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One of the leading most respected resources for gastric bypass surgery information on the web.

This file contains the information from our web site, in one large downloadable file.  Patients from all over have found it very helpful in learning about Bariatric Surgery.   You can contact us here, and if you are a candidate, we will verify that your insurance covers your weight loss surgery.

 

Laparoscopic Operations

The newest and most exciting breakthrough in obesity surgery is the use of laparoscopic techniques.

Laparoscopic Surgery Benefits:

    Tiny Incisions

    Less Discomfort

    Reduced Risk of Incisional Hernias

    Less Stress on Body's Defenses

    Shorter Hospital Time

    Quick Recovery

 

Our surgeons developed the Laparoscopic Gastric Bypass, and are the most experienced in the world in performing it. People come to us from all over the world, for this special operation.

No brag, just fact!

What is Laparoscopy?

Laparoscopic surgery began to be performed widely in the United States in the early 1990's, when it first began to be used for removal of the gallbladder. Using a thin tubular telescope and a tiny high-resolution video camera, the surgeon can see, on a TV monitor, what the camera sees inside the abdomen, through a pencil-sized "portal" passed through the abdominal wall. Other "ports" are placed, through which long, slender instruments can be inserted, to do the actual surgery. The surgeon must learn to move the instruments, based upon what he sees on the screen, not what he feels.  Sometimes lasers are used as well, although many operations are accomplished just as well, without the need for lasers. Although the operation achieves the same result, there is no large and painful incision. Patients who have undergone Laparoscopic Gallbladder surgery can attest to reduced discomfort and rapid recovery, and excellent cosmetic results that are usually achieved with this method.

In just a few years, a wide variety of instruments have been developed, including sophisticated stapling and suturing devices, which permit laparoscopy to be applied to many other types of surgical operations. The use of laparoscopy for more complex operations, in which the stomach or bowel is cut and re-connected, is called "Advanced Laparoscopy". Few surgeons can and have become skilled in these techniques, and none had performed the Gastric Bypass laparoscopically, until Dr's. Wesley Clark and Alan Wittgrove of CSWC first developed the technique in 1993. They have now performed over 3000 such operations by this method, as well as other advanced laparoscopic procedures, and they have trained hundreds of other advanced surgeons in the performance of the operation.

Laparoscopic Gastric Bypass, Roux en-Y

Gastric Bypass, Roux en-Y has been said to be the "gold standard" operation for the treatment of Morbid Obesity, for several years, meaning that it is a solidly established reference, to which other operations must measure up.. It is, in our opinion, the procedure with the best combination of benefits and risks, for most patients. The operation is complex and difficult, whether performed by an open incision, or by laparoscopy.  It can be organized into three steps:

The steps of the operation are described in How We Do the Operation
You can read more about the effects of this operation, in
Surgical Operations for Morbid Obesity.

In 1993, we set out to recreate the Gastric Bypass, Roux en-Y as an advanced laparoscopic procedure, using the same anatomy and connections, and varying only the instruments used to perform it laparoscopically.  That way, we did not sacrifice principles, and known effectiveness, to make the operation easier to perform by this new method.

The results of this operation, which we have published and presented internationally, show:

Laparoscopic Adjustable Silicone Gastric Banding

The Laparoscopic Adjustable Silicone Gastric Band (LAP-BAND System , Inamed) was approved by the FDA in June 2001, for use in treatment of Severe Obesity.

The LAP-BAND System  is a device designed to produce a small upper gastric pouch, and a narrow opening from it into the lower stomach. It causes a sense of fullness after only a few bites of food, and it helps make the decision to reduce food intake, and to lose weight. We participated as one of the original eight centers whose studies were the basis for FDA approval, and we therefore had experience with this device long before it became available to most U.S. surgeons.  We were required to use the Lap-band system according to a strict protocol which required the patient to participate in frequent follow-up examinations for 3 years.

The Lap-band system has several potential advantages:

Over several years, many thousands of these devices have been used, primarily overseas. The preliminary indications are that they are reasonably safe, when inserted by a skilled laparoscopic surgeon, and that they produce an average weight loss of more than half the excess body weight, for most patients. In several European reports, mortality risk has been acceptably low, and complication rates have been low. The most common problem is a slippage of the stomach through the band, causing the upper stomach pouch to enlarge and obstruct, often requiring a revisional surgery, which can usually be done laparoscopically.

This operation is especially attractive to persons who can spare only a small amount of time, and who need to return quickly to full activity.  With one to two days hospitalization, a busy executive can return to his desk, and gain control over troublesome weight problems.

The Laparoscopic Decision

The bottom line on the laparoscopic approach:

If shorter hospital stay, reduced discomfort and disability, and superior cosmetic results are important to your decision, the choice of Laparoscopic Gastric Bypass or Lap-band system, is a choice you should consider.  

We were the among the first to perform these procedures, and have an experience of thousands of operations, and a worldwide reputation as leaders in Bariatric Surgery.

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What is Morbid Obesity?

Medically, the word "morbid" means causing disease or injury. Morbid Obesity is a serious disease process, in which the accumulation of fatty tissue on the body becomes excessive, and interferes with, or injures the other bodily organs, causing serious and life-threatening health problems, which are called co-morbidities.

Morbid Obesity is also called Clinically Severe Obesity, and is recognized by the consensus of medical opinion as a very serious health problem, a disease process. In most cases, the underlying cause is genetic -- you inherit the tendency to gain weight, and once the problem is established, there is very little that will power can do about it -- any more than a diabetic might control his blood sugar by will power.

How do we know it's genetic?

Numerous scientific studies have established that there is a very powerful genetic predisposition to Morbid Obesity:

How do you know if you are Morbidly Obese?

We use three criteria:

What can you do to regain your health?

In our opinion, surgery is the only effective way to achieve lasting weight control, and a healthy body weight.

A person who chooses surgery can reasonably anticipate loss of at least 50% of excess body weight (average loss is 80%), as well as improved health, and the chance to live life in a normal-sized body.


Health Effects of Morbid Obesity

Severe obesity damages the body by its mechanical, metabolic and physiological adverse effects on normal bodily function. These "co-morbidities" affect nearly every organ in the body in some way, and produce serious secondary illnesses, which may also be life-threatening. The cumulative effect of these co-morbidities can interfere with a normal and productive life, cause endless frustration and can seriously shorten life, as well.

Shortened Life Span

Dysmetabolic Syndrome X

This recently recognized syndrome, involving abdominal obesity, abnormal blood fat levels, changes in insulin sensitivity, and inflammation of the arteries, is associated with a markedly increased risk of heart and blood vessel disease.  It is also a precursor to the onset of Diabetes in adults.

Heart Disease

Severely obese persons are approximately 6 times as likely to develop heart disease as those who are normal-weighted. Heart disease is the leading cause of death in the United States today, and obese persons tend to develop it earlier in life, and it shortens their lives.  Coronary disease is pre-disposed by increased levels of blood fats, and the metabolic effects of obesity. Increased load on the heart leads to early development of congestive heart failure. Severely obese persons are 40 times as likely to suffer sudden death, in many cases due to cardiac rhythm disturbances.

High Blood Pressure

Essential hypertension, the progressive elevation of blood pressure, is much more common in obese persons, and leads to development of heart disease, and damage to the blood vessels throughout the body, causing susceptibility to strokes, kidney damage, and hardening of the arteries.  If your doctor finds you have high blood pressure, the first thing he or she will recommend to you is weight loss (but doctors have never been able to tell us how).

High Blood Cholesterol

Cholesterol levels are commonly elevated in the severely obese -- another factor predisposing to development of heart and blood vessel disease.  This abnormality is not just related to diet, but is an effect of the massive imbalance in body chemistry which obesity causes.

Diabetes Mellitus

Overweight persons are 40 times as likely to develop Type II, Adult-Onset, Diabetes. Elevation of the blood sugar, the essential feature of Diabetes, leads to damage to tissues throughout the body: Diabetes is the leading cause of adult-onset blindness, a major cause of kidney failure, and the cause of over one half of all amputations. It is the #4 cause of death in the United States.  Diabetics suffer severely from their disease, and once Diabetes occurs, it becomes even much harder to lose weight, because of hormone changes which cause the body to store fat even more than before.

Sleep Apnea Syndrome

Sleep apnea -- the stoppage of breathing during sleep -- is commonly caused in the obese, by compression of the neck, closing the air passage to the lungs.  It leads to loud snoring, interspersed with periods of complete obstruction, during which no air gets in at all. The sleeping person sounds to an observer like he is holding his breath, but the sleeper is, himself, usually unaware that the problem is occurring at all, or only notices that he sleeps poorly, and awakens repeatedly during the night. The health effects of this condition may be severe, high blood pressure, cardiac rhythm disturbances, and sudden death. Affected persons awaken exhausted and often fall asleep during the day -- sometimes even at the wheel of their car, and complain of being tired all the time. This condition really has a high mortality rate, and is a life-threatening problem.

Obesity Hypoventilation Syndrome

This condition occurs primarily in the very severely obese -- over 350 lbs. It is characterized by episodes of drowsiness, or narcosis, occurring during awake hours, and is caused by abnormalities of breathing and accumulation of toxic levels of carbon dioxide in the blood. It is often associated with sleep apnea, and may be hard to distinguish from it.

Respiratory Insufficiency

Obese persons find that exercise causes them to be out of breath very quickly, during ordinary activities. The lungs are decreased in size, and the chest wall is very heavy and difficult to lift. At the same time, the demand for oxygen is greater, with any physical activity. This condition prevents normal physical activities and exercise, often interferes with usual daily activities, such as shopping, yard-work or stair climbing, making even ordinary living difficult or miserable, and it can become completely disabling.

