Gastric bypass surgery increases risk of kidney stones, study reports

Kidney stone risk increased by gastric bypass surgery

Dallas, TX

Patients who undergo gastric bypass surgery experience changes in their urine composition that increase their risk of developing kidney stones, research from UT Southwestern Medical Center investigators suggests.

A new study, published in the March issue of The Journal of Urology, found that some of these urinary changes place weight-loss surgery patients at higher risk for developing kidney stones than obese patients who do not undergo the procedure.

For the study, researchers collected urine samples from 38 study participants. There were 16 women and three men in each of two groups. One group had undergone Roux-en-Y gastric bypass (RYGB) surgery; the second group contained normal obese individuals. RYGB, which is one of the most commonly performed weight-loss procedures, involves the creation of a small gastric pouch and allows food to bypass part of the small intestine.

The researchers found that the excretion of a material called oxalate in urine was significantly greater in the participants who had the surgical procedure than those who did not (47 percent, compared with 10.5 percent, respectively). In addition, the amount of a chemical called citrate in the urine was low in many gastric bypass patients in comparison to the obese nonsurgical group (32 percent to 5 percent).

Oxalate is found in the majority of kidney stones, while citrate inhibits stone formation.

“Almost half of the patients who had undergone gastric bypass and did not have a history of kidney stones showed high urine oxalate and low urine citrate – factors that lead to kidney-stone formation,” said Dr. Naim Maalouf, assistant professor of internal medicine in the Charles and Jane Pak Center for Mineral Metabolism and Clinical Research and the study’s lead author.

The cause for stone formation after bariatric surgery is not entirely clear, but the study reinforces the message that weight-loss surgery patients and their physicians should be alert to the heightened risk, Dr. Maalouf said.

“These findings illustrate that the majority of patients are at risk for kidney-stone formation after RYGB,” Dr. Maalouf said. “This complication may not be well-recognized in part because it tends to occur months to years after the bypass surgery.”

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

Kalamazoo, MI

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

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

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

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

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

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

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

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

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

Divided opinions

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

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

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

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

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

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

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

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

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

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

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

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

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

Surgery and support

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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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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Better gastric bypass surgery outcomes linke to preoperative weight loss

Trenton, NJ

Preoperative weight loss is associated with fewer complications after gastric bypass surgery, according to the results of a record review reported in the December issue of Archives of Surgery.

"Despite the improved ability to accurately predict an increase in surgical risk, the optimal preoperative preparation of such high-risk bariatric surgery candidates remains controversial," write Peter N. Benotti, MD, from Saint Francis Medical Center in Trenton, New Jersey, and colleagues.

"Proposed risk-reducing strategies supported by varying degrees of evidence include staged surgical procedures, preoperative gastric balloon placement for weight loss, and preoperative medical weight reduction....Because the major determinant of postoperative length of stay is operative morbidity, we hypothesized that preoperative weight loss will reduce the frequency of surgical complications in patients who undergo bariatric surgery."

At a comprehensive, multidisciplinary obesity treatment center at a tertiary referral center serving central Pennsylvania, the investigators reviewed records of 881 patients undergoing open or laparoscopic gastric bypass surgery from May 31, 2002, through February 24, 2006. Before surgery, all patients underwent a 6-month multidisciplinary program with the goal of achieving a 10% preoperative weight loss. The primary endpoints of the study were loss of excess body weight and rates of total and major complications.

Loss of 5% or more excess body weight was achieved by 592 (67.2%) of the 881 patients and loss of more than 10% excess body weight by 423 patients (48.0%). Compared with patients undergoing laparoscopic gastric bypass surgery (n = 415), those referred for open gastric bypass (n = 466) were generally older (P < .001), had a higher body mass index (P < .001), and were more often men (P < .001). In addition, they had higher total complication rates (P < .001) and major complication rates (P = .03) vs patients undergoing laparoscopic gastric bypass surgery. Increased preoperative weight loss was associated with decreased rates of total complications (P = .004) and, most likely, decreased rates of major complications (P = .06), based on univariate analysis. In a multiple logistic regression model controlling for age, sex, baseline body mass index, and type of surgery, increased preoperative weight loss predicted reduced rates of total complications (P = .004) and major complications (P = .03). "Preoperative weight loss is associated with fewer complications after gastric bypass surgery," the study authors write. "We hope that these findings will be confirmed by prospective, controlled trials and that bariatric surgeons will consider this modality for preoperative risk reduction in selected patients who are deemed high risk for complications after surgery." Limitations of this study include retrospective design, lack of a control group, referral bias, and possible unmeasured confounding variables. In an accompanying invited critique, Patricia L. Turner, MD, from the University of Maryland Medical Center in Baltimore, recommends emphasizing an aggressive preoperative weight loss regimen. "Overall, this article presents the largest study thus far, to our knowledge, which may demonstrate a significant advantage to preoperative weight loss," Dr. Turner writes. "Moreover, the authors did not experience the attrition feared by some surgeons should they require preoperative weight loss of their patients. These findings suggest that consideration be given to incorporating either a suggestion of or the requirement for modest weight loss prior to bariatric surgery as a means of decreasing postoperative complications."

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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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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 and anemia: Monitoring nurtitional deficiencies needed

Washington, D.C. (National Anemia Action Council)

In recent years, bariatric surgery has become a much more common procedure to treat morbidly obese patients in the United States, with the number of surgeries increasing more than 10-fold in the last decade.1 This growth has occurred in part due to the large number of obese and morbidly obese individuals in need of weight reduction and the relative success of the surgery at shedding excess weight and reducing obesity-related health conditions.

Yet, surgery often creates permanent alterations of the digestive tract, which can lead to a variety of nutritional consequences. Many bariatric patients develop new or worsen preexisting iron and vitamin deficiencies, with some patients becoming anemic in the months and years following the procedure. These patients may then be relying on you, their primary care providers, to monitor their nutritional health. This article explains why bariatric surgery patients are prone to developing nutritional deficiencies and what you can do help them avoid anemia.

