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Suicide Risk

October 11, 2010 11:46 am

To follow are studies focused on suicide risk after bariatric surgery. Risk of Suicide after Long-term Follow-up from Bariatric Surgery. Tindle et al. Sept 2010 PubMed Abstract Full Article PURPOSE: Bariatric surgery is recognized as the treatment of choice for class III obesity (body mass index >/= 40) and has been increasingly recommended for obese patients. Prior research has suggested an excess of deaths due to suicide following bariatric surgery, but few large long-term follow-up studies exist. We examined postbariatric surgery suicides by time since operation, sex, age, and suicide death rates as compared with US suicide rates. METHODS: Medical data following bariatric operations performed on Pennsylvania residents between January 1, 1995 and December 31, 2004 were obtained from the Pennsylvania Health Care Cost and Containment Council. Matching mortality data from suicides between September 1, 1996 and December 28, 2006 were obtained from the Division of Vital Records, Pennsylvania State Department of Health. RESULTS: There were 31 suicides (16,683 operations), for an overall rate of 6.6/10,000; 13.7 per 10,000 among men and 5.2 per 10,000 among women. About 30% of suicides occurred within the first 2 years following surgery, with almost 70% occurring within 3 years. For every age category except the youngest, suicide rates were higher among men than women. Age- and sex-matched suicide rates in the US population (ages 35-64 years) were 2.4/10,000 (men) and 0.7/10,000 (women). CONCLUSIONS: Compared with age and sex-matched suicide rates in the US, there was a substantial excess of suicides among all patients who had bariatric surgery in Pennsylvania during a 10-year period. These data document a need to develop more comprehensive longer-term surveillance and follow-up methods in order to evaluate factors associated with postbariatric surgery suicide.

Economic Impact of Bariatric Surgery

October 10, 2010 1:45 pm

Articles highlighting the return on investment and economic impact of bariatric surgery. Economic Impact of the Clinical Benefits of Bariatric Surgery in Diabetes Patients With BMI >/= 35 kg/m(2). Klein et al. Sept 2010 PubMed Abstract ABSTRACT: The medical costs for a type 2 diabetes patient are two to four times greater than the costs for a patient without diabetes. Bariatric surgery is the most effective weight-loss therapy and has marked therapeutic effects on diabetes. We estimate the economic effect of the clinical benefits of bariatric surgery for diabetes patients with BMI >/= 35 kg/m(2). Using an administrative claims database of privately insured patients covering 8.5 million lives 1999-2007, we identify obese patients with diabetes, aged 18-65 years, who were treated with bariatric surgery identified using Healthcare Common Procedure Coding System codes. These patients were matched with nonsurgery control patients on demographic factors, comorbidities, and health-care costs. The overall return on investment (RoI) associated with bariatric surgery was calculated using multivariate analysis. Surgery and control patients were compared postindex with respect to diagnostic claims for diabetes, diabetes medication claims, and adjusted diabetes medication and supply costs. Surgery costs were fully recovered after 26 months for laparoscopic surgery. At month 6, 28% of surgery patients had a diabetes diagnosis, compared to 74% of control patients (P < 0.001). Among preindex insulin users, insulin use dropped to 43% by month 3 for surgery patients, vs. 84% for controls (P < 0.001). By month 1, medication and supply costs were significantly lower for surgery patients (P < 0.001). The therapeutic benefits of bariatric surgery on diabetes translate into considerable economic benefits. These data suggest that surgical therapy is clinically more effective and ultimately less expensive than standard therapy for diabetes patients with BMI >/= 35 kg/m(2). Medication utilization and annual health care costs in patients with type 2 diabetes mellitus before and after bariatric surgery. Makary et al. Aug 2010 PubMed Abstract OBJECTIVE: To examine the relationship of bariatric surgery with the use of diabetes medications and with total health care costs in patients with type 2 diabetes mellitus. DESIGN: We studied 2235 adults with type 2 diabetes and commercial health insurance who underwent bariatric surgery in the United States during a 4-year period from January 1, 2002, through December 31, 2005. We used administrative claims data to measure the use of diabetes medications at specified time intervals before and after surgery and total median health care costs per year. SETTING: Seven states in the Blue Cross/Blue Shield Obesity Care Collaborative. PATIENTS: Two thousand two hundred thirty-five patients with type 2 diabetes mellitus who underwent bariatric surgery. RESULTS: Surgery was associated with elimination of diabetes medication therapy in 1669 of 2235 patients (74.7%) at 6 months, 1489 of 1847 (80.6%) at 1 year, and 906 of 1072 (84.5%) at 2 years after surgery. Reduction of use was observed in all classes of diabetes medications. The median cost of the surgical procedure and hospitalization was $29,959. In the 3 years following surgery, total annual health care costs per person increased by 9.7% ($616) in year 1 but then decreased by 34.2% ($2179) in year 2 and by 70.5% ($4498) in year 3 compared with a preoperative annual cost of $6376 observed from 1 to 2 years before surgery. CONCLUSIONS: Bariatric surgery is associated with reductions in the use of medication and in overall health care costs in patients with type 2 diabetes. Health insurance should cover bariatric surgery because of its health and cost benefits. A Study on the Economic Impact of Bariatric Surgery Bushwald et al. Sept 2008 PubMed Abstract OBJECTIVE: To evaluate the private third-party payer return on investment for bariatric surgery in the United States. STUDY DESIGN: Morbidly obese patients aged 18 years or older were identified in an employer claims database of more than 5 million beneficiaries (1999-2005) using International Classification of Diseases, Ninth Revision, Clinical Modification code 278.01. Each of 3651 patients who underwent bariatric surgery during this period was matched to a control subject who was morbidly obese and never underwent bariatric surgery. Bariatric surgery patients and controls were matched based on patient demographics, selected comorbidities, and costs. METHODS: Total healthcare costs for bariatric surgery patients and their controls were recorded for 6 months before surgery through the end of their continuous enrollment. To account for potential differences in patient characteristics, we calculated the cost differential by estimating a Tobit model. A return on investment was estimated from the resulting coefficients. Costs were inflation adjusted to 2005 US dollars using the Consumer Price Index for Medical Care, and the cost savings were discounted by 3.07%, the 3-month Treasury bill rate during the same period. RESULTS: The mean bariatric surgery investment ranged from approximately $17,000 to $26,000. After controlling for observable patient characteristics, we estimated all costs to have been recouped within 2 years for laparoscopic surgery patients and within 4 years for open surgery patients. CONCLUSIONS: Downstream savings associated with bariatric surgery are estimated to offset the initial costs in 2 to 4 years. Randomized or quasiexperimental studies would be useful to confirm this conclusion, as unobserved characteristics may influence the decision to undergo surgery and cannot be controlled for in this analysis. The impact of weight reduction surgery on health-care costs in morbidly obese patients. Christou et al. Aug 2004 PubMed Abstract BACKGROUND: The treatment of obesity and related comorbidities are significant financial burdens and sources of resource expenditure. This study was conducted in order to assess the impact of weight-reduction surgery on health-related costs. METHODS: This was an observational two-cohort study. The treatment cohort included patients having undergone weight-reduction (bariatric) surgery at the McGill University Health Centre (MUHC) between 1986 and 2002. The control group included age and gender matched obese patients who had not undergone weight-reduction surgery from the Quebec provincial health insurance database (RAMQ). The cohorts were followed for a maximum of 5 years from inception. The primary outcome measure was overall direct healthcare costs. Secondary outcomes included cost analysis by diagnostic category for the treatment of new medical conditions following cohort inception. RESULTS: The cohorts were well-matched for age, gender and duration of follow-up. Patients having undergone bariatric surgery had significant reductions in mean percent initial excess weight loss (67.1%, P <0.001) and in percent change in initial body mass index (34.6%, P <0.001). Bariatric surgery patients had higher total costs for hospitalizations (per 1,000 patients) in the first year following cohort inception (surgery cohort = CDN 12,461,938 dollars; control cohort = CDN 3,609,680 dollars). At 5 years after cohort inception, average cumulative costs for operated patients were CDN 19,516,667 dollars versus CDN 25,264,608 dollars, for an absolute difference of almost CDN 6,000,000 dollars per 1,000 patients. CONCLUSION: Weight-reduction surgery in morbidly obese patients produces effective weight loss and decreases long-term direct health-care costs. The initial costs of surgery can be amortized over 3.5 years.

