WLS for kids?

On December 18, 2009, in Uncategorized, by Andrea

I worry.  ADULTS won’t follow vitamin requirements, will kids?  For life?

From Medscape:

Bariatric Surgery for Obese Adolescents: Should Surgery Be Used to Treat the Childhood Obesity Epidemic?

Christy H. Lynn; Jennifer L. Miller

Posted: 03/16/2009; Pediatr Health. 2009;3(1):33-40. © 2009 Future Medicine Ltd.

Abstract and Introduction

Abstract

The prevalence of pediatric obesity has greatly increased over the past several decades, affecting both males and females among all racial and ethnic groups, and bringing with it comorbidities that were only observed in adults in the past. Childhood obesity is the most alarming public health issue facing the world today. Lifestyle modifications to reverse obesity are considered the cornerstone of treatment, but compliance is often poor and results may be minimal. Thus, many adolescents are turning to bariatric surgery as a treatment for obesity and its complications. The long-term success rate, consequences and risks for the pediatric population are still unknown, as is the compliance rate with the necessary dietary modifications that are required after these procedures.

Introduction

Over the past two decades, pediatric obesity has been on the rise throughout the world. In the USA, the prevalence of children who are obese has increased from 4% in 1971 to more than 15% in 2007.[1] Not only has there been an increase in childhood obesity, but the severity of the obesity is greater, with an estimated 4% of children meeting criteria for extreme obesity (BMI >3 kg/m2 standard deviation score for age and gender) in the USA during 2008.[2] These trends are reflected in children around the world. Obesity in the pediatric population tracks into adulthood. Obese children have a 70% chance of becoming obese adults, and this risk increases to 80% if one or both parents are also obese.[3] Medical consequences of pediatric obesity are well documented, including premature morbidity and mortality.

As the incidence of childhood obesity has increased, so has the identification of the consequences of obesity in children, including obstructive sleep apnea, orthopedic problems, hyperandrogenism, Type 2 diabetes, hypertension, hyperlipidemia, fatty liver disease and premature cardiovascular disease.[4] Over 50% of overweight adolescents meet the criteria for the metabolic syndrome (insulin resistance, hypertension, hyperlipidemia and abdominal obesity).[5] Children with low socioeconomic status and certain ethnic/racial groups have the highest prevalence of childhood obesity. In the USA, African–Americans, Native Americans and Hispanics have the highest rates of pediatric obesity, while in Europe those of Black African and Indian ethnicity have the highest prevalence of childhood obesity.[6] Children from these ethnic/racial backgrounds also have greater insulin resistance, thus, predisposing them to a higher rate of complications from obesity.[7] The comorbidities of obesity in children persist into adulthood, thus, increasing both the medical burden on society and the risk for early morbidity and mortality. Owing to the rising prevalence of both childhood obesity and its comorbidities, it is estimated that up to a third of the US and European populations will develop Type 2 diabetes during their lifetime.[8] A twofold increased risk of mortality has been detected as early as the fourth decade of life for obese adolescents, and there has been shown to be a dose–response relationship between BMI during young adulthood and the risk of death.[9] The epidemic of obesity beginning in childhood is threatening to reverse the gains in life expectancy that were made through control of hypertension, hyperlipidemia and smoking, with this generation of children being predicted to be the first to not outlive their parents.

Prevention of obesity in children should be the first line of treatment. The cornerstone of management for childhood obesity is modification of dietary and exercise habits. Decreasing portion sizes, decreasing high calorie food and drinks and decreasing snacks are the most common dietary recommendations for obese children. Diet modification alone is often not sufficient to achieve optimal weight loss in individuals with morbid obesity. When caloric intake decreases, metabolism slows, resulting in decreased calorie utilization and difficulty achieving weight loss, typically resulting in a maximum weight loss of 5–10%, which is unlikely to be sustained.[10] Fewer than 5% of people who attempt diet and exercise modifications to lose weight actually lose a substantial amount of weight and maintain that weight loss.[10] Greater than 90% regain their weight within 1 year.[11] Although substantial, long-term weight loss is difficult to achieve, the loss of 5–10% of bodyweight results in a significant improvement in the presence of comorbidities and the risk for premature morbidity and mortality.[10] These data suggest that more effective treatments for childhood obesity should be aggressively pursued.

