Some doctors worry about overuse of weight-loss surgery: Others excited about gastric bypass surgery for moderately obese

Kalamazoo, MI

As gastric bypass and other bariatric surgeries are becoming more popular for weight loss and as minimally invasive surgical techniques are developed, some health professionals worry that the procedures may be overused.

“I think it’s wrong to do it on people who are minimally overweight,” said Dr. Jerome Cooper.

Cooper is the medical director of the Medical Weight Loss Clinic, a Southfield-based business that has 34 locations in Michigan and northern Ohio, including one in the Kalamazoo area.

“Bariatric surgery is a last resort, as I see it,” said Cooper, who was trained as a bariatric physician but has not done bariatric surgery.

He was raising his concerns in response to a recent Los Angeles Times report saying that new, incisionless techniques that are now in human trials at major hospitals may end up broadening the use of bariatric surgery to people who are only moderately overweight or on the lower end of the obesity scale.

“I think 100 pounds overweight or more with co-morbidity (another health condition such as diabetes) is a good rule to follow,” Cooper said.

The clinics that Cooper oversees are devoted to medically supervised weight loss through diet, exercise and medication. “We do some referrals for bariatric surgery” when it’s appropriate, he said.

“Bariatric surgery does offer the best results of any weight-loss treatment available today,” Cooper said, “but it’s not without the possible recurrence of weight gain, and there are post-surgical issues” such as the risks of leakage, bowel obstruction and dumping syndrome, which is involuntary vomiting or defecation.

“The risks of bariatric surgery must be weighed against the risks of being morbidly obese (overweight by 100 pounds or more or with a body mass index of 40 or greater), diabetes, arthritic problems, heart problems, certain cancers,” Cooper said. “It’s appropriate for the right people.”

Divided opinions

Health professionals at major medical centers who were quoted in the L.A. Times report — and in a similar Chicago Tribune story — were about evenly divided on using bariatric surgery in those who are not extremely obese.

Some said the surgery is underused as a way to deal with Type 2 diabetes and other obesity-related health problems, while others said the surgery carries the risk of long-term complications and that diet changes, exercise and medication should be recommended instead for the overweight or moderately obese.

The L.A. Times noted that statistics from the American Society for Metabolic & Bariatric Surgery show bariatric surgery rates have doubled in the United States in the past six years, with 220,000 of the procedures done in 2008.

Diabetes, though, is on the rise, too, and studies show bariatric surgery is achieving good results in controlling that disease in patients with BMIs between 30 and 35, said Dr. Stuart Verseman, who has been medical director of bariatric surgery at Borgess Medical Center since October 2005 and does bariatric surgery at both Borgess and Bronson Methodist Hospital.

“They’re finding a marked improvement in their diabetes after bariatric surgery and a decreased usage of medication,” Verseman said.

An example of someone with a BMI of 30 would be a person who is 5-foot-9 inches tall and weighs 203 pounds. That person would be 35 pounds above the normal weight range for that height, according to the U.S. Centers for Disease Control and Prevention.

While that example might not strike some people as a case of obesity, Verseman said that “even people with BMIs of 30 are considered clinically obese.”

Verseman, following National Institutes of Health guidelines, does bariatric surgery only on those with a body mass index of 35 or more and certain related medical conditions or 40 or more without those conditions.

But he said he finds it “very exciting to think about offering that to a larger population, especially with the number of diabetics increasing astronomically every year.”

Verseman is the only surgeon in Kalamazoo currently doing bariatric operations. Dr. Alan Saber, who had been the main physician doing bariatric surgery at Bronson, left in November and now works at Case Western Reserve University Hospitals, in Cleveland.

Verseman, like Cooper, said bariatric surgery should never be the first choice for weight loss. But he is much more open to the potential of its use in the moderately obese who have diabetes, high blood pressure or other weight-related conditions.

Krista Hampton, a registered dietitian who is Bronson’s bariatric coordinator, sees the value of bariatric surgery for the extremely obese, but she expressed reservations about using it in people who are overweight or moderately obese.

“Coming from my background, I would want someone to exhaust all other weight-management options first,” she said.

Surgery and support

Bariatric surgery is on the rise at Borgess and Bronson, as it is nationwide. In the fiscal year ending June 30, 2004, there were 14 bariatric surgeries at Borgess. From July 2008 through June 2009, there were 187 at Borgess, and in the last six months of 2009 there were 110, according to Rebecca Blades, a registered nurse who leads the Borgess bariatric program.

