Monday, March 03, 2008

If the RNY is so risky, why do they keep doing it?

I recently received a very thoughtful comment by someone researching WLS and decided that since many other folks may have similar questions, I would try to address the issues this individual raised.

First, Daisy asks:
If RNY is so harmful to the organism why do doctors still continue to indicate it?
The answer here is not a simple one so bear with me.

First, those who advocate the RNY are often those who are not involved in the long term follow up of their patients (most RNY follow up is done by Emergency Rooms, hospitalists and gastroenterologists). These individuals are impressed by the early results and may not be aware of the long term results (which admittedly are hard to ferrit out due to the lack of long term studies and the unavailability, for whatever reason, of many patients after 5 or 10 years). They also may feel that even though the vitamin deficiencies which cannot be supplemented, may shorten the lives of RNY patients, that untreated obesity, may shorten their lives even more.

Many surgeons answer the longevity question (i.e. how long you live after a gastric bypass) as Dr Wittgrove of the Alvarado Clinic did in the online interviews at the time of Carnie Wilson's gastric bypass:

Question: Dr. Wittgrove, I really need to know about how this surgery will effect me when I am old (70, 80 and 90's)

Dr. Alan Wittgrove: Hopefully you will live that long..... People who are morbidly obese don't have long life spans... Ideal body weight tables were based on actuarial data.... It is commonly known that people who are morbidly obese die earlier than those who are not morbidly obese.
One study by Dr David Flum which was delivered before a group of obesity surgeons but for some reason, never published in peer reviewed journals, which carefully examined 62,000 hospital records of RNY patients, did find an alarmingly high death rate in these patients. The researchers found that 1 in 50 RNY patients die within 30 days of surgery. And another 3-9 percent (depending on age and other factors) die within the first year. But when Flum and associates compared this to a group of 2000 obese patients who had been hospitalized for other reasons, they found a slightly higher death rate in the obese patients than in the RNY and concluded that, risky as the RNY was, the risk may be higher for untreated obesity.

The problem with that conclusion, as having been pointed out by several other researchers, was that comparing the RNY patients to any critically ill patients, even slim ones, would have yielded a similar result that is, it is predictable that among critically ill patients of any weight, the death rate will be higher than among healthy fat people who are in the hospital to have WLS. (report delivered to the College of surgeons in Oct 21, 2003.[Study title: The Impact of Bariatric Surgery on Patient Survival: A Population-Based Study]

It is unknown whether obesity really shortens your life or not, although lifestyle factors i.e. amount of exercise, quality of diet, stress factors may have an effect on health and even how long you live regardless of what you weigh.

For as many epidemiological studies which are available which suggest that obesity does effect longevity, there are an equal number of epidemiological studies which suggest that obesity alone does not affect your lifespan.

And the few clinical studies we have available, suggest that lifestyle alone is what seems to affect lifespan and health regardless of what someone weighs and also that obesity alone doesn't seem to have that much effect, one way or another on lifespan or even health.

This story of what science really says about obesity is not seen in the media because, perhaps the media is more "marketing oriented".

The second reason why some surgeons continue to advocate the RNY may be because the public is demanding quick weight loss at any cost. It is true that some patients, even those who are very ill from the repercussions of the RNY, are still happy to not be fat anymore due to the societal pressures on the overweight population. It is also a fact that because of the massive healing internally after the digestive tract has been so drastically (and yes, permanently) rearranged, takes about a year and during that year, that, and also that patients find it somewhat uncomfortable to eat at all (food getting stuck, vomiting etc), often causes early post op RNY patients to lose their appetites - these end up eating very few calories a day i.e. 300-500 and some of what they eat is not absorbed. This is why some surgeons called the RNY "surgically induced anorexia" The idea of not having an appetite and the weight dropping off quickly and easily, is of course, highly attractive to folks who have struggled with diets for many years. However, those RNY patients in the 3rd and 4th year often end up on the same diets which didn't work before only the years of fasting and semi fasting have greatly lowered their metabolism.

