New study finds gastric bypass surgery not more risky for senior citizens than young

Dallas, TX

About 26% of seniors 65 and older in U.S. are obese, nearly 40% are overweight, putting them at a higher risk for Type 2 diabetes, high blood pressure and heart disease

Morbidly obese seniors, age 65 and over, who had laparoscopic gastric bypass surgery lost nearly 76 percent of their excess weight after two years and had low complication rates and short hospital stays comparable to younger surgical patients, according to a new study presented today at the 26th Annual Meeting of the American Society for Metabolic & Bariatric Surgery (ASMBS).

“Bariatric surgery in the older population is underutilized because of a misperception that old age alone puts patients at higher risk for complications and mortality,” said Joseph Kuhn, MD, co-author and director of General Surgical Research at Baylor University Medical Center in Dallas, TX.

“We found seniors can benefit just as much as younger people from bariatric surgery without taking on additional risk.”

In one of the largest series of laparoscopic gastric bypass surgeries performed on elderly patients, researchers from Baylor University Medical Center analyzed a prospective database of 100 patients over age 65 and compared safety and outcomes to a younger population.

All patients had laparoscopic gastric bypass surgery between January 2005 and July 2008.

Prior to surgery, older patients demonstrated higher operative risk profiles compared to their younger counterparts in relation to -
● sleep apnea (45% vs. 34%),
● Type 2 diabetes (65% vs. 33%) and
● hypertension (81% vs. 57%).

Older patients ranged in age from 65 to 77 with an average BMI of 45, and younger patients ranged in age from 18 to 64 with an average BMI of 47.

Post-operative excess body weight loss (EWL) and complication rates were comparable in both groups.

At 12 and 24 months, both lost nearly the same amount of weight -- patients over age 65 showed 75.9 percent EWL after one year and 75.5 percent after two years; patients under 65 showed 77.8 percent EWL after one year and 79.2 percent after two years.

Neither group reported any deaths in the two-year follow-up period.

Post-operative complications were -
● low: bleeding (>65 1% v. < 65 1.3%),
● pulmonary infections (>65 3% v. <65 1.3%),
● cardiac (>65 2% vs. <65 0.36%) and
● wound infections (>65 1% v. <65 1.7%).

Due to the age and overall health status of the older group, researchers noted it was particularly interesting to also find length of hospital stays (1.9 vs.1.3 days) and 30 day readmissions rates (6% vs. 7.4%) to be so comparable.

About 26 percent of people 65 and older in the U.S. are obese and another nearly 40 percent are overweight, putting them at a higher risk for Type 2 diabetes, high blood pressure and heart disease. Since 1990, the prevalence of obesity has increased more than 50 percent in the elderly.

“The population is getting older and unfortunately more obese, so we will see a corresponding increase in the number of patients over 65 who are eligible for bariatric surgery and surgery needs to be an option for them,” said Christopher Willkomm, MD, study co-investigator from Baylor University Medical Center.

People who are morbidly obese are generally 100 or more pounds overweight, have a BMI of 40 or more, or a BMI of 35 or more with an obesity-related disease, such as Type 2 diabetes, heart disease or sleep apnea.

According to the ASMBS, more than 15 million Americans are considered morbidly obese and in 2008 an estimated 220,000 people had some form of bariatric surgery. The most common methods of bariatric surgery are laparoscopic gastric bypass and laparoscopic adjustable gastric banding (LAGB).

The ASMBS is the largest organization for bariatric surgeons in the world. It is a non-profit organization that works to advance the art and science of bariatric surgery and is committed to educating medical professionals and the lay public about bariatric surgery as an option for the treatment of morbid obesity, as well as the associated risks and benefits.

It encourages its members to investigate and discover new advances in bariatric surgery, while maintaining a steady exchange of experiences and ideas that may lead to improved surgical outcomes for morbidly obese patients. For more information about the ASMBS, visit www.asmbs.org.

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Studies underway to determine why obesity surgery thins bones

from Red Orbit

Experts say melting fat from obesity surgery somehow thins bones and even suggest that patients who undergo these procedures might have twice the average person's risk for a fracture, and are more likely to break a hand or foot, The Associated Press reported.

