EXTRA EDITION “BARIATRIC SURGERY REVISITED, A FURTHER IN DEPTH ANALYSIS”

A good friend and wise philosopher Walter E. Kurtz.

Kurtz: [intercepted radio message] I watched a snail crawl along the edge of a straight razor. That’s my dream; that’s my nightmare. Crawling, slithering, along the edge of a straight razor… and surviving. (Apocalypse Now).

That is what obesity is like, “Crawling slithering along the edge of straight razor… and surviving.” The thinner we get the greater the likelihood of longer survival. Obesity is in all its myriad forms an insidious disease not to be embraced, ignored, or accepted as the status quo!

According to an article published, in the pamphlet Bariatric and Metabolic Surgery, the “body works to defend it set point, dieting and exercising are rarely effective in helping people with obesity achieve and maintain a healthy weight long-term. When you go on a diet, your body thinks it’s being starved and its survival instincts kick in. As a result, your body stores energy-rich body fat, and you can’t lose weight easily. A landmark Swedish study found that, on average, 200-pound patient fighting obesity with diet and exercise alone would only be able to achieve a sustained weight loss of 4 pounds over 20 years.

When weight is lost, lower body fat levels trigger hormones that encourage the body to get back to its previous weight set-point. The New England Journal of Medicine study showed that while dieters may initially lose weight, their bodies change levels of hormones that encourage weight gain in response to the weight loss. These hormones increased appetite, decrease feelings of fullness, and slow down metabolism. This study also found that these hormones had not returned to create diet levels even 12 months after the initial weight loss, meaning their bodies were still encouraging weight to regain a year after they stopped dieting. This is a powerful defense mechanism and may explain why the majority of weight-loss attempts fail.

95% of obese people who lose weight with a rigorous weight loss program will regain the weight (or more) within 2 to 5 years. ” (1)

Therefore, all dear fellow travelers this leads us once again to revisit the option to have bariatric surgery. Most insurance and Medicare will cover approved mainstream surgeries if you have a BMI  ≥ 35 with two comorbid factors e. g. elevated blood pressure, type 2 diabetes, high cholesterol, etc., or a BMI  ≥  40 without comorbid factors.

Our Gazette namesake. He approves most heartily.

As you already know, if you are an august reader of this splendid piece of yellow journalism, the Captain had a sleeve gastrectomy performed on November 24, 2014. I am six months out and cannot recommend the surgery enough. Before surgery, I weighed 305 pounds at my heaviest. I lost 64 pounds before surgery but still decided to go ahead with it. Post-surgery I have lost another 52 pounds to date. I now weigh 189 pounds as of this writing and of course, am still losing weight. Therefore, when you do the math weight-loss post-surgery in percentage is 17% and that is in just six months! This surgery is most efficacious beating diet alone, diet pills, and all-sundry weight-loss programs.

Endoscopic view of sleeve gastrectomy in progress.

As the Captain has said so many times before, this surgery is painless. In the hands of a skilled U.S. or British surgeon with computer assist, you cannot miss. The surgery itself takes about 3 hours; recovery from anesthesia varies. With the gastric sleeve, you are up and walking the same day. I was roaming the halls of the hospital with absolutely no problem, no pain pills, and no pain. It is an overnight stay with this surgery.

I knew I needed a tool that would put the brakes on my bad behavior having lost the ability to binge and starve. That tool was a sleeve gastrectomy. My bad behavior started as a teenager but the weight only caught up with me when I hit my forties then the weight slowly crept up to 305 pounds at the age of 64. I have been on the thin side most of my life. It was quite a shock to see a fat, morbidly obese blob in the mirror.

Besides high cholesterol, high triglycerides, shortness of breath with exertion, and elevated blood pressure, I was an inveterate binge eater. Three weaknesses were sandwiches, pizza, and double portions for dinner. I could eat half-pound sandwiches or a large pizza without any problem, double portions I expected it. These problems do not magically disappear however, I still order pizza but can only consume two slices as to the sandwiches I have virtually given them up, they are too hard for me to consume and the double portions forget about it. Portion size is now totally controlled by the size of my sleeve. I can consume approximately 4 to 6 ounces of food at a sitting comfortably if I go over that I become uncomfortable. Another problem I have is eating too fast and not allowing myself to feel full. This again is taken care of by the sleeve size; it physically metes out the punishment for my indiscretion by making me feel full before I have even finished my 6 ounces of food. That said, my eating behaviors have dramatically improved and I am definitely on the road to recovery.

