Before you choose Gastric Bypass (RNY) Read This:
NoMore B.
on 7/27/11 12:59 am
on 7/27/11 12:59 am
From General Surgery News......
Recent studies are showing that the significant weight regain many see after the gastric bypass is due to mechanical changes of the surgery, not due to the compliance of the patient. What this means, is it is NOT just up to the attitude of the patient and the effort they put forth to lose weight - there is a real physical reason as to why many people regain weight.
ISSUE: JULY 2011 | VOLUME: 38:7
Study Makes Case for Pylorus-Preserving Bariatric Operations
Major Fluctuations in Blood Sugar May Be Root of Weight Regain in Gastric Bypass Patients
by Gabriel Miller
San Antonio—A pilot study charting the rise and fall of insulin in bariatric surgery patients suggests that the dumping syndrome seen in some gastric bypass patients may be related to the higher rates of weight regain associated with that operation.
On a basic level, the study documents how vertical sleeve gastrectomy, duodenal switch and Roux-en-Y gastric bypass each affect post-meal insulin levels; however, on a deeper level, the paper suggests that pylorus-preserving operations may be superior for long-term weight loss because these procedures are more likely to better control glucose homeostasis and hunger. The study, funded by Covidien, was presented at the 2011 annual meeting of the Society of American Gastrointestinal and Endoscopic Surgeons (abstract S087).
“I think it’s been fairly well established that bariatric surgery is an effective treatment, but less is known about glucose regulation and homeostasis after these operations," said Mitchell Roslin, MD, chief of obesity surgery at Lenox Hill Hospital in New York City, and the study’s lead author.
“There is something in the physiology of the [gastric bypass] operation that we’re designing that’s encouraging [dumping syndrome], and I think that we really have to be thinking more about normal glucose regulation going forward," Dr. Roslin added. “We believe we may be getting more physiologic glucose regulation doing a duodenal switch or vertical sleeve gastrectomy."
Although dumping syndrome is a well-established clinical phenomenon, Dr. Roslin took a greater interest during a trial studying revisional options for patients in whom gastric bypass was not successful. In that population, he heard a lot of patients “complaining of inter-meal hunger, feeling lightheaded and very hungry one to two hours after eating—symptoms that sounded an awful lot like hypoglycemia.
Dr. Roslin looked retrospectively at some of the data he was collecting and found abnormal glucose tolerance in patients who had gastric bypass, suggesting that “reactive hypoglycemia was causing a significant amount of hyperinsulinemia and hypoglycemia." The hypoglycemia, he believed, was leading to maladaptive eating behaviors and the subsequent weight gain.
As a step toward confirming this hypothesis, Dr. Roslin set up the current prospective study, which compared glucose homeostasis following gastric bypass, duodenal switch and vertical sleeve gastrectomy. The design provided comparisons with two pylorus-preserving operations and two intestinal bypass operations.
So far, Dr. Roslin collected six-month data on 26 self-selected patients—seven Roux-en-Y gastric bypass (RYGB) patients, 12 vertical sleeve gastrectomy patients and seven duodenal switch (DS) patients.
At this point, the main outcome measures are glucose and insulin responses to an oral glucose tolerance test (OGTT), given preoperatively to obtain baseline data and again six months after the operations. As the study progresses to include 60 patients with 12-month follow-up, it also will look into other measures, like response to a solid meal challenge.
To date, the data show all of the operations were successful, with patients experiencing weight loss (percentage of total body weight) of an average of 18% for RYGB and 28% for DS at six months. All of the operations also produced significant decreases in insulin sensitivity and hemoglobin A1C (HbA1C) levels at six months. Similarly, all of the operations improved patients’ glucose response in the OGTT administered six months postoperatively.
However, the insulin responses to the glucose tolerance test differed dramatically. “This is where it really becomes very interesting," Dr. Roslin said.
In the OGTT given six months after surgery, at time zero, the RYGB patients’ insulin levels were lower than those of the sleeve gastrectomy and DS patients—a lower fasting insulin level. But at one hour after ingesting glucose, the bypass patients had insulin levels that skyrocketed above those of the sleeve gastrectomy and DS patients, which rose and fell far less dramatically.
“When we look at insulin levels, fasting insulin levels go down appreciably with gastric bypass," said Dr. Roslin. “But when we stimulate with glucose, the amount of insulin goes up 20-fold at one hour approximately, and [at two hours] the insulin level is higher than what we see at baseline."
As a result, the glucose levels in RYGB patients also fell faster and to lower levels than those in patients who had sleeve gastrectomy or DS, ultimately leaving gastric bypass patients with lower glucose levels than at baseline before they consumed a meal.
“This is a fantastic study," said William Richards, MD, a professor and chair of surgery at the University of South Alabama in Mobile, who was not involved in the research. “We’re starting to elucidate some of the reasons why gastric bypass is associated with some significant weight regain over the longer term."
Alternatively, the study can be seen as supporting the pylorus-preserving bariatric operations. This study shows that “the pylorus is an effective means to modulate energy, and with that preserved pylorus in duodenal switch and sleeve gastrectomy, you get certain benefits," said Daniel Cottam, MD, a bariatric surgeon at the Surgical Weight Loss Center of Utah, in Salt Lake City.