Heartburn - Reflux Disease and Reflux Nocturnal Aspiration

Acid belongs in the stomach, which makes it to help digest your food, and it seldom causes any problem when it stays there. When it escapes into the esophagus, through a weak or overloaded valve at the top of the stomach, the result is called "heartburn", or "acid indigestion". The real problem is not with digestion, but with the burning of the esophagus by the powerful stomach acid, getting to where it doesn't belong. When one belches, the acid may bubble up into the back of the throat, causing a fiery feeling there as well. Often this occurs at night, especially after a large or late meal, and if one is asleep when the acid regurgitates, it may actually be inhaled, causing a searing of the airway, and violent coughing and gasping.

This condition is dangerous, because of the possibility of pneumonia or lung injury. The esophagus may become strictured, or scarred and constricted, causing trouble with swallowing. Approximately 10 - 15% of patients with even mild sporadic symptoms of heartburn will develop a condition called Barrett's esophagus, which is a pre-malignant change in the lining membrane of the esophagus, a cause of esophageal cancer.  The incidence of this type of cancer is increasing in the United States, in parallel with the increase in obesity.

Asthma and Bronchitis

Obesity is associated with a higher rate of asthma, about 3 times normal.  Much of this effect is probably due to acid reflux (described above), which can irritate a sensitive airway and provoke an asthmatic attack.  The improvement of asthma after surgery is often very dramatic, even before much weight loss has occurred.

Gallbladder Disease

Gallbladder disease occurs several times as frequently in the obese, in part due to repeated efforts at dieting, which predispose to this problem. When stones form in the gallbladder, and cause abdominal pain or jaundice, the gallbladder must be removed. 

Stress Urinary Incontinence

A large heavy abdomen, and relaxation of the pelvic muscles, especially associated with the effects of childbirth, may cause the valve on the urinary bladder to be weakened, leading to leakage of urine with coughing, sneezing, or laughing. This condition is strongly associated with being overweight, and is usually relieved by weight loss.

Degenerative Disease of Lumbo-Sacral Spine

The entire weight of the upper body falls on the base of the spine, and overweight causes it to wear out, or to fail. The consequence may be accelerated arthritis of the spine, or "slipped disk", when the cartilage between the vertebrae squeezes out. Either of these conditions can cause irritation or compression of the nerve roots, and lead to sciatica -- a dull, intense pain down the outside of the leg.

Degenerative Arthritis of Weight-Bearing Joints

The hips, knees, ankles and feet have to bear most of the weight of the body. These joints tend to wear out more quickly, or to develop degenerative arthritis much earlier and more frequently, than in the normal-weighted person. Eventually, joint replacement surgery may be needed, to relieve the severe pain. Unfortunately, the obese person faces a disadvantage there too -- joint replacement has much poorer results in the obese, and complications are more likely.. Many orthopedic surgeons refuse to perform the surgery in severely overweight patients

Venous Stasis Disease

The veins of the lower legs carry blood back to the heart, and they are equipped with an elaborate system of delicate one-way valves, to allow them to carry blood "uphill". The pressure of a large abdomen may increase the load on these valves, eventually causing damage or destruction. The blood pressure in the lower legs then increases, causing swelling, thickening of the skin, and sometimes ulceration of the skin.  Blood clots also can form in the legs, further damaging the veins, and can also break free and float into the lungs -- called a Pulmonary Embolism -- a serious or even fatal event.

Emotional/Psychological Disease

Seriously overweight persons face constant challenges to their emotions: repeated failure with dieting, disapproval from family and friends, sneers and remarks from strangers. They often experience discrimination at work, and cannot enjoy theatre seats, or a ride in a bus or airliner. There is no wonder, that anxiety and depression might accompany years of suffering from the effects of a genetic condition -- one which skinny people all believe should be controlled easily by will power.

Social Effects

Seriously obese persons suffer inability to qualify for many types of employment, and discrimination in employment opportunities, as well. They tend to have higher rates of unemployment, and a lower socioeconomic status. Ignorant persons often make rude and disparaging comments, and there is a general societal belief that obesity is a consequence of a lack of self-discipline, or moral weakness. Many severely obese persons find it preferable to avoid social interactions or public places, choosing to limit their own freedom, rather than suffer embarrassment.

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Surgical Operations for Morbid Obesity

We'll discuss here all the operations for Morbid Obesity, even the ones we don't do, so you know about all of the choices, and why we choose certain ones ourselves.

Gastric Bypass, Roux en-Y (Proximal Gastric Bypass, RYGBP)

We consider Gastric Bypass to be the premium operation, offering the best combination of maximum weight control, and minimum nutritional risk.

The Gastric Bypass, Roux en-Y is considered the "gold standard" of modern obesity surgery -- the benchmark to which other operations are compared, for evaluation of their quality and effectiveness. Our group has experience with over 4000 of these procedures, and we have striven to refine our techniques and methods to produce the maximum sustained weight loss achievable.

This operation achieves its effects by creating a very small stomach pouch (thumb-sized, actually), from which the rest of the stomach is permanently divided and separated. The small intestine is cut about 18 inches below the stomach, and is re-arranged so as to provide an outlet to the small stomach, while maintaining the flow of digestive juices at the same time. The lower part of the stomach is bypassed, and food enters the second part of the small bowel within about 10 minutes of beginning the meal.

There is very little interference with normal absorption of food - the operation works by reducing food intake, and reducing the feeling of hunger. The result is a very early sense of fullness, followed by a very profound sense of satisfaction. Even though the portion size may be small, there is no hunger, and no feeling of having been deprived: when truly satisfied, you feel indifferent to even the choicest of foods.  Patients continue to enjoy eating - but they enjoy eating a lot less.

The Gastric Bypass provides an excellent tool for gaining long-term control of weight, without the hunger or craving usually associated with small portions, or with dieting. Weight loss of 80 - 100% of excess body weight is achievable for most patients, and long-term maintenance of weight loss is very successful -- but does require adherence to a simple and straightforward behavioral regimen.

Laparoscopic Gastric Bypass, Roux en-Y

We developed the techniques for performing the Gastric Bypass by laparoscopy, or limited access, and performed the first such procedure in 1993 -- we have now performed approximately 3000 such operations. This operation duplicates the anatomy and physiology of the standard, open procedure.

Laparoscopic surgery first became available around 1990, when small, light-weight, high-resolution video cameras were developed, allowing surgeons to "see" into the abdomen using a pencil-thin optical telescope, and to project the picture from the video camera on a TV monitor at the head of the operating table. The surgeon must develop skills in operating by this new method, without being able to feel tissue directly, and by learning to determine where instruments are by seeing them on TV.

The benefits of the laparoscopic approach come from the very small incisions which are necessary, which cause much less pain, and very little scarring. Patients are able to get up and walk within hours after surgery, can breath easier, and move without discomfort. Bowel activity usually is not affected, as it is with an open incision. Most persons find they can return to normal activities within 10 – 12 days, sometimes even sooner.

The risks of surgery performed laparoscopically are comparable to those the standard operation – when done by an experienced and skilled laparoscopic surgeon. Some bariatric surgeons have been unable to master the techniques of advanced laparoscopic surgery, and therefore do not offer this method – or may even try to claim that it is less effective – which is certainly not true.

At Hospital, we have now performed over 3000 Gastric Bypass procedures, using the laparoscopic technique – one of  the largest series of this procedure in the world. Our results have been equal to, or better than, those obtained with the open operation, but with major reduction of discomfort and disability, and excellent cosmetic results as an additional benefit.

Of the first 500 patients who have undergone Laparoscopic Gastric Bypass surgery, weight loss averages 80% of excess body weight, one year after surgery, and has been maintained at 80% for over 5 years. Over 95% of all health problems (co-morbidities) associated with their obesity have been resolved following surgery. Patients enjoy a normal-style dietary regimen, and are satisfied to eat smaller portions.

Gastroplasty (Stomach Stapling, Gastric Stapling)

We mention this operation for completeness, although we do not offer it, because we do not believe in it, as an effective treatment.

Gastroplasty, or Stomach Stapling (Gastric Partitioning) is widely performed in the United States and elsewhere. It is a technically simple operation, accomplished by stapling the upper stomach, to create a small pouch, about the size of your thumb, into which food flows after it is swallowed. The outlet of this pouch is restricted by a band of synthetic mesh, which slows its emptying, so that the person having it feels full after only a few bites (one thumbful) of food. Characteristically, this feeling of fullness is not associated with a feeling of satisfaction - the feeling one has had enough to eat.

Patients who have this procedure, because they seldom experience any satisfaction from eating, tend to seek ways to get around the operation.  Trying to eat more causes vomiting, which can tear out the staple line and destroy the operation. Some people discover that eating junk food, or eating all day long by "grazing" helps them to feel more sense of satisfaction and fulfillment -- but weight loss is defeated.   In a sense, the operation tends to encourage behavior which defeats its objective.

Overall, about 40% of persons who have this operation never achieve loss of more than half of their excess body weight. In the long run, five or more years after surgery, only about 30% of patients have maintained a successful weight loss. Many patients must undergo another, revisional operation, to obtain the results they seek.

Because of the poor reported results with this surgery, we do not recommend or offer it - we can achieve far better results, with no increased risk, or increased expense.   When revision of a Gastroplasty is necessary, we recommend conversion to a Gastric Bypass.