Candidates for Bariatric Surgery

In 2008, about 220,000 bariatric surgeries were performed in the United States to help patients permanently reduce excess body weight.2 Only morbidly obese patients are eligible for the surgery, as determined by their body mass index (BMI) – calculated by weight relative to height (kg/m2). Patients with a BMI >40, or a BMI >35 in combination with comorbidities, are considered for bariatric surgery. Comorbidities may include type 2 diabetes, heart disease, hypertension and sleep apnea, among many others. Approximately 15 million people in the United States (about 5%) are considered morbidly obese and about one-third are considered obese, with a BMI >30.2,3

Prior to surgery, morbidly obese patients may have numerous chronic illnesses and health complications, including nutritional deficiencies and anemia. According to Dr. John W. Baker, President of the American Society for Metabolic & Bariatric Surgery (ASMBS), about 60% of his patients have low or deficient levels of vitamin B12 prior to surgery and about 20%, both male and female, had preoperative iron deficiency. This rate is consistent with current statistical data of nutritional deficiencies among bariatric surgery candidates.4

Although prevalent, the etiology of their preoperative anemia can be elusive, with some morbidly obese patients displaying evidence of both iron deficiency and chronic inflammation. In a considerable percentage of candidates, the cause of anemia may be undiagnosed. Dr. Baker advises that preoperative anemia should be treated prior to surgery either by the surgeon or by the patient’s primary doctor. Following bariatric surgery, the surgeon and the patient’s primary care doctor often communicate about continuing care of the patient to decide the roles and responsibilities of each physician in the postoperative period. This coordination is especially important for a patient with any preexisting anemia, which will need to be monitored closely.

The Surgery Itself

Bariatric surgery has a considerable impact on both a patient’s overall weight and many of the obesity-related conditions that affect quality of life. A meta-analysis of over 22,000 bariatric surgery patients revealed that patients lost on average 60% of their excess weight. In contrast, patients treated with conventional diet and exercise reported losing less than 10% of their excess weight for a sustained time period and exhibited only mild effects on reduction in obesity-related conditions.4

Studies have reported type 2 diabetes being resolved in 73-87% of patients following bariatric surgery, depending on the type of surgery.5,6 Risk of coronary heart disease was cut in half5 and sleep apnea was resolved in more than 85% of patients.7 Additionally, when compared to candidates who did not have surgery, patients improved their life expectancy 89% of the time8 and reduced their risk of premature death by 30-40%.9 Risk of death from diabetes, cancer, and from coronary artery disease was also reduced by 92%, 60%, and 56%, respectively.10

Speaking in regards to the effectiveness of bariatric surgery at treating concomitant conditions of obese patients, Dr. Baker said, “This is one of the most durable procedures we have for resolution of chronic diseases. What other procedure can improve hypertension, heart disease, diabetes, sleep apnea and high cholesterol?”

How bariatric surgery affects a patient is largely determined by the type of procedure and how it alters the mechanics of the digestive tract. Weight loss results from reduction in the capacity of the digestive tract and number of calories consumed (restrictive), alteration of the absorption of food (malabsorptive), or a combination of both approaches. Restrictive methods include vertical banded gastroplasty (VBG) and laparoscopic adjustable gastric banding (LAGB). Malabsorptive procedures with some restriction include biliopancreatic diversion (BPD) and biliopancreatic diversion with duodenal switch (BPD-DS). Restrictive procedures with some malabsorption include roux-en-Y gastric bypass (RYGB) and vertical banded gastric bypass.11

Following surgery, a patient’s body must get necessary nutrients from less food with a smaller, less effective digestive system. Although helpful in reducing their caloric intake and fat absorption, these physical and metabolic changes leave them susceptible to nutritional deficiencies and subsequent anemia. Depending on the form of bariatric surgery, alterations to the digestive tract which may lead to an increase in nutritional deficiencies and anemia include the:

* Lower intake of food and essential nutrients
* Decrease in the absorptive surface area in the digestive tract
* Decrease in available stomach acid to help break down food and nutrients
* Possible intolerance to some nutrient-rich foods, such as red meat

Nutritional Deficiencies Related to Anemia

Iron deficiency is the most common cause of anemia after bariatric surgery and can be found in 20-49% of patients. This is especially true after the RYGB procedure in menstruating women (51%) and in patients with super obesity (49-52%).12 Other deficiencies which can lead to anemia are less common, but do include vitamin B12 and folic acid, which are most common in patients who exhibited signs of the deficiency prior to surgery or who are not receiving adequate supplementation. For instance, vitamin B12 deficiencies can occur in older patients, patients taking H2 blockers or proton pump inhibitors (PPIs), or in roughly 12-33% of patients not receiving supplementation after the RYGB procedure.

Baker quoteAlthough these deficiencies are mostly related to the altered absorption in the digestive tract, all forms of bariatric surgery can contribute to lower serum levels or reduced stores of nutrients. Dr. Baker has observed that, “Even in patients who didn’t have a malabsorptive procedure, I still see them coming in with deficiencies at follow-up; often due to preoperative deficiencies or preexisting conditions.”

The ASMBS Allied Health Nutritional Guidelines for the Surgical Weight Loss Patient states that, “Taking daily micronutrient supplements and eating foods high in vitamins and minerals are important aspects of any successful weight loss program. For the morbidly obese, taking vitamin and mineral supplements is essential for appropriate micronutrient repletion both before and after bariatric surgery.” The surgeon will recommend the necessary vitamins during presurgical education and consultation. Concerning anemia-related nutrients, these recommendations include a multivitamin with at least 100% of daily value for vitamin B12, 18 mg of iron, and 400 μg of folic acid. Following surgery, an additional vitamin B12 supplement or oral iron supplement may be required if monitoring indicates low or deficient levels of these nutrients.12 Patients may also be taking a recommended 1200 mg of calcium citrate daily, but should not ingest it at the same time as an oral iron supplement because the two will compete for absorption.

