health problem is present.  The most common ones include diabetes, hypertension and obstructive sleep apnea, although the list is truly very long and includes nearly every organ system.  The proposal from Allergan Corporation would lower these criteria to a body mass index of 30 with an obesity related disease or 35 without documented disease.

Should the FDA grant this approval?

The recommendations should be grounded in data and should not take into account fears of excess costs, social implications and politics.  The recommendation should acknowledge the deadly seriousness of the obesity epidemic and the tragedy of the lives claimed by obesity.

To most of us working in the field of obesity treatment, obesity research and bariatric medicine, all too often it seems the media focus on sensational stories about unusual complications of weight loss treatments and weight loss surgery.  Most stories do not focus on the deadly effects of obesity, although it now ranks as the number one cause of early disease and death in the United States.

At least five longitudinal studies have examined weight loss surgery and compared surgical patients with similarly obese non-surgical patients over a period of time.  Each study demonstrated a profound disadvantage for people electing not to undergo weight loss surgery.  In studies by Flum and Christou, obese individuals undergoing weight loss surgery enjoyed a dramatic reduction in disease and mortality risk over the span of just a few years.  Other authors have confirmed these findings.

What these studies indicate, in my view, is less a commentary about the dramatic success of surgery, but more about the deadliness of obesity and disease.

More to the point on low BMI LAP-BAND, O’Brien and numerous other authors have examined and continued to examine the outcomes of low BMI patients who undergo LAP-BAND surgery.  The complication rate of this out-patient, thirty minute procedure is markedly low and pales in comparison to the deadliness of obesity as a disease.  The reductions in weight achieved with LAP-BAND surgery, and an associated weight loss program complete with counseling, weigh-ins, band adjustments and support groups are profound and significant.  And because obesity is such a deadly risk factor, even modest weight loss produces major gains in health status and longevity.

So whether the FDA committee will examine the data critically and without bias remains to be seen.  There are indeed major implications of a decision which would expand the recommendations to tens of millions of Americans.  But time and time again, healthcare providers, leaders and regulators have continued to overlook obesity as a serious disease and have continued to turn away from treatments and policies that would favorably impact obesity related disease and deaths.

In my view and in the view of most experts in the field of obesity treatment, the data for LAP-BAND approval for BMI 30 and over has been in for a long time.  Its approval is well overdue.

WHAT TO DO ABOUT THE PROBLEM OF MEXICO BARIATRIC SURGERY?

Monday, August 30th, 2010

I practice in Reno, Nevada, which is not particularly close in distance to Mexico, and yet with increasing frequency, I find myself caring for people who have suffered devastating complications after undergoing bariatric surgery in Mexico.  The phenomenon poses many challenging questions for all of us and it is difficult to know exactly how to solve the problems posed by this practice.

It’s no secret that healthcare in the United States is expensive.  It’s also no secret that weight loss surgery is among the most beneficial health interventions available in the world today as measured by any outcomes measure.  And yet, while insurance plans pay for things like Viagra and futile advanced radiation and chemotherapy treatments, often they do not pay for weight loss surgery.  An increasing number of people seek the effective solution for improved health and longevity that weight loss surgery represents and they shop for the best locations, surgeons and prices.  And on price, it is difficult to compete with Mexico.

Mexican surgeons and centers are unabashed in promoting their services and their cut-rate prices.  It is impossible to do an internet search for weight loss surgery information without being bombarded with numerous advertisements and promotions of discount weight loss surgical procedures performed in Mexico.  So it’s quite understandable why a person would travel to Mexico to undergo a badly needed procedure and also save thousands of dollars.  Even the media in the United States have encouraged this phenomenon.  I previously commented on a National Public Radio story by the usually more thoughtful Jason Bovian who described the development of surgical centers and technology and availability in Mexico, and he didn’t make the slightest mention of the tremendous problems associated with this phenomenon for US citizens.