Further research is now under way to see if The Mayo Clinic's finding is significant. But specialists say uncovering long-term side effects from bariatric surgery and how to counter them takes on new urgency as more and more overweight people are electing to try it.

Dr. Shonni Joy Silverberg of Columbia University told last week's annual meeting of The Endocrine Society that these procedures are now being sold as a panacea.

"It is of heightened importance to find the answers to these questions," he said.

And perhaps the only positive thing you'll ever hear a doctor say about too much fat is that obesity actually is considered protective against bone-weakening osteoporosis.

Mayo bone-metabolism expert Dr. Jackie Clowes said overweight people are starting out better than most of us when it comes to staving off osteoporosis.

Therefore, researchers are working towards answering whether those who undergo the procedures really end up with worse bones, or just go through a transition period as their bones adjust to their new body size.

In the United States, some 15 million people are classified as extremely obese (100 pounds or more overweight). With rampant diabetes and other health problems, surgery is fast becoming the preferred treatment.

Options include stomach stapling called gastric bypass to less invasive stomach banding procedures, where patients tend to lose between 15 percent and 25 percent of their original weight — dramatically improving diabetes symptoms.

The American Society for Metabolic and Bariatric Surgery shows that more than 1.2 million U.S. patients have undergone the surgery in the past decade, 220,000 in the last year alone.

Now large National Institutes of Health studies on both adults and teens are underway to find more data on how patients fare many years after the surgeries.

However, doctors know that radical weight loss can speed bone turnover until the breakdown of old bone outpaces the formation of new bone.

A year after gastric bypass, adults' hip density drops as much as 10 percent, raising concern about a common fracture site of old age, according to more recent studies.

And while almost half of peak bone mass develops during adolescence, more research is needed to determine if teen bones react similarly.

The Mayo team is comparing the medical records of nearly 300 adults who've had bariatric surgery with similarly aged Minnesotans who haven't, to see if such changes translate into fractures.

Mayo's Dr. Elizabeth Haglind told the endocrinology meeting that a quarter of the 142 surgery recipients studied so far experienced at least one fracture in the following years. That group had twice the average risk six years after the surgery.

Interestingly, the surgery recipients had three times the risk of hand and foot fractures than their Minnesota neighbors.

Dr. Scott Shikora, president of the bariatric surgeons group, said he was shocked at the numbers because he hasn't seen a significant fracture problem in his own practice.

Shikora estimates about half of surgery patients follow their doctor’s advice to take extra calcium and vitamin D, and other research suggests higher doses may be needed anyway as the obese tend to start out with vitamin D deficiency.

“Don't skip checkups, where doctors monitor bone health, and aggressively treat nutrient deficiencies,” Clowes advised.

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No scars: New TOGA obesity surgery goes through mouth

Chicago, IL

Doctors are testing a new kind of obesity surgery without any cuts through the abdomen, snaking a tube as thick as a garden hose down the throat to snap staples into the stomach. The experimental, scar-free procedure creates a narrow passage that slows the food as it moves from the upper stomach into the lower stomach, helping patients feel full more quickly and eat less.

Doctors say preliminary results from about 200 U.S. patients and 100 in Europe look promising.

After about 18 months, obese European patients have lost an average of about 45 percent of their body weight, said Dr. Gregg Nishi, a surgeon at Cedars-Sinai Medical Center in Los Angeles. He discussed the European and U.S. studies during a Chicago conference this week for digestive disease specialists.

The procedure is only being done in the studies, which recently ended enrollment. Makers of the device used in the operation plan to seek federal approval if the research continues to go as planned.

While the two studies are still under way and only brief details are being released, Nishi said results so far are slightly better than typical results from with conventional stomach stapling.

Risks include perforating the esophagus, as Nishi said happened to a patient at another center, but otherwise, he said, there have been no major complications.

Some study patients have lost weight after unknowingly undergoing fake procedures — sedation and the tube, but no stapling. Results comparing them with the real thing aren't yet available.