Again a good line bears repeating and repeating often, “95% of obese people who lose weight with a rigorous weight loss program will regain the weight (or more) within 2 to 5 years.” (1)

The Captain highly recommends the last section of this article on the misconceptions concerning gastric surgery. It will enlighten and disabuse all of the untruths that are bandied about by the unknowing to the unknowing.

We shall now move on to the three main types of bariatric surgery, taken from the American Society for Metabolic and Bariatric Surgery, ASMBS,  that are usually covered by Medical Insurance.

Gastric Bypass

The Roux-en-Y Gastric Bypass – often called gastric bypass – is considered the ‘gold standard’ of weight loss surgery and is the most commonly performed bariatric procedure worldwide.

The Procedure

Roux-en-Y Gastric Bypass. Click to enlarge

There are two components to the procedure. First, a small stomach pouch, approximately one ounce or 30 milliliters in volume, is created by dividing the top of the stomach from the rest of the stomach. Next, the first portion of the small intestine is divided, and the bottom end of the divided small intestine is brought up and connected to the newly created small stomach pouch. The procedure is completed by connecting the top portion of the divided small intestine to the small intestine further down so that the stomach acids and digestive enzymes from the bypassed stomach and first portion of small intestine will eventually mix with the food.

The gastric bypass works by several mechanisms. First, similar to most bariatric procedures, the newly created stomach pouch is considerably smaller and facilitates significantly smaller meals, which translates into fewer calories consumed. Additionally, because there is less digestion of food by the smaller stomach pouch, and there is a segment of small intestine that would normally absorb calories as well as nutrients that no longer have food going through it, there is probably to some degree less absorption of calories and nutrients.

Most importantly, the rerouting of the food stream produces changes in gut hormones that promote satiety, suppress hunger, and reverse one of the primary mechanisms by which obesity induces type 2 diabetes.

Advantages

1. Produces significant long-term weight loss (60 to 80 percent excess weight loss)
2. Restricts the amount of food that can be consumed
3. May lead to conditions that increase energy expenditure
4. Produces favorable changes in gut hormones that reduce appetite and enhance satiety
5. Typical maintenance of >50% excess weight loss

Disadvantages

1. Is technically a more complex operation than the AGB or LSG and potentially could result in greater complication rates
2. Can lead to long-term vitamin/mineral deficiencies particularly deficits in vitamin B12, iron, calcium, and folate
3. Generally has a longer hospital stay than the AGB
4. Requires adherence to dietary recommendations, life-long vitamin/mineral supplementation, and follow-up compliance

• Additional Reading

Sleeve Gastrectomy

The Laparoscopic Sleeve Gastrectomy – often called the sleeve – is performed by removing approximately 80 percent of the stomach. The remaining stomach is a tubular pouch that resembles a banana.

The Procedure

Laparoscopic Sleeve Gastrectomy. Click to enlarge

This procedure works by several mechanisms. First, the new stomach pouch holds a considerably smaller volume than the normal stomach and helps to reduce significantly the amount of food (and thus calories) that can be consumed. The greater impact, however, seems to be the effect the surgery has on gut hormones that impact several factors including hunger, satiety, and blood sugar control.

Short-term studies show that the sleeve is as effective as the roux-en-Y gastric bypass in terms of weight loss and improvement or remission of diabetes. There is also evidence that suggests the sleeve, similar to the gastric bypass, is effective in improving type 2 diabetes independent of weight loss. The complication rates of the sleeve fall between those of the adjustable gastric band and the roux-en-y gastric bypass.

Advantages

1. Restricts the amount of food the stomach can hold
2. Induces rapid and significant weight loss that comparative studies find similar to that of the Roux-en-Y gastric bypass. Weight loss of >50% for 3-5+ year data, and weight loss comparable to that of the bypass with the maintenance of >50%
3. Requires no foreign objects (AGB), and no bypass or re-routing of the food stream (RYGB)
4. Involves a relatively short hospital stay of approximately 2 days
5. Causes favorable changes in gut hormones that suppress hunger, reduce appetite, and improve satiety

Disadvantages

1. Is a non-reversible procedure
2. Has the potential for long-term vitamin deficiencies

• Additional Reading

Adjustable Gastric Band

The Adjustable Gastric Band – often called the band – involves an inflatable band that is placed around the upper portion of the stomach, creating a small stomach pouch above the band and the rest of the stomach below the band.