Of course, glucose regulation is just one aspect of a bariatric operation. In the case of gastric bypass, a surgeon might be revising because of patient weight regain, but he or she might also be revising DS patients at the same rate because of nutritional deficiencies resulting from that operation.
And because individual surgeons’ results are so often tied to patient screening, education and follow-up, it can be difficult to tell whether the results are purely physiologic. Thus, the study also begs a more fundamental question: Should bariatric surgeries be promoted as “physiologic" operations that cause weight loss and resolve comorbidities, or are they merely tools that help modify eating behaviors?
“If we are going to do bariatric surgery and say that patients get better because of what we are doing to their physiology, then we can’t say they are noncompliant if they gain weight," Dr. Roslin said. “If it’s physiology on the way in, then it’s got to be physiology on the way out."
Recent studies are showing that the significant weight regain many see after the gastric bypass is due to mechanical changes of the surgery, not due to the compliance of the patient. What this means, is it is NOT just up to the attitude of the patient and the effort they put forth to lose weight - there is a real physical reason as to why many people regain weight.
ISSUE: JULY 2011 | VOLUME: 38:7
Study Makes Case for Pylorus-Preserving Bariatric Operations
Major Fluctuations in Blood Sugar May Be Root of Weight Regain in Gastric Bypass Patients
by Gabriel Miller
San Antonio—A pilot study charting the rise and fall of insulin in bariatric surgery patients suggests that the dumping syndrome seen in some gastric bypass patients may be related to the higher rates of weight regain associated with that operation.
On a basic level, the study documents how vertical sleeve gastrectomy, duodenal switch and Roux-en-Y gastric bypass each affect post-meal insulin levels; however, on a deeper level, the paper suggests that pylorus-preserving operations may be superior for long-term weight loss because these procedures are more likely to better control glucose homeostasis and hunger. The study, funded by Covidien, was presented at the 2011 annual meeting of the Society of American Gastrointestinal and Endoscopic Surgeons (abstract S087).
“I think it’s been fairly well established that bariatric surgery is an effective treatment, but less is known about glucose regulation and homeostasis after these operations," said Mitchell Roslin, MD, chief of obesity surgery at Lenox Hill Hospital in New York City, and the study’s lead author.
“There is something in the physiology of the [gastric bypass] operation that we’re designing that’s encouraging [dumping syndrome], and I think that we really have to be thinking more about normal glucose regulation going forward," Dr. Roslin added. “We believe we may be getting more physiologic glucose regulation doing a duodenal switch or vertical sleeve gastrectomy."
Although dumping syndrome is a well-established clinical phenomenon, Dr. Roslin took a greater interest during a trial studying revisional options for patients in whom gastric bypass was not successful. In that population, he heard a lot of patients “complaining of inter-meal hunger, feeling lightheaded and very hungry one to two hours after eating—symptoms that sounded an awful lot like hypoglycemia.
Dr. Roslin looked retrospectively at some of the data he was collecting and found abnormal glucose tolerance in patients who had gastric bypass, suggesting that “reactive hypoglycemia was causing a significant amount of hyperinsulinemia and hypoglycemia." The hypoglycemia, he believed, was leading to maladaptive eating behaviors and the subsequent weight gain.
As a step toward confirming this hypothesis, Dr. Roslin set up the current prospective study, which compared glucose homeostasis following gastric bypass, duodenal switch and vertical sleeve gastrectomy. The design provided comparisons with two pylorus-preserving operations and two intestinal bypass operations.
So far, Dr. Roslin collected six-month data on 26 self-selected patients—seven Roux-en-Y gastric bypass (RYGB) patients, 12 vertical sleeve gastrectomy patients and seven duodenal switch (DS) patients.
At this point, the main outcome measures are glucose and insulin responses to an oral glucose tolerance test (OGTT), given preoperatively to obtain baseline data and again six months after the operations. As the study progresses to include 60 patients with 12-month follow-up, it also will look into other measures, like response to a solid meal challenge.
To date, the data show all of the operations were successful, with patients experiencing weight loss (percentage of total body weight) of an average of 18% for RYGB and 28% for DS at six months. All of the operations also produced significant decreases in insulin sensitivity and hemoglobin A1C (HbA1C) levels at six months. Similarly, all of the operations improved patients’ glucose response in the OGTT administered six months postoperatively.
However, the insulin responses to the glucose tolerance test differed dramatically. “This is where it really becomes very interesting," Dr. Roslin said.
In the OGTT given six months after surgery, at time zero, the RYGB patients’ insulin levels were lower than those of the sleeve gastrectomy and DS patients—a lower fasting insulin level. But at one hour after ingesting glucose, the bypass patients had insulin levels that skyrocketed above those of the sleeve gastrectomy and DS patients, which rose and fell far less dramatically.
“When we look at insulin levels, fasting insulin levels go down appreciably with gastric bypass," said Dr. Roslin. “But when we stimulate with glucose, the amount of insulin goes up 20-fold at one hour approximately, and [at two hours] the insulin level is higher than what we see at baseline."