Available pharmacologic and behavioral interventions for the morbidly obese rarely result in the magnitude of weight loss necessary to improve health outcomes. For individuals suffering from complications associated with morbid obesity, bariatric surgery is recognized as an effective treatment to provide significant weight loss and long-term weight control. Gastric bypass surgery, which is the most commonly used surgical intervention for severe obesity in the USA, appears to overcome the compensatory responses of the body to decreased caloric intake, and results in long-term, clinically significant weight loss.[12,13] In the adult population, bariatric surgery has been shown to improve both quality of life and obesity-related conditions, such as diabetes, hypertension, pulmonary disease and hyperlipidemia.[14] However, in the adolescent population there is less evidence to make those same conclusions and, therefore, a conservative approach to this surgery is mandated.

Approach to Bariatric Surgery in Adolescents

The benefits of bariatric surgery must be carefully weighed against the risks. For morbidly obese adolescents with comorbidities of obesity, who have been unable to achieve clinically significant weight loss with conventional treatments, bariatric surgery is an option that can be considered. Several studies have demonstrated significant reductions in BMI in obese adolescents who have undergone gastric bypass surgery.[15–18] One study demonstrated an average of a 36% reduction in BMI by 5 years postoperatively with those results maintained for up to 10 years postsurgery.[18] These results are comparable to those reported in adults. All of the studies investigating the long-term effects of bariatric surgery in adolescents have included small numbers of patients with up to 10-years follow-up postoperatively, but inadequate numbers of patients followed out further than 10 years.[18] Therefore, considerable uncertainty remains regarding the incidence of weight regain and other side effects of the surgery, such as vitamin and mineral deficiencies, as these individuals enter their third decade of life.

Current recommendations suggest that adolescents who should be considered for bariatric surgery include those who:

  • Have failed greater than 6 months of organized attempts at weight management with the assistance of a multidisciplinary weight-loss program;
  • Have attained physiologic maturity;
  • Have morbid obesity with comorbidities;
  • Demonstrate commitment to psychological and medical evaluations before and after surgery;
  • Agree to avoid pregnancy for at least 1 year postoperatively;
  • Be capable and willing to adhere to nutritional guidelines postoperatively;
  • Demonstrate decisional capacity;
  • Provide informed assent;
  • Have a supportive family environment.[19,101,102]

Those who should not be considered for possible surgery include those who:

  • Have a medically correctable cause of obesity;
  • Have a substance abuse problem within the preceding year;
  • Have a psychiatric, medical or cognitive condition that would impair their ability to follow nutritional recommendations;
  • Current or planned pregnancy;
  • Whose parents or patient have the inability to comprehend the consequences of this surgical procedure and the need for lifelong medical surveillance.[19,101,102]

Preoperative education of the patient and family is essential for the success of bariatric surgery. Since obese children often have obese parents, parental recognition of the lifelong dietary recommendations and requirements must be ascertained before proceeding forward with surgery. The adolescent whose home is stocked with high calorie, high sugar foods, will not be successful postoperatively and this must be clearly communicated to the parents before a referral to surgery is made. The family must all be ready to accept the necessary dietary changes that will occur postoperatively and be willing to change their lifestyle to accommodate this.

It is not known how bariatric surgeries performed before completion of puberty and epiphyseal fusion will affect neuroendocrine, skeletal and psychosocial maturation. While the majority of puberty and skeletal maturity occurs before the age of 14 years in girls and the age of 15 years in boys, the assessment of pubertal stage and bone age must be done before surgery is considered.[20] If the bone age radiograph indicates that the individual has achieved greater than or equal to 95% of their adult stature, then there is little concern that a bariatric procedure would adversely affect the adult height.[20]

Although most childhood obesity is the result of environmental effects on a susceptible population, some individuals with obesity in childhood have a genetic or neuroendocrine cause of their weight excess.[21] These individuals have either defective feedback from the gut to the brain regarding hunger and satiety signals or a monogenic defect resulting in dysfunction of the hormones and neurotransmitters involved in brain recognition of satiety.[21] These conditions must be evaluated for and ruled out before bariatric surgery can be considered ( Table 1 ). These causes of childhood obesity are not amenable to bariatric surgery and would have a tremendously increased risk of postoperative morbidity and mortality.

