You and your doctor have agreed: surgery could be the answer to your weight-loss problems.

But what are the disadvantages – and the possible risks – of bariatric surgery? And how will this operation change your life?

Risks of bariatric surgery
Any operation that requires an anaesthetic, which takes between 1 and 3,5 hours to complete, is potentially dangerous.

If one also keeps in mind that patients who undergo these operations are morbidly obese and often suffer from a variety of associated complications such as respiratory disorders, diabetes and heart disease, the risks may be even more.

According to scientific literature, the following risks are associated with bariatric surgery:

a) During or shortly after the operation:

Pulmonary embolism (a blood clot in the lungs), which accounts for up to 70% of deaths that occur during or immediately after surgery
Major wound infections
Peritonitis (inflammation of the membrane of the abdominal cavity)
Narrowing of the entrance to the stomach
Abscesses
Slippage of the gastric band or staples which then require re-operation
b) After surgery

Vomiting
Dysphagia (inability to eat)
Hernia
Heartburn
Diarrhoea
Dumping syndrome (see below)
Malnutrition
Vitamin and mineral deficiencies (see below)
Regain of weight that has been lost
(Msika (2003), Sugermann (2001), Sugermann et al (2003)).

Dumping syndrome
According to Krause (2000), dumping syndrome is “a complex physiological response to larger than normal amounts of food and liquid in the upper parts of the small intestine” due to changes in the rate at which the stomach is emptied.

The symptoms associated with dumping syndrome usually start off with mild effects that include a feeling of fullness and nausea 10 to 20 minutes after eating. Patients may also experience flushing, heart palpitations, fainting, sweating and the urge to sit or lie down.

About one hour after eating, patients may develop abdominal bloating, winds, cramps and abdominal pain and diarrhoea.

Finally, the most extreme stage of dumping syndrome can cause hypoglycaemia (low blood sugar). Patients may perspire, feel anxiety, weakness, shakiness, or hunger, and may be unable to concentrate.

Ironically, the fact that these symptoms can be so severe, can act as a strong motivation to patients to stick to the post-operative dietary rules that they will need to follow for the rest of their lives.

To avoid dumping syndrome, the following guidelines should be applied:

Eat only small meals, which should be spread throughout the entire day (6-8 meals per day).
Eat mainly high-protein, low-fat foods.
Include some dietary fibre if you find that you can tolerate this (e.g. brown bread, oats, brown rice).
Try to rest or lie down one hour after your meals to slow down stomach emptying.
Avoid drinking liquids with your meals, but make sure that you have small quantities of liquid (no more than 100ml), all day long between meals to prevent dehydration.
Avoid cold drinks, juices, pies, cakes, biscuits and frozen desserts or any very sweet foods.
If you find that milk and dairy products don’t agree with you or worsen the symptoms of dumping syndrome, then you may have to avoid them. In such cases, it is essential to take a calcium supplement. Cheese and yoghurt can usually be eaten without discomfort.
Vitamin and mineral deficiencies
Post-operative vitamin and mineral deficiencies are common in patients who have undergone bariatric surgery, namely:

Iron deficiency which can cause anaemia (this is particularly common in female patients who menstruate)
Vitamin B12 deficiency, which can also lead to megaloblastic anaemia
Calcium deficiency, which may cause osteoporosis later in life
Folic acid deficiency
Most bariatric surgery patients need to take vitamin and minerals supplements for the rest of their lives and your surgeon or dietician will advise you which products to use. Regular monitoring of vitamin and mineral levels in the blood is a recommended precautionary measure to pinpoint potential deficiencies.

Advantages of bariatric surgery
The greatest advantage of bariatric surgery is, of course, the significant weight loss that morbidly obese patients achieve. Losses of up to 120kg have been reported.

As these patients lose weight, many of their so-called co-morbidities either disappear or improve dramatically, for example type 2 diabetics may find that they no longer have to take medication and can control their condition with diet alone.

Improvements are also seen in: hypertension, sleep apnoea, obesity hyperventilation syndrome, gastro-oesophageal reflux, venous stasis, urinary incontinence, female sexual hormone dysfunction (e.g. polycystic ovarian disease), degenerative joint disease, and most other obesity-related diseases.

Any patient who has lost a third to half of his/her body weight will naturally be more mobile and active.

In addition, patients experience a great increase in self-esteem, less depression and anxiety, and feel much more self-confident. Patients also find it easier to get jobs and find romantic partners.

