Interesting Reading....

Ok you guys, I continue to do research before my big day. Well I ran across an article last night entitled, "Surgery For Weight Loss:Comparison of Risk and Benefit". Since the article was more than 10 years old, I decided to e-mail the author. I was not expecting such a quick response, but I recieved a response from a medical researcher today. Well her response has me a little scared. I do not mean to scare any of you, but would you please read it, and tell me what you guys have found to be true or not true when you researched wls surgery for yourselves. The first portion, is my email to Dr. Ernsberger. The second portion is her response to my email. Paul Ernsberger, Ph.D., I just read your article entitled, "SURGERY FOR WEIGHT LOSS: COMPARISON OF RISK AND BENEFIT". I am a 30-year-old woman who is currently considering having a gastric bypass surgery (I fit the profile of the typical woman who has this surgery, as noted in your 1991 article). You pose many concerns in regards to bypass surgery. A number of those concerns are as follows: Nutritional deficiencies Neurological damage Lack of good systemic research on patients who have had the surgery Lack of evidence of the benefits of surgery on long-term health You were also critical of the 1978 NIH panel's endorsement of intestinal bypass surgery. I was wondering what your current position is on intestinal bypass surgery, specifically the RNY procedure. As I am sure you know, there has been some advances and/modifications in the procedures and aftercare since your 1991 article. The nutritional deficiencies are now addressed through careful vitamin regimens that are outlined and given to you before surgery. For example, I will begin taking Vista Vitamins one month prior to surgery to optimize the levels vitamins and nutrients my body has. Vista Vitamins are supposedly designed for gastric bypass patients. Does this modification sufficiently address the problem of nutritional deficiencies in bypass patients and/or is there scientific data reflecting that vitamin supplements work? I have not found any information on neurological damage. Could you please elaborate on these findings and/or please give me a list of possible places I could research such information. Has there been any major research on the long-term health benefits and/or complications of patient's that have had the RNY procedure, since your published article in 1991? I have yet to find any data on patients who are 10 to 15 years post operative as it relates to their overall health. Is the lack of research still a major concern in regards to this surgery? I am sorry for the rather long e-mail. I am trying to be as well informed as possible before making such big decision. Thanks in advance for any information that you can provide, LaTonia Hi LaTonia, Dr Ernsberger sent your email to me - I am uncertain what you are looking for here so what I am going to do is give you the quick less technical answer first and then, if you are seeking a more technical answer, let me know and I can follow with some facts about the digestive tract and why the gastric bypass causes so many problems. Disruption in cognitive abilities has been observed to follow any severe dieting (even Reuters has presented some studies on this) and the food Institute of the UK has some studies suggesting that this brain damage might be irreversible even in those with normal digestive tracts. This damage may include impairment of short term memory, and other "minimal brain dysfunctions" like dyslexia, word selection disablement etc. Neurological damage from vitamin deficiencies may include patches of lack of sensation in your limbs or actual partial paralysis of a part of a limb. You did not inquire about auto immune disease - this happens to many gastric bypass patients and is thought to be in part, a result of B12 and other B complex deficiencies (could also result from poor absorption and digestion of the so call 'fat soluble' vitamins also) - Raynaud's, LUPUS, rheumatoid arthritis or bypass arthritis are common. Occasionally we see cases of myesthenia gravis or multiple sclerosis after surgery. Osteoporosis and osteopenia - very common. Calcium is poorly digested after a gastric bypass. Some can be absorbed by the kidneys but likely only less than a third of what the body requires on a daily basis. The rest the body leeches from the bones. Bone scans, according to an article by a "bone doctor" in "Internal Medicine Review" in 2003, only caught 50 percent of the cases of osteoporosis. He warned the physician readers of that periodical that "most cases of osteoporosis are diagnosed upon the first breakage of bone". Another issue rarely discussed is the possibility of heart damage - this from starvation (average WLS post op patient is eating 500-800 calories a day and deficient in protein etc). It's not often discussed with anorexia either but I've observed that a small percentage of patients seem to develop arrhymias etc after surgery. A man in one of my WLS communities just had a pacemaker inserted. Admittedly this is a problem which happens more often to those over 50. But it can happen to younger folks also. Some studies of dieters actually suggest that ANY dieting doubles the strain on the heart and those remaining weight stable even IF at a higher BMI, came out with less heart risk. The problem with the gastric bypass is not that vitamins are not ingested but that the parts of the digestive tract which digest nutrients, vitamins and minerals have been greatly compromised through excision and rearrangement of the major digestive organs, i.e. the stomach and the small bowel. Gastric bypass patients digest the following poorly: protein, fats (and we need some fats for various processes in the body), trace elements like magnesium etc, iron, vitamin B12 (patients need shots daily or AT LEAST, weekly but these are expensive and cumbersome and often not covered by insurance and most patients forgo those shots), other B complex vitamins, calcium and more. One duodenal switch (weight loss surgery) surgeon is telling his patients that he recommends iron infusion for 50 percent of his DS/BPD patients right after surgery because that many will get anemic. Iron infusion is an out patient procedure but has some risks and is described as uncomfortable by some patients. Additionally since the gastric bypass pouch does not have a valve into the intestines (a "spinctor"), but merely a hole (a stoma) which is very narrow and does not stretch, many gastric bypass patients have problems with vegetables. Bezoars or balls of undigested food are common... food which just stays in the pouch... causes a lot of pain ... requires endoscopy to remove. In fact the only thing the post op patient can still well digest are simple carbs which means they can re-gain weight very easily while STILL being vitamin deficient. Compliance after a gastric bypass is NOT as they show on TV at all but very painstaking and if you do not do it, you can get sick, and perhaps fatally so. It includes: Vitamin B12 shots (shots are often not covered by insurance) heavy supplementation (supplements are expensive and usually not covered by insurance) protein drinks (because you will no longer digest protein well so must intake pre-digested product) Measuring food to fit your pouch because if you don't and you vomit, you can rip apart the assembly inside causing internal bleeding, staple line disruption and more. (see Dr Terry Simpson's book... obesitydr.com - Simpson is a WLS surgeon with experience in all procedures) Even normal people only use 2 percent of vitamins from supplements! The David Flum study of 62,000 gastric bypass patients showed that 1.9 percent of them died within 30 days of surgery. (November 2003) The gastric bypass was based on a surgery invented in 1888 called the Billroth II ... before they KNEW how important vitamins were. There