17 Year Old Bariatric Surgery Patient Jessy Inspires Others

October 09, 2010 1:47 pm

Meet one of the most inspiring Duodenal Switch patients. 17 year old bariatric surgery patient Jessy inspires others seeking a solution to obesity. Her weight loss surgery journey and her post-op transformation moves me to tears. At 11 months post-op Jessy had lost 129 pounds and posted stunning pictures of herself before heading out to her prom. “I danced all night tonight and don’t hurt at all!” She reminds so many of us of the courage and tenacity it can take to fight to have surgery and why we chose this path to embark on the journey towards improved health and enhanced quality of life. Jessy was just 17 when she had Duodenal Switch surgery July 11, 2009 with Dr. Marchesini in Brazil. She is no longer 17, is growing up and moving on with her life. Her story is worth the read.

Jessy’s Story in Her Own Words

My life since having Duodenal Switch (DS) surgery one year ago is absolutely wonderful. I mean that! It’s better then I could have ever imagined. All this time I’ve been thinking about being “one year out”. I was wondering if I should tell my back story, so here goes!

About 4 years ago my mom’s older brother was sent to Mississippi to a training camp because he was going to be deployed to Iraq once he was done. But while going from one training camp to the other his Humvee was hit from behind by a man high on drugs, my uncle and the man in the driver’s seat were instantly killed.

You may wonder what this has to do with anything, but this was a big part of me being able to get my DS.

After my uncle’s tragic death my mother received a call from my aunt (this was around the time that I was getting very serious about getting the DS) telling us that my uncle had left her just enough money to cover my weight loss surgery. To this day it saddens me that he died, but in a way he helped saved my life… without that money I would not have been able to get the DS in time. That funding came JUST in time. I was 16 years old and weighing in at 535 pounds, my body was completely broken. I always had this feeling, no matter how hard things got, no matter how scary, that I was not going to die at such a young age. It was not acceptable or believable to me.

I had gotten to the point where I could not turn myself over in my bed, I could not do anything. I felt like this gigantic burden to my mom and sister’s, my sister was a “pre-teen” and she was ashamed of me. I’ve always had confidence no matter how big I was, so I tried not to pay attention to those things. But it got harder and harder. I started to develop lymphedema in my legs. I had no idea what it was at the time, I went to a local ER and as soon as the doctor saw me he said “it’s just fat” and walked out.