Recommendations for Bariatric Surgery in Adolescents

In order to determine which adolescents should be referred for bariatric surgery, the degree to which their medical and psychologic health is being compromised by obesity must be assessed. Adolescents who are determined to be possible candidates for bariatric surgery should be referred to a center with a multidisciplinary team capable of managing the unique challenges of adolescents undergoing this surgery.[19] This team should consist of a pediatric endocrinologist who can assess for obesity-related comorbidities and determine if puberty and growth are completed, a geneticist who can evaluate for genetic causes of obesity that would not be amendable to bariatric surgery, a psychologist who can assess patient readiness and understanding of the surgery and the necessity of long-term adherence to dietary restrictions, a nutritionist and exercise physiologist and a surgeon who has experience doing this procedure in adolescents.[19] The whole family should also undergo psychological evaluation to determine factors that could either positively or negatively impact compliance. The importance of the child being mature enough to understand the consequences of this surgery and the family´s ability to maintain compliance with diet is paramount in making the decision about which children are viable candidates for this procedure.

Current recommendations are that adolescents with a BMI greater than 35 kg/m2 and comorbidities of obesity, and those with a BMI greater than 40 kg/m2, regardless of the presence of comorbidities, be considered for bariatric surgery.[19,101,102] Several laboratory evaluations should be done to assess for the presence or absence of obesity-related comorbidities, including a hemoglobin A1c, oral glucose tolerance test, liver function tests, complete blood count, thyroid function tests, screening for micronutrient deficiencies and pregnancy tests for females.[102] It may also be prudent to perform overnight polysomnography to evaluate for sleep apnea, to have a pulmonologist assess the child´s airway and breathing and to evaluate for orthopedic problems prior to surgery. Some institutions require preoperative weight loss, as the first 10% of weight loss is from visceral stores, which makes a difference in the time and ease of operation by allowing a greater intra-abdominal area when insufflated.[22]

For those candidates who meet criteria to undergo surgery, there are four operations for bariatric surgery: the adjustable gastric band, Roux-en-Y gastric bypass, gastric sleeve and biliopancreatic bypass with a duodenal switch.[23] The two most commonly used and well-studied procedures for adolescents are the adjustable gastric band and the Roux-en-Y gastric bypass.[23–25] Of these, gastric bypass is the only approved surgical option for adolescents in the USA. While both gastric bypass and banding are effective in treating the medical consequences of obesity in adolescents, gastric bypass surgery has been shown to be the most effective for optimal weight loss, while the gastric band has been found to have a lower incidence of operative and postoperative complications.[23,24] Polling of the members of the International Pediatric Endosurgery Group (IPEG; n = 125) as to the best operation for adolescents: 59% chose the gastric band, 22% chose the Roux-en-Y gastric bypass, 14% chose gastric sleeve, 1% chose biliopancreatic diversion and 3% chose other surgical treatments.[24]

Surgical Options

From 2000 to 2003, there was a threefold increase in utilization of weight-loss procedures (90% gastric bypass) in adolescents.[26,27] Estimates indicate that approximately 2700 adolescents per year undergo bariatric surgery in the USA.[26] However, only 0.7% of the 140,000–150,000 bariatric surgery cases per year are actually performed on adolescents.[28] These data underscore the fact that surgeons who will perform bariatric surgery on adolescents should undergo subspecialty training in bariatric medical and surgical care as detailed by the American College of Surgeons and the American Society for Bariatric Surgery.[28]

Gastric bypass has become the most commonly used surgical intervention for weight loss and is considered the most effective operation against which all other bariatric procedures should be judged.[25] Roux-en-Y gastric bypass dates back to the 1960s for adults and the 1980s for adolescents. The operation entails the creation of a 15–30 ml gastric pouch just beyond the gastroesophageal junction. A section of the jejunum is connected to the gastric pouch using a 1–1.5 cm anastomosis, which impairs rapid emptying of the pouch.[23,28] The pouch restricts meal size, which results in a period of negative energy balance leading to a 25–30% weight loss initially (Figures 1A & 1B).[28] Subsequently, equilibrium of the energy balance occurs and the weight is stabilized at the reduced level. This procedure is increasingly being performed through minimally invasive methods, which result in quicker recovery and fewer potential complications. Even in the hands of the most experienced surgeons, gastric bypass carries a 1% mortality rate.[29]

Click to zoom

Figure 1.Most commonly used bariatric surgical procedures in adolescents.
(A) Normal stomach. (B) Roux-en-Y gastric bypass. (C) Gastric banding.

Figure 1.

Most commonly used bariatric surgical procedures in adolescents.
(A) Normal stomach. (B) Roux-en-Y gastric bypass. (C) Gastric banding.

