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Month: September 2009

Does Size Matter

September 28, 2009 12:14 pm

The scientific basis for weight loss surgery, for the majority of the part relies on the premise that overeating and lack of exercise are the principal mechanisms contributing to the increase in the incidence of obesity over that last decade. Much has been said about our unhealthy life style that involves sedentary activity and immobility. Fast foods, high fat content meals, calorie dense food, are some of the examples of possible contributing factors to this health crisis.

The contrary position would be that there are other factors that contribute to obesity. These may include environmental factors, food preservatives, genetics, and exposures to toxins.

If one assumes that the over eating is the core problem, then you can also assume that the most successful operation will have the smallest stomach, since it will reduce the ability to over eat most drastically. This is where the scientific evidence does not support the theory and we all have to reassess the principal that the treatments are directed toward.

Recently there have been a number of studies that have been published in scientific journals that suggest size of the stomach or the pouch does not matter. So if obesity is the result of over eating then the operation that provides the smallest stomach must work the best. This argument should be true for the pouch size after gastric bypass, and the opening of the gastro-jejunostomy (connection between the stomach pouch and the small bowel connected to it after the gastric bypass, RNY operation). The same theory applies to the sleeve gastrectomy of the duodenal switch operation.

This argument that over eating and lack of exercise is the major contributing factor seems to be loosing ground.

The studies below are outline to demonstrate the disparity between the theory and the lack of scientific support for it.

1- Sanchez-Pernaute et.al. (Obesity Surgery, 17, 2007) reported that “After DS, gastric tube volume is not directly related to weight changes.” He proposed that there are other factors that may contribute to the weight loss than the size of the gastric tube.

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This graph taken from the referenced study above shows that the size of the stomach sleeve does not correlate with the %EBWL in DS patients. The smaller stomach sleeve does not result in the more weight loss.

2- O’Connor et.al. (SOARD 4(2008)399-403) reported that “With construction of divided, vertical, lesser curve-based small-volume (=<20cm3) gastric pouches, the actual size of the gastric pouch did not correlate wit the %EBWL at 1 year after Laparoscopic, GB [gastric bypass]”.

3- Nishie et.al. (Obesity surgery, 17, 2007) concluded that “pouch size area, measured by routine UGI [upper GI series] on the first post operative day, does no influence short-term postoperative weight loss”.

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This a sample of a number of graph that Nishie published in her study. The similar graphs were for 3, 12, and 24 months. They all had a flat line distributions. What they are showed was regardless of the time lapsed from surgery, the %EBWL was independent of the size of the pouch measured immediately post operatively.

4- Cottam et.al. (Obesity Surgery, 2009, 19:13-17) reported “The level of restriction or the presence of stenosis achieved by different circular stapler sizes does not have a significant role in weight loss”.

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This study was focused on the size of the opening that is made between the stomach pouch and the small bowel in the gastric bypass (RNY) operation. The weight loss did not differ in the two groups of the patients. One group had a 21mm stapler and the other one 25mm stapler used. The weight loss, as measured by %EBWL was nearly identical in both cases.

In summary, the size does not seem to matter. The size of the stomach pouch, when it gets to a certain size in not important. The smaller stomach pouch or the narrower connection of the stomach and the small bowel will not make a patient loose more weight. Doesn’t this prove, to at least some degree, that there is much more to obesity than the simple notion of eating small portion and exercising?

Get informed

September 26, 2009 6:56 pm

As a surgeon, one of my duties is to discuss Informed Consent. There are two components to this, one of which is the consent part. This is where the discussion of risks, benefits, and complications takes place. It is also where options are discussed. A patient cannot give consent if he or she is not informed, which is the second component. The patient should only grant his or her consent if provided with details and every available option.
In my clinical practice, I routinely discuss all the surgical options with a prospective patient. It is my duty to explain in great detail what the surgical alternatives are, what their relative risks are when compared to each other, and the pros and cons of each procedure. Once this information is presented, I would then discuss the rationale as to why certain procedures are superior in certain clinical conditions. It is ultimately the patient who makes the decision as to which procedure is right for the treatment of morbid obesity. In some cases, however, if I do not believe that the procedure the patient has decided on will serve the patient’s long or short-term health needs, I will ask that the patient seek another surgeon. One of the most common examples of this situation is when patients are seen in my office for surgical treatment of morbid obesity and inquire about the Lap Band®. They have seen an advertisement on television, radio, or even on a billboard. There are even those patients that are told by the primary care physicians that they should ONLY have the Lap Band® done because it will solve all of their problems. The promotional marketing material is only a small portion of a large body of information that is made available to patients and their primary care physicians. To most patients, Adjustable Gastric Banding (Lap Band®, Realize Band®) are “drive-thru” procedures.  They have been advertised as a procedure in which a patient goes to a surgeon’s office, gets examined, operated on, loses weight, and lives happily ever after. This is untrue on a number of fronts and far from the way it actually works for the overwhelming number of patients that get the Lap Band® done. I am not against the adjustable gastric banding procedures. I only advocate that the expectations be set for the patients on an appropriate level. First of all, the Lap Band® is not for everyone. The scientific information on this matter is overwhelming. The educational booklet that is available and published by Allergan (the manufacturer of the band) has a list of conditions in which the band should not be used. Then there is the relative efficacy of the banding procedure compared to the Duodenal Switch and the Gastric Bypass operation. The questions a patient and a primary care physician should ask:
Are the treatment options effective in both treating and resolving the specified conditions of each patient? 
What are the chances that a patient suffering from diabetes, high cholesterol, or high blood pressure will be cured of these conditions if they have the Gastric bypass, Duodenal Switch, or the Lap Band done. 
The reality is that, in my opinion, most patients opting for the Lap Band procedure have not been educated and provided with the information necessary to make an informed decision. When you consider how little most patients will lose with the Lap Band, one has to realize that the risks, as little as they may be compared to other procedures, are not worth taking. 
 

Weight loss information

September 22, 2009 4:22 am

I have posted a new newsletter to our web site. It is located here. I will continue to update the information both here and on our website.
I also read an interesting article in Newsweek Magazine dated September 21, 2009. While I know it is not a scientific journal, this particular article had medical sources quoted as the basis of the content. For anyone who believes obesity is just about overeating and lack of exercise, I encourage you to read it. Does overeating and lack of activity contribute to obesity? Yes, but there is much more to it than that. We should stop blaming the patients for a condition over which they may have little control.
Different weight loss surgical procedures have different outcomes, independent of the type of surgical procedure. The long term success and complications of these procedures is summarized on our website.