Scientists say they may have found out why people get hungry at mealtime, why dieters who lose weight often gain it back and why certain types of stomach surgery help very obese people lose a great deal of weight.
The reason may be a hormone called ghrelin, which makes people hungry, slows metabolism and decreases the body’s ability to burn fat.
Ghrelin Levels
Ghrelin levels in the blood peak before meals and drop afterward. People given ghrelin injections felt voraciously hungry, and, when turned loose at a buffet, ate 30 percent more than they normally would.
Dieters who lose weight and then try to keep it off make more ghrelin than they did before dieting, as if their bodies are fighting to regain the lost fat, researchers are reporting today in the New England Journal of Medicine.
By contrast, the same study showed that very obese people who have an operation called gastric bypass to lose weight wind up with relatively little ghrelin, which may help explain why their appetites decrease markedly after the surgery. Sleeve Gastrectomy operations also remove the section of the stomach in which Ghrelin is produced
Below is an extract from a Scientific paper published in Obesity Surgery, Vol15, 2005
Sleeve Gastrectomy and Gastric Banding: Effects on Plasma Ghrelin Levels
F. B. Langer1; M. A. Reza Hoda1; A. Bohdjalian1; F. X. Felberbauer1;
J. Zacherl1; E.Wenzl1; K. Schindler2; A. Luger2; B. Ludvik2; G. Prager1
1Department of Surgery, Division of General Surgery, and 2Department of Medicine III, Division of
Endocrinology and Metabolism, Medical University Vienna, Vienna, Austria
Ghrelin, recently described as a hunger regulating peptide hormone mainly produced in the fundus of the stomach, is reported to be significantly increased in diet-induced weight-loss. Inconsistent changes in plasma ghrelin levels, however, were reported following different bariatric surgical procedures. Laparoscopic sleeve gastrectomy (LSG), which can be regarded as an advancement of the Magenstrasse and Mill procedure, has been introduced as the first part of a two-step laparoscopic gastric bypass in the “super-super-obese� (i.e. BMI >60 kg/m2) patients in order to reduce the perioperative risk. Furthermore, it has been applied as a definitive bariatric operation in a series of high-risk super-obese patients. Because the gastric fundus, known as the main localization of ghrelin-producing cells, is resected by sleeve gastrectomy, plasma ghrelin levels are expected to decrease following surgery. The aim of this prospective study was to determine the effects of laparoscopic sleeve gastrectomy (LSG) on immediate and 6 months postoperative ghrelin levels, compared with laparoscopic adjustable gastric banding (LAGB).
In this study in 20 morbidly obese patients, we found significantly reduced levels of plasma ghrelin following laparoscopic sleeve gastrectomy immediately after surgery and up to a period of 6 months. In contrast, plasma ghrelin was not changed postoperatively after LAGB and increased significantly after 1 and 6 months. In parallel, excess weight loss was more pronounced following LSG compared with LABG.        To our knowledge this is the first study investigating plasma ghrelin levels in sleeve gastrectomy.                                                                                                                               
Because ghrelin is supposed to be involved in the regulation of appetite, the effects of various bariatric operations on the plasma levels of ghrelin have been a focus of interest in a growing number of recentlypublished papers. While it has been shown that plasma ghrelin increases following diet-induced weight loss18 thereby potentially contributing to weight regain, the data on ghrelin after bariatric operations are inconclusive so far.
In contrast to LAGB, Roux-en-Y gastric bypass was found to decrease the plasma ghrelin level. To explain this discrepancy, it has been speculated that ghrelin-producing cells in the gastric fundus have no further contact with ingested nutrients resulting in an override suppression after RYGBP. In gastric banding patients, however, the ghrelin producing cells are not bypassed. Therefore, these cells remain to function, leading to increased ghrelin levels following LAGB, comparable to diet induced weight loss.                                                                                                          
Sleeve gastrectomy has been established as part of the BPD-DS. Only three studies of sleeve gastrectomy as sole bariatric intervention have been published so far, without focusing on changes of plasma ghrelin levels. In this series of LSG, the greater curvature and the gastric fundus as the main locus of ghrelin production were completely resected, forming a narrow gastric tube that permits oral intake of only small amounts of food. This extensive type of LSG may be understood as a restrictive procedure augmented by the reduction of the ghrelin producing tissue. While the majority of plasma ghrelin originates from the stomach, other locations of ghrelin secretion outside the gastric fundus have been reported. The restrictive effect on food ingestion after LAGB and LSG is comparable. In contrast to Adami, who found ghrelin levels following biliopancreatic diversion comparable to preoperativevalues only 2 months postoperatively, we observed no compensatory hypersecretion of ghrelin as stable low levels were found in the postoperative course up to 6 months following laparoscopic sleeve gastrectomy. This difference could be explained by the extent of gastric resection. In our series the complete fundus was resected, while the fundus was left in situ in the series of Adami
Within 6 months, LSG patients were able to reduce their weight in a more effective way than LAGB patients. In this series, LSG patients presented with higher preoperative plasma ghrelin levels compared with the patients of the LAGB group (109.6 ± 32.6 fmol/ml vs 73.7 ± 24.8 fmol/ml, P=0.005).
Postoperatively, LSG led to significantly decreased and stable plasma ghrelin levels at up to 6 months. In contrast, patients who underwent LAGB presented with significantly increased plasma ghrelin in the postoperative course. Because the restrictive effect regarding food intake is comparable between both methods, the superior effect on weight loss by LSG could be attributed to the permanently lower ghrelin levels preventing an increase in appetite as a compensatory mechanism.
In conclusion, we have demonstrated that in contrast to LAGB, ghrelin levels are significantly decreased following LSG immediately postoperatively, as well as up to 6 months postoperatively in morbidly obese patients. This is paralleled by a superior weight loss after LSG which might be related to the permanent decrease in ghrelin levels preventing a compensatory increase in hunger.
 

