Dr Wittgrove answers some questions about Carnie's surgery

We all have questions about gastric bypass surgery. Some of these questions were tackled below:

Carnie and her surgeon, Dr Alan Wittgrove answered questions for those signed into the chat. As is usual, most questions did not address health concerns.  What is addressed in the following excerpt are the few questions relating to health issues.

At the time of the chat, Carnie, from her laparoscopic gastric bypass, had lost 45 lbs and was very pleased with the surgery.

Carnie went on to lose to 155 lbs in the year after this interview.  Since the career they promised her if she got "slim" never materialized (despite her being a talented singer and talk show host), she makes a living giving speeches in favor of gastric bypass as well as selling other products, though lately this has been mostly through infomercials and a website which has photos of her taken several years ago before her weight gain.  She appeared last season (2007) on "Celebrity Weight Loss" but has a Youtube out of appearing later that season on a talk show, carrying a plateful of cookies and speaking to being "of size".  She stated that she was 55 lbs heavier than her lowest weight which would make her 210 lbs on the show. She also states she is wearing a very tight body suit.  Although her highest weight (right before surgery) was 298 lbs, her AVERAGE weight before surgery was around 250.  Since her RNY gastric bypass in 1999, she has battled with both transfer addictions (marajuana and alcohol) and a food addiction.  She has had two hernias and has another now.  Despite working out a lot and watching what she eats, it's a struggle to keep her weight in the 210-230 lbs zone.

Pundits hope that people forget about those who have regained... Carnie Wilson, Roseanne Barr and Al Roker - the poster kids for WLS are usually 1-2 year post ops.  It seems that for many people, the weight loss RETAINED after a gastric bypass is modest about 30-50 lbs but of course, the repercussions of the drastic altering of the anatomy of the digestive system are on going.  Hence there are increasing numbers of not real happy patients...

Following are some direct quotes from questions asked and answers given:

(question) 'Dr Wittgrove, in bypassing the small intestine, is that
essentially how this type of surgery helps in weight loss??

Dr. Alan Wittgrove: No....

Dr. Alan Wittgrove: I bypass the portion of the stomach so
there's a smaller reservoir, therefore there is less that
the person's able to eat.

This answer might be confusing.  The surgery Carnie had, does indeed, bypass the first 18-20 inches (or more) of the small gut as well as the stomach and many medical providers credit the intestinal bypass part of the surgery as playing an important role in weight loss retention.

Carnie did not appear to understand the details of her surgery.   Her comment on this was as follows:

Carnie Wilson: Over time my stomach will expand a bit so 

that in the first year when I'm losing the bulk of my

weight....

Carnie Wilson: It will eventually get to a smaller than

normal sized stomach, but I will begin to maintain my

weight..

Although surgeons theorize that the 1-2 oz pouch in a gastric bypass patient may stretch to twice its size after a year or two (4 oz), there is no evidence to suggest that the stomach ever returns to anything close to "normal".

(Question) Dr. Wittgrove, can a person with GERDS have this surgery?

Dr. Alan Wittgrove: Absolutely...
Dr. Alan Wittgrove: It's one of the prime indications for
this type of surgery.....
Dr. Alan Wittgrove: The gastric bypass is very effective as
an operation for relief of GERDS

GERD (Gastro-Esophageal reflux disorder) is where the individual regurgitates food and stomach acid, often injuring the part of the esophagus where it empties into the stomach and causing that spincter to lose its elasticity.  At this point, it's possible to regurgitate the contents of the stomach which can go into the lungs and cause a lot of pain if not more.  Also, some GERD sufferers can no longer swallow big chunks of food because the food might get caught in the esophagus which in many patients narrows and looses elasticity due to scarring from stomach acid.

In a gastric bypass the esophagus is not touched at all so if esophageal spincter gaps open before the surgery, it will gap open after the surgery as well.  Reading Dr Wittgrove's site sheds some light on what he was referring to.  He observes that since very little acid is produced in the thumb-sized pouch of a stomach, there is a relief of acid reflux.   Even though this is true in many cases, patients need to understand that some of the complications of GERD such as strictures of the esophagus will not be 'cured' through the surgery.  And also the less acid which is produced, the less digestion which will take place.

3. Another question about a possible intestinal bypass - 

(question)
Carnie, did you also have the bowels re-sectioned along with
the stomach stapling?

Dr. Alan Wittgrove: There's no resection of the bowels.
Dr. Alan Wittgrove: Go to gastricbypass.com for more of an
explanation.

This answer confused me because to me, the questioner appeared to be asking was there any bypass of the small gut, any cutting involved and Dr Wittgrove appeared to be saying "no" on this. Lucky for me only recently the confusion was cleared up for me by a bariatric surgeon visiting my site.  The following answer by Dr Brian Quebbeman, a bariatric surgeon in California, clarifies things:

"A resection means specifically REMOVING some portion of an organ. Cutting the intestine and rerouting things is, of course, how the operation works; but nothing is resectioned." (Dr Brian Quebbeman, MD)

(Do visit Dr Quebbeman's website - it's well done- link above!) 