Many people can read the informed consent information, can read the testimonies of patients who are extremely ill for life from WLS and still request WLS. I personally know of cases where family members have died and the sibs still go ahead with the surgery. This may be a simple case of human nature - what drives many who choose to use tobacco also - the idea that "if it's bad, it won't happen to me."

In this scenario, a better way to make a decision would be to consider all the possibilities and ask if this would be ok with you. That is 'reactive hypoglycemia' - would you be ok if that happened to you? etc.

People want to believe the dream that a surgery can change a fat person into a slim one. However, any surgeon will tell you that the RNY is for making very fat people, somewhat less fat because after the first or second year, most patients experience a rebound gain of 50 percent or more of what they originally lost. Keep in mind that the medical profession considers even a small weight loss as something which will lower health risks.

And the underlying reason why most folks do something about obesity remains "improving looks" although we cover our quest for looks with a thin veneer of "health".

Often the medical profession has advocated unhealthy practices, especially in a field where there is not much research. Classic was the cover of a Journal of the American Medical Association in the 1930's, which featured a photo of a group of doctors smoking cigarettes! Cigarette ads in the 1950's were still featuring medical advocacy of smoking like "more doctors recommend Camels than any other cigarette!"

Even today, many medical providers do not aggressively attack the smoking habit as they do, obesity, despite the fact that the proofs for the dangers of smoking are now, well documented and the proofs for obesity risks are not well documented at all.

Your second question:

have you ever assisted a patient who had complications due to the RNY surgery? And if yes, were these complications caused just because of the procedure itself or did the patients have some previous condition, such as diabetes or high blood pressure or high cholesterol level?
Yes, I have assisted many ill longer term patients and in most cases, their problems were strictly due to the repercussions of their weight loss surgery. Things like "Leaky gut" causing auto immune disorder, bowel obstructions and ulcers in the small bowel due from the leakage of stomach acid (the small bowel does not have a protective covering against acid from the stomach) and those vitamins like calcium which cannot be successfully supplemented resulting in maladies such as osteoporosis etc.

Problems like this are predictable because of the nature of the surgery and are not unknown in the medical profession because there is a long history with a similar surgery done to treat ulcers in the first segment of small bowel. This surgery upon which the RNY was based, is called the "Billroth II" and the mere mention of this procedure causes many medical providers to pale due to the various illnesses resulting from it, however, the surgery was considered preferable to the death which an ulcer in the small bowel would have caused.

It's a no brainer that when a major organ system is so greatly re-arranged as done in the RNY, that there will be serious repercussions from the surgery itself. Those who claim "no repercussions" are never the medical providers but rather those early term patients who are still somewhat concepting the surgery as a "magic bullet".

You further commented:

the floor for sick WLS patients... Why is it such a difficult floor? It takes me a lot to believe that it can be more difficult than a floor crowded with patients who have terminal diseases.
This is hard to understand from the outside but severely modifying such an important organ system so that it works differently can cause painful, terrible suffering. The best way you can get a feel for some of this, is to read the messages on the "gone wrong" group suggested by one of those who commented:

ossg-gone_wrong

This group is rapidly approaching a membership of 2000, many of whom have had dreadful experiences with the RNY.

Another comment of yours:

your campaign against RNY made me think that it is a totally irreversible process and those who submit themselves to it are condemned to live ill for the rest of their life, when this is not true. Complications exist in all kinds of surgeries.
First, can you see where not all surgeries are the same? For instance, the death rate in gall bladder surgery is about 1 in 7000 people - the same as one finds with the lap band.

Secondly, the RNY is irreversible and if you carefully research you will find this to be true. The only procedure they can do with a "gastric bypass gone bad" (as medical providers call it) is to reconnect the small bowel and arrange the organs in a manner similar to the VBG or stomach stapling only. It's kind of a no brainer that you cannot remove 300 staples from a stomach which has been resectioned into 2 pieces.