 

Laparoscopic Adjustable Gastric Banding

Gastric Banding is a variation on the gastroplasty, in which the stomach is neither opened nor stapled -- a band is placed around the outside of the upper stomach, to create an hourglass-shaped stomach, and to produce a small pouch with a narrow outlet. The special device used to accomplish this is made of implantable silicone rubber, and contains an adjustable balloon, which allows us to adjust the function of the band, without re-operation. This device enjoys considerable advantage over the standard gastroplasty:

This device has now been approved by the Food and Drug Administration (FDA) for use in the United States, and many thousand have been implanted in Europe.  The early track record of safety is well established. Although many insurance carriers which would cover surgery for weight control will not cover this operation as an investigational procedure, an increasing number are allowing this option.

This operation may be particularly suited to persons with a BMI between 35 and 42, who need to find a rapid and more convenient solution, and to return to full activity very quickly:  businesspersons, salespersons, and the self-employed.  Although its effects may not be as profound as the gastric bypass, the risk of the procedure appears to be less, and the recovery time is the shortest.  

For best success, frequent adjustments of the band are needed, and one must learn to change eating behavior.  Satisfaction after meals is a much less prominent feeling, requiring the patient to exert more personal control.

Bilio Pancreatic Diversion

The most powerful operation currently available, but accompanied by significant nutritional problems in some patients. We're concerned about this, and no longer recommend the operation for most patients.

This very powerful operation involves removal of approximately the lower 2/3 of the stomach, and re-arrangement of the intestinal tract so that the digestive enzymes are diverted away from the food stream, until very late in its passage through the intestine. The effect is to selectively reduce absorption of fats and starches, while allowing near-normal absorption of protein, and of sugars. Calorie intake is much reduced, even while normal-sized food portions are eaten.  The ability to eat normal amounts is a great attraction for hearty eaters, but consumption of rich foods increases the side-effects, and nutritional risks, of the operation.

Although this operation is very powerful, patients are subject to increased risk of nutritional deficiencies of protein, vitamins and minerals. Vitamin supplementation recommendations must be carefully followed, and dietary intake of protein must be maintained, while intake of fat must be limited. Patients are annoyed by frequent large bowel movements (4-6 per day), which have a very strong odor, as does the bowel gas-- a potential source of embarrassment.  Excess fat intake leads to irritable bowel symptoms, and may lead to rectal problems (hemorrhoids, painful fissures) as well.

We have performed over 400 of these operations, and have analyzed our results and outcomes over a long term. Although most patients obtain excellent weight loss, and maintain good health and nutrition, we have been concerned that some do not maintain contact with us, or follow a healthful diet and vitamin regimen, and that this may lead to serious nutritional disturbances, or the need to revise the operation. When compared to the Gastric Bypass, in our hands, this operation achieves similar weight loss, but at a higher risk of nutritional side-effects. Therefore, we recommend it only in certain specific situations, and advise against its routine performance.

Duodenal Switch (DSBPD)

This operation is a variation of the BilioPancreatic Diversion, which was designed to reduce some of the problems of that procedure, and to retain more of the physiology of the normal stomach and its outlet valve, the pylorus.  In the Duodenal Switch, the stomach is converted to a narrow tube (removing the rest), and the pylorus and a small part of the duodenum (the first part of the small intestine) are left connected to it.  The lower part of the small intestine is then connected to this.  Food passes through the stomach tube, which makes one feel full due to its smaller size.  The food leaves the stomach through the pylorus, as it did before, and passes through the upper part of the duodenum.  The result is said to be better metering of the outflow of  food from the stomach, and better absorption of iron and calcium by the duodenum.  

The Duodenal Switch appears to answer some of the problems of the BPD, although some of the claims made for it are hard to reconcile with the physiology:  patients are said to have less frequent bowel movements, and less bowel gas odor.  Since these effects are a consequence of the malabsorption of fats and starches, and the action of bacteria in the large bowel, it is hard to understand how changing the stomach can affect them.

Distal Gastric Bypass

This procedure is offered by some, as a means of avoiding late weight gain which may follow the restrictive operations.  We prefer to perform the restrictive operation to a higher standard, and to emphasize the importance of appropriate eating afterward.   

The Gastric Bypass operation can be modified, to alter absorption of food, be moving the Y-connection downstream ("distally"), effectively shortening the bowel available for absorption of food.  The weight loss effect is then a combination of the very small stomach, which limits intake of food, with malabsorption of the nutrients which are eaten, reducing caloric intake even further.  

However,  malabsorption leads to a new set of problems.   Patients have increased frequency of bowel movements and increased fat in their stools (bowel movements).  The odor of bowel gas is very strong, which can cause social problems or embarrassment.  Calcium absorption may be impaired, as well as absorption of vitamins, particularly those which are soluble in fat (Vitamins A, D, and E).  Vitamin supplements must be used daily, and failure to follow the prescribed diet and supplement regimen can lead to serious nutritional problems in a small percentage of patients.  We. and others, have noted an increased incidence of ulcers post-operatively, in patients having this procedure.

We have performed approximately 50 of these operations, as the primary procedure, and have generally been disappointed in the results.   Our experience is that patients lose the satisfaction which is a prominent effect of the standard Gastric Bypass, and that the risks of mal-nutritional complications is significantly increased.  Since our results with the standard Gastric Bypass have been very satisfying, and the lifestyle of our patients is very comfortable, we do not advise this procedure, except in special circumstances - such as when a standard Gastric Bypass requires revision.   

In a sense, this procedure combines the least-desirable features of the Gastric Bypass with the most troublesome aspects of the BilioPancreatic Diversion.  We do not offer this procedure as primary treatment. 

Loop Gastric Bypass (MiniGastric Bypass)

This form of Gastric Bypass was developed years ago, and has generally been abandoned by most bariatric surgeons as unsafe.  Although easier to perform than the Roux en-Y, it creates a severe hazard in the event of any leakage after surgery, and seriously increases the risk of ulcer formation, and irritation of the stomach pouch by bile.  Most bariatric surgeons agree that this operation is obsolete, and should remain defunct.

This operation has been resurrected, in order to make the laparoscopic procedure easier to perform, requiring only one connection.  The surgeon trades safety and long-term risk, for ease of performance. A fundamental principle of laparoscopic surgery is that the operation should not be compromised or degraded, in order to accomplish it using limited access techniques.  We feel that this principle is violated here, and that long-term results with this procedure will prove very disappointing.

Jejuno-Ileal Bypass  -- Historical Note, and Caution

JI Bypass, or Intestinal Bypass, is no longer performed in the United States, and has not been for about 24 years.  This operation was one of the earliest procedures devised for serious obesity, and achieved its effects by shortening the overall length of the bowel to less than 10% of its normal length. It caused severe, non-selective malabsorption of foods, which brought about weight loss, but also resulted in serious nutritional and metabolic side-effects, some of which were very dangerous.  Patients could eat all they wanted, but absorbed very little of the food.  All patients  experienced diarrhea, up to 15 - 20 bowel movements per day.  Many had a strange body odor.  Worse, the  procedure was responsible for strange arthritic symptoms, kidney damage, and irreversible liver damage, in many patients.

This operation contributed to mortality in significant numbers of patients, and its risks certainly outweigh any benefits of weight loss by this method. Persons who have already undergone the procedure should take care to have close medical surveillance by their personal physician, and should undergo reversal (preferably with conversion to another weight-control operation) at the first sign of abnormalities of liver or kidney function, or other complication. We believe that conversion of this operation to a gastric bypass offers the best results - this is a difficult operation, often with a slow recovery.  Simple reversal of the operation, without substitution of another bariatric construction, leads to inevitable regain of all the weight lost, usually at a terrifying rate.

We only mention this operation, because many persons who are poorly informed confuse it with the Gastric Bypass (it has the same last name). Even some physicians do not understand that these are totally different procedures, with very different anatomy and physiology. The Gastric Bypass is the best operation, while the intestinal bypass is the worst.

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Benefits and Risks of Surgical Treatment of Serious Obesity

 

Benefits and Risks of Surgical Treatment of Serious Obesity

For someone who is interested in the ideal of surgery, to get control of serious obesity, the key question is the benefits to be gained from surgery, versus the risks that one must go through, in order to have an operation. Usually, the risks are taken right away, when the surgery is performed, and the benefits take a while to pay you back, in the form of improved health, reduced long-term risk of illness, and enhancement of your lifestyle.

It’s a personal decision, as well as a medical one. Our doctors can teach you about the risks, and help you measure the likelihood of benefits, and will tell you frankly, if they are out of balance for you. Still, the final decision is up to you. To make it intelligently, you need to know all about the risks, and the benefits, of the operation.

Risks and Complications of Surgery

The risk of a weight control operation is mainly the risk of having any abdominal operation. It is the act of having an operation, not the particular operation which is done, that causes most of the risk. Severely obese persons are well known to be at a disadvantage, when having surgery, and their risks are higher than they would be at a normal body weight.  The excessive body weight and fat accumulation interfere make it difficult for the surgeon to reach and see structures which often lie deep in the abdomen.  He must use long instruments, which are harder to control.  Every surgical maneuver, such as sewing tissue, tying knots in sutures, and even recognizing organs embedded in the fat, is made much more difficult.  

Weight and fat interfere with the healing process, with resistance to infection, and with susceptibility to complications.  Patients have difficulty moving out of bed, or even turning, and require special nursing skills and assistance, as well as special hospital equipment.  Wheelchairs and commodes must be larger.  Special beds, with more powerful motors, are often necessary.  X-Ray equipment must accommodate the size and weight of the obese patient.  

The risk of surgery comes mainly from its complications: things can go out of control, causing serious problems, often without any good reason. Having an abdominal operation places a lot of stress on the body. It creates an open wound, which can bleed or fail to heal, and it opens the door to potential infection. The emergency reaction of the body to injury can itself by harmful, when it leads to reactions such as increased clotting of blood, which can cause a fatal pulmonary embolism. Let’s look at the risks in detail.

