Abandon Gastric Banding Bariatric Surgery, Say Experts

Kate Johnson

quoted from: http://www.medscape.com/viewarticle/767489?src=mp&spon=14

July 16, 2012 (San Diego, California) — Bariatric surgeons should abandon gastric banding in favor of sleeve gastrectomy or gastric bypass procedures, several researchers reported here at the American Society for Metabolic and Bariatric Surgery 29th Annual Meeting.

In the United States, the use of gastric banding is still "peaking," but elsewhere in the world it has largely fallen out of favor, said Michel Gagner, MD, in an interview with Medscape Medical News.

Dr. Gagner, from Hôpital du Sacré-Coeur in Montreal, Quebec, Canada, is a world-renowned bariatric surgeon who has established several bariatric surgery centers of excellence in the United States. He said he has virtually abandoned gastric banding, and performs sleeve gastrectomy in 90% of his cases.

His approach matches that of Luigi Angrisani, MD, director of the general and laparoscopic surgery unit at Giovanni Bosco Hospital in Naples, Italy.

Dr. Angrisani presented 10-year follow-up data from a prospective randomized trial comparing gastric bypass with banding, and said the evidence is clearly in favor of bypass.

"There is no point in doing further study comparing bypass with banding at this point," he told meeting attendees. "If you consider the revisions and the failures, only 26% of the banding patients had the band successfully implanted and a successful weight loss," he told Medscape Medical News in an interview. "That is not a nice result."

The study by Dr. Angrisani and colleagues involved 51 patients who were randomized from January to November 2000 to either laparoscopic adjustable gastric banding or laparoscopic Roux-en-Y gastric bypass.

In the banding group, mean age was 33.3 years and mean body mass index (BMI) was 43.4 kg/m²; in the bypass group, mean age was 34.7 years and mean BMI was 43.8 kg/m².

Of the 27 banding patients, 3 had hypertension and 1 had sleep apnea. Of the 24 bypass patients, 2 had hyperlipidemia, 1 had hypertension, and 1 had type 2 diabetes.

Ten years after surgery, 81.4% of the banding group and 87.5% of the bypass group remained in follow-up, reported Dr. Angrisani.

Of the 22 remaining banding patients, 9 (41%) had had their bands removed, leaving 13 for weight-loss evaluation.

The BMI of 6 of these 13 patients exceeded 35 kg/m², so the procedures were considered "failures"; only 7 patients in the banding group were successful in losing weight, he said.

In contrast, of the remaining 21 bypass patients, mean BMI dropped from 43.8 to 30.4 kg/m²; only 20% of the procedures in this group were considered failures.

There were no deaths in the study, and improvement in baseline comorbidities was similar in the 2 groups. However, reoperation rates were higher in the banding group than in the bypass group (41% vs 29%).

In the banding group, reasons for reoperation were pouch dilations (n = 3), band migration (n = 1), unsatisfactory weight loss (n = 4), and untreatable reflux (n = 1).

Reasons for reoperation in the bypass group were potentially life-threatening, said Dr. Angrisani — internal hernia (n = 1), cholecystectomy (n = 4), and incisional hernia (n = 1).

"The complications of bypass are iatrogenic," he told Medscape Medical News. "There is inadvertent bowel injury during manipulation of the bowel. When you do banding, you do not manipulate the bowel."

Like Dr. Gagner, Dr. Angrisani has virtually abandoned gastric banding, reserving it for a select group of smaller patients. An analysis of the Bariatric Outcomes Longitudinal Database (BOLD), presented separately at the meeting (as reported by Medscape Medical News), showed that from 2007 to 2010, banding and bypass surgery were performed in almost equal numbers in 540 hospitals in the United States (117,365 vs 138,222).

Europeans are ahead of the game, having started banding procedures before North America, and therefore detecting problems earlier, said Dr. Angrisani. "This is a very common story. While we as Europeans accept the messages from the US world of surgery, the US community does not accept data coming from Europe. So they are now living the experience we had in the last few years."

