Study to examine Gastric Bypass for treatment of diabetes in non-obese patients

Gastric bypass surgery to treat diabetes in non-obese patients?

New York, NY

Patients with a body mass index below 35 generally do not qualify for weight loss surgery. But, researchers at Weill Cornell Medical Center in New York City are embarking on a new study to determine whether gastric bypass surgery can be an effective treatment for type 2 diabetes in people who are overweight but not obese.

The study aims to explore the correlation of diabetes and clinical obesity. Lead researcher Dr. Francesco Rubino notes that many people with a lower BMI can develop diabetes, and likewise, that someone who is severely obese could be diabetes free.

“For this reason alone, we need to start questioning whether BMI should be the only clinically appropriate way to decide who gets diabetes-targeted surgery,” Dr. Rubino said in a recent press statement. Diabetes affects more than 200 million people worldwide, and several studies have demonstrated that gastric bypass surgery can lead to spontaneous improvement or even resolution of the disease.

Dr. Rubino generally performs the standard Roux-en-Y bypass procedure in patients with a BMI over 35. Now, the potential benefits of the procedure are being extended to 50 non-obese patients as part of the current study.

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Heavier patients carry increased risk in gastric bypass and other bariatric surgery

Higher risk for heavier patients in bariatric, gastric bypass surgery

Chattanooga, TN

For someone who weighs more than 500 pounds, the options for reaching a healthy weight can seem slim, but local bariatric surgeons say there is hope.

Dr. Jaime Ponce, medical director of bariatric surgery at Chattanooga's Gastric Band Institute, said special measures must be taken to operate on patients classified as super-obese and super-super-obese -- who have a body mass index above 50 and 60, respectively -- but it can be done.

"You have to take a totally different approach," Dr. Ponce said.

That means measuring to ensure the patient can fit on the operating table, working in a hospital certified to handle such patients and putting the person on a strict diet before surgery, he said.

Dr. Ponce performs about 300 bariatric surgeries each year, and he said 25 percent of those are on patients who have a BMI above 50.

Before the procedure, it's essential the patient is clear on what to expect from the experience, he said. Weight loss results often are less in patients with BMIs above 50, compared to those who are in the 35 to 45 range, Dr. Ponce said.

"They need to understand there is more risk," he said. "Every time the BMI goes up, there is more risk of bleeding because you're pulling fat to be able to see, and fat can start bleeding. There's more risk of damaging internal structures, more risk of having a breathing problem when trying to put the patient to sleep."

Despite the increased danger, for some patients the rewards are worth the risks.

Ducktown, Tenn., resident Sonya Standridge, 38, became one of Dr. Ponce's patients two years ago when she had Lap-Band bariatric surgery. She had a BMI of 63 before the surgery, which has dropped to 34 since the procedure.

With the Lap-Band, a small silicone tube is fastened around the upper stomach to create a tiny stomach pouch, slowing digestion and making the person feel full with less food.

Ms. Standridge said she has good days and bad days, but ultimately the surgery was the right choice for her. Being a nurse, she said she knew the risks beforehand and felt it was her "last resort option."

WHAT IS BMI?

Body mass index is a measure of body fat based on height and weight that applies to both adult men and women, according to the U.S. National Institutes of Health.

"If you asked me today would I have the surgery again, the answer is absolutely, 100 percent, no questions asked," Ms. Standridge said. "I had never felt the feeling of fullness before, so I would literally eat until I was gluttoned."

Local bariatric surgeon Dr. Jack Rutledge said there are two main factors that put high BMI patients at a greater risk than other patients.

The first, he said, is that people who fall into that category generally are unhealthy. Secondly, the additional weight creates a situation where it is more difficult to move instruments inside the body.

What he suggests to patients who are super-obese or super-super-obese is to first lose weight.

"I think they do have hope, but it's going to be expensive and it's going to be complicated," Dr. Rutledge said. "But there is a way to lose 100 pounds."

That's what 50-year-old Rossville resident Jimmy Allmond is trying to do now. After being told the increased risks of performing procedures on his 510-pound body, he decided to try to lose weight the old-fashioned way.

But he's still not sure on whether he'll eventually have surgery.

"With all that going on, I'm still not sure," he said. "If I can lose it without it, that would be good."

BARIATRIC SURGERIES

* Gastric band: A ring is fastened on the top of the stomach, creating a small pouch. The ring has a balloon portion that can be filled with fluid to limit the amount of food the patient can eat. The apparatus acts as an hourglass, and food sits on top and slowly trickles down into the stomach. This is the least invasive of the bariatric surgeries.

* Gastric bypass: The top portion of the stomach is cut and stapled to create a small pouch. The rest of the stomach and the first portion of the intestines are then re-routed. The patient can eat only small portions, and some of the food does not get absorbed. This is the most invasive of the bariatric surgeries.

* Sleeve gastrectomy: About 80 percent of the stomach is taken out, creating a small, banana-like sleeve. It allows patients to eat less and feel less hungry because the procedure removes some hormones that signal hunger. This is the newest of the bariatric surgeries.

Source: Dr. Jaime Ponce, medical director of the Gastric Band Institute

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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 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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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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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 increased risk of iron deficiency

New York, NY

Weight loss surgery can help you lose weight, but it's also likely to leave you unable to absorb iron, a new study suggests: Iron deficiency is a common problem after stomach bypass surgery to treat severe obesity -- and standard iron supplements may not be enough to prevent it in some patients.

Researchers found that among 67 Chilean women who had undergone the most common form of weight-loss surgery, 39 percent developed low blood counts, also known as anemia, within 18 months of surgery. That anemia was most often due to a deficiency in iron, which the body needs to produce healthy red blood cells that carry oxygen.

In contrast, less than two percent of the women had been anemic before surgery, the researchers report in the American Journal of Clinical Nutrition.

It's well known that nutritional deficiencies are a risk after the type of surgery examined in the trial, known as Roux-en-Y gastric bypass, the most common and most effective form of weight- loss surgery for severe obesity.

