The tremendous progress being made in the field of weight management, including alternatives to gastric bypass surgery is being highlighted in new research being presented today at Digestive Disease Week® 2009 (DDW®).
DDW is the largest international gathering of physicians and researchers in the fields of gastroenterology, hepatology, endoscopy and gastrointestinal surgery.
"Gastric bypass surgery may be the best option for morbidly obese patients who have not had weight loss success using diet and exercise. However, less invasive techniques may be a better option as a method of modest weight loss in the super obese as a bridge to gastric bypass or as the sole treatment in patients suffering lesser degrees of obesity," according to Robert H. Hawes, MD, FASGE, Medical University of South Carolina. "Advances in less invasive weight loss procedures not only provide options for these patients, but also offer alternatives to the pain and recovery associated with more traditional weight loss surgery."
Does Insurance Status Affect Gastric Bypass Surgery Outcomes? (Abstract #M1588)
A new study shows that patients with private insurance have the best outcomes from gastric bypass surgery, and investigators said this is all the more reason to develop protocols to ensure that patients with public insurance are equally successful with the procedure.
Investigators sought to determine whether patients with different types of insurance have different demographic characteristics and surgical outcomes. They collected demographic, pre-operative and 12-month post-operative data on 750 gastric bypass patients who were divided into private insurance, Medicare and MediCal groups.
Researchers found many differences such as Medicare patients tend to weigh more and have higher rates of depression, blood pressure, heart disease, diabetes, cholesterol and sleep apnea. Lead investigator John Morton, MD, MPH, associate professor at Stanford University School of Medicine, said that was not surprising since patients have to be over 65 or disabled to qualify for Medicare and an overwhelming number of Medicare patients who come in for gastric bypass surgery are disabled, which is why they tend to have higher rate of depression and weight.
While complications were low for all patients, they were still more prevalent in Medicare patients. The percentage of weight loss after one year was higher for private insurance patients; for Medicare patients it was lower but still considered good at 57 percent. Dr. Morton said the better results can in part be attributed to the fact that Medicare patients are older and disabled in some way, so they might not have the ability to exercise, nor the resources and access to exercise.
He added that the study points up the need to address the fact that some Medicare patients are starting with more profound disadvantages, and that certain measures such as preoperative rehabilitation programs in exercise and nutrition that would increase their chances for success. Although Medicare patients did not have the best outcomes, they are still good candidates for the surgery; their outcomes might have been less positive precisely because they are larger than the patients with private insurance, which demonstrates that they are at greater risk and in need of help.
"Gastric bypass surgery is very successful so we should work to ensure that everyone has the same chance at success," Dr. Morton said, adding that this relatively small investment would pay off huge dividends. "If we assume that these patients are on Medicare or Medicaid because they are disabled, it makes a lot of sense to help them achieve weight loss which would help them reclaim their lives and function at home and work more effectively and healthily."
He added that this is especially important since morbid obesity is the leading public health crisis in the U.S. and bariatric surgery is the only effective treatment for many patients.
Dr. Morton will present these data on Monday, June 1 at 8 a.m. CDT in South Hall, McCormick Place.
Duodenal Switch Provides Superior Resolution of Metabolic Comorbidities Independent of Weight Loss in the Super-obese Compared with Gastric Bypass (Abstract #459)
Duodenal switch (DS) surgery may be more effective than gastric bypass surgery for certain obesity-related medical problems such as diabetes, high blood pressure and high cholesterol.
Investigators sought to find out how results differ between DS and gastric bypass surgery in 350 super-obese patients — those with a body mass index (BMI) ≥ 50 kg/m2, which averages to more than 200 pounds above ideal body weight. They sought to determine the comparative effectiveness of DS because of the increased rate of inadequate weight loss witnessed with gastric bypass surgery in super-obese patients. With gastric bypass, surgeons create a small gastric pouch by separating it from the rest of the stomach. With DS, there is no pouch; instead, the stomach is reshaped into a long and narrow tube or sleeve. In contrast to the gastric bypass, however, in DS the small intestine is reconfigured so as to reduce the amount of calories absorbed from the food that the patient eats.
Vivek N. Prachand, MD, assistant professor of surgery, University of Chicago, said that post-surgery, investigators compared the rate of resolution of obesity-related diseases — whether patients with disease were able to stop taking medications to treat their conditions as a result of their operation. They found that resolution of diabetes, hypertension and dyslipidemia (high cholesterol) was greater at three years in DS patients than with gastric bypass (diabetes: 100 percent vs. 60 percent; hypertension: 68 percent vs. 38.6 percent; and dyslipidemia 72 percent vs. 26 percent). However, resolution was greater for acid reflux disease with gastric bypass than DS (76.9 percent vs. 48.5 percent).
