A prospective study of risk factors for nephrolithiasis after Roux-en-Y gastric bypass surgery (Abstract)

Roux-en-Y gastric bypass surgery has become an increasingly common form of weight management. Early retrospective reviews have suggested that new onset nephrolithiasis develops in some patients after undergoing Roux-en-Y gastric bypass. We present a prospective longitudinal study to assess risk factors for nephrolithiasis after Roux-en-Y gastric bypass.

A total of 45 morbidly obese patients scheduled to undergo Roux-en-Y gastric bypass surgery were enrolled in this prospective study between November 2006 and November 2007. Exclusion criteria included history of nephrolithiasis or inflammatory bowel disease. Serum uric acid, parathyroid hormone, calcium, albumin, and creatinine and 24-hour urine collections were obtained within 6 months before Roux-en-Y gastric bypass, and at 6 to 12 months postoperatively. A Wilcoxon signed-rank test was used to compare preoperative and postoperative serum laboratory values and 24-hour urine values. McNemar's test was used to determine if the percent of abnormal values underwent a statistically significant change after Roux-en-Y gastric bypass. For both statistical methods a p value was calculated for the change in each variable with p <0.05 considered statistically significant. Statistically significant changes included increased urinary oxalate and calcium oxalate supersaturation, and decreased urinary citrate and total urinary volume postoperatively. A statistically significant percentage of patients exhibited decreased urinary calcium, while a statistically significant percentage of patients experienced increased urinary oxalate and calcium oxalate supersaturation. Our prospective study demonstrated multiple factors that increase the relative risk of nephrolithiasis after Roux-en-Y gastric bypass. These changes may make stone formation after Roux-en-Y gastric bypass increasingly likely and pose an ongoing challenge in the realm of urology. Gastric Bypass Malpractice Lawsuit Attorneys

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Doctors embrace bariatric surgery as effective treatment for diabetes

Los Angeles, CA

Fifty international scientific and medical experts have issued a "consensus statement" declaring that bariatric surgery should be considered a treatment option for patients with Type 2 diabetes, even if they are not extremely obese.

The new guidelines, published today online in the Annals of Surgery, urge surgeons performing bariatric surgery and healthcare insurers reimbursing for such treatment to relax criteria, adopted in 1991, that have restricted such surgery to patients with a body-mass index of 35 or more.

Reviewing more than a decade's worth of studies on weight-loss surgery and diabetes, clinicians and researchers backing the document have concluded that the improved metabolic function that is typical in diabetic patients who undergo bariatric surgery is not merely an incidental effect of weight loss. "Surgery is a specific treatment for diabetes...the effect on diabetes is a direct consequence of the new anatomy created by surgery," said lead author Dr. Francesco Rubino, director of the gastrointestinal metabolic surgery program at New York-Presbyterian Hospital/Weill Cornell Medical College.

The implications, added Rubino in an interview, "are enormous." For starters, that finding should drive a broadening of the patient population offered the option of gastric bypass surgery or less invasive procedures that reduce the capacity of the gastrointestinal tract. Rubino said that patients with Type 2 diabetes that is poorly managed by diet, exercise and medicine should now routinely be assessed as surgery candidates.

Some of those will likely be far less overweight than the bulk of patients who have had the surgery for weight loss. Rubino cited the example of diabetic patients of Asian descent, who rarely reach a BMI of 35 but who might benefit from bariatric surgery.

For the more than 20 million Americans -- and counting -- thought to have Type 2 diabetes, bariatric surgery may offer more than just another treatment option. Research shows that for many patients, diabetes abates dramatically and permanently with surgery. That, said Rubino, makes the possibility of a "cure"--a prospect not discussed until very recently--real for many patients who have been told that "living with diabetes" is the best they can do.

Beyond that, said Rubino, clinicians caring for these patients will need to optimize their pre- and post-operative care to serve a new objective: that of improving metabolic function. Currently, many bariatric surgery patients continue on diabetes medicines after their operation when that might not be optimal or even necessary.

Finally, the consensus finding should guide the search for drugs that can better treat Type 2 diabetes. Those should focus on how metabolic function is changed by an alteration of the gut's anatomy, and whether drugs could be developed or adapted to work in the same way, Rubino said.

