ObesityHelp February 15, 2007 online chat with Dr. Philip Schauer

ObesityHelp: Welcome to tonight?s chat with Dr. Philip Schauer! The chat will be starting at 7pm EST. If you have a question for Dr. Schauer; please submit the question at the area on the bottom of the page and press enter. We will get the question and present them in the order we receive them.

ObesityHelp: Welcome to tonight?s chat Dr. Schauer, are you ready to begin? First, can you tell us a little bit about yourself? How long you have you been performing bariatric surgery and what got you interested in this field?

Dr. Schauer: I have been performing bariatric surgery since 1996. I have performed more then 4,000 bariatric procedures. The procedures include gastric bypass, gastric banding, sleeve gastrectomy, re-operative surgery, and less commonly malabsorption surgery. Approximately 75 percent of my experience had been with gastric bypass.

Debbie: Dr. Schauer, I am 2 years out from GBS. In the last year my hiatal hernia has returned. At this time it is 2-3 cm's according to my Gastroenterologist. I am having Acid reflux so severe that my throat again is being intensely burned and I have on occasion aspirated this into my lungs. This acid is like battery acid it?s extremely intense when this happens which is about 3-4 times a week. Christmas Eve I was in a level 10 pain that lasted for 10 hours, knowing from pre-GBS experience there.

Dr. Schauer: Debbie, gastric bypass is generally effective in treating acid reflux and hiatel hernia. If you are having heart burn symptoms, you should get a full evaluation that might include endoscopy and x-rays. Often medications are satisfactory to treat reflux after gastric bypass. Some patients might require revisional surgery. If you need revisional surgery, go to a surgeon with much experience in this area.

Rebecca: My father's doctor gave him a report from Medicare that 1 in 9 patients who get the gastric bypass and are over the age of 62 pass away. What is the legitimacy of this report and what can I do to help educate my family?

Dr. Schauer: Rebecca, patients older than age 65, no matter what surgery they are going to have, are higher risk for complications and mortality.  Severely obese patients tend to have many medical conditions that further add to risk. Therefore, elderly seeking weight loss surgery are higher risk than younger patients. However, elderly patients can benefit from surgical weight reduction.  Some elderly patients have a very poor quality of life and will likely die if they don?t have dramatic weight reduction through surgery. An older patient must weigh the risks and benefits of surgery with their surgeon. Mortality  figures in this age population vary between 1 and 5 percent. Not the 10 percent that you had quoted.

Pat: What can we do to get the health insurance industry to treat morbid obesity as a disease, and allow WLS to be covered? We all know they pay out millions to treat the complications of obesity.

Dr. Schauer: Pat: This is perhaps the biggest problem we are facing today with bariatric surgery. Despite the tremendous growth in bariatric surgery over the last 10 years, only 1 percent of patients who qualify for surgery are getting access to surgery because most insurance carriers do not cover bariatric surgery or have severe restrictions. There is hope however. Last year Medicare mandated coverage for bariatric surgery for all Medicare patients who qualify. This Medicare determination was based on review of the scientific evidence for bariatric surgery. We expect the commercial carriers who insure most Americans to follow Medicare?s lead in covering this potentially life saving and life enhancing surgery.

Web Medic: Does the stomach, that has been cut away and is retained within our body, ever have a chance of becoming necrotic and/or possibly cancerous specifically due to what it has been through with RNY surgery?

Dr. Schauer: The stomach that is bypassed continues to make digestive juices that flow downstream and connect at the Y. The bypassed stomach does not become necrotic nor is there any increase incidence of cancer. We know this because gastric bypass surgery has been around since the 1970's and we have not seen these problems develop.

Maria: Am scheduled for VSG at CCF in 10 days. My question is: Is there hormonal change due to the surgery? And what are the affects? Are these temporary or do they stabilize after a period of time?

Dr. Schauer: By VSG, I believe you mean sleeve gastrectomy. This procedure is a restrictive operation only involving no bypass. It does involve removal of approx. 2/3rds of the stomach, making the stomach much smaller.  Patients have reduced hunger and enhanced sense of fullness after eating. We don?t quite know exactly what happens to all the hormones that affect appetite and satiety.

Paula: Since the "bigger" stomach is not attached to your pouch but it does have a role in you body still (this would be for the RNY) and is functioning like it would could that be were your "Hunger pains" come from when people get hunger pains? Or better yet, how come the bigger stomach doesn't have hunger pains?

Dr. Schauer: After Roux-en-Y the small pouch, size of a golf ball, becomes full after a small meal. The stretching of the small pouch sends signals to the brain via nerves that say you are full. The bypassed stomach is out of the circuit and therefore has a much smaller affect on appetite and satiety.

Gayle: What is your criteria in deciding to do a proximal or distal gastric bypass?

Dr. Schauer: A proximal gastric bypass involves a 75-250 cm roux-limb and actually bypasses a relatively small portion of the intestines. A distal bypass involves bypassing a majority of the intestines and is associated with greater weight loss but, a greater risk of nutritional deficiencies due to malabsorption. A distal bypass therefore, carries a much higher risk to achieve greater weight loss. Many surgeons reserve the distal bypass procedure only for patients who require aggressive weight loss to achieve a healthy state.

