MEDICAL MONDAYS: News Notes
Monday, October 15, 2012
TOPIC: Surgery for Weight Loss
Charles Morton, MD: Medical Director, bariatric surgeon
Mary Sha Miller, RN: Center Director, Metabolic Surgery Center at Baptist
News notes via www.webmd.com
Tennessee's Obesity Rates IMPROVING
For the 2nd YEAR in Row--Obesity rates in Tennessee are going down. The latest results reveal that Tennessee is now the 15th fattest state in the country, which is an improvement when just a few years ago the state was ranked third (in 2009). According to the Tennessee Obesity Task force there is more good news. In a state where 69 % of people used to be overweight that number has dropped to 66%.
NEW Weight Loss Procedure Trial at The Metabolic Surgery Center at Baptist Hospital | The Plicated Adjustable Gastric Band
The Plicated Adjustable Gastric Banding procedure has been recently introduced as an investigational procedure for weight loss. Early data appears encouraging as a safe means of surgical weight loss. However, larger series and longer follow-up are needed to determine the durability and long term success of this combined procedure. To this endeavor, Dr. Charles Morton has acquired IRB approval to study 100 patients over a five year period.
During the Laparoscopic Gastric Plication the stomach volume is reduced about 70% which makes the stomach able to hold less and may help you eat less. There is no cutting, stapling, or removal of the stomach or intestines during the Gastric Plication. Today, a newer investigational procedure combines the benefits of the gastric plication with the laparoscopic gastric band, known as the Plicated Laparoscopic Adjustable Gastric Band or Plicated Adjustable Gastric Band. The rationale for this procedure is to decrease the gastric volume combined with the gastric band to be more restrictive, yet not requiring any staples or cutting of the stomach.
The new, investigational procedure is performed through a laparoscope in addition to the gastric band and creates at least one infold along the stomach, with sutures (stitches), not cutting away or removing the stomach. This infold should make the stomach capacity smaller.
The Plicated Adjustable Gastric Band procedure is minimally invasive and takes approximately one to two hours to complete. Most patients stay in the hospital for 1-2 days after the procedure. Typically, patients return to work within one week.
How Does Weight Loss Occur?
The Plicated Adjustable Gastric Band is a restrictive procedure--greatly reducing the size of the stomach and limiting the amount of food that can be eaten at one time. It does not cause decreased absorption of nutrients or bypass your intestines. After eating a small amount of food, patients feel full very quickly and continue to feel full for several hours. This procedure may also cause a decrease in appetite.
Who are candidates?
The Plicated Adjustable Gastric Band procedure is relatively new, and considered investigational as a primary procedure for weight loss. This procedure is being offered to patients by Dr. Charles Morton at the Metabolic Surgery Center at Baptist Hospital as part of a clinical research trial that will better define short and long-term benefits of the procedure.
What Are The Risks?
There are risks that are common to any laparoscopic procedure such as bleeding, infection, injury to other organs, or the need to convert to an open procedure. There is also a small risk of a leak from the suture line used to imbricate/plicate ("fold") the stomach. These problems are rare and major complications occur less than 1% of the time.
What Are The Possible Benefits?
Depending on their pre-operative weight, patients can expect to lose between 40% to 70% of their excess body weight within the first year following surgery. Many obesity-related comorbidities improve or resolve after bariatric surgery. Diabetes, hypertension, obstructive sleep apnea and abnormal cholesterol levels are improved in more than 75% of patients. Though long-term studies are not yet available, the weight loss that occurs after the Plicated Adjustable Gastric Band results in significant improvement in these medical conditions in the first year after surgery.
If you are contemplating Lap-Band surgery, or if you have experienced insufficient weight loss with the Lap-Band procedure as a lone source of treatment and wish to be a part of this trial, which adds the plication procedure to the Laparoscopic Adjustable Gastric Banding, please contact Dr. Charles Morton at The Metabolic Surgery Center at Baptist Hospital (615.284.2400) or simply visit www.baptistweightloss.com
Weight Loss Surgery: Experience Matters
Surgeon Experience and Hospital Volume Most Important Criteria
People considering weight loss surgery can reduce their risk of complications by choosing a surgeon and hospital with a lot of experience performing the procedures, according to new research published in the Journal of the American Medical Association.