"It's a complete disaster, when you think that banding in the United States, based on the BOLD data, is the second-most common procedure," said Dr. Gagner. "Europeans are abandoning banding and the Americans are not getting the message. This abandonment that we see in Europe — we are probably going to see this in the next few years in the United States."

Although there is already a trend toward replacing banding with sleeve gastrectomy, lack of insurance coverage for the sleeve procedure remains a major barrier, he said. In the BOLD analysis, 21% of sleeve procedures were self-paid, compared with 5.7% of band procedures and 1.9% of bypass procedures.

"The European experience is more mature than the US experience with gastric banding," agreed John Morton, MD, from Stanford University in California, who reported the BOLD data at the meeting.

In an email to Medscape Medical News, Dr. Morton said that "although 6-year data for sleeve gastrectomy indicate that it is safe and effective, the potential long-term complications for the sleeve may not be fully apparent yet, and gastric banding may still be preferred due to it's favorable short-term safety profile."

Dr. Angrisani has disclosed no relevant financial relationships. Dr. Gagner reports being a speaker for Covidien, Ethicon, and Gore. Dr. Morton reports being a consultant for Vibrynt and Ethicon.

American Society for Metabolic and Bariatric Surgery (ASMBS) 29th Annual Meeting: Abstract PL 103. Presented June 20, 2012.

An Endocrinologist Talks about Hypoglycemia after Gastric Bypass

Post-gastric bypass hypoglycemia: A serious complication of bariatric surgery | Endocrine Today:

Post-gastric bypass hypoglycemia: A serious complication of bariatric surgery

• Endocrine Today, November 2010
  Dawn Belt Davis, MD, PhD

Obesity is a rapidly increasing problem in the United States and worldwide, with more than 30% of adult Americans now affected. Unfortunately, we are lacking in effective therapies to promote significant weight loss.

See Also

• Modified bariatric surgery led to remission of type 2 diabetes ...
• Study to compare bariatric surgery vs. medical therapy in ...
• Type 2 diabetes and surgery: band or bypass? | Endocrine ...

Although aggressive lifestyle modification is highly effective, it is plagued by difficulties with poor compliance, access and reimbursement. Medical therapy for obesity has limited efficacy and significant side effects, and with the recent withdrawal of sibutramine from the US market, there are limited options (See more info on this here). Therefore, more patients and providers are turning to bariatric surgery for the treatment of obesity and its comorbidities. Especially in the case of Roux-en-Y gastric bypass surgery, this is a highly effective therapy that can lead to significant weight loss and also improve metabolic parameters independent of weight loss.

Dawn Belt Davis

Roux-en-Y gastric bypass surgery involves attaching a small pouch of the upper stomach to the early part of the jejunum, thereby bypassing the majority of the stomach and the duodenum. This results in an increased sense of fullness and reduction in appetite, as well as alterations in hormonal release from the small intestine in response to food. This procedure has been found to lead to resolution of type 2 diabetes in up to 80% of patients. It has therefore been proposed as a potential “cure” for type 2 diabetes.

Evaluating risks of surgery

As with any therapy, Roux-en-Y gastric bypass surgery can result in adverse effects and complications. Although the immediate risks of morbidity and mortality from the surgery are low, the long-term risks associated with malabsorption and other complications are still being clarified as an increasing number of patients are undergoing this procedure.

One long-term risk is the development of postprandial hypoglycemia. This phenomenon was first described in the literature in 2005. The prevalence still remains unknown, but as endocrinologists we will undoubtedly be seeing more of these patients. Hypoglycemia typically does not present until 2 to 3 years after gastric bypass surgery. These hypoglycemic episodes are characterized by low blood sugars that occur 2 to 3 hours after a meal. Fasting hypoglycemia is typically not seen. The etiology seems to be excessive insulin secretion in response to the meal. It is well documented that patients are more insulin sensitive after gastric bypass surgery, but the pathophysiology of these specific patients who develop hypoglycemia remains unclear. It is hypothesized that it may be related to elevations in the incretin hormones glucagon-like peptide 1 and gastric inhibitory polypeptide, and their ability to stimulate additional insulin secretion. It has also been debated whether increased beta-cell mass may lead to excessive insulin secretion.