The procedure involves stapling off the upper portion of the stomach to create a small pouch that restricts the amount of food a person can eat at one time. The surgeon also makes a bypass from the pouch that skirts around the rest of the stomach and a portion of the small intestine, limiting the body's absorption of nutrients.
The new findings suggest that impaired iron absorption, rather than reduced iron intake, is the major cause of long-term deficiency after gastric bypass, according to the researchers.

Tests done six months after surgery showed that, on average, women were absorbing just one-third of the iron from food that they had before surgery.

What's more, their absorption of iron from supplements showed nearly as great a decline. And many women became deficient in iron despite taking supplements after surgery, according to the researchers, led by Manuel Ruz of the University of Chile in Santiago. More "Gastric bypass surgery increased risk of iron deficiency"

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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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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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New study claims gastric bypass and gastric banding weight-loss surgery safe

St. Louis, MO

Obese patients who undergo weight-loss surgery have a low risk of dying or developing complications that require a second surgery or longer hospital stay, a study found.

About 4.1 percent of 4,610 people in the study who had either gastric bypass surgery or gastric banding developed at least one major complication in the 30 days after surgery, according to research published today in the New England Journal of Medicine. Those who underwent gastric banding had fewer complications.

Weight-loss surgery has soared in popularity in the U.S. The number of such operations rose more than tenfold to about 171,000 in 2005 from about 16,200 in 1994, according to an editorial in the journal. The data shows that, at least in the short term, these procedures are relatively safe and future research may help identify which surgery is best for a particular patient, said study author Bruce Wolfe, a professor of surgery at Oregon Health and Science University in Portland, in a telephone interview. Based on the findings, he said, "the surgery is basically safe."

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Weight-loss surgery may decrease the risk of cancer in women

from CancerConsultants.com

Researchers from Sweden have reported that weight-loss surgery (bariatric surgery) was associated with a reduced incidence of cancer in obese women but not in obese men. The details of this study appeared in an early online publication in Lancet Oncology on June 24, 2009.[1]

Previous studies have suggested that obesity increases the risk of developing cancers of colon, rectum, liver, gallbladder, pancreas, breast, uterus, cervical, ovary, and kidney as well as lymphoid tumors such as non-Hodgkin’s lymphoma and multiple myeloma. It has been estimated that obesity increases the cancer death rate in men and women by more than 50%. It has been suggested that obesity causes 14% of all cancer deaths in men and 20% of all cancer deaths in women in the United States.

Weight loss surgery is usually the last resort for morbidly obese individuals when diets fail. Weight loss surgery refers to various procedures that restrict nutrient intake such as bands or bypasses. (See Wikipedia [http://en.wikipedia.org/wiki/Bariatric_surgery] for descriptions of the various surgical procedures currently being used.)

The current study evaluated the risk of cancer in 2,010 obese patients with a body mass index greater than 34 kg/m2 in men and greater than 38 kg/m2 in women who underwent weight loss surgery. Outcomes were compared with 2,037 controls who were comparably obese but did not opt for weight loss surgery. The median follow-up of this study was over 10 years.

* Weight loss surgery was associated with a 20 kg weight loss over the 10 years of observation compared with a 1.3 kg gain in controls.
* There were 117 cancers in the surgery group and 169 in the control group.
* There were 79 cancers in women in the surgery group and 130 in the control group.
* There were 39 cancers in men in the surgery group and 39 in the control group.
* Similar results were obtained when cancers developing in the first three years from surgery were excluded.

These authors concluded: “Bariatric surgery was associated with reduced cancer incidence in obese women but not in obese men.”

Comments: This is the first study to document a decreased risk of cancer following significant weight loss. It is very interesting that this decreased risk was limited to women. This may suggest that cancers in women are more hormonally dependent than in men. It has been speculated that hormones produced by fat may be the cause of increased breast, uterine, and ovarian cancer risk in obese individuals.

References:

[1] Sjostrom L, Gummesson A, Sjostrom CD, et al. Effects of bariatric surgery on cancer incidence in obese patients in Sweden (Swedish Obese Subjects Study): a prospective, controlled intervention trial. Lancet Oncology [early online publication]. June 24, 2009.

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New study finds gastric bypass surgery not more risky for senior citizens than young

Dallas, TX

About 26% of seniors 65 and older in U.S. are obese, nearly 40% are overweight, putting them at a higher risk for Type 2 diabetes, high blood pressure and heart disease

Morbidly obese seniors, age 65 and over, who had laparoscopic gastric bypass surgery lost nearly 76 percent of their excess weight after two years and had low complication rates and short hospital stays comparable to younger surgical patients, according to a new study presented today at the 26th Annual Meeting of the American Society for Metabolic & Bariatric Surgery (ASMBS).

“Bariatric surgery in the older population is underutilized because of a misperception that old age alone puts patients at higher risk for complications and mortality,” said Joseph Kuhn, MD, co-author and director of General Surgical Research at Baylor University Medical Center in Dallas, TX.

“We found seniors can benefit just as much as younger people from bariatric surgery without taking on additional risk.”

In one of the largest series of laparoscopic gastric bypass surgeries performed on elderly patients, researchers from Baylor University Medical Center analyzed a prospective database of 100 patients over age 65 and compared safety and outcomes to a younger population.

All patients had laparoscopic gastric bypass surgery between January 2005 and July 2008.

Prior to surgery, older patients demonstrated higher operative risk profiles compared to their younger counterparts in relation to -
● sleep apnea (45% vs. 34%),
● Type 2 diabetes (65% vs. 33%) and
● hypertension (81% vs. 57%).

Older patients ranged in age from 65 to 77 with an average BMI of 45, and younger patients ranged in age from 18 to 64 with an average BMI of 47.

Post-operative excess body weight loss (EWL) and complication rates were comparable in both groups.