In 2001, the LAP-BAND® was approved by the US FDA for patients who are at least 18 years of age. A small number of facilities have approval for an investigational study of gastric banding in adolescents under the age of 18 years. Gastric banding is a restrictive bariatric procedure in which an adjustable silicone band is placed around the stomach to create a small proximal gastric pouch that enhances early satiety and consequently induces weight loss (Figure 1c).[30] The size of the gastric pouch can be adjusted by inflation or deflation of a balloon lining the lumen of the band. Small studies have demonstrated that adolescents treated with gastric banding lost 55% of their excess bodyweight in the first 2 years, had resolution or improvement of comorbidities of obesity and had minimal morbidity as compared with those undergoing gastric bypass.[24,29–31] There is growing support and evidence of the safety and efficacy of gastric banding as an adolescent procedure. Compared with other surgical procedures, gastric banding is the only operation that is reversible and it is the least invasive procedure.[30] Although gastric banding requires a commitment to return for frequent office visits for adjustment of the band, adolescents are capable of making this type of commitment. Gastric banding works the best for individuals with a BMI of less than 50 kg/m2 who are willing to change their eating habits and to increase physical activity after surgery.[31] The super morbidly obese patients (i.e., those with a BMI > 50 kg/m2) have a better success rate with gastric bypass than with gastric banding.[31] Bariatric surgery can positively change the health of a severely obese adolescent and should be considered as a treatment option for certain adolescents with morbid obesity.

Diet & Compliance After Surgery and Future Perspective

Diet & Compliance After Surgery

Before surgery, a candidate is required to meet with a multidisciplinary team that includes a dietitian. Postoperatively, dietary restrictions must be followed, and compliance with supplements and medications must be maintained to ensure a beneficial outcome. The dietitian should meet with the patient following surgery to review the expected dietary management. After surgery, patients begin a liquid diet and once tolerated, will gradually introduce small portions of solid food. On a ‘full diet´, the typical procedure is to consume meals that are less than a cup in size, contain both protein and fiber and to avoid fluids with a meal. Hydration is vital and in order to improve meal success, it is suggested to drink water only 90 min after a meal and no later than 15 min prior. Patients must chew their food slowly and thoroughly.

Following surgery, nutrient deficiencies may occur owing to poor micronutrient supplementation and poor absorption.[32] Nutritional supplements are required in order to help prevent such deficiencies, including calcium, vitamin D, iron, folate, thiamin and B vitamins (B1, B6 and B12). A total of 5–16% of gastric bypass patients who did not receive adequate vitamin B supplementation developed peripheral neuropathy.[33] In addition, after a gastric bypass procedure patients are at risk of fat malabsorption with resultant fat-soluble vitamin deficiencies (A, D, E or K). Of special concern for adolescents is the potential for suboptimal calcium and vitamin D intake following surgery, with a greater risk of deficiency with malabsorption following surgery. It is necessary to monitor bone mineral density levels over the lifespan for adolescents who have undergone bariatric surgery. Owing to the poor absorption of iron, specific iron supplementation may help prevent iron deficiency anemia; however, mild anemia may still occur despite normal vitamin levels.[32] Females are at greater risk for iron deficiency if they are menstruating or become pregnant. Although women can safely support pregnancy after bariatric surgery, it is recommended that patients use contraception to prevent pregnancy, especially within the first year following surgery, owing to the rapid weight loss.[19,101,102] Additional postoperative complications vary according to the surgical procedure. Following the gastric band procedure port-related complications, including infection and hematoma, can occur, as can band erosion and slippage.[34] After gastric bypass surgery, complications include stricture formation at gastrojejunostomy, anastomotic leak, fistula formation and leaking into the excluded part of the stomach.[34,35] The failure rate for weight loss with gastric banding is 40% at 5 years and for gastric bypass the failure rate is 10–20%.[34,35]

Factors that may increase weight loss following bariatric surgery include a daily exercise regimen of at least 20–30 min and a food diary that includes any of the mentioned side effects.[36] Postsurgical management can be overwhelming and frustrating, even for adults, and poor compliance with supplements and medications is not unique. Weight loss can fluctuate from an initial quick loss to a plateau, followed by slower weight loss. Patients need to understand that behavior modifications, medications and supplements still need to be maintained in order to continue their success of reaching a goal weight. Adolescents are at particular risk for noncompliance, especially if their maturity level is not optimal to understand the consequences of their behaviors. As such, the National Institute of Diabetes and Digestive and Kidney Diseases established a program to follow the longitudinal outcomes of bariatric surgery in adolescents (Teen-Longitudinal Assessment of Bariatric Surgery [Teen-LABS]) with the goal of obtaining a realistic estimate of the risks and benefits of bariatric surgery in this population.[37]