Unfortunately, the effect of this disorder on the lives of patients can be devastating and severe. They become trapped in a vicious cycle in which the very treatment of their hypoglycemia leads to yet another episode a few hours later. Hypoglycemic unawareness can develop relatively rapidly, as these patients may have several episodes per day. Patients can have loss of consciousness and seizures, which may result in motor vehicle accidents. Many patients go undiagnosed for extended periods of time, as there is limited awareness of this disorder in the medical community and the initial episodes are often mild with subtle symptoms.

There are limited resources to determine the appropriate treatment strategy for these patients, with most studies reporting only a small number of cases.

First-line treatment should be educating the patient to follow a diet with strict avoidance of high-glycemic-index carbohydrates and limited portions of any carbohydrate. In addition, acarbose (Precose, Bayer Pharmaceuticals) is often successful in patients with relatively mild disease to reduce carbohydrate absorption. In patients who do not respond to these initial therapies, the addition of medications to antagonize insulin activity or minimize insulin secretion can be helpful. Calcium-channel blockers, octreotide or diazoxide are other options that can be tried. In the most severe patients, partial pancreatectomy has been performed; unfortunately, it has not been universally successful at reversing the hypoglycemic episodes. It is unknown if reversal of the gastric bypass is a successful strategy.

Fostering awareness

As endocrinologists, we need to be aware of this complication and ask about symptoms in all patients after gastric bypass surgery. In my experience, many patients have been struggling to self-manage these symptoms and are relieved to learn that this is a recognized complication and treatment options exist. Many patients respond well to dietary modification and acarbose alone. Those patients with the most severe and difficult to control symptoms are challenging. Surgical options should be considered as a last resort, as their effectiveness is unclear and there is obvious associated morbidity. Ongoing research efforts continue to determine the underlying etiology of this disorder and therapeutic options, including nutritional, pharmacologic and surgical approaches.

In the meantime, treatment of these challenging patients requires a bit of creativity, good communication with the patient and the rest of the care team (nutritionists, bariatric surgeons and gastroenterologists), and attention to the latest advances in the literature. Most importantly, we will need to further determine the frequency of this complication and carefully consider this when we weigh the risks and benefits of Roux-en-Y gastric bypass procedures.

With an increasing number of these procedures being performed every year and with a recent push to consider this procedure as a curative therapy for type 2 diabetes, it is crucial to learn more about this serious complication so we can educate patients about the risks and hopefully identify those at highest risk before the procedure.

Dawn Belt Davis, MD, PhD, is an assistant professor in the section of endocrinology, diabetes and metabolism at the University of Wisconsin-Madison and is a member of the Endocrine Today Editorial Board.

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Unique Brain Activity After Successful Weight Loss Surgery

Unique Brain Activity After Successful Weight Loss Surgery:

By Rob Goodier

NEW YORK (Reuters Health) Jun 25 - Differences in brain activation at the sight of food may explain why some patients do better than others after bariatric surgery, new research suggests.

The study, presented June 21st at the annual meeting of the American Society for Metabolic and Bariatric Surgery in San Diego, showed that gastric bypass patients who lose 50% or more of their excess weight had unique neural responses to images of food.

The brains of these successful patients showed more activation of the prefrontal cortex on functional magnetic resonance imaging in response to food cues.

"We're seeing an increase in activation in areas that correspond to planning and decision making," Dr. Rachel Goldman, who led the study at the New York University School of Medicine and Bellevue Hospital Center, told Reuters Health.

In the study, 40 patients submitted to fMRI scans one to five years after gastric bypass. Twenty-seven were considered successful and had lost an average of 71.9% of their excess weight. The 13 unsuccessful patients had lost 41.6% of their excess weight.

While in the scanner, the patients looked at a random mix of pictures of food and neutral images. They first allowed themselves to crave the food, then in a separate round they tried to resist the craving.

While craving, the successful patients displayed more activity in the left prefrontal cortex, insular cortex, putamen, anterior cingulate, posterior cingulate and the supramarginal gyrus compared to the other patients.

While resisting their cravings, the successful patients again had more activity in the left prefrontal cortex.