At 12 and 24 months, both lost nearly the same amount of weight -- patients over age 65 showed 75.9 percent EWL after one year and 75.5 percent after two years; patients under 65 showed 77.8 percent EWL after one year and 79.2 percent after two years.

Neither group reported any deaths in the two-year follow-up period.

Post-operative complications were -
● low: bleeding (>65 1% v. < 65 1.3%),
● pulmonary infections (>65 3% v. <65 1.3%),
● cardiac (>65 2% vs. <65 0.36%) and
● wound infections (>65 1% v. <65 1.7%).

Due to the age and overall health status of the older group, researchers noted it was particularly interesting to also find length of hospital stays (1.9 vs.1.3 days) and 30 day readmissions rates (6% vs. 7.4%) to be so comparable.

About 26 percent of people 65 and older in the U.S. are obese and another nearly 40 percent are overweight, putting them at a higher risk for Type 2 diabetes, high blood pressure and heart disease. Since 1990, the prevalence of obesity has increased more than 50 percent in the elderly.

“The population is getting older and unfortunately more obese, so we will see a corresponding increase in the number of patients over 65 who are eligible for bariatric surgery and surgery needs to be an option for them,” said Christopher Willkomm, MD, study co-investigator from Baylor University Medical Center.

People who are morbidly obese are generally 100 or more pounds overweight, have a BMI of 40 or more, or a BMI of 35 or more with an obesity-related disease, such as Type 2 diabetes, heart disease or sleep apnea.

According to the ASMBS, more than 15 million Americans are considered morbidly obese and in 2008 an estimated 220,000 people had some form of bariatric surgery. The most common methods of bariatric surgery are laparoscopic gastric bypass and laparoscopic adjustable gastric banding (LAGB).

The ASMBS is the largest organization for bariatric surgeons in the world. It is a non-profit organization that works to advance the art and science of bariatric surgery and is committed to educating medical professionals and the lay public about bariatric surgery as an option for the treatment of morbid obesity, as well as the associated risks and benefits.

It encourages its members to investigate and discover new advances in bariatric surgery, while maintaining a steady exchange of experiences and ideas that may lead to improved surgical outcomes for morbidly obese patients. For more information about the ASMBS, visit www.asmbs.org.

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Bariatrics surgery increases fertility of women and men

Pittsburgh, PA

Melody and Phillip McIntyre, both morbidly obese, tried unsuccessfully for three years after their 2003 marriage to have a child before Mrs. McIntyre decided to try a gastric bypass in hopes of increasing her fertility. Some obstetric nurse friends had told her they had seen "many success stories after the surgery."

And so Mrs. McIntyre, a nurse at UPMC-Horizon in Greenville who lives in West Middlesex, Mercer County, headed to Allegheny General Hospital for an appointment with surgeon Dr. Joseph Colella, director of the hospital's bariatric center.

"That was the first question I asked. I said, 'I want to have a baby. Can you help me?' " Mrs. McIntyre recalled.

The doctor answered "of course," talked to her and her husband about how obesity affects fertility, then suggested the same operation for Mr. McIntyre, a residential adviser for mental health patients. It was advice he followed after a cardiologist got his heart function working well enough to undergo surgery in April 2007, when he was 35 years old.

Mrs. McIntyre had her laparoscopic procedure in late October 2006 and then settled back to follow medical advice that female bariatrics patients wait a year to a year and a half -- or maybe even two years -- before trying to get pregnant in order to ensure there are no complications.

But it was Mr. McIntyre who had a complication during his 2007 procedure, hemorrhaging because his spleen had been traumatized. In going back in to find and stop the bleeding, doctors found a cancerous kidney tumor that they watched for a year before removing it all last April.

By that time, Mrs. McIntyre, now 34, was pregnant with little Trent, who was born Dec. 6. He was conceived just five months after she went off birth control.

Leslie Gore's story is even more amazing. The 24-year-old Penn Hills woman was told when she was 16 that she probably never would get pregnant because she had polycystic ovarian syndrome, a problem in which a woman's hormones are out of balance. Treated with hormones to induce periods, she steadily packed on the weight until she reached 285 pounds on a 5-foot-3 frame for a body mass index in the high 40s to low 50s.

Mrs. Gore, who is a pregnancy caseworker for Unison Health Plan, went to Dr. Dan Gagne (pronounced ga-NYAY), director of West Penn Hospital's Bariatric Surgery Center, for two reasons: in hopes of having a child and of getting healthy enough to live to raise him.

The surgery on Jan. 8, 2008 worked beyond her and husband Tyrone's wildest dreams: She got pregnant in October while still taking birth control pills. The baby is due July 4.

"We were both floored. We were completely caught off-guard," Mrs. Gore said.

She called Dr. Gagne to pass on the news and, she remembered, got this response: "I'm not surprised. Congratulations."

No wonder.

Since West Penn's bariatrics center opened in July 1999, Dr. Gagne said, "we've had at least 39 women get pregnant after bariatric surgery." Those are women who delivered full-term babies, he said, adding that at least five in the practice are pregnant now.

"Some of them had had previous pregnancies; a lot did not. A lot had diagnoses of polycystic ovary disease ... We had several who had had problems getting pregnant that did get pregnant."

Dr. Colella has had similar experience at Allegheny General and so has Dr. Anita Courcoulas at UPMC, where she is director of minimally invasive bariatric and general surgery.

"It's over 30 and that would be in six years," Dr. Colella said, "and those are the ones I know about who had infertility problems who moved on to successful conception and delivery."

One couple was so grateful that they named their son Joseph.

Dr. Courcoulas said the number of women who have become pregnant after weight loss surgery at UPMC's center in Magee-Womens Hospital is "definitely in the hundreds" but noted that the big number is due in large part to the size of the UPMC practice. "Just at Magee we do 1,100 weight-loss operations a year."

Though one recent medical bulletin from the Practice Committee of the American Society for Reproductive Medicine declared that "most obese women are not infertile," it also goes on to say, "Conversely, ovulatory function and pregnancy rates frequently improve significantly after weight loss in obese anovulatory women."

