California woman seriously ill after gastric bypass surgery finds hope

Modesto, CA

Tests have shown that Sandi Krueger's golf-ball-sized pouch no longer breaks down the food she eats, but dumps it directly into her small intestine. Before the feeding tube, her attempts to eat caused nausea and she often had dumping syndrome, a reaction when certain foods pass too quickly into the intestine, resulting in sweating, rapid heart beat and weakness.

Her journey began in 2002 with a gastric bypass at Doctors Hospital of Manteca, which later closed its bariatric program. She had constant dumping and severe weight loss, had a falling out with her surgeon and went to the University of California at San Francisco for corrective surgery in 2004.

Her condition improved for several months and then her condition gradually deteriorated. She stopped working as a nursing assistant last year and then UCSF rejected her request for a reversal surgery.

Repairs are complex

She's made the 165-mile trip to Delano because Keshishian accepted her Medi-Cal coverage and he specializes in revising or reversing gastric bypasses. A reversal has some of the same risks as gastric bypass; in addition, the surgeon must deal with scar tissue that grows between the left side of the liver and upper part of the stomach.

"You have to peel the stomach away from the liver," Husted said. "It's tricky and can take a long time."

Many patients who aren't absorbing enough nutrients can improve with counseling and treatment, experts say.

Until her surgery is scheduled, Krueger will stay with the tube- feeding routine — 44 ounces of water mixed with a formula of protein, vitamins and other stuff costing the family $549 a month. With her husband drawing unemployment, it strains the family budget, but at least she feels healthy.

"It is nice to be a mom again," she said. "It feels like I have missed six years of my life."

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Gastric bypass surgery death rates drop, study reveals

Seattle, WA

Obese, but worried that surgery for it might kill you? The risk of that has dropped dramatically, and now is no greater than for having a gall bladder out, a hip replaced or most other major operations, new research shows.

The study looked at safety results for gastric bands and stomach stapling at 10 U.S. hospitals specializing in these procedures from 2005 through 2007. For every 1,000 patients, three died during or within a month of their surgery, and 43 had a major complication.

That is much better than the 20 or so deaths per 1,000 patients that studies found just a few years earlier. And it's surely lower than the longer term risk of dying of heart disease, diabetes and other consequences of lugging around more pounds than an obese person's organs can handle, experts say.

Many studies have compared those odds, and "all show a higher risk of dying if you do not have surgical treatment than if you do," said Dr. Eric DeMaria, weight loss surgery chief at Duke University Medical Center.

He had no role in the new study, which was led by Dr. David Flum at the University of Washington in Seattle. Results appear in Thursday's New England Journal of Medicine.

About one-third of American adults are obese, with a body mass index of 30 or more. The index is based on height and weight. Someone who is 5-feet-4 is obese at 175 pounds; a 6-foot person is obese at 222 pounds.

Federal guidelines say obesity surgery shouldn't be considered unless someone has tried conventional ways to shed pounds and has a BMI over 40, or a BMI over 35 plus a weight-related medical problem like diabetes or high blood pressure.

Last year, at least 220,000 obesity surgeries were done in the United States, says the American Society for Metabolic & Bariatric Surgery. The most popular method is a gastric bypass in which a small pouch is stapled off from the rest of the stomach and connected to the small intestine. People eat less because the pouch holds little food, and they absorb fewer calories because much of the intestine is bypassed. This can be done with traditional surgery or laparoscopically, through small keyhole incisions.

Another solution is a gastric band. A ring is placed over the top of the stomach and inflated with saline to tighten it and restrict how much food can enter and pass through the stomach.

The new study looked at the safety of these methods in 3,412 gastric bypass patients and 1,198 given stomach bands.

Death, serious complications or the need for another procedure occurred in 1 percent of people receiving bands, nearly 5 percent having laparoscopic gastric bypass, and nearly 8 percent of those given a traditional surgical bypass. Maybe

DeMaria cautioned against comparing the numbers, because healthier people may have been steered toward laparoscopic procedures that may not have been an option for others with more health risks.

Complication rates were greater in people with a history of clot problems, sleep apnea and certain other medical issues, the study found.

The federal government paid for the study. Many of the researchers have ties to companies that make obesity treatments, and several have testified in surgery lawsuits.