I was so ashamed of my weight that I hadn’t gone to a PCP for a while, because the last time I did she did nothing but hurt me, emotionally. She blamed me for “trying to kill” myself by eating, my reply to her was “oh yeah, because I totally enjoy dying a SLOW PAINFUL death.” (HEAVY sarcasm) The last straw with her was when she told me that she would have a bet that I would die before I turned 20. She also refused to even let me think about WLS as an option because she said I “simply needed to stop eating so much” even though at that time I was on a STRICT diet (and she knew).

My mom finally convinced me to go to her PCP, and so out of desperation I agreed. He turned out to be a wonderful man who played a big role in me getting the DS. When I went to see him for the first time I had not been weighed in a very long time. I got on that scale and it read 500 pounds and I cried. I cried like I never cried in my life, when I saw that number it felt like I was looking death in the face. I cried and he and my mother sat with me, he was the first doctor to ever treat me kindly.

He looked me in the eyes and told me that there is something WAY more wrong with me then just “over eating” (he knew I wasn’t) and said that it would take something more then just over eating to get me to my weight I was at. I finally had met someone who understood; who didn’t blame and bash me, someone who knew that it was my body that was messed up, and not my mind! It was one of the best feelings in the world to meet someone who finally believed me, who finally saw my pain and frustration and who was just as puzzled as I was!

He himself only knew about the lap-band and the RNY (like a majority of the doctors) and so he told me that he supported me 100% in my pursuit of weight loss surgery (WLS) and that he would fill out every paper and do every lab I needed done, as soon as possible. At that time I only knew about the RNY and lap-band as well and so we submitted my paperwork to the only RNY surgeon in Alaska. And after we did, I had to wait.

I was sleeping when the RNY office called. My mom came down to me with a red swollen face from crying and hugged me and told me that the RNY surgeon’s assistant said they would not do my surgery and told me to loose 100 pounds and then come back to them. I lost all hope. That was the worst feeling in my life; loosing my hope. I remember sitting there and there was no feelings. I felt empty, then the rejection began to sink in and I felt the worst pain I’ve ever felt in my life, I knew that without WLS I was going to die and I felt like death was my only option left and I felt like I was just going to sit in my home and eventually just pass on.

For the next couple days after my rejection the only way I could get myself up in the morning was by promising myself that I would take my own life rather then succumb to my obesity. I already felt so ashamed for being the size I was, and I felt that I would be even more ashamed if I let obesity be my cause of death (and obviously it would have been). Looking back at that time in my life, how I promised myself that I would take my own life hurts me. I’ve never been one to feel like that, to say such a thing. I’ve always loved life no matter my size, but I had come to the realization that I would never get to enjoy a life at that size and I saw no reason to live anymore.

I would set my day to when I wanted to possibly end it all, and I would make a mental promise. But something, something kept me waiting. I would say “next Sunday.” and when Sunday came around I would say “next Tuesday.” and when that day came I would say another day.

But then one day I remembered the Obesity Help website, I hadn’t been on it in a while and so basically as a last straw when I went and posted about being rejected for RNY surgery and many lovely people came to my aid, and told me about this wonderful WONDERFUL weight loss surgery, Duodenal Switch! I am SO thankful to all those people everyday of my life; every single day. The more time I spent on the Obesity Help website and the more people that educated me about the DS, I began to get my hope back and that was one of the best feelings I have felt.

So from there on I did my research on DS and my hope grew and grew. I knew that I was going to have to travel for the DS because no one here in Alaska does it and I was ok with that. I took all the information I could find on the DS and showed my mom, and my PCP. Because of my age I needed them, I had to convince them. And I did.

The DS was all I ever talked about, I was on the Obesity Help website everyday reading all the success stories to my mom. Because we were on a budget and because of my age (which was annoying!) I started to look at out of USA options and I found Dr. Marchesini in Brazil. I talked to his past patients and I liked him more and more. I remember asking my mom what her reaction would be if I told her we had to go to Brazil for my surgery. Her answer was “NO WAY. I am not going out of the country!” But as we all know she ended up changing her mind lol!

I remember being worried about my size, being as big as I was I felt like no one would take me, such a high risk. Plus my age bothered some surgeons. But I began to talk to Dr. Marchesini through e-mails and he told me he would love to help me, and he’d love to do my surgery. And from there on I was set. I got all my paperwork done, and I waited. My surgery date was set for July 11th.

And so I have just been loving my DS ever since.

Now in my life I feel like I can do anything, I have high expectations for myself because my obesity is no longer holding me back as much. I am still pretty big but that’s ok, I know my DS is still working and I am still doing what I need to do. While I was at my biggest I wasn’t able to do school, so I did online classes, something happened with the home school program computer system and they lost my grades and refused to give me my credits so I am still in high school just finishing up my last year. I go to a public school now that I found right after getting home. It’s wonderful because at that time I was still healing, and I couldn’t go to a normal school everyday but this school has a flexible schedule and I love it.

I currently have straight A’s and I only have a couple classes to finish and I graduate!