A recent edition of the Pretoria News featured an article on bariatric surgery, entitled “When diets and exercise fail, surgery can help”, written by Barbara Cole.

This article reported on how Natashua Fourie lost 34kg since last November, following keyhole laparoscopic surgery for morbid obesity. According to the report, the surgeons, who are authorised to perform such operations at St Augustine’s Hospital in Durban, have recorded even greater successes, including one patient who lost 120kg of weight after this type of operation.

As many Health24 readers also suffer from morbid obesity with BMIs exceeding 35, coupled with a variety of so-called comorbidities (other health conditions such as diabetes, sleep apnoea, painful joints, high blood pressure and impending heart disease), I decided to read up on the available scientific literature and to share my findings.

What do these operations entail?
Bariatric surgery involves a reduction in the size of the digestive tract to restrict how much food the patient can eat and absorb. Most of the present-day techniques reduce the size of the stomach.

For example, gastroplasty involves placing stainless steel staples across the top of the stomach, leaving a small opening so that only a small amount of food can pass into the stomach at any one time.

A gastric bypass, on the other hand, also entails a reduction in the size of the stomach (with the aid of staples) and connecting the part of the stomach that is still functioning to the small intestine (Krause, 2000).

Laparotomy vs. laparoscopic surgery
Initially, bariatric surgery always involved a laparotomy (surgical opening of the abdomen). But nowadays keyhole laparoscopic surgery, which only requires small incisions in the abdomen, has become more popular. The latter procedure is much less invasive and faster, thus exposing the patient to less risk during the operation.

In one study conducted at the University of California, researchers found that laparoscopic bypass surgery took less operation time, caused less blood loss, reduced the length of time that patients were in intensive care after surgery and the length of their stay in hospital (Nguyen et al, 2000).

An Italian study reports that, on average, laparoscopic procedures took 60 minutes to perporm compared to up to 3,5 hours for the more invasive, full-scale operations (Angrisani et al, 2007).

From the point of view of the patient undergoing surgery, it is evident that the more recent keyhole surgery techniques are faster and safer.

Can one expect the same weight-loss results?
A valid question is if the keyhole laparoscopic technique produces the same long-term results as the longer, more invasive surgical procedure.

A German research team, who studied 100 patients who underwent laparoscopic adjustable gastric banding, found that this procedure produced excellent results with an average weight loss of nearly 60% eight years post-operatively with reductions in BMI from 46.8 to 32.3 kg/m (Weiner et al, 2003). These researchers concluded that laparoscopic adjustable gastric banding is safe and has a lower complication rate than other bariatric operations.

Nguyen and coworkers (2000) also concluded that the keyhole technique produces the same initial weight loss as the more invasive surgical procedure.

Thanks to progress in the field of bariatric surgery, the keyhole operation appears to be faster and potentially safer than techniques that require full-scale opening of the abdomen, and this newer approach apparently also gives good weight-loss results.

According to the newspaper report, Natashua Fourie, who shed 34kg, was treated with the keyhole procedure. Her mother and a friend had the same operation and lost 29kg and 25kg, respectively.

