Stomach reduction procedures are effective in suppressing the body's ability to produce Ghrelin, the hormone attributed to hunger and weight gain.


Scientists and researchers have discovered that the hormone responsible for stimulating the human appetite, Ghrelin, has been reduced and even neutralized by bariatric surgical procedures like vertical gastrectomy , (also known as sleeve gastrectomy), gastric bypass and duodenal switch .


Most of the hormone Ghrelin is produced in the stomach, and scientists believe that it evolved to fight weight loss in the human body. Professor Stephen Bloom, a British obesity researcher, describes it this way: "We are machines designed to live through famine. We are survivors of the obese. All we need is a plentiful supply of food and we gain weight. That's the way we are made and how we evolved."


To combat this predisposition to weight gain, bariatric surgical procedures have become popular in helping counteract the debilitating effects of obesity. Bariatric surgeons like Dr. Paul Cirangle, of Laparoscopic Associates of San Francisco, have seen the effects of neutralizing Ghrelin firsthand. "We have discovered that, after performing a vertical gastrectomy and other stomach reduction procedures, the Ghrelin levels have decreased dramatically within 24 hours of the stomach being removed. We consider this proof that surgery can favorably alter the hormonal drive to eat and allow individuals to lose large amounts of weight without feeling hungry."


Researchers found elevated levels of Ghrelin in people who lost weight through dieting whenever they were measured for it, leading them to conclude that the body was signaling its owner to eat more in order to gain back lost weight. This conclusion has lent additional credence to the surgical option for obese people searching for a long-term solution to losing weight and keeping it off.


The reduction of Ghrelin levels from vertical gastrectomy and other bariatric procedures has captured the attention of scientists around the world who are striving to find the magic bullet to the obesity epidemic. Controlling the way the body produces Ghrelin, through surgery and medical research, may hold the key to the future of fighting an ever-increasing worldwide disease.

Posted on: Sunday, 29 April 2007, 09:00 CDT

Popular, but Private Insurers Are Sometimes Reluctant to Cover Them.
By Julius A. Karash, The Kansas City Star, Mo.


Apr. 29--After nearly 30 years of failed dieting attempts, well-known
Kansas City chef Jasper Mirabile Jr. was desperate to lose weight.


The co-owner of Jasper's Italian restaurant was 5 feet, 7 inches tall
and weighed 280 pounds. His feet and legs hurt, and his cholesterol
was sky-high.


So last August, Mirabile underwent weight loss reduction surgery at
Weight Loss Surgical Center, which opened last year in Overland Park.
Now 44, he's happy about dropping 45 pounds and losing his pains
along with the fat. He aims to slim down to 190 in the next 12 to 14
months.


But Mirabile is not happy about having to pay for the $15,000
procedure out of his own pocket. He said his health plan, a Humana
PPO, refused to cover the operation.


"I asked them if they would cover it and I was turned down," Mirabile
said. "They said I wasn't overweight enough to be considered. I was
disappointed. But my medical conditions were at the point where my
weight was affecting my life. I just figured I'll pay for it myself."


Mirabile's lack of health insurance coverage for this increasingly
popular weight loss surgery -- also known as bariatric surgery -- is
not unusual. While Medicare broadened its coverage last year to
include more types of procedures, some private health insurers won't
pay for bariatric surgery or cover it under very limited
circumstances.


The surgery is expensive. Locally the cost can range from about
$14,000 to $23,000, depending on the type of procedure, said surgeon
C. Thomas Hitchcock with the Bariatric Center of Kansas City, which
is on the campus of Shawnee Mission Medical Center.


"We have a huge number of people on our waiting list, pending
approval by their insurance company," Hitchcock said. "Insurance
companies are very slow to certify these patients."


Yet while the patient backlog builds, America is reeling from a
flurry of reports that point to a national epidemic of obesity and
resulting fallout. The Rand Corp., a California-based nonprofit
research institution, said recently that according to 2005 data, more
than one in five U.S. adults was classified as obese based on self-
reported weight. Nearly one out of three was obese based on
objectively measured weight.


The Rand study found that obesity is associated with more chronic
medical conditions than smoking or problem drinking.


Last week, researchers announced plans for a federally funded study
of the benefits and risks of bariatric surgery on adolescents. Also
last week, Duke University Medical Center reported that obese workers
filed twice the number of workers' compensation claims, had seven
times the medical costs from those claims and lost 13 times more days
of work from work injury or work illness than did workers who were
not obese.


