Sunday, July 23, 2006

On the bandwagon

Other than during training, when we were investigating a weight-loss operation now abandoned, my experience with bariatric (weight-loss) surgery has come during my recent semi-retirement. As mentioned in my last post, I'm exclusively assisting on laparoscopic surgery, and it happens to be with a group of bariatric surgeons. By osmosis, I've become more knowledgeable in the field than I was in my own practice. And I'm here to tell you: I've become a believer in the value of bariatric surgery in the right circumstances, and if I were to have it myself or recommend it to another, I'd unequivocally recommend the laparoscopic adjustable gastric band ("lap-band.")

For the sake of brevity, and my previously admitted laziness (as well as a so-far less than easy relationship with the intricasies of this blogging stuff) I won't get into the indications or the "morality" issue of weight-loss surgery. Let's just talk about mechanics.

Although there are a few variations, two main options are out there: gastric bypass and lap-band. Both are typically done laparoscopically, meaning via several very small incisions through which a camera and very cool instruments are passed. The former involves stapling off a big chunk of the stomach, re-plumbing a segment of intestine, and attaching that segment to the small gastric pouch created by the stapling. It works by restricting intake by way of the small pouch, and by creating some degree of malabsorption (reducing the intestine's ability to absorb food) by short-circuiting a portion of the bowel. The latter works by restricting intake only, by means of squeezing off the top of the stomach so there's only room for a small amount at a time.

Hormones are at work, as well. Recently discovered, it's now known that the stomach produces at least one and probably more hormones that send a signal to the brain when it's full. In fact, bariatric surgeons may end up on the streets selling pencils if the pharmacology of those guys gets fully worked out and becomes manipulatable by drugs. Interestingly, messing with the stomach in either of the bariatric procedures may invoke hormone production that tells the brain the stomach is full when it's not. Neat-o!

So why the band over the bypass? (Coincidentally "band over bypass" is an operation we do not rarely: meaning banding a patient who's failed to lose weight or to maintain weight-loss after bypass.) Simply this: it's faster, cheaper, safer, and equally as effective. The weight-loss is slower, which some people see as good, others as bad. But at a couple of years it's the same. And the malabsorption of bypass means that many patients need forever to take various supplements; bandees don't, because they can eat and absorb pretty much all foods, just less of them. To me, the main thing is complications: no operation is free of them, and in obese people there are certain irreducible -- if generally predictable and therefore manageable and usually preventable -- risks, especially as relate to anesthesia. But surgically speaking -- which is what I purport to do -- the complications of bypass are far greater, if they occur. When you cut and staple bowel and stomach, the big worry is leakage. A bad thing when it occurs. Using a band, nothing is cut or stapled, so leakage is really extremely remote. Band complications are pretty rare, and generally not life-threatening, and are easy to fix. And -- at least where I work -- the band procedure can be done as an outpatient operation. Quicker recovery, significant cost savings. Admittedly, it takes excellent anesthesia management, which I witness every time I'm there at the practice. Hard for a surgeon to wax laudatory about mere anesthesiologists, but there it is: they're great.

Doing justice to the subject would take a post much longer than most people would like to read, is my guess. But let me finish with this interesting revelation: I used to voluntarily post medical answers on a couple of online forums. On one, I ventured into this subject, trying to give useful information to people interested in all forms of weight-loss surgery. In some context or other I made the prediction that in a few years, bypass would be a thing of the past, because of what seem to be obvious advantages of banding. Yikes! You'd think I'd advocated baby-killing. Turns out, it's like religion out there. If you've had one procedure, it's like being a Yankee to another's Red Sox. You'd think I'd have learned a lesson.


UPDATE:
There's an article in today's (7/24) New York Times about the high rate of complications of bariatric surgery. As usual in such articles, no distinction is made among the various forms of surgery. But it's pretty easy, in reading the article, to see that they are talking almost exclusively about bypass surgery. Res ipsa loquitur. As the Stones once sang, "Ti-i-e-imes is on my side, yes it is..."

2 comments:

Intelinurse2B said...