Some WOW Moments:

Before surgery I wanted to be able to drive SO bad, but I could not fit. At one year post-op I am down 141 pounds and I now I fit and have my license!!!
I can wear regular size flats!! My feet no longer look pudgy and weird in flats! They look like normal people feet! I love flats!!
My younger sister and I share some clothing (she’s a lot smaller then me, but some things fit her lol! if that makes sense)
I go on a bike ride at least once a day, and go on walks all the time! I love them!
I can stand for so long now.
I can feel my knees. Before my sister use to tease me and saw “Wheres your knee cap Jessica??” and she would feel around and it was funny. She went to tease me the other day and was saying “Where’s….” and she said “WHOA! I can feel your knee cap! Ah….weird….I’m not use to feeling you all bony….this isn’t fun.” and we laughed so hard. I was so excited that I yelled “MOM! I CAN FEEL MY KNEE CAPS!!” and she clapped. Awesome.
I am now a size 9 shoe 🙂 I use to be a 10 or 11 wide. Now I’m just a normal 9.

Sept 2010 Update – Down 180 pounds since surgery

Jessy got her first job!

“I went in for the interview with two other ladies applying for the same position, I having no past work experience felt that I didn’t really have a chance. But going with my personality and my ability to learn fast and work hard I kept with it, went through the hour long interview, submitted my paperwork and waited. For the first time in my life I didn’t feel that my weight could or would hold me back. I didn’t go into that building worrying I’d be the biggest person there; I didn’t shoot myself down standing next to much smaller women. I had confidence (something I’ve always had) but I was also at peace with myself. The whole interview the thought “oh no I won’t get this job because I’m fat” never ran through my head like it would of.

Another amazing day living life with my DS.”

More WOW Moments:

All of the things above are amazing wow’s! But for me the one that tops them all was when I went with my mom to her doctor appointment (we have the same PCP) when he walked in and saw my weight loss he said “Holy sh*t” he then went on to say “excuse my language but you are a success! I haven’t had a weight loss surgery patient loose as much as you! Amazing!”
I got to play tag with my youngest sister the other day. We all went on a long walk and it was awesome!
2X shirts are on their way to becoming baggy!
My double chin is almost gone!

Jessy, we wish you continued success in your weight loss journey and look forward to continued updates.

Bowel Habits Post-Op

October 09, 2010 10:49 am

Clinical data addressing bowel habits post-op. Gastric Emptying and Postprandial PYY Response After Biliopancreatic Diversion with Duodenal Switch. Hedberg et al. Sept 2010 PubMed Abstract BACKGROUND: Super-obesity (BMI>50) is increasing rapidly. We use the biliopancreatic diversion with duodenal switch (BPD-DS) as one option in this patient category. The aim of the present study was to investigate the emptying of the gastric tube, PYY levels and dumping symptoms after BPD-DS. METHODS: Emptying of the gastric tube was investigated with scintigraphy after an overnight fast. Twenty patients (median age 43 years, BMI 31.1 kg/m(2)) having undergone BPD-DS in median 3.5 years previously were included in the scintigraphic study. A technetium-labelled omelette was ingested and scintigraphic evaluation of gastric emptying was undertaken. Ten of the patients also underwent PYY measurements after a standardised meal and were compared to nine non-operated age-matched normal weight controls, both in the fasting state and after the test meal. Frequency of dumping symptoms was evaluated in all patients. RESULTS: The half-emptying time was 28 +/- 16 min. Lag phase was present in 30% of the patients. PYY levels were significantly higher in BPD-DS patients as compared to controls both in the fasting state (p<0.001) and after the test meal (p<0.001). Dumping symptoms were scarce and occurred in 17 of the 20 patients only few times yearly or less. CONCLUSIONS: Although the pylorus is preserved in BPD-DS, the stomach emptying is faster than in non-operated subjects. PYY levels are elevated in the fasting state after BPD-DS and a marked response to a test meal is seen, likely due to the rapid stimulation of intraluminal nutrients in the distal ileum. In spite of this, dumping symptoms are uncommon. Bowel Habits after Gastric Bypass Versus the Duodenal Switch Operation. Wasserberg et al. Aug 2008 PubMed Abstract BACKGROUND: One of the perceived disadvantages of the biliopancreatic diversion with duodenal switch operation is diarrhea. The aim of this study was to compare the bowel habits of patients after duodenal switch operation or Roux-en-Y gastric bypass. METHODS: A prospective comparative case series design was used. Forty-six patients who underwent duodenal switch (n = 28) or gastric bypass (n = 18) were asked to complete a daily diary for 14 days after losing least 50% of their excess body weight. Data were collected on number of bowel episodes, incontinence, urgency, stool consistency, and awakening from sleep to defecate. Background variables were recorded from the medical files. RESULTS: The duodenal switch group was heavier (body mass index 53.5 vs 47.0 kg/m(2), p = 0.03) and older (47.5 vs 41.0 years, p = NS) than the gastric bypass group. Median time to 50% excess body weight loss was 22 months in the duodenal switch group compared to 10.0 months in the gastric bypass group (p = 0.001). Patients after duodenal switch surgery reported a median of 23.5 bowel episodes over the 14-day study period compared to 16.5 in the gastric bypass group (p = NS). There was no between-group differences in any of the other bowel parameters studied. CONCLUSIONS: Although duodenal switch is associated with more bowel episodes than gastric bypass, the difference is not statistically significant. Bowel habits are similar in patients who achieve 50% estimated body weight loss with duodenal switch surgery or gastric bypass.

Achalasia

October 08, 2010 7:05 pm

I was asked if a patient with achalasia could have the duodenal switch operation.

My first reaction was why would anyone with achalasia need to have any weight loss surgery? This is because an almost universal finding with achalasia patients is significant weight loss.