Mortality

A bariatric operation is a very complex major surgery.  Persons who are seriously overweight face a serious mortality increase, with any major operation, such as gallbladder surgery, hysterectomy, or orthopedic surgery.  It's being overweight, not the type of operation, that causes the penalty.

Mortality of bariatric operations, as reported across the United States is approximately 0.5%.  Surgical mortality of less than 1% is usually considered to be very acceptable for major surgery, even in normal weighted persons.  However, if one does the math on  0.5%, it means that 1 out of 200 patients who have a bariatric operation will not survive it for a month. 

Our mortality at Hospital Surgical Weight Reduction Program has been less than 1 in 1000 for the laparoscopic operation, and somewhat higher for open operations (which are more often done on super obese patients, complicated cases, and when prior surgery has been done on the stomach).  

Lung Problems

This condition is a partial collapse of a part of the lung, caused by lack of motion of the chest wall. Normally, your lung is filled with tiny air spaces, like the tiny spaces in a loaf of bread, only much smaller. Picture what happens, when you take a loaf of bread and sit on it, and you get an idea of how the lung collapses. The best treatment is to prevent it, by deep breathing and lung exercises. We teach you these before surgery, and encourage you to do them again and again, after the operation. We also have special treatments, and even pulmonary medicine specialist consultants, to help you and your lungs recover, if atelectasis occurs. Atelectasis can cause a fever after surgery, and can also lead to developing pneumonia.

Pneumonia is an infection in the lungs, and after surgery it can be especially serious, because the infecting organisms often come from the gastrointestinal tract, and they can be very destructive. We try to prevent pneumonia by clearing out the GI tract ahead of surgery, by using antibiotics at the time of operation, and by generally using good anesthesia and respiratory treatment, to prevent atelectasis.  We will carefully observe for signs of pneumonia after surgery.

This problem affects the lungs and the heart, but it usually starts in the legs, with the formation of blood clots. Although these can occur at any time, and are more likely in overweight patients, they are especially likely at the time of, and soon after surgery, because people who have an operation don’t like to move around, or exercise their legs. The blood becomes stagnant and clots in the leg veins, and if a clot breaks off and floats through the veins to the lungs, it is called a pulmonary embolism. The blood clot blocks the arteries in the lungs, and can cause a part of the lung to lose its circulation and die – a pulmonary infarction. If the circulation to a large part of the lung is affected, the heart is placed under a lot of strain, and it may fail suddenly, which can be fatal.

We prevent a pulmonary embolism, first, by thinning the blood with heparin, which makes it less likely to clot. We prescribe elastic stockings, to compress the legs and keep the blood flowing faster in the veins. We try to keep the operation short, by operating efficiently (not hurriedly), and by getting patients up to walk as soon as possible.

Infection

An abscess is a collection of infected fluid, or pus, which occurs somewhere in the body. After an abdominal operation, a pocket of fluid or a puddle of blood may develop, and if any bacteria are present, they may infect it and create an abscess. The treatment of any abscess is to drain away the infected fluid, and kill the bacteria with antibiotics.

We prevent abscesses by trying to avoid any collections of fluid or blood in the abdomen, at the time of surgery, and by placing a drain if one might possibly occur. If an undrained abscess develops, we now have very skillful specialists, called interventional radiologists, who often can achieve drainage, and resolve the problem, without a need for an operation to drain it.

A wound infection is a type of abscess, and is treated the same way, by drainage. Seriously obese persons have a very deep layer of fat under the skin, and the usual methods which surgeons use for treating infection there do not work very well in the obese. We have developed special methods, and using these, most such infections are relatively easy to treat, although they can cause discomfort and inconvenience for a while.

A seroma is a collection of serum (the fluid part of blood, without the red blood cells), which tends to fill any open space in the wound.  A seroma usually seeks a way out through the incision somewhere, and when it drains, it is rapidly resolved.  Seromas are really a minor type of wound infection.

Many overweight female patients have an unnoticeable low grade urinary tract infection all the time.  Urine flow is altered after surgery, and patients also have trouble straining down, to void. Use of a tube, or catheter, may be necessary to drain the bladder. In a few cases, this low flow, or use of a catheter, can lead to symptomatic (noticeable) infection of the bladder. Usually such an infection can be readily eradicated with antibiotic treatment, without any additional hospital stay.

Bleeding

We use heparin, a blood thinner, to prevent blood clotting and pulmonary embolism. At the same time, if blood does not clot at all, bleeding will occur, when surgery is performed. We have to try to find a middle ground, but because the sensitivity of different individuals may vary, delayed bleeding may occur after surgery in some persons. We observe closely for this, and can stop the heparin if bleeding gets to be a bigger risk.

When surgery is performed, blood vessels must be cut. We handle these by tying them with a piece of thread, called a ligature, or by using a device called an electrocautery, which coagulates the blood, and the end of the blood vessel. Sometimes, a blood vessel may be cut, but not bleed immediately, and then begin to bleed again, several hours later. This can cause a hemorrhage, either inside the abdomen, or at the skin level.

Hemorrhage must be stopped. We have several strategies for this, but in some cases, a return to the operating room may be needed. This is a rare event.

When blood loss occurs, that tend to make the pulse and blood pressure unstable, a transfusion may be needed. The blood bank has very high quality standards, and the blood is quite safe, but there is still a possibility of getting hepatitis, and a very small risk of receiving the AIDS virus (about 1 in 500,000), from a transfusion. These risks can be reduced, by donating your own blood and having it saved for your surgery – a procedure called autologous donation. This costs quite a lot (about $125 per pint), and we feel it is probably not economically sound, since the likelihood of needing the blood is quite low.  The service is available to patients who prefer it.

We also have performed surgery successfully on many occasions under the Bloodless Surgery Program, when patients decline to receive blood or blood products for religious reasons. We will honor a commitment to avoid transfusion, on your instructions.

Bowel Obstruction

After any abdominal operation, scars called adhesions will form in the abdomen. These look like strands of latex, or sometimes like a piece of fibrous cord, and can snag a piece of bowel – just like your garden hose can wrap itself around the smallest bump, when you pull on it. Sometimes, even many years after the original operation, the bowel becomes kinked around an adhesion, becomes obstructed, and nothing can get through. This must be relieved, especially before the bowel loses its blood supply and dies, which can make the bad situation even worse. Usually an emergency operation is necessary.

Obstruction can also occur due to formation of an "internal hernia", where the bowel gets trapped within a cavity inside the abdomen.  The loss of a large amount of fat from within the abdomen may open up areas for a hernia to form, months after the original operation. 

Occasionally, a bowel obstruction can occur within a few days after surgery. In this case, the adhesions are much softer, and will often come apart on their own, if conditions are made right.

Leakage of Bowel Connections

When the surgeon fastens bowel to bowel, or bowel to stomach, the connection is called an anastamosis.  We try to make these connections water-tight, and we often test them during surgery, using either dye, or a puff of air (we look for bubbles).  Sometimes, a tiny part of the bowel wall may lose its blood supply and die, or a suture may work back and forth to make a small hole.  

If the anastamosis does not maintain a complete seal, and leakage of fluid from within the bowel occurs, it is called an anastamotic leak. Fluid from the GI tract, containing at least some bacteria, leaks out into the abdomen where it doesn't belong, and causes a serious infection, accompanied by much swelling, a rapid pulse rate, and sometimes, formation of an abscess. This is always a very serious complication, and its diagnosis and treatment are made much more difficult by severe obesity.

Conventional wisdom indicates that an immediate operation is required, to seal the leak and drain away the infection. Often, repair of a leak at surgery is impossible, or the leak soon recurs. Therefore, the main purpose of this second operation is to clean up, and then to place a drain, so that any further leakage is conducted away to the outside.  If the leak is small, and is contained in a small area, the second operation may have the unfortunate side-effect of spreading infectious material around the abdomen.

Our experience has taught us that, more than half the time, a second operation may cause more harm than good, and that it can and should be avoided. Adequate drainage may already be present, and if not, it can often be obtained by the interventional radiologist, without surgery. When this is possible, the insult of surgery, and the spreading of infection through the rest of the abdomen, can be avoided. 

Anastamotic leak almost always causes some increase in hospitalization, and increased discomfort from the drain, and the need for repeated X-rays.

Obstruction of the Stomach Outlet

In performing the Gastric Bypass, when the stomach is connected to the bowel, to opening is deliberately made small, about inch in diameter, to slow the flow of food out of the small stomach pouch. All healing occurs by scar formation, and scars always have a tendency to contract. This may cause the opening between stomach and bowel to become too small, so that no food can get through. This causes repeated vomiting, and must be corrected.

This type of problem used to occur in about up to 10% of cases (our experience is around 3-4%), and many surgeons continue to be troubled by this complication. The treatment is quite simple, and can be done as an outpatient procedure. However, as we have worked to refine the Gastric Bypass, we have noticed that the incidence of this problem has declined.  We believe this may be due to improved anatomy, and improved blood supply to the affected bowel,  

Chronic Nutritional Problems

Nutritional problems are quite rare after the Gastric Bypass, and are quite readily avoided by use of the proper vitamin and mineral supplements, and by eating a healthy diet. One of our most important objectives during our long follow-up is teaching food values, and the content of a healthy eating regimen. A remarkable effect of the Gastric Bypass is the progressive change in attitudes toward eating. Patients begin to eat to live - they no longer live to eat.