Continuing Care Following Surgery

Surgical patients are typically enrolled in postoperative programs to help them adjust to their new lifestyle and reinforce compliance with recommended dietary restrictions and nutritional supplementation. All patients in these programs are instructed to take multivitamin supplements, usually with iron. Many physicians recommend life-long supplementation, with iron-deficient patients being treated initially with oral iron. Patients who cannot or will not take oral iron because of gastrointestinal side effects may need to receive the generally more tolerable ferrous fumarate oral preparation or parenteral iron supplementation.

Postoperative nutritional care puts a great deal of responsibility on the patient who may not realize the drastic nature of the procedure as it relates to nutrient absorption and the need to comply with supplementation and follow-up care. It can be difficult for patients to adhere to these programs with many of them dropping out 3-6 months after surgery. Dr. Annette von Drygalski, a hematologic fellow at the University of California-San Diego who has worked with many anemic patients following bariatric surgery, has witnessed this. She said, “Some patients may not be educated enough about the surgery and some may not even remember what procedure they had. And, because bariatric surgery is a relatively new field, some physicians may not be educated about the nutritional implications.” Patients may remain healthy for a short time and may attribute postoperative symptoms of fatigue to the procedure alone while deficiencies develop. Iron deficiency and other causes of anemia can manifest years later, potentially putting primary care physicians in a tough spot.

“Sometimes patients won’t follow-up with anybody until they finally develop a complication,” noted Dr. Baker. “We encourage our patients to identify their primary care physician so that lab work and recommendations can be shared. This way, physicians can identify patients who are not following up after the surgery.”

Monitoring Nutrition & Deficiencies

Patients are often enrolled in a postsurgical program operated by the surgical team. Programs of this nature normally require patients to attend follow-up visits at the first, third, sixth and 12th months to monitor their overall health and address any symptoms they may be experiencing. At a minimum, screening for nutritional deficiencies occurs at the 6-month and 12-month visits. Adjustments to a patient’s dietary supplementation levels, initially set by the surgeon, may occur at these visits, if necessary. Some patients prefer to have these visits coordinated with their primary doctors instead of with the surgical team. In this case, the primary doctor should continue to update the surgical team of the patient’s care and status, and the surgeon should remain available for consultation.

Information for Bariatric Surgery Patients

* Bariatric surgery is not harmless, it drastically alters your body
* There are lifelong dietary and nutritional considerations
* You may not absorb vitamins or iron as well from the food you eat
* It is important to follow vitamin and iron supplementation
* Do not take iron supplements with tea, cola, coffee, calcium citrate or levothyroxine
* Remember the type of surgery you had performed and be sure to tell your doctor

If you are working with a known bariatric surgery patient for the first time, even if you have not had prior consultation with their surgeon, Dr. Baker recommends inquiring about their dietary intake, types of foods they eat, their menstrual blood loss if they are female, and any symptoms of fatigue which could be related to anemia, in addition to monitoring their levels of iron, vitamin B12 and folate as described below. Notable things to watch for include excess tea, cola or coffee consumption, which may interfere with iron conversion to an absorbable form. If taking an iron supplement, it is necessary to wait at least two hours before drinking any tea, taking calcium supplements, or taking the synthetic thyroid hormone levothyroxine. If possible, communication with their surgeon about recommended supplementation and follow-up care should be pursued prior to subsequent visits.

The first step in screening for anemia is acquiring a complete blood count that includes red blood cell indices. If anemia is present – determined by a hemoglobin <12 g/dL in women and <13 g/dL in men – indices can point toward the appropriate further investigation.13 Patients with a microcytic, hypochromic anemia most likely have an iron deficiency. Vitamin B-12 deficiency produces macrocytic red blood cells. Remember that the cause of anemia may be multi-factorial, so indices are not the final answer. Some screening guidelines of anemia-related nutrients, taken in part from the ASMBS Allied Health Nutritional Guidelines for the Surgical Weight Loss Patient,12 are listed below.

Iron – Ferritin levels should be checked at six months, one year and annually at a minimum following bariatric surgery. A normal ferritin level for men is 15-200 ng/mL and for women is 12-150 ng/mL.12 Also check serum iron (normal range 60-170 mcg/dL), total iron binding capacity (normal range 240-450 mcg/dL) and transferrin saturation (normal range 20-50%). Note that normal ranges vary by lab, so be sure to check for their established levels.
Related Research Review

A recent research review of the study by Coupaye et al prospectively compared the prevalence of nutritional deficiencies after adjustable gastric banding and gastric bypass procedures. Read more about the study in Research Reviews:
Evaluation of Short-term Nutritional Regimens Following Bariatric Surgery

Vitamin B12 – Serum B12 levels should be checked at six months, one year and annually at a minimum following bariatric surgery. A normal vitamin B12 range is 200-900 pg/mL,14 but serum measurements may miss 25-30% of deficiency cases in lower normal ranges. If symptoms of a vitamin B12 deficiency are present (including fatigue, bright red/smooth tongue or tingling/numbness in hands and feet) and vitamin B12 levels are 200-250 pg/mL, MMA and tHcy measurements may help identify the cause.12

Folate – RBC folate should be checked at six months, one year and annually at a minimum following bariatric surgery. A normal RBC folate range is 280-791 ng/mL, with a deficiency present at <305 nmol/L and the presence of anemia <227 nmol/L.12 Serum folate more closely reflects recent dietary intake than actual folate status measured by RBC folate. Although relatively uncommon before and after bariatric surgery, folate deficiencies should be monitored, especially in women who may become pregnant.

The Lasting Effects

Bariatric surgery and the behavioral changes patients adopt have shown to be very effective reducing excess weight and the effects of obesity-related health conditions. However, the physical and metabolic alterations as a result of the procedure must be monitored by patients and their healthcare providers for the rest of their lives.

A dedication to following supplementation recommendations and monitoring nutrient levels should be incorporated into routine care which the patient can follow, the primary care physician can execute, and which allows the bariatric surgeon to remain informed and available for consultation.

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Patient bleeds to death after gastric band surgery

A mother told to lose weight to avoid serious health problems died hours after surgery to fit her with a gastric band.

Susan Alderson had three litres of blood in her abdomen and had bled to death, a post mortem found.