The Procedure

Adjustable Gastric Band.
Click to enlarge

The common explanation of how this device works is that with the smaller stomach pouch, eating just a small amount of food will satisfy hunger and promote the feeling of fullness. The feeling of fullness depends upon the size of the opening between the pouch and the remainder of the stomach created by the gastric band. The size of the stomach opening can be adjusted by filling the band with sterile saline, which is injected through a port placed under the skin.

Reducing the size of the opening is done gradually over time with repeated adjustments or “fills.” The notion that the band is a restrictive procedure (works by restricting how much food can be consumed per meal and by restricting the emptying of the food through the band) has been challenged. Studies show the food passes rather quickly through the band, and that absence of hunger or feeling of being satisfied was not related to food remaining in the pouch above the band. What is known is that there is no malabsorption; the food is digested and absorbed, as it would be normally.

The clinical impact of the band seems to be that it reduces hunger, which helps the patients to decrease the number of calories that are consumed.

Advantages

1. Reduces the amount of food the stomach can hold
2. Induces excess weight loss of approximately 40 – 50 percent
3. Involves no cutting of the stomach or rerouting of the intestines
4. Requires a shorter hospital stay, usually less than 24 hours, with some centers discharging the patient the same day as surgery
5. Is reversible and adjustable
6. Has the lowest rate of early postoperative complications and mortality among the approved bariatric procedures
7. Has the lowest risk for vitamin/mineral deficiencies

Disadvantages

1. Slower and less early weight loss than other surgical procedures
2. A greater percentage of patients failing to lose at least 50 percent of excess body weight compared to the other surgeries commonly performed
3. Requires a foreign device to remain in the body
4. Can result in possible band slippage or band erosion into the stomach in a small percentage of patients
5. Can have mechanical problems with the band, tube, or port in a small percentage of patients
6. Can result in dilation of the esophagus if the patient overeats
7. Requires strict adherence to the postoperative diet and postoperative follow-up visits
8. Highest rate of re-operation (2)

• Additional Reading

Bariatric Surgery Misconceptions

Misconception: Most people who have metabolic and bariatric surgery regain their weight.

Truth:

As many as 50 percent of patients may regain a small amount of weight (approximately 5 percent) two years or more following their surgery. However, longitudinal studies find that most bariatric surgery patients maintain successful weight-loss long-term. ‘Successful’ weight-loss is arbitrarily defined as weight-loss equal to or greater than 50 percent of excess body weight. Often, successful results are determined by the patient, by their perceived improvement in quality of life. In such cases, the total retained weight loss may be more, or less, than this arbitrary definition. Such massive and sustained weight reduction with surgery is in sharp contrast to the experience most patients have previously had with non-surgical therapies.

Misconception: The chance of dying from metabolic and bariatric surgery is more than the chance of dying from obesity.

Truth:

As your body size increases, longevity decreases. Individuals with severe obesity have several life-threatening conditions that greatly increase their risks of dying, such as type 2 diabetes, hypertension, and more. Data involving nearly 60,000 bariatric patients from the ASMBS Bariatric Centers of Excellence database show that the risk of death within the 30 days following bariatric surgery averages 0.13 percent, or approximately one out of 1,000 patients. This rate is considerably less than most other operations, including gallbladder and hip replacement surgery. Therefore, despite the poor health status of bariatric patients before surgery, the chance of dying from the operation is exceptionally low. Large studies find that the risk of death from any cause is considerably less for bariatric patients throughout time than for individuals affected by severe obesity who have never had the surgery. The data show up to an 89 percent reduction in mortality, as well as highly significant decreases in mortality rates due to specific diseases. Cancer mortality, for instance, is reduced by 60 percent for bariatric patients. Death in association with diabetes is reduced by more than 90 percent and that from heart disease by more than 50 percent. Also, numerous studies have found improvement or resolution of life-threatening obesity-related diseases following bariatric surgery. The benefits of bariatric surgery, concerning mortality, far outweigh the risks. It is important to note that as with any serious surgical operation, the decision to have bariatric surgery should be discussed with your surgeon, family members, and loved ones.