Who qualifies for bariatric surgery?
In my reading of the scientific literature, a number of authors repeatedly stated that “bariatric surgery is NOT to be regarded as a cosmetic procedure, but as a life-saving intervention in patients who suffer from morbid obesity.”

It is very important to understand that individuals who only need to shed a few kilos or who have a BMI of less than 35 are usually not regarded as candidates for bariatric surgery. In fact, the majority of studies I investigated were treating patients with BMIs exceeding 40!

If your BMI is lower than 40, surgeons may, therefore, only consider you as a candidate for bariatric surgery if you have severe comorbidities such as diabetes mellitus, very high blood pressure or raised blood fat levels, and if you are at risk of suffering a heart attack.

In most cases, the decision to do a gastric bypass operation is determined by its effect on potentially life-threatening obesity and other risk factors.

If you do not suffer from morbid obesity and accompanying life-threatening conditions, then most surgeons would recommend that you use diet and exercise, plus medications such as Xenical, to lose your excess weight. COSMETIC BLISS NOTE: The insertion of a BIB Intragastric Balloon for candidates with a BMI which is not high enough to justify surgery is proven to give good weight loss results, and can be seen as a very useful tool in giving a six month “training period” in which eating habits and the relationship to food can be permanently changed.
Read the full story at
http://www.health24.com/dietnfood/Weight_Centre/15-51-2992-3081,41241.asp

Extremely obese people suffering from depression or anxiety tend to lose less weight after obesity surgery than mentally healthy people, researchers reported in a study that suggests such patients could benefit from treatment beforehand.

People diagnosed with mood or anxiety disorders on average lost 81 pounds six months after gastric bypass surgery compared to their counterparts who shed 86 pounds. Although both groups lost significant weight after surgery, people without mental health problems did slightly better. Researchers plan to follow patients for up to two years to determine if there’s a weight difference over time.

Many hospitals and insurers require surgery candidates to go through a psychological evaluation before obesity surgery to make sure they are mentally fit for the operation and the lifestyle change afterward. Depressed people aren’t automatically disqualified for surgery, but those who are suicidal or abusing drugs and alcohol are usually ruled out.

How depression and other mental health disorders are handled before obesity surgery vary widely by medical center.

Those with serious problems are usually treated before surgery. That could include antidepressants, psychotherapy or more family involvement, said the center’s director William Perry.

In the new study, Pittsburgh researchers interviewed 207 surgery candidates and found two-thirds had a history of depression, bipolar disorder, post-traumatic stress syndrome or panic attacks. The vast majority were women with an average body-mass index of 51. A person with a BMI of over 40 is considered morbidly obese.

After adjusting for age, gender and race, researchers compared weight loss six months after surgery. Patients with a history of depression on average weighed 322 pounds before surgery and 241 afterward. Those with no mental health problems weighed 303 pounds before the operation and 217 pounds afterward.

Having a history of mental health problems should not prevent people from getting obesity surgery, even though they may not lose quite as much weight as mentally healthy people, said Dr Philip Schauer, president of the American Society for Bariatric Surgery.

I’ve been banded for almost four years now and have always been very happy with my band. I had never been able to lose weight on diets, but with the band the weight came off quite easily. Everything seemed to be going so well, after about the first two years I almost sort of *forgot* about the band on a day to day basis.

HOWEVER, I recently realized that it is important not to become complacent about the band!  Just a few days ago, while having lunch, I noticed that I had suddenly lost ALL my restriction, and it scared me because I knew that it had to be some kind of band problem with such a sudden onset.
Yesterday, I finally had an upper GI test done, and it turns out that I have a dilated pouch. Believe it or not, I was actually HAPPY to hear that news, because I was relieved that it was a problem that can be corrected without surgery.
My surgeon simply took all my fill out for two weeks to help my pouch shrink back down to proper size. I’m trying to give my band/stomach a break by trying to stay on liquids and soft food for that time period (plus I find it hard to eat enough liquids to pack on weight than I would if I were on solids, which is obviously a big concern while my band is empty!).
At the end of these two weeks I will hopefully be able to get a fill again.
I still feel the lap-band complications are not that bad compared to how bad things can get with a gastric bypass operation. One thing I found comforting
when I first realized something was wrong with my band but didn’t know what was going on was that, no matter what was wrong with my band, I knew it wasn’t something that truly posed a danger to my life or health.