Experts had advised the 49-year-old to have the band fitted, a procedure which reduces the size of the stomach.

Susan Alderson received gastric band surgery at the former Derby City General Hospital in January. She later bled to death

But after the operation, which was also to repair a hernia, Mrs Alderson suffered internal bleeding, which claimed her life, an inquest was told.

Mrs Alderson, a diabetic who weighed more than 16 stone, was told by dieticians she would need the surgery to help prevent other potentially life-threatening illnesses.

She was admitted to the former Derby City General Hospital in January.

The hearing, attended by Mrs Alderson's husband and son, was told the operation went ahead without complications and Mrs Alderson appeared to be recovering well.

Derby Coroner's Court heard she started bleeding internally hours later, leading to a cardiac arrest and her death the next morning.

Paul Leeder, who carried out the operation, said: 'I had never experienced any problems with patients having severe complications. I had not had a death either before that operation or since.'

He said Mrs Alderson's body mass index (BMI), which determines whether a patient has a healthy body weight by measuring their height and weight, was 44, classing her as morbidly obese.

A patient who weighs too much in comparison to their height is in danger of developing problems such as strokes, heart problems, arthritis and an increased risk of cancer.

Mr Leeder said: 'Mrs Alderson had been on a low-calorie diet but had only lost four kilogrammes (nine pounds).

'The three options were for her to carry on as she was, without surgery, to have a gastric bypass or to have the gastric band.

'The risk of bleeding, risk of death and failure rate of the procedure were explained. But the long-term benefits of sustained weight loss would have far outweighed the risks involved with the surgery.'

After surgery, Mrs Alderson, of Sinfin, Derby, was moved into a recovery area, where her blood pressure started to drop.

Doctors gave her injections to help boost her blood pressure but, later that evening, it started to drop again. She was moved to a higher dependency ward and appeared to be recovering.

Mrs Alderson was later transferred to a 'step-down' ward, where she suffered a heart attack and later died.

Her post mortem examination found between two-and-a-half to three litres of blood collected in her abdominal wall, close to the repaired hernia.

Dr Andrew Hitchcock, consultant pathologist at Royal Derby Hospital, said it was not clear where the bleeding had originated.

Dr Hitchcock said Mrs Alderson's medical cause of death was internal bleeding, related to the hernia repair and gastric band operation.

Recording a narrative verdict, deputy coroner Louise Pinder gave the cause of death as intra-abdominal haemorrhage and incisional repair and gastric band application.

Miss Pinder said: 'She had no particular interest in losing weight for interests of vanity, this was very much a medically-based decision.'

A spokesman for Derby Hospitals, said: 'Our thoughts are with Mrs Alderson's family.

'Any surgery carries a risk and in Mrs Alderson's case the risks were higher due to her high BMI, severe diabetes, liver problems and a hernia repair.

'These factors meant that when Mrs Alderson developed complications, her blood did not clot in the normal way.

'The coroner said that the clinical team could not have foreseen the tragic outcome in Mrs Alderson's case.'

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Risk of alcohol abuse increases after gastric bypas surgery

Sacramento, CA

On Friday's Live_Online at 11 a.m., we learned that an unintended consequence of gastric bypass surgery is the risk of alcohol abuse, said Laura Lagge, a certified alcohol and drug counselor with New Dawn Recovery in Citrus Heights.

Lagge told viewers she's seeing more women who turned to gastric bypass for their weight problem now struggling with alcohol abuse.

She said after the surgery, alcohol enters a person's system more quickly and the effects are stronger.

Lagge said, "If you are considering gastric bypass, tell your doctor truthfully about how much alcohol you currently drink." Once the surgery is done, patients must reduce the amount of food and beverages they consume or face serious health consequences, such as alcohol abuse.

Several high profiles DUI cases involving women, most recently the off-duty Sacramento County deputy who crashed into a Natomas Starbucks, prompted Friday's discussion on women and addiction.

Lagge added that alcoholism and addiction is a disease that "strikes all kinds of people, regardless of age, race, economic standing, gender or education."

"Having the disease does not mean you are immoral, weak or defective," and that recovery is a gradual process, like any other chronic disease, she said.

If you're wondering if you have a drug or alcohol problem, Lagge said consider the following questions:

1. Have you ever felt you should cut down or try to control your drinking or drug use?

2. Have you ever felt guilty or bad about your drinking or using drugs?

3. Do you ever take a morning eye-opener to steady your nerves or to get rid of a hangover? Do you use drugs or drink daily or weekly? Do you use prescription medications more often than prescribed?

4. Are alcohol or drugs sometimes more important that other things in your life, such as your family or your job?

5. Do you find yourself lying to your spouse, your kids, or your employer to cover up your drinking or using?

6. Have you ever switched from one type of drug to another to either prove you're not addicted or to help with withdrawal symptoms from another drug?

7. Have you had problems with your job, your relationship, finances, legal or your health due to your drinking or drug use?

8. Have friends or family members expressed concern for you about your drinking or drug use?

9. Have you gone to work or driven while intoxicated or in a drug-induced haze?

10. Have you been drunk or high more than four times in the past year? Do you sometimes stay drunk or high for days at a time?

11. Do you need more alcohol or drugs in order to do something (start the day, have sex, clean the house, socialize, for example) or to change how you feel?

12. Do you need more of the drug or alcohol in order to get the same effect?

13. Are you uncomfortable when you have to be somewhere where no alcohol or drugs will be available?

Lagge said if people answer yes to two or more of the above questions, "they are at the very least abusers and would benefit greatly from stopping."

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California woman seriously ill after gastric bypass surgery finds hope

Modesto, CA

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

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

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

Repairs are complex

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

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

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

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

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

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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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Studies underway to determine why obesity surgery thins bones

from Red Orbit

Experts say melting fat from obesity surgery somehow thins bones and even suggest that patients who undergo these procedures might have twice the average person's risk for a fracture, and are more likely to break a hand or foot, The Associated Press reported.

Further research is now under way to see if The Mayo Clinic's finding is significant. But specialists say uncovering long-term side effects from bariatric surgery and how to counter them takes on new urgency as more and more overweight people are electing to try it.

