Physicians debate best candidates for gastric bypass

Washington, D.C.

Recent studies showing that gastric bypass surgery extends the lives of obese patients is forcing surgeons to make tough decisions about who should go under the knife and who shouldn't.

Internists, cardiologists and endocrinologists, more than ever, are referring patients who traditionally haven't been candidates for the weight-loss surgery, also called bariatric surgery.

"I am being asked to operate on 78-year-olds with co-morbidities of heart disease and diabetes," said Dr. Edward H. Phillips, executive vice chairman of the Department of Surgery and a surgeon at the Center for Weight Loss at Cedars-Sinai Medical Center in Los Angeles. Phillips questions whether these patients will benefit, or if the damage has already been done.
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"So, while it is obvious a 30-year-old will benefit, at what age is too old?" he asked.

The success of gastric bypass is also stoking debate about its use as a treatment for type 2 diabetes. Mounting evidence suggests this type of surgery may dramatically improve patients with the disease, freeing them from a lifetime of diabetes medications.

"There's more acceptance now of the concept that bariatric surgery is a truly life-saving type of therapy rather than just a way to shed pounds," said Dr. Francesco Rubino, chief of Gastrointestinal Metabolic Surgery at Weill Cornell Medical College in New York City.

Still, more long-term studies are needed, and clinicians and policymakers must reach a consensus on who should have access to this type of surgery, noted Rubino, who directed the 1st World Congress on Interventional Therapies for Type 2 Diabetes, held in New York City in September.

An estimated 205,000 bariatric surgeries were performed in the United States in 2007, according to the American Society for Metabolic & Bariatric Surgery (ASMBS). That's an increase of almost 20 percent from two years earlier.

If patients commit to making necessary changes in their diet and exercise regimens, gastric bypass surgery can provide long-term, consistent weight loss, according to the Mayo Clinic.

Not only does it help shed pounds, but a pair of studies published last year in the New England Journal of Medicine found that it can help obese people live longer.

One study, led by Ted Adams of the University of Utah School of Medicine, tracked almost 16,000 obese people, half of whom had weight-loss surgery. After an average of seven years, the death rate was 40 percent lower for people who had the surgery compared with those who didn't. Diabetes-related deaths were cut by a whopping 92 percent.

The other study, led by a Swedish team, involved more than 6,000 obese patients. After an average follow-up of more than a decade, those who had bariatric surgery were 29 percent less likely to die than those who did not undergo surgery.

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Student will be first adolescent to have gastric bypass as part of UM Health System program

Ann Arbor, MI

She wants to shop for a prom dress, buy clothing at a regular mall store and walk easily across the stage on graduation day.

"I don't want to wheeze when I grab my diploma," said Sarah White, 16, of Vandercook Lake. "I don't want to graduate in a really large gown."

With more than 410 pounds on her 5-foot, 4-inch frame, the Vandercook Lake High School junior is desperate to lose the weight that for years has restricted her activities, drawn sneers from some classmates and compromised her health.
About gastric bypass surgery

The surgery changes the anatomy of a patient's digestive system to limit the amount of food that can be eaten and digested. It redirects food to bypass most of the stomach and flow directly into the middle of the small intestine, which limits calorie absorption. The surgeon uses staples to create a walnut-sized pouch at the top of the stomach that holds about an ounce of food and sews part of the small intestine directly onto the pouch. Risks include death, blood clots in the legs, leaking at the staple lines in the stomach and dumping syndrome, caused by stomach contents moving too quickly through the small intestine. The syndrome causes diarrhea, abdominal cramps, vomiting, sweating and dizziness.

— Source: Mayo Foundation for Medical Education and Research

She is scheduled to undergo gastric bypass surgery Tuesday at C.S. Mott Children's Hospital at the University of Michigan in Ann Arbor. White will be the first adolescent to have the weight-loss surgery as part of the UM Health System's new Pediatric Comprehensive Weight Management Center program.

"Her health is so significantly affected that surgery is warranted," said Dr. Susan Woolford, a university pediatrician and the center's medical director.

The university set up the family-focused program a year ago to combat the growing problem of childhood obesity. White entered in February 2007 when she was at her peak weight of 423 pounds, said her mother, Patricia White.

Sarah White revamped her diet and started exercising more, but did not lose much weight due to underlying health conditions, including a thyroid problem, Woolford said.

The surgery, which restructures the digestive tract and shrinks the stomach to limit the intake of food, is becoming increasingly common among teens as more struggle with obesity. But it still is not performed often, doctors said.