Bronson, which started its bariatric program in 2007, did 47 surgeries that year, 99 in 2008 and 112 in 2009, said public-relations specialist Erin Smith.

Verseman said his bariatric surgeries have had a major-complications rate of 2 percent, while the national average is 3.5 percent.

Representatives of both hospitals emphasized that they carefully screen those interested in bariatric surgery and offer continued support to those who get the surgery, trying to help them avoid overeating and stay active.

Borgess, for example, offers support groups, both in person and online, and offers classes in active living, Blades said.

“None of these operations are cures,” Verseman said. “They’re tools to help patients. And it’s a team approach we take, involving a dietitian, a psychotherapist, the primary-care physician. Patients need to follow guidelines afterward to improve their medical conditions.”

“If you start grazing, over time you can get a lot of calories in even after surgery,” Verseman said.

But if people getting bariatric surgery have to learn to make dietary and behavioral changes and stick with those changes to lose weight, why not instead work closely with people to support new eating habits and more exercise without doing bariatric surgery?

“I wouldn’t have somebody undergo bariatric surgery who has never attempted anything else before,” Verseman said. “Almost every patient (who undergoes bariatric surgery) has completed numerous diets” but has not succeeded in losing enough weight to improve their medical condition, he said.

“You don’t just wake up one morning and say, ‘I want to have gastric bypass surgery.’”

The surgery helps people feel full and therefore have less of an urge to eat, Verseman said. One type of surgery he does — a sleeve gastrectomy — takes out 75 percent of the stomach and gets rid of the hormone that causes hunger, he said.

Even without bariatric surgery, though, people can learn to ease feelings of intense hunger, Hampton said, by increasing the protein and fiber in their diets and decreasing the kinds of high-carbohydrate foods that cause blood sugar to spike and then drop.

She said some people who enter a weight-management program at Bronson with the idea of getting bariatric surgery decide not to have it once they learn to cook and eat differently, get more exercise and overcome some behavioral issues.

“We need to get back to the basics of how to cook and how to meal plan,” she said. “Convenience food is way too easy to get our hands on.”

Verseman expressed a similar sentiment but said he is glad he can help improve people’s lives through bariatric surgery.

“To see people get over medical conditions and get their lives back ... is really gratifying,” he said.

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Risks of bariatric rurgery reduced by preoperative weight loss before surgery

Trenton, NJ

As part of the preoperative process for preparing for bariatric (weight loss) surgery, many programs require a strict diet to promote weight loss before the procedure. A new study published in the Archives of Surgery finds that this protocol could reduce the risk of surgical complications.

Dr. Peter Benotti of the Saint Francis Medical Center in Trenton NJ reviewed the medical records of 881 patients who had gastric bypass surgery between 2002 and 2006 for weight loss. All patients completed a 6-month multidisciplinary program that encouraged a 10% preoperative weight loss.

Those who lost more than 10% of their excess body weight were less likely to have postoperative complications such as infections, blood clots, and kidney problems. Conversely, the post-surgery complication rate was nearly twofold higher in patients who gained weight.

The study also affirmed that patients who undergo Laparoscopic bariatric surgery have fewer complications than those who have the more invasive open surgery. This correlation was found regardless of preoperative weight loss. Patients who have open surgery are typically older men with a higher body mass index, according to the results of the study.

Bariatric surgery can be an effective and durable treatment for morbid obesity and the number of operations each year is increasing. According to the American Society for Metabolic and Bariatric Surgery, the number of bariatric procedures in the Unites States increased from 12,775 in 1998 to about 220,000 in 2008. Because Medicare has approved weight loss surgery when performed in a high-volume approved center, patients seeking the surgery have become older and sicker.

In an accompanying editorial commentary, Dr. Patricia L. Turner says “Strategies to further improve outcomes after bariatric surgery are of significant interest. Post operative complications can be particularly difficult to manage and deadly.” As more of the high risk patients seek out surgical weight loss options, doctors are faced with a need to identify risk factors and help patients prepare for successful surgery. The current study suggests that preoperative weight loss may be one step that will help achieve good outcomes.

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Gastric band surgery can help extend lives of obese people, says study

New York, NY

A new study backs up the belief that bariatric surgery is beneficial for losing weight and extending the lives of obese men and women.

