It is difficult for me to include a section on bariatric surgery within a website designed to get folks motivated to lose weight and get stronger. The problem with weight loss is that the more weight you are carrying the less chance you have for success. Once your extra weight is in the 100 pound range, the chances of losing down to a reasonable BMI become close to zero. The reasons are multiple.
1. What are the chances of me going for a long walk every day if I had to carry a 90 pound bag of concrete mix on my shoulder?
2. Large amounts of fatty tissues secrete hormones that would not be present if your weight were normal.
3. There is just so much room in your body cavities. Fat competes for space with your organs, causing malfunction.
So weight loss gets more and more difficult, the more there is to lose. Bariatric surgery is like going to the top of a tall building by taking the elevator rather than going up stair by stair. There is some risk to the surgery and considerable expense, but it makes far more sense to get it done and lose the weight and get on with your life – rather than go up and down for the next 5 years and lose all that time. As we say on the wrist bands – “life is short – snap to it”.
Here is a link to a good article on fat distribution and the way large amounts of fat start to “run the show” and get in the way of your dieting.
We will start with an interview with Debbie, who had bariatric surgery over a year ago. After that we will interview the doctor that did her surgery.
Debbie’s Bariatric Surgery
A diet and exercise website really shouldn’t have information on bariatric surgery because after all, we are all about success without needing surgery, right?
What Thindex is all about is success one way or another. We do not recommend trying all your life to get to a healthy you and failing. Statistics tell us that after a person gains in excess of 100 pounds the chance of successfully dieting it off and keeping it off are 2 per cent. With that in mind, lets go and talk with Debbie. She owns her own barbershop and while cutting my hair she mentioned that she had had bariatric surgery and was dropping off a few pounds. I thought that the website visitors might like to ask Debbie a few questions about her surgery and how she is getting along.
Debbie, did you have any success with dieting?
I have dieted since being a teenager and I managed to diet my way to a very large size. My mom had me take a bunch of pills from a doctor that did not help. I have tried and failed Schick, Nutrisystem, Fen-Fen, Atkins, Slimfast, Lean Cuisine. I have fasted and tried hypnotherapy.
Were you ever thin?
I was a little chubby, not fat.
Did you put on weight when you had your kids?
I put on 70 pounds with the first son and 30 pounds with the second.
Did you do much exercising or walking with your attempt to lose the weight?
Walking was always my first choice of exercise and I worked out at the gym also.
How far did you walk?
One to two miles.
And at what point did you decide to look into the surgery? What brought you to that point/?
Any diet I tried failed or I would just gain back the weight plus more. I felt that I was out of options and would never be fit. I was so tired from working that I did not feel like doing anything. It was becoming difficult to buckle my seat belt and to get out of chairs. I couldn’t wrap a bath towel around myself. I was worried about my health and my personal hygiene. A couple of my customers had gone with the surgery and told me of a meeting at the hospital where it was described in detail. My husband and I went and took a step towards a new life.
Have you got any pre-surgical pictures?
Can you walk us through what a surgeon needs to see before agreeing to do the surgery?
I just needed to explain my life story of unsuccessful dieting, all while gaining weight.
Was your family supportive of your choice?
My husband felt the surgery was like cheating and that I should be able to lose the weight the old fashioned way, if I really wanted to.
When was your surgery?
Did it hurt much?
I had very little pain. None that I can recall. I missed about a month of work and then worked half days for a few weeks.
What do you remember about the first month with your new small stomach?
I remember measuring such small feedings and eating frequently. Getting used to a new eating habit was my main reason for missing work.
When did the weight start coming off?
The scale showed the gradual loss right away. My husband took pictures of me in a swimsuit each month and after a few months I could see the difference. All of a sudden my clothes started feeling baggy.
Did you have to buy a new wardrobe?
Not for a while. I had some that would work. But now I am so much smaller that I do have to purchase new clothes.
Can you tell us how much weight you have lost in this past 14 months?
That is the size of a person. Are you happy you did it?
I am thrilled.
How much food do you eat with your new little stomach?