Certainly, the experiences of the Pittsburgh bariatrics doctors are that many presurgical patients are at least less fertile than normal.

"The take-home message is that fertility is certainly improved." said Dr. Ronald Thomas, director of maternal fetal medicine at AGH, whose department collaborated with Dr. Colella's on two published studies about pregnancy outcomes after the laparoscopic gastric bypass known as Roux-en-Y.

"In one article we talked about the fact that the typical advice is wait two years and stabilize before getting pregnant and the problem is many get pregnant after six, seven or eight months. ...

"[What happens is] patients begin to ovulate and get pregnant without trying to. The fertility comes back roaring into place. These patients don't realize their fertility markedly improves."

Hormones involved

Why does this happen? Doctors interviewed all cited changes in hormonal activity post-weight loss.

"A lot of times it seems to be the interplay of female hormones and fat," Dr. Gagne said. "Just as we see improvement in other health problems, this too happens in weight loss."

"I agree with that," Dr. Courcoulas said, "but we don't know exactly how."

"There's a dramatic change in the way hormones in the body are regulated after they lose all the fat cells," Dr. Colella said. "It's called the hypothalamic-pituitary axis, and its interaction with the ovaries gets reset to normal function so women begin to experience the normal circulation of hormones that trigger ovulation that occurs each month. ...

"The way we understand it in our world is the fat cells are an estrogen-producing engine and it overwhelms the axis and stops it from producing two hormones, follicle stimulating hormone and luteinizing hormone, and those two hormones are the ones responsible for triggering ovulation. So if they're not made in the appropriate amount in the appropriate time you don't get a normal ovulation event.

"And there also may be some changes in the lining of the uterus that make it less likely to allow implantation if an egg gets fertilized, but most commonly it's that they don't ovulate."

Dr. Scott Kauma, reproductive endocrinologist and director of the Jones Institute for Reproductive Medicine at the West Penn Allegheny Health System, theorized that resumed ovulation "might have to do with decreasing insulin resistance. It may be decreased circulating testosterone levels as they're losing weight or some unknown metabolic changes that stimulate the body to ovulate better. None of this is certain."

He said there's a similar uncertainty about why heavier women respond differently to other treatments, such as in vitro fertilization: "... the amount of medicine you need to use to get women to respond appropriately is much higher and pregnancy rates are lower. When I see the the pregnancy rates [of IVF] ... you're not guaranteed a pregnancy, but if you're obese the likelihood of getting pregnant compared to normal weight women is less."

Obese men are much less likely to undergo bariatric surgery because of fertility issues, but only because they are less likely to have the surgery at all. "There's an 8-2 ratio, women to men," Dr. Colella said, "but that's not because obesity is contained to women but because men are reluctant to seek help in specialty practices. The prevalance of obesity is roughly the same between men and women."

Helping men

And, Dr. Kauma said, men's fertility also is affected by their overweight.

"The heavier you are, the more of a problem you have with a lower sperm count," he said. "It may be that men who are heavy may have more estrogen floating around their bodies. The fat will convert testosterone to estrogen, and the estrogen tends to decrease the signals to the testes, which increase the sperm."

The other problem is that fat enveloping the scrotum elevates the temperature, affecting manufacturing of sperm. "The testes are in the scrotum because it's cooler there, which works better for sperm production," Dr. Kauma explained.

Though he was most interested in getting healthy and living long enough to raise a child, Phillip McIntyre said he had been told by two doctors that his fertility would be improved "and it was in the back of my mind that it would help."

Dr. Courcoulas also said she has "a couple [male patients] in the works right now [with improved fertility] as one of the reasons they're pursuing surgery."

Weight loss achieved through diet or a preferred combination of diet and exercise also would improve fertility, but, Dr. Kauma said, "90 percent of people who diet have trouble keeping it off. ...

"The most successful way to lose weight and keep it off for good is gastric bypass or banding."

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Weight loss surgery improves sexual function in men

New York, NY

Sexual dysfunction that commonly occurs in morbidly obese men improves after weight loss surgery, according to a new study.

"Sexual dysfunction should be considered one of the numerous potentially reversible complications of obesity," the study team concludes.

Dr. Ramsey M. Dallal, from Albert Einstein Healthcare Network, Philadelphia, and colleagues measured the degree to which 97 morbidly obese men suffered from sexual dysfunction and then analyzed the change in sexual function after substantial weight loss following gastric bypass surgery.

Before surgery, the morbidly obese men had significantly lower sexual function relative to that of a previously published reference control group of men before surgery, the investigators report.

After losing an average of two thirds of their excess weight, men experienced significant improvements in sexual function, with the amount of weight loss predicting the degree of improvement.

"We estimate that a man who is morbidly obese has the same degree of sexual dysfunction as a nonobese man about 20 years older," the investigators report. "Sexual function improves substantially after gastric bypass surgery to a level that reaches or approaches age-based norms."

"Sexual function is an important aspect to quality of life and is now well documented to be a reversible condition," Dallal explained.

"We are interested in examining sexual function in females, as well as understanding the mechanism of obesity-related sexual dysfunction," Dallal added.

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Gastric bypass surgery resolves diabetes in teens

Los Angelos, CA

Teenagers who undergo gastric bypass surgery are often immediately relieved of Type 2 diabetes, according to research published today in the journal Pediatrics.

Studies on adults with Type 2 diabetes show that gastric bypass can result in disease remission or better disease control. However, this study is the first to explore the effects of the surgery in children. The study examined adolescents with Type 2 diabetes, which is usually related to obesity and is being diagnosed with alarming frequency in American children and teenagers.