Protein is the essential stuff, of which our muscles, organs, heart and brain are all constructed. Our bodies require a constant supply of protein building materials, to repair and replace tissues which become worn out or damaged. The Gastric Bypass and the Gastric Banding both reduce the capacity of the stomach to a very small volume, so that protein-containing foods must be carefully eaten with each meal, to be sure that the body gets enough to maintain itself. If the first half of each meal is taken as protein-containing foods, deficiency is very unlikely to occur. We do not advise the use of protein supplements or beverages.

Conventional nutritional teaching has been that vitamins are contained in adequate amounts in a well-balanced diet, and supplements should not be required, provided that one eats a well-balanced diet. After weight-control surgery, the diet is initially much less than enough to supply complete nutrition – that’s why you lose weight. In order to have any chance of getting enough vitamins, a high potency multivitamin supplement must be taken daily. We think its safest to do this for the rest of your life, after this type of surgery.

In addition, we have seen a few persons develop deficiency of Vitamin B-12, even when taking a multi-vitamin supplement. B-12 is absorbed in the stomach and duodenum, which are largely bypassed with this surgery. Simple use of a sub-lingual (under the tongue) tablet of B-12, once a week, maintains very adequate vitamin levels, and prevents deficiency, which can develop without warning, until it becomes very dangerous.

Our recommended multivitamin preparation contains mineral supplements in generous amounts. We also recommend daily use of calcium, and many patients, particularly women, will require a special iron supplement, to maintain adequate iron stores and prevent anemia of iron deficiency.

The total cost of all the needed supplements is about $20 per month.

Side-Effects of the Gastric Bypass, and the Gastric Banding

Side-effects occur with any operation. Although they are less serious than complications, they may be permanent, and may require a change in lifestyle, to avoid continuing discomfort.

After gastric restriction, if one gets a full feeling, and continues to eat, chances are an episode of vomiting will result. Most patients have this happen several times, and most quickly learn to follow instructions to eat slowly, chew food well, and avoid that last bite when fullness occurs. Typically, with the gastric Bypass, a profound feeling of satisfaction follows the fullness within a few minutes, and makes further eating a matter of indifference. The Gastric Banding does not produce this sense of satisfaction as quickly, or as intensely.

During the first few days to weeks, another kind of nausea may follow the gastric bypass. This results from delayed function of the Y-limb, and spontaneously resolves with time.

After either the gastric bypass, or the gastric banding, red meats are not well tolerated, and may cause vomiting. This is purely a mechanical effect – your stomach cannot tell steak from chicken, except that steak is much harder to break down so that it will fit through the small stomach outlet. If the outlet gets plugged, vomiting will result. We advise patients to avoid red meats until their stomach is functioning very well, usually after at least 3 – 4 months.

Refined sugars and candy consist of many small molecules, which tend to draw fluid into the intestine. After the gastric bypass (not after the gastric banding), a condition called "dumping syndrome" may occur, when sugar is taken on an empty stomach, passes rapidly through the stomach into the intestine, and draws a large amount of fluid into the bowel. The physiology is complicated, but the result is a condition like shock: one turns ghostly pale, breaks out in a profuse sweat, feels butterflies in the stomach, a rapid pulse, and a feeling of prostration. Nausea and vomiting, cramps and diarrhea may follow. Most people who have this reaction never try to sneak another candy bar – and we think that’s not such a bad effect, if you’re trying to lose weight.

The problem of dumping is avoided by avoiding sweets, candies, and fruit juices on an empty stomach. Certain dressings, barbecue sauce and mayonnaise may also cause problems, and need to be avoided.

To digest milk sugar (lactose), our bodies need and enzyme called lactase, which is often in short supply in the lower small intestine. After gastric bypass (not after gastric banding), milk and milk products may not be fully digested. Farther downstream, they are fermented by bacteria, and this causes gas, cramps and diarrhea.

Milk can be treated, to make it tolerable. In the big picture, it’s probably better to avoid it. Many prepared foods (those that come in a box, or frozen entrees) contain milk sugar as an additive. It is important to learn to be a label-reader, or to avoid packaged foods, and especially junk food.

After restrictive surgery, the amount of food consumed is greatly reduced, and the quantity of roughage consumed may be much smaller. Correspondingly, the amount of bowel movements will be diminished, causing less frequent bowel activity, and constipation. If this becomes a problem, a stool softener supplement may be needed, to avoid rectal difficulties.

During the phase of rapid weight loss, calorie intake is much less than the body needs, and protein intake is marginal. The body is in a panic state, like what would happen during a period of starvation. One of the side-effects, in some persons, is inactivation of 30 – 40% (rather than the usual 10%) of hair follicles, causing noticeable amounts of hair to fall out. This is a transient effect, and resolves when nutrition and weight stabilize. We advise patients to avoid hair treatments and permanents, and be sure of adequate protein intake. Sometimes a zinc supplement will help, and Minoxidil (a drug to prevent and reverse hair loss) may be tried.

When the body is in a panic state, and trying to combat starvation, it hoards its precious fat until any other usable fuel has been burned. Practically, the body will prefer to burn muscle mass, before consuming its precious fat (don’t ask us why – we didn't write the rules). If muscle is not regularly used for exercise, like every day, it will be consumed to meet energy needs.

Loss of muscle mass is preventable. It is very important, during active weight loss after surgery (or even when on a diet), to exercise vigorously every day. We recommend at least 20 minutes a day of aerobic activity, and it is well to devote attention to upper body strength as well. Many persons find, after a few weeks or months of regular daily exercise, that they actually begin to enjoy it, and start to work out even more. Fairly vigorous exercise, for more than 30 minutes a day, can greatly enhance fat-burning, and hasten weight loss. It also builds a healthy and beautiful body.

Seriously obese persons are very strong, and powerful – after all, just getting out of bed, you lift more than some people pick up all day long! It’s a shame to let that power be lost, when you need it to enjoy your life, and to make up for all the excitement you’ve put off. Save the power, while losing the fat, and you can just imagine how much energy you can have, and how much more you can accomplish!

OK, so it’s not exactly our fault, but it happens often enough to give a special warning. Many severely overweight women are also infertile, because the fatty tissue soaks up the normal hormones, and makes some of its own as well, completely confusing the ovaries and uterus, and causing a lack of ovulation. As weight loss occurs, this situation may change quickly.

We believe it is important to avoid conception during the phase of rapid weight loss – about one year after surgery – to maintain adequate nutrition. This requires special attention to contraception, even by those who think that it can't happen, because "natural" infertility may not last – in fact, it can go away in one night.

Benefits of Surgical Weight Loss

Finally, we can talk about the good stuff. In our section about the health consequences of severe obesity, we listed problems, or co-morbidities, which affect most of the organs in the body. The remarkable and wonderful fact is that most of these problems can be greatly improved, or will entirely resolve, with successful weight loss. Most people have actually observed this, at least for short periods, after a weight loss by dieting. Unfortunately, with dieting, such benefits usually do not last, because diets don’t last.

We have shown that the weight loss achieved with Gastric Bypass, Roux en-Y can average 80% of excess body weight, and can be maintained for years following surgery. We instruct patients in a very simple program, which is much easier to follow when one is not constantly starving on a diet.

Weight Loss Results after Laparoscopic Gastric Bypass

Now let's look at the health benefits of weight loss:

At least 70% of patients who have high blood pressure, and who are taking medications to control it, are able to stop all medications and have a normal blood pressure, usually within 2 – 3 months after surgery. When medications are still required, their dosage can be lowered, with reduction of their annoying side-effects.

Over 80% of patients will develop normal cholesterol levels within 2 – 3 months after operation.

Although we can't say definitively that heart disease is reduced, the improvement in problems such as high blood pressure, high blood cholesterol, and diabetes certainly suggests that improvement in risk is very likely. In one recent study, the risk of death from cardiovascular disease was profoundly reduced in diabetic patients, who are particularly susceptible to this problem. It may be many years before further proof exists, since there is no easy and safe test for heart disease.

Over 90% of Type II diabetics obtain excellent results, usually within a few days after surgery: normal blood sugar levels, normal Hemoglobin A1C values, and freedom from all their medications, including insulin injections. Based upon numerous studies of diabetes and the control of its complications, it is likely that the problems associated with diabetes will be arrested in their progression, when blood sugar is maintained at normal values. There is no medical treatment for diabetes which can achieve as complete and profound an effect, as surgery - which has led some physicians to suggest that surgery may be the best treatment for diabetes, in the seriously obese patient..

Abnormal Glucose Tolerance, or "Borderline Diabetes" is even more reliably reversed by gastric bypass. Since this condition becomes diabetes in many cases, the operation can frequently prevent diabetes, as well.

Most asthmatics find that they have fewer and less severe attacks, or sometimes none at all. When asthma is associated with gastroesophageal reflux disease, it is particularly benefited by gastric bypass.

Improvement of exercise tolerance and breathing ability usually occurs within the first few months after surgery. Often, patients who have barely been able to walk, find that they are able to participate in family activities, even sports activities.

Dramatic relief of sleep apnea occurs as our patients lose weight. Many report that within a year of surgery, their symptoms were completely gone, and they had even stopped snoring completely – and their spouses agree.

Relief of all symptoms of reflux usually occurs within a few days of surgery, for nearly all patients. We are now beginning a study to determine if the changes in the esophageal lining membrane, called Barrett's esophagus, may be reversed by the surgery as well – thereby reducing the risk of esophageal cancer.

When gallbladder disease is present at the time of the surgery, it is "cured" by removing the gallbladder during the operation. If the gallbladder is not removed, there is some increase in risk of developing gallstones after the surgery is performed, and occasionally, removal of the gallbladder may be necessary at a later time.

This condition responds dramatically to weight loss, usually by becoming completely controlled. A person who is still troubled by incontinence can choose to have specific corrective surgery later, with much greater chance of a successful outcome, with a reduced body weight.