I am currently taking care of a critically ill man who may not survive his weight loss surgery that was performed in Mexico weeks ago.  After returning to his community and mine, the problems with the surgery became evident.  He became toxic with severe sepsis and has clung to life with the aid of life support, multiple corrective operations and all of the modern, sophisticated ICU care that can be provided.  It is unlikely his American, employer based insurance plan will pay for any of the bills, making this multi-million dollar hospital stay and indigent case and huge loss for our community hospital.

While the finances are a serious matter to community hospitals that are struggling to stay in the black, the problem is even more devastating for my patient and his family.  While there are no good studies on the subject, it is without a doubt that the firm impression of nearly every bariatric surgeon in the United States that the rate of serious complications is markedly higher among people who travel to Mexico.

A more insidious problem is the poor weight loss results achieved by individuals who travel to Mexico for their surgery.  If we’ve learned anything over the last decade, we have learned that weight loss surgery provides fantastic results when it is more properly a “weight loss surgery program”.  The surgery in itself is not a magic wand, but it creates the conditions for change and for success.  After that, it takes education, support, follow-up, accountability, expert advice, laboratory testing and in short, a “program” to ensure success.  No such program exists for people who travel outside the country to undergo their procedure hence weight loss results suffer greatly.

Among the many concerns I have for members of my community is that they are not adequately informed about these risks when they travel to Mexico for weight loss surgery.  The expose themselves to financial ruin and personal bankruptcy as has occurred among patients I have personally cared for.  They expose themselves to poorer weight loss results due to lack of an effective follow-up program with their surgeon and they expose themselves to surgical risks and complications that certainly appear to be much higher than what they would experience undergoing surgery at a US based center of excellence with all of its emphasis on continuous quality improvement and rigorous reporting of results.

A complex problem, doubtless, but one that deserves more consideration by all of us.  Greater  responsibility by employers and insurance carriers to cover weight loss surgery as a proven health benefit, greater responsibility among Mexican bariatric surgeons to provide informed consent and a mechanism for follow-up.  Greater responsibility on the part of the media to discuss these potentially devastating problems arising from traveling to Mexico for surgery.  Greater responsibility among providers, hospitals and surgery centers in the United States to cut costs and reduce profits in order to make the procedure more affordable and reduce the incentive for unwitting patients to travel to Mexico.  And greater responsibility among manufactures of bariatric surgical devices, namely the REALIZE Band manufacturers to stop providing the critical piece of equipment, the adjustable gastric band, to the centers south of the border at cut-rate prices, further adding to the incentives for Americans to travel south of the border (Allergan, the maker of the Lap-Band, does not offer the most recent  version of the Lap-Band in Mexico, but does offer older generations, which American consumers are not as interested in).  All of these are controversial areas deserving of more attention.  What do you think?

DELAYED PERFORATIONS AFTER SLEEVE GASTRECTOMY POSE A PROBLEM

Tuesday, August 24th, 2010

As I write this, I am taking care of a gentleman who is extremely ill, in critical condition and in the intensive care unit of one of our hospitals having undergone a sleeve gastrectomy approximately three months ago.  He experienced one of the more devastating complications of this procedure, namely a delayed perforation of the stomach.  Such perforations occur in sleeve gastrectomy more so than with other procedures.  In fact, I have seen several of these devastating delayed perforations in sleeve gastrectomies while they are nearly unheard of in the other weight loss procedures (with the exception of perforated ulcers, which can occur years later, usually as a result of Motrin, Aleve and other non-steroidal anti-inflammatory drugs attacking the stomach lining).

