From: "Howard McCollister" <nospam@nospam.net>
Newsgroups: sci.med
Subject: Re: If then...
Date: 12 Jul 2004 12:21:10 -0500
Message-ID: <40f2c7cb$0$48970$45beb828@newscene.com>

"Beachhouse" <sendnomail@please.com> wrote in message
news:ccudid$15fc$1@spnode25.nerdc.ufl.edu...
> What % of patients assessed as psychologically "stable" or "suited" to
> undego gastric stapling or other form of gastric bypass eventually revert to
> prior eating behaviors to the degree that the residual stomach/pouch is
> distended enough over time to yield a return to morbid obesity?
>


Nationally, statistics suggest about 20% will not lose weight, or will
regain it within 4 years. Typical statistics indicate that for RNY, average
%EWL in the first year is ~70%, 2nd year ~ 65%, 3rd year ~60%, 4th year ~
50% and it tends to level off there. Our own statistics are significantly
better than that, due primarily (I think) to our substantially rigorous
psychological evaluation, screening, and counseling pre-and post-op. Some
patients are better suited to behavior modification than others. And partly
due to the fact that we only have about 5 years of data, I'm sure.

It's not so much the pouch getting bigger (it does, but only a little) and
the patient eating large quantities at one sitting. Rather it's the
patient's return to the grazing eating behaviors that got them morbidly
obese in the first place. The behavior modification induced by the
aggressive gastric partitioning can be defeated by such eating patterns. We
preach "pouch management" endlessly and weight loss management requires the
patient be motivated, and dedicated to the concept.

HMc

From: "Howard McCollister" <nospam@nospam.net>
Newsgroups: sci.med
Subject: Re: If then...
Date: 12 Jul 2004 22:37:14 -0500
Message-ID: <40f35836$0$13322$45beb828@newscene.com>

"J" <me0020@privacy.net> wrote in message
news:40F3323C.27C6BD03@execulink.com...
> Kurt Ullman wrote:
>
> >     Not the 4-5 lbs you are talking.
>
> I did not mention any specific weight (loss).
>
> > This is not even remotely cost effective.
>
> And what is the cost of liposuction?
> Compared to what?  The cost to society of heart problems and diabetes?
> Compared to Howard's surgery  (which he admits doesn't necessarily work)?
> J
>

Doesn't necessarily work *20% of the time* (in some programs). As opposed to
diet/exercise which doesn't work about 92-94% of the time and liposuction,
which doesn't work at all.

Liposuction is a lot of money to ask someone to pay out of their pocket for
something that has no hope at all of returning them to a healthy weight
range and eliminating or ameliorating the co-morbidities.

HMc

From: "Howard McCollister" <nospam@nospam.net>
Newsgroups: sci.med
Subject: Re: If then...
Date: 12 Jul 2004 18:27:09 -0500
Message-ID: <40f31dd4$0$1530$45beb828@newscene.com>

"Beachhouse" <sendnomail@please.com> wrote in message
news:ccurfr$177c$1@spnode25.nerdc.ufl.edu...
> this is interesting info.  we do see morbidly obese patients awaiting
> bariatric surgery who *still* believe that they will be cured of the urge to
> overeat because of the small pouch and resulting early satiety.
> when we discuss the need to continue to practice portion control/sensible
> eating -- some patients will respond that the surgery will make all of that
> unnecessary.  i often wonder how rigorous the psychological evaluation is
> and it seems key to long-term success.
>
>

Such patients are poorly oriented and would have a MUCH higher liklihood of
failure, IMHO. It is *crucial* that patients learn that lack of satiety
signals is only part of the problem. Portion control and sensible eating
(key aspects of "pouch management") are critical components that the
patients must fully understand. If they don't show evidence of grasping it
in the 4-8 months they spend in our program pre-op, they are out. They
psychologists that do our evaluating and counseling are *very* demanding
that these concepts be understood fully.

HMc

From: "Howard McCollister" <nospam@nospam.net>
Newsgroups: sci.med
Subject: Re: If then...
Date: 12 Jul 2004 09:04:10 -0500
Message-ID: <40f299b7$0$56715$45beb828@newscene.com>

"Lisa" <natenlisa@comcast.net> wrote in message
news:77f444.0407112159.553b9608@posting.google.com...
> HMc:
>
> What are your thoughts on Xenical?  Even though it has that unwanted
> side effect of the fat exiting in the stool, it is a good medication.
> It helped me lose a few pounds.  Mind you, I'm not 'overweight' in a
> big way.  Maybe 20 lbs of which I lost on Xenical.  www.xenical.com
>
> I'd love to hear your thoughts on this medication.
>


By the time patients get to me, they have already repeatedly failed all
forms of non-surgical management. I have never prescribed Xenical and know
very little about it.