Patients usually experience considerable relief of pain and disability from degenerative arthritis and disk disease, and from pain in the weight-bearing joints. This tends to occur early, with the first 25 -30 pounds lost, usually within about a month after surgery. Of course, if there is nerve irritation, or structural damage already present, it may not be reversed by weight loss, and some pain symptoms can persist.

The Scientific Proof

Measurement of the benefits and outcomes of modern bariatric surgery is one of the most important areas of surgical research in obesity. We are proud to say that we have followed our patients with Laparoscopic Bypass prospectively, and have very solid information never before measured, on the effects of this operation. We have several additional studies in progress, to further measure the improvement in health and lifestyle that weight-control surgery can accomplish.

Weight Loss

We have maintained follow-up with over 90% of the first 300 patients to undergo Laparoscopic Gastric Bypass, Roux en-Y.  The chart below shows average weight loss, as a percentage of Excess Body Weight, for 300 patients between 3 and 48 months following surgery.

Percentage of Excess Body Weight Loss over 3 - 60 Months -- 500 Laparoscopic Gastric Bypasses:

                   

We have studied, and recently reported, the relief of the symptoms of co-morbidities in our patients who underwent Laparoscopic Gastric Bypass. For the first 500 patients who underwent that operation, these are the numbers:

 

Condition

Pre-Op

Post-Op

GERD

269

4

HyperCholesterolemia

275

8

Hypertriglyceridemia

158

1

Diabetes

85

1

Glucose Intolerance

50

0

Stress Incontinence

201

6

Sleep Apnea

225

5

Hypertension

118

10

Arthritis (symptoms)

371

36

TOTALS

1752

71

 

Over 96% of health problems which are related to obesity are completely resolved and reversed, usually within days to months after surgery. 

That's what fat does to you, and that's what surgery can do to heal you.

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Financial and Insurance Information

An operation such as the Gastric Bypass requires an average of 3 - 4 days in the hospital, and from one to six weeks of recovery afterwards, depending on the method of operation, your condition, and the type of work you do, before you can return to full activities.

The cost of the operation includes:

Bariatric surgery is covered by many insurance policies, and the amount which it costs depends upon the type of policy and its terms, as well as any contractual arrangement with the hospital.  Insurance coverage's come in many types, and coverages really cannot be predicted, since they vary from policy to policy, even when issued by the same insurance company. If you wish to come to us for evaluation and surgery, we perform the insurance authorization and approval process without charge.  With specific policy information and approval, we can obtain your out-of-pocket expected costs before you schedule surgery.

Many patients choose to pay for the operation themselves. In cooperation with Hospital Medical Center, we offer special packages for cash patients, which include all usual services, at a substantial discount.  The actual rate varies, depending on the type of surgery chosen, and initial weight and health status.

It is best to remember that insurance companies make money, and profits, by collecting premiums - that's their business. Every bit of care you receive, and which they have to pay for, decreases their profit. In general, we've observed the following:

Medical Necessity

As you may have noticed above, the need for surgery, and the coverage by insurance, usually depends upon the doctor's determination that surgery is "medically necessary" to improve health, to reduce risks to life, and to permit a normal lifestyle. It also depends upon the patient's determination, in developing the arguments for surgical treatment, and in accumulating corroborating information, and physician opinions, to substantiate the medical necessity.

The process of getting coverage involves several steps, and various strategies, depending upon the type of insurance, and the specific practices of the insurance company.

The Medical History

A thorough Medical History must be obtained, in which the specific the course of development of serious obesity is made clear, current weight and height are measured, and Body Mass Index is calculated. The efforts to achieve weight control by non-surgical methods are described in detail, and each of the specific co-morbidities with which you are afflicted are identified and characterized. From this history, a detailed picture of current health status, and the adverse effects of obesity can be demonstrated.

We use a detailed history questionnaire, which is supplemented by a telephone interview, to determine your current health status and indications for surgery.  We may also ask that you consult your personal physician for an examination, and medical testing. 

Supporting Documentation

A brief letter from physicians who have treated you, especially specialists who have cared for a weight-related health problem, can be very valuable. Ask your doctor to state that your health problem is related to your excess weight, and that weight loss is indicated, or medically necessary, to relieve it.

Insurance carriers often want proof that you have dieted, under supervision of a physician - even though no one has ever shown scientifically that diets have any therapeutic benefit in the seriously obese. If you have been through a diet program, such as those with medications, HCG shots, hypnotism, acupuncture, psychotherapy, behavior modification, even powdered eye-of-newt, try to get records, receipts, or a statement from the doctor that you tried it.

Medical Testing

In some cases, the history may show the need for medical testing, to measure and clarify the degree of health risk of a given co-morbidity. For example, a diagnosis of Sleep Apnea syndrome may need to be confirmed by sleep study, when symptoms suggest that it is present. In most cases, diagnostic tests support and corroborate the indications for surgery, and can be quite helpful in obtaining needed treatment. Sometimes, insurance carriers demand tests, such as psychological or psychiatric evaluation - this is not really a problem, since few overweight persons are so seriously affected emotionally as to be unsuitable for surgery.

Insurance Request

Once the indications for surgery have been evaluated, and needed testing is accomplished, a request can be made for the health care benefits. The method of this request varies with the type of coverage:

We will prepare and submit a letter to your insurance carrier, requesting certification of your insurance coverage, and authorization for you to proceed with surgery, with our center. This letter will be detailed and specific, stating each of your indications, and the corroborating information. If they issue an initial denial, we will try to pursue an appeal, with further arguments.

HMO's and the like will not accept a letter or request from us directly, nor will we be able to order diagnostic testing for you. We can prepare a version of our request letter, addressed to you, which details the severity of your weight-related health problems, and the desirable further testing to be done. Armed with this information and knowledge, you can approach your "gatekeeper" doctor and request consideration for surgery. Ultimately, you may need to pursue a grievance process, or request an arbitration hearing, to obtain the care you need. Most persons who have valid indications, and who persevere through the whole process, will prevail in the end. Your HMO will want to refer you to a contracted surgeon - be sure that this is a surgeon with current experience and competence in bariatric surgery, operating in a comprehensive surgical weight control program, as recommended by the NIH Consensus Panel.

Under Medicare, the Gastric Bypass is available only as an open operation, not laparoscopically.  

Medicare specifies criteria for bariatric surgery, and persons over 65 and retired will not meet them.  We can determine if you meet these criteria, based upon your medical information and measurements.  

We are "opted out" of the Medicare program, meaning that neither you nor we can bill the program for our services.  You may make private arrangements with us, to pay for the surgery yourself, when appropriate indications are present.  

Regulations in this program vary from state to state, and most states will require that surgery be done in your home state, if it is available there at all. California MediCAL patients will find the initial response discouraging, but where clear medical necessity exists, they can obtain coverage through perseverance, and possibly some legal aid.

Most do not participate in the MediCAL program.

If You Get a Denial

Many insurance companies will deny an initial request, even when well-substantiated, and well within the consensus criteria recommended in the NIH report. When faced with a determined appeal, from a determined person, they will often relent, and provide coverage, to avoid a confrontation.

If your insurance carrier remains unreasonable, you may wish to seek legal assistance in obtaining good faith coverage of your medical needs.

For information on legal assistance, you may want to check with the Obesity Law and Advocacy Center.

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The Surgeons and Staff

Choosing Your Surgeon

Bariatric surgery, although not a formally designated surgical sub-specialty, is still a highly specialized field of surgery, which requires not only exceptional surgical skills, but dedication to long-term follow-up care, to help the afflicted person to achieve profound weight loss, and permanent control. Most surgeons avoid operating on the very-obese, believing that the risks are too great, and dreading the difficulty of performing operations in the obese abdomen. Some choose to "dabble" with an occasional procedure, which means they usually discover all the problems, and never get to learn the solutions - they can easily get pessimistic and negative about obese patients.

Like flying on an airliner, where you want a skilled pilot, when you have surgery, you should seek an experienced and skilled surgeon, with a proven safety record, who performs this surgery frequently. You will also need frequent and long-term follow-up, as a part of the package..

Primary site contributor:

Dr Clark is an internationally recognized leader in the field of bariatric surgery. He  pioneered the technique of Laparoscopic Gastric Bypass, and has performed careful follow-up research on the procedure and its results, which has been published in several medical journal articles. He has co-authored and published several research papers regarding the operation.  He has demonstrated the Laparoscopic Gastric Bypass to surgeons from throughout the world, performed telesurgery at the Congress of the American College of Surgeons, and has taught the procedure to hundreds of other surgeons. 

G. Wesley Clark, M.D.

Dr. Clark is a native of New York State, is a graduate of the University of Notre Dame, and the State University of New York, Upstate Medical Center, in Syracuse, where he received the degree of Doctor of Medicine. He interned at Albany Medical Center Hospital, and received his surgical training at Albany Medical Center, and at the Great Lakes Naval Hospital, after joining the U.S. Navy as a General Medical Officer. He served on the surgical teaching staff of Naval Hospital Long Beach, and Naval Hospital San Diego, and as an instructor in the surgical training programs at Long Beach Memorial Hospital, and at Cottage Hospital in Santa Barbara. He is a member of the American Society for Bariatric Surgery, the San Diego Society of General Surgeons, the San Diego County Medical Society, and the California Medical Association. 

Dr. Clark was among the first surgeons in the United States to perform laparoscopic surgery, and has received training in advanced laparoscopic techniques, at several centers.  He was a developer of  the technique for Laparoscopic Gastric Bypass.  He has now educated hundreds of surgeons throughout the world in the method for performing the operation.

