Medical Advisors - Dr. Ahmad Attar

Obesity and Bariatric Surgery: Should We Do It?

The United States is in the midst of an obesity epidemic. It is estimated that over 300 million people worldwide are morbidly obese. Obesity is defined by a person's body mass index (BMI), which is weight in kilograms, divided by height in meters, squared.

People are classified as underweight if their BMI is less than 18 kg/m², normal weight is a BMI of 18-25, and overweight is a BMI >25<30 kg/m². Obesity is further defined accordingly: having a BMI >30<40 kg/m² considered obese, and morbidly obese is a BMI >40 kg/m². According to NIH criteria, patients with a BMI over 35 kg/m² and co morbid conditions such as diabetes, hypertension, or sleep apnea, or those with a BMI ? 40 kg/m² are considered candidates for surgical management of their obesity and co morbid conditions.

In the USA, two thirds of our population is overweight ( BMI > 25 kg/m²). One third of our population is obese (BMI ?30 kg/m²), and 5% are morbidly obese (BMI ?40). Obesity has been associated with many life threatening conditions, including hypertension, diabetes, obstructive sleep apnea, and multiple cancers, including colon and breast cancer. The primary aim of a bariatric operation is the control of weight and co morbid conditions.

There are three main types of bariatric operations performed today:

1. Restrictive procedures: mainly Laparoscopic adjustable gastric banding (LAGB) and Vertical banded gastroplasty (VBG).

2. Malabsorptive procedures: highlighted by Biliopancratic diversion (BPD) or Duodenal switch (DS). These are not commonly used.

3. Combination procedure: consisting of the Roux-en-Y gastric bypass. This is the most popular procedure in the USA, followed by LAGB.

Complications:

1. Death: death following Bariatric surgery is relatively rare. The morbidity rate for Restrictive surgery is 0.1%, and for Gastric bypass it is 0.5%. Death appears to be related to cardiac events, sepsis, leaks, or pulmonary emboli.

2. Leak: intestinal leaks are one of the most feared complications for Bariatric surgery. Leaks are often heralded by tachycardia and tachypnea. Intestinal leakage may occur at any anastomosis or staple line. The occurrence rate is 2-4%. The treatment is drainage, either radiologic guided or surgical re-exploration, control of sepsis, and nutritional support. Recently, endoscopic stenting has shown success. Patients with LAGB are at reduced risk for intestinal leakage. When this does occur, it is typically due to technical misadventure. The band should be removed, and the injury repaired and drained.

3. Bleeding: The LAGB has the lowest risk of bleeding due to the minimal manipulation needed to perform the surgery. All other procedures carry a 1-2% risk. When an anastomosis is performed, there is a small risk of intestinal bleed from the newly created staple lines. If the bleeding is from a proximal anastomosis, it can be managed endoscopically.

4. Gallstones: Rapid weight loss increases the risk of gallstone formation. The use of ursodeoxycholic acid for 6 months has reduced the formation of gallstones dramatically , from 35% to 2%, in bariatric patients. Choledocholithiasis often poses a challenge after gastric bypass. The limb length inhibits passage of endoscopes to perform an ERCP. In these particular patients, the stomach may be accessed laparoscopically, or opened, to provide access to the duodenum. An ERCP may be performed with the patient in the supine position with this approach.

5. Gastro-gastric fistula: A gastro-gastric fistula is an abnormal connection between the gastric pouch and the remnant stomach. It is often seen with poor weight loss or recurrent marginal ulceration. Surgical resection is the treatment of choice, although endoscopic endoluminal therapies may be of benefit in the future.

6. Small bowel obstruction: The incidence varies from 2-8%, depending on surgical skills. It is life threatening and more common in the laparoscopic approach of gastric bypass surgery. The two most common causes are adhesions and internal hernias. Surgical intervention is required.

7. Stomal Stenosis: Stricture of the anastomosis following gastric bypass occurs in two phases: early (within 4-8 weeks), which is associated with local ischemia, and late, when ulceration and fistula should be considered. Patients often complain of dysphagia, and an endoscopy will easily identify this problem. When it is an early stricture, dilatation is successful.

Lap Band Complications:

1. Acute band obstruction: This can occur after placement or adjustment of the band. It happens if the band is too small, or there is edema or hematoma at the site. Treatment is band replacement with a larger size in the OR.

2. Band slip: An unfortunate complication of LAGB is slippage or herniation of the stomach through the band. This occurs in up to 4% of the cases. A slip may follow a severe vomiting episode. The typical symptoms are sudden intolerance to solids and liquids. The diagnosis can be confirmed on plain abdominal radiograph, which indicates a flattening of the angle of the band, or on contrast study, which portrays a pocket of contrast overhanging the band. Treatment consists of removal of all fluid from the band, and laparoscopic revision, replacement, or removal. Severe pain associated with this is a sign of ischemia and constitutes an urgent situation.

3. Band erosion: 2% of the patients may experience an erosion of the band. This is often heralded by the persistent post site infection, or weight gain, with a nearly full band. The band can often be seen in the stomach on endoscopy and must be removed.

