The first patient I met on my surgery rotation was Mark Cob.* He was friendly, even though he was in a lot of pain. Two medical students and I introduced ourselves, along with a resident, to learn how to inject lidocaine (a local anesthetic) into his incision sites.
The resident did a brilliant job of including us, while making Mr. Cob feel at ease. Mr. Cob cheerfully participated in our lesson. He even made jokes as the resident quizzed us about the pharmacology and dangers of lidocaine injection. He was remarkably pleasant.
Mr. Cob was my age, but not my size. He was in a special “bariatric” bed that raises into a chair, so those with obstructive sleep apnea can sleep sitting-up (without getting-up). The hospital gowns did not completely cover his chest and stomach, and he was sweating profusely, his face glistening. Mr. Cob underwent bariatric (weight-loss) surgery the day before I met him. His BMI was over 50.
He had always been “big,” and his mother had “the surgery” in the 80’s. He had diabetes and high blood pressure by the time he was twenty. He had tried many diet programs, but all had failed. He knew about the lifestyle changes that would be forced upon him permanently, and he seemed cheerful and ready.
He was similar to others I’ve met in the last few weeks. Although their ages ranged from 19 to 65, and their BMI’s from 36 to 50+, these people felt like they had tried everything to lose weight, everything except surgery. This was their last resort, and they had been through months of preparation (doctor’s visits, nutritionist counseling, psychiatric evaluation, support group attendance, medical tests, etc.).
It was fitting that my first general surgery case was a laparoscopic “roux-en-Y,” one of the three major types of bariatric surgery available today. I felt overwhelmed by the anatomy of the surgery. The surgeons made five tiny slits in the abdomen, inflated the large belly with gas, and then began to orchestrate a complex symphony of instruments, cutting, stapling, etc. I kept gazing from the abdomen to the screen, feeling dizzy and lost.
“What’s this?” the surgeon asked. “The spleen?” I answered. “Yes!” The surgeon asked me to identify all the major organs, but I had to keep track of which direction the camera was pointed in order to answer correctly.
They seemed to know exactly which parts of the stomach and small intestines to cut. The roux-en-Y is the most complicated surgery, because part of the stomach is detached and then the small intestine is split to resemble a “Y.” The other surgery I saw was a “gastric sleeve” (which involves removing most of the stomach). Although I have not seen “gastric band” placement, it is the third option (during which an inflatable band is placed around the top of the stomach connected to a port under the skin into which saline can be injected or removed).
Bariatric surgery is a relatively new medical response to the rising levels of obesity. During my first year of medical school, I learned about the indications for surgery in my nutrition class. I remember seeing the dismal statistics about rising BMI in our country, and failure of weight loss treatments. And there is no doubt obesity attributes to the rising costs of health care.
Meanwhile obese people are still stigmatized, even by medical students and professionals. Unlike diseases like cancer, many physicians feel frustrated that these patients seem to willfully be making themselves ill. Most health professionals feel defeated after spending precious, unrewarded time counseling a patient who returns to their office several pounds heavier the next visit.
There are no good solutions. Despite the clear need for lifestyle changes, few people seem to be able to make them last permanently. Some argue bariatric surgery is the only “good” solution because it is the only treatment that shows weight loss that lasts 10+ years. While this surgery is new, controversial and perhaps frightening, it is becoming widely accepted and utilized (much more than I realized before this rotation).
I wonder how many of my future patients will have undergone bariatric surgery. These people are our friends, our relatives and our neighbors. With such tiny surgical scars, we might never know their past unless they told us.
Besides the growing popularity of bariatric surgery, there are many other interesting facts. This is also one of the few types of elective surgery that insurance companies pay for completely. These patients cannot take any NSAIDs besides Tylenol, ever again (no ibuprofen and no aspirin), and must take special vitamin formulations forever. Also bariatric surgery seems to cure type II diabetes immediately. Nobody understands how this happens.
At the “weight control” clinic, I watched the surgeons screen and consent patients for surgery. The process seemed quick and dry, involving statistics and standardized questions. The most personalized question was, “If you could eat any food without counting the calories, what would it be?” Most people seemed nervous as they eventually signed the paperwork.
Mr. Cob was re-admitted to my surgery service after a couple weeks because he had a minor complication that required treatment. He seemed different. He was less friendly, even somber. He kept his eyes closed while he spoke to me. “I lost 25 pounds already and I don’t have to take any medications for diabetes anymore,” he told me without any hint of pride or excitement.
The surgery may be simple, but the aftermath is not. Adjusting to a tiny stomach and new diet is treacherous. I saw how it took a toll on the spirits of my young, energetic patient, and I wonder how it will affect the future lives of my patients and so many others.
*Please note all patient identifying information has been intentionally changed or omitted. The details are modified, but the overall experience remains true.
I had my knees replaced in Highland Hospital where a lot of this type of surgery is done. The room where I registered had many seats that ere two seats wide for these patients. it makes me sad just to think of how many of these surgeries are needed. One day at the public market I spoke with a young woman who had had this done and was very pleased with the results.
Liz- Can you tell to what degree the high financial costs of treating obesity works as an incentive for people to practice healthy habits? Put another way- Under universal healthcare bariatric surgery will become much cheaper/free. Will more people try to go the surgery route in that case, since eating healthy is a pain?
I suspect financial stress makes people eat worse and exacerbate the problem, and that obesity may go down under universal coverage, but you can probably tell better than I.
You know it is rarely the case that insurance companies cover a procedure even though it will save them money in the long run. For example, they often don’t cover abortions or birth control, but will finance labor and delivery and cover the baby’s health care. Or they might refuse to pay for galbladder surgery, but will cover all the ER visits when a person has painful attacks. Or they would refuse to cover the more expensive antidepressant, but then pay thousands of dollars when somebody is hospitalized because they tried to commit suicide… etc. This is true for universal coverage (programs like medicare or medicaid) as well.
So, I was surprised that insurance companies pay for weight loss surgeries. Will this encourage more people to do surgery? Absolutely! Most doctors require a 6-month pre-operative follow-up and a 5% weight loss before they will do the surgery. So, it’s not as simple as saying “yes,” but pretty close.
Fascinating post. It is really interesting how our quick fix culture affects everything. I have known people who have had these surgeries and still are the size they were when they started, but for some it works. I think people don’t really realize it is a lifestyle change.
I’m amazed that it wipes out type II diabetes!
Do you know what the statistics on success rate for weight loss with these surgeries?
That is an excellent question. The truth is that there is no good longterm data available because the surgery is still a relatively new procedure.
According to “Bariatric Surgery and Long-term Control of Morbid Obesity” (Brolin, JAMA 2002 article): weight loss with gastric bypass “corresponds to loss of approximately 35% of initial weight. However, there is some degree of recidivism between 3 and 5 years…” After 5 years there is probably even more potential to regain weight because tissue can stretch over time. To compare, I think mean weight loss with diet/ exercise programs and drug therapy usually 70% regain that weight after a year.
Besides the actual pounds lost, success can be measured in terms of resolution of diabetes, sleep apnea, heart disease, cancer risks, urinary incontinence, etc. (these benefits may be somewhat independent from exact % of weight lost). About 30% of Americans are obese (BMI>30), and so far we have not found any promising solutions. Surgery may be the best option available today, even though it may not be wonderful.
Your writing style for this blog usually gives me a very good sense of how you feel during a given situation, or about a certain topic…This post seems so different, at times I think you like the procedure, at times not, am I picking up on your confusion, or is it something else?