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Gastric bypass surgery: Couple sticks together through thick and thin

Lehi, UT

A couple in Utah County went under the knife together on a weight loss journey in hopes of losing hundreds of pounds.

The couple is Mike and Lorena Downey. The two took their vows 26 years ago promising to love each other in good times or bad, for better or for worse, in sickness and in health and to see each other through thick and thin.

When they married, in 1983, Mike and Lorena had a combined total weight of just under 300 pounds, but this year they tipped the scales at almost 600 pounds.

“I look in the mirror, I’m not happy with who I see. When I got to 270 pounds it blew my mind. I couldn’t believe it. I was so close to 300 pounds,” said Lorena.

Although the Downeys were happily married with children, their weight slowly started to come between them.

“How could you look at your wife and say you’re not the woman I married, when you’re looking at yourself and saying you’re not the man she married,” said Mike.

The two knew something had to be done and began researching options. In a desperate effort to shed the weight they turned to gastric bypass surgery. After deciding that the surgery’s pros outweighed the cons they chose to do the surgery together.

They went to St. Mark’s hospital where Lorena had her surgery on October 7th and Mike had his one week later.

Gastric bypass surgery is growing more popular every day as America’s obesity epidemic tips the scales. The surgery has been known to save lives but there can also be life changing drawbacks.

Their journey consisted of three trips to the ER during the week of Mike’s surgery and complications for Lorena resulting in two additional surgeries.

Both are fine and after just five weeks the couple has lost nearly 100 pounds. They have been walking everyday and both say they’re feeling better and have more energy.

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Gastric sleeve surgery expected to become more popular

El Paso, TX

Doctors recommend that people battling obesity first turn to diet and exercise to drop their extra pounds.

But conventional weight loss methods aren't enough for some.

Sometimes, surgery is the only option.

For years, gastric bypass surgery and the Lap-Band procedure were among the only surgical options available for weight loss in El Paso. But the gastric sleeve procedure is poised to surge in popularity as patients learn more about the operation.

Dr. Benjamin Clapp, a bariatric surgeon at Sierra Providence Bariatric Center, said the two previous surgical options caused anxiety among patients for different reasons.

"A lot of people are uncomfortable with the aggressive remodeling of your gastrointestinal tract with a gastric bypass, but it has the best weight loss," he said. "A lot of people are also uncomfortable with the Lap-Band, which is a foreign band which stays inside your body."

The new alternative, he said, is the gastric sleeve procedure. In this procedure, the stomach is reduced to about 40 percent of its original size. Its appearance after the procedure resembles a tube or sleeve.

"The gastric sleeve is sort of a nice in-between procedure where you have almost as good weight loss as gastric bypass, but you don't have to rearrange everything and you also don't have to have a foreign body in there," Clapp said.

"The weakness of it would be it's not really adjustable and we don't know what the 10- to 15-year effects are, but we think we
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can predict them."

The Sierra Providence Bariatric Center began offering the sleeve procedure in August 2008, but Clapp has performed it elsewhere for about three years.

So far, 10 have been done at his facility.

Of the three surgical techniques most often used today, the gastric bypass was the first to be widely used. In this procedure, doctors reduce the stomach size to only a small pouch, which is then connected to the middle of the small intestine. The procedure limits the amount of food consumed and limits the absorption of nutrients and calories in the small intestine.

The Lap-Band, or laparoscopic adjustable gastric band, also reduces the amount of food the stomach can hold. An inflatable band is placed around the top part of the stomach to create a smaller pouch for food. The patient is forced to eat less and subsequently loses weight.

The band can be adjusted to allow in more or less food, depending on the patient's situation.

Clapp said an advantage of the gastric sleeve is that if the patient does not lose the desired amount of weight, a gastric bypass procedure remains an option.

Michele Collins, director of Sierra Providence Bariatric Center, said the center has completed more than 1,650 weight-loss surgeries since it opened. This year, 300 patients will have received bariatric surgery at the center.

Collins said the center experiences a spike around this time each year as people meet their insurance deductible amounts or have extra vacation time to allow for their recuperation.

Dr. Bruce Applebaum, medical director of the Sierra Providence Bariatric Center, said patients who undergo gastric bypass can expect to lose about 70 percent of their excess body weight over about a year.