The results put the spotlight on cost issues, Dr. Malcolm K. Robinson, a surgeon at Harvard Medical School, wrote in an editorial accompanying the study.

"In the past, now outdated bariatric procedures carried unacceptably high risks. The weight loss associated with the procedures was questionable, and the long-term health benefits were unproven," he wrote.

Now, the evidence shows that "surgery is safe, effective, and affordable," because it can lower doctor visits, medication use and other medical expenses, Robinson wrote. However, "the expense of operating on the millions of potentially eligible obese adults could overwhelm an already financially stressed health care system."
On the Net:

* New England Journal: http://www.nejm.org
* National Institutes of Health surgery explanation: http://win.niddk.nih.gov/publications/gastric.htm

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Gastric bypass surgery patients with seep apnea at higher risk, study says

Overland Park, KS

While short-term complications and death rates are low following bariatric surgery, according to the Longitudinal Assessment of Bariatric Surgery (LABS-1), patients with a preoperative history of sleep apnea remain at a greater risk of complications.

According to the study, funded by the National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK), part of the National Institutes of Health, less than 1% (0.3%) of patients died within 30 days of surgery. The findings support the short-term safety of bariatric surgery as a treatment for patients with extreme obesity.

"Evaluating the 30-day safety outcomes of bariatric surgery in large populations is an essential step forward," said coauthor Myrlene Staten, MD, senior advisor for diabetes translation research at NIDDK in an announcement. "And LABS-1 data are from all patients who had their procedure performed by a surgeon participating in the study, not from just a select few patients."

The LABS-1 consortium followed 4,776 patients having bariatric surgery for the first time, and evaluated complications and death rates within the first 30 days after surgery. Patients were at least 18 years old and had an average body mass index (BMI) of 44. The majority of LABS-1 patients were white and female, which, according to the NIDDK, is the most common population to undergo bariatric surgery. The study took place over 2 years at 10 medical sites, with one additional center coordinating data collection and analyses.

Within 30 days of surgery, 4.1% of patients had at least one major adverse outcome, defined as death, development of blood clots in the deep veins of the legs or in the pulmonary artery of the lungs, repeat surgeries, or failure to be discharged from the hospital within 30 days of surgery.

Thirty-day mortality was low but varied depending on the type of bariatric surgery performed. This ranged from no deaths in the laparoscopic adjustable gastric band group, to six (0.2%) in the laparoscopic Roux-en-Y gastric bypass group, to nine (2.1%) in those undergoing open Roux-en-Y gastric bypass. After adjusting for patient and center characteristics, there were no significant differences in complication risk that could be attributed to the type of procedure. Patient factors such as a preoperative history of deep vein blood clots and sleep apnea increased the risk of postoperative complications. Patients with a very high BMI were also at an increased risk: A patient with a BMI of 75 had a 61% higher risk of complications than those with a BMI of 53.

LABS-1 is part of the Longitudinal Assessment of Bariatric Surgery consortium, an NIDDK-funded study launched in 2003 to examine the short- and long-term benefits and risks of bariatric surgery for adults with extreme obesity.

Results appear in the July 30 issue of the New England Journal of Medicine

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Obese student seeks charitable donations for gastric bypass surgery

Seattle, WA

A Seattle college student doesn't want to be the "biggest" man on campus and has started a Web site asking for donations to help him get gastric bypass surgery.

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Comedianne Mo'Nique becomes weight loss leader

Philadelphia, PA

Lately, the blogosphere has been blowing up over two big sisters: comedian Mo'Nique and President Obama's pleasingly plump new surgeon general, Dr. Regina Benjamin.

There's so much controversy that I'll need two columns to address it all. First, let's talk about Mo'Nique.

Actress-comedian Mo'Nique Imes Jackson, author of "Skinny Women Are Evil" and "Skinny Cooks Can't Be Trusted," has lost 40 pounds. Rumors have been flying that she had gastric bypass surgery, which she flat- out denies. But that hasn't appeased the size-acceptance camp, whose members are angrily abuzz about the weight loss she disclosed in a recent interview with Jet magazine.

In the interview, Mo'Nique says she knew it was time to lose weight when her husband, Sidney Hicks, watched her step off the scale at 262 pounds and said, "Baby, that's too much, and I want you for a lifetime."