Misconception: Surgery is a ‘cop-out’. To lose and maintain weight, individuals affected by severe obesity just need to go on a diet and exercise program.

Truth:

Individuals affected by severe obesity are resistant to long-term weight loss by diet and exercise. The National Institutes of Health Experts Panel recognize that ‘long-term’ weight-loss, or in other words, the ability to ‘maintain’ weight loss, is nearly impossible for those affected by severe obesity by any means other than metabolic and bariatric surgery. Bariatric surgeries are effective in maintaining long-term weight loss, in part, because these procedures offset certain conditions caused by dieting that are responsible for rapid and efficient weight regain following dieting. When a person loses weight, energy expenditure (the number of calories the body burns) is reduced. With diet, energy expenditure at rest and with activity is reduced to a greater extent than can be explained by changes in body size or composition (amount of lean and fat tissue). At the same time, appetite regulation is altered following a diet increasing hunger and the desire to eat. Therefore, there are significant biological differences between someone who has lost weight by diet and someone of the same size and body composition to that of an individual who has never lost weight. For example, the body of the individual who reduces their weight from 200 to 170 pounds burns fewer calories than the body of someone weighing 170 pounds and has never been on a diet. This means that to maintain weight loss, the person who has been on a diet will have to eat fewer calories than someone who naturally weighs the same. In contrast to diet, weight loss following bariatric surgery does not reduce energy expenditure or the number of calories the body burns to levels greater than predicted by changes in body weight and composition. Some studies even find that certain operations even may increase energy expenditure. In addition, some bariatric procedures, unlike a diet, also cause biological changes that help reduce energy intake (food, beverage). A decrease in energy intake with surgery results, in part, from anatomical changes to the stomach or gut that restrict food intake or cause malabsorption of nutrients. In addition, bariatric surgery increases the production of certain gut hormones that interact with the brain to reduce hunger, decrease appetite, and enhance satiety (feelings of fullness). In these ways, bariatric and metabolic surgery, unlike dieting, produces long-term weight loss.

Misconception: Many bariatric patients become alcoholics after their surgery.

Truth:

Only a small percentage of bariatric patients claim to have problems with alcohol after surgery. Most (but not all) who abuse alcohol after surgery had problems with alcohol abuse at some period before surgery. Alcohol sensitivity, (particularly if alcohol is consumed during the rapid weight-loss period), is increased after bariatric surgery so that the effects of alcohol are felt with fewer drinks than before surgery. Studies also find with certain bariatric procedures (such as the gastric bypass or sleeve gastrectomy) that drinking an alcoholic beverage increases blood alcohol to levels that are considerably higher than before surgery or in comparison to the alcohol levels of individuals who have not had a bariatric procedure. For all of these reasons, bariatric patients are advised to take certain precautions regarding alcohol:

• Avoid alcoholic beverages during the rapid weight-loss period
• Be aware that even small amounts of alcohol can cause intoxication
• Avoid driving or operating heavy equipment after drinking any alcohol
• Seek help if drinking becomes a problem

If you feel the consumption of alcohol may be an issue for you after surgery, please contact your primary care physician or bariatric surgeon and discuss this further. They will be able to help you identify resources available to address any alcohol-related issues.

Misconception: Surgery increases the risk for suicide.

Truth:

Individuals affected by severe obesity who are seeking bariatric and metabolic surgery are more likely to suffer from depression or anxiety and to have lower self-esteem and overall quality of life than someone who is normal weight. Bariatric surgery results in highly significant improvement in psychosocial well-being for the majority of patients. However, there remain a few patients with undiagnosed preexisting psychological disorders and still others with overwhelming life stressors who commit suicide after bariatric surgery. Two large studies have found a small but significant increase in suicide occurrence following bariatric surgery. For this reason, comprehensive bariatric programs require psychological evaluations before surgery and many have behavioral therapists available for patient consultations after surgery.

Misconception: Bariatric patients have serious health problems caused by vitamin and mineral deficiencies.