The weight loss with achalasia is the result of dysphagia (inability to swallow) both solids and liquids. Patient with other esophageal motility disorders have primarily solid intolerance, but with proper positioning tolerate liquids well. This is because unlike other esophageal motility disorders (where the esophagus fails to push the food down after swallowing is initiated) in achalasia, the food is carried down to a certain level, but it gets stuck, because of non relaxation of muscles that form the lower esophageal. The key would be to make the proper diagnosis by manometry, endoscopy, and radiologic studies. The treatment for achalasia is very different-than that of an esophageal motility disorders.

Now going back to the question of a patient with achalasia having duodenal switch… If the diagnosis is correct, then the patient will benefit from a procedure where the outer muscle layers of the esophagus are divided, without entering the lumen of the esophagus. As a part of the same procedure,

Table 1
	Esophageal Motility	Achalasia
Weight Loss	Some	Significant
Intolerance	Solids	Solids and liquids

the patient then has to have a Nissen wrap to prevent reflux. In my
opinion, any procedure that increase the possibility reflux should be avoided. Any procedure that causes vomiting should be avoided. Additionally from a technical perspective, for a Nissen wrap to be done, the top part of the stomach should be left intact.

In my opinion, this rules out the possibility of Adjustable gastric banding or the gastric bypass. Both of these are restrictive procedures that slow passage of the food past the stomach pouch. This is recreating the problem more than solving it.

Duodenal switch operation will probably be the best option. A larger stomach sleeve can be done, with a warp to prevent reflux. The lengths of the common and alimentary limbs can be adjusted so that the patient looses weight. I would have to once again raise the issue of correct diagnosis, in that most achalasia patients have significant weight loss, and will probably not be in the need of any weight loss surgery.

An esophageal motility disorder however is something that I have seen as a complication of Adjustable gastric banding. In a quest for more weight loss, the band is continuously filled. There is a fairly large body of scientific published data (both case reports and small series) that talk about the problem of AGB causing esophageal motility disorders.The universal belief is however, that the conversion to alternative operations, Duodenal switch or gastric bypass will is at least some cases reverse the motility disorder.

Lecture at Glendale College

September 23, 2010 10:44 pm

Weight Loss Surgery: Benefits and Risks
Dr. Ara Keshishian, Bariatric Surgeon
Tuesday, September 28, 2010
12:20 to 1:20 in SB 243
”Weight Loss Surgery: Benefits and Risks” is a free lecture at Glendale
Community College to be presented on Tuesday, September 28 as part of
the monthly Science Lecture Series.

The lecture will be held at 12:20 p.m. in Santa Barbara Building room 243.

Admission is free and open to the public.

The speaker is a bariatric surgeon, Dr. Ara Keshishian. He is the medical
director of Bariatric and Metabolic surgery at Verdugo Hills Hospital and has
a private practice in Glendale, Ca. Dr. Keshishian will discuss the subject beyond the billboards, radio ads and TV commercials and explore the future of weight loss surgery and treatment of obesity.

Omega Fatty Acids

September 22, 2010 12:24 am

Fatty acids are a byproduct of fat metabolism. These are acids that are produced when fat is broken down in our body. Fatty acids are important in a number of metabolic functions in our body. They help move oxygen, keep skin healthy, prevent aging at a cellular level, promote weight loss by promoting cholesterol processing by the body, and prevent build up of plaques in blood vessels. Examples of different types of Omega fatty acids are Omega-3, Omega-6, and Omega-9.

Omega-3 and Omega-6 fatty acids are essential fatty acids (EFA) because unlike other fatty acids, our body is not able to make them. Omega-9 fatty acids can be produces in out body.

These EFA are involved more specifically in regulation of blood pressure, cardiovascular health and others.

I have looked and have not found any studies regarding any relationship (positive or negative) associating Duodenal Switch and Omega Fatty acids.

I would however make some educated guesses here: The fact is that the lipid profile improves significantly with the duodenal switch operation is known. The duodenal switch operation can be performed with limited or not gastrectomy to correct significant lipid disorders that are either non responsive to medical treatments, or in cases where the side effect of statin medications are debilitating.

With this known, I would guess that even if the Omega fatty acids are not absorbed as well at least some of the beneficial effects are not lost. I would recommend that a healthy diet be used to assure adequate absorption of EFA.

Ask Dr. K: Problems over the years

September 09, 2010 10:42 pm

There are numerous sources available on the internet for patients to search for information. The information that one can find ranges from scientific to anecdotal. Patients individually have asked me a number of questions and I will peridically address them in an “Ask Dr. K” newsletter. I would also like for my opatients to submit their questions by emailing it to me.

“Problems Over The Years”

Question:
“What are the main things we should be looking for “symptom wise” at 3, 5, 7, or 10, etc. years out. I’d like to know how the duodenal switch effects teeth? On hydration as I think my body pulls water from my stool when I’m not drinking enough. Actually – it’s not “enough” it’s that my body passes it out my kidneys if I am not sipping constantly throughout the day. Is that normal? Omega Fatty Acids – are we screwed? What do those deficiencies look like?”

Answer:
I do not know of any particular study that looks at the health of the
teeth specifically, however, I would assume that if a patient is not
complaint with their Calcium, or even complaint, and they are deficient
in minerals such as Calcium, Vitamin D, Magnesium, and others, then
one can develop poor teeth. Hydration is a very important issue. Surgery or not, most of us tend to run around a little “dry”. Constipation may be a side effect of inadequate water intake.
For the Omega fatty acids, see the next newsletter dated 9/22.