Liliana Gomez, an administrative coordinator at Cedars-Sinai, was among the first Americans to have the scarless obesity surgery last year, as a test case for the U.S. study. She had planned on more invasive conventional surgery until learning that doctors at her hospital were studying the scarless stapling technique.

"When I found out it was going to be oral, through your mouth, I was like, 'Wow, that's kind of different,'" she said.

Since her operation in August, Gomez has lost about 40 pounds and dropped from size 22 to size 16.

The 35-year-old mother of three has a long way to go — she's still obese according to body mass index standards. But Gomez says she has cut her meal portions by more than half and still feels full, and is optimistic she'll continue to lose weight.

The new method is part of a medical movement to perform surgery through body openings such as the nose, mouth and vagina instead of making cuts. The idea is to reduce chances of infection and pain, and speed recovery. With no scars, there are cosmetic advantages, too.

Gomez had considered a gastric bypass operation, a more complex kind of stomach stapling, but worried about risks from that surgery. It reduces the stomach to the size of a golf ball and reroutes the digestive tract.

Whether done through one large abdominal incision or several tiny ones, gastric bypass is far more invasive and increases chances for malnutrition because it repositions how the stomach attaches to the intestines to restrict calorie absorption.

Another popular weight-loss surgery option involves putting an adjustable band around the top part of the stomach to create a small pouch.

The experimental method Gomez had is the oral version of a different kind of stomach surgery, which reduces the size of the stomach with staples but doesn't reroute the digestive system.

Surgery is generally considered a last-resort treatment for obesity, which affects more than 15 million Americans. Still, demand is high. More than 200,000 Americans are expected to have conventional forms of obesity surgery this year, according to the American Society for Metabolic & Bariatric Surgery.

Dr. Scott Shikora, the society's president, called the oral procedure exciting and innovative, but said, "It is too early for us to say this is going to be a breakthrough."

Shikora said many U.S. obesity surgeons prefer the rerouting surgery or flexible bands, and that it remains to be seen whether the oral method has the same drawbacks as more outmoded stapling procedures.

The U.S. study is taking place at 10 centers. Patients will be followed for at least one year, with final results expected in 2010. They are randomly selected to undergo either the operation or a sham procedure.

Nishi said of 25 patients enrolled at his hospital, 17 got the real treatment, with no complications.

"I'm very impressed with it," Nishi said. So far, it looks like "a viable alternative," he said.

Satiety Inc., a California company that created the medical devices used in the technique, is paying for the research. Nishi said he has no financial ties to the company.

At Washington University School of Medicine in St. Louis, where the first U.S. procedure was done last summer, about 30 patients have undergone the treatment. Side effects have been minimal, including sore throats, nausea and some abdominal pain lasting less than a week, said Dr. J. Christopher Eagon. He said weight loss results from his center aren't yet available.

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New procedure for obesity surgery - enter through mouth, no scars

Denver, CO

A new kind of obesity surgery without any cuts in the abdomen is being tested in small experimental groups. In this surgery the stomach is stapled by means of a tube that has been put down the throat of the patient. Preliminary results from US and European studies look promising.

In the experimental procedure the stomach is stapled to create a narrow passage that slows the food down as it moves through the stomach. This helps the patients feel full after eating small amounts of food and as a result eat less. Stapling the stomach is not a new technique, but this procedure is unique as there are no scars.

About 300 patients have undergone this new procedure. If all goes well, the makers of the tube, which is as thick as a garden hose, plan to seek federal approval of the device. This procedure is part of a move by the medical community to perform surgeries through body openings instead of incisions. The goal is to reduce chances of infection, pain, and speed recovery as well. Obviously, with no scars there are cosmetic advantages as well.

Studies in the US and Europe are still underway, so only brief details are being released. According to Dr. Gregg Nishi, a surgeon at Cedars-Sinai Medical Center, results so far are slightly better than typical results from conventional stomach stapling. In the European study, over the course of 18 months the patients have lost an average of 45 percent of their body weight. Final results from the US study, which is taking place at ten centers, are expected in 2010.