"We all know obesity is bad for the individual, but it isn't solely a
personal medical problem -- it spills over into the workplace and has
concrete economic costs," said physician Truls Ostbye, a Duke
professor of community and family medicine.


Susan Pisano, a spokeswoman for the industry trade group America's
Health Insurance Plans, said coverage of weight loss surgery varies
widely among insurers.


"Right now there is a substantial amount of coverage for it, but it's
not universal," Pisano said. "It's good to try other things before
settling on a major surgery with life-altering implications."


Blue Cross and Blue Shield of Kansas City, the area's largest health
insurer, does not usually cover such procedures but is thinking of
expanding its coverage.


Even if insurance companies provide coverage, they may require six to
12 months of dieting before they give the green light, Hitchcock
said. "It just slows things down," he said. "Diets fail."


Some experts question whether bariatric surgery can adequately
address the growing epidemic of obesity. Even surgeons such as
Hitchcock point out that surgery is not the answer for every person
who suffers from obesity. Patients must be in reasonably good health,
both physically and mentally, and they must say goodbye to
overeating.


The operations are not foolproof, and some patients find a way
to "outeat" their procedures by frequently eating small portions of
high-calorie food.


Surgery choices

When Mirabile decided to have weight loss surgery, he joined the
ranks of a big trend in health care.


The number of Americans opting for bariatric surgery jumped from
13,386 in 1998 to 121,055 in 2004, according to the federal Agency
for Healthcare Research and Quality. Experts estimate that as many as
200,000 of the procedures were performed in 2006.


The impact is apparent in the Kansas City area, where several
bariatric surgery programs have begun in recent years. One of the
newest facilities is St. Luke's Center for Surgical Weight Loss,
which was established at St. Luke's Hospital last year.


"This is the answer for the majority of obese patients," said surgeon
John Price, head of the St. Luke's program.

Health providers use a height- and weight-based calculation known as
body mass index to determine whether a person is overweight or obese.
Bariatric surgery is usually considered if a patient has a BMI
exceeding 40, or a BMI greater than 35 if accompanied by medical
conditions such as diabetes.


A person who is 5 feet, 8 inches tall and weighs 230 pounds has a BMI
of 35, and a person of the same height who weighs 263 pounds has a
BMI of 40, according to the federal Centers for Disease Control and
Prevention. (To figure your own body mass index, check the BMI
calculator at www.cdc.gov.)


Two of the most common types of bariatric surgery performed today are
the Roux-en-Y Gastric Bypass and laparoscopic gastric banding , also
known as the lap-band.


With the Roux-en-Y, the surgeon creates a pouch out of a small
portion of the stomach and attaches it to the small intestine,
bypassing a large part of the stomach and the first part of the small
intestine, known as the duodenum. The resulting stomach pouch is too
small to hold large amounts of food, and bypassing the duodenum
substantially reduces the absorption of fat.


The lap-band procedure uses an adjustable gastric band to create a
small pouch in the upper part of the stomach, which limits food
intake.


"With the Roux-en-Y, the change is dramatic," Hitchcock said. "It's
overnight. With the band, it's a gentler transition."


Mirabile had the lap-band operation.

"I still have a craving for sweets but I don't feel as hungry," he
said.


Jeff Blunt, a Humana spokesman, said federal patient privacy laws
prohibit him from commenting on Mirabile's insurance coverage issues.


However, Blunt said, bariatric surgery is excluded from Humana
employer group coverage unless employers purchase an
additional "rider," or add-on, that covers the surgeries.


"The vast majority (of employers) choose not to purchase the
coverage," Blunt said.


Coverage issues

Stephanie McBee, who lives in the Stilwell area of southern Johnson
County, had Roux-en-Y surgery in late 2005 at the Bariatric Center of
Kansas City.


McBee, a registered nurse, was working for North Kansas City Hospital
at the time. She learned in November 2005 that the hospital planned
to drop employee coverage for bariatric surgery on Jan. 1, 2006.


"I was just sick" upon hearing the news, McBee recalled. But she had
gotten in the pipeline for the surgery in August and completed all
the requirements in time to have the procedure done on Dec. 27, five
days before the cutoff. Without the coverage, she said, she would
have had to fork over $30,000 to $35,000.


"If my insurance hadn't paid for it, I wouldn't have been able to pay
for it," said the 37-year-old McBee, who has lost 97 pounds since her
surgery and now weighs 168 pounds.


When asked about McBee's coverage experience and the hospital's
current stance on such coverage for employees, North Kansas City
Hospital issued this statement from Beverly Johnston, vice president
of human resources: "Due to published and documented complications
with these types of procedures, we've chosen not to cover them or
related maintenance charges for weight reduction."