I eat three main meals a day and snack every few hours. My stomach feels about the size of a golf ball but it can take a little more food than that.
Do you take supplements?
Vitamin D, B-12, Calcium, and a multivitamin twice daily. I take the gummy bear vitamins because I don’t like swallowing a big pill.
What choices of surgery are there for a person that is serious about getting this done and stop fooling around?
I know of the gastric by-pass, the banding, and a new procedure that is done through the mouth.
Did you have any complications?
Dairy gives me gas, but I can eat anything else. I did have emergency surgery for a bleeding ulcer but it was unrelated to my bariatric surgery.
Would you do it again?
I would. I wish I would have done it years ago. I wasted a lot of living with one failed diet after another.
Did it cost much?
40,000 dollars. I paid 1000 dollars. I save a lot of money on food now. If I eat out I bring a doggie bag home for my little dog. He never had it so good.
Is he gaining weight?
Maybe, he won’t go near the scale.
Have you had any improvement in medical conditions related to being over weight?
I am much healthier now. I am off my blood pressure meds.
I know there is an age limit to these surgeries. So just how old are you anyway?
None of your business.
Okay, touchy subject for us all.
Here is another post surgery picture of Debbie, a little over a year post op.
a lot about how to lose weight. Virtually every bariatric patient loses massive amounts of weight, usually in excess of 100 pounds within a year. Some people will creep back up if they try to stretch their stomach to hold more food.
Obviously, screening out those that would try to torpedo a good result is important. Debbie is an ideal candidate and loves her new look and not having to carry around 116 extra pounds.
If there is interest, we can follow up with Debbie in 6 months and see how she is doing. She would like to lose some more weight and is continuing to do so but more slowly.
Casey – bad dog, get out of this picture; you have nothing to do with bariatric surgery. Thanks Debbie, for talking with us today.
What has bariatric surgery taught us? It confirms what Luigi Cornaro told us 500 years ago. If you want to lose weight and be healthy just eat small infrequent portions. Luigi ended up deciding that 12 ounces per day in multiple small feedings was just right for him. ( Discourse on the Sober Life by Luigi Cornaro)
That is probably a bit less than Debby eats.
Another shocking piece of knowledge is that there is no such thing as an overweight person that can maintain their weight with a low calorie diet. They all lose weight. The final bulletin is that overweight people require more food to stay overweight than a thin person. If you eat like a bird, you will become the size of a bird. There are no exceptions. The reason diets fail is that people do not adhere to the diets.
So eating small amounts of food is one way to lose weight. At thindex we recommend higher volume, vegetable based, low protein diet. The disadvantage of our program is that the stomach doesn’t shrink like Luigi’s did so the opportunity to gorge is still present.
If you want to check out our progressive health steps that represent our program, be our guest. Be advised that Casey, the eco-dog, sticks his nose in once in a while and can be a bit of a problem. I let him pick the rose of the day to keep him on the sidelines, and he helps pick up roadside trash. You can see how he got into one of Debbie’s pictures where he knows did not belong. Sorry.
Thanks again, Debbie, for agreeing to this interview. Perhaps a few more pictures will be needed in 6 months or so.
Monday, February 21, 2011
Wednesday, October 10, 2012. I spoke with Debbie today about her surgery. She remains pleased with her results and would do it again.
Bariatric surgery. An interview with Dr. Leslie Cagle
Bariatric surgery is a subspecialty in the field of general surgery that is devoted to changing the anatomy of the upper digestive tract in such a way that fewer calories are consumed. The goal of the surgery is weight loss. The practice has become more common as so many people have seen their lives be jeopardized by the ravages of obesity. The surgery is becoming less and less invasive and less expensive.
Dr. Leslie Cagle practices general surgery and bariatric surgery in Vancouver, Washington. I am speaking with her at her Vancouver office, suite 301, 505 NE 87th Ave, 98664. She will answer some questions that people might have about this specialty.
Hi, and welcome, I have been doing bariatric surgery since 1997. Dr. Dally and I started a program of bariatric surgery in 1999 at Good Samaritan in Portland. We have done over 1000 cases.