The unsuccessful patients, on the other hand, showed more activity in the posterior cingulate and precuneous regions while trying not to crave. Those regions are associated with emotion and anticipation of reward.

Dr. Jennifer Lundgren, an associate professor of psychology at the University of Missouri-Kansas City who was not involved in the research, told Reuters Health by email that the new findings "are consistent with other fMRI studies showing increased activation in brain regions associated with cognitive control and inhibition after weight loss by both surgical and non-surgical means."

"Those who lose less weight after surgery may find food more rewarding or have increased emotional response to food cues, compared to those who are more successful with weight loss," Dr. Lundgren said.

Both she and Dr. Goldman raised the possibility of a future test for patients before surgery to better predict outcomes. That may be one of Dr. Goldman's targets for future research.

"If preoperative neural imaging can identify the success of surgery, maybe that would tell us if the individual already has the necessary activation of the brain to be successful," Dr. Goldman said. "Or maybe there's something going on after surgery that changes the brain activity - an interaction between the surgery and the brain activation. Another area (for study would be whether) cognitive or brain interventions could change that."

In the meantime she speculates that interventions such as mindful meditation or even transcranial direct current stimulation could someday improve weight loss in gastric bypass patients.

 From Medscape

Race Might Play Role in Success of Weight-Loss Surgery

Black women lost less than whites, but the gap was narrower when diabetes was present, study finds

WEDNESDAY, June 20 (HealthDay News) -- Black women without diabetes lost about 10 percent less weight than white women after having a weight-loss procedure called gastric bypass surgery, but having diabetes helped increase their weight loss, a new study finds.

For the study, Duke University researchers compared outcomes among nearly 300 obese white and black women with an average age of 40 who underwent gastric bypass surgery, a procedure that makes the stomach smaller in order to help people lose weight.

Overall, black women lost nearly 57 percent of their excess weight in the three years after surgery; white women lost less than 65 percent. Black women with type 2 diabetes, however, lost about 60 percent of their excess weight, the investigators found.

Among women with diabetes, both blacks and whites had similar diabetes remission rates (75 percent and 77 percent, respectively) after the surgery, according to the study, which is scheduled for presentation Wednesday at the annual meeting of the American Society for Metabolic & Bariatric Surgery in San Diego.

"For some reason, diabetes was the great equalizer when it came to weight loss," study co-author Dr. Alfonso Torquati said in a society news release. "[Black] women with type 2 diabetes lost a similar amount of excess weight as [white] women. Racial differences in excess weight loss only emerged between non-diabetic women."

"Further study is needed to determine if the reasons are genetic or because of differences in body-fat distribution or both," said Torquati, director of the Duke Center for Metabolic and Weight Loss Surgery.

Although the study uncovered an association between having diabetes and greater weight loss after the surgery in black women, it did not prove a cause-and-effect relationship.

In addition, because this study was presented at a medical meeting, the data and conclusions should be viewed as preliminary until published in a peer-reviewed journal.

More than 23 million Americans have diabetes, with type 2 diabetes accounting for more than 90 percent of cases, according to the U.S. National Institutes of Health. Nearly 13 percent of black Americans have diabetes, compared with about 7 percent of whites, according to the American Diabetes Association.

More information

The U.S. National Institute of Diabetes and Digestive and Kidney Diseases has more about weight-loss surgery.

-- Robert Preidt

SOURCE: American Society for Metabolic & Bariatric Surgery, news release, June 20, 2012

Bariatric Surgery is Associated With Increased Likelihood of Alcohol Problems

In full, from Medscape -

May 15, 2012 (Lyon, France) — Bariatric surgery is associated with an increased likelihood that patients will report and be diagnosed with problems related to alcohol consumption. Different levels of risk are associated with different gastric surgery procedures, Per-Arne Svensson, PhD, from the Sahlgrenska Center for Cardiovascular and Metabolic Research at the University of Gothenburg in Sweden, reported here at the 19th European Congress on Obesity.