Now the 5-foot-6-inch star is making the necessary sacrifices and has vowed to get her weight down to 200 pounds.

"This was truly making the commitment to watch what I eat and commit to working out," she said. "I stopped eating red meat. I want to say to big people, 'Let's be healthy big people. Everybody can't be a size 0, but let's be healthy.' "

Her efforts are worthy of applause. So why the criticism?

It is true that for years, this fat and fabulous one has been a champion for size acceptance. She has made a generous living dissing so-called "skinny bitches" while encouraging fat women to stay, well, fat.

Mo was always the first to say how proud she was to be representing for the big girls. So is this some sinister plan she's made to unleash an internal skinny bitch who's been dying to get out?

I don't think so.

Quite frankly, it has always stupefied me why the plus-size community feels betrayed when a plus-size celebrity - or a friend, for that matter - decides to slim down. Why are efforts at living a healthier lifestyle viewed as a personal affront?

Mo'Nique shouldn't be shunned for losing weight. Even if she reaches her goal of 200 pounds, she'll have a BMI of 32.3, which still makes her medically obese.

Would size acceptance groups prefer that Mo'Nique eat herself into disease, disability or death?

I suspect that fat advocates' swagger and confidence is really false bravado. Embracing your size does not make your health problems disappear. None of us has the luxury of throwing in the towel on a healthy lifestyle of daily exercise and good nutrition.

From where I sit on the front lines, it's clear we cannot continue this masquerade. And this is especially true for black folks. Black women, who have the highest overweight and obesity levels of any U.S. population, cannot afford false bravado. We need solutions. We need to keep it real with ourselves and take control of our health.

Why can't we be honest with ourselves and admit that being overweight or obese is not healthy? Why don't we understand that this hits the black community especially hard?

It's not healthy to carry an extra 20 pounds, let alone 100 pounds. Our bodies are just not designed for this type of trauma.

I have seen enough premature death, disease and disability in the black community to confirm the truth. I don't even have to cite the statistics on this, but I will.

If you are still on the fence about where black women are on the obesity front, then check this out:

_ African Americans, particularly African-American women, need to protect themselves against the ravages of obesity, which strikes us harder than any other group.

According to the Centers for Disease Control and Prevention Web site, 31.2 percent of African Americans were obese in 2001, up from 19.3 percent from the previous decade. That's a whopping increase in just 10 years. And experts say that today, half of all African-American women are obese.

_ African Americans suffer disproportionately from heart disease, hypertension, and diabetes, among other lifestyle-related diseases.

Surely, Mo'Nique is aware of all this. Now she's on the precipice of change.

Mo'Nique has the extraordinary potential to save some lives. Her decision to tackle her weight may influence more women to take charge of their health.

Can you imagine it? Maybe, just maybe, Mo'Nique is going to help lead the battle against obesity. Could she be the one to kick-start Obama's new health initiative? And will she get some help, perhaps, from a recent Obama appointee?

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More than 50% Increase in gastric bypass surgeries over past 12 months in UK

York City, UK

Operations to combat weight gain have increased by more than a half in the past 12 months.

The news follows the tragic death of York mum Kerry Greaves, who underwent gastric bypass surgery to try to slim down so her daughter, Melissa, would not be teased at school. Sadly, complications led to Kerry’s death at the age of only 30.

Figures released by the NHS show that in the 12 months leading up to April this year, 4,324 people nationally underwent operations to have gastric bypasses or gastric bands fitted to help them lose weight. That is a 52 per cent increase over the 2007-2008 figures, when 2,838 opted for surgery.

Operations of this type can cost about £10,000 and most of those who opt to go “under the knife” are women – about three-quarters of the total who opt for surgery.

The treatment is predominantly available for patients whose body mass index (BMI) exceeds 50 – the average BMI is between 18 and 25.

People with a BMI of more than 40 are considered to be morbidly obese while a measurement of more than 30 is classed as obese.

According to the NHS figures, only 38 per cent of people are a healthy weight. The rise in the number of people wanting gastric bypass surgery has been borne out by York GP Dr David Fair, who said he had seen a marked increase in the number of people wanting the procedure.

But surgery should always be seen as the last option when dieting and exercise has failed.