But the precise pluses of the procedure vary by individual and are influenced by many variables, including a patient’s age, weight and gender, according to the Guardian.

The research was carried out at the University of Cincinnati Academic Health Center.

In one type of bariatric surgery, a physician wraps a band around the patient’s stomach, reducing its size. Because they feel full faster, people eat less.

Over time, they shed weight, which helps to prevent heart attacks, strokes and type 2 diabetes, according to The Guardian.

Bariatric surgery is typically given to people whose body mass index (BMI) is over 40.

But because any type of surgery comes with risk, including infection, other complications and even death, the study looked at potential positive outcomes versus the inherent danger of undergoing the knife.

Age was a significant variable, since younger patients undergoing surgery are less apt to die from surgery or develop complications.

Researchers found that for a 42-year-old woman with a body mass index of 45, weight-loss surgery could extend her life by up to 3 years.

A 44-year-old man with a BMI of 45, reaped slightly less dramatic results. He could expect to increase his life by 2.6 years after surgery.

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Da Vinci gastric bypass surgery: Robot assisted surgical system for weight loss

Knoxville, TN

More and more these days, Dr. Michael Fields is taking a hands-off approach to surgery.

Since he began using it in 2006, Fields, an obstetrician/gynecologist at St. Mary's Medical Center, has been one of the da Vinci surgical robot's biggest proponents. He quickly adjusted to the console that allows a surgeon, via a joystick-and-magnified-view-screen system, to manipulate various surgical instruments mounted on robot arms inside small spaces. He touted the advantages of needing only 1- to 2-centimeter incisions for many surgeries: less blood loss, less chance of infection, weeks knocked off of recovery time.

By the end of 2009, Fields had performed more than 400 of the robot-assisted surgeries, including the first hysterectomy in the nation using a new laser-robotic tool. He believes the robot has rendered open surgery in his specialty all but obsolete, necessary in just a "fraction of a percent" of cases.

Now he's ready to give a hand to others who want to learn robot-assisted surgery.

Last month, St. Mary's became the only hospital in Tennessee to be named a Robotic Epicenter for training physicians in robot-assisted gynecological surgery. Mercy Health Partners, which owns the hospital, spent $2.1 million for an upgraded teaching model robot, with two control consoles. It was used for the first time with three Dec. 15 cases.

"The guest physician can sit at the second console and look, with 3-D vision, at what I'm doing" during a procedure, Fields said. "This learning technique is very visual because you don't have touch feedback with the robot" as a surgeon using his hands during an open surgery would.

Fields, who has already trained some area surgeons on robot-assisted procedures, now will train physicians from around the country at St. Mary's, traveling to their hospitals afterward to proctor their first robot surgeries. He expects colleagues Dr. Chris Ramsey, a urologist, and Dr. Thomas Pollard, a cardiothoracic surgeon, both of whom use the robot frequently, to do some training in their specialties as well.

New 'standard of care'

Knoxville's first da Vinci robot was put into use at Fort Sanders Regional Medical Center in 2005 after staff urologist Dr. Jeff Flickinger saw one elsewhere and returned to tell his employer that he was sure a Knoxville hospital would get one soon, and he hoped it was Fort Sanders.

"I think people got pretty excited right away," said urologist Dr. Edward Tieng, who said Fort Sanders surgeons were already doing a lot of laparoscopic surgeries, but the robot "kind of takes it to a whole new level."

Tieng said Fort Sanders urologists use the robot for about 95 percent of prostectomies, and doctors there keep finding new uses for it.

Doctors at sister Covenant Health hospital Parkwest Medical Center also have access to the robot. Three years later, Methodist Medical Center at Oak Ridge had its own, the money partially raised in a hospital foundation campaign.

The robot, introduced in 2000 by Intuitive Surgical Inc., has become almost a standard of care in America, with the majority of large hospital systems boasting at least one. Three hospitals each in Chattanooga and Nashville have it. In 2007, University of Tennessee Medical Center bought a robot, which is used for heart, prostate and gynecological surgeries. The hospital recently recruited gynecologic oncologist Dr. Larry Kilgore, a Knoxville native who practiced at the University of Alabama-Birmingham for the past 20 years, in part because of his skill using the robot for gynecologic cancer surgeries.