Prachand and his co-investigators had previously shown that super-obese DS patients had better weight loss than those who underwent gastric bypass, and hypothesized that the greater weight loss may help explain why they had higher resolution of their obesity-related diseases. In the current study, however, there was not a clear correlation between the magnitude of the weight loss and the resolution of obesity-related conditions, suggesting that other mechanisms besides weight loss alone may lead to the improvements seen.
One potential downside of DS is that the reduced absorption of calories also results in reduced absorption of vitamins and nutrients, which can lead to vitamin deficiencies and even malnutrition. This is especially important to understand because obese patients often have preexisting nutritional deficiencies, so addressing those concerns with vitamin supplementation is critical.
"The effort to better manage the potential vitamin and nutritional deficiencies associated with DS is worthwhile it because it appears that the DS is more successful in terms of weight loss and resolution of significant obesity-related disease for super-obese patients," Prachand said, adding that the research is still evolving; the next phase of study will compare the nutritional outcomes of the two operations.
In the last 15 years, the prevalence of super-obesity has increased faster than other categories of obesity, and this population has a very low chance of weight loss success without surgical intervention
Dr. Prachand will present these data on Monday, June 1 at 2:15 p.m. CDT in S505a, McCormick Place.
Study of Tran-Oral Technique Continues to Demonstrate Viability as Treatment for Pediatric Obesity (Abstract #S1499)
A new technique called endoluminal vertical gastroplasty (EVG) continues to show promise for the treatment of obesity in teens even one year post-procedure.
Roberto Fogel, MD, of the Department of Gastroenterology, Hospital de Clinicas in Caracas, Venezula and Bariatric Research Physician at Mercy Hospital in Miami, performed the EVG procedure on 21 adolescent patients ages 13 to 17. No adverse events occurred during the approximately 40-minute procedures that used trans-oral suturing to connect the anterior and posterior gastric walls to reduce the capacity of the stomach in order to induce weight loss. Fogel's use of EVG in pediatric patients builds upon earlier work in which he used the procedure on adults that yielded similarly positive results.
"We continue to see very good results at one year post-procedure, especially in patients with a strong motivation and determination to lose weight," said Dr. Fogel. "All patients lost weight and showed a significant reduction in their body mass index."
Dr. Fogel adds that additional studies need to be conducted to determine the efficacy of the procedure in larger numbers of pediatric patients.
Dr. Fogel will present these data on Sunday, May 31 at 8 a.m. CDT, South Hall, McCormick Place.
Transoral Gastric Volume Reduction as an Intervention for Weight Management (TRIM) Multicenter Feasibility Study: A Report of Early Outcomes (Abstract #M1259)
Researchers have found that an effective new suturing system, an incisionless weight loss procedure known as transoral gastric volume reduction (TGVR), holds promise as an alternative to weight loss surgery.
Investigators at Brigham and Women's Hospital in Boston and the Cleveland Clinic Foundation in Cleveland studied 18 patients with body mass index (BMI) scores ranging from 30 to 45. Standard gastric bypass surgery requires a BMI of 40 or more. Patients underwent a procedure that involved sewing together the sides of their stomach to prevent the stomach from relaxing to accept food, thereby reducing the feeling of hunger in the patient and allowing them to feel sated with less food.
Preliminary results are very encouraging; currently six patients are at nine months post-procedure and have achieved a mean loss of 36.5 pounds (an average 34.4 percent excess weight loss) and a reduction of waist circumference from 48 to 42.4 inches. Twelve patients are six months post-procedure and have achieved a mean loss of 27.9 pounds (an average of 30.4 percent excess weight loss) and a reduction in waist circumference from 46.3 to 41.6 inches. Researchers expect continued positive results through the conclusion of the study at 12 months.
Recovery from the procedure is vastly improved over that of traditional weight loss surgery. "This procedure is safe and allows patients to resume their normal activities almost immediately," said Christopher C. Thompson, MD, MSc, FACG, director of developmental endoscopy at Brigham and Women's Hospital. "It offers great potential for patients in lower BMI categories or for those who are not candidates for gastric bypass."
While Dr. Thompson, who conducted the study along with Phillip Schauer, MD, chief of surgery at the Cleveland Clinic Foundation, cautions that there is no magic bullet for significant weight loss, he said he believes that the procedure holds promise for preventing obesity.
Dr. Thompson will present these data on Monday, June 1 at 8 a.m. CDT in South Hall, McCormick Place.