Although low risk, Dr Fair said that potential problems could arise with any type of operations.

That is what happened to Kerry. After having the operation her stomach failed to heal properly, and she underwent a further 14 operations before dying of organ failure.

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Study identifies several risk factors linked to poor bariatric surgery utcomes

Cambridge, MA

Several risk factors may help identify factors linked to poor outcomes for bariatric surgery, according to the results of a prospective, multicenter, observational study reported in the July 30 issue of the New England Journal of Medicine.

"To improve decision making in the treatment of extreme obesity, the risks of bariatric surgical procedures require further characterization," write David R. Flum, MD, from the University of Washington in Seattle, and colleagues from the Longitudinal Assessment of Bariatric Surgery (LABS) Consortium. "Concern about the safety of bariatric surgery has grown with its increasing popularity and has been heightened by periodic high-profile reports in the lay press of deaths after bariatric surgery and of the closure or threatened suspension of bariatric programs because of safety issues. Malpractice insurers have expressed concern about the increased risk they incur when they provide liability-insurance coverage to bariatric surgeons."

From 2005 through 2007, the investigators evaluated 30-day outcomes in consecutive patients undergoing bariatric surgical procedures at 10 clinical US sites. For 4776 patients undergoing first-time bariatric surgery, the composite endpoint of 30-day major adverse outcomes included death; venous thromboembolism; percutaneous, endoscopic, or operative reintervention; and failure to be discharged from the hospital.

Mean age of the study sample was 44.5 years, 21.1% were men, 10.9% were nonwhite, and more than half had at least 2 comorbid conditions. Median body-mass index (BMI), defined as weight in kilograms divided by the square of the height in meters, was 46.5 kg/m2.

The bariatric procedure performed was Roux-en-Y gastric bypass in 3412 patients (performed laparoscopically in 87.2% of these patients) and laparoscopic adjustable gastric banding in 1198 patients. The analysis excluded 166 patients who underwent other procedures. Among patients treated with Roux-en-Y gastric bypass or laparoscopic adjustable gastric banding, 30-day mortality rate was 0.3%, and 1 or more major adverse outcomes occurred in 4.3% of patients.

Factors independently associated with an increased risk for the composite endpoint were a history of deep-vein thrombosis or pulmonary embolus, a diagnosis of obstructive sleep apnea, and impaired functional status. Although extreme BMI values were significantly associated with increased risk for the composite endpoint, age, sex, race, ethnicity, and other comorbid conditions were not.

"The overall risk of death and other adverse outcomes after bariatric surgery was low and varied considerably according to patient characteristics," the study authors write. "In helping patients make appropriate choices, short-term safety should be considered in conjunction with both the long-term effects of bariatric surgery and the risks associated with being extremely obese."

Limitations of this study include possible lack of generalizability to the general community; limited size of certain patient subgroups, resulting in a type II error that did not identify a difference in safety among groups; comorbid conditions determined by patients' self-report; and inability to determine the case volume at the centers.

In an accompanying editorial, Malcolm K. Robinson, MD, from Harvard Medical School in Boston, Massachusetts, is hopeful that learning more about how bariatric surgery works may help develop even less invasive procedures.

"It is a sobering fact that some obese young adults may lose up to 20 years of life expectancy if they do not reduce their weight," Dr. Robinson writes. "One must treat obesity aggressively, though thoughtfully, and with an eye toward developing effective prevention and better therapies that ideally would eliminate the need for surgery altogether. But until we get to that point, the weight of the evidence indicates that bariatric surgery is safe, effective, and affordable."

The National Institute of Diabetes and Digestive and Kidney Diseases and the General Clinical Research Center supported the LABS study. Some of the study authors have disclosed various financial relationships with Covidien, legal firms representing cases involving bariatric surgery, Allergan, Pfizer, sanofi-aventis, Stryker, GlaxoSmithKline, Lilly Research, Legacy Health System, W.L. Gore and Associates, Ethicon Endo-Surgery, Johnson & Johnson, Tyco, and/or EnteroMedics.

Dr. Robinson has received consulting fees from Storz and has served as an expert witness in legal cases regarding standards of care in bariatric surgery.

N Engl J Med. 2009;361:445-454, 520-521.

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