The phenomenon of a delayed perforation after gastric sleeve procedure is one that is increasingly discussed at meetings, but not fully understood.  There may be a phenomenon of local ischemia, meaning a local area of lack of blood supply along the gastric staple line or it may be due to other factors we may not fully comprehend.  Another theory is that some bleeding, bruising or hematoma has formed along the staple line and as this breaks down and is absorbed it creates a perforation.  What we do know is that the stomach tube or sleeve is a high pressure system after the sleeve gastrectomy procedure is performed.  With most of the stomach volume having been removed, the pressure as measured within the remaining stomach tube is higher than it would be after gastric bypass surgery or after Lap-Band.  The long staple line itself creates some vulnerability to perforation and this high pressure may play a role.  But whatever the exact cause is, it is phenomenon that we do not fully understand and we cannot fully prevent.  It is particularly devastating because it can occur weeks or months after surgery when a person appears to have been healing up nicely.

CELEBRITIES UNDERGOING LAP-BAND WEIGHT LOSS SURGERY

Sunday, June 27th, 2010

Joining the ranks of celebrities that have disclosed they have undergone Lap-Band surgery is New York Jets coach, Rex Ryan and golf star, John Daly. In addition, a change is beginning to take place in the urban centers of New York, Los Angeles and Las Vegas wherein celebrities including entertainers, athletic personalities and politicians are undergoing a Lap-Band procedure because it can be done discreetly and without much disclosure.

I personally feel we should applaud and encourage people like Rex Ryan who publically acknowledge their weight struggles and make no effort to conceal their efforts to lose weight. It is a somewhat delicate and complex new era that we are entering, but one that needs to be faced with courage and honesty.

Most Americans are now overweight or obese and in the future nearly all of us will be overweight or obese if current trends hold. So pursuing solutions for weight gain and obesity simply means taking care of one’s self and pursuing better health. So why should a celebrity be ashamed of this? Would they hide the fact that they took blood pressure medicines or underwent coronary artery bypass grafting surgery? Of course not, there is no stigma associated with these interventions even though they are aimed at exactly the same outcome: better health and longer life. Perhaps it is because we associated obesity with indulgence, lack of self control and lack of self discipline that we find people ashamed to volunteer information about their obesity treatments.

I would just note that it is certainly no secret when a celebrity becomes obese. It is generally not possible to hide this particular disease and photographs will convey far more about the obesity condition than they will about the status of somebody’s coronary artery plaques. So I would like to see a day when people openly and courageously pursue the best available weight loss solutions- and today this is undoubtedly a combined program and weight loss surgery and medically supervised long term weight loss follow-up – because it is the best thing for their health. It is also the best thing to promote and acknowledge as healthy for other people who suffer with the same conditions. For if celebrities serve any useful purpose whatsoever it is to influence the rest of us toward better and healthier behaviors.

WHEN SHOULD CHILDREN BE CONSIDERED CANDIDATES FOR WEIGHT LOSS SURGERY?

Monday, May 17th, 2010

The subject of children and adolescents potentially undergoing weight loss surgery has evolved greatly in a short number of years. When it was initially proposed the only operations were invasive procedures such as the open Roux-en-Y gastric bypass. With the advancements of minimally invasive surgery and laparoscopic instrumentation, there are now several minimally invasive choices, most notably the laparoscopic adjustable gastric band (LAGB, Lap-Band or REALIZE Band). The LAGB procedure does not involve any cutting, rerouting, reconnecting or other irreversible changes to the gastrointestinal system of a young person and so has emerged as a potential procedure, perhaps more worthy of consideration on a wider scale in young people.

The rationale for weight loss surgery being performed among young people is that serious comorbid conditions are developing in young people and extremely important formative events are occurring in social, intellectual, academic and career realms for the young person, all of which are profoundly negatively impacted by obesity. Weight loss surgery performed at a young age offers the potential benefit of impacting not only the young person’s health and quality of life, but also substantially enhancing long term prospects for improved career, earnings, relationship formation and social development. For this reason many advocates of childhood health and adolescent well being have endorsed the concept of offering weight loss surgery to obese adolescents and young people.

When should a young person be considered for weight loss surgery?