He now specializes only in bariatric surgery, and has performed over 1000 Laparoscopic Gastric Bypasses, and over 2000 total bariatric procedures..

Dr. Clark has seven children and five grandchildren.   He favors airplanes, fast cars, motorcycles (Indian and Harley), cowboy boots, and is a computer enthusiast.  He is also an avid photographer.

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How the operation is done:

When we do the Gastric Bypass, Roux en-Y, we want to make a very small pouch out of the upper stomach, to restrict the amount of food which can be eaten.  That pouch is separated from the rest of the stomach, which is bypassed, by creating a new pathway into the intestines.  This pathway is called a "Roux en-Y" (named after the French surgeon, Dr. Roux, who first described this reconstruction in the 1800's).  The bowel is cut, and reconstructed in a Y configuration, so that two parts of the GI tract can feed into one.

Whether we do the operation through an incision, or laparoscopically, the basic methods, anatomy, and the results are the same, although the instruments differ.  Here's how we do the operation laparoscopically:

Operating Ports:

Laparoscopy is done through "ports", which are tubes that we pass instruments through, to operate on the internal organs.  We place several of these in the abdominal wall, through tiny incisions.

Measuring the Stomach Pouch:

We make the upper stomach pouch very small, so that it will hold about one tablespoon of liquid.  To do this, we pass a tube through the back of the mouth into the stomach (while you're asleep), and blow up a balloon on the end of the tube to a volume of 15 milliliters (one tablespoon).  That serves as a measure, as we cut the stomach into upper and lower parts.

 

Drawing courtesy of Ethicon Endosurgery, Inc.

 

Cutting the Stomach:

With the balloon tube serving as a guide, we place a special stapler across the stomach, which makes several rows of staples on each side, and cuts between them.  We then make additional cuts with the stapler, until the stomach is completely divided.  The small upper pouch will be the new stomach.  The large lower part of the stomach will no longer contain any food.  It still has all its blood vessels, and makes normal secretions, and these can exit through its bottom connection, the pylorus, which is undisturbed.

 

 

Constructing the Roux Limb:

We cut the small intestine a few inches below the stomach, and measure a length of it, to be used as the "Roux limb", which will attach to the new little stomach.  The bowel is connected side-to-side, to form the 'Y'.  The upper end of the Roux limb is passed behind the large intestine and the bypassed stomach, because that is the most direct and shortest route to the little upper stomach pouch.

 

 

 

 

Inserting the: Stapler Anvil:

The stomach pouch is so small, that suturing a connection would be very difficult, especially by laparoscopy.  From the beginning, we devised a method of inserting part of the stapler, the "anvil", by passing it through the throat into the stomach pouch, pulling it down into the pouch with a length of fine wire.  When the anvil is in place, we bring its stem through the side of the pouch, to connect it to the body of the stapler.

 

 

 

 

Inserting the Stapler and Connecting:

With the anvil in place, we insert the body of the stapler into the abdomen, through one of the small port sites, and then slide it inside the bowel, to make the connection.  The stapler and anvil are snapped together, and the stapler is screwed shut, then fired, creating two circles of staples, with a hole through their middle, like a donut, and uniting the stomach pouch to the upper end of the Roux limb.

 

 

 

 

After the circular stapler is removed, the opened end of the bowel is re-closed with another application of the linear stapler.  This completes the construction of the connection between the stomach and small bowel.  The main part of the operation is now over.

 

 

 

 

 

 

 

The final result looks like this.  Note that food enters the tiny stomach pouch, and exits through a small hole into the small intestine, which has been moved up, behind the lower stomach and large intestine, to be connected.  The lower, larger stomach pouch no longer receives any food, but still has a blood supply and is able to secrete digestive juices, which can leave by the same route as they always have, through the connection at the lower end (the "pylorus"), to pass down the duodenum, to the Y-connection just a few inches downstream.  All the food and digestive juices still travel through about 25 feet of small intestine, where absorption is essentially complete.  However, the small size of the stomach pouch makes one feel full quickly, while the food entering the upper small intestine causes a sense of satisfaction and indifference to further eating - the "Who Cares?" feeling.  

 

       Here's what the final operation looks like, when complete.                                                                                     

 

 

 

 

 

 

Testing and Tidying Up:

Once all the connections are made, we test the upper one by inflating the stomach pouch with air from above, and looking for air bubbles while the connection is submerged under rinse water in the abdomen.  The abdomen is rinsed out and tidied up, a small drain tube is put in place, the ports are removed, and the operation is over.

All drawings courtesy of Ethicon Endosurgery, Inc.

 


Frequently Asked Questions

What is the youngest patient you can operate upon?

We have performed surgery on patients as young as 16 years of age. In this age group, we are concerned that the patient make the decision for surgery him- or her-self, and that there be a full understanding and commitment to the altered eating pattern which will be necessary for success.

What is the oldest patient you can operate upon?

Patients over 65 require very strong indications for surgery, and must also meet MediCARE criteria, which are stringent. The risk of surgery in this age group is increased, and the benefits, in terms of reduced risk of mortality, are reduced. In many instances, this argues against the surgery.

What are the routine tests before surgery?

We always do certain tests: a Complete Blood Count (CBC), Urinalysis, and a Chemistry Panel, which gives us a readout of about 20 blood chemistry values. We do a Glucose Tolerance Test to evaluate for diabetes, which is very common in overweight persons, and frequently is undiagnosed. Most persons, except the very young, get a Chest X-Ray and an Electrocardiogram. We do a vaginal ultrasound (women only), to look for abnormalities of the ovaries or uterus, and a gallbladder ultrasound (everybody) to look for gallstones. Other tests which we frequently order when indicated include Pulmonary Function Testing, Echocardiogram, Sleep Studies, GI Evaluation, or Cardiology Evaluation.

What is the purpose of all these tests?

Primarily, we need an accurate assessment of your health, before undertaking a big operation. The best way to treat a complication is to never have it in the first place, due to advance knowledge.

We want to know if your thyroid function is adequate (hypothyroidism can lead to sudden death post-operatively), if you are diabetic (we will have to take special steps to control your blood sugar), if your heart is sound (surgery increases cardiac stress). We look for signs of liver malfunction, breathing difficulties, excess fluid in the tissues, abnormalities of the salts and minerals in body fluids, and abnormal blood fat levels.

Why do I have to have a GI Evaluation?

Patients who have significant gastrointestinal (GI) symptoms such as upper abdominal pain, heartburn, belching sour fluid, may have serious underlying problems, such as a hiatus hernia, gastroesophageal reflux, or a peptic ulcer. For example, many patients have symptoms of reflux, and we know that up to 15% of such persons may have early changes in the lining of the esophagus which could predispose to cancer. It is important to identify these changes, so that a suitable surveillance program can be planned for the future.

When our doctors detect GI symptoms on your preliminary evaluation, we ask that you have an evaluation before surgery, so that we can take care of them at the same time, and avoid complicating surprises at surgery.

Why do I have to have a Sleep Study?

The sleep study detects a tendency for abnormal cessation of breathing, usually associated with airway obstruction when the muscles relax during sleep. This condition is associated with a high mortality rate, just during ordinary living. After surgery, you will be sedated, and will be receiving narcotics for pain, which also depress normal breathing drive, and reflexes. At that time, airway obstruction becomes even more dangerous, and we need to have a clear picture of what to expect, and how to handle it.

Why do I have to have a Psychiatric Evaluation?

We do not believe that people with weight problems are crazy! When our office asks for a psychiatric evaluation, by far the most common reason is that your insurance company has required it, or we already know that they usually do, and we are trying to shorten the process for you. Normally, we ask the psychiatrist to evaluate for understanding and knowledge, and ability to follow the basic recovery plan. Very few persons are disqualified by the psych evaluation, it is usually painless, and it may be very helpful to you in defining your goals and your decision.

Insurance Issues

How long does it take to schedule surgery?

We can ordinarily schedule surgery within about 2 - 3 weeks, once financial arrangements are made. Insurance approval is a pre-requisite for many persons. When we obtain approval, we contact you to determine if, and when, you wish to schedule surgery. From that time, surgery can be done in 2 - 3 weeks, or at your convenience (we recommend that you do not wait more than about 90 days, or re-approval may be needed).

Why does it take so long to get insurance approval?

From the time when your telephone interview consultation is completed, it usually takes us 1 - 2 days to send a letter to your insurance carrier, to start the approval process. The time it takes to get an answer can vary, from about 3-4 weeks, to as long as they can dawdle without being asked. Our insurance analysts try to follow-up regularly on approval requests, and each telephone call can consume several minutes of frustrating waiting, just to get through. Try calling the claims service of your insurance company yourself, about a week after your letter is submitted, and ask them what the status of your request is – our insurance analysts do that all day long.

We are trying to speed up our process, and have added several new analysts in our office. It really does help, when you get behind the process and call your carrier regularly to inquire.

How can they deny insurance coverage for a life-threatening disease?

Coverage may be denied because there is a specific exclusion in your policy for obesity surgery, or "treatment of obesity", which is manifestation of the attitude of our society toward obesity, and the discrimination which obese persons suffer. Such an exclusion can often be attacked, by the reasoning that the surgical treatment is recommended as the best therapy for the co-morbidities, which usually are covered.

Coverage may also be denied for lack of "medical necessity". A therapy is deemed to be medically necessary when it is needed to treat a serious or life-threatening condition. In the case of Morbid Obesity, alternative treatments are considered to exist – according to conventional wisdom – such as dieting, exercise, behavior modification, and some medications. Usually, medical necessity denials hinge on the insurance company’s demand for some form of documentation, such as 1 to 5 years of physician-supervised dieting or a psychiatric evaluation. The best approach to these demands is to try to produce reasonable information. Once you have successfully jumped over all the obstacles, it is more difficult for you to be denied.