But all surgeries carry risks, and there are indications that
bariatric surgery is becoming safer. In January, the agency said the
national inpatient death rate associated with bariatric surgery had
declined from 0.89 percent to 0.19 percent between 1998 and 2004.


Furthermore, proponents of bariatric surgery say it helps reverse
dangerous medical conditions that frequently accompany obesity, such
as diabetes and high blood pressure.


Neil Hutcher, a Virginia bariatric surgeon and immediate past
president of the American Society for Bariatric Surgery, said he
thinks insurance companies are afraid of "opening up the floodgates
of patient demand."


Such fears are unfounded, Hutcher said. He said about 15 million
Americans could benefit from the weight loss surgery, but surgeons
can't get to them all.


Blue Cross review

Despite the resistance of some insurers, the numbers and anecdotal
evidence indicate that more patients have been having bariatric
surgery and getting it covered.


The biggest jump in surgeries between 1998 and 2004 was for patients
with private health insurance, the Agency for Healthcare Research and
Quality said.


Medicare last year broadened its coverage to include more types of
procedures, but it will only pay for bariatric surgery in cases that
include related medical problems.


In addition, Medicare will only pay for bariatric surgeries performed
at facilities certified by the American College of Surgeons and/or
the American Society for Bariatric Surgery, such as the Bariatric
Center of Kansas City.


Officials with Blue Cross and Blue Shield of Kansas City said it does
not cover weight loss reduction surgery except in cases involving
certain self-funded employer groups.


"One of the things we strive for is keeping the price of insurance
affordable," Blue Cross spokeswoman Susan M. Johnson said.

"Bariatric surgery is very expensive. Complications are not uncommon,
and they can be very expensive."


But physician Blake Williamson, Blue Cross vice president and senior
medical director, said the insurer is reviewing its stance and
considering whether to broaden its coverage.
"We should have a decision on that in the next couple of months," he
said.


Meantime, even proponents such as Hitchcock say that the decision to
undergo bariatric surgery shouldn't be made lightly.

"The surgery is not a cure, it's a tool," he said. "They have to be
intellectually, physically and emotionally prepared."

------

Thinking ahead

As numerous reports point to a national obesity epidemic, more
consumers are opting for weight loss surgery.


--According to the federal Agency for Healthcare Research and
Quality, the number of Americans choosing bariatric surgery rose from
13,386 in 1998 to 121,055 in 2004. Experts estimate that as many as
200,000 of the procedures were performed in 2006.


--The average cost of the most common bariatric surgery can vary from
about $14,000 to $23,000, though costs of up to $30,000 to $35,000
have been reported. Coverage varies widely from one health insurance
plan to another.


--Health providers use a height- and weight-based calculation known
as body mass index to determine whether a person is overweight or
obese. Bariatric surgery is usually considered if a patient has a BMI
exceeding 40, or a BMI greater than 35 if accompanied by medical
conditions such as diabetes.

Matt Bush, Online Content Producer
Created: 4/30/2007 9:36:05 AM
Updated: 4/30/2007 1:57:27 PM

Printer Friendly Version

Yoga can do more than help increase your flexibility and reduce
stress. It can also help patients who've had weight loss surgery
connect with their new bodies.


Yoga can do more than help increase your flexibility and reduce
stress. It can also help patients who've had weight loss surgery connect with
their new bodies.


Some are turning to bariatric yoga, a new spin on a centuries-old
practice. Karleen does yoga any chance she gets. It's a dramatic change for a
woman who never used to exercise.


The difference now is Karleen is more than 70 pounds lighter, thanks
to lap band surgery and a new yoga class designed for people who've
had weight loss surgery.


Karleen says, "We're all pretty much at the same level and we don't
feel intimidated by the tiny little skinny people that can do
everything and bend into a pretzel."


Karleen is showing off the moves she learned from the bariatric yoga
class she takes twice a week at Good Samaritan Hospital in San Jose,
California.

Anesthesiologist and yoga master Dr. Mathew Cook teaches the class.
Dr. Mathew Cook says, "The combination of the mindfulness in yoga and
then the meditation -- what it does is it brings you really into a
place of feeling like you can take on the world, you can engage, you
can be in your body, you can do things. And I think people do much,
much better when it's not just a physical aspect."


Karleen says because meditating helps her relax, she's cut back on
stress related snacking. She has more energy too. Karleen says, "We work a lot on balance so I'm more flexible, I'm able to do other exercises."
These moves have helped her lose 101 inches in a year.