Demand for obesity surgery is high in the US with more than 15 million obese Americans. According to the American Society for Metabolic & Bariatric Surgery more than 200,000 Americans are expected to undergo conventional forms of obesity surgery this year. Existing procedures are far more invasive. Gastric bypass changes how the stomach attaches to the intestine which increases the chances for malnutrition while restricting calorie absorption. Another popular procedure involves putting an adjustable band around the top part of the stomach.

Dr. Scott Shikora, president of American Society for Metabolic & Bariatric Surgery, called the oral procedure exciting and innovative, but said, "It is too early for us to say this is going to be a breakthrough."

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Gastric Bypass surgery: Pros and Cons

Tulsa, OK

Gastric bypass surgery is growing more popular every year as America's obesity epidemic tips the scales. Even the elderly, and people with health problems are turning to this surgical solution to obesity.

It is a surgery that saves lives. But some also warn there can be life-changing drawbacks.

"These were 26 - and I wear a size 8 now," said Leslie Blunt as she proudly showed off the pants she will never wear again thanks to gastric bypass surgery. She has lost 140 pounds. "It works. It does. You live a healthier life," she added.

Micah Anderson chose gastric bypass surgery when his weight ballooned to 500 pounds. "Lost little over 200 pounds - easy," he told 2News anchor Karen Larsen. "I'm happy with myself. More confidence."

While gastric bypass is known for bringing on drastic weight loss, what many do not realize are specific changes it may cause for an individual, along with health benefits.

"A lot of this junk food they were eating before - their taste has disappeared they don't want it anymore," according to Dr. Luis Gorospe, gastric bypass surgeon at Bailey Medical Center in Owasso. Both Anderson and Blunt went to Dr. Gorospe for surgery. His patients come from surrounding states, drawn by his surgery success rate, the promise of dramatic weight loss and the immediate health benefits of gastric bypass.

"If they have diabetes - 70 percent of these patients wake up with normal blood sugar and will not require medications - forever," Dr. Gorospe said.

Studies show gastric bypass may improve or even eliminate such health problems as:

Leslie Blunt says she is living proof, "I don't have high blood pressure. I don't have diabetes. I am pill free."

However, Micah Anderson tells a different story. "I'll vomit maybe not every week - but if something doesn't agree it does come right back up."

When surgeons create a tiny new stomach for patients, vomiting is a common problem when patients eat too much, too fast - until they get used to their new, smaller stomach. Micah says he expected that - but then he started fainting - once behind the wheel of his car.

Anderson's wife Katie said, "The passing out has happened four times. Spells where he could potentially pass out... weekly!"

Frightened by the potential danger such episodes represented, the Andersons began researching online and discovered other gastric bypass patients having such problems.

"Describing the same kind of drunk-like symptoms, incoherent, can't talk, slurring the speech. and people were experiencing the same things," Katie added.

The Andersons say they went to numerous doctors and nutritionists, trying to find a physician who was experienced with gastric surgery side effects. After trial and error, they say they have finally found the right doctor to care for Micah. As a result, Micah now follows a diet carefully crafted to meet his personal needs. He eats every two hours, consumes plenty of protein and takes vitamins.

"For me its lack of eating. I forget to eat and that's what causes my issues. It's partially my fault as much as it is the surgery," Micah said. "If I don't follow the rules like they tell you - you do have issues."

Doctor Gorospe agreed. He said healthy eating - the same issue obese patients struggle with before gastric bypass - is more important than ever after surgery. "If you follow the rules, this surgery will be successful," Dr. Gorospe said.

Because some patients do encounter issues following surgery, and with their new lifestyle, Doctor Gorospe offers monthly support groups. "I make it a point of being there," he said. "I want to be available to my patients." The meetings offer patients an opportunity to share their stories and talk with Dr. Gorospe.

Micah did attend the monthly meetings. However, some of his problems did not occur until several years following the procedure. As a result of his struggle, the Anderson's suggest to those considering gastric bypass surgery: do plenty of research, know the rules they will have to live by, and read up on potential side effects.

"There is a list and, by golly, one of those things on the list will affect you," Katie Anderson said. "They just need to tell you flat out - you are trading one set of issues for another set of issues."