Question:
I would love to know what types of problems are seen in post operative patients and what the distributions are by years post-op.

Answer:
In very broad terms, I can classify them in both time frame, and in term of causes of complication (mechanical vs. nutritional). See table 1.

Please note that this is by-no-means a complete list, only a brief, very brief, overview of some of the potential problems that may surface. This list is not meant to be all inclusive or complete.

Table 1
Post operative Time Frame	Nutritional	Mechanical
Days	Dehydration	Leaks, abscesses, infection (urinary, pulmonary) DVT, PE, Wound dehiscence, Bowel Obstruction
Weeks	Dehydration, protein calorie malnutrition-acute	Wound infections, DVT, PE, Bowel Obstruction
Months	Protein Calorie Malnutrition, mineral deficiency, Kidney stones	Bowel obstruction, Cholecystitis (if your gallbladder not removed)
Years 1-3	Protein Calorie Malnutrition, mineral deficiency, Kidney stones	Bowel obstruction, Cholecystitis (if your gallbladder not removed)
Years 3-5	Occasional mineral deficiency, Kidney stones	Bowel obstruction, Skin Rashes (if applicable)
Years over 5	Occasional mineral deficiency, Kidney stones	Bowel obstruction, Skin Rashes (if applicable)

Deep Vain Thrombosis (DVT) Where a blood clot is formed in the deep venous system of the lower legs and can travel and block the flow of the blood to the lungs. If large enough in it a common cause of death in post operative patients. DVT’s are not the same as varicose veins.

Pulmonary Embolism (PE) A clot or a tumor that is dislodged from one part of the venous circulatory system and blocks the flow of the blood to the lungs. The most common source for the PE is a DVT.

Wound Dehiscence Complete or partial breakdown of the suture line at the deep layers where the bowel may become unprotected. In some cases this needs re-operation on an urgent fashion.