The current epidemic of pediatric obesity has resulted in an increasing number of adolescents with obesity-related complications and bariatric surgery provides an opportunity for significant weight loss and reversal of these complications in the most severe cases. Many surgeons believe that performing bariatric surgery in adolescence will result in decreased morbidity and healthcare costs in adulthood.[28] There is some evidence that weight loss in adolescence can preserve pancreatic β-cell function and, thus, decrease the progression from insulin resistance and glucose intolerance to Type 2 diabetes for these obese teens.[28] Although there is good evidence that adolescents can have successful weight loss following bariatric surgery, questions remain about the long-term effects of these operations for adolescents. In addition, the degree to which weight loss after bariatric surgery in adolescence can be sustained over a lifetime is unknown. The long-term follow-up of individuals who undergo this treatment during adolescence is needed to determine if there are environmental, behavioral and biologic predictors of success that can be used in the determination of who are the best candidates with the most chance of success for this surgery. At this point, recommendations for bariatric surgery in youngsters should be conservative and prior to undergoing bariatric surgery, it should be emphasized that this surgery mandates a lifetime commitment to lifestyle change.

Future Perspective

Over the next 5–10 years, physicians will gain a better understanding of the effectiveness and long-term consequences of bariatric surgery for morbidly obese adolescents. As more is learned about the genetics that contribute to obesity in our current obesogenic environment, it may be possible to determine which adolescents are the best candidates for bariatric surgery and who are destined to fail these procedures. As the consequences of childhood obesity are better understood and the public becomes better educated about the risks associated with pediatric obesity, hopefully, the current epidemic will begin to subside.

Positive Outcomes from Gastric Banding

On December 15, 2009, in Uncategorized, by Andrea

From Medscape:

ASMBS 2009: Gastric Banding Achieves Sustained Weight Loss, Improvement of Diabetes

Louise Gagnon

June 29, 2009 (Dallas, Texas) — Laparoscopic adjustable gastric banding has a sustained and substantial positive effect on metabolic parameters in morbidly obese patients with type 2 diabetes, according to data presented here at the annual meeting of the American Society of Metabolic and Bariatric Surgery.

Investigators assessed the 5-year outcomes of 95 morbidly obese patients with type 2 diabetes, recording age, sex, race, body mass index (BMI), diabetes history, fasting glucose level, hemoglobin A1c (HbA1c), and use of medications. The patients underwent laparoscopic adjustable gastric banding between January 2002 and June 2004.

Morbid obesity was defined as a BMI of 40 kg/m2 or more or a BMI of 35 kg/m2 with an obesity-related illness. The mean age of patients before surgery was 49.3 years, and mean duration of diabetes was 6.5 years. The mean preoperative BMI was 46.3 kg/m2 (range, 35.1 – 71.9 kg/m2), which fell to 35.0 kg/m2 (range, 21.1 – 53.7 kg/m2) at 5-year follow-up. Mean excess weight loss was 48.3%.

The mean fasting glucose level fell from 146 mg/dL to 118.5 mg/dL (P = .004). The mean HbA1c decreased from 7.53% to 6.58% at 5 years after banding (P < .0001).

Diabetes resolution was defined as the patient being medication-free with an HbA1c of less than 6% and/or a glucose level less than 100 mg/dL. Resolution occurred in 23 (39.7%) of 58 patients. Improvement, defined as fewer medications required and fasting glucose levels between 100 and 125 mg/dL, was seen in 41 (71.9%) of 57 patients.

The overall combined improvement/resolution rate was 80% (64 of 80 patients).

“Our study shows that for the vast majority of diabetic, morbidly obese patients, they will have improvement in their diabetes and often times a resolution of their diabetes, which extends out to 5 years,” said Christine Ren, MD, FACS, an associate professor of surgery at New York University School of Medicine in New York City, and one of the study’s senior authors.

“We saw [that] the only difference between those who had complete resolution of diabetes vs those who did not was their weight loss,” said Dr. Ren.

“It appears that in gastric banding, the probability of a patient having improvement or resolution of diabetes depends on how much weight you lose and keep off.”

Investigators did not find a statistically significant difference in remission of diabetes based on the duration of diagnosis prebanding. A total of 83 (88.3%) of 94 patients were on oral medications before gastric banding, and 14.9% were on insulin. Five years after gastric banding surgery, 33 (46.5%) of 71 patients were on oral medications and 8.5% were on insulin.

