The Groening of Weight Loss Surgery

The parents of Matt Groening, creator of the Simpsons, were friends of my parents. It might interest his fans to know, if they don't already, that his parents' names are Homer and Marge. Several years ago, my mom got Marge Groening to finagle a favor from Matt: he sent our son, on his birthday, several items of wittily signed simpsonalia, along with a couple of original drawings of Bart offering greetings, relating, as I recall, to a cow. This does not keep me from criticizing Mr. Groening on surgical matters.

On the most recent Simpsons episode, which I watched with my usual devotion, Homer underwent weight-loss surgery. During the pre-operative meeting with the surgeon he was told about "gastric bypass surgery," but the explanation, complete with diagram, was of placing a band around the stomach. There's a lot of misunderstanding out there.

Before I became a blogger, I spent some time voluntarily answering medical questions on a couple of online medical fora. Weight loss surgery, I discovered, is a little like religion. Criticize gastric bypass in favor of lap-band, and expect serious flaming. When I predicted that, as the word got out, lap-band would replace gastric bypass as the procedure of choice, personal epithets were flung far, fast, and furious, as if I'd said Osama bin Laden ought to be president. The fact is that when most people think of bariatric surgery, gastric bypass is what comes to mind; and to date, it's what most have had (although the teeter is tottering). Good branding. Like MP3 player = iPod. But iPods don't kill 1.5% - 3% of their owners within days of purchase.

Disclosure: to the extent that I'm still a surgeon, it's only as a participant in the laparoscopic placement of lap-bands. Further disclosure: they pay me by the hour. Got no dog in the fight. Statement: if I were going to have a weight loss operation (and, depending on where I am on the sine-wave of my devotion to cycling and other factors, it's not inconceivable) there's no doubt I'd have the lap band. Why? Cheaper, safer, faster, doable as an outpatient procedure, quicker recovery, equal weight loss in the long run. More disclosure: not even all bariatric surgeons would agree with what I just said -- mainly the last phrase.

It's a strange world. Until pretty recently, those insurers who covered bariatric surgery (not many, for a long time) only paid for bypass, despite significantly higher initial cost and much more frequent (and very dangerous -- not to mention expensive) complications. In part, they claimed it was because (despite much world-wide experience with tens of thousands of patients) they considered the band "experimental." Cynical me: I think it's really because they figured that in covering only the more expensive and more dangerous operation, fewer people would choose to have it. Short sighted? Surprised?

Ain't no free (small) lunch. The main downside of lap band, as I see it, is that it affords less of having and eating your cake. Bypass works in significant measure by causing malabsorption of food. Stuff passes through. Although that often leads to diarrhea and nutritional problems for which the typical patient must take lots of supplements (as opposed to the typical band patient who needs none), some people are attracted to it because they may not be as restricted on intake. With a band, you can't eat as much, and you may need to give up certain things, like bread. On the other hand, a high percentage of people with a band in place find their appetite is wiped away like spilled crumbs in a white tablecloth restaurant. And there's this: the best results are with programs that are comprehensive and provide ongoing support. Some surgeons, of course, don't like that; which, I think, accounts for the disagreement amongst them. Cut and run, is what they prefer, and that's what they can more easily do with bypass patients. The people with whom I work set a very high standard of continuous followup.

Adjustability is another attraction of the band. There's a small "port" placed under the skin into which fluid can be injected, which fills a balloon on the inside of the ring. You can make it tighter or looser, depending on a patient's needs. Women who'd had trouble conceiving a baby while fat may get pregnant when thin, and need a little more room to eat for two. No problem.

Since there's none of the cutting of bowel and stomach that happens with bypass, there's practically no incidence of leakage or serious immediate surgical problems. Mortality rate is much lower (for the group with which I work, it's one (last I heard) in about three thousand.) The most irksome problem with the band is an incidence of "slip," wherein too much stomach ends up above the band, often requiring reöperation to reposition it. I think it's generally a misnomer, because in most cases it's not that the band has slipped, but that the originally small portion of stomach above the band has become stretched and dilated; which nearly always happens in people who go off the reservation, meaning people who force in too much food and end up vomiting a lot. Technical issues that might also be a factor are slowly being investigated and placement techniques have changed, which has lowered the incidence. That, of course, says that not all the problems are related to patient coöperation. (Love that ¨ thing, since I discovered how to do it recently.)

So. If you're like me and you get most of what you know about the world from watching the Simpsons, be of good cheer. As long as there are people around to correct the (very rare) occasional divergence from reality, you can keep watching with confidence. The internet is a wonderful thing.