And doctors at Baptist West succeeded late last year in convincing Mercy to invest in a robot for that hospital. Installed a few weeks ago, the robot will be used for urologic and gynecologic procedures beginning Jan. 27.

"My (robotic surgery) patients have seen great outcomes with less pain and discomfort in the recovery period," said urologist Dr. Christopher Harris, who has used the da Vinci robot at other hospitals and is scheduled to perform Baptist West's first robot-assisted procedure - removal of a prostate gland. "Now it is great to be able to offer them this service at Baptist Hospital West."

A monitor shows the robotic tools of the da Vinci surgical system operating on a patient in an operating room.

Mercy Hospital gynecologist Dr. Michael Fields has been a staunch advocate for robot surgery in the Knoxville area and has now been selected as a trainer for other surgeons.

Trickling down

Even smaller community hospitals, such as Johnson City Medical Center and Jackson-Madison County Hospital, are making the da Vinci investment - usually about $1.3 million for the robot and several hundred thousand dollars a year in maintenance fees. Blount Memorial Hospital in Maryville purchased a da Vinci SI surgical system late last year, which surgeons (some trained by Fields) began using for urological and gynecological procedures in early December.

On Dec. 21, bariatric surgeon Dr. Mark Colquitt of Maryville's Foothills Weight Loss Specialists performed the area's first robot-assisted gastric bypass weight-loss surgery, which he did laparoscopically, with several small incisions.

"The robotic technology makes hand-sewing much easier by allowing surgeons better access to some of the hard-to-reach abdominal and gastrointestinal areas," said Colquitt, adding that he thinks robot-assisted surgery will become the "preferred method" for bariatric surgery. "This allows us to perform the delicate and challenging bypass procedure with even greater precision. The most important advantage is the ability to make very precise incisions and sutures, resulting in the most effective surgical outcomes for our patients."

Sonya Newman, Blount Memorial's chief nursing officer and assistant administrator, said the hospital plans to offer robot-assisted thoracic procedures as well.

Cookeville Regional Medical Center also has a da Vinci robot, which has been used primarily for prostatectomies, although its use in other fields is growing, said hospital marketing director Melahn Finley.

"We've done a lot of marketing," Finley said.

Finley said she thinks patients are beginning to expect even smaller hospitals to have the robot, and that area patients, desiring smaller incisions and quicker recovery times, "are starting to request it" and are being referred from places that don't have da Vinci.

She said the hospital considers the robot a good investment.

"It elevates the perception of your medical center, that you can offer such state-of-the-art technology," Finley said.

Future applications

Fields said the robot also can make surgery easier on the surgeon by eliminating fatigue from standing during a long procedure and by keeping a physician's hands from shaking during delicate motions.

Using the console is like having one's hands inside the patient, but allows for more range of motion, making it easier to get up under tissue or do precise dissections, he said. In addition, the video screen provides the surgeon with a better, clearer view, he noted.

Fields said the robot is now gaining use for cardiothoracic, colon and ear-nose-and-throat surgeries.

"You can reach and access spaces in the throat areas without having to disarticulate the lower jaw," he said.

And he wonders if, someday, only a minority of surgeries will not be robot-assisted. After all, he's become amazed at all he can do better with the robot - and he's excited to pass that knowledge on.

"All of our hard work over the last three years has been to prepare us" to become a training center, Fields said. To "transfer our knowledge and our incredible patient outcomes that we have to these physicians, for their benefit and for their patients' benefit."

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Gastric bypass was route to a new life for Sheriff

Milwaukee, WI

A little more than a year has passed since I grazed with John Schroeder at a Christmas party buffet table.

At 375 pounds, John knew this territory well - sandwiches, chips, rich dips, shrimp, desserts. But all that was about to change.

John, a friend of some friends of mine, told me he was having his stomach stapled a few days later. You know, bariatric surgery. The ol' gastric bypass.

His stomach would be reduced from about the size of a football, overinflated in his case, to the size of an egg. I wondered how a guy who clearly lived to eat would possibly manage portions to fit a space that small.

Well, I ran into John at the same party this Christmas and hardly recognized him. He had shed enough pounds, about 130, to build an average-size teenager.

"I'm still heading down," said the 41-year-old Wauwatosan. The married father of two is a Milwaukee County sheriff's deputy assigned to the jail.