Dr. Thomas Inge, director of the Cincinnati Children's Surgical Weight Loss Program for Teens, studied 11 extremely obese teens with Type 2 diabetes who had gastric bypass surgery and 67 obese teens who were receiving medical management for Type 2 diabetes. Among the 11 teens who underwent surgery, all but one had a remission in diabetes. The response was so rapid, the patients often discontinued medication for diabetes control before leaving the hospital after surgery. These teens lost an average of 34% of their body weight one year after surgery. In contrast, the teens who were medically managed did not have any weight change after one year and were all still taking medication for diabetes. The adolescents who had surgery also had improvements in blood pressure, cholesterol and triglyceride levels.

"The results have been quite dramatic and to our knowledge, there are no other anti-diabetic therapies that result in more effective and long-term control than that seen with bariatric surgery," Inge said in a news release.

Inge and his co-authors noted that future studies will be needed to track the long-term health of teenagers who participated in the study. Cincinnati Children's Hospital is home to a study funded by the National Institutes of Health that will collect and report outcomes on 200 teens undergoing weight-loss surgery nationwide.

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Can gastric bypass surgery make you smarter?

More than 140,000 severely overweight Americans have gastric bypass surgery every year. It's done for weight loss, but a new study shows it can solve a host of medical problems, and may even be a boost to your brain.

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Stanford study: Gastric bypass may boost smarts

San Francisco, CA

In the United States, with most Americans overweight or obese, the demand for gastric bypass surgery is booming. The procedure often results in dramatic weight-loss, but a study now suggests it could also lead to increased brain power.

Stanford researchers found that gastric bypass surgery improved a patient's ability to remember, think through problems, and pay attention to details. The findings were reported Tuesday at the American College of Surgeons annual meeting held this year in San Francisco.

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Study: Gastric bypass not effective diabetics

San Francisco, CA

Gastric bypass has helped thousands of people effectively lose weight, but a new study finds diabetics who undergo the surgery are less likely to see good results.

Researchers at the University of California San Francisco studied over 300 gastric bypass patients a year after their procedure.

They found patients with diabetes were unable to lose more than 40-percent of their excess body weight.

Researchers believe the medications diabetics take like insulin actually stimulate the body's production of fat and cholesterol.

They say changes in the use of these medications could give diabetics a better chance to achieve better weight loss results after gastric bypass.

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Could gastric bypass surgery cure diabetes?

Raleigh, NC

Gastric bypass and other surgeries have become a popular way for the obese to lose weight. The procedure has also proven effective at curing diabetes.

Mary Stanford weighed 300 pounds four years ago and was a Type 2 diabetic. Gastric bypass surgery helped her lose 140 pounds, and her diabetes disappeared almost immediately.

“(It was) definitely a relief. Your sugars are normal, you don't have to worry about testing every day (and) you don't have to worry about remembering to take your medication,” she said.

Some doctors are considering gastric bypass for a larger number of diabetics.

“We now have sufficient evidence that gastric bypass can improve diabetes dramatically,” said Dr. Francesco Rubino with the Weill Cornell Medical Center in New York.

There is an obesity threshold. Someone who is 5 feet 8 inches tall has to be at least 230 pounds to get the surgery. Rubino said he planned to begin a new study, performing the surgery on patients about 30 pounds lighter.

“We're going to compare surgery [with] conventional medical treatment to understand whether surgery might be preferable in this subset of patients,” he said.

Researchers say it's not just the weight loss that rids the body of diabetes. The surgery might also spark hormonal changes in the body.

“A large number of people with diabetes will see their diabetes drop off within days to a few weeks after the bypass, long before they've lost much weight,” said Dr. David Crumpler, an endocrinologist.

Experts say they believe it's possible that the surgery could even help diabetics who are just overweight and not obese.

“We have to be very cautious and do more studies before we offer surgery to everybody,” Rubino said.

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Robot may reduce risk of gastric bypass

Houston, TX

U.S. surgeons say using a robot may lower the risk of a rare but serious complication of weight-loss surgery.

The five-year study, published in the Journal of Robotic Surgery, compared 605 patients undergoing laparoscopic gastric bypass without and with robotic assistance. Six in the first group experienced a gastrointestinal leak while none in the robot group did.

"While robotic surgery may take slightly longer and be more costly to use than traditional laparoscopy, we believe that the improved outcome and decreased leak rates may offset the cost to some extent," study senior author Dr. Erik Wilson of the University of Texas Medical School at Houston said in a statement.

Symptoms of a gastrointestinal leak which may occur when the small intestine is reconnected to a small pouch created in the stomach can include pain, shortness of breath, fever, nausea, vomiting and -- rarely -- death. In this study, there were no deaths in either group, and the rate for all complications was slightly lower than those previously reported in journals.

Lead author Dr. Brad Snyder says the robot allows for more precise suturing.

"The angles encountered during a laparoscopic gastric bypass are sometimes awkward and can make the surgical technique challenging," he says. "With the robot, this additional challenge is minimized."

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Weight loss more difficult for diabetics after gastric byass surgery, new study shows

Winter Park, FL

Diabetics and people with larger stomachs may have more difficulty losing weight after gastric bypass surgery, according to a new study.

The surgery involves doctors creating a smaller stomach pouch that restricts food intake and bypasses large sections of the digestive system. Although it’s an effective way for thousands of obese people to lose weight, approximately five to 15 percent of patients do not lose weight successfully.

In the study, 12 percent of patients did not lose the expected amount of weight a year after the surgery. Diabetes and having a larger size stomach pouch after surgery were independently associated with poor weight loss, researchers said.

The study’s authors said diabetics might take insulin or other drugs that stimulate the production of fat and cholesterol. They concluded that changes in the use of diabetes medications may reduce the risk of poor weight loss after gastric bypass surgery.

During gastric bypass, surgeons estimate the stomach pouch size using anatomical landmarks rather than using a sizing balloon.

“As the use of gastric bypass continues to grow, we believe it is critical to stress the importance of and to teach the creation of the small gastric pouch and to better standardize the technique used for pouch creation,” the authors wrote.