My closing remarks:

Although gastric bypass or gastric lap band are helpful in treatment of morbid obesity, they should be used as a last resort. The GOLD STANDARD in the management of obesity remains to be a proper diet and lifelong behavior modification associated with exercise. It is simple: weight gain occurs as a result of excessive caloric intake beyond the needs of the body. To lose weight, one must achieve a caloric deficit state that can be aided with increased calorie consumption by exercising and increasing physical activities. Once an ideal body weight is achieved, as reflected by your BMI, a calorie balanced state is mandatory to prevent regaining the weight. To maintain a calorie balance, you must modify your eating behavior for life. In my opinion, the feared complications (which encompass more than what was discussed in this article) of bariatric surgeries, especially gastric bypass, should warrant a closer look at non-surgical approaches. If you have any questions, please feel free to call me at: 513-791-8882. I will be delighted to help!

March is Colon Cancer Awareness Month

Why Does Cincinnati Have a High Rate of Colon Cancer? Can You Protect Yourself?
By: Ahmad Attar, M.D.

Ohio ranks sixth in the nation for colon cancer related deaths; Cincinnati has the highest rate in Ohio, and one of the highest rates for colon cancer in the country. There are theories for this, but no definite answer. You are taking an unnecessary risk with your life if you are 50 or over (40 or over if you are African American or Hispanic, or have other risk factors), live in the Cincinnati area, and have not had an examination for colon cancer this year. Cancer of the colon is one of the most common causes of cancer-related deaths in the USA; every year about 54,000 Americans die from it. Death from colon cancer is often preventable. Early detection is the best protection! Colon cancer typically starts from polyps; small benign growths on the lining of the colon, that have the potential of becoming cancerous. Polyps usually cause no symptoms at an early stage, and people are unaware of their existence. Colonoscopy, which is an examination with a flexible instrument, is the only definite way to detect polyps and colon cancer in the early, curable stage.

Individual risk factors include a personal history of:
1. Ulcerative colitis or Crohn's disease
2. Colonic polyps
3. Breast, ovarian, cervical, or uterine cancer
4. Close family members with a history of cancer, especially colon cancer.

Everyone 40 years of age or over, or with other risk factors, should minimally have a yearly occult blood stool exam, complimented with a colonoscopy at intervals recommended by a Gastroenterologist (a doctor specializing in digestive disorders), based on your personal history. Symptoms of colon cancer, which typically don't occur until advanced stages, include a change in bowel habits (including constipation and/or diarrhea), rectal bleeding (sometimes dangerously mistaken as only hemorrhoids), pencil-thin stool, abdominal pain, weakness, fatigue, anemia, and unexplained weight loss. If you or a loved one experiences any of these symptoms, consult with a Gastroenterologist for further evaluation, as any number of things can cause these symptoms, and a definitive cause needs to be established for proper treatment. Colonoscopy has facilitated early discovery of colon cancer related diseases, and the safe, painless removal of polyps which have the potential of becoming cancerous. Since colon cancer progresses slowly, at least 95% of its victims can be saved by early detection, diagnosis, and treatment. The exact cause of colon cancer remains unknown, but studies indicate a strong correlation with diet. A high fat, low fiber diet increases your risk. Studies indicate that colon cancer risks are higher in countries with a greater total fat dietary intake than those which consume little fat. The average American diet consists of 40-45% of their total calorie intake coming from fat, which correlates to a higher risk of colon cancer. Fruits, vegetables, and whole grains are the main sources of fiber. Fiber supplements are available for people that don't eat enough fiber. Excessive amounts of red meat may increase your risk for polyps and colon cancer. The recommended amount of red meat is less than 7 ounces per week. The impact of vitamins in relation to cancer is still investigational. Limited data exists to substantiate that foods high in vitamins A and C could act as antioxidants in the prevention of colon cancer. It remains ambiguous whether or not vitamin E has any preventative role. Other vitamins are not known to be helpful. There is potentially a preventative role for dietary calcium. Calcium has a protective effect on the lining of the colon. My dietary/health recommendations are as follows:

1. Low fat, high fiber diet. This means avoiding fried foods, butter, margarine, and any type of animal fat. Prepare foods by grilling, steaming, or baking. If you must fry, stir fry foods with cooking sprays, or a small amount of vegetable oil. Tip: Vegetable oils such as Canola and Corn, and Olive Oil are lowest in saturated fat, and conveniently located in all food stores.
2. Decrease your intake of red meat and other high fat/cholesterol foods.
3. Increase fresh fruits and vegetables, and whole grains into your diet.
4. Avoid preserved and processed foods. The closer a food is to its natural state, the better.
5. Maintain normal weight in relation to your height.
6. Be physically active on a regular basis; at a minimum do 30 minutes of moderate intensity activity on most days, preferably every day. This is in addition to your regular activities.
7. Smoking increases your risk, so make a plan to quit now.
8. Decrease, or preferably eliminate, alcohol intake.
9. Make an appointment today for a screening colonoscopy if you are 50 or older- sooner if you have risk factors.

Knowledge is the key to beating colon cancer. Regular colonoscopy screenings can prevent its occurrence by enabling the removal of polyps before they develop into a cancer. Colon cancer is beatable and treatable!

Dr. Ahmad Attar is a Greater Cincinnati Gastroenterologist and Endoscopist. He is an active member of the American Gastroenterology Association, American College of Gastroenterology, American Society of Gastrointestinal Endoscopy, and American Society of Laser Medicine and Surgery. He is on staff at the TriHealth, Alliance, and Mercy hospitals. Dr. Attar can be reached at 10496 Montgomery Road, Suite #208, Cincinnati, Ohio 45242. (513) 791-8882.