Now, more than ever, from seeing how my urge to eat excessively has come back in full force since I lost my restriction, I understand that morbid obesity is not just a personality flaw or a lack of control, but a disease that needs to be treated by surgery.
However, even if I had to lose my band, I would seek out a surgeon to do the Sleeve Gastrectomy operation, rather than getting a bypass.

The sleeve gastrectomy seems to be becoming more popular nowadays.
Back when I was looking into weight loss surgery (which was only about five years ago, remember), nobody was even talking about the Sleeve gastrectomy as an option. My choice was basically between the lap-band or one of the drastic, risky bypass procedures (the RNY or the Duodenal Switch).
Back when I first started looking at weight loss surgery, I was rapidly soaring towards 400 pounds, and I knew I had to do SOMETHING to put an end to the madness. If the lap-band hadn’t been around at that time, I probably would have resorted to a bypass operation out of desperation back then. However, I’m only in my early 20s, so I would not have been very happy about having to condemn myself to live out the rest of my life (hopefully 50+ years!) with constant malabsorption of nutrients and vitamins. I don’t think that’s a healthy way to live in the long-term even though in some cases it may be necessary as a last resort for someone whose obesity will kill them soon.

So, even *if* I had to lose my band at this point or somewhere down the road, I’d be grateful for these years of service it provided me with, because it saved me from having to get a bypass operation back then when the bypass was pretty much the only option, and now we seem to have other promising options like the Sleeve gastrectomy that don’t require a drastic malabsorption component like the bypass does.
It’s amazing how much the weight loss surgeries have changed in just these past 5 or 10 years. In another five or ten years, who knows how many other major
changes might happen in the field? So, for that reason, I definitely am glad to have an option that is effective, but also relatively “gentle” and easily reversible, even though the trade-off is that we occasionally have to worry about issues like slippage/erosion.
http://www.lapbandtalk.com/f78/my-dilated-pouch-story-why-i-still-love-my-band-regardless-33335/
 

GMTV    20 June 2007

Should Jemma Butler be allowed to have her stomach stapled? Tell us your thoughts here
Jemma Butler is only 25, but already weighs 32 stone and is desperate to lose weight. Two years ago she was told she only has 5 years to live, but her local NHS trust has refused to give her the stomach stapling operation she thinks will save her life. 

Jemma, aged 25 struggled with her weight since childhood and all through her teenage years.  Things came to a head about five years ago after a work-related injury.

She sunk into a deep depression, comforting herself with food.  Her weight ballooned to 30 stone, and in 2005, her doctors told her she had 5 years to live. Emma was on anti-depressants and had become increasingly isolated as her weight had increased.

She asked doctors to put her forward for a stomach stapling operation, and went on the waiting list.  After almost 2 years, she got a letter in November ’06,  telling her telling her she’d be removed from the waiting list, as she didn’t meet Health Commission Wales’ strict criteria for stomach stapling operations. 

Although her BMI is 70, she wasn’t suffering from the complications of obesity – heart disease, diabetes, sleep apnoea – and therefore didn’t qualify for surgery.  She appealed the decision, but in March 2007, she lost. 

She definitely considers herself an addict, although she’s finally trying to do something about it – she weighs somewhere between 32-33 stone, though she says she has lost some weight, as she’s been on a diet for 6 months.

Her doctor feels frustrated that she’s being denied the surgery. It would allow her to re-build her life, return to work, and reduce her chance of developing other complications.

More on http://www.gm.tv/index.cfm?articleid=26183

Authors: Baltasar, Aniceto1; Serra, Carlos2; Pérez, Nieves2; Bou, Rafael2; Bengochea, Marcelo2; Ferri, Lirios2
Source: Obesity Surgery, Volume 15, Number 8, September 2005 , pp. 1124-1128(5)
Publisher: Springer

Abstract:
Background: The use of the laparoscopic sleeve gastrectomy (LSG), a restrictive operation, in different settings, is presented.
Methods: 31 patients underwent LSG in the following groups: 1) 7 patients with very high BMI as a first stage of the duodenal switch (DS); 2) 7 morbidly obese patients with severe medical conditions; 3) 16 obese patients with lower BMI (35-43); and 4) 1 patient converted from a prior gastric banding.
Results: 1 patient with BMI 74 died, a 3.2% mortality. The percentage of excess BMI loss (%EBMIL) in group 1 above was 63.1% from 4-27 months. The %EBMIL of the cirrhotics in group 2 was 76.0% (69-100%). The %EBMIL in group 3 patients was 68.5% (58.3-123%) at 3-27 months. The %EBMIL of the group 4 patient is 13% because she had previously lost almost all of her EBMI.
Conclusion: LSG may become the ideal operation for staging in patients with BMI >55, for treating morbidly obese patients with severe medical conditions, as an excellent alternative to adjustable bands in lower BMI patients, or for conversion of gastric banding patients.

