Here are some explanations to a question that was posted on obesityhelp.com website at:

http://www.obesityhelp.com/forums/DS/4108700/This-very-well-could-be-a-stupid-question/

The Swedish Obese subject group of studies (SOS studies) have been looking at a lot of the questions that are raised.

1-The relationship between diet-exercise, and weight loss surgery. It is the study that demonstrated that weight loss surgical procedures were far more superior than the conventional diet and exercise plans. Their original data offered a relationship between the non surgical method and the RNY gastric bypass, VBG, and banding procedures. The long term outcomes (15 year data are plotted. What is of significance is that the control (the non surgical group) had no sustained weight loss.

2- The follow up questions was in reference to if there are any mortality benefit to weight loss surgical procedures.  This is a question that only recently been answered, since it takes time to see if patients that have had weight loss surgery leave longer or not. The published data in NEJM in 2007 by SOS group answered this same specific question.

This data (graph on the left) demonstrated that in a 16 year period the cumulative mortality rate was better (lower) in the weight loss surgical limb than that of the non surgical limb. 

This was the very first time that a large enough study showed that not only a patient looses weight, but also leaves longer after weight loss surgery. 

This does not specify the differences between different weight loss surgical procedures. It also does not distinguish between the long term outcomes of the different procedures. 

Ara Keshishian, MD, FACS, FASMBS

The graphs are from http://content.nejm.org/cgi/content/full/357/8/741

Obesityhelp.com revision Forum information

I am not sure what has happened over the last two weeks or so, but I have received a number of inquiries from patients that had questions about revision of their RNY or the Lap Band® for weight regain, inadequate weight loss or other complications.

I finally had to ask one of them as to where did he get his information and hear about us? His source of information was obesityhelp.com website.

I have spent some time looking over and responding to some the posting on the forum sites. There were a number of publication that I have referred to in some of my postings on the obsityhelp.com.

Nishie et.al. (Obesity Surgery, 17, 2007 1183-1188) reported:
“Pouch size area, measured by routine UGI on the first postoperative day does no influence short term postoperative weight loss. “

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

O’Connor et.al. (Surgery for Obesity and Related Dis. 4(2008) 399-403) summarizes:
“With restriction of divided, vertical, lesser curvature based small-volume =<20 cm3 gastric pouches, the actual size of the gastric pouch did not correlate with the % EBWL at the 1 year after laparoscopic GB.

I am a firm believer that the best patient is the most knowledgeable patient. It is always safer to spent as much time as needed to ask questions, and investigate all the options. If I can provide any information please contact us at info@dssurgery.com

Ara Keshishian, MD, FACS, FASMBS.

Get informed

As a surgeon, one of my duties is to discuss Informed Consent. There are two components to this: One aspect of this is the consent part. This is where discussion of risks, benefits, and complications takes place. It is also where options are discussed. A patient cannot give a consent if it is not informed and this is the second component. A consent is not informed if the patient was not provided with all the options and details.

In my clinical practice, I routinely discuss all the surgical options with a prospective patient. It is my duty to explain in great detail what the surgical alternatives are, what their relative risks are when compared to each other, and what are the pros and cons of each procedure. Once this information is presented, I would then discuss the rationale as to why certain procedures are superior in certain clinical conditions. It ultimately is the patient that makes the decision as to what procedure to have for treatment of their morbid obesity. In some cases, however,if I do not think that the procedure that the patient has decided to have will serve the patients' long or short term health needs I will ask that the patient seek another surgeon.

One of the most common examples of a scenario like this is when patients are seen in my office for surgical treatment of morbid obesity, and are inquiring about Lap Band®. They have seen an advertisement in television, radio, or even on a bill board. There are even those patients that are told by the primary care physicians that they should ONLY have the Lap Band®  done because it will solve all their problems. The promotional marketing material is only a small portion of a large body of information that is made available to patients and their primary care physicians. To most patients, Adjustable Gastric Banding (Lap Band®, Realize Band®) are “drive thru” procedures.  They have been advertised as a procedure where a patient goes to a surgeons’ office, gets examined, and operated on and looses weight, happy ever after. This is untrue on a number of fronts, and far from the way it works for overwhelming number of patients that get the Lap Band® done. I am not against the adjustable gastric banding procedures. I only advocate that the expectations be set for the patients appropriately

First of all the Lap Band® is not for every one. The scientific information on this matter is overwhelming. The educational booklet that is available, and published by Allergan (the manufacturer of the band) has a list of conditions in which the band should not be used. Then there is the relative efficacy of the banding procedure compared to the Duodenal Switch and the Gastric Bypass operation. The question a patient and a primary care physician should ask:

1. Are the treatment options as good in treating, and resolving, certain conditions of a patient.
2. What are the chances that a patient with diabetes, high cholesterol or high blood pressure, will have cure of those conditions if they had the Gastric bypass, Duodenal Switch or the Lap Band done.

The reality is that, in my opinion most patients that are having the Lap band done have not been educated and provided with the information to make an informed consent. When you consider how little most patient will loose with Lap Band, then one has to realize that the risks, as little as they may be compared to the other procedures are not worth taking.

Weight loss information

I have posted a new newsletter to our web site. It is located here. I will continue to update the information both here and on our website.

I also read and interesting article in Newsweek Magazine dated September 21, 2009. Yes I know it is not a scientific journal, but this particular article had medical sources quoted as the basis of the content. For all those that say that obesity is just about over eating and lack of exercise, I encourage you to read it.

Does over eating and lack of activity contribute to obesity? Yes, but there is much more to it than that. We should stop blaming the patients for a condition that they may have little control over