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Gastric bypass surgery can reverse metabolic syndrome

Rochester, MN

Metabolic syndrome, a cluster of conditions that increases the risk of heart disease, stroke and diabetes, in extremely obese patients can be cured by gastric bypass surgery, according to the findings from a new study.
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"Reversibility of metabolic syndrome depends more on the percentage of excess weight lost than on other clinical or demographic characteristics," the research team reports in the journal, Mayo Clinic Proceedings.

To determine the effect of major weight loss on the metabolic syndrome, Dr. Francisco Lopez-Jimenez and colleagues evaluated patients being considered for bypass surgery at the Mayo Clinic in Rochester, Minnesota, between 1990 and 2003.

All patients met at least three of the five criteria for the metabolic syndrome - high levels of triglycerides (a "bad" fat), low levels of high-density lipoprotein "good" cholesterol, increased blood pressure, high blood sugar levels and obesity.

The study group included 180 patients who underwent gastric bypass and 157 patients who did not undergo the procedure, either because they declined surgery, were denied coverage by insurance providers, or did not maintain lifestyle interventions during their evaluation. All patients received medical and dietetic care and extensive counseling about the importance of physical activity.

The mean body mass index (BMI) was 49 in the surgical group and 44 in the nonsurgical group. A normal BMI is considered to be between 18.5 and 24.9.

During an average follow-up of 3.4 years, the prevalence of metabolic syndrome decreased from 87 percent to 29 percent in the surgical group, and from 85 percent to 75 percent in the control group. The authors estimate that the number of patients needed to treat with bypass surgery to cure one patient of metabolic syndrome was 2.1.

Weight loss averaged 44 lbs in the surgical group and 0.2 lbs in the nonsurgical group. Additional analysis showed that the percentage of excess weight lost was the primary factor that determined the resolution of the metabolic syndrome.

"Our study provides robust data to practicing clinicians about the benefits of counseling weight reduction in metabolic syndrome patients," Lopez-Jimenez and his associates conclude.

They recommend "gastric bypass surgery should be considered as a treatment option in patients with metabolic syndrome that has not responded to conservative measures" in those eligible for surgery.

SOURCE: Mayo Clinic Proceedings, August 2008.

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Can gastric bypass cure diabetes?

San Francisco, CA

A new study is trying to learn whether a surgery meant to cure obesity, could also cure the symptoms of diabetes, even if the patient isn't overweight. It's a strategy that's not without controversy.

Pat Prescott is fighting to control her type 2 diabetes. She carries her blood glucose meter, a cooler for her insulin and gets regular exercise through ballroom dancing.

Still she says her symptoms have been getting worse.

"It just doesn't work anymore," said Prescott.

So when she learned that a surgery used to treat obesity has the side effect of improving diabetes, she approached her doctors, but was told she wasn't overweight enough to qualify.

Now, she's hoping to join a new clinical study, headed by surgeon Francesco Rubino. He is testing whether that same surgery, similar to gastric bypass, can improve diabetes in people who aren't obese.

"We're shifting towards a new concept, which is using surgery to intentionally treat diabetes," said Dr. Francesco Rubino from Weill-Cornell Medical School.

As he documented in the Journal Diabetes Care, when obese patients have surgery that bypasses part of their small intestine, their symptoms often disappear within days, long before they begin to lose weight.

"With some operations like gastric bypass or similar procedures, the remission of diabetes symptoms is very quick after surgery, which even precedes the weight loss," said Dr. Rubino.

In fact, researchers have known about those effects for several years. But offering gastric bypass to non-obese diabetics is controversial.

"I think it has no place outside of obesity surgery," said UCSF professor of endocrinology Dr. Robert Lustig.

Dr. Lustig says diabetes can be caused by combination of factors, including the health of beta cells, the agents in the pancreas that produce insulin.

"Diabetes is a complex disease. If you have a problem with your beta cells, then doing a bariatric surgery isn't going to rescue you," said Dr. Lustig.

Still, patients like Pat Prescott may have a part in testing the theory. Recruitment for the study begins this fall.

"I want to live long enough to enjoy my grandchildren. I want to keep dancing, I like to dance," said Prescott.

It's significant to note that the type of gastric bypass being tested in the study is performed on the small intestine, which has a complex role in how the body processes food.

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Bariatric gastric banding and gastric bypass as cure for diabetes

It may be the closest thing to a cure for type-2 diabetes -- gastric bypass surgery.

Currently, the procedure is only performed for major weight loss.

But one surgeon hopes to prove that a similar surgery could help non-obese diabetics.

ABC's Brad Kloza introduces us to one diabetes patient who's determined to have the surgery.

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Laparoscopic gastric bypass provides better results

New York, NY

Performing gastric bypass surgery to reduce the weight of morbidly obese patients using a laparoscopic method, rather than the conventional more invasive "open" abdominal method, reduces postoperative complications, the need for a second operation, and shortens hospital stays, new research shows. Nevertheless, laparoscopic gastric bypass is more expensive.

Obesity surgery, also called bariatric surgery, is growing in popularity and more and more of these operations are being done using a laparoscope, note co-authors Dr. Wendy E. Weller, from the University at Albany in New York, and Dr. Carl Rosati, from Albany Medical Center.

This is done by placing one or more small incisions in the abdomen, through which a hollow tube is inserted. This allows very small instruments to be inserted to perform the gastric bypass. The entire procedure is visualized on a screen. In contrast, the more invasive "open" procedure involves making an incision to open the abdomen so the procedure can be performed.

The current study, reported in the Annals of Surgery, involved an analysis of data from 19,156 subjects who underwent gastric bypass surgery in 2005 and were logged in the Nationwide Inpatient Sample, the largest all-payer inpatient database in the U.S.

Slightly less than 75 percent of the patients underwent laparoscopic gastric bypass, the report indicates.

Laparoscopic gastric bypass was linked to a reduced risk of several complications. With open surgery, the risk of pulmonary complications was increased by 92 percent, for cardiovascular complications it was 54 percent, for sepsis, a serious system-wide infection, the risk was more than doubled and the risk of anastomotic leak, leakage from the operative site, 32 percent higher.