has not been any significant modification since Dr E wrote his article in 1991 except for doing gastric bypass laparoscopically and this can be a mixed blessing. It is easier for wound healing which is the LEAST of the problems a patient has after a gastric bypass but it is harder for the surgeon to see well and not damage other organs, it is harder to do the re-assembly well. And it DOES NOT (as they previously thought) prevent hernias which many patients get. Insurance companies, many of them, have cut off funding for ALL weight loss surgery as of Jan 2005, due to the obtaining of actuarial data showing that the high complication rate on the gastric bypass (as high as 40 percent in some studies) makes it MORE EXPENSIVE to treat post op gastric bypass patients than it is to treat obesity! re: lack of research still a problem. Yes and no! Most of the followup research has not been released to the public. Those studies on longer term patients which have been released have shown disappointing results. They include: 1. psychologist's study of 100 gastric bypass patients 15 years out. This was a survey study and included no physical exam or examination of patient records, thus it is likely that patients were under-reporting complications as well as weight loss retention (which is common in survey studies). Showed at the 15 year point, patients had an average BMI of 35 (still severely obese). Also 68 percent of patients suffered involuntary vomiting often as well as stoma plugging and repeat hospitalizations. (Obesity Surgery, Vol. 11 No. 4 August 2001, pp 464-468) 2. Israel study of 10 year out gastric bypass patients. This just dealt with weight loss retention - 25 percent re-gained to morbid obesity, and only 7 percent kept off all the excess weight. This isn't much better than the stats for dieting. (70 percent kept off "some weight", specific amounts were not specified in the abstract in English) ----Dept. of Surgery C, Soroka Medical Center, Beer Sheba (Israel study) ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=8495893&dopt=Abstract Harefuah 1993 Feb 15;124(4):185-7, 248 (article is in Hebrew) 3. Livingston UCLA followup studies - 800 patients up to about 8 years out. Showed 40 percent serious complication rate. (you have to contact him to get these - they were reported in several media articles including a "Self Magazine" article - I'll give the "Self" reference) ---p 175, Self Magazine, April 2001 "Would you have surgery to lose weight?" (log on self.com to request reprints on this) 4. Mayo Clinic study, July 2000 in "Proceedings". This study was very "sanitized" i.e. any higher risk patients were eliminated from the study. The study was on "proximal gastric bypass" over a period of five years after surgery. (so did not study those patients with longer limb intestinal bypasses like the Duodenalswitch/BPD/distal bypass). This study showed a 20 percent rate of serious complications within 5 years - this percentage is similar to the medication "Phen-Fen" which was removed from the market. ---Mayo Clinic study: mayo.edu/proceedings/2000/jul/7507a1.pdf 5. Wittgrove released some of his follow up for articles here and there (Alvarado Clinic). These results are reported very incompletely and mostly deal with weight loss retention rather than percentage of autoimmune disease and other vitamin deficiency disorders 6. There is an ongoing study in Sweden called the Swedish Obesity Study on large numbers of individuals but this study has been somewhat misrepresented by some providers. First of all, the focus of the study is to contrast the health of people who diet (among which are counted those who had surgery to help them diet) with the health of people who do not diet but remain obese without any significant lifestyle changes. i.e. it is not, as some providers would have us believe, contrasting dieters with those having Weight Loss Surgery. Secondly, my research has shown that most of those patients in the diet group who had weight loss surgery, had the much safer adjustable lap band (this is the procedure of choice outside the USA - a procedure which inserts a band at the top of the stomach to restrict food passage but includes no stapling at all, no intestinal bypass, no rearrangement of small bowel and is reversible). The most important problem, *I* see with the SOS (as it is called) is that an important factor has not been considered. That is, how do individuals *****main obese WHO DO MAKE LIFESTYLE CHANGES of exercise and better food choices compare in health to those who diet ( by any means). The studies of the Cooper Institute which are 30 year follow up studies of over 30,000 individuals, seem to strongly suggest that obese individuals who make lifestyle changes of doing cardio MOST days and avoid unhealthy food choices, do not seem to suffer much more risk (if any) than slim individuals who exercise and make good food choices .... also, obese individuals who exercise appeared to be about 40 percent LESS at risk than slim individuals who did NOT exercise. At present, no one guarantees the long range results, weight loss wise OR health wise of these surgeries. The AMA called it an "ethical haze" for surgeons to do this surgery and stated that: >>>>" Short-term outcomes are impressive-patients undergoing bariatric surgery maintain more weight loss compared with diet and exercise. Comorbidities such as type 2 diabetes can be reversed. But long-term consequences remain uncertain. Issues such as whether weight loss is maintained and the long-term effects of altering nutrient absorption remain unresolved.">The ethical haze surrounding bariatric procedures is not unknown in surgery, said Laurence B. McCullough, PhD, a professor of medicine and medical ethics at Baylor College of Medicine in Houston, Texas. >>>>>>"This is the classic problem in surgery-innovation without the research to guide it. So all this should be brought under experimental protocols," McCullough said. "That's how you handle the conflict of interest make sure you tell the patient, `The procedure is investigational; we don't know if it will help you."' 1762 JAMA, April 9, 2003-VoL 289, No. 14 Where to read about neurological damage: read any information on B12 and B complex deficiency, read the entry in the Merck Manual about starvation and anorexia (merck.com ). Additionally: obesitysurgery-info.com/vitamins.htm (vitamin deficiencies in gastric bypass patients) Finally you mentioned intestinal bypass. The JIB is no longer done because it was shown to cause liver damage in the long term as well as to have been observed to be very ineffective at weight loss persistance - most patients regained all or most of their weight due to intestinal reconfiguration done by the body (Note: this has also been observed in the so called "newer surgeries" involving any intestinal bypass). The ASBS in their "story of WLS" states that any procedure which involves an intestinal bypass (including gastric bypass and duodenalswitch) can be expected to be at risk for at least some of those complications observed with the JIB (this document can be read at asbs.org ). Feel welcome to write for more info. I'll send you the gastric bypass consent document from Kaiser Permanante and a list of groups on yahoo to lurk to read patients' candid talk about after surgery issues in another email. NOTE: I have not dealt at all, in this letter about other complications like bowel obstruction, ulceration of the small bowel, kidney stones and more but have tried to restrict it to those areas you inquired about. I can provide further information and resources about the other complications which have been observed if you wish. Your efforts to inquire more thoroughly into these matters is very commendable and will undoubtedly help you to make the decision which will work the best for you. regards, Sue Widemark Independent medical researcher obesitysurgery-info.com

