Monday, September 22, 2008

Bariatric surgery, stress eating, marginal ulcer and PTSD

Here is something not talked about EXCEPT in medical journals (where it's OFTEN talked about): (from Melting Mama's blog)

... [she] had roux en y gastric bypass a couple years back. She's been having burning "acid" pain and discomfort and took her concerns to her Bariatric Surgeon. He says it's a "Marginal Ulcer." The doctor said there will be NO denying when it perforates, and to get to the hospital.

My reaction here is that many Weight Loss surgery (WLS) post ops especially longer term post ops, are living with a form of "Post Traumatic Stress syndrome" - i.e. when things "just happen" to you suddenly, rather unusual things which do not happen with such regularly, frequency or severity to the general public, or like the individual above, you are WAITING for "things to happen", it tends to cause a type of stress which can lead to catastrophic thinking (and fear and anxiety) on a daily basis.

Again this is NEVER discussed at pre op seminars and seldom discussed when post op depression (which many post ops I know, have) is encountered. They are given medications which they may or may not absorb and sent home. If they eat to help their stress, they are often verbally abused by medical providers.

Meanwhile the ads and promos and seminars for WLS continue to brag that it will help depression to lose weight with WLS! I guess they hope folks won't read some of the yahoo listserves where longer term post ops hang out....

Also, I know cases where overeating has gotten folks through periods of extreme trial and stress, in their lives when, without this method of stress management, they might have had nervous or physical breakdowns.

Again, medicine almost never acknowledges stress and how it can be the MOST devastating thing to a person's health - much MORE devastating than some extra pounds (to put it mildly).

One person on another list talked about being recently hospitalized for "being suicidal". I've known this person for quite some time now, and she is usually an upbeat, cheerful, optimistic person and also of very high intelligence. So when I heard she had been thinking of the ultimate bad ending, I was more than a bit shocked. Did anyone ever consider that her "suicidal ideation" might be because of her gastric bypass which not only did NOT produce the