Urologist's opinion: Gastric band placement for obesity is not associated with increased urinary risk of urolithiasis compared to gastric bypass surgery

Berkley, CA

As morbid obesity is becoming increasingly prevalent in our western society, the surgical options for management of this disorder are being more widely utilized. These procedures include Roux-en-Y gastric bypass and gastric band surgery. It has been estimated that the number of bariatric surgeries performed has increased ten-fold in the past decade. It has been observed that in some patients undergoing bariatric surgery for obesity, new onset nephrolithiasis can develop.

These two studies very nicely show that patients at greatest risk are those with Roux-en-Y gastric bypass in which the normal gut flow and absorption is interrupted. These patients typically have an elevation in their urinary oxalate and a significant reduction in their urinary volume. Interestingly, patients with gastric banding appear to have a more significant reduction in their urinary volumes compared to the Roux-en-Y group of patients. However, the Roux-en-Y gastric bypass procedure results in a more significant hyperoxaluria and hypocitraturia.

Both of these studies note that due to the small numbers and the limited time of their study, they were unable to demonstrate that the increased urinary risk factors translated into an actual increased risk for renal stone development. However, it would seem prudent to counsel these patients even before they come to their surgical procedure with regards to dietary modifications to reduce their risk factors for renal stone development. These dietary modifications include maintaining an adequate fluid intake to potentiate a 2-liter urine output per day, 1,200 to 1,500 mg calcium citrate with Vitamin D and 500 mcg Vitamin B-12 and B-complex supplementation. Additional citrate supplementation may be important particularly in those patients with a prior history of stone disease.

Further clinical studies are still required to illustrate the effect of nutrition and pharmacologic therapy on the risk of stone development in patients undergoing bariatric surgery.

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Beverly Hills bariatric surgeon claims he performs most lap band surgeries

Beverly Hills, CA

Dr. Michael Feiz, lead surgeon at the Beverly Hills Comprehensive Weight Loss Center, has performed more Lap Band surgeries than any other doctor. For overweight Los Angeles residents, Lap Band surgery is the answer they have been looking for to shed the unhealthy weight and return to a more active life. Performed laparoscopic with almost no scarring, Lap Band surgery has the added benefit of enabling the patient to control their weight loss progress. Unlike gastric bypass surgery, Lap Band surgery does not involve the permanent reduction in size of the stomach. Instead, a small cinched section of plastic is placed around the upper area of the stomach, creating a temporarily shrunken stomach area for food to pass through. The other factor that makes Lap Band surgery so unique from gastric bypass is that the Lap Band is connected to a port that enables adjustment of the amount of solid food that can pass through the stomach. Finally, Lap Band
surgery is so attractive because it can be easily reversed by simply removing the Lap Band if something goes amiss.

A pioneer in successful Lap Band surgery, Dr. Michael Feiz of the Beverly Hills Comprehensive Weight Loss Center has performed the world's most cosmetic Lap Band surgery. With degrees from UCLA, New York Medical College and a residency and fellowship at USC Medical Center and Cedars Sinai, Dr. Feiz is highly trained and skilled in Bariatric and minimally invasive surgery. All prospective Lap Band surgery patients who visit the Beverly Hills Comprehensive Weight Loss Center must first undergo a full 360 degree evaluation of their health - mental and physical - as well as their habits and attitudes toward exercise and food.

Typical Los Angeles Lap Band surgery patients lose multiple pounds per week, but the real success after Lap Band surgery is keeping the weight off. The Beverly Hills Comprehensive Weight Loss Center ensures that their Lap Band surgery patients lose the weight and keep it off. So many people turn to the Beverly Hills Comprehensive Weight Loss Center due to the success rate of this center.

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Gastric band weight-loss surgery can boost reflux

From U.S. News & World Report

Obese patients with GERD may choose gastric bypass instead, experts say

Gastric banding, a surgical procedure designed to combat obesity, appears to boost the risk for developing or exacerbating symptoms of gastro-esophageal reflux disease (GERD).