Linda: In your opinion which surgery is the best?

Dr. Schauer: There are many safe and effective bariatric procedure including gastric bypass, gastric banding, sleeve gastrectomy, and biliopancreatic diversion. Gastric banding generally has the lowest rate of major complications and mortality. However, operations like gastric bypass tend to yield greater weight loss. The patient should discuss with his/her surgeon which operation is most suitable for his/her goals and condition. There is no perfect procedure.  In the US today, approximately 75 percent of procedures are gastric bypass, 20 percent gastric banding, and less than 5 percent are biliopancreatic diversion. Gastric banding is increasing in popularity.

Heidi: Do I really have to give up drinking soda pop for life?

Dr. Schauer: After RNY, patients who drink soda pop get "dumping". Dumping occurs because high calorie substances dump rapidly into the intestines causing undesirable side effects such as abdominal cramps, nausea, loose stools, and feeling really bad. These dumping symptoms are not dangerous but are strong enough to make it easy for patients to "give up drinking soda pop for life".

Monarch: What are the complications related to pregnancy and delivery post RNY?

Dr. Schauer:  Most surgeons suggest that patients avoid becoming pregnant within the first year after RNY to avoid theoretical problems with nourishing the developing baby. During the 1st year after RNY patients lose weight rapidly and this may potentially inhibit proper nourishment to the baby. After a patient has lost her weight (greater than one year after surgery), it is quite safe to become pregnant. In fact, because the woman is lighter there is less stress on her and the baby.

Bob Haller: Hi Dr. Schauer Bob & Jen Haller from Pittsburgh We miss you! Any advice for those of us over 5 years fighting regain? THANKS YOU SAVED OUR LIVES!

Dr. Schauer: Dear Bob and Jen, I miss you and all of my friends from Pittsburgh. Please come visit me sometime in Cleveland. For patients who had surgery more than 5 years ago, appetite generally increases a little bit. Therefore, patients need to utilize all the powerful tools they developed during the previous 5 years such as good exercise habits i.e. 30 minutes of aerobic activity 4-5 times a week and good eating habits i.e. avoiding junk food and avoid snacking (grazing) between meals. For patients who find themselves gaining much weight, they should go see their surgeon or other weight management specialist to determine if there is something wrong with their surgery or more often, a problem with eating and exercise behavior. You both are my star patients and good models for others. Thank you!

MissKris: What is the long term effect of RNY on absorption? Will I find it easier to lose or keep weight off in the future due to malabsorption in addition to continued portion restriction or will my intestines eventually 'relearn' and begin to absorb everything?

Dr. Schauer: We think RNY works by decreasing calorie intake because patients have reduced appetite and feel full quicker. Reduced absorption of calories plays a lesser role. The average patient loses 65-70 percent of excess body fat after RNY and studies have shown that most of this weight loss is maintained for 10 years and beyond.

Karen VA: I have a BMI of 66, what can I do now that will help with the safety of the surgery and recovering time.

Dr. Schauer: Great question! We encourage our larger patients (BMI greater than 50) to participate in a short term medical weight loss program to decrease weight prior to surgery. Studies have shown that even relatively small amount of weight loss (30-50 lbs.) can make a big difference in reducing complications from surgery. There are many different ways to achieve short term weight loss. A good example is the protein sparing modified fast diet that should be utilized under medical supervision. Another very important point for preparation is to stop smoking. Smoking is associated with a very high risk of complications after RNY.

Carissa: Can the lap band be done under local anesthetic?

Dr. Schauer: No.

Leon: Do a lot of men have surgery? And which one is better for men?

Dr. Schauer: 80 percent of bariatric patients are women. Men have a similar rate of obesity as women but are less likely to seek bariatric surgery. Obesity in men is generally more dangerous than women therefore, men should be more aware of the potential benefit of bariatric surgery. The previously mentioned operations are equally beneficial to men. There is no perfect operation for men.

ObesityHelp: Last question for the evening goes to Lindas.

Lindas: Can you explain why the further out we get from surgery the more food we seem to tolerate without dumping, in particular sugars?

Dr. Schauer: Dumping is quite variable from patient to patient. Some patients have severe dumping their entire life after RNY, which is a good thing. Others lose their dumping response for reasons we don?t quite know. I encourage patients to work very hard to avoid sugars immediately after surgery when dumping is generally strong so that this avoidance of sugar can be a life long, healthy habit.

Dr. Schauer: Good night and thank all of you for participating. The American Society for Bariatric Surgery, for which I am currently President, has much valuable information for patients on their website which is www.asbs.org. Also, please get involved locally to help improve coverage for bariatric surgery. There are many people who may strongly benefit but do not have insurance that covers surgery. Your collective voice is very powerful. I want to thank ObesityHelp for providing these valuable learning opportunities for patients.

ObesityHelp: Dr. Schauer we appreciate you taking time to join us for the chat tonight. We hope to have you back soon for another chat! We've had many great questions tonight and we thank you for your involvement with Obesityhelp.

ObesityHelp: If you are would like more information about Dr. Schauer and The Cleveland Clinic please visit: http://cms.clevelandclinic.org/bariatricsurgery/ or call their office at 216-445-3030.