Third, as for living ill for the rest of their lives, this also is true. Here is a quote from a WLS surgeon who is still doing the RNY:

"By doing this surgery, you're creating a medical disease in the body. Before you expose someone to that risk, you have to be absolutely sure that you are treating an illness which is equal to or greater than the one you are creating."
(Dr Edward Livingston, bariatric surgeon in Self Magazine, 4-2001)
Note his terminology... "medical disease" etc.

it takes me a lot to believe that a doctor would recommend it if he/she was aware that it wouldn't bring any benefits in the future.
You have to realize the manner of thinking in the medical profession and that is, for the moment, not necessarily for the future, for many reasons, one of which is that if a questionable procedure is done now, it is possible that problems occurring in the future will be able to be handled by newer treatments. (and it is true that treatments are being developed daily which are changing the face of medicine).

There is a whole body of research which suggests that people never have to lose weight for health and that any type of losing weight program, even one which seeks a healthy lifestyle, poses some pretty serious risks, especially if done again and again as is the case with 95 percent of the public.

The following blog presents a summary of that research and does provide the cites:

the case against dieting

I hope this has, in part, answered some of your questions and I do invite you to research those websites I have provided.

Further research can be done at:

obesitysurgery-info.com

13 comments:

Rachel said...

Secondly, the RNY is irreversible and if you carefully research you will find this to be true.

I'm not sure if this is what you were referring to, but my good friend just had a procedure done known as the Duodenal Switch (DDS). She frequents a WLS-related board where people who have had RNY and are suffering health complications often post in the DDS forum for information on the surgery. According to my friend, if you have had the RNY, you may still be able to modify the surgery to the DDS, which, as my friend says, carries less of a health risk.

AnnieMcPhee said...

I didn't have time to read all of this before work (what I have read is great though!) but there is also the question - "Why, when they're so dangerous, did doctors do lobotomies?" Answered here: http://junkfoodscience.blogspot.com/2008/01/when-science-was-forgotten-lobotomist.html

SueW said...

Rachel, whether the DS/BPD (duodenal switch) carries less risks than the RNY is not certain although the DS advocates will tell you it's a walk in the park. If they do not have a lot of early complications, they like it because they can continue somewhat overeating and most of what they eat, passes on through. The DS/BPD includes a long limb intestinal bypass and as we have seen with intestinal bypasses of the past, carries its own risks including malabsorption of the fat soluble vitamins and protein absorption problems. Also in the DS/BPD, most of the stomach is removed and thrown in the garbage, leaving a very tiny portion of the stomach so it is not reversible at all and DSers who have problems can only be helped by reconnecting some of the bypassed bowel. This, while giving them more absorption, does not solve problems involved with auto immune disorder etc. In the long term, intestinal bypasses were linked with liver failure. About the DS/BPD, Paul Ernsberger, a professor at Case Western Medical School stated:

*** The BPD and the duodenal switch involve permanent removal of part of the stomach and bypassing of a large amount of intestine. It is more radical than the original intestinal bypass operation that was abandoned many years ago. BPD is associated with horrific side effects including kwashiorkor. It takes several years for the body to be fully depleted of stored nutrients so most likely recent post ops have not been affected yet. DS patients should be followed by a gastroenterologist.

Paul Ernsberger, PhD, Department of Nutrition, Case Western Reserve School of Medicine, 10900 Euclid Ave., Cleveland, OH 44106-4906
****

This surgeon used to do the DS/BPD but now specializes in the Lap band which he feels renders the same weight loss results (or better) without rearranging or discarding any organs in the digestive tract. You might find his website good reading:

drsimpson.net

violet_yoshi said...

I saw a show on Discovery Health about a 500 pound woman named Jackie. I was interested in the whole WLS thing, and since I didn't know anyone personally who went through it, I thought this show would be a good chance to see if what was said on the FA blogs were true.

Pretty much from the moment they discussed the surgery, how she would only be able to eat a cup of food for meals, IF that. I said, "If that doesn't just scream, SURGICALLY INDUCED ANOREXIA!! there, then I don't know what does."