Some children's hospitals do not offer the surgery, and Woolford said she doesn't know of gastric bypass ever having been performed on an adolescent at UM.

According to medical literature, there are concerns about the long-term effects and the ability of pediatric patients to give informed consent to an invasive procedure that involves a lifetime of follow-up care and dietary restrictions.

"I had no other option," said White, who with support from her mother made the decision to go ahead with the procedure despite some early reservations.

"I was scared about all my intestines looking like a modern-day Picasso," she said Friday at the high school. She plays clarinet in the band, belongs to Students Against Destructive Decisions and said she has a 3.79 grade point average.

She had some qualms about the permanency of the surgery, "But it's either face up to eternity or die at 20," she said.

Fighting the weight

For years, White's weight-loss attempts have failed.

"I remember in elementary school, she bought salads and white milk or water when she bought lunch every day; that didn't work. She walked three miles a day and that didn't work," said her friend, Kelsey Weathers, 16, a diminutive girl who has been friends with White since kindergarten.

White once joined Weight Watchers with her grandmother, but said it seemed weird to be with a group of older women. She didn't lose weight, became frustrated and quit.

She weighed 6 pounds, 13 ounces at birth but quickly gained weight, developing faster than average children, her mother said.

Sometimes it is just easier and cheaper to eat at McDonald's than buy healthier foods, said Sarah White, who listed her weaknesses as Mexican food and pizza. At times, she struggled with emotional eating, but wasn't the type who raided the refrigerator at night, her mother said.

"Her body just doesn't metabolize the food," Patricia White said of her daughter, who was diagnosed at an early age with a type of hypothyroidism, meaning her thyroid gland doesn't produce enough of certain hormones, which impact metabolism.
By Dave Weatherwax | Jackson Citizen PatriotSarah White collapses her head on her mother's shoulder, Patricia White, after finishing her workout Friday afternoon at Planet Fitness of Jackson.

Both sides of her family have overweight members, said Patricia White, whose brother had gastric bypass surgery about two years ago. "She is genetically screwed."

Her daughter was obese by age 8, said White, a single, working mother who is both fiercely protective and proud of her daughter.

The two are clearly close and tease each other continually.

Friday, Patricia White razzed her daughter about her weight-induced spinal curvature, calling her Quasimodo.

"Well, he got the girl in the end, so there is hope for me," Sarah White countered, smiling.

Struggling with pain

The surgery is expected fix some of her problems, such as the curvature and the weight-related pain she feels in her back and knees.

At 8, Sarah White was diagnosed with type 2 diabetes and metabolic syndrome, a cluster of conditions that occur together and increase risk of heart disease, stroke and diabetes.

The excess weight has affected her self-esteem, her friends said. She regularly endures strangers' stares. It also makes school occasionally difficult.

Though White is witty, reads regularly and impresses friends with her vocabulary, her classmates haven't always been accepting, she said. "Especially in middle school, when everyone is discovering the opposite sex."

She cried often then.

Before she got involved with the program at UM Health System, which taught her to change some of the behaviors that contributed to her weight issues, she said she felt like a panda.

"All I did was sit around and eat and look cute," said White, who likes pandas and has many stuffed versions of them in her oriental-themed bedroom.

By the time she got to high school, things got better as the focus turned to academics.
More info

For more information about the University of Michigan's Pediatric Comprehensive Weight Management Center, visit www.med.umich.edu/MPOWER

"I've always been the smart fat kid, which is better than just being the fat kid," said White, who speaks openly and often comically about her situation.

"What I can't do physically, I make up mentally."

Her band director, Chip Williams, called her a "very good student."

"She is one of my top players," he said after class Friday.

However, White said she cannot both play her clarinet and march because it requires too much air and energy.

Her size keeps her from sitting at classroom desks. Instead, she sits at a table outside the rows other students fill.

For school dances, she has worn a purple pin-stripe suit. "It is hard to be girly in this body," she said.

A new chapter

She is looking forward to shopping for a prom dress after her surgery, which could help her lose 100 pounds by her birthday in January.

Her goal is to lose at least 200 pounds.

The surgery is about 90-percent successful in spurring and maintaining weight loss, said Dr. Henry Buchwald, professor of surgery at the University of Minnesota in Minneapolis, who has specialized in metabolic or bariatric surgery for decades.

The mortality rate in surgery is about 0.5 percent, he said.

Long-term effects of the operation on teens have not entirely been explored because the surgeries have been performed for about 20 years. But the procedures have held up over five-, 10- and 20-year periods, Buchwald said.