Wow, very good finding. I'm impressed with your letter to the doctor. But, being 3 months post-op...I guess I could say I was aware of most of these. I just had to weigh everything out..diabetes has so much complications etc. It was a very difficult decision. I would share this with Dr. Iragau and get his input. I think it would help you to hear what his findings have been as well. I trust he will be honest with you. You need these answered before you have surgery. You need that piece of mind. Perhaps you can email this or fax the letter to the office...and he can call and discuss it with you. I have to say..that just at 3 months post-op..although I am having some vitamin issues(potassium, protein, iron)..which I'm working on...so much has changed. I can sleep now(sleep apena has improved dramatically), I can climb stairs and not get out of breath. My blood sugar is awesome. My hips no longer hurt, my heels aren't in pain and so on. Its such a toss-up in many ways. Its a decision you will have to feel comfortable with. I also wonder..of the research done...if this was done on many of the old surgeries before RNY. I know one friend of mine had banded surgery and had more issues. Thanks so much for sharing this. It needs to be out there..we need long-term studies...we need to take our bodies seriously...and we need to be informed. I'll keep you in my prayers as you seek the answers you need. Feel free to email me anytime. Hugs, Kimberly

Hi Shay, How are you? I read it too, Thanks for posting it on the DE boards. I have researched this surgery so long that I kinda knew about most of the complications. I have to say the one complication that worry me the most is the autoimmunie diseases. I asked Dr. Miller about this when I went to my initial consultation, he wanted examples of diseases. My mind went blank then, however, I think I will revisit the topic when I go for my second visit. Talk with you soon. ~Shelly

I'd be interested in what Drs Irgau and Winn have to say about this very interesting article. Shay, I'm impressed.

wow, that's really interesting. i just popped my vitamins!!!! seriously, the thing that has me really concerned lately, and evident even in our own immediate group, is the chance of internal hernia and bowel twist issues/surgeries. For something that is only supposed to be about a 2 % risk of the population...this seems to be having greater odds. thanx for the info, kimberly.... (((hugs))) -Karen