Dr. Shonni Joy Silverberg of Columbia University told last week's annual meeting of The Endocrine Society that these procedures are now being sold as a panacea.

"It is of heightened importance to find the answers to these questions," he said.

And perhaps the only positive thing you'll ever hear a doctor say about too much fat is that obesity actually is considered protective against bone-weakening osteoporosis.

Mayo bone-metabolism expert Dr. Jackie Clowes said overweight people are starting out better than most of us when it comes to staving off osteoporosis.

Therefore, researchers are working towards answering whether those who undergo the procedures really end up with worse bones, or just go through a transition period as their bones adjust to their new body size.

In the United States, some 15 million people are classified as extremely obese (100 pounds or more overweight). With rampant diabetes and other health problems, surgery is fast becoming the preferred treatment.

Options include stomach stapling called gastric bypass to less invasive stomach banding procedures, where patients tend to lose between 15 percent and 25 percent of their original weight — dramatically improving diabetes symptoms.

The American Society for Metabolic and Bariatric Surgery shows that more than 1.2 million U.S. patients have undergone the surgery in the past decade, 220,000 in the last year alone.

Now large National Institutes of Health studies on both adults and teens are underway to find more data on how patients fare many years after the surgeries.

However, doctors know that radical weight loss can speed bone turnover until the breakdown of old bone outpaces the formation of new bone.

A year after gastric bypass, adults' hip density drops as much as 10 percent, raising concern about a common fracture site of old age, according to more recent studies.

And while almost half of peak bone mass develops during adolescence, more research is needed to determine if teen bones react similarly.

The Mayo team is comparing the medical records of nearly 300 adults who've had bariatric surgery with similarly aged Minnesotans who haven't, to see if such changes translate into fractures.

Mayo's Dr. Elizabeth Haglind told the endocrinology meeting that a quarter of the 142 surgery recipients studied so far experienced at least one fracture in the following years. That group had twice the average risk six years after the surgery.

Interestingly, the surgery recipients had three times the risk of hand and foot fractures than their Minnesota neighbors.

Dr. Scott Shikora, president of the bariatric surgeons group, said he was shocked at the numbers because he hasn't seen a significant fracture problem in his own practice.

Shikora estimates about half of surgery patients follow their doctor’s advice to take extra calcium and vitamin D, and other research suggests higher doses may be needed anyway as the obese tend to start out with vitamin D deficiency.

“Don't skip checkups, where doctors monitor bone health, and aggressively treat nutrient deficiencies,” Clowes advised.

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Gastric Bypass surgery: Pros and Cons

Tulsa, OK

Gastric bypass surgery is growing more popular every year as America's obesity epidemic tips the scales. Even the elderly, and people with health problems are turning to this surgical solution to obesity.

It is a surgery that saves lives. But some also warn there can be life-changing drawbacks.

"These were 26 - and I wear a size 8 now," said Leslie Blunt as she proudly showed off the pants she will never wear again thanks to gastric bypass surgery. She has lost 140 pounds. "It works. It does. You live a healthier life," she added.

Micah Anderson chose gastric bypass surgery when his weight ballooned to 500 pounds. "Lost little over 200 pounds - easy," he told 2News anchor Karen Larsen. "I'm happy with myself. More confidence."

While gastric bypass is known for bringing on drastic weight loss, what many do not realize are specific changes it may cause for an individual, along with health benefits.

"A lot of this junk food they were eating before - their taste has disappeared they don't want it anymore," according to Dr. Luis Gorospe, gastric bypass surgeon at Bailey Medical Center in Owasso. Both Anderson and Blunt went to Dr. Gorospe for surgery. His patients come from surrounding states, drawn by his surgery success rate, the promise of dramatic weight loss and the immediate health benefits of gastric bypass.

"If they have diabetes - 70 percent of these patients wake up with normal blood sugar and will not require medications - forever," Dr. Gorospe said.

Studies show gastric bypass may improve or even eliminate such health problems as:

Leslie Blunt says she is living proof, "I don't have high blood pressure. I don't have diabetes. I am pill free."

However, Micah Anderson tells a different story. "I'll vomit maybe not every week - but if something doesn't agree it does come right back up."

When surgeons create a tiny new stomach for patients, vomiting is a common problem when patients eat too much, too fast - until they get used to their new, smaller stomach. Micah says he expected that - but then he started fainting - once behind the wheel of his car.

Anderson's wife Katie said, "The passing out has happened four times. Spells where he could potentially pass out... weekly!"

Frightened by the potential danger such episodes represented, the Andersons began researching online and discovered other gastric bypass patients having such problems.

"Describing the same kind of drunk-like symptoms, incoherent, can't talk, slurring the speech. and people were experiencing the same things," Katie added.

The Andersons say they went to numerous doctors and nutritionists, trying to find a physician who was experienced with gastric surgery side effects. After trial and error, they say they have finally found the right doctor to care for Micah. As a result, Micah now follows a diet carefully crafted to meet his personal needs. He eats every two hours, consumes plenty of protein and takes vitamins.

"For me its lack of eating. I forget to eat and that's what causes my issues. It's partially my fault as much as it is the surgery," Micah said. "If I don't follow the rules like they tell you - you do have issues."

Doctor Gorospe agreed. He said healthy eating - the same issue obese patients struggle with before gastric bypass - is more important than ever after surgery. "If you follow the rules, this surgery will be successful," Dr. Gorospe said.

Because some patients do encounter issues following surgery, and with their new lifestyle, Doctor Gorospe offers monthly support groups. "I make it a point of being there," he said. "I want to be available to my patients." The meetings offer patients an opportunity to share their stories and talk with Dr. Gorospe.

Micah did attend the monthly meetings. However, some of his problems did not occur until several years following the procedure. As a result of his struggle, the Anderson's suggest to those considering gastric bypass surgery: do plenty of research, know the rules they will have to live by, and read up on potential side effects.

"There is a list and, by golly, one of those things on the list will affect you," Katie Anderson said. "They just need to tell you flat out - you are trading one set of issues for another set of issues."