As a former Risk Manager for a third party administrator, I was often involved in mediating appeals for this procedure. The amount of data I was exposed to (5 years ago) regarding the amount of people who gained the weight back after the by-pass was astonishing! I hope those numbers have changed and we are figuring out how to alter someones anatomy AND their lifestyle after the surgery.

Heather said...

I had gastric bypass surgery on 4/27/05 I weighed in at the time of surgery just under 400lbs at the time I was 31 years old. Had just passed EMT school at the top of my class, teacher said one of the best grades he'd ever seen. Graduated with honors . I cant even begin to tell you what a different life I have now after my laparoscopic roux-en-y. I am bypassed 100cm and I have made it to my dieticians goal of 170 as a 6'2" female with very long but small bones. I had pseudotumor cerebri and have had 30 yes THIRTY lumbar punctures. Lethal spinal pressures.. talk of shunts which I REFUSED EVERY TIME. I had my last tap 16 days before my surgery. I had a while where I was fighting intracranial pressures but was able to keep it under control with diamox (which a local mom and pop pharmacy made into liquid for me) I have now been symptom free for a long time (knock on wood) I had this surgery to save my life. I know its certainly not a cure all. It helped me to lose 241 pounds. I BALLED MY EYES OUT the day the scale read 199.. I hadnt been in the 100's since I was.. uhh... 12 probably. My story goes on.. BUT.. my point is this... I knew going into this surgery that there HAD to be an emotional reason for my incredibly POWERFUL addiction to food! I have seen my therapist every week for the last 18 months. I feel like I have gotten through some of the things that I used food to comfort. I will continue. I am not a closet eater. I will not eat and hide it. I tell my story all the time and carry pictures around with me. I work in a doctors office and we have some wls patients that come in and since I read and read and read I am very up on all the latest research and how is best to care for your new pouch. BUT more importantly.. I always encourage them to come to support groups and I am active in support groups. I have a very close family member who had wls and almost died. I see it as his fault for not going back to the surgeon and saying .. look.. something is NOT RIGHT.. he had a perforation of his gastrojejunostomy and the hospital he went to said it was a PE.. yet.. free air in the abdomen.. UHH GEE.. well I'm no doctor for sure.. but I did stay in a Holiday Inn last night. (giggles) IT SAVED MY LIFE It's saved the lives of many many people I know. I would do it again in a heartbeat. As for posting and helping. I have found that some people think they are the "god" of thier surgery. Everyone makes thier choices with thier own body. I meet people all the time opposed. Or that knows someone who almost died so they are against it. I laid right back down on the surgeons table while my family member was still in the ICU (107 days total in ICU) and had an adhesion removed that was causing a nagging ache. Same surgeon.. never even gave it a second thought.. there are bad surgeons out there but... there are bad patients too. he was a bad patient and didnt take responsibility for his own body. Shame on him. He was just released from the rehab with intensive outpatient rehab... he was admitted for the PE on october 17 2006 and its now March 13 2007... he spent more than three months in the icu then released to the rehab.. what a shame. Ok..so.. if you have surgery.. remember the surgeon fixes your body not your mind. you must seek the help you need emotionally and admit you are addicted to food for whatever reason and stay active with support groups. Food is a more powerful addiction than any other in my personal opinion becuase we HAVE to have it. A crack head does not HAVE to have crack. So.. that being said. I know I could gain some or all of my weight back. I am going to try my hardest to work through the emotional stuff to be able to stay at this weight. As long as the scale NEVER says the 2 number again I will be thrilled. So.. if you make the choice to have surgery.. people who arent educated on it may be negative.. also people who have had it and arent a loud mouth like me.. will be very defensive "protecting" their surgery so to speak... feeling defensive all the time becuase they cant handle the verbal "attack" Those people who do that to me get hit back with a verbal attack of EDUCATION AND HOW IT SAVES LIVES> We all go into it KNOWING we COULD die.. but damnit.. I could get hit by a semi on the way to work. Come on people.. I HAVE STOPPED EXISTING AND STARTED LIVING THANKS TO MY WONDERFUL SURGEON. HE GAVE ME LIFE!...