About the fantasy of a surgery to magically make people thin. Rod Serling had an episode from the Twilight Zone called Number 12 Looks Just Like You, which was about the concept of a surgery to make someone look extremely similar to everyone else. This was written in the 50's. It's amazing how Rod Serling was able to forsee things to come. It is disturbing how that episode has come to reality in today's world.

SueW said...

With regards to Jackie (the 500 lb woman), a sequel called "they lost 800 lbs" showed Jackie at 250 lbs, unable to walk anymore due to complications from her gastric bypass, being pushed in a wheelchair by a 400 lb lady who had lost quite a bit but not by surgery but by a healthy lifestyle. I am not sure Jackie is still among the living - either she succumbed ( she had constant nausea and couldn't eat without vomiting) or she got her gastric bypass taken down. Naturally, since she did not portray the bypass in the light they wish to portray it, information about her now, is hard to find.

Jason said...

Found this post from a google search and wanted to post some actual "PEER REVIEWED" studies as counter-point. As a medical researcher you should know better than to present a study not peer reviewed as fact. This is wrong and misleading.

The fact of the matter is that having gastric bypass has dramatically reduced deaths in patients who had the surgery versus patients who didn't! These are in PEER REVIEWED studies, with many patients. http://www.efluxmedia.com/news_Gastric_Bypass_Extends_Life_Expectancy_07960.html

There are complications possible with any surgery and gastric bypass is no different. However, it is indisputable with statistics that the majority of patients are better off having the surgery than not.

Also, there is some interesting research going on right now about longevity. Specifically, why some people live into their 90's and 100's and why some do not. Many studies have shown that animals live longer when they eat, on average, about 30 percent less than normal. http://www.kevinhogan.com/eatless.htm

Also, you severely downplay the health problems of obesity. True you can be obese and be healthy, but if you continue to be morbidly obese you will not be healthy for long. You WILL get diabetes. You WILL have heart problems. These are indisputable.

So please, I am all for giving everyone both sides of the issue but cherry picking data from one source that wasn't even peer reviewed is nothing more than a conditional bias.

SueW said...

Jason, to address your issues which are probably the issues many others have, I have written a new blog. Please read:

Does Gastric bypass lengthen lifespan?"

thanks for your comment,
Sue

~Melissa~ said...

I became anorexic after my RNY bypass, done in Jan. 2001. I had dealt with wt. issues all my life. I've had some form of eating disorder since I was a child. I gained wt. to qualify for the surgery, (approx 30 lbs.)

All my live I wanted to be anorexic. It used to be regarded as a rare "cultural achievement" according to my upbringing.

I would never go back and undo the surgery. However, now, if asked, I suggest the Lapband above all other gastric bypass choices.

I have been considerably ill off & on, since my RNY. My vitamin def.s and malnourishment are serious issues for me.

Because I was not lucky enough to have plastic surgery, my self esteem has been affected in ways that are hard to describe. Amazingly, they are worse than pre-surgery at times. I feel better with my clothes on but I feel like I have a "deformed body now" when I am naked. I have since been dx'd with Body Dimorphic Disorder, which is horrible.

I have had one health problem after another...in my research, (as open-minded as possible character), I believe that all my illnesses have been directly or indirectly negatively affected by my RNY surgery. The worst being dx'd with a "compromised immune system" severe anemia, severe vitamin deficiencies. (I try very hard to take all the supplements but they don't seem to be absorbed as they should, even sublinginguals.)

It's hard to explain how I really feel about all this. I wouldn't go back or reverse my surgery, but I would never recommend the RNY procedure to anymore.

I have been looking desperately for on-line support & cannot find it. If anyone knows of years past their surgery date, forums, or any patient interaction, please comment & let me know where to look. I will come back to ck comments to my post from time 2 time.

Surely I cannot be alone in my experiences???

Thanks for reading my post. I really hope the moderator will allow it to be posted, even though some of what I have said may not be Socially acceptable comments within "the community".