However, when asked if he would have the surgery again, Micah's answer is, "Unfortunately, yes." He went on to say he is pleased with his more than 200 pound weight loss. His joints ache less when he gets out of bed in the morning, and it is easier to be active.

Leslie Blunt agrees. Now, this svelte hair stylist says work is easy. No more suffering from carrying too much weight while being on her feet each day. Plus, she loves buying clothes with her new look and the fact that she is setting a good example for her young children by living a healthier lifestyle.

In fact, Leslie says gastric bypass surgery is the best thing she ever did for herself. "Yes! I would do it over and over and over again! I never want to be that way again."

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Family demand answers after gastric bypass death

Macclesfield, UK

The family of a woman who died following a gastric bypass are demanding answers into her death.

Suzanne Wrighton, aged 59, died on May 30, 2008, less than 36 hours after having three operations at The Regency Hospital in Macclesfield.

Mrs Wrighton, who lived in Moreton Road, Crewe, decided to go in for the surgery paid for by the NHS at the private hospital because she was overweight and suffered from back pain.

Her husband Brian, aged 64, yesterday told an inquest into her death at Macclesfield Town Hall that he and his wife had been to two consultations prior to the operation and had been told there was a one per cent chance of fatality.

He said: "Suzanne had suffered from back pain for a long time. It started after she had a car crash in 1987. She had two operations on her spine but she still suffered from pain and she put on weight because she couldn't exercise.

"She decided on a bypass rather than a band. We know there is a risk with any operation but the risks we were told about weren't enough to worry her."

The inquest heard that after the first operation on May 28 Mrs Wrighton was in severe pain.

The following day consultant surgeon William Brough decided to perform a second operation to find out what the problem was but it wasn't until May 30 after the third operation that he found Mrs Wrighton had suffered a bleed.

Mr Brough said: "This was a rare complication that could not have been seen beforehand.

"It is the first time I have heard of a bleed from the staple line."

Mr Brough said that since Mrs Wrighton's death the hospital has altered protocol to ensure that all patients no matter how ill they are will have blood tests the day after the operation.

Mrs Wrighton died from adult respiratory distress syndrome (ARDS), which is when the lungs become filled with fluid and can't function properly.

Deputy coroner for Cheshire Janet Napier recorded a verdict of death due to complications following an operation for weight loss.

After the inquest Mr Wrighton, said: "We will be speaking to our solicitor and launching a complaint against the hospital. We are not happy with how Suzanne was treated. She was screaming out in pain most of the time she was in the hospital."

Suzanne's daughter-in-law Tammy Buxton, from Burslem, said: "The inquest hasn't really answered our questions.

"We still don't know why they failed to find the bleed until after the third operation.

"We have got to the bottom of the reason why she died. We don't want other families to go through the same pain and trauma we've been through."

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The trouble with gastric bypass surgery

Phoenix, AZ

Many extremely obese people these days, under the mistaken belief that it will be the answer to their health problems, are flocking to get gastric bypass surgery. Now this treatment option may be pushed on even more people. A study published in The American Journal of Managed Care reports that bariatric surgery can "pay for itself" by diminishing the number of insurance claims filed by people who are grossly overweight.

Gastric Bypass Surgery Is No Picnic

However, gastric bypass surgery has many associated risks. The risks, according to a Mayo Clinic article, include death, blood clots in the legs, leaking at the staple lines in the stomach, incision hernia, narrowing of the opening between the stomach and small intestine, dumping syndrome, iron deficiency anemia, vitamin B-12 deficiency, vitamin D deficiency, dehydration, gallstones, bleeding stomach ulcers, intolerance to certain foods, kidney stones, low blood sugar, body aches, fatigue (like when one has the flu), feeling cold, dry skin, hair thinning and hair loss, and mood changes. Of course, there are also the same risks that go along with any surgery, like bleeding, infections, and adverse reactions to the anesthesia. That doesn't exactly sound like a picnic, no pun intended.

Will Surgery Save Insurance Companies Money?

Unfortunately, there is even more reason to be concerned about gastric bypass surgery. Dr. Douglass warns in an article that the funding for the study that purports that this surgery will save insurance companies money came from a company known as Johnson & Johnson's Ethicon Endo-Surgery, Inc., which is a major manufacturer of bariatric surgical instruments. Additionally, Dr. Douglass points out that Dr. Scott Shikora, a co-author of the study, is the president of the American Society for Metabolic and Bariatric Surgery. It's easy to see that the members of this group would clearly benefit if insurance providers would decide that they could save money if more patients were approved for this course of treatment.

Up to Five Percent Die Within a Year of Surgery

The sad truth of the matter is that, according to Dr. Douglass, up to five percent of the patients who undergo this course of treatment are dead within a year. (That's certainly one way to trim down future medical costs.) While Dr. Douglass believes that surgery should always be a last resort, many other doctors believe that the current requirement by insurance companies that people first try to lose weight by a six-month doctor-supervised weight loss program is unreasonable. Says Douglass: "People like Shikora would prefer that patients go right from the dining room table to his operating table." While natural health advocates might not agree with Dr. Douglass on all of the issues, most certainly appreciate his acerbic wit. Hmmm... was the guy who said that "the way to a man's heart is through his stomach" a bariatric surgeon?

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Risks of gastric-bypass surgery are often underplayed, some experts say

Greenwood Lake, NY

Despite the growing popularity of obesity surgery, it’s no easy path. Four in 10 patients developed complications within the first six months, according to one study.

Eileen Wells was smiling as she was wheeled into surgery. She was too excited to feel nervous. At 38, she was about to get “a new lease on life,” she says, echoing jargon in weight loss surgery ads. She had seen the before and after pictures in celebrity tabloids, watched the TV infomercials, listened to the patient testimonials and researched online. She was ready to begin her own transformation. At 5 foot 3 and 290 pounds, she was sick of being fat. Her joints ached. Her feet hurt. A stroll through the mall near her home in Greenwood Lake, New York, was enough to leave her sweat-slick and gasping for air. She was anxious to say good-bye to sleep apnea and dieting, ready to take control. And so in March 2005, Wells underwent a laparoscopic gastric bypass. She was grinning right up until the anesthesia knocked her out.