The finding stems from a review of research on the link between obesity and reflux. The experts concluded that gastric bypass may help reduce GERD, but gastric banding does not -- a finding patients may want to consider when choosing one form of weight-loss surgery over another.

"For people with obesity and reflux together, the gastric bypass procedure appears to be effective not only for weight loss, but also for the control of reflux symptoms," concluded the review's lead author, Dr. Frank K. Friedenberg, an associate professor in the section of gastroenterology at Temple University School of Medicine, Philadelphia. "Because in this case, most of the acid from the stomach is being partitioned away, so it doesn't have exposure to the esophagus," he explained.

"However, with gastric banding, the problem is that you actually create a pocket which acid has the ability to fill from the remainder portion of the stomach," Friedenberg said. "And this acid can just sit there above the band, and make its way back up to the esophagus. This can cause reflux disease to develop, or make it worse than it had been if it was a problem before the procedure."

Friedenberg and his colleagues published their findings in the August issue of The American Journal of Gastroenterology.

Gastroesophageal reflux disease (GERD) occurs when a muscle at the end of the esophagus does not close properly, allowing irritating stomach contents to leak back into the esophagus. Symptoms include heartburn and acid indigestion.

According to the new analysis, involving numerous studies, a high body mass index (BMI) and/or high amounts of abdominal fat does appear to raise the odds for significant acid reflux.

The researchers also found that diet-induced weight loss can help minimize GERD symptoms.

However, not all weight-loss surgeries were equally beneficial with respect to GERD, Freidenberg's team found.

Across several studies, a procedure known as Roux-en-Y gastric bypass -- which involves the creation of a small gastric pouch walled off from (or bypassing) the rest of the stomach and intestinal track -- consistently appeared to help patients shed pounds and eliminate or reduce GERD symptoms.

However, laparoscopic (gastric) banding was found to be less helpful in tackling GERD.

The popular surgery, which involves the placement of a band to divide and reduce the size of the stomach, initially debuted in 1993. It has proven effective in helping patients feel satiated earlier, spurring weight loss.

Patients often did lose weight after banding, the researchers found, and this reduction in weight did not immediately encourage GERD. In fact, in some cases, post-procedure weight loss appeared to moderately reduce some reflux disease symptoms, the researchers said.

However, the inserted gastric band often seems to shift in place over time, they said, leading to a reversal of any initial benefit and a gradual worsening of GERD symptoms.

Based on these findings, Friedenberg and his team concluded that gastric bypass may be "the preferred surgical technique" with specific regard to GERD risk. But they also pointed out that more rigorous studies need to be conducted to better understand the how's and why's of reflux disease in the context of weight-loss surgery.

One expert said the current work highlights the need to carefully assess the pros and cons of each weight-loss procedure.

"Gastric bypass is the most common and the most successful of the surgical procedures to deal with obesity," noted Dr. Anthony A. Starpoli, an attending gastroenterologist at Lenox Hill Hospital and director of gastro-esophageal research and endo-surgery at St. Vincent's Hospital, both in New York City. "But the advantage to the banding procedure is that, although it will not be an effective option for all patients -- depending on the level of obesity -- it's a lot less aggressive than bypass and has a lot less morbidity associated with it. And it's much more reversible. So, there are reasons some patients might choose that option."

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Hospital surgeon first in North Carolina to implant gastric band

Southern Pines, NC

A surgeon at FirstHealth Moore Regional Hospital who specializes in treating morbidly obese patients is the first in North Carolina to implant a recently approved adjustable band around a patient's stomach to help with weight loss.

Bariatric surgeon Dr. Kenneth Mitchell Jr. first used the device on Feb. 18. Since then, he has laparoscopically placed the Realize adjustable gastric band in several other patients.

Certain patients who are morbidly obese, meaning their weight poses a serious risk to their health, are candidates for the procedure in which the adjustable gastric band is placed laparoscopically around the top of the stomach.