HMc

From: "Howard McCollister" <nospam@nospam.net>
Newsgroups: sci.med
Subject: Re: If then...
Date: 13 Jul 2004 07:42:11 -0500
Message-ID: <40f3d809$0$363$45beb828@newscene.com>

"Shirley Gutkowski RDH" <shirdent@aol.commonly> wrote in message
news:20040713075719.05916.00001677@mb-m05.aol.com...
> >this is interesting info.  we do see morbidly obese patients awaiting
> >bariatric surgery who *still* believe that they will be cured of the
> >urge to overeat because of the small pouch and resulting early satiety.
>
> I've always said it's not in the stomach, it's in the head.  When people
> can eat past those rubber bands, and gain weight again even with a tiny
> fraction of what stomach they started with I have to wonder why so many
> continue on with the surgery. That's also why I really think that there
> is an imbalance somewhere else, it's not in the stomach.


A large part of morbid obesity is psychological, and a large part of the
reason for gastric partition operations (Lap Band, lap Roux-en Y) is
therefore behavior modification.

The reason so many continue on with the surgery is that it works far better
than anything else currently available.

HMc

From: "Howard McCollister" <nospam@nospam.net>
Newsgroups: sci.med
Subject: Re: If then...
Date: 15 Jul 2004 07:29:07 -0500
Message-ID: <40f6780d$0$1576$45beb828@newscene.com>

"J" <penguin@privacy.net> wrote in message
news:40F5ABEE.699F2484@execulink.com...
> bae@cs.toronto.no-uce.edu.yyz wrote:
>
> Not according to doctors in this area.
> Example: a person who should be 155 pounds is 200 pounds. they're
> morbidly obese according to doctors.
>

There is no insurance company or any other third-party payor in the US that
would pay for bariatric surgery of any kind for someone whose BMI is less
than 35, and even then only if they have substantial co-morbidities.

BMI (body mass index) is the sole criteria in the US for determining whether
or not someone is morbidly obese. Do a Google search on "BMI".

The NIH Consensus statement from 1991 defines the criteria for morbid
obesity. Educate yourself by reading it at
http://consensus.nih.gov/cons/084/084_statement.htm .

HMc

From: "Howard McCollister" <nospam@nospam.net>
Newsgroups: sci.med
Subject: Re: If then...
Date: 15 Jul 2004 07:20:11 -0500
Message-ID: <40f675e6$0$1521$45beb828@newscene.com>

<bae@cs.toronto.no-uce.edu.yyz> wrote in message
news:2004Jul14.112943.29148@jarvis.cs.toronto.edu...

> Practically speaking, the definition of morbid obesity is weight at
> least twice what it should be.  'Curing' obesity with liposuction would
> involve removing more than half the person's body, possible 150-200
> pounds or more.  I don't think this would be survivable, since blood
> loss is a significant issue when even a pound or so of fat is removed
> in 'sculpting' by liposuction.

Te
>
> After all, fat tissue is tissue, it's got a blood supply, it's attached
> to all kinds of stuff, it's not just subcutaneous -- it's around your
> viscera and between your muscles and muscle fibers (have a look at a
> well-marbled steak).  Even the subcu part is attached to a really
> important organ - your skin.  It's not like siphoning cooking oil out
> of a drum.  Go to the supermarket and buy some pork with the skin on,
> take it home, warm it to body temp and experiment.  Of course, the pork
> roast is already dead so it doesn't bleed or have to recover.

The definition of morbid obesity is a BMI of 40 or greater, or 35 or greater
if co-morbidities exist. It has nothing to do with twice normal weight, or
100 pounds overweight etc etc. These definitions were established by the NIH
at Concensus Conference in 1992 and are basically the only criteria
recognized.


> Maybe a surgeon can comment on whether a morbidly obese person could
> survive *surgical* removal of hundreds of pounds of fat tissue.  I
> suspect it would be very risky and very hard to justify, and not only
> because morbid obesity is a significant risk in any surgery.  Stomach
> stapling would be safe and simple in comparison.

Liposuction is a cosmetic procedure used for body contouring only. It is
simply not possible to use it as a means of returning someone to a healthy
weight range and it doesn't even make physiologic sense in that role..

HMc