Duodenal Switch Compared to Gastric Bypass

September 06, 2010 12:51 pm

Articles that discuss Duodenal Switch Compared to Gastric Bypass surgery. Randomized clinical trial of laparoscopic gastric bypass versus laparoscopic duodenal switch for superobesity. Søvik et al. Feb 2010 PubMed Abstract BACKGROUND: Laparoscopic Roux-en-Y gastric bypass (LRYGB) and laparoscopic biliopancreatic diversion with duodenal switch (LDS) are surgical options for superobesity. A randomized trial was conducted to evaluate perioperative (30-day) safety and 1-year results. METHODS: Sixty patients with a body mass index (BMI) of 50-60 kg/m(2) were randomized to LRYGB or LDS. BMI, percentage of excess BMI lost, complications and readmissions were compared between groups. RESULTS: Patient characteristics were similar in the two groups. Mean operating time was 91 min for LRYGB and 206 min for LDS (P < 0.001). One LDS was converted to open surgery. Early complications occurred in four patients undergoing LRYGB and seven having LDS (P = 0.327), with no deaths. Median stay was 2 days after LRYGB and 4 days after LDS (P < 0.001). Four and nine patients respectively had late complications (P = 0.121). Mean BMI at 1 year decreased from 54.8 to 38.5 kg/m(2) after LRYGB and from 55.2 to 32.5 kg/m(2) after LDS; percentage of excess BMI lost was greater after LDS (74.8 versus 54.4 per cent; P < 0.001). CONCLUSION: LRYGB and LDS can be performed with comparable perioperative safety in superobese patients. LDS provides greater weight loss in the first year. Registration number: NCT00327912 (https://www.clinicaltrials.gov). Copyright (c) 2009 British Journal of Surgery Society Ltd. Published by John Wiley & Sons, Ltd. Duodenal switch provides superior resolution of metabolic comorbidities independent of weight loss in the super-obese (BMI > or = 50 kg/m2) compared with gastric bypass. Prachand et al. Feb 2010 PubMed Abstract OBJECTIVE: Increased body mass index is associated with greater incidence and severity of obesity-related comorbidities and inadequate postbariatric surgery weight loss. Accordingly, comorbidity resolution is an important measure of surgical outcome in super-obese individuals. We previously reported superior weight loss in super-obese patients following duodenal switch (DS) compared to Roux-en-Y gastric bypass (RYGB) in a large single institution series. We now report follow-up comparison of comorbidity resolution and correlation with weight loss. METHODS: Data from patients undergoing DS and RYGB between August 2002 and October 2005 were prospectively collected and used to identify super-obese patients with diabetes, hypertension, dyslipidemia, and gastroesophageal reflux disease (GERD). Ali-Wolfe scoring was used to describe comorbidity severity. Chi-square analysis was used to compare resolution and two-sample t tests used to compare weight loss between patients whose comorbidities resolved and persisted. RESULTS: Three hundred fifty super-obese patients [DS (n=198), RYGB (n=152)] were identified. Incidence and severity of hypertension, dyslipidemia, and GERD was comparable in both groups while diabetes was less common but more severe in the DS group (24.2% vs. 35.5%, Ali-Wolfe 3.27 vs. 2.94, p<0.05). Diabetes, hypertension, and dyslipidemia resolution was greater at 36 months for DS (diabetes, 100% vs. 60%; hypertension, 68.0% vs. 38.6%; dyslipidemia, 72% vs. 26.3%), while GERD resolution was greater for RYGB (76.9% vs. 48.57%; p<0.05). There were no differences in weight loss between comorbidity “resolvers” and “persisters”. CONCLUSIONS: In comparison to RYGB, DS provides superior resolution of diabetes, hypertension, and dyslipidemia in the super-obese independent of weight loss. Vitamin status after bariatric surgery: a randomized study of gastric bypass and duodenal switch. Aasheim et al. July 2009 PubMed Abstract BACKGROUND: Bariatric surgery is widely performed to induce weight loss. OBJECTIVE: The objective was to examine changes in vitamin status after 2 bariatric surgical techniques. DESIGN: A randomized controlled trial was conducted in 2 Scandinavian hospitals. The subjects were 60 superobese patients [body mass index (BMI; in kg/m(2)): 50-60]. The surgical interventions were either laparoscopic Roux-en-Y gastric bypass or laparoscopic biliopancreatic diversion with duodenal switch. All patients received multivitamins, iron, calcium, and vitamin D supplements. Gastric bypass patients also received a vitamin B-12 substitute. The patients were examined before surgery and 6 wk, 6 mo, and 1 y after surgery. RESULTS: Of 60 surgically treated patients, 59 completed the follow-up. After surgery, duodenal switch patients had lower mean vitamin A and 25-hydroxyvitamin D concentrations and a steeper decline in thiamine concentrations than did the gastric bypass patients. Other vitamins (riboflavin, vitamin B-6, vitamin C, and vitamin E adjusted for serum lipids) did not change differently in the surgical groups, and concentrations were either stable or increased. Furthermore, duodenal switch patients had lower hemoglobin and total cholesterol concentrations and a lower BMI (mean reduction: 41% compared with 30%) than did gastric bypass patients 1 y after surgery. Additional dietary supplement use was more frequent among duodenal switch patients (55%) than among gastric bypass patients (26%). CONCLUSIONS: Compared with gastric bypass, duodenal switch may be associated with a greater risk of vitamin A and D deficiencies in the first year after surgery and of thiamine deficiency in the initial months after surgery. Patients who undergo these 2 surgical interventions may require different monitoring and supplementation regimens in the first year after surgery. This trial was registered at ClinicalTrials.gov as NCT00327912. Bowel Habits after Gastric Bypass Versus the Duodenal Switch Operation. Wasserberg et al. Aug 2008 PubMed Abstract BACKGROUND: One of the perceived disadvantages of the biliopancreatic diversion with duodenal switch operation is diarrhea. The aim of this study was to compare the bowel habits of patients after duodenal switch operation or Roux-en-Y gastric bypass. METHODS: A prospective comparative case series design was used. Forty-six patients who underwent duodenal switch (n = 28) or gastric bypass (n = 18) were asked to complete a daily diary for 14 days after losing least 50% of their excess body weight. Data were collected on number of bowel episodes, incontinence, urgency, stool consistency, and awakening from sleep to defecate. Background variables were recorded from the medical files. RESULTS: The duodenal switch group was heavier (body mass index 53.5 vs 47.0 kg/m(2), p = 0.03) and older (47.5 vs 41.0 years, p = NS) than the gastric bypass group. Median time to 50% excess body weight loss was 22 months in the duodenal switch group compared to 10.0 months in the gastric bypass group (p = 0.001). Patients after duodenal switch surgery reported a median of 23.5 bowel episodes over the 14-day study period compared to 16.5 in the gastric bypass group (p = NS). There was no between-group differences in any of the other bowel parameters studied. CONCLUSIONS: Although duodenal switch is associated with more bowel episodes than gastric bypass, the difference is not statistically significant. Bowel habits are similar in patients who achieve 50% estimated body weight loss with duodenal switch surgery or gastric bypass. Duodenal Switch Provides Superior Weight Loss in the Super-Obese (BMI >50kg/m2) Compared With Gastric Bypass Prachand et al. Oct 2006 PubMed Abstract OBJECTIVES: Although weight loss following Roux-en-Y gastric bypass is acceptable in patients with preoperative body mass index (BMI) between 35 and 50 kg/m, results from several series demonstrate that failure rates approach 40% when BMI is > or =50 kg/m. Here we report the first large single institution series directly comparing weight-loss outcomes in super-obese patients following biliopancreatic diversion with duodenal switch (DS) and Roux-en-Y Gastric Bypass (RYGB). METHODS: All super-obese patients (BMI > or =50 kg/m) undergoing standardized laparoscopic and open DS and RYGB between August 2002 and October 2005 were identified from a prospective database. Two-sample t tests were used to compare weight loss, decrease in BMI, and percentage of excess body weight loss (% EBWL) after surgery. chi analysis was used to determine the rate of successful weight loss, defined as achieving at least 50% loss of excess body weight. RESULTS: A total of 350 super-obese patients underwent DS (n = 198) or RYGB (n = 152) with equal 30-day mortality (DS,1 of 198; RYGB, 0 of 152; P = not significant). The % EBWL at follow-up was greater for DS than RY (12 months, 64.1% vs. 55.9%; 18 months, 71. 9% vs. 62.8%; 24 months, 71.6% vs. 60.1%; 36 months, 68.9% vs. 54.9%; P < 0.05). Total weight loss and decrease in BMI were also statistically greater for the DS (data not shown). Importantly, the likelihood of successful weight loss (EBWL >50%) was significantly greater in patients following DS (12 months, 83.9% vs. 70.4%; 18 months, 90.3% vs. 75.9%; 36 months, 84.2% vs. 59.3%; P < 0.05). CONCLUSIONS: Direct comparison of DS to RYGB demonstrates superior weight loss outcomes for DS. Roux-en-Y gastric bypass versus a variant of biliopancreatic diversion in a non-superobese population: prospective comparison of the efficacy and the incidence of metabolic deficiencies. Skroubis et al. April 2006 PubMed Abstract BACKGROUND: In the non-superobese population, an agreement has not been made as to the optimal bariatric operation. The present study reports the results of a prospective comparison of Roux-en-Y gastric bypass (RYGBP) and a variant of biliopancreatic diversion (BPD) in a non-superobese population. METHODS: From a cohort of 130 patients with BMI 35 to 50 kg/m(2), 65 patients were randomly selected to undergo RYGBP and 65 to undergo BPD. All patients underwent complete follow-up evaluation at 1, 3, 6, and 12 months postoperatively and every year thereafter. RESULTS: Patients in both groups have completed their second postoperative year. Mean % excess weight loss (%EWL) was significantly better after BPD at all time periods (12 months, P=0.0001 and 24 months, P=0.0003), and the %EWL was >50% in all BPD patients compared to 88.7% in the RYGBP patients at 2-year follow-up. No statistically significant differences were observed between the 2 groups in early and late non-metabolic complications. Hypoalbuminemia occurred in only 1 patient (1.5%) after RYGBP and in 6 patients after BPD (9.2%). Only 1 patient from each group was hospitalized and received total parenteral nutrition. Glucose intolerance, hypercholesterolemia, hypertriglyceridemia and sleep apnea completely resolved in all patients in both groups, although mean total cholesterol level was significantly lower in BPD patients at the second year follow-up (t-test, P<0.0001). Diabetes completely resolved in all BPD patients and in 7 of the 10 diabetic RYGBP patients. CONCLUSION: Both RYGBP and BPD were safe and effective procedures when offered to non-superobese patients. Weight loss after BPD was consistently better than that after RYGBP, as was the resolution of diabetes and hypercholesterolemia. Because the nutritional deficiencies that occurred following this type of BPD were not severe and were not significantly different between the 2 operations, both may be offered to non-superobese patients, keeping in mind the severity and type of preoperative co-morbidities as well as the desired weight loss.

