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?

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.

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.

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

This past weekend was our 8^th 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.

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.