2. Why did you do the extra training after being a general surgeon?
I was in Scotland doing a fellowship in laparoscopic surgery (key-hole surgery). Scotland has a higher incidence of heart disease than we do. They have a short growing season and eat everything deep-fried. I knew little of bariatric surgery but had an opportunity to go to Brussels to see some bariatric surgery. My mentor there did banding procedures – one every hour. Changing someone’s life for the better with a one hour operation really peaked my interest.
3. Where did you go for your fellowship?
Scotland. My fellowship was in laparoscopic surgery and bariatric surgery is a laparoscopic procedure. All of my partners have all been trained on all current techniques.
4. How many years beyond college does it take to become a bariatric surgeon? Med school, internship, residency,
Eight years beyond med school which for me included oncology as well as the laparoscopic training. In truth, surgery has been changing so quickly, that even after 20 years of practice I still learn new things.
5. What are the plusses and minuses for you of bariatric surgery verses just general surgery?
There is very little need for long term follow-up after most general surgical procedures. However, with the bariatric surgical population, we see whole families that have the surgery and we follow these patients yearly once their weights have become stable. This is our little way of doing family medicine and staying in touch with the people we help. That part of the practice is quite fun.
6. Any regrets so far?
No, none at all.
7. What is your patient criteria for the surgery? How can you tell if they are truly committed or not? Is a patient’s self image a criteria or is it mostly health?
We use the NIH (national institute of health) criteria. By the time they get to us, they have tried and failed multiple diets and have met the criteria of a BMI over 40 or a BMI over 35 with a co-morbidity. In the future, there may be some easing of the BMI criteria down to 30 – 35 with a medically related condition that is not resolving.
As for self-image – that is not really what patients say they care about. They care about being able to walk, move better, sit in an airplane seat, tie their shoes, and play with their kids, i.e. lifestyle. As their surgeon, I look at blood pressure coming under control, getting off meds, sleep apnea clearing up, resolving diabetes, and so on, but the patients mostly talk about the life style benefits.
8. What are the surgical options, and who gets what procedure?
We offer three options, banding, the sleeve procedure, and the by-pass procedure. The by-pass procedure creates a small pouch in the stomach and connects the small bowel to that pouch. The other end of the bowel reconnects downstream and the stomach is bypassed.
The band is simply that, a surgical band that encircles the top of the stomach creating just a small exit for food. The band can be tightened by filling it with a saline solution.
The sleeve is a newer operation. The stomach is stapled, changing it from a bag to a sleeve, so that food moves down a narrowed tube. Once again, the goal is to limit the amount of food that can be consumed.
The surgery selected depends on what the patient wants and what they are approved for. Some patients are better candidates for one operation rather than another. We talk about the options in an office visit.
9. What are the complications that patients need to know about?
We used to council that with surgery, one in a hundred might die. After all, surgery in this unhealthy population is risky and there can be complications. With the band, there is less healing to be done but with the by-pass there are suture lines that need to heal. We are now able to say that with bariatric surgery there is a risk of death of one in a thousand. That is still very acceptable when you realize that morbidly obese people are dying at far greater rates than the non-obese patients.
10. What kind of patient will you turn down as a candidate that might not perform post op or has too many risks?
They need to be drug and alcohol free and be off cigarettes for 6 months. They have to be committed to follow-up and an exercise program. They need to not be trying to conceive a child in the year following surgery, but after that it’s okay. I will turn down a person that doesn’t seem to have the years left that could be enjoyed even if the surgery was successful.
11. What are the youngest and the oldest you would consider? Does long history of GERDS compromise results or push you to do one surgery or the other?
So far, 15 is the youngest and 70 is the oldest. There are children that are younger that could benefit but there are specialty centers that they should go to. It is sad to see a 12-year-old child who is morbidly obese and know that there is going to be a lifetime of problems for that child. We don’t operate on children younger than 15, but could suggest other programs. Doing this life altering operation on teenagers is not to be taken lightly. They need to be mature enough to follow through with the program just like anyone else.
At the other end of the age spectrum, there are not many obese patients that live to the Medicare age. It is a lethal disease. Most of our patients are in their 30s or 40s.