However, when asked if he would have the surgery again, Micah's answer is, "Unfortunately, yes." He went on to say he is pleased with his more than 200 pound weight loss. His joints ache less when he gets out of bed in the morning, and it is easier to be active.

Leslie Blunt agrees. Now, this svelte hair stylist says work is easy. No more suffering from carrying too much weight while being on her feet each day. Plus, she loves buying clothes with her new look and the fact that she is setting a good example for her young children by living a healthier lifestyle.

In fact, Leslie says gastric bypass surgery is the best thing she ever did for herself. "Yes! I would do it over and over and over again! I never want to be that way again."

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Help now available after failed gastric bypass surgery

San Diego, CA

A new procedure, called a ROSE procedure, is now available for patients who have had gastric bypass, lost weight and then slowly put weight back on again as their stomach pouch stretched. One of the problems with surgeries that reduce the size of the stomach for weight loss is that the pouch size may not be permanent. Over time, the pouch can enlarge to the point where meals of significant size can be eaten.

Rose, or Restorative Obesity Surgery, Endolumenal, is an outpatient procedure where the surgeon inserts a tiny camera and special tools into the stomach by introducing them into the mouth and down through the esophagus. Remarkably, no incisions are made to reduce the size of the stomach opening and the actual stomach. The surgeon essentially makes folds in the tissue of the stomach from the inside, similar to creating pleats, then uses stitches to hold the folds in place.

The procedure is currently available at the Center For The Treatment of Obesity at UC San Diego Medical Center.

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Woman's decision to undergo gastric bypass changes her life

Harrisburg, PA

Corinna Van Hine's moments of reckoning with her weight were mounting. At 30, she was out of breath when she walked with her husband, often avoiding hills. Shopping for women's clothes was a thing of the past, and she was buying from the racks in men's departments instead. She could barely squeeze into seats at movie theaters or amusement parks.

The worst setback was when her 320-pound frame kept her from horseback riding, a passion since she was 5 years old. "It really limited me because you have to have a big enough horse to handle your weight," Van Hine said. "My weight had gotten to a point where it wasn't safe for the horse for me to be riding it."

That's when the Steelton woman decided enough was enough. After years of shedding pounds through dieting and exercise only to regain the weight and sometimes more, she hit the books and Internet for any information on weight-loss surgeries.

It eventually led Van Hine to Penn State Milton S. Hershey Medical Center's Surgical Weight Loss Program, where patients go through an extensive evaluation before undergoing six months of medically supervised weight loss prior to approved surgery. In March 2006, she attended an informational session with surgeons who explained the types of surgery offered -- Roux-en-Y gastric bypass surgery and laparoscopic adjustable gastric banding -- the risks involved and what to expect afterward. Van Hine left the meeting feeling more confident than she had in a long time.
Vince CassaroSince gastric bypass surgery, Van Hine has lost 115 pounds. She also eats better and exercises, often for a 2-mile walk with Callie, her dog, in and around her Swatara Township home.

Although she had lost 60 to 70 pounds on her own in 2001, she was sidelined by a broken collarbone, and the weight became increasingly difficult to keep off. "I said to myself, 'This is probably my only answer out of it,'" Van Hine said. "I thought, at 30 years old, I can't be doing this my whole life -- losing it and gaining it back. It hurts too much to be yo-yoing back and forth again and again."

Ann M. Rogers, a physician and the director of Hershey's weight loss program, said Van Hine is one of hundreds who have turned to its surgeries to lead healthier lives. About 80 percent of the patients are women, all of whom are severely obese -- 100 pounds over their ideal weight or a body mass index greater than 40 -- with health issues linked to their weight, Rogers said.

Like Van Hine, most candidates also are well informed about the surgeries before they walk in the hospital's doors. "I'd say 99.9 percent of them are ready to go with surgery by the time they come to our informational sessions," Rogers said. "Most of them have already spent years trying to lose weight. No matter how much they are able to lose, they invariably gain it back and then some. They simply can't keep it off."