"What we hope we are doing for these adolescents is giving them time. Obesity is a fatal disease," Buchwald said.

The Tuesday surgery likely will keep White in the hospital for a week and a half, she said.

Her diet will be seriously limited in the weeks after surgery, as it has been in the weeks leading up to surgery.

For lunch Friday, she ate applesauce, a protein shake and yogurt, in compliance with a liquid diet she has been required to follow since Aug. 26.

To avoid temptation, all solid food has been removed from the house, Patricia White said.

After surgery, patients have to stay on course and maintain healthy life style habits to be successful, Woolford said. "Weight-loss surgery is not a magic bullet."

White has made the necessary changes, including incorporating physical activity into her weekly schedule, Woolford said, and has a strong family support structure.

She is rarely, if ever, negative, her friend Weathers said.

Some of the dietary restrictions have been difficult, Sarah and Patricia White said, but the payoff will be worth it.

"It's a small sacrifice to live longer," Patricia White said.

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Are you a candidate for gastric byoass surgery?

The option of surgery to treat obesity has gained in popularity over the past several years. As the techniques and knowledge regarding the subject have improved, so too have the results. However, not everyone is a candidate for surgery when it comes to their weight. Moreover, one must be sound psychologically as well as physically to undergo either of the two most common procedures, Rous-En-Y gastric bypass and adjustable gastric banding.

Generally speaking, one must have a body mass index (BMI) greater than 40 to be considered for surgery, or have a BMI greater than 35 with one or more obesity related co-morbidities such as diabetes, obstructive sleep apnea, hypertension or the metabolic syndrome. In addition, it is rare that a physician or other healthcare provider will move right to the surgical option without first exhausting all the non-surgical options. Usually, both the surgeon who will perform the procedure and the individual's insurance company will want to see that the patient has truly "failed" diets, exercise, and group programs such as Weight Watchers, Nutrisystem and others, before agreeing to go ahead with surgery.

Both Rous-En-Y gastric bypass procedure and adjustable gastric banding are very effective at helping people lose weight. One study, which looked at any type of weight loss surgery, showed maximal weight loss at 1-2 years with a 32% drop for the gastric bypass procedure and 20% with the gastric banding procedure. The loss at 10 years post surgery was more modest but rather significant nonetheless with gastric bypass at 25% and gastric banding at 14%.

If you are an individual with the above mentioned criteria for severe obesity (a.k.a morbid obesity), and you have indeed failed many attempts at sustained weight loss over a period of a few years, weight loss surgery may certainly be an option, and you are encouraged to speak with your primary care provider about the subject. Be cautious though.

Firstly, by its mere nature, obesity, especially with co-morbid conditions such as diabetes, hypertension and high cholesterol, will put you in a higher surgical risk category with potential for more complications. Your surgeon and primary care provider will most likely want you to undergo a battery of tests to ascertain your overall health and suitability for the procedure as well as assess your perioperative risk for complications.

Also, often overlooked, is the psychological trauma for patients, many of whom have been heavy their entire lives and are not fully prepared for the change they will experience after surgery. For instance, some patients have battled depression and anxiety having come to identify themselves as obese, but now are no longer. They can have difficulty adjusting their psyche to a new body image. Moreover, the individual's relationship with food can change dramatically, especially after gastric bypass surgery, an added trauma. Often, one cannot eat as much post surgery and patients can find that an unusual issue to deal with having not anticipated this before the surgery. In all likelihood, one will most likely be required to undergo a psychological evaluation in addition to the physical one.

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Gastric bypass surgery, last resort for morbidly obese

North Andover, MA

Although most people can lose weight the old-fashioned way through disciplined eating and regular exercise, bariatric (the treatment of obesity) surgery is an option for very overweight people who have tried everything else.

"You don't just jump into this," says Dr. Frederick Buckley Jr., F.A.C.S., who practices general, vascular and bariatric surgery in Salem. "We're the last stop, and this solution is intended to be forever."

Weight-loss surgery is not for the slightly overweight, nor is it a quick fix for people who haven't tried other methods first. To be eligible, patients must be at least 100 pounds overweight, undergo psychological and cardiac screening and commit to a new eating pattern for the rest of their lives. Insurance companies may also require them to undergo six months of physician-monitored weight loss (usually by a primary-care provider) during the year prior to surgery or their own six-month phone-monitored system, which Buckley believes is less effective than proceeding directly to what he considers "life-saving" surgery.