On average, performing laparoscopic rather than open gastric bypass reduced the hospital stay by about 1 day.

The average total charges were similar for the two procedures, but median total charges were significantly higher with laparoscopic gastric bypass: $30,033 vs. $28,107 respectively.

After accounting for various patient and hospital factors, laparoscopic surgical patients were less likely than their open-surgery counterparts to require reoperation, the investigators found.

While these findings suggest some advantages with the laparoscopic operation, "most reassuring for the bariatric surgery community is that the hospital outcomes were excellent overall in both the laparoscopic and open procedures," Dr. Michael G. Sarr, from the Mayo Clinic in Rochester, Minnesota, comments in a related editorial.

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Gastric Bypass study at targets obese teens

Cincinnati, OH

It's arguably one of the most controversial weight loss options currently available -- gastric bypass surgery.

When it works, patients often lose hundreds of pounds that they would be hard pressed to get rid of in other ways.

When it doesn't work, it can lead to serious illness or death.
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Cincinnati Children's Hospital is one of five running a 10-year study of the procedure and its effectiveness on a segment of the population that often feels the brunt of weight shame -- teenagers.

"No one likes to see teenagers get to this point of this level of obesity that they can't go to school, they don't have friends," Dr. Meg Zeller said. "Their medical health resembles an adult's medical health, but the surgery and the weight loss that follows can alter that trajectory."

"We are seeing kids with average weight of nearly 400 pounds. The range is 250 to 650," Dr. Thomas Inge said.

Kylie Crovo said she can tell you about the benefits. She came to Children's Hospital at age 15 weighing 255 pounds. Now 17, she's lost 110 pounds in 18 months.

"It just feels great to live life not having to worry about any potential medical problems," she said.

Inge said he knows the procedure has its critics, especially when it involves teenagers.

"I think the average person who is hearing about weight loss surgery for teenagers and thinks, 'Oh my gosh, what are (they) thinking?' are not able to put themselves in the shoes of the people we are seeing," he said.

Amanda Munson has lost 100 pounds so far.

"The study means to me, basically I'm helping everyone else. We can give more information to other people," she said.

Doctors said they will follow all the patients over the next 10 years to study the long-term effects of the procedure.

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ASMBS: Bariatric Surgery Found Superior to Drugs in Controlling Diabetes

Washington, D.C.

For morbidly obese patients with type 2 diabetes, bariatric surgery led to more improvement in glycosylated hemoglobin than standard treatment, a retrospective analysis showed.

Those who underwent Roux-en-Y gastric bypass had an average drop in hemoglobin A1c of 21% within a year (P<0.001), compared with an increase of 11% with conventional treatment (P<0.05), which included oral hypoglycemics and insulin, according to Daniel Mumme, M.D., of Gundersen Lutheran Medical Center in La Crosse, Wis.

Body mass indices fell from an average of 47.3 to 30.9 kg/m2 (P<0.05) in the surgery group and did not change significantly from 44.9 kg/m2 in the conventional-treatment group, he reported at the American Society for Metabolic & Bariatric Surgery meeting here. More >>

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Nutritional deficiencies after Roux-en-Y gastric bypass often cannot be prevented by standard multivitamin supplements, study says

Nutritional deficiencies after Roux-en-Y gastric bypass for morbid obesity often cannot be prevented by standard multivitamin supplementation

From the American Journal of Clinical Nutrition, Vol. 87, No. 5, 1128-1133, May 2008

Background: Despite the increasing use of Roux-en-Y gastric bypass (RYGBP) in the treatment of morbid obesity, data about postoperative nutritional deficiencies and their treatment remain scarce.

Objective: The aim of this study was to evaluate the efficacy of a standard multivitamin preparation in the prevention and treatment of nutritional deficiencies in obese patients after RYGBP.

Design: This was a retrospective study of 2 y of follow-up of obese patients after RYGBP surgery. Between the first and the sixth postoperative months, a standardized multivitamin preparation was prescribed for all patients. Specific requirements for additional substitutive treatments were systematically assessed by a biologic workup at 3, 6, 9, 12, 18, and 24 mo.

Results: A total of 137 morbidly obese patients (110 women and 27 men) were included. The mean (±SD) age at the time of surgery was 39.9 ± 10.0 y, and the body mass index (in kg/m2) was 46.7 ± 6.5. Three months after RYGBP, 34% of these patients required at least one specific supplement in addition to the multivitamin preparation. At 6 and 24 mo, this proportion increased to 59% and 98%, respectively. Two years after RYGBP, a mean amount of 2.9 ± 1.4 specific supplements had been prescribed for each patient, including vitamin B-12, iron, calcium + vitamin D, and folic acid. At that time, the mean monthly cost of the substitutive treatment was $34.83.

Conclusion: Nutritional deficiencies are very common after RYGBP and occur despite supplementation with the standard multivitamin preparation. Therefore, careful postoperative follow-up is indicated to detect and treat those deficiencies.

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Vagotomy: Doctors studying safer alternative to gastric bypass surgery

Seattle, WA

More than 177,000 Americans had weight loss surgery in 2006. This can mean massive weight loss, but the surgery doesn't come without risks. Now, there's an investigational approach that's helping patients shed pounds a whole lot safer.

Losing weight was never easy for Garth Michaels.

"I've felt fat all my life, really," he said.

Michaels reached 320 pounds.

"I really was just up against a wall," he said. "I was praying daily. I didn't know where to turn."

Then, he found Dr. Robert Lustig, an endocrinologist at the University of California-San Francisco.

"Everyone in the world seems to think that obesity is just one problem," said Lustig. "You eat too much, exercise too little and it couldn't be further from the truth."

Lustig says the vagus nerve plays a big role in obesity.

"Every single thing the vagus nerve does is designed to get energy into your fat cells," said Lustig.

He's testing a new surgery called laparoscopic vagotomy, where he actually cuts the vagus nerve.