The study of outcomes among more than 15,000 bariatric surgery patients in Michigan showed a very low rate of serious complications and death.
But potentially life-threatening complications occurred at twice the rate in patients whose surgeries were performed by the least experienced surgeons compared to the most experienced.
Likewise, the serious complication rate was almost twice as high for patients whose surgeries were performed at the lowest-volume hospitals compared to facilities where bariatric surgery was performed most often.
For low-volume surgeons working at low-volume hospitals, the serious complication rate was 4%, compared to 1.9% for high-volume surgeons working at high-volume hospitals..
In the absence of reliable data on outcomes, patients should seek out high-volume hospitals and surgeons when considering bariatric surgery.
More Than 200,000 Surgeries a Year
About 220,000 people in the United States had weight loss surgery in 2009, according to the American Society for Metabolic and Bariatric Surgery (ASMBS). That is a more than tenfold annual increase in the surgeries in less than a decade…Message to Patients: ‘Do Your Homework'
Which Weight Loss Surgery Is Best?
The ideal weight loss surgery depends on your current health and body type. For instance, if you are very obese, or had abdominal surgery before, minimally invasive surgeries might not be possible. It really pays to talk with your doctor about the pros and cons of each procedure.
If possible, go to a medical center that specializes in weight loss surgery. Studies have shown that the risk of complications is lower when weight loss surgery is done by experts. No matter where you are, always make sure that your surgeon has had plenty of experience performing the procedure you need.
Is Weight Loss Surgery Right for Me?
Weight loss surgery is not for everyone. Doctors only recommend it for people who:
In early 2011, the FDA approved the use of LAP-BAND surgery in those with a BMI of 30 or higher who have at least one obesity-related condition, such as diabetes.
Even if you meet these basic criteria, there's a lot more you have to consider. Perhaps most importantly, you need to be mentally ready. Weight loss surgery can be lifesaving, but it is not a cure. Instead, it's the first step in a lifelong commitment. For any surgery to help, you need to be dedicated to making dramatic and permanent changes to how you eat, exercise, and live.
Weight Loss Surgery Procedures
LAPAROSCOPIC GASTRIC BANDING is the second most common weight loss surgery, after gastric bypass.
Gastric banding surgery involves the following:
Laparoscopic adjustable gastric banding leads to loss of about 40% of excess weight, on average. Someone people who are 200 pounds overweight could expect to lose an average of 80 pounds after gastric banding. However, these results vary widely.
Gastric banding is considered the least invasive weight loss surgery. It is also the safest. The procedure can be reversed if necessary, and in time, the stomach generally returns to its normal size.
Gastric banding surgery has a low complication rate. The most common problems after gastric banding surgery include:
Unlike gastric bypass surgery, gastric banding does not interfere with food absorption. For this reason, vitamin deficiencies are rare after gastric banding.
What is it? This is a relatively new form of restrictive weight loss surgery. In the operation, which is usually done with a laparoscope, about 75% of the stomach is removed. What remains of the stomach is a narrow tube or sleeve, which connects to the intestines.
Usually, a sleeve gastrectomy is a first step in a sequence of weight loss surgeries. It's typically followed up by gastric bypass or biliopancreatic diversion, which will result in greater weight loss. However, in some cases, it might be the only surgery you need.
The Pros. For people who are very obese or sick, standard gastric bypass or biliopancreatic diversion may be too risky. A sleeve gastrectomy is a simpler operation that allows them a lower-risk way to start losing weight. Afterwards, once they've lost weight and their health has improved -- usually after 12-18 months -- they can go on to have a second surgery, such as gastric bypass. In people with high BMIs, sleeve gastrectomies result in an average weight loss of 40% to 50% of excess weight after three years. People with lower BMIs tend to lose even more of their excess weight. The preliminary evidence suggests that sleeve gastrectomy works about as well as adjustable gastric banding.
Because the intestines aren't affected, a sleeve gastrectomy doesn't affect the absorption of food, so nutritional deficiencies are not a problem.
The Cons. Since a sleeve gastrectomy is often just the first step in weight loss surgery, you will probably face further operations later on. Unlike gastric banding procedures, a sleeve gastrectomy is irreversible. Most importantly, since it's relatively new, the long-term benefits and risks aren't yet known.