Truth:

Bariatric operations can lead to deficiencies in vitamins and minerals by reducing nutrient intake or by causing reduced absorption from the intestine. Bariatric operations vary in the extent of malabsorption they may cause and vary in which nutrients may be affected. More malabsorptive bariatric procedures also increase the risk for protein deficiency. Deficiencies in micronutrients (vitamin and minerals) and protein can adversely affect health, causing fatigue, anemia, bone and muscle loss, impaired night vision, low immunity, loss of appropriate nerve function, and even cognitive defects. Fortunately, nutrient deficiencies following surgery can be avoided with an appropriate diet and the use of dietary supplements, i.e. vitamins, minerals, and, in some cases, protein supplements. Nutrient guidelines for different types of bariatric surgery procedures have been established by the ASMBS Nutritional Experts Committee and published in the journal, Surgery for Obesity and Other Related Disorders. Before and after surgery, patients are advised of their dietary and supplement needs and followed by a nutritionist with bariatric expertise. Most bariatric programs also require patients to have their vitamins and minerals checked regularly following surgery. Nutrient deficiencies and any associated health issues are preventable with patient monitoring and patient compliance in following dietary and supplement (vitamin and mineral) recommendations. Health problems due to deficiencies usually occur in patients who do not regularly follow up with their surgeon to establish healthy nutrient levels.

Misconception: Obesity is only an addiction, similar to alcoholism or drug dependency.

Truth:

Although there is a very small percentage of individuals affected by obesity who have eating disorders, such as binge eating disorder syndrome, that may result in the intake of excess food (calories), for the vast majority of individuals affected by obesity, obesity is a complex disease caused by many factors. When treating addiction, such as alcohol and drugs, one of the first steps is abstaining from the drugs or alcohol. This approach does not work with obesity as we need to eat to live. Additionally, there may be other issues affecting an individual’s weight, such as psychological issues. Weight gain generally occurs when there is an energy imbalance or, in other words, the amount of food (energy) consumed is greater than the number of calories burned (energy expended) by the body in the performance of biological functions, daily activities, and exercise. Energy imbalance may be caused by overeating or by not getting enough physical activity and exercise. There are other conditions, however, that affect energy balance and/or fat metabolism that do not involve excessive eating or sedentary behavior including:

• Chronic sleep loss
• Consumption of foods that, independent of caloric content, cause metabolic/hormonal changes that may increase body fat (sugar, high fructose corn syrup, trans fat, processed meats, and processed grains)
• Low intake of fat-fighting foods (fruits, vegetables, legumes, nuts, seeds, quality protein)
• Stress and psychological distress
• Many types of medications
• Pollutants

Obesity also ‘begets’ obesity, which is one of the reasons why the disease is considered ”progressive.” Weight gain causes several hormonal, metabolic, and molecular changes in the body that increase the risk for even greater fat accumulation and obesity. Such obesity-associated changes reduce fat utilization, increase the conversion of sugar to fat, and enhance the body’s capacity to store fat by increasing fat cells size and numbers and by reducing fat breakdown. Such defects in fat metabolism mean that more of the calories consumed are stored as fat. To make matters worse, obesity affects certain regulators of appetite and hunger in a manner that can cause an increase in the amount of food eaten at any given meal and the desire to eat more often. There are many causes for obesity and that the disease of obesity is far more than just an ‘addiction’ toward food. The treatment of obesity solely as an addiction may be beneficial for a very small percentage of individuals whose only underlying cause for obesity is excessive and addictive eating, but would be unlikely to benefit the multitudes, particularly those individuals affected by severe obesity. (3)

Dear readers, if you have read this far, the Captain would be most heartened if you would rate this and future articles and/or leave a comment at the top of the blog posts whether positive or negative. In this way, “The Fat Bastard Gazette” may better serve you and our entire readership.

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1.  (Bariatric and Metabolic Surgery, 2012)
2.  (ASMBS, 2015)
3.  (ASMBS, 2015)

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ASMBS. (2015). Bariatric Surgery Misconceptions. Retrieved May 29, 2015, from ASMBS American Society for Metabolic and Bariatric Surgery: http://asmbs.org/patients/bariatric-surgery-misconceptions

ASMBS. (2015). Bariatric Surgery Procedures. Retrieved May 29, 2015, from ASMBS American Society for Metabolic and Bariatric Surgery: http://asmbs.org/patients/bariatric-surgery-procedures

Bariatric and Metabolic Surgery. (2012). Bariatric and Metabolic Surgery. Ethicon.

 

Captain Hank Quinlan, Owner and Publisher, Chief Curmudgeon with Sam Borsalino, Assistant Publisher

Dear Hail-Fellows well met, “The Fat Bastard Gazette” is written and edited by your favorite curmudgeons Captain Hank Quinlan and

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