Most of Buckley's patients have tried other programs without success. "Our patients have lost and regained hundreds of pounds," he said. "It is not a pure willpower thing and it's not for lack of trying that they come here." More >>

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Before gastric bypass surgery, a commitment to change a lifestyle

Pittsburgh, PA

After the birth of her third child, Karen Elliott noticed her weight was steadily creeping up. By the time she hit 280 pounds, Elliott knew something needed to be done. She chose to have gastric bypass surgery at Excela Health Westmoreland Hospital.

"It has really saved my life," said Elliott, 47, of Greensburg.

Choosing surgery was easy, Elliott said -- even an invasive procedure that reduced the size of her stomach and left her unable to eat big meals.

The hard part was taking the steps required before doctors would consent to the procedure. More >>

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Teen Opts for Gastric Bypass Surgery

New York, NY

Girl, 17, discusses long battle with obesity and decision to gastric bypass surgery.

When she was in the third grade, Amanda Baron bent the scales at 200 pounds, and in the next eight years she did everything she could to lose weight – personal trainers, fat camps, diets. Finally, at the age of just 17 and with her weight pushing 250 pounds, she underwent bariatric surgery (gastric bypass surgery) to reduce the effective size of her stomach. more >>

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Another Complication For Gastric Bypass Patients

November 27, 2007

Obese patients who suffer complications after gastric bypass surgery may face further health risks because their weight exceeds the limits of diagnostic imaging equipment, according to a study presented November 27 at the annual meeting of the Radiological Society of North America. In the study, approximately 27 percent of patients weighing more than 450 pounds needed imaging to diagnose a problem after surgery and could not be accommodated because of their size.

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"When patients weigh more than 450 pounds, standard diagnostic imaging often cannot be used," said Raul N. Uppot, M.D., an assistant radiologist at Massachusetts General Hospital (MGH) and instructor of radiology at Harvard Medical School in Boston. "In these cases, physicians must resort to other means of diagnosis such as exploratory surgery or using less accurate or more invasive techniques."

According to the Centers for Disease Control and Prevention, obesity has grown dramatically in the last 20 years. Today, nearly one-third of the American population is obese. Along with the rise in obesity among American adults has come an increase in the number of gastric bypass procedures performed.

The American Society for Bariatric Surgery estimated approximately 140,000 gastric bypass procedures were performed in the United States in 2005. In a gastric bypass procedure, the stomach is surgically reduced, and part of the small intestine is bypassed. Like any surgical procedure, gastric bypass is not without risks. Most common complications include suture tears and leaks, pulmonary embolism, pneumonia and infection. Serious complications tend to be more prevalent among the severely overweight.

Dr. Uppot and colleagues conducted an eight-year retrospective study of all patients weighing more than 450 pounds who underwent a gastric bypass procedure at MGH between June 1999 and April 2007. Patient imaging usage and clinical course were tracked using electronic health records and evaluated to determine the outcomes of those who, based on their weight, were denied their physicians' first choice of imaging. The maximum weight limit for a computed tomography (CT) table is 450 pounds.

The researchers found that 12 (27 percent) of the 44 patients who weighed more than 450 pounds required postsurgical imaging because of a clinical condition, but were denied because they were above the weight restriction for the equipment. Four patients who could not be evaluated with imaging for suspected leaks were required to return for surgery.

Two additional patients with suspected lung blood clots could not undergo a chest CT. Of two patients who came in with nonspecific abdominal pain, one was evaluated with ultrasound and the other one had a barium swallow test. Because imaging was not an option, one patient who suffered trauma underwent exploratory surgery in lieu of noninvasive imaging. Another patient was denied a chest CT and received no further imaging evaluation.

"When obese patients cannot be diagnosed using standard-of-care imaging techniques, then other diagnostic measures have to be instituted," Dr. Uppot said. "Patient care may be ultimately affected due to a compromised diagnosis."

Dr. Uppot noted that the obesity trend cannot be ignored. "Unless major changes are made to the American diet or exercise habits, this is a problem that we will have to address," he said. "When an obese person is contemplating gastric bypass surgery, he or she should consider that they will need follow-up imaging but may not be able to get the appropriate tests."

Co-authors of the paper presented by Dr. Uppot are D.V. Sahani, M.D., D.A. Gervais, M.D., P.R. Mueller, M.D., P.F. Hahn, M.D., Ph.D., and S.I. Lee, M.D., Ph.D.

Adapted from materials provided by Radiological Society of North America.

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Gastric Bypass: Star Jones Opens Up About Her Weight Loss

November 22, 2007

For years, Star Jones Reynolds refused to reveal how she lost half of her body size, but now a confident and secure Star is talking in detail about her gastric bypass surgery --- to Access Hollywood’s Tim Vincent.