  If you go to the website (the Alvarado Clinic) Dr Wittgrove mentioned,  the explanation of 'gastric bypass' clears up the confusion as well:

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.

Unfortunately, some chat attendees might have been like me and understood Dr's answer in the chat to mean that there is no intestinal bypass in the gastric bypass..

(Question) Dr. Wittgrove, How do you feel about the Duodenal Switch
procedure? Do you think you will ever add this to your
surgeries?

Dr. Alan Wittgrove: No....
Dr. Alan Wittgrove: I don't think we'll do that switch....
Dr. Alan Wittgrove: We've had experience with the EPD and,
although it can be very powerful,....
Dr. Alan Wittgrove: Our practice is to avoid malabsorptive
operations and concentrate on restrictive operations.

The Duodenal switch surgery is done with a variation of the intestinal bypass called the BPD or Bileopancreatic Diversion.  Dr Wittgrove did 400 BPDs but later follow-up showed a rate of malnutrition in these patients which concerned him. He does not do this surgery now and neither does the ASBS recommend it except in very extreme cases in which the surgeon feels that a gastric bypass would not do the job.  Dr Wittgrove stated more about this surgery in Carnie Wilson's book, GUT FEELINGS (NY, 2001):

"The third type is the bileopancreatic diversion with the duodenal switch which is malabsorptive surgery. Most of us worry about the malnutrition that can occur after malabsorptive operations and favor the gastric bypass instead."

"The common channel was originally very short -- about 50 cm (19.7 inches or less than 2 feet). Now it's usually about 100 cm in length (39. Even so, there is not a lot of absorption capacity which leads to malnutrition in some patients."

Other surgeons have expressed that they feel the DS/BPD may be too drastic for most patients:

In a recent survey conducted by the American Society for Bariatric Surgery (1999) about 75 percent of surgeons preferred the RYGB (RNY) as their primary operation, 15 percent preferred the VBG and 10 percent preferred the BPD or DS.

Malnutrition occurs in about 10 percent of patients with additional nutritional deficiencies such as low calcium levels and bone disease in even more (note: other sources have put this as 30 percent of DS/BPD). Most surgeons in the United States feel that the BPD is too radical an operation for most patients and its precise role in the management of severe obesity remains to be determined.

The following question has been asked many surgeons and there doesn't seem a good answer for it.  Interestingly enough many patients assume that having a gastric bypass will give them a normal lifespan.  Information on what is the expected lifespan after surgery is not available at this time.

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.....
Dr. Alan Wittgrove: People who are morbidly obese don't have
long life spans...
Dr. Alan Wittgrove: Ideal body weight tables were based on
actuarial data....
Dr. Alan Wittgrove: It is commonly known that people who are
morbidly obese die earlier than those who are not morbidly
obese.

Again Dr Quebbeman, MD provides a more complete answer about lifespan:

"The issue of life span is difficult. The assumption is that lifespan will be increased with the decrease in other medical diseases seen after bariatric surgery. However, there are only a few studies dealing specifically with bariatric surgery, to date, which seem to indicate this. Studies with weight loss have almost always shown a decrease in severe medical issues and a decrease in mortality (early death in particular) after weight loss. Further studies are being done."

What seems to be the consensus is that the gastric bypass while causing problems of its own, may lengthen the obese person's life IF it causes a remission of problems like high blood pressure and diabetes which it appears to do in the early years, however, the Swedish Obesity Study observed that at the 10 year check point, only 36 percent of patients were still "diabetes free".  Many patients on the lists have to go back on blood pressure medications a few years after their gastric bypass.  In short, it has NEVER been proven that gastric bypass will prolong life at all.

.  Interestingly enough, many patients seem to go into surgery assuming that the surgery WILL give them a normal lifespan, but there seems at present, no evidence that post gastric bypass patients do have a normal lifespan.  And although some studies have shown a decreased mortality with weight loss, did these studies factor in the exercise habits of the individuals?   For example if an obese person begins an exercise program and losses weight, will the decrease in mortality rate be from the exercise or the weight loss? The Cooper Institute studies which DID factor in exercise, concluded that the decrease in mortality and morbidity was from the EXERCISE and not any resulting weight loss.

Dr Livingston, a bariatric surgeon at UCLA medical center had this to say:

"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." Ref: p 175, Self Magazine, April 2001 "Would you have surgery to lose weight?"

Finally, Dr Mason, inventor of the gastric bypass surgery wrote the following in 1998 suggesting that he was not certain that the benefits of the gastric bypass outweighed the risks in many cases:

Dr Edward Mason: "For the vast majority of patients today, there is no operation that will control weight to a "normal" level without introducing risks and side effects that over a lifetime may raise questions about its use for surgical treatment of obesity."

The NIH seems to suggest that large people can be healthy (without surgery) by making lifestyle changes.  The following website carries many useful suggestions how to do this:  

NIH - Active at Any Size

thanks to 

Dr Alan Wittgrove - Alvarado Clinic

Dr Brian Quebbeman - Calsurg

Dr Louis Flancbaum - Doctor's Guide to WLS

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