  1. When the body mass index is over 35 it is reasonable to begin consideration.

  2. When the body mass index is over 40 weight loss surgery should be included in any discussion with the patient and family of the weight loss options.

  3. Attempts at non-surgical weight loss: young people by virtue of their higher resting metabolic rate than older persons, often have a greater ability to lose weight through non-surgical means. Additionally, young people may have a greater power to make behavior and lifestyle change than older people. So, determined efforts should be made to engage in non-surgical weight loss programs with a structured medically supervised approach involving dietary change, counseling, exercise, psychotherapy, use of protein based meal replacements and support groups. If these efforts fail then weight loss surgery should be considered.

  4. Health status: For adolescents who have already shown health problems stemming from obesity such as type 2 diabetes, high blood pressure and obstructive sleep apnea, weight loss surgery should be a consideration.

  5. Age: At what age should weight loss surgery be considered? This remains a debated topic. Our own center chose a lower range cutoff of age 15 below which we offer non-surgical, medically supervised weight loss. At 15 and above we will offer laparoscopic adjustable gastric banding weight loss surgery. At age 18 and above patients and families generally have the option of LAGB or laparoscopic Roux-en-Y gastric bypass surgery. Other centers around the country have chosen a lower age cutoff of, for example age 12 and above for consideration of weight loss surgery.

Tips for success with adolescents and weight loss surgery:

  1. This must be a whole family effort. Everyone must be educated and motivated to help the young person succeed.

  2. Support groups for the young person and the parents and siblings. This is not a “go-it-alone” journey. Quite the opposite is true. Support, encouragement and coaching from parents, siblings and peers enhances successful weight loss.

  3. 0-calorie beverages. This principle must be enforced within the household to avoid “drinking all your calories” and maintaining resuming obesity.

  4. Protein first. This principle means that everything eaten, drunk, prepared, bought, opened, sniffed or dreamed about must be protein first. This guarantees a greater sense of satiety and an emphasis on lower intake of simple carbohydrates, which are appetite stimulating.

  5. Exercise for life. The habit must be engrained not only for the young person, but for the whole family that daily exercise is part of life even if it is simple walking. Exercise is a powerful predictor of long term weight loss success

8th Annual Bariatric Fashion Show A Success

Wednesday, May 12th, 2010

This past weekend was our 8th Annual Fashion Show hosted by The Obesity Prevention Foundation and Western Bariatric Institute.  It was a great event that allowed some of our patients to share their success with friends, family and the Reno community. It also provided us with a great opportunity to spread the word about the obesity prevention foundation. Thank you to everyone who came out to the show.

I would also like to send out a very special thank you to Joe Hart who, as usual, performed impeccably as the Master of Ceremonies.  As always, Joe is a very gracious and professional host noting the tremendous life change and improvement in health of our models while also highlighting the great clothes they were wearing that were provided by many local clothiers.

I don’t have official numbers in, but it looked to me like there were around one thousand attendees of the event this year and it was near standing room only in the Rose Ballroom at the Convention Center. The Convention Center staff did a fantastic job making this year’s show appear glamorous and professional as did Kathy Parker and her excellent team in planning and coordinating the event.

This year, greater awareness was raised and mention made of the activities of Obesity Prevention Foundation, which this summer will be kicking off quite a few activities meant to raise awareness for healthy kids and healthy families.

Incisional Hernias And Obesity

Thursday, March 4th, 2010

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.

Sleeve Gastrectomy Versus Intragastric Balloon

Thursday, February 18th, 2010

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)


Dr. Kent Sasse, Medical Director | 75 Pringle Way Suite 804 Reno, NV 89502 | Phone: 775-829-7999

Dr. Kent Sasse serves the entire city of Reno and all the surrounding areas. Dr. Sasse is one of the nation's foremost medical weight loss and bariatric surgical experts.
Dr. Sasse has educated patients about food nutrition and weight loss for many years.

Copyright © 2007-2010 Kent Sasse, M.D. All Rights Reserved.

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