“The only reason I am talking to you today is to help other women understand they are not by themselves. They are not alone,” Star told Tim.

“Do you regret not having said something earlier?” Tim asked.

“I really wished, god, I could have. I really do. If there’s a regret that’s it,” Star said. “The regret is I wish I was stronger.”

Undergoing gastric bypass surgery in 2003, it wasn’t until August of this year that Star Jones Reynolds finally went public on how she dramatically lost 160 pounds. More >>

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LAP-BAND(R) System Weight-Loss Surgery Associated With More Than 70 Percent Reduced Risk of Death in People With Severe Obesity

November 21, 2007

About Obesity

In the United States, obesity is considered the second leading cause of preventable death (7). Further, research has shown that individuals with a BMI of 35 or more have a reduced life expectancy of nine to 13 years (8). A BMI of 35 or more translates to a weight of 200 pounds or more for a woman of average height (5' 4") when ideal weight at this height is considered to be 140 pounds, and to a weight of 250 pounds or more for man who is six feet tall when ideal weight for this height is considered to be 177 pounds.

About the LAP-BAND(R) System

The LAP-BAND(R) System was approved by the FDA in June 2001 for severely obese adults with a Body Mass Index (BMI) of 40 or more or for adults with a BMI of at least 35 plus at least one severe obesity-related health condition, such as Type 2 diabetes, hypertension and asthma. Used in more than 300,000 procedures worldwide, this simple reversible surgically implanted device has safely helped severely obese adults successfully achieve and maintain long- term weight loss.

The LAP-BAND(R) System was developed to facilitate long-term weight loss and reduce the health risks associated with severe and morbid obesity. Unlike gastric bypass, it does not involve stomach cutting, stapling or intestinal re-routing (9,10). Using laparoscopic surgical techniques, the device is placed around the top portion of the patient's stomach, creating a small pouch. By reducing stomach capacity, the LAP-BAND(R) System can help achieve long-term weight loss by creating an earlier feeling of satiety. The LAP-BAND(R) System is adjustable, which means that the inflatable band can be tightened or loosened to help the patient achieve a level of satiety while maintaining a healthy diet. It is also reversible and can be removed at any time.

Severely obese people who received the LAP-BAND(R) Adjustable Gastric Banding System to lose weight had a 72 percent reduction in their risk of dying compared to obese people who were not offered any specific weight-loss treatment, according to findings published in the December issue of the Annals of Surgery (1). The LAP-BAND(R) System was approved in June 2001 by the U.S. Food & Drug Administration for weight reduction in severely obese adults.

"This research is critical because it shows that people with severe obesity, who are known to be at a much higher risk than the general population for dying prematurely, may be able to significantly decrease their risk with laparoscopic adjustable gastric banding," explains Dr. Paul O'Brien, FRACS a study author from the Monash University Centre for Obesity Research and Education (CORE) in Melbourne, Australia, head of the Centre for Bariatric Surgery in Melbourne and the National Medical Director for the American Institute of Gastric Banding in Dallas, Texas. "What is also particularly compelling is that this study shows it is possible to gain a significant survival benefit without the risks associated with more invasive bariatric surgical procedures, such as gastric bypass." http://www.earthtimes.org/articles/show/news_press_release,228703.shtml

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Gastric Bypass Surgery for Teens: How Young is too Young

Tackling Teen Obesity With Surgery: How Young Is Too Young?
Debi Chard, Live 5 News
Teens are tipping the scales. There's an epidemic of kids who are so heavy they face serious adult health problems.

In two days, Alexis Khan will undergo surgery to help her lose weight.
"We've tried every diet under the sun," says her mother. So Alexis is trying something much different, a gastric bypass. Because she's only 16 years old, having major surgery is not a decision she can make on her own. More >>

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Gastric Bypass Surgery: Are You a Proper Candidate

(MayoClinic.com)
It's always best to lose weight through a healthy diet and regular physical activity. But if you're among those who have tried and can't lose the excess weight that's causing your health problems, weight-loss (bariatric) surgery may be an option. Gastric bypass surgery — one type of bariatric surgery — changes the anatomy of your digestive system to limit the amount of food you can eat and digest. Weight loss is achieved by restricting the amount of food that your stomach can hold and by reducing the amount of calories that are absorbed. Gastric bypass surgery isn't for everyone, however. It's a major procedure that poses significant risks and side effects and requires permanent changes in your lifestyle. An extensive and careful screening process determines whether you're a candidate for this surgery.

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