From the menu of weight loss (bariatric) operations, Wells had chosen the Roux-en-Y bypass, the most popular option in the United States. The surgery sectioned off her stomach to a thumb-sized sac — sharply limiting the amount of food Wells could eat — then connected it to a deeper portion of her small intestine, to limit absorption of the calories she did consume. (An increasingly popular alternative, gastric banding, cinches in the stomach to restrict its capacity.) The rearrangement required Wells to radically overhaul her eating habits. She learned to eat tiny, frequent meals, cutting her food into pencil eraser–sized bites. On her doctor’s orders, to replace nutrients no longer absorbed by her digestive tract, she faithfully swallowed a multivitamin, calcium and B12 supplements and two protein shakes daily. Soon she resembled the women in those weight loss infomercials: Fifteen months post-op, Wells had lost an amazing 160 pounds — more than half her body weight — bringing her down to a trim 130.

But although Wells looked like a satisfied customer, she didn’t feel like one. Seven months after surgery she had developed an agonizing ulcer on the new inner seam between her stomach and intestine, which required a second operation. Not long afterward, Wells recalls eating a bite of tuna steak her husband, Ron, had prepared and doubling over in pain; an ambulance rushed her into surgery yet again, this time for an intestinal hernia — her bowel had snagged on a slit in her abdominal wall. A fourth procedure followed to ease the pain of the abdominal scarring from her previous surgeries. Meanwhile, Wells’s gastrointestinal pain had become so severe that she could barely eat. One day while shoe shopping, she realized she couldn’t flex her right foot. Within weeks her limbs began to tingle, her energy evaporated and her weight plummeted. She stopped menstruating. By late 2006, Wells had shrunk to 105 pounds.

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48 year-old father dies 5 weeks after gastric bypass surgery

Manchester, UK

An obese father of two died after suffering complications from surgery to help reduce his weight, a coroner has ruled.

Gary Cooper, 48, of Ashton-under-Lyme, Manchester, died five weeks after having gastric bypass surgery last October.

The "gentle giant", who was believed to have weighed around 26 stone, had the NHS-funded operation at the private Alexandra Hospital, Cheadle, on October 14 last year.

Mr Cooper was released from hospital four days later despite being breathless and in agony, the inquest at Stockport Magistrates' Court heard.

The following day, he was rushed to Tameside General Hospital after his condition deteriorated and, the next day, he had an emergency operation to repair two leaks in his stomach.

Nine days later, he had a second operation to repair a third leak and, after a brief spell in intensive care, appeared to be recovering well.

However, on November 22, the day before he was due to be released and the date of his wife Sonia's birthday, he collapsed and died.

Coroner John Pollard said he had doubts about the way the risks of surgery were explained to Mr Cooper by his surgeon, Bart Decadt.

He said: "I am satisfied that these risks were discussed, but I am left with a remaining doubt as to whether they were perhaps addressed by Mr Decadt in a rather light-hearted way and the real risk may not have had as firm an impression in the mind of Gary Cooper as ought to have been the case to enable him to make a fully considered and informed decision."

Mr Pollard said he intended to ask the Alexandra Hospital to review its patient discharge policy and to report back to him.

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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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Obesity epidemic leading to rise in gastric bypass surgery

Longview, TX

As advancements continue to change the field of medicine, patients continue to benefit. Average life expectancy is still rising, and new medicines are increasing the quality of life for patients with chronic conditions.

In spite of these medical advancements and a cultural shift emphasizing the importance of exercise, one particular area that remains unsettling is the growing number of overweight or obese Americans. Using measured heights and weights, the 2003-2004
National Health and Nutrition Examination Survey (NHANES) reported that 66 percent of American adults are either overweight or obese.

For many obese or overweight Americans, shedding weight has led them to lifestyle changes, such as a healthier diet and a new exercise regimen. Many others go the surgical route, as 177,000 Americans opted for weight loss surgery in 2006 alone. The vast majority of those surgeries were Roux-en-Y gastric bypass surgery. While gastric bypass can seem like a quick fix that enables patients to shed weight almost overnight, the surgery and its ramifications are in fact quite complicated, and should never be looked at as an easy way to drop weight.

What Is Gastric Bypass?

Roughly 80 percent of the weight loss surgeries performed in America this year will be gastric bypass procedures. This is a two-part procedure.

· Stomach pouch: The creation of a stomach pouch is the portion of the procedure many people refer to as “stomach stapling.” During this part of the surgery, the stomach is divided unequally, with one large pouch and one much smaller pouch. After this division, the smaller pouch is sewn or stapled. That pouch can only hold a very small amount of food (roughly one cup). Such a small holding capacity is designed to make people feel full faster, which in turn will make them eat less.

· Bypass: In the second stage the surgeon will employ the Roux-en-Y technique, in which the smaller pouch is disconnected from the first part of the small intestine (the duodenum). The surgeon will then reconnect the stomach to a lower portion of the intestine (the jejunum). Once that has occurred, any food consumed will pass directly from the stomach into this lower portion, where fewer calories and nutrients are absorbed.

What Happens After the Surgery?

While patients can expect to lose weight after gastric bypass surgery, there are negative consequences as well. Though not all patients will experience such consequences, and death is extremely rare (especially when surgery is performed by an experienced gastric bypass surgery), some of the following might occur after surgery.

· Wound infections

· Problems with digestion

· Bleeding

· Ulcers

Those are some of the more common complications after surgery. Some of the less common, though extremely serious and potentially life-threatening, complications include the following.

· Pulmonary embolism (blood clot)

· Serious infection and persistent bleeding

· Heart attack

· Leakage in the surgical connections in the intestines

Because of the nature of the surgery, in which food is re-routed into the jejunum where less nutrients are absorbed, certain health problems can arise as a result. For example, the human body needs a certain amount of iron and calcium to remain healthy. However, the jejunum does absorb these nutrients well, and therefore conditions such as anemia and osteoporosis can arise as a result. Iron and calcium supplements, as well as routine blood tests, can lower the risk of developing such conditions.