His goal is to drop 20 more pounds and settle at 225. After falling off at two to three pounds a week, the weight lately has resisted disappearing a bit more.

You hear so much about how fat America has become, and it has. John Schroeder doesn't want to play that role anymore. This might be your New Year's resolution, too. Again.

A couple years ago, he tried out for TV's "The Biggest Loser," which has turned weight loss into a spectator sport. He got a callback but ultimately was passed over.

He seemed to have the right stuff for the show. John of buffet tables past was always hungry.

"I fit the old mode, I guess, the doughnut shop and that type of thing," he said.

Two hours before dinner, he'd stop at a fast-food drive-through for two big burgers. When the wind was right, he could smell the nearby pizza restaurant and bakery from his backyard spa.

"That would basically put me into a trance. I'd walk out of the hot tub and down the street in my swim shorts and unfortunately end up in the store buying pizza," he said.

Ice cream seemed to call out his name. His daily calorie intake? He had stopped counting. Never a small guy, he watched his weight go north of 300 and stay there.

He once was refused entry to a Disney World ride with his kids because he was too heavy. Airplane seats were brutal. His knees and feet hurt from holding him up. He was reinforcing his buttons with fishing line. The final straw was when he re-injured an old ankle injury from his football-playing days while chasing down a criminal.

John found his way to Craig Siverhus, a general/bariatric surgeon at Columbia St Mary's. In December of 2008, after extensive consultations and even psychological testing, Siverhus performed what's known as Roux-en-Y surgery on John, a common form of gastric bypass first done in the 1960s in the United States.

A small part of the stomach is cut away and stapled to form a pouch to accept food. The rest of the stomach and duodenum are bypassed to limit absorption, and the small intestine is surgically attached to the pouch, Siverhus explained.

The procedure usually results in the loss of 70% to 80% of a person's excess body weight, most of it in the first six months. There are risks. A tiny percentage of patients die. Ulcers and gallstones can appear. Eating sugary foods, pasta, bread or simply too much can make you sick. But Siverhus said the surgery often greatly reduces a patient's risk from high blood pressure and cholesterol, diabetes and sleep apnea.

The surgery can run $25,000 to $30,000. Insurance doesn't always cover it. Luckily for John, his did.

"John was a great candidate. He was very well informed, he was very well motivated to proceed with this, and he was willing to make lifestyle changes that would allow him to succeed with it," the doctor said.

John's wife, Kate, said people sometimes call this weight loss route a quick fix, but she has seen how radically John has changed his habits. Under stress, he might still hit the fridge, but now it's for yogurt rather than a hot dog with all the fixins.

John said Kate occasionally has to remind him to eat. His eyes are still sometimes bigger than his stomach, which isn't saying much. He'll fill a bowl with chili but eat only a small amount. He learned a painful lesson from a Reuben sandwich he chanced on St. Patrick's Day.

Kate said her husband has lost his desire to eat out, but some restaurants will charge him for a child's meal when he flashes his bariatric surgery membership card.

She'd love to lose 30 pounds herself, using traditional dieting, Kate said. People are always telling John how fabulous he looks now. The family bought bikes and plans more trips to the gym this year. Fewer frozen pizzas are on the horizon.

John has spent lots of money on new clothes and work uniforms as the pounds fell off. It's a nice problem to have. His waistline is down to nearly 36 after peaking at 52.

In December, for the first time, all four Schroeders appeared in the family Christmas card. John, who used to hate cameras and mirrors, finally wanted to be included. Recently, John noticed his clavicle peeking out from what had been excess fat, and he had to look online to see what it was.

For John, eating now means a few ounces at a sitting, about a third of a kid's meal or part of a Lean Cuisine dinner. He eats small pieces of fruit, nuts and veggies, and everything has to be chewed to death. It's crucial to drink enough water, but just sips at a time. He has so much more energy, despite eating so little.

What about beer?

"You're not supposed to," he said. "But I'm from Milwaukee so, yes, I'll sneak one in periodically."

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"Gastric Banding" not a stand-alone weight loss solution

Buffalo, NY

Medical Edge from Mayo Clinic
January 8, 2010
DEAR MAYO CLINIC: Lately, I've seen a lot of advertisements for lap band surgery for weight loss. How is this different from bariatric surgery, which I don't hear as much about lately? Does it work? What are the dangers?