Continued -

The nonrandomized prospective Swedish Obese Subjects (SOS) trial matched 2010 patients undergoing bariatric surgery in 25 surgical departments from 1987 to 2001 with 2037 contemporary control subjects. People who had alcohol problems at baseline or who consumed more than 34 g/day of pure alcohol (equivalent to 3 bottles of wine per week) were excluded from the study.

The treating surgeon determined the kind of surgery; 19% of patients underwent gastric banding, 68% underwent vertical banded gastroplasty, and 13% underwent gastric bypass surgery. At baseline, the mean ages in the 3 surgery groups and in the control group were 47.0 to 48.7 years (range, 37 to 60 years), and mean body mass indices were 40.1 to 43.9 kg/m². There were no differences in alcohol-related parameters in the groups.

Previous results from the SOS study showed that gastric bypass produced the greatest long-term weight loss, and that gastric banding and vertical banded gastroplasty produced similar degrees of weight loss. It has also shown that alcohol consumption decreases in the first 6 months after gastric bypass, but subsequently increases.

Dr. Svensson and colleagues assessed the long-term changes in alcohol consumption and abuse after bariatric surgery. Median follow-up time was 10 years. Alcohol consumption was self-reported for the previous 3 months, and alcohol problems were self-reported at progressively longer time intervals after surgery. Data on diagnosed alcohol abuse came from a national register, according to International Classification of Diseases codes (ICD-9 and ICD-10).

The World Health Organization defines medium-risk alcohol consumption as 40 g/day for men and 20 g/day for women. Men and women in the control and bariatric surgery groups, as a whole, were well below these respective levels.

"During the first year, we actually see a reduction in alcohol consumption," which is similar to what has previously been reported, Dr. Svensson said. "But things change over time."

For men, median alcohol consumption in the gastric bypass group increased. However, because of individual variation in the groups, the researchers looked at the cumulative incidence of the alcohol-related parameters.

Medium-risk alcohol consumption was greatest with gastric bypass (about 14% at 10 years and 20 years for men and women combined, compared with about 5% in the control group). Self-reported alcohol problems and alcohol abuse diagnoses were also greatest with gastric bypass. For vertical banded gastroplasty, the incidence of medium-risk alcohol consumption fell between the gastric bypass and control groups. For gastric banding, the incidence did not differ significantly from that in the control group.

Adjusted Hazard Ratios, Compared With Control Group (95% Confidence Interval)*

Type of Surgery	Medium-Risk Alcohol Consumption	Self-Reported Alcohol Problems	Diagnosed Alcohol Abuse
Gastric bypass	5.91 (3.40–10.39)	2.69 (1.58–4.57)	4.97 (2.70–9.15)
Vertical banded gastroplasty	1.52 (1.09–2.11)	2.30 (1.45–3.66)	2.23 (1.38–3.59)
Gastric banding	1.22	1.44	1.57

*All values statistically significant at P < .05, except for gastric banding.

Possible mechanisms contributing to the alcohol abuse are the faster transport of alcohol to the small intestine and the reduced first-pass metabolism of ethanol by alcohol dehydrogenase in the stomach, leading to higher peak blood alcohol levels after gastric bypass surgery, and alterations in gastrointestinal hormones. Dr. Svensson speculated that there might also be "addiction transfer," in which alcohol addiction substitutes for food addiction.

He concluded that gastric bypass and vertical banded gastroplasty increased the risk for alcohol-related problems, with gastric bypass presenting the most risk. He suggested that healthcare professionals and patients be informed of these risks.

Luca Busetto, MD, from the Department of Medical and Surgical Sciences at the University of Padova in Italy, who was not involved in the trial, told Medscape Medical News that the potential for alcohol abuse after bariatric surgery has been known for many years, but that now we probably "have a more precise estimation of the numbers of the problem."

Dr. Busetto explained that in gastric bypass surgery, the pylorus is bypassed, "so the alcohol goes directly into the jejunum and is absorbed very rapidly. You may have a higher peak in alcoholemia after the same amount of wine," which can be a problem if someone is prone to alcohol addiction and experiences the effect of the consumed alcohol more rapidly. He said that studies have shown this faster absorption rate.