"If they're 100 pounds above their ideal body weight, they can expect to lose about 70 pounds in the course of a year," he said.

He said most of the weight is lost in the first six months after the procedure.

The weight loss achieved through the the gastric sleeve procedure is comparable to that of the gastric bypass, he said.

Lap-Band patients can expect to lose up to about 60 percent of their excess weight over the course of about two years.

Alejandro Romero, director of bariatrics at Del Sol Bariatric Center, said patients must be absolutely certain of their decision and be committed to their weight loss when they choose to have the weight-loss surgery.

"Make sure this is really your last resort. Make sure you've really given it your good effort in losing the weight, because it's a lifestyle change, both physically and mentally," he said.

Bariatric surgery providers require their patients first undergo a psychological evaluation as well as several other tests.

Clapp said even a flawless procedure won't work without a patient's commitment, which typically includes sensible diet, regular exercise and a vitamin supplement.

"People can do an amazing amount to overcome what we can do with surgery (with) constant grazing, choosing the wrong kinds of foods, not exercising, not paying attention to a post-operative diet," he said. "Nobody will ever tell these patients this is foolproof, this is some kind of magic button --Êit's not."

For those who do commit and successfully lose their excess weight, the improvements to their health can be vast. Significant weight loss can help alleviate conditions such as diabetes, high blood pressure, high cholesterol and sleep apnea.

"You've got to change for the rest of your life," Clapp said.

Applebaum said the procedures are gaining in popularity as more people become aware of them and more insurance plans cover them.

The current advances in the field are not the end of the road for bariatric surgery.

Clapp said he has begun performing the Lap-Band procedure through a single laparoscopic incision.

Applebaum said an endoscopic method is being studied in other parts of the country and could one day be available in this area.

"We do this because ... when patients come in smiling ear to ear, it provides positive feedback to us that we're doing the right thing for people who are obese," Applebaum said.

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3 Years after gastric bypas surgery, man loses 259 pounds and competes in triathalons

St. Petersburg, FL

Three years ago, Chad Soileau was sitting in a roller coaster seat at Six Flags amusement park near Washington, D.C., when he was overcome with panic. He had waited in line for more than an hour for the four-minute ride on the Wild One, but when it came time to buckle up, the seat belt wouldn't fit.

"The attendant walked up and told me I was too big for the ride," recalled Soileau. "She yelled back to her co-workers, 'Bring the tool, we've got a large rider.' "

Five minutes seemed like an eternity as the crew struggled to extend the roller coaster's seat belt.

"Hundreds of people were watching," Soileau said. "It was the most humbling, humiliating experience of my life."

Afterward, Soileau stumbled off the ride and ran to the nearest restroom. "My stomach was in knots," he said. "I vomited for 10 minutes."

On Nov. 14, a very different Soileau will again face an audience — but this one will be cheering his remarkable achievements.

The Louisiana man will be among the 1,500 or so elite athletes who will gather on Clearwater Beach to swim 1.2 miles, bike 56 miles and run 13.1 miles in the Ironman World Championship 70.3. (The name comes from the combined distance of the three events, which is half the distance of the world famous Ironman World Championship held each October in Kona, Hawaii.)

"It has been a long road to get here," said Soileau, 37. "And I still have a long way to go."

Team 464

Despite the trauma of the roller coaster incident, it wasn't until a few months later that Soileau realized the full extent of his obesity.

"I was on the scale at the doctor's office when he asked if I knew how much I weighed," he said. "I figured about 350. He said no, 464."

Soileau couldn't believe he was off by 114 pounds. He made up his mind, then and there, that he would do something about his weight.

On March 22, 2006, he underwent gastric bypass surgery. "I call it my re-birthday," he said.

The surgery came with complications. He developed several blood clots and had to undergo three additional surgeries, including one to have his gallbladder removed and another to repair a twisted bowel and an internal hernia. But Soileau persevered.

Soileau was 34 when he started his weight-loss journey. Overcoming his longtime addiction to food was his first obstacle.

"I used to order double of everything . . . two appetizers, two entrees, two desserts," he said. "When I would go to the drive-through I would pretend there was somebody else in the car because I was ordering so much food."