Evidence has been available on the efficacy of gastric bypass surgery on resolution of diabetes, but these results point to the efficacy of laparoscopic adjustable gastric banding in resolving diabetes and in controlling metabolic parameters in the morbidly obese patient with diabetes, said Alan Wittgrove, MD, FACS, a member of the executive council of the American Society of Metabolic and Bariatric Surgery and medical director of the Bariatric Surgical Program at Scripps Memorial Hospital in La Jolla, California.

“It’s important because the study follows the patients for at least 5 years,” said Dr. Wittgrove. “It shows the longevity of the procedure in resolving diabetes through weight loss and [its] impact on the metabolic syndrome.”

Although the study did not reveal the duration of diagnosis to be a factor that influenced whether or not patients experienced improvement in their diabetes, duration of diagnosis may have emerged as a variable that affected outcomes in a larger study, according to Dr. Wittgrove.

“That is probably a function of the power of the study,” he said, noting that several studies have found that the timing of surgery has an effect on resolving diabetes in this type of patient. Surgery performed earlier results in more durable resolution, he pointed out.

“Since [duration of disease] has been shown to be a factor in other studies, I would extrapolate that if [the researchers] get more numbers, it would reach [statistical] significance,” Dr. Wittgrove said.

The study was independently conducted. Dr. Ren is a member of the Speaker’s Bureau, sits on an advisory board, and receives research and educational grants from Allergan Inc. She receives research and educational grants from Ethicon Endo-Surgery Inc and is a consultant for Explora Med Development, LLC. Dr. Wittgrove is a consultant for Ethicon Endo-Surgery Inc and receives research funding from Stryker Corporation.

American Society of Metabolic and Bariatric Surgery 2009 Annual Meeting: Abstract PL-104. Presented June 24, 2009.

Pregnancy and the band..

On December 12, 2009, in Pregnancy after WLS, by Andrea

A bit of “duh!” ahead, but none-the-less..

Severe Obesity And The Use Of Gastric Bands During Pregnancy

Bariatric surgery is used to treat morbid obesity. A common treatment is gastric banding where a constricting device is tied around the stomach to regulate food intake and appetite. According to a doctor presenting a case study at the 8th RCOG International Scientific Meeting, if a patient is pregnant, the gastric band may need releasing to prevent pregnancy complications.

Dr Neena Garg, a specialist trainee in obstetrics and gynaecology from Dewsbury District Hospital, dealt with a case of 33-year old patient who sought help at Rotherham Hospital for severe morning sickness and significant weight loss when she was 17 weeks pregnant. Prior to falling pregnant, she underwent a laparoscopic adjustable gastric banding because of obesity.

Doctors found she was severely malnourished. To correct this, parenteral nutrition was given and she received multivitamin supplements. The gastric band was released and this led to some improvement. Due to further deterioration, the gastric band was removed laparoscopically at 21 weeks. The patient was followed-up with serial growth scans and had a normal full-term vaginal delivery.

Dr Garg said, “Our case study shows that women who have had bariatric surgery may require release of the band when they become pregnant to avoid pregnancy complications.

“When a woman is pregnant, she needs to take extra care of her diet. She must eat healthily so that the fetus receives the nourishment it needs to grow. This includes having well-balanced meals and the recommended nutritional supplements. A gastric band may prevent these essential nutrients from reaching the mother and baby and has been shown to induce the unpleasant side effect of nausea.

“Pregnant women who have had bariatric surgery should therefore inform their doctors and midwives so that an assessment could be made and further action taken.”

The Royal College of Obstetricians and Gynaecologists 8th International Scientific Meeting is taking place in Abu Dhabi, the United Arab Emirates, from Monday 7 to Wednesday 9 December 2009. The meeting is held in collaboration with the Abu Dhabi Health Services Co. (SEHA) and sponsored by the Abu Dhabi Tourism Authority. For more information about the meeting, please click here.

Source
Royal College of Obstetricians and Gynaecologists

Metabolic Surgery Statistics — 2008

On November 29, 2009, in Uncategorized, by Andrea

This morning, I came across this article by Buchwald and Oien (thanks Bonamy) outlining worldwide WLS statistics for 2008.  According to the authors, the last evaluation was done in 2003 and this evaluation was done by sending a survey to 39 nations or national groupings (of which 36 responded).  Given this was a survey, it will be somewhat biased based on the person answering the survey, as well as the fact that the numbers are worldwide — some procedures are done in other parts of the world that are not performed in the US routinely (such as Vertical Banded Gastroplasty {VBG}) or the Scopinaro Biliopancreatic procedure.  Of course, I am a numbers girl and wish that all numbers are exact figures, but let’s face it — it’s not realitySo given that, I have to concede that these are not going to be 100% exact.