"The severe hunger that many obese patients report seems to be just completely obviated. It goes away completely," said Lustig.

So far, the 20 minute procedure is resulting in an average 18 percent excess weight lost.

"The weight loss that the patients have achieved appears to be durable and we're very happy about that," said Lustig.

Michaels has lost more than 100 pounds since having the procedure nearly two years ago.

"Definitely life-saving," said Michaels. "I think I added at least 10 to 20 years to my life… It's a whole new life, a whole new lease on life and at age 56. That's pretty good."

And after a lifetime of big clothes, Michaels is proud to finally shed that image.

Compared to gastric bypass surgery, this procedure is about one-fifth the cost, has fewer side effects, but patients will not lose as much weight. This technique is still being studied and not yet widely available.

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Gastric bypass surgery may also relieve low back pain

Los Angeles, CA

Obese people who underwent surgery that reduced the amount of food they could ingest not only lost weight, they also lost some of their lower back pain, according to a new report.

Thirty-eight morbidly obese patients with low back pain who underwent gastric bypass surgery reported that their pain decreased by an average of about 44 percent six months after surgery, according to researchers at the University of Southern California. The average amount of individual weight loss among the group of 30 women and eight men was about 85 pounds.

"This study provides evidence that substantial weight reduction following bariatric surgery results in moderate reductions in pre-existing back pain within six months of weight loss. While this initial research is promising, larger long-term trials are needed to prove the efficacy of this treatment," Dr. Paul Khoueir said in a prepared statement.

Khoueir was expected to present the findings in Chicago April 29 at the annual meeting of the American Association of Neurological Surgeons.More >>

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Volunteers wanted in obesity study: VBLOC, gastric bypass surgery alternative

Stanford researchers to test alternative to risky surgical procedures

Stanford University is starting a clinical research study on obesity that would give patients an alternative to invasive surgical procedures. The study, called Empower, will evaluate the safety and efficacy of an experimental method, called VBLOC Therapy, that periodically stops the body's neural messages of hunger and fullness from reaching the brain.

Empower is searching for recruits from around the Bay Area. Applicants must be between 18 and 65, with a body mass index between 35 and 45.

A 2001-2004 health and nutrition study by the National Institutes of Health found that about 66 percent of American adults are overweight and nearly one-third are obese.

"About 12 million Americans qualify for the study," said Dr. John Morton, associate professor at Stanford Hospital and Clinics.

"Obesity is now a global medical concern," added Morton, who is leading the study, "and is considered to be one of the leading causes of preventable death, second only to smoking."

Obesity is related to serious health risks such as hypertension, high cholesterol, sleep apnea and osteoarthritis as well as certain types of cancer.

To avoid these health problems, patients often turn to gastric bypass surgery, a major abdominal procedure with high risks and moderate benefits, according to Morton.

"No clinical or medical complications occurred" during international VBLOC trials, said Morton, who added that he has recorded no patient deaths in 1,200 gastric bypass
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operations.

Through the use of implanted electrodes, the VBLOC Therapy blocks the vagus nerve, intermittently stopping the signals of hunger and satisfaction carried from the stomach to the brain.

After a trial VBLOC study conducted outside the United States showed nine participants had excess weight loss of 29.5 percent after nine months, the Food and Drug Administration approved Morton's clinical study.

Participants can expect a comprehensive trial study as they meet with staff during 43 clinical visits that include nutritional and psychological counseling over the course of five years.

To learn more about the study, visit http://www.empowerstudy.com or call 866-978-2562.

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Genes may determine success of gastric bypass surgery

Danville, PA

Researchers study genetic factors in success of gastric bypass surgery and other bariatric procedure.

Two obesity-related genetic variations may be associated with higher body mass index (BMI) among severely obese patients (BMI of 40 or higher) who have bariatric surgery to help them lose weight, say American researchers.

Bariatric surgery is a highly effective treatment for severely obese patients, according to background information in the study. However, some patients don't lose weight after bariatric surgery.

"Identification of variables that determine the success of bariatric surgery have shown little consistency, and long-term success may depend on not yet identified factors," noted the researchers at the Geisinger Clinic in Danville, Pa.

They studied 707 severely obese (average BMI 51.2) patients who had gastric bypass surgery. Blood samples from the patients were analyzed for two common single nucleotide polymorphisms (SNPs) previously found to be associated with obesity. SNPs are variations caused by alteration of single building block of DNA.

The researchers found that about 21 percent of the patients had two copies of one obesity-related SNP, 13 percent had two copies of the other SNP, and 3.4 percent had two copies of both SNPs.

There was no significant BMI difference between patients with two identical copies of either one of the SNPs and those without two identical copies. However, patients with either two copies of both SNPs, or two copies of one and one copy of the other SNP, had much higher BMIs than other patients. Less than 20 percent of the patients in the study had these genetic features.

The findings were published in the March issue of the journal Archives of Surgery. More >>

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Study: Obesity surgery can cure diabetes

Chicago, IL

A new study gives the strongest evidence yet that obesity surgery can cure diabetes. Patients who had surgery to reduce the size of their stomachs were five times more likely to see their diabetes disappear over the next two years than were patients who had standard diabetes care, according to Australian researchers.

Most of the surgery patients were able to stop taking diabetes drugs and achieve normal blood tests.

"It's the best therapy for diabetes that we have today, and it's very low risk," said the study's lead author, Dr. John Dixon of Monash University Medical School in Melbourne, Australia.
The patients had stomach band surgery, a procedure more common in Australia than in the United States, where gastric bypass surgery, or stomach stapling, predominates.

Gastric bypass is even more effective against diabetes, achieving remission in a matter of days or a month, said Dr. David Cummings, who wrote an accompanying editorial in the journal but was not involved in the study.
"We have traditionally considered diabetes to be a chronic, progressive disease," said Cummings of the University of Washington in Seattle. "But these operations really do represent a realistic hope for curing most patients."

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