Weight-loss surgery is no sure bet; plenty of people regain weight after the procedure. But after his surgery, Soileau found it easier to control his urges. (See related story, Page 12.)

"Physically I couldn't eat as much," he said.

The physical changes soon were followed by emotional ones. "After a while I stopped wanting the food,'' he said.

The victories piled up. One day, he discovered he could bend over to tie his shoes. "It was a huge accomplishment for me when I could get in my truck without my stomach hitting the steering wheel," he said.

Soileau set weight goals, which he published on his Web site, www.Team464.com:

"Weigh less than 400 pounds — DONE!''

"Weigh less than 350 pounds — DONE!''

He also kept track of his progress by his pants size: He went from a size 64 to a size 34.

ONE STEP AT A TIME

As he recovered from the surgery and started to drop pounds, he began to exercise.

He started off small, walking back and forth to the stop sign a block from his house. Gradually, his walks got longer and longer. Eventually, he started running, then swimming, then biking.

"I came up with a list of goals for myself," he said. "One of them was to complete a triathlon."

To help him reach his goals, he kept a training log.

"At first it was just a mile, then 2 miles, then 3 miles," he said. "The whole time I dreamed about completing a marathon."

Soileau, who has a girlfriend, works as a Web site designer in New Orleans. He struggles to find time for the one to two hours of daily training a triathlon requires. As for his diet, he focuses on fruits, vegetables, whole grains and lean protein to help power his new physique.

The discipline paid off. In February 2008, Soileau finished the Mardis Gras Marathon in New Orleans with a time of 5 hours and 36 minutes.

IRONMAN

Soileau has completed dozens of road races and triathlons. He was invited by the World Triathlon Corporation to be its guest at this year's event in Clearwater. Officials hope Soileau's story will inspire others to try the sport.

"It is an honor to be here," he said. "What other sport lets you share the course with the pros?"

But despite his success, Soileau doesn't feel as if he has won his battle against obesity. He won't feel victorious, he said, until he completes a full-distance Ironman.

"I will know I won when I step over the finish line and I hear the announcer yell, 'Chad Soileau, you are an IRONMAN!' "

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Gastric bypass and diabetes: CNN Health Q&A

Q: Does roux-en-Y gastric bypass cure diabetes?

Expert Answer: (by Dr. Melina Jampolis)

Hi, Rick. I'm not a surgeon, so to answer your question more thoroughly, I consulted with a very well-respected bariatric surgeon in San Francisco, John Rabkin, M.D. He explained that the roux-en-Y gastric bypass (RGB) improves type 2 diabetes via at least three different mechanisms:

1. The surgery decreases caloric intake immediately after the procedure because food intake is restricted by the small volume of the created stomach pouch, which holds only 1 ounce. The decrease in food intake, particularly refined carbohydrates, which are not well-tolerated after this procedure, can help stabilize blood sugar levels and immediately improves control of diabetes.

2. The significant amount of weight loss that results from the surgery improves insulin resistance over time.

3. There are changes in hormones and caloric processing because the food ingested bypasses the segment of the small intestine closest to where it attaches to the stomach (the duodenum and proximal jejunum), but not quite as much as you mentioned (not one-third of the small intestine). Because of the anatomical changes resulting from the surgery, it appears that these hormonal changes are greater than would be seen with weight loss via diet and exercise, but no research has yet to compare the two directly and evaluate hormonal changes.

The overall outcome is complete resolution of type 2 diabetes in greater than 70 percent of patients with diabetes before the procedure.

Unfortunately, as many RGB patients regain weight over time, the durability of the cure isn't as high as with a newer procedure called the duodenal switch.

In this procedure, there is a much larger pouch created (4 to 5 ounces), and the complete stomach anatomy is preserved, which helps preserve more normal stomach function. In this procedure, the rearrangement of the intestines leads not only to some restriction of food, but also causes your body to absorb significantly fewer calories, which has a more lasting effect.

Rabkin, a leader in this procedure, reports that he has had a 96 percent cure of type 2 diabetes at one year after surgery, which has persisted for five and 10 years post -op and seems to be similarly durable out past 15 years post-op.

Hope this helps. I strongly recommend spending a considerable amount of time with your surgeon if you are considering either of these procedures, as both have important lifestyle-related issues that should be discussed to determine the best procedure for you for the long term.

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