Some direct quotes and figures from the report:

  • In 2008, 344, 221 bariatric surgery operations were performed by 4,680 bariatric surgeons, 220,000 of these operations were performed in USA/Canada by 1,625 surgeons
  • Seven other countries or national groupings with more than 100 bariatric surgeons: Australia/New Zealand (118), Brazil (700), Chile (100), France (310), Italy (300), Mexico (150), and Spain (400)
  • 91.4% of world bariatric surgery was performed laparoscopically
  • Considering all gastric bypasses together (distal and prox, open and lap), number of RNY exceeds AGB’s.
  • In Europe, relative percent of AGB decreased from 63.7% to 43.2% from 2003 to 2008, while RYGB increased from 11.1% to 39%.  In USA, AGB increased from 9% to 44% and RYGB decreased from 85% to 51%.  In both Europe and USA, VSG went from 0% in 2003 to 4%.
  • Most common type of procedures were purely restrictive (AGB, VSG, VBG) (48.6%), restrictive/malabsorptive (RNY) (49.0%), and primarily malabsorptive (BPD/DS) (2%).

Surgical types by breakdown (Lap and Open combined)

  1. Proximal RNY – 45.4%
  2. AGB – 42.4%
  3. VSG – 5.4%
  4. VBG – 1.1%
  5. BPD and DS procedures combined – 1.1%
  6. Other – 0.1%

The authors make a few conclusions about the numbers they received in this survey — some of which bother me.  There is quite a disenchantment of AGB in Europe, where there is quite a long history of it’s use there, and a growing trend towards VSG and RYGB there.  USA and Canada, where we want newer and better (and have marketing via TV commercials?  WTF?) is moving away RYGB (which we have a longer history) and are moving towards AGB and VSG.  In no cases are we moving closer to DS — which in many ways to ME seems to be an excellent choice and not given any credit or opportunity to shine.  The authors also clearly bring up the fact that many people would presumably want metabolic surgery if they could get their paws on it — would even, I dunnow, self-pay for it, or change jobs for it, or go work part-time at the Buxx for it?  For those of us in the community, we’ve seen and heard this time and time again so nice to see the professionals recognize it in a published article.  Additionally — patients are getting smarter, using the interwebz and understanding a bit more about what we are doing to our guts when we go and get chopped up — and it’s all for the betterment:

Further involved factors may be the predictable craving for something regionally newer, the imposition of payer mandates, media-derived prejudices and and biases, advertisement campaigns by the bariatric surgery industry, increased patient sophistication and use of websites, and, of course, relative regional economic advantages for bariatric surgeons.

I have to say the thing I’m most concerned about is the complete lack of yeast in the DS numbers.  This is a wonderful surgery — doesn’t have many of the RNY pitfalls (and let me tell you, I know several of them first hand), doesn’t require all that much more work than far-out RNY patients (despite what some may tell you — it’s not all roses and rainbows and unicorns) and just isn’t getting the recognition or the opportunity to shine and show it’s stuff.  I wish more surgeons would learn how to perform it.  I wish more people would learn the stats.  I wish more people would stop spreading misinformation crap about it in hopes of making their own surgery look better.  And I wish many of the surgeons that don’t perform it would also stop this practice — it’s unprofessional as all hell and only perpetuates the problems as their patients then do the exact same thing and continues to spread the misinformation, fear, and, eventually, hatred, around.

Europe at least is performing the DS a bit more than we are -0-  they had a 58.7% increase of surgeries from 03 to 08 — but still that increase only comprised 4.9% of the total surgery population in 08 which is an actual decrease from 6.1% surgical population in 03.  Comparatively, the US went from 4.5% surgical population in 03 to 1%?!? in 08?  with a 52.5% decrease.  WHY? I don’t get it.  There is too much good in the DS for this statistic.  At least the US wasn’t as abysmal as Asia and the Pacific.. those numbers were too depressing to even type out.

So what does all of this mean?  WLS is on the rise, but not as much as it was in 03.  Considering how quickly the rate of obesity is climbing, this isn’t quite proportionate as some critics claim (including many private payers who don’t want to cover WLS as it would “cost too much”) — and given how diabetes costs are going to triple by 2023? This is a way to go to help avoid these ballooning costs.  Some surgeries are growing by leaps and bounds regionally — some are growing regardless (VSG, anyone?)  and some are still performed in areas while considered completely antiquated in others (VBG in the US).