"There is a balloon on the inside of the band, and we can adjust its size by injecting or removing saline through a port that we place underneath the skin," Mitchell says. "It is a portion-control device, limiting the amount a person can eat. Patients don't feel it around their stomach; they just start feeling full a lot sooner."

To be a candidate for placement of an adjustable gastric band, a patient must meet the same strict standards for gastric bypass surgery. Both treatments are only for patients who meet the clinical criteria for morbid obesity.

The goal of both is not only to help patients lose weight, but also to help control obesity-related conditions such as diabetes, high blood pressure, high cholesterol and sleep apnea.

According to Mitchell, people who have a gastric band implanted typically lose less weight and lose it more slowly than those who have gastric bypass surgery.

Whichever treatment a patient chooses -- gastric band or gastric bypass -- it shouldn't be considered a cure for obesity, Mitchell says. Permanent lifestyle changes, especially those involving diet and exercise, are essential to long-term weight loss.

"Bariatric procedures just provide an opportunity for patients to control their health problems associated with obesity and to control and maintain their weight loss," Mitchell says.

The Realize adjustable gastric band that Mitchell has begun using was developed by a Swedish company and has been used successfully in Europe for a number of years. The U.S. Food and Drug Administration (FDA) approved it for use in this country only last October.

The Realize device is very similar to the LapBand, another adjustable gastric band that received FDA approval in 2001. Both are made of silicone; the primary difference involves the size and width of the balloons.

"The two bands function the same way, and they are both good options," Mitchell says. "As a state and nationally recognized Center of Excellence for Bariatric Surgery, we are committed to providing all available surgical options to our bariatric patients.

"We feel this is in the best interest of our patients, and we will continue to use both adjustable gastric band systems. Some patients might prefer one over the other, and that's a decision we make together. It's nice that we now have a choice."

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Webcast: Laparoscopic Gastric Bypass and Sleeve Gastrectomy to be broadcast at OR-Live.com

Ft. Lauderdale, FL

ORLive.com will broadcast two (2) bariatric procedures: a laparoscopic gastric bypass performed at Flagler Hospital, in St. Augustine, Florida and a laparoscopic sleeve gastrectomy performed at Holy Cross Hospital, Ft. Lauderdale, Florida. Both procedures were recorded live-to-tape and are presented unedited during this combined broadcast.

The gastric bypass procedure will be performed by Robert Marema, MD, FACS, Medical Director of Bariatric Services, Flagler Hospital and CEO of U.S. Bariatric. Michael Perez, MD, FACS, Medical Director Bariatric Surgery, Holy Cross Hospital will perform the gastric sleeve procedure. More >>

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The Bariatric Surgery Conundrum

November 18, 2007 - New York Times

This year, more than 200,000 weight-loss, or bariatric, operations will be performed in the United States, a nearly ten-fold increase in just a decade. The most prominent types are gastric bypass and laparoscopic adjustable gastric banding (or “Lap-Band”), although there are a few others. Each one works a bit differently, but the general aim is to reduce the stomach’s capacity and thereby thwart the appetite. If all goes well, bariatric surgery leads to substantial weight loss, especially among the morbidly obese.

Marc Bessler, director of the Center for Obesity Surgery at New York-Presbyterian/Columbia University Medical Center, is an innovator in the field who personally performs about 200 bariatric operations a year. Because his own father was morbidly obese, Bessler brings a personal zeal to his work. “The whole time I was growing up, he was so overweight he couldn’t play ball with us,” he says. “He died at age 54 from colon cancer. It may have been picked up late because of his obesity.”

Bessler acknowledges that bariatric surgery has a checkered history. “In the past, it killed people, and it didn’t work,” he says. “In the late 1950s and early 1960s, even though it was effective for weight loss, there was lots of complications and mortality. Then in the late ’70s and early ’80s, there were much better surgeries, but they didn’t really work that well. The weight would start coming back.”