ANSWER: Bariatric surgery is a general term used to describe operations that help a person lose weight more consistently and effectively. The two most common types of bariatric surgery performed in the United States are adjustable gastric banding -- sometimes called lap band surgery -- and gastric bypass surgery.

In general, adjustable gastric banding is safe, and serious complications are uncommon. Gastric banding helps people lose weight by restricting the amount of food they can eat. But it's not a stand-alone weight loss solution. For the procedure to be effective, people must be carefully screened to ensure they are good candidates for gastric banding. Follow-up care, along with exercise and healthy eating, also are key to long-term weight loss for people who undergo adjustable gastric banding.

Adjustable gastric banding involves placing a small, inflatable band around the upper part of the stomach to restrict the amount of food that the stomach can hold. The band is filled with fluid that can be added or removed as needed through a small tube (port) placed under the skin. Fluid can be added to constrict the stomach if the band isn't tight enough and allows in too much food. Or, fluid can be removed if the band is too tight and is causing problems such as vomiting.

In gastric bypass surgery, the surgeon staples the stomach to make a small pouch and then connects the pouch to the small intestine, creating a passage (bypass) around most of the stomach, as well as the first section of the small intestine (duodenum).

Both procedures limit the amount of food that can fit in the stomach. Also, after both procedures, people feel full much sooner than normal, which helps decrease the amount of food they eat. One of the noticeable differences between adjustable gastric banding and gastric bypass -- and the one frequently talked about in advertising for gastric banding -- is that gastric bypass surgery usually requires a two-day hospital stay, whereas adjustable gastric banding can be done as an outpatient procedure.

Adjustable gastric banding is a low-risk procedure that's less complex than gastric bypass surgery. But as with any medical procedure, complications are possible. With adjustable gastric banding, complications can include infection of the band or the port, and movement of a portion of the stomach -- that's supposed to be below the band -- up through the band (slippage). The most serious complication associated with adjustable gastric banding is erosion of the band. This occurs when the band works its way inside the stomach, usually as a result of an infection or ulcer. Erosion is very rare, however, occurring in less than 1 percent of gastric banding cases.

Adjustable gastric banding can be an effective way to help people lose weight. It's not for everyone, though. First, if you're considering this procedure, be aware that people who have adjustable gastric banding generally have a slower rate of weight loss than those who have gastric bypass. There's nothing wrong with this, but it is something to consider prior to undergoing the surgery. Average weight loss is about one-third to one-half of a person's excess weight.

Like all bariatric procedures, gastric banding is intended for people who have a body mass index (BMI) of 40 or above or for those who have a BMI between 35 and 40 with a serious weight-related health problem, such as diabetes, high blood pressure or heart disease. In addition, this surgery isn't recommended for people who have certain medical conditions, such as Crohn's disease, large hiatal hernias or connective tissue disorders.

Finally, adjustable gastric banding isn't a cure-all. Follow-up care is critical because all patients need some adjustment of the band after surgery to ensure optimal weight loss. Even after having this operation, patients still need to consistently make good food and exercise choices in order to lose weight. In essence, gastric banding provides people with an opportunity to consistently take in a smaller amount of calories while they're moving forward with the other healthy steps that are necessary to lose weight. -- James Swain, M.D., Gastroenterologic and General Surgery/Director of Bariatric Surgery, Mayo Clinic, Rochester, Minn.

(Medical Edge from Mayo Clinic is an educational resource and doesn't replace regular medical care. E-mail a question to medicaledge@mayo.edu , or write: Medical Edge from Mayo Clinic, c/o TMS, 2225 Kenmore Ave., Suite 114, Buffalo, N.Y., 14207. For more information, visit www.mayoclinic.org.)

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Study: Weight loss 6 months after gastric byass no different for patients who had mood and eating disorders pre-op

Storrs, CT

Researchers detail in 'Effect of mood and eating disorders on the short-term outcome of laparoscopic Roux-en-Y gastric bypass,' new data in eating disorders. "We examined whether patients with a history of mood and eating disorders (MED) had less weight loss and poorer treatment compliance after laparoscopic Roux-en-Y gastric bypass (LRYGBP) than patients with a history of either mood (MD)or eating disorders (ED), or no history of mood or eating disorders (ND). Consecutive LRYGBP patients (n=196; 43.6 ±10.9 years; BMI 47.2 ±7.4 kg/m2; 83.2% female, 91.8% Caucasian) underwent a preoperative psychological evaluation," investigators in the United States report (see also Eating Disorders Therapy).

