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..."