He noted that alcohol problems occur in a relatively small minority of patients. "It's a minor problem in comparison to the benefits [of surgery], but it's a problem that a doctor caring for patients with gastric bypass should be aware of," Dr. Busetto said.

In his experience, "in the first year after bariatric surgery, everything goes perfectly." Patients lose weight, are happy, attend all appointments, and follow the prescriptions — they are perfect patients. "After that, things change," he said. "So in bariatric surgery...you need to wait at least 5 years to have reliable results."

Commercial entities funding the study were Hoffmann La Roche, Cederroth, AstraZeneca, sanofi-aventis, and Ethicon Endosurgery. Dr. Svensson and Dr. Busetto have disclosed no relevant financial relationships.

19th European Congress on Obesity (ECO): Abstract 155. Presented May 11, 2012

Links to Studies about Post-Gastric Bypass Hypoglycemia or Hyperinsulinemia

Hypoglycemia or Hyperinsulinemia are getting more attention in post-gastric bypass patients. It is turning out to be more common than once thought. Below are the links to studies related to this issue. The link is followed by a snippet from the abstract (summary). 

Most of the links go directly to the abstract, rather than the full text. Often times, the full text of a more recent research study requires access to an academic library or to the journal itself. So, if you would like to read more than the abstract, ask your bariatric practitioner or maybe a friend who works at a college to if they would mind getting a copy of the full text for you.

______________________________________________

1) Hyperinsulinemic Hypoglycemia After Roux-en-Y Gastric Bypass: Unraveling the Role of Gut Hormonal and Pancreatic Endocrine Dysfunction

Profound hypoglycemia occurs rarely as a late complication after Roux-en-Y gastric bypass (RYGB). We investigated the role of glucagon-like-peptide-1 (GLP-1) in four subjects who developed recurrent neuro-glycopenia 2 to 3 y after RYGB.

_____________________________________________________________

2) Abnormal glucose tolerance testing following gastric bypass demonstrates reactive hypoglycemia

Symptoms of reactive hypoglycemia have been reported by patients after Roux-en-Y gastric bypass (RYGB) surgery who experience maladaptive eating behavior and weight regain. A 4-h glucose tolerance test (GTT) was used to assess the incidence and extent of hypoglycemia.
___________________________
3) Glucagon Treatment for Post-Gastric Bypass Hypoglycemia
Hyperinsulinemic hypoglycemia is a rare complication of RYGB; its pathophysiology remains incompletely understood (1,3,4). These patients exhibit inappropriately high insulin and C-peptide concentrations during hypoglycemia (5,6). In addition, exaggerated insulin and incretin responses are observed during mixed meal tolerance test (5) and may contribute to hypoglycemia, potentially mediated in part by islet cell hyperplasia and/or altered function (1,4). Although most cases are mild and managed with dietary modification, symptoms can be profound and result in serious adverse consequences, and clinical management can be challenging. Treatment options include intensive dietary modification (6,7), α-glucosidase inhibitors, octreotide, and diazoxide (5,7). However, some patients remain refractory to treatment, and partial pancreatectomy has been undertaken, with varying success (4). Given the lack of efficacy of available interventions in some patients, and the goal of averting pancreatectomy, additional pharmacologic options are needed.

_____________________________________________
4) Advances in the Etiology and Management of Hyperinsulinemic Hypoglycemia After Roux-en-Y Gastric Bypass      Treatment of hypoglycemia after RYGB should begin with strict dietary (low carbohydrate) alteration and may require a trial of diazoxide, octreotide, or calcium-channel antagonists, among other drugs. Surgical therapy should include consideration of a restrictive form of bariatric procedure, with or without reconstitution of gastrointestinal continuity. Partial or total pancreatic resection should be avoided.

Addiction Tip Sheet – Addiction and Weight Loss Surgery: A Social Worker’s Perspective « Helpstartshere.org

Here's an excellent article by Katie Jay about transfer addiction after bariatric surgeon. She does a very nice job of showing how this risk exists for WLS patients by telling one person's story. It's worth the read.

Addiction Tip Sheet – Addiction and Weight Loss Surgery: A Social Worker’s Perspective « Helpstartshere.org:

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