In December 2006, after months of preparation and restricted dieting, Van Hine was wheeled in for a laparoscopic Roux-en-Y gastric bypass, in which doctors create a small pouch and bypass a portion of a patient's intestines through several small incisions.

Weight loss occurs rapidly in the first six months following surgery and slowly tapers off 18 to 24 months afterward. Patients can expect to lose an average of 77 percent of their excess body weight within a year after surgery, according to experts. As with any surgery, however, the procedure carried its risks, and they weighed on Van Hine's mind.

Death can occur in about 1 percent of gastric bypass surgeries, and less severe complications can arise in 10 percent of cases. Surgical risks include intestinal leakage and internal bleeding, while all surgeries carry the risk of pneumonia, heart attack and blood clots.

Fortunately, Van Hine said, she escaped any serious complications and, to her surprise, didn't feel much pain when she awoke from her surgery." I was shocked that I didn't feel bad. It didn't hurt, but it felt like I had done some sit-ups," she said. "I didn't use any pain medication by the second day."

There were challenges ahead, Van Hine said, and she was mentally prepared for it. For weeks, she would have to live on a liquid-only, protein diet. Small amounts of foods would come in several months. "I've gotten sick a few times," Van Hine said, usually because she didn't chew her food long enough. "That's the tool of the surgery. It's your body saying, 'No, you can't eat that.'"

As of October, Van Hine has dropped nearly 115 pounds, taking her from a size 32 to 14 or 16 --in the women's departments. The real payoff though: She is finally feeling more like herself.

"Mentally, I never felt like a fat person. Finally, the person I was in my head and the person I am on the outside are ... becoming closer together. It feels like being let out of jail."

Before surgery, Corinna ate more than the average person -- when she wasn't dieting over the years, that is. It wasn't uncommon for her to go through fast-food drive-throughs for loaded hamburgers and greasy fries. She also didn't know "when to say when" during dinners. Today, her appetite is very satisfied with smaller amounts of food, and she can still enjoy her favorite prime rib -- she just has to chew it to death before swallowing.

She's not concerned about losing more weight because she's happy at her current level. If she loses more, great. If she doesn't, that's fine, too. She is well aware that she has to exercise and keep a healthy diet to maintain the surgery's results.
Vince CassaroJason Van Hine, Corinna's husband, has lost 40 pounds with his wife. He didn't undergo surgery; he's just exercising and eating better.

Van Hine's husband, Jason, didn't realize how overweight his wife was until he recently stumbled upon some old photographs. "She kind of looked miserable," he said. "I didn't see that when I took those pictures then."

The couple now exercises together at a local gym, enjoys walks and is working to restore their old home.

"A lot of people think this a quick and easy fix, and it's not at all," she said. "It's a massive lifestyle change. You need to be committed to it. You can build a house with a hammer, but the hammer is not going to do the work by itself. You've got to choose to use the tool."

Surgical treatments

There are three ways that bariatric surgery may promote weight loss in obese patients:

• Decreasing food intake (restriction).
• Causing some food to be poorly digested or absorbed (malabsorption).
• Combination of restriction and malabsorption.

The Roux-Y Gastric Bypass is the surgical procedure offered at Penn State Hershey Medical Center. It provides gastric restriction combined with some malabsorption. Both the open and laparoscopic surgical procedures are available.

Open gastric bypass surgery can now be performed through a 6- to 8-inch midline incision. This operation is restrictive in nature but also creates a "dumping physiology." A 30- to 60-cc gastric pouch is created using several staple lines. The gastric pouch is drained into a segment of jejunum (small intestine) and "bypasses" the distal stomach and duodenum.

The small gastric pouch is "restrictive" and consumption of excessive carbohydrate rich liquids causes "dumping" or abdominal discomfort. The result is sustained weight loss of 50 percent excess body weight in more than 80 percent of patients. Gastric bypass is associated with iron and vitamin B12 deficiency, therefore patients must take supplemental vitamins after surgery.

You're not eligible: If your body mass index is below 35, you are not eligible for this surgical procedure. To find your body mass index, type the term into any Internet search engine to come up with a calculator.

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