What can I do the help the process?

First, help us to get all the information (diet records, medical records, medical tests) together in your case, so the carrier cannot deny for failure to provide "necessary" information. Letters from your personal physician and consultants, attesting to the "medical necessity" of treatment, are particularly valuable – when one or several physicians corroborate the necessity of treatment, it will be hard for the carrier to contradict them.

When the letter is submitted, call your carrier regularly (about once a week), to ask about your status. You may also be able to protest unreasonable delays through your employer or human relations/personnel office.

Surgery

Does Laparoscopic Surgery decrease the risk?

No.  Laparoscopic operations carry the same risk as the similar procedure, performed as an open operation.  The benefits of laparoscopy are typically, less discomfort, shorter hospital stay, earlier return to work, and much reduced scarring.  

How long does the operation last?

Typically, the gastric bypass or the gastric banding requires a total time in the operating room of 2 - 3 hours – the operation itself takes 1½ to 2½ hours. If your family will be waiting, they should understand that the operation may not begin immediately, so they should not watch the clock. If the operation is lasting longer, the doctor may be able to send word.

Will I have a lot of pain?

We try very hard to control pain after surgery, to make it possible for you to move about quickly, and become active, which helps avoid problems and speeds recovery. We use several drugs together, and a system called Patient Controlled Analgesia (PCA), which allows you to give yourself a dose of pain medicine on demand, whenever you need it. Most of our patients are pleasantly surprised at how little discomfort they experience.

How long do I have to stay in the hospital?

As long as it takes to be self-sufficient. Typically, the hospital stay (including the day of surgery) is 1 day for a Laparoscopic Band, 2 days for a Laparoscopic Gastric Bypass, and 3 days for an Open Gastric Bypass.

Do you use a drain.

Most patients will have a small tube to allow drainage of any accumulated fluids from the abdomen. This is a safety measure, and can be removed a few days after the surgery. It produces no more than minor discomfort.

How soon will I be able to walk?

Almost immediately after surgery. Patients walk or stand at the bedside on the night of surgery, and take several walks the next day and thereafter. On leaving the hospital, you will be able to care for all your personal needs, but will need help with shopping, and with transportation.

How soon can I drive?

We recommend that you do not drive until you have stopped taking narcotic medications, and can move quickly and alertly to stop your car, especially in an emergency. This is for your own safety, and that of others on the road. Usually this takes 7 -14 days after surgery.

When can I leave the area?

Patients who come from outside the San Diego area for surgery are required to remain in the vicinity for 10 days after the day of surgery. There are important educational sessions, as well as post-operative tests and X-Rays, that must be done during this time. Most patients stay at a nearby hotel (our office has a list), or sometimes with relatives or friends in the area.

Life After Surgery

Can I drink carbonated beverages after surgery?

Many centers advise against this. We do not, and believe that they will not harm you, or your operation. Many patients do find carbonated beverages uncomfortable, from the gas they produce.

We do recommend that you avoid any flavored drinks between meals, such as diet soda, coffee and tea – use of these tends to activate your hunger mechanism.

Why can’t I eat red meat after surgery?

You can, but you will need to be very careful, and we recommend that you avoid it for the first several months. Red meats contain a high level of meat fibers, or gristle, which hold the piece of meat together, preventing you from separating it into small parts when you chew. It can plug the outlet of your stomach pouch, and prevent anything from passing through, which is very uncomfortable.

What is Dumping Syndrome?

Dumping syndrome is caused by eating sugars, or other foods which contain many small particles, on an empty stomach. These substances produce a high osmotic load. Your body handles these by diluting the food particles with water, which reduces blood volume, and causes a shock-like state. Sugar may also induce insulin shock, due to the altered physiology of your intestinal tract. The result is a very unpleasant feeling, as you break out in a cold clammy sweat, turn pale white, feel butterflies in your stomach and a pounding pulse. This may be followed by cramps and diarrhea. This state can last for 30 - 60 minutes, and is quite uncomfortable – most have to lie down until it goes away. It can be avoided by not eating the foods which cause it, especially on an empty stomach. A small amount of sweet, such as fruit, is well-tolerated at the end of a meal.

What is the problem with milk products?

Milk contains a special sugar, called lactose, or milk sugar, which is not well digested. This sugar passes through undigested, until bacteria in the lower bowel act on it, producing irritating byproducts, as well as gas. Depending on individual tolerance, some persons find even the smallest amount of milk or milk sugar will cause cramps, gas and diarrhea.

What do I do to use the Gastric Bypass "tool" successfully?

The basic rules are simple, and easy to follow:

When each meal is satisfying, this is not a diet, but a style which you can easily achieve, and which will result in rapid weight loss followed by weight maintenance. 

Why can’t I snack between meals?

Snacking is the worst thing you can do to your weight control process. Snacking, nibbling or grazing on foods, usually high-calorie and high-fat foods, can add hundreds of calories a day to your intake, while defeating the restrictive effect of your operation. Since most snacking is done out of impulse, hunger-limitation or satiety has a limited effect in preventing it. Snacking will definitely slow down your weight loss, and can lead to late regain of weight (usually not all of it, unless you get really ridiculous). Snacking is also a habit, which is easier to avoid, than to stop once it is started.

If you start snacking after a while, and notice the bad effects, we’ll help you to stop. It’s a lot easier, and more rewarding, never to start.

Why drink so much water?

When you are losing weight, there is a heavy load of waste products to eliminate, mostly in the urine. Some of these substances tend to form crystals, which can cause kidney stones. A high water intake protects you, and helps your body to rid itself of waste products efficiently, promoting better weight loss.

Water will also fill your stomach, and will help to prolong and intensify your sense of satisfaction with food. If you feel a desire to eat between meals, it is because you did not drink enough water in the hour before.

What’s so important about exercise?

When you have a Gastric Bypass, you lose weight because the amount of food energy (calories) which you are able to eat is much less than your body needs to operate. It has to make up the difference by burning reserves, or unused tissues. Your body will burn any unused muscle first, before it begins to burn the precious fat it has saved up. If you do not exercise daily, your body will consume your unused muscle, and you will lose muscle mass and strength. Daily aerobic exercise for 20 minutes will communicate to your body that you want to use your muscles, and force it to burn the fat instead.

The idea of having an operation is to become slender and healthy, not skinny and weak. If you lose most of your excess fat, and retain most of your muscles, imagine how much power and energy you will have, to enjoy your new life!


References

Gastrointestinal Surgery for Severe Obesity. Consensus Development Conference Panel, National Institutes of Health. Ann Int Med 115: 956-961, 1991.

Methods for Voluntary Weight Loss and Control. NIH Technology Assessment Conference Panel Ann Int Med 116: 942-949, 1992.

Health Implications of Obesity. Consensus Development Panel, National Institutes of Health. Ann Int Med 103: 1073-1077, 1985.

Laparoscopic Gastric Bypass, Roux en-Y: Preliminary Report of Five Cases. Wittgrove AC, Clark GW & Tremblay LJ Obesity Surgery 4: 353-357, 1994.

Laparoscopic Gastric Bypass, Roux en-Y: Experience of 27 Cases, with 3-18 Months Follow-up. Wittgrove AC & Clark GW. Obesity Surgery 6: 54-57, 1996.

Laparoscopic Gastric Bypass, Roux en-Y: Technique and Results in 75 Cases with 3-30 month follow-up. Wittgrove AC & Clark GW. Obesity Surgery 6:500-504, 1996..

Body Weight and Mortality among Women. Manson JE, Willett WC, Stampfer MJ, et. al. NEJM 333: 677-685, 1995.

Gastric Surgery in Morbid Obesity: Outcome in Patients 55 Years and Older. McGregor AMC, Rand CSW. Arch Surg 128: 1153-1157, 1993.

Why Does the Gastric Bypass Control Type 2 Diabetes Mellitus? Pories WJ Obesity Surgery 2:303-313, 1992.

Is Type II Diabetes Mellitus (NIDDM) a Surgical Disease? Pories WJ, MacDonald KG, Flickinger EG et al Ann Surg 215:633-643, 1992.

The Gastric Bypass Operation reduces the progression and mortality of non-insulin dependent Diabetes Mellitus. MacDonald KG, Jr., Long SD, Swanson MS, Brown BM, et alJ Gastrointestinal Surg 1:213-220, 1997.

Coexistence of Gallbladder Disease and Morbid Obesity. Calhoun R & Willbanks O Am J Surg 154:655-658, 1987.

Nutritional Status seven years after Roux-En-Y gastric bypass surgery Avinoah EA, Ovnat A & Charuzi I Surgery 111:137-142, 1992.

Obesity. Part I - Pathogenesis Bray GA & Gray DS West J Med 149:429-441, 1988 (77 refs)

Obesity Part II - Treatment Bray GA & Gray DS Western J Med 149:555-571, 1988 (109 ref)

Excessive Mortality and Causes of Death in Morbidly Obese Men Drenick EJ et al. JAMA 243:443-445, 1980

A Twin Study of Human Obesity. Stunkard AJ, Foch TT & Hrubec Z. JAMA 256:51-54, 1986

An Adoption Study of Human Obesity. Stunkard AJ et al. NEJM 314:193-198, 1986.

The Body-Mass Index of Twins Who Have Been Reared Apart. Stunkard AJ et al. NEJM 322:1483-1487, 1990

A Prospective Study of Obesity and Risk of Coronary Heart Disease in Women Manson JE, et al. NEJM 322:882-889, 1990

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