GERDS . (Gastro-esophageal reflux disease)
is generally cured by this surgery because acid is made in the lower stomach and the surgery keeps that acid from refluxing up into the esophagus. If an obese patient came to me with resistant GERDS but not mentioning their weight as a problem, I would encourage them to kill two birds with one stone.
12. Are more insurances getting on board?
The data is there – it saves them money. But of course they will come up with hoops to jump through like a 6-month program of diet and exercise even if not one pound is lost.
13. Are these procedures cost effective and over how many years?
The data for diabetes is best known. It costs 10,000 dollars a year to treat a diabetic. The company gets its return back in 2 and a half years.
14. Some people regain their weight – would you ever re-operate them? Has it happened?
There are revision procedures that are sometimes necessary, however the risks are higher because suture lines in the previously operated area are more prone to failure.
15. My wife had a needle injection into her neck under x-ray control at the hospital and the surgeon charged 300 dollars but the hospital cost 5000 dollars and it took less than an hour with no anesthesia – why do the hospitals get so much? Is it the same for bariatric surgery?
Yes, it is. We have been negotiating with the hospital for the last few months to bring the cash cost of this surgery down so it is more affordable and competitive with out of country surgeries as in Tijuana. The charge there is 10,000 dollars. I suspect that there are some centers in Mexico that they do good work. Nonetheless, I had to re-explore a couple of patients done in Mexico that had major complications. Their insurance did not approve of the original procedures and could not cover the complications. Costs can be staggering.
18. What is this “sleeve” procedure that is now being done here?
It amounts to creating a “sleeve” in the stomach instead of a bag. The food goes through the esophagus and then into this sleeve. Again, it minimizes the amount that can be eaten, which is common to all the successful procedures. The benefit is that no transverse suture line is made and the food is not rerouted as in the by-pass.
With the sleeve and by-pass procedure, weight loss stabilizes at a year and a half. Both procedures should lower weight by 100 plus pounds depending on patient cooperation. Banding patients generally lose less weight.
17. What percentage of Americans would right now benefit health wise and longevity wise from bariatric surgery of some type?
Fifteen million Americans are morbidly obese. Although, 220,000 Americans underwent bariatric surgery in 2009, only 1% of candidates get surgery. There is certainly plenty of work to be done.
18. There are many heavy people out there looking at this website and wondering if they should consider this surgery or not. It used to be considered radical, but when you look at a persons life being ruined by obesity, diabetes, hypertension, syndrome x, angina – it sounds more sane to get something done that can work if nothing else will. Right?
Hands down, bariatric surgery works. It is cost effective and it is lots safer than even 10 years ago. Bariatric surgery is certainly less dangerous than carrying an extra 100 pounds.
19. Is there any evidence that bariatric surgery can reverse cardiovascular disease? I see that the coronary by-pass procedures need to be redone if life style changes are not modified.
The heart has a much easier job if 100 pounds of fat is no longer on board. That tissue has to be perfused so losing it is like becoming a smaller person, which makes the heart’s job so much easier. Bariatric surgery significantly reduces long term cardiovascular risk.
20. What do you see down the road for bariatric surgery? Will Americans ever learn to eat and exercise, or will there be a new pill for exercise some day?
I see job security for the next ten years.
21. What is the hardest habit to break? Cigarettes, Alcohol, hard drugs, or overeating and obesity?
Probably overeating, because the food is just always there.
22. How far away geographically can a person be and be considered for surgery by you?
We just need the patient to have a network of physicians to work with us, will give us follow-up and keep the patient focused on the post op regimen. We have done patients from Alaska. It takes some work both from our office and from the patient and their doctors, but it can work out well.
23. What would you say to a person that was going to have the surgery done in a distant country in order to save money?
Be wary. Sometimes you do “get what you pay for”. Shop around and be sure your surgeon is well qualified and then find out where you are going to get care after the initial surgery.
Thank you Dr. Cagle. Here she is with a patient that had a sleeve procedure 2 months ago. The procedure is resulting in progressive weight loss.