The Risks. Typical surgical risks include infection, leaking of the sleeve, and blood clots.
GASTRIC BYPASS SURGERY (ROUX-EN-Y GASTRIC BYPASS)
What is it? Gastric bypass is the most common type of weight loss surgery. It makes up about 80% of all weight loss surgeries in the U.S., and combines both restrictive and malabsorptive approaches. It can be done as either a minimally invasive or open surgery.
In the operation, the surgeon divides the stomach into two parts, sealing off the upper section from the lower. The surgeon then connects the upper stomach directly to the lower section of the small intestine. Essentially, the surgeon is creating a shortcut for the food, bypassing a section of the stomach and the small intestine. Skipping these parts of the digestive tract means that fewer calories get absorbed into the body.
The Pros. Weight loss tends to be swift and dramatic. Most of it happens in the first six months. It may continue for up to two years after the operation. Because of the rapid weight loss, health conditions affected by obesity -- like diabetes, high blood pressure, high cholesterol, arthritis, sleep apnea, heartburn, and other conditions -- often improve quickly. You'll probably also feel a dramatic improvement in your quality of life.
Gastric bypass also has good long-term results; studies have found that many people keep most of the weight off for 10 years or longer.
The Cons. By design, surgeries like this impair the body's ability to absorb food. While that can cause rapid weight loss, it also puts you at risk of serious nutritional deficiencies. The loss of calcium and iron could lead to osteoporosis and anemia. You'll have to be very careful with your diet -- and take supplements -- for the rest of your life.
Another risk of gastric bypass is dumping syndrome, in which food is "dumped" from the stomach into the intestines too quickly, before it's been properly digested. About 85% of people who get a gastric bypass have some dumping. Symptoms include nausea, bloating, pain, sweating, weakness, and diarrhea. Dumping is often triggered by sugary or high-carbohydrate foods, and adjusting the diet helps. However, some experts actually see dumping syndrome as beneficial, in that it encourages people to avoid foods that could lead to weight gain.
Unlike adjustable gastric banding, gastric bypass is generally considered irreversible. In has been reversed in rare cases. Therefore, getting this surgery means that you're permanently changing how your body digests food.
The Risks. Because these weight loss surgeries are more complicated, the risks are higher. The risk of death from these procedures is low -- under 1% -- but they are more dangerous than gastric banding. Infection and blood clots are risks, as they are with most surgeries. Gastric bypass also increases the risk of hernias, which can develop later and will need further surgery to fix. One side effect of rapid weight loss is the formation of gallstones. Usually, they are treated with medicine. But in some bypass surgeries, the gallbladder might actually be removed to prevent this problem.
BILIOPANCREATIC DIVERSION (DUODENAL SWITCH)
What is it? This is essentially a more drastic version of a gastric bypass, in which part of the stomach -- as much as 70% -- is removed, and even more of the small intestine is bypassed.
A somewhat less extreme version of this weight loss surgery is called biliopancreatic diversion with a duodenal switch. While still more involved than a gastric bypass, this procedure removes less of the stomach and bypasses less of the small intestine. It also reduces the risk of dumping syndrome, malnutrition, and ulcers, which are more common with a standard biliopancreatic diversion.
The Pros. Biliopancreatic diversion can result in even greater and faster weight loss than a gastric bypass. Studies show an average loss of 75%-80% of excess weight. Although much of the stomach is removed, the remainder is still larger than the pouches formed during gastric bypass or banding procedures. So you can actually eat larger meals with this surgery than with others.
The Cons. Biliopancreatic diversion is less common than gastric bypass. One of the reasons is that the risk of nutritional deficiencies is much more serious. It also poses many of the same risks as gastric bypass, including dumping syndrome. However, biliopancreatic diversion with a duodenal switch may lower some of these risks.
The Risks. This is one of the most complicated and high-risk weight loss surgeries. According to National Institutes of Health, the risk of death from a biliopancreatic diversion with duodenal switch range between 2.5% to 5%. As with gastric bypass, this surgery poses a fairly high risk of hernia, which will need further surgery to correct. However, this risk is lower when the procedure is done laparoscopically.