As a result, the glucose levels in RYGB patients also fell faster and to lower levels than those in patients who had sleeve gastrectomy or DS, ultimately leaving gastric bypass patients with lower glucose levels than at baseline before they consumed a meal.
“This is a fantastic study," said William Richards, MD, a professor and chair of surgery at the University of South Alabama in Mobile, who was not involved in the research. “We’re starting to elucidate some of the reasons why gastric bypass is associated with some significant weight regain over the longer term."
Alternatively, the study can be seen as supporting the pylorus-preserving bariatric operations. This study shows that “the pylorus is an effective means to modulate energy, and with that preserved pylorus in duodenal switch and sleeve gastrectomy, you get certain benefits," said Daniel Cottam, MD, a bariatric surgeon at the Surgical Weight Loss Center of Utah, in Salt Lake City.
Of course, glucose regulation is just one aspect of a bariatric operation. In the case of gastric bypass, a surgeon might be revising because of patient weight regain, but he or she might also be revising DS patients at the same rate because of nutritional deficiencies resulting from that operation.
And because individual surgeons’ results are so often tied to patient screening, education and follow-up, it can be difficult to tell whether the results are purely physiologic. Thus, the study also begs a more fundamental question: Should bariatric surgeries be promoted as “physiologic" operations that cause weight loss and resolve comorbidities, or are they merely tools that help modify eating behaviors?
“If we are going to do bariatric surgery and say that patients get better because of what we are doing to their physiology, then we can’t say they are noncompliant if they gain weight," Dr. Roslin said. “If it’s physiology on the way in, then it’s got to be physiology on the way out."
Yes. They are. By following a very strict diet and exercise. The moment I start eating carbs - even so called "good carbs" I start gaining like crazy and deal with severe RH.
Hala. RNY 5/14/2008; Happy At Goal =HAG
"I can eat or do anything I want to - as long as I am willing to deal with the consequences"
"Failure is not falling down, It is not getting up once you fell... So pick yourself up, dust yourself off, and start all over again...."
RH - rective hypoglycemia. RNY long term "Curse"... IMO...
Hala. RNY 5/14/2008; Happy At Goal =HAG
"I can eat or do anything I want to - as long as I am willing to deal with the consequences"
"Failure is not falling down, It is not getting up once you fell... So pick yourself up, dust yourself off, and start all over again...."
On July 27, 2011 at 8:13 AM Pacific Time, Maria612 wrote:
There are MANY people who have been very successful with their RNY's. mariaStatistics don't apply to individuals---they tell us what happens when you look at a GROUP. In any random group, some will be wildly successful, and some will fail miserably. Statisticas tell us how LIKELY an individual is to be a success or a failure.
Reactive hypoglyecmia is something that's only recently been treated seriously. I've been here at OH for going on eight years, and when I first joined NO ONE talked about RH. Now, there are posts about it EVERY DAY.
It's something that everyone considering WLS needs to be aware of.
There are many successful BUT there are also many NOT successful.
I've seen quite a bit on these boards in 6 years; as newbies many do not acknowledge what can/may happen further out as the honeymoon euphoria keeps them focused on the fun of losing and once it's gone then the real life as a post-op begins.
I've seen quite a bit on these boards in 6 years; as newbies many do not acknowledge what can/may happen further out as the honeymoon euphoria keeps them focused on the fun of losing and once it's gone then the real life as a post-op begins.
Proximal RNY Lap - 02/21/05
9 years committed ~ 100% EWL and Maintaining
www.dazzlinglashesandbeyond.com
Yes, there are....I am one of them. HOWEVER, that doesn't mean that the information presented isn't valid. Statistics are statistics and the truth is MANY people do regain and/or battle regain.
The information presented makes a lot of sense if you understand the SCIENCE of glucose metabolism, fat metabolism, and why SO MANY MORE PEOPLE ARE OBESE TODAY compared to a generation ago. I recommend everyone read Why We Get Fat by Gary Taubes.
The information presented makes a lot of sense if you understand the SCIENCE of glucose metabolism, fat metabolism, and why SO MANY MORE PEOPLE ARE OBESE TODAY compared to a generation ago. I recommend everyone read Why We Get Fat by Gary Taubes.
Marilyn (now in NM)
RNY 10/2/01
262(HW)/150-155(GW)/159(CW)
(updated March 2012)
Yeap. You got that right. I hate how my RH (reactive hypoglycemia ) due to RNY is messing me up.
I can somewhat limit my regain by following a very strict diet (low carb) and exercise.
The moment I start eating carbs - even so called "good carbs" I start gaining like crazy and deal with severe RH.
I can somewhat limit my regain by following a very strict diet (low carb) and exercise.
The moment I start eating carbs - even so called "good carbs" I start gaining like crazy and deal with severe RH.
Hala. RNY 5/14/2008; Happy At Goal =HAG
"I can eat or do anything I want to - as long as I am willing to deal with the consequences"
"Failure is not falling down, It is not getting up once you fell... So pick yourself up, dust yourself off, and start all over again...."
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