Karleen says, "I never feel I can't do that and don't even want to
try. I always feel really good. I leave really rejuvenated. "

NBC /

The duodenal switch (DS) is a variation of the biliopancreatic diversion and also works primarily by malabsorption.

The operation can be performed as an open operation through a midline incision from the base of the breastbone, or laparoscopically. Technically it is a complex operation which can take 5–7 hours to complete, and will usually require a post–op hospital stay of 4–6 days.

A large portion of the stomach is removed by dividing it lengthways along the inner curve (called a sleeve gastrectomy) and the pyloric valve at the bottom of the stomach (which regulates how quickly to stomach contents empty into the small intestine) is left intact. This means that although the food holding capacity of the stomach is reduced, its function remains intact.

A short segment of the duodenum at the base of the stomach is left but the remainder cut and the second half of the small intestine bought up and joined to the duodenum (this part of the operation is very similar to a RNY gastric bypass but is slightly lower down in the digestive tract).

Then, as in the BPD operation, the bypassed section of small intestine is then rejoined to carry bile and pancreatic juices to the latter part of the small intestine near where it joins the large intestine (colon).

Digestion and absorption of fat depends on it mixing with bile (from the liver and normally entering the duodenum). As this mixing does not occur until much further on in the intestine after a DS, the body's ability to digest and absorb calories from fat is severely reduced. As a result weight drops, even when eating quite normally.

Of all the operations, DS is associated with the greatest weight loss (after 2 years 80% of patients have achieved normal weight). However, the risks and side effects are also higher with a DS than with other operations.

The risk of death from surgery is the same as a RNY gastric bypass at 1 in 100 operations. However, about 30% of patients experience major problems with offensive wind and diarrhoea, resulting from the undigested fat and the upset to the normal balance of bacteria in the intestines. This can be minimised by following a low fat diet.

As well as preventing the absorption of fat and calories, the DS also hampers absorption of protein and essential minerals and vitamins such as iron, zinc and Vitamins A, D E and K. This can lead to a life threatening condition called protein–calorie malnutrition. Unfortunately, without regular follow up this condition can creep up and overwhelm the patient before anything can be done to correct it.

To avoid this happening, as well as taking vitamin and mineral supplements, DS patients need to take double the normal intake of protein in their diet for the rest of their life. For this reason a good multi–disciplinary team, and a patient committed to complying with diet, supplement instructions and to attending appointments are both vital ingredients to successful outcomes with this surgery.

Resource: http://bospa.org

A Safe and Effective Surgical Weight-Loss Procedure for Highest-Risk Patients:
A relatively new procedure, the Vertical Gastrectomy/Gastroplasty was developed to minimize postoperative complications for our highest-risk patients. It is ideal for older patients (>50 years old) and extremely obese patients (BMI>50), due to excellent weight loss and minimal incidence of complications or postoperative problems.

How the operation works:
1) The surgeon staples the stomach vertically, removing the part of the stomach responsible for storing the majority of food and causing patients to get hungry.

2) The surgeon then removes about 90-95% of the stomach, leaving a small, thin, tube-like stomach with a capacity of about 2 ounces (50-60cc).
This procedure generally takes about 90 minutes to perform. Patients can expect a hospital stay of 1-3 days after this type of weight-loss surgery and the ability to return to work and normal activities very quickly.

Vertical Gastrectomy Works Safely and Quickly:
Large and rapid weight loss and very few complications - even in patients weighing 500 pounds or more - make VG weight-loss surgery a smart choice for many patients. On average, patients lose 1/2 to 1 pound or more per day after this surgery; we have witnessed weight losses of more than 250 pounds in a year.

Because there is no malabsorption or rearrangement of the intestinal tract, vitamin deficiencies or nutritional problems are almost non-existent after this procedure.

Post-Op Dietary Plan for the Vertical Gastrectomy:
Following surgery, it is imperative that VG patients adhere to a strict postoperative diet. Patients are placed on a liquid-based diet for 2 weeks after surgery; 4-6 weeks after the operation, they graduate to a 600-800 calorie/day solid diet. Most patients can consume about 1000-1200 calories per day once their goal weight is achieved (usually 1-2 years after surgery).

Long-Term Results with Vertical Gastrectomy Weight Loss Surgery:
Patients who undergo Vertical Gastrectomy surgery experience a 70-80% loss of excess weight, on average.

Consider VG Weight-Loss Surgery:
Is Vertical Gastrectomy right for you? First, determine your Body Mass Index, then learn more about the specific requirements and benefits of each type of bariatric surgery we offer.