Although there can be complications, many gastric bypass patients experience positive results. Weight loss is often dramatic, especially for patients who were considerably overweight.

Another benefit of gastric bypass is that patients who have obesity-related health problems often see improvements in those conditions after surgery. Such conditions include diabetes, sleep apnea and high blood pressure.

While the benefits of gastric bypass surgery are numerous and have helped many a public figure, it’s important to recognize the surgery is not a one-size-fits-all solution, and each case needs to be examined on an individual basis.

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What to do when gastric bypass surgery obesity fails

Los Angeles, CA

The number of people getting obesity surgery has more than doubled in the past eight years. But the highly popular and risky procedure doesn't always work for everyone. So can these patients be helped? One local doctor offers a high-tech solution.

When 47-year-old Patricia Weiss gets on a scale these days, she smiles.

"I've lost about 35 pounds since I had it. It's been a year almost a year," said Patricia.

It's been a year since her second time around with an obesity procedure. The first time was in 2002 -- Patricia underwent a gastric bypass and lost 150 pounds. But then the weight started to creep back on.
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"I put on about 30 to 40 pounds, and I said, 'No, no, going the wrong way.' I didn't do all this to have this come back," said Patricia.

In 2007, there were about 160,000 to 200,000 gastric bypasses performed -- that's at least double the number performed in 2000. Of those surgeries, doctors say about 15 percent fail.

Often patients regain because they start to over eat again and stretch out their reconstructed pouch. Patricia went to see Dr. Jeremy Korman. He says standard x-rays and endoscopes don't give doctors the whole picture and this makes it difficult to proceed. He says he may be the only surgeon in the U.S. to use the 64 slice CT scan technology on obesity surgery patients.

"Now once we understand accurately the size of the pouch, we can plan what kind of operation would be appropriate, what size of revision operation is appropriate," said Dr. Korman.

Dr. Korman says he can either redo the original surgery, implant a LAP-BAND to restrict the pouch growth, or perform a new minimally invasive endoscopic procedure in which he sews up and shrinks the pouch from the inside.

Patricia opted for the LAP-BAND. More >>

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Vagotomy: Gastric bypass surgery alternative?

Orlando, FL

Weight loss surgery is becoming a more popular choice for obese Americans. There were nearly 10 times as many weight loss procedures performed in 2005 as 1998. Gastric bypass surgery is a real option for patients, but it also comes with real risks. Nutritional deficiencies occur in more than 30 percent of patients and nausea and vomiting after eating occurs in up to 15 percent of patients. Other major risks include ulcers, hernias and even death.

SAFER APPROACH: A procedure that was once commonly used to treat ulcers, called a vagotomy, is now being tested as a safe weight loss surgery. Robert Lustig, M.D., from the University of California, San Francisco Medical Center, says, "[Vagotomy] was actually the most common procedure done in this country between 1944 and 1978." But the way the procedure was performed back then for ulcers caused lot of undesirable side effects. Even so, doctors noticed that people who had the procedure for ulcers also lost weight. Because it was invasive and had bad side effects, the procedure fell to the wayside, especially as newer drugs and treatments for ulcers emerged and, of course, so did gastric bypass surgery for obesity. Doctors are now revisiting vagotomies as a way to lose weight. They have modified the procedure so that it is safe and side effects are minimal -- and they've also made it a laparoscopic procedure. For weight loss, the procedure can be done non-invasively with five small incisions in about 20 minutes.

WHAT IS IT? During a laparoscopic vagotomy, doctors actually go in and cut the vagus nerve in the esophagus. Dr. Lustig says, "The vagus nerve is the energy storage nerve. That's its job. That's part of why you get hunger is the vagus nerve from the stomach to the brain tells you, the stomach is empty, you need to eat." By cutting the nerve, Dr. Lustig can eliminate the severe hunger that many obese patients report. Their hunger just simply goes away. Dr. Lustig says, "The majority of the weight loss that's achieved is primarily in the first six months, nine months and then it definitely slows down. But they're not regaining it. They are actually keeping their weight down." More >>

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Gastric bypass surgery Part I: A big risk

Orlando, FL

Monica Ramos lost about 200 pounds the hard way. In 2004, a doctor stapled her stomach and rerouted her intestines.

She underwent gastric bypass surgery. A year later, Ramos collapsed in her home and was rushed to the hospital, where she needed another operation to stop internal bleeding.

Her weight-loss surgery represents the gamble that legions of morbidly obese Americans are taking every year. For many, it 's worth the risk. More >>

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Despite risks, gastric-bypass surgeries soar

Herald, FL

Monica Ramos lost about 200 pounds the hard way.

In 2004, a doctor stapled her stomach and rerouted her intestines.

A year later, Ramos collapsed in her home and was rushed to the hospital, where she needed another operation to stop internal bleeding.

Her weight-loss surgery represents the gamble that legions of morbidly obese Americans are taking every year. For many, it is worth the risk.

When Ramos had her initial operation, she was on 17 medications for diabetes and other ailments. Today, she needs no prescriptions. Her diabetes is gone; she feels great.

But the soft-spoken nursing student warns that surgery is not a cure for obesity.

"This is a lifelong commitment, and there are going to be days when you're sorry you've made this commitment," said Ramos, 26, who runs a support group in Orlando for weight-loss-surgery patients.

If current trends continue, she will be busy.

Weight-loss surgery -- commonly referred to as bariatric surgery -- has exploded in the United States from an estimated 16,200 procedures in 1992 to about 205,000 in 2007. More >>

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Woman on death bed warns of gastric bypass surgery dangers

December 2, 2007

As she lay dying, Jan Malcolm made her husband promise.

"Tommy, we've got to tell people," she said. "If I live through this, we need to warn everyone so that no one else has to suffer like this. If I die, you must warn everyone so they will be aware of what to do to avoid this."

The last words T.F. "Tom" Malcolm heard from his wife of 47 years were, "You were right." more >>

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