Very interesting.  Somewhat sad.  But very interesting.

ASMBS suggested supplementation

On November 16, 2009, in General Nutrition, Vitamins, by Andrea

The American Society of Metabolic and Bariatric Surgeons has made a series of suggestions for postoperative vitamin supplementation prior to labs dictating otherwise.

Multivitamin
- Adjustable Gastric Band/VSG: 100% of daily value
- RNY: 200% of daily value
- BPD/DS: 200% of daily value

  • Choose a multivitamin that is a high-potency vitamin containing 100% of daily value for at least 100% of daily value of 2/3 of nutrients
  • Begin with chewable or liquid
  • Progress to whole tablet/capsule as tolerated
  • Avoid time-released supplements
  • Avoid enteric coating
  • Choose a complete formula containing at least 18 mg iron, 400mcg folic acid, as well as selenium, and zinc in each serving
  • Avoid children’s formulas that are incomplete
  • May improve gastrointestinal tolerance when taken close to food intake
  • May separate dosage
  • Do not mix multivitamin containing iron with calcium supplement, take at least 2 hours apart
  • Individual brands should be reviewed for absorption rate and bioavailability
  • Specialized bariatric formulations are available

Additional cobalamin (B12)
- AGB/VSG: Not Applicable
- RNY: 350-500mcg if taken orally, 1000mcg / mo intramuscular injection
- BPD/DS: NA

Additional elemental calcium
- AGB/VSG: 1500mg /day
- RNY: 1500-2000mg
- BPD/DS: 1800-2400mg

  • Choose a brand that contains calcium citrate and vitamin D3
  • Begin with chewable or liquid
  • Progress to whole tablet / capsule as tolerated
  • Split into 500-600 mg doses; be mindful of serving size on supplement label
  • Space doses evenly throughout day
  • Suggest a brand that contains magnesium, especially for BPD/DS
  • Do not combine calcium with iron containing supplements
  • Wait 2 or more hours after taking multivite or iron supplement to take
  • Wait 2 or more hours between doses
  • Promote intake of dairy beverages and/or foods that are significant sources of dietary calcium in addition to recommended supplements
  • Combined dietary and supplemental calcium intake greater than 1700 mg/day might be required to prevent bone loss during rapid weight loss

Additional elemental iron
- AGB / VSG: NA
- RNY: Minimum 18-27mg / day elemental
- BPD/DS: Minimum 18-27mg / day elemental

  • Recommended for menstruating women and those at risk of anemia
  • Begin with chewable or liquid
  • Progress to tablet as tolerated
  • Dosage may need to be adjusted based on biochemical markers
  • No enteric coating
  • Do not mix iron and calcium supplements, take at least 2 hours apart
  • Avoid excessive intake of tea due to tannin interaction
  • Encourage foods rich in heme iron
  • Vitamin C may enhance absorption of non-heme iron sources

Fat-soluble vitamins
- AGB / VSG: NA
- RNY: NA
- BPD/DS: 10,000 IU of vitamin A, 2000 IU of vitamin D, 300 mcg of vitamin K

  • With all procedures, higher maintenance doses may be required for those with a history of deficieincy
  • Water-soluble preparations of fat-soluble vitamins are available
  • Retinol sources of vitamin A should be used to calculate dosage
  • Most supplements contain a high percentage of beta carotene which does not contribute to vitamin A toxicity
  • Intake of 2000 IU vitamin D3 may be achieved with careful selection of multivitamin and calcium supplements
  • No toxic effect known for Vitamin K1, phytonadione (phyloquinone)
  • Vitamin K requirement varies with dietary sources and colonic production
  • Caution with vitamin K supplementation should be used for patients receiving coagulation therapy
  • Vitamin E deficiency is not prevalent in published studies

Optional B complex
- AGB / VSG: 1 per day
- RNY: 1 per day
- BPD/DS: 1 per day

  • B-50 dosage
  • Liquid form is available
  • Avoid time released tablets
  • No known risk of toxicity
  • May provide additional prophylaxis against B-vitamin deficiencies, including thiamin, especially for BPD/DS procedures as water-soluble vitamins are absorbed in the proximal jejunum
  • Note >1000mg of supplemental folic acid provided in combination with multivitamins could mask B12 deficiency
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