Technological innovations, especially the use of laparoscopic procedures, have made for considerable gains in safety and efficacy. While the operation is still dangerous in some circumstances — one study found that for a surgeon’s first 19 bariatric operations, patients were nearly five times as likely to die than patients that the surgeon later operated on — the overall mortality rate is now in the neighborhood of 1 percent.

But even if bariatric surgery doesn’t kill you, there are things to worry about. The operation often produces complications — physiological ones, to be sure, but also perhaps psychological ones. A significant fraction of postbariatric patients acquire new addictions like gambling, smoking, compulsive shopping or alcoholism once they are no longer addicted to eating. In certain cases, some people also learn to outfox the procedure by taking in calories in liquid form (drinking chocolate syrup straight from the can, for instance) or simply drinking and eating at the same time. Surgery is also a lot more expensive than even the most lavish diet, with a Lap-Band procedure costing about $20,000 and a gastric bypass about $30,000.

But Bessler and other bariatric advocates argue that the upsides outweigh the downsides, especially for a morbidly obese patient whose quality of life is already suffering. While asking a bariatric surgeon if bariatric surgery is a good idea might seem akin to asking a barber if you need a haircut — in fact, Bessler does consult for companies in the industry — the data seem to back up his claims: not only do most patients keep off a significant amount of weight but the other medical problems that accompany obesity are also often assuaged. One recent analysis found that 77 percent of bariatric-surgery patients with Type 2 diabetes experienced “complete resolution” of their diabetes after the procedure; the surgery also helps eliminate hypertension and sleep apnea. From an economic standpoint, research suggests that the operation can pay for itself within a few years because a postbariatric patient now requires less medical care and fewer prescriptions. That’s why some insurance companies cover bariatric surgery — as more do, it will likely lead to a further spike in the volume of operations. This is especially good news for the hospitals that have already grown dependent on the significant cash flow that bariatric surgery generates.

There are at least two ways to think about the rise in bariatric surgery. On the one hand, isn’t it terrific that technology has once again solved a perplexing human problem? Now people can eat all they want for years and years and then, at the hands of a talented surgeon, suddenly bid farewell to all their fat. There are risks and expenses of course, but still, isn’t this what progress is all about?

On the other hand, why is such a drastic measure called for? It’s one thing to spend billions of dollars on a disease for which the cause and cure are a mystery. But that’s not the case here. Even those who argue that obesity has a strong genetic component must acknowledge, as Bessler does, that “the amount of obesity has skyrocketed in the past 30 years, but our genetic makeup certainly hasn’t changed in that time.” More >>

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Gastric Band Competition in the Bariatric Surgery Market

Allergan, J&J face off in obesity market
October 12, 2007: 03:32 PM EST

Oct. 12, 2007 (Thomson Financial delivered by Newstex) --

NEW YORK (AP) - The recent approval of Johnson & Johnson's (NYSE:JNJ) Realize gastric band has stepped up competition in the surgical weight-loss market, which until now has been dominated by Allergan's (NYSE:AGN) Lap-Band.

The Lap-Band and Realize are adjustable gastric bands, which are surgically implanted around the stomach to help severely obese adult patients lose weight by forcibly limiting food intake. This procedure presents an alternative to more invasive gastric bypass surgery, commonly known as stomach stapling.

Analysts predict the Realize will cost about the same as the Lap-Band procedure, roughly $12,000 to $20,000. In what could be a fierce battle for market share, some analysts see the companies eventually splitting the market.

Irvine, Calif.-based Allergan, which also makes Botox, acquired the Lap-Band with its 2006 purchase of Inamed and has so far faced no competition in the U.S. market. But on Sept. 28, J&J's Ethicon Endo-Surgery Inc. unit said the Food and Drug Administration cleared its Realize band, ending Allergan's honeymoon a few months earlier than expected.

J&J plans to launch Realize in December; analysts hadn't expected approval until the end of the year or early 2008. More >>

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