Keywords: MORBID OBESITY; SLEEVE GASTRECTOMY; LAPAROSCOPY; BILIOPANCREATIC DIVERSION WITH DUODENAL SWITCH
Document Type: Research article
DOI: 10.1381/0960892055002248
Affiliations: 1: Clínica San Jorge and Alcoy Hospital, Chief of the Surgical Service, Alcoy, Spain 2: Clínica San Jorge and Alcoy Hospital, Surgical Staff, Alcoy, Spain

http://www.ingentaconnect.com/content/klu/os/2005/00000015/00000008/art00007

 Stomach reduction procedures are effective in suppressing the body’s ability to produce Ghrelin, the hormone attributed to hunger and weight gain.
Scientists and researchers have discovered that the hormone responsible for stimulating the human appetite, Ghrelin, has been reduced and even neutralized by bariatric surgical procedures like vertical gastrectomy, (also known as sleeve gastrectomy), gastric bypass and duodenal switch.
Most of the hormone Ghrelin is produced in the stomach, and scientists believe that it evolved to fight weight loss in the human body. Professor Stephen Bloom, a British obesity researcher, describes it this way: “We are machines designed to live through famine. We are survivors of the obese. All we need is a plentiful supply of food and we gain weight. That’s the way we are made and how we evolved.”
To combat this predisposition to weight gain, bariatric surgical procedures have become popular in helping counteract the debilitating effects of obesity. Bariatric surgeons like Dr. Paul Cirangle, of Laparoscopic Associates of San Francisco, have seen the effects of neutralizing Ghrelin firsthand. “We have discovered that, after performing a vertical gastrectomy and other stomach reduction procedures, the Ghrelin levels have decreased dramatically within 24 hours of the stomach being removed. We consider this proof that surgery can favorably alter the hormonal drive to eat and allow individuals to lose large amounts of weight without feeling hungry.”
Researchers found elevated levels of Ghrelin in people who lost weight through dieting whenever they were measured for it, leading them to conclude that the body was signaling its owner to eat more in order to gain back lost weight. This conclusion has lent additional credence to the surgical option for obese people searching for a long-term solution to losing weight and keeping it off.
The reduction of Ghrelin levels from vertical gastrectomy and other bariatric procedures has captured the attention of scientists around the world who are striving to find the magic bullet to the obesity epidemic. Controlling the way the body produces Ghrelin, through surgery and medical research, may hold the key to the future of fighting an ever-increasing worldwide disease.

Article courtesy of  “the Morbid Me�  14/06/07

Jun 4 2007 by Madeleine Brindley, Western Mail

WEIGHT-LOSS surgery could “cure� diabetes in overweight patients according to Welsh research.  As many as 95% of morbidly obese people – those with a body mass index of more than 40 – have type 2 diabetes.  But eight out of 10 of these patients who have gastric bypass surgery to reduce the size of their stomachs and small intestines, have found that their diabetes disappears within two to three days – before any weight loss has occurred.

Scientists at Swansea University have been awarded £93,000 to further investigate the reasons for the phenomenon.  The research could have a huge impact on the management of diabetes and could even lead to new non-surgical treatments.

Jeffrey Stephens, senior clinical lecturer, who is leading the research, said, “Although patients with type 2 diabetes do not always require insulin treatment, the average diabetic needs about 30 units of insulin a day to control blood sugar levels.

“For obese patients, this can rise to 200 units a day. To go from such a high level of insulin-dependency to not needing insulin in a matter of a few days is a dramatic result, and we need to understand the reasons why this happens.�

The research team, which includes Professor Steve Bain and Professor Rhys Williams from Swansea University’s School of Medicine, and Professor John Baxter, a bariatric surgeon at Swansea NHS Trust, will focus its research efforts on a protein known as Glucagon Like Peptide 1 (GLP-1), which is produced in the small intestine.

It is estimated that thousands of people in Wales could have undiagnosed type 2 diabetes and experts fear that increasing levels of obesity in society could cause an explosion in diabetes, especially in the young. Although often regarded as a benign condition, diabetes can cause serious, and even potentially fatal, complications such as heart disease, blindness and kidney failure.