"At 6 months post-surgery, body mass index (BMI), % excess weight loss (%EWL), hospital readmissions, and adherence to behavioral recommendations were assessed. Of the patients, 10.2% had MED, 36.7% had ED only, 24.0% had MD only, and 29.1% of patients had ND. MED patients fared worse than all other groups in dietary violations (p=0.03), exercise habits (p=0.05), and readmission rates (p=0.06) but there were no group differences in either BMI change or %EWL," wrote A.A. Gorin and colleagues, University of Connecticut, Center for Health.

The researchers concluded: "MED patients are at-risk for poor treatment compliance following LRYGBP; however, they achieve similar weight losses 6 months postoperatively."

Gorin and colleagues published their study in Obesity Surgery (Effect of mood and eating disorders on the short-term outcome of laparoscopic Roux-en-Y gastric bypass. Obesity Surgery, 2009;19(12):1685-90).

For additional information, contact A.A. Gorin, University of Connecticut, Dept. of Psychology, Center for Health, Intervention and Prevention, Storrs, CT

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After gastric bypass surgery, couple loses 249 pounds in a year

Chicago, IL

Their daily Starbucks drink of choice was once a Venti Java Chip Frappuccino -- a whopping 600 calories in a cup.

These days, Lorie and Todd Richmond splurge on coffees with Splenda and a dash of half-and-half. But they are more likely to be riding their bikes, shooting hoops with their three kids or shopping for new clothes.

The Chicago Sun-Times featured the Richmonds in a Dec. 22, 2008, story after the couple from northwest Indiana had weight-loss surgery at the University of Chicago Medical Center on the same day.

Before the surgery, Lorie weighed 402 pounds, Todd 305.

A year later, Todd is at his goal weight of 207 pounds. He's off cholesterol and blood-pressure medications. Lorie weighs 251 pounds and is confident she can lose another 60 pounds or more to reach her goal.

Together, the two have lost 249 pounds in one year.

"It makes you feel so good that people notice," Lorie said. "For the first time in my life, I don't mind telling people my weight."

The Richmonds' say their quality of life also skyrocketed as their weight decreased.

They vacationed in the Smoky Mountains, hiking and riding roller coasters -- things they couldn't do before.

They bought bikes, and Todd consistently rode about 10 miles every other day throughout the summer. When she started, Lorie could only ride a block before having to stop; by the end of the summer, she took an eight-mile ride.

And when she ran to pick up an errant basketball while shooting baskets with her 7-year-old son, he said words she had never heard before: "I just saw my mom run."

"I almost cried," she said. "I was so happy I could do that with him. It gives me even more drive to keep going."

Dr. Vivek Prachand, an assistant professor of surgery at the University of Chicago Medical Center, performed Lorie's duodenal switch and Todd's gastric bypass.

A duodenal switch involves removing part of the stomach and bypassing much of the small intestine to limit how many calories are absorbed. A gastric bypass shrinks the stomach.

But the surgery alone wouldn't help the Richmonds lose and keep off the weight. They altered their diet and exercise habits -- something they had tried repeatedly in the past but without success.

"You have to recognize the surgery is a tool, it's not a cure," Prachand said. "I only take half the credit for it. You accomplish the other half."

The Richmonds said they were stung by hostile online anonymous critics who said the surgery was "cheating'' and accused the couple of laziness.

Prachand said he has heard all the criticism before, but said they are unfair. He said the surgery is highly effective and corrects multiple medical issues with one procedure.

"What we're dealing with when we're talking about surgery for severe obesity, we're talking about people who are 10 to 15 times heavier than the 10 to 15 pounds all of us have struggled with at one point or another," Prachand said. "Sometimes it's hard to project the added difficulty of that much more."

Beyond the surgery and added exercise, the Richmonds dramatically changed what they ate.

Todd said a year ago, he could "put a buffet out of business."

Now, the couple eat off saucers to help control portions.

They eat small meals consistently throughout the day, including daily breakfast.

And while they haven't abandoned Starbucks completely, they cut out the oversize sweet drinks and other treats -- even though they say they are constantly celebrating.

"This year has been awesome for us," Lorie Richmond said. "There's so much, I want to shout at the rooftops. Life is opening up for us."

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