~Moonsinger

SueW said...

Hi again, Melissa, I welcome candid comments like yours - you are so not alone! it's time the "conspiracy of silence" about the "other side" of these procedures is spoken about. Fact remains only a small percentage of gastric bypass patients remain healthy and slim - for most, when the body adapts then they have to fight regain more than they did before surgery or some become so ill that although they are not gaining weight, they all say, they had more of a life when they were at their original weight. And still others become fat and ill. I have posted a couple of support communities under your other comment on the lifespan blog, where you would be very welcome (and candid speech is encouraged). I have a webpage of "testimonials" and wonder if you would like to be included - if so, you are welcome to get hold of me through this blog - just click on my name and it should offer option to send email.

Hugs,
Sue

impendingrapture said...

I got curious about what happened to Jackie after reading this article. It took me almost no time to locate this page,http://www.figure8films.tv/shows/wl8.htm, which appears to have a link to directly contact her. I mention this only because it was mentioned on here that info on her currently is hard to find. All it takes is a few clicks. I have no intentions to contact her so I can't say that the link works, but I would be interested in knowing how her life is this long out of surgery if anyone finds out.

SueW said...

Impendingrapture, Jackie Finley is the one who ended up in a wheelchair after her gastric bypass and if you click through on this page you provided, she is pictured in a wheelchair. Robin did not have bariatric surgery and at the time of the writing of that website you gave, Robin had lost 400 lbs. I saw the show and at the time Jackie was around 200 lbs but sick and malnourished. Robin was around 350 lbs and was pushing Jackie in the wheelchair at the zoo. :(

Shabby Chick said...

I just watched the TLC broadcast of The 627lb. Woman. My heart went out to Jackie, and her struggle. But I just had to comment here that it looked to me based on that they showed in the video, that her surgery results began to fail her first night home after her first procedure; due to extreme infection. Was I the only one that noticed her surgeon adjusting the steps on the floor next to the operating table with UN-GLOVED hands just prior to the surgery then rubbing his UN-GLOVED hand over her belly??? I was not surprised she came home with infection, and because of her size, and just having had major surgery, treating her, and recovery would make her journey that much harder and less successful.

Jackie would have already had compromised health, because of her body size. So to be careless in the area of germs was not wise. Have doctor's forgotten what Louis Pasteur's germ theory proved???

"Pasteur fought to convince surgeons that germs existed and carried diseases, and dirty instruments and hands spread germs and therefore disease. Pasteur's pasteurization process killed germs and prevented the spread of disease".

I think doctors' rely to heavily on the expected course of followup antibiotics.

Jennifer Pague said...

I understand you completely. I had a gastric bypass in July of 2013. Insurance forced me into using a surgeon I didn't know at all. That was the only thing I would change as I feel most of my issues stemmed from his mistakes. I had several complications. Stricture, 2 fistulas, internal ulceration, failed gall bladder 9 EGD with dilation, 4 of which ruptured me, and I spent 6 months on a feeding tube. I went from a size 38 to a 2. I now have problems swallowing, my nutrition is a very delicate balance. I have surgically induced IBS, partial gastric paralysis, Anorexia, Body Dismorphia,and the weight of all the hanging skin against my spine has caused severe back problems that have resulted in considerable pain and a transient Drop Foot condition. Insurance will not pay a dime to remove all the skin. It will take 4 surgeries over 2 years at the cost of $55,000 to deal with that. As much as I hate what this did to my life, I am so terrified of gaining weight that I refuse to do anything that could effect that. This lifestyle unlocked demons I didn't know that I had, and now they are all I know. I feel alone in this most of the time. I know a lot of things are only in my mind, and I use my physical limits as a crutch to feed those behaviors, but I can't exist outside of them anymore. All I am most days is a number on a scale. I know I should seek help, but they will make me gain weight. I'd rather kill myself than ever be 400lb again. Until I had that surgery, I didn't realize how much I really meant that. I like knowing I'm not alone in this world. Thank you for sharing your story.