Summary of Selected Presentations of ASMBS Meeting Part 5

September 03, 2010 10:46 am

Long-Term Outcomes and Consequences of Distal Gastric Bypass (D-GB) In Severe Clinical Obesity

Sugerman et.al.-Surgery, Virginia Commonwealth University, Richmond, VA

This study was conducted to measure longterm weight loss and metabolic results in Distal Gastric Bypass (D-GB) patients within a 24 year time span. Through a bariatric database and office visits statistics were inquired about a 3 year cliental list of 40 super – obese and 6 morbidly obese cases that had the D-GB done with the Roux-En-Y bypass. Preoperative BMI in patients was 59 kg/m2 (80% being women) and the average age was around 36 years old. In addition, approximately 40% of the patients required limb-lengthening revision as a result of protein-calorie malnutrition, and thirteen patients required another surgery. Unfortunately, six to nineteen years later after the D-GB surgery was performed, eight patients died. As a followup, patients who did not have revision surgery showed some weight loss, resulting in a BMI of 34 kg/m2 and an initial excess weight loss of 67%. Patients did have beneficial results in terms of weight loss; however, the protein-calorie malnutrition was too high and some patients’ levels of iron and vitamin D dropped. Distal-GB isn’t the best primary operation for morbid or super obese patients.

Editorial: There has been a resurgence of the distal gastric bypass as a salvage operation for failed proximal gastric bypass operation. The distal gastric bypass operation is a tested procedure, with is known complication rates. The number of distal procedures had gone down significantly, till recently when some centers and surgeons started offering is a revision to other restrictive procedures. It is my opinion that the distal gastric bypass has significant metabolic and nutritional sequel that do not justify its superior weight loss. It is also important to remember that distal gastric bypass is not the same as the duodenal switch or the BPD operation.
Ara Keshishian, MD

Short Term Outcomes Comparing Roux-En-Y Gastric Bypass vs. Sleeve Gastrectomy as Treatment for Failed or Complicated Gastric Banding

Lieb et.al. Cleveland Clinic Florida, Weston, FL

Laparoscopic adjustable gastric band (LAGB) is a commonly performed bariatric operation; however, when major problems take place or weight loss disappoints a revision surgery may take place; Laparoscopic Roux-En-Y Gastric Bypass (LRYGB) and Laparoscopic Sleeve Gastrectomy (LSG) are the most popular options. This study was conducted to compare the efficiency of LRYGB and LSG from 2003 until 2008 analyzing weight loss in terms of the body mass index (BMI). A total of 25 conversions were performed, 13 from LAGB to LRYGB (patients losing 10 BMI points) and 12 from LAGB to LSG (8 points lost in BMI). Hence, after a year the LAGB to LRYGB portrayed more weight loss in comparison to the LAGB to LSG.

Editorial: A common patient presented to our office is a gastric bypass or a lap band that has had less than desirable weight loss. More so, some patients are presenting with complications, such as dumping syndrome, weight regain, nutritional deficiencies, slipped band, dilation of the esophagus and other. There are solutions that are being offered, and most are nothing more than a band aid. I believe that the best reversional operation for failed gastric bypass and the adjustable gastric banding is the duodenal switch operation. This issue was discussed at length last in July 2009 newsletter.
Ara Keshishian, MD