Bariatric surgery has become an accepted, but drastic, surgical treatment for obesity, but Health Commission Wales, which took over commissioning the service, does not routinely provide funding for the operation on the NHS!!

http://icwales.icnetwork.co.uk

By LORETTA GRANTHAM – Palm Beach Post Staff Writer   Sunday, June 24, 2007

Patients who’ve lost nearly 100 pounds are thrilled!

A new weight-loss surgery doesn’t require you to reroute your digestive system or deal with an adjustable implant. You will, however, have to give up more than three-quarters of your stomach, which is permanently removed.
But for lifelong dieter John Linehan, who dropped 100 pounds after having a sleeve gastrectomy last year, this was a triumph, not a sacrifice. A potent blow to the tyranny of an insatiable appetite.

“I don’t want people to think it’s a magic pill, but in my opinion, it’s pretty darn close,” he says. “I’m not a slave to the cravings anymore. I can eat a small amount and feel full.”
Linehan is one of nearly 200 patients who’ve had gastric sleeve surgery in the past two years at the Cleveland Clinic in Florida, a Weston research hospital that’s among a handful of bariatric centers pioneering the procedure.
The operation involves cutting off the crescent moon-shaped part of the stomach and leaving behind a tube, or “sleeve,” which can hold from about 2 ounces to 6 ounces.
Not only is food capacity shrunk from the size of a football to that of a thin banana, but there also appears to be a bonus: The stomach section that gets “tossed in the pan,” as one surgeon put it, is where ghrelin, a hormone that stimulates hunger, is produced.
This may explain, at least in part, why Linehan spends less time pondering snacks.
While the Delray Beach graphic designer, 61, is doing well out of the gate, doctors say that his chance of long-term success is unknown. That’s because most gastric sleeve studies are less than four years old.
“I’m watching the procedure closely,” says Dr. Andrew Larson, bariatric surgeon at JFK Medical Center in Atlantis. “If it really does have lasting results, I might be willing to do it. But I don’t think it’s quite ready for prime time.
“The downside is that we don’t know what’s going to happen in the long run. On the other hand, there are advantages.”
All weight-loss surgeries, doctors say, carry the risk of regain. The stomach, regardless of its post-operative size, eventually can stretch. And diet and exercise are up to the patient. Plus, early suppression of ghrelin, one of many appetite regulators, appears to ebb over time.
But bariatric surgeons, eager to boost their arsenal against obesity and related diseases, are eager to see how the sleeve stacks up.
Dr. Raul Rosenthal and his Cleveland Clinic colleague, Dr. Samuel Szomstein, have published several studies.
“Because we don’t have long-term data, we recommend this to patients with caution,” Rosenthal says. “We say, ‘Listen, there is a possibility that you may not lose what you need to lose or you may regain a considerable amount of weight.’
“But the good thing is that the sleeve leaves the door open to additional surgery if needed.”
Gastric sleeve goes solo
Sleeve gastrectomy emerged in the late 1980s as part of a procedure called the biliopancreatic diversion with duodenal switch, which limits food absorption.
And the stomach-tube technique also has been used as a first step to help severely obese patients drop pounds before gastric bypass, still considered the gold standard of bariatric surgeries.
But only in recent years has the sleeve been offered by itself — especially for adolescents, seniors and patients with health problems that limit their options — because of fewer complications. Unlike gastric bypass, it doesn’t hinder food absorption, which can cause vitamin and protein deficiencies, anemia and osteoporosis.
The Lap-Band, meanwhile, an adjustable ring placed around the top of the stomach, also allows normal digestion. But some patients don’t want (or can’t tolerate) an implanted device that may cause food to get stuck temporarily.
“The good thing about the sleeve is that it doesn’t create the complications of a bypass or require the follow-up of a band,” Rosenthal says. “You don’t need vitamins for the rest of your life, you don’t develop ulcers, and it doesn’t create dumping.”
Dumping refers to the nausea, cramps, vomiting and heart palpitations that may occur when bypass patients eat foods that are high in fat and sugar. Some people view this potential side effect as a plus because it makes you think twice before indulging.
‘Impressed by early results’
Less than two weeks ago at a national conference in San Diego, members of the American Society for Bariatric Surgery were abuzz about gastric sleeve and how it might expand treatment options.
“I think we’re all very impressed by the early results,” says Dr. Neil Hutcher, immediate past president of the group and a surgeon at Bon Secours St. Mary’s Hospital in Richmond, Va.
“There are several things that can be said pretty clearly now. The operation is safe, and there probably will be fewer potential negative side effects when compared with the gastric bypass.
“But we’ve seen operations that are restrictive in nature show early good results and then deteriorate. We really have to be very careful and go through an extensive review process.”
A Cleveland Clinic study published in the January/February edition of Bariatric Times showed that the mean percentage of excess weight loss six months after gastric sleeve was 53 percent, on par with gastric bypass.
In other words, most patients drop about half of the pounds they need to lose within six months. But keeping it off remains to be seen.
Case in point: Linehan has regained about 10 pounds.
“It probably wouldn’t have happened had I been exercising,” he admits, quipping that his rowing machine makes a nice clothes rack. “I know I need to stay active to keep the weight off.”
Rosenthal, meanwhile, says that when it comes to bariatric surgery, the scale is just part of the story. Treating obesity-linked diseases is the other.
“Obviously, if you do surgery, a patient will lose weight and solve related problems,” he explains.
“But what we’re seeing with gastric bypass is that three days after surgery, diabetes is gone — even before weight loss has started. We believe that the sleeve may have similar results.
“We haven’t figured out exactly how everything works together, but we’re making major progress not only in weight loss but in curing diabetes, hypertension and high cholesterol.”
A family history of diabetes was one reason why Susan Welborn of Jupiter sought weight-loss surgery for her son, Matt Luongo, who’d hit 289 pounds by age 12.
“I contacted numerous bariatric surgeons, but nobody would do it because of his age,” she says. “They’d say, ‘Come back when he’s 18.’
“It was very frustrating because he was the size of an adult, and he continued to gain weight no matter what we tried. I worried that once he hit puberty, the problem would get even worse.”
Rosenthal agreed to evaluate the boy and, with the approval of Matt’s pediatrician, performed a sleeve gastrectomy April 17, 2006.
Explains the surgeon: “I was reluctant to do a bypass because I didn’t want him to have trouble absorbing vitamins and minerals while he was still growing. And I didn’t want to do a Lap-Band on a child because of adjustments and needles.”
(A needle is used to inject saline into a port under the skin of the abdomen when tightening or loosening the band.)
The high school freshman, now 13, since has lost 79 pounds and gained self-esteem, even hoping to try out for football.
He’s among the youngest weight-loss surgery patients in the country, but the number of 12- to 19-year-olds going under the knife has tripled in recent years, according to a hospital study published in the Archives of Pediatrics & Adolescent Medicine in March.
“Surgery should always be a last resort,” Rosenthal says. “And for a child, the very, very, very last resort.
“Unfortunately, our country is the world champion of childhood obesity with about 32 percent of our kids being overweight. As surgeons, we have to be ready to deal with the major medical problems, like Type 2 diabetes, that are already showing up as part of this epidemic.”
Moving toward the mainstream
Recovery after gastric sleeve, which is performed through tiny incisions in the abdomen instead of through an open procedure, is relatively quick.
Matt, for instance, only missed a week of school. And Linehan jokes that he was so pain free he thought Rosenthal hadn’t done anything.
Both endured a liquid diet immediately after surgery, easing their way up from clear broth to puréed chicken to regular food, albeit in small portions, after a few weeks.
But all surgery is risky, and although the sleeve is less internally complex than gastric bypass, leaks and bleeding can occur along the staple line where the stomach is severed.
Research presented at the bariatric conference in San Diego, however, shows that sleeve gastrectomy, which takes about 90 minutes in the operating room, is generally safe and, at least in the short term, effective in helping quell appetite and combat obesity.
“There are upcoming papers that have five-year data, so we’re getting tantalizingly close to being able to make a statement on intermediate efficacy,” Hutcher says.
In other words, surgeons will know more tomorrow — and in the days to come — about how gastric sleeve measures up in America’s waistline war.
But for Matt Luongo’s mom, Susan Welborn, it’s enough to know that she’s given her son a chance at a normal life starting in high school, not decades after a host of health problems have taken their toll.
“Before he’d come home, and all he wanted to do was play video games,” she says. “He didn’t want to go to the beach, he didn’t want to hang out with friends. Now he’s willing to go out and do things.
“I remind him that having surgery is just the beginning, a way to take the edge off the hunger. He knows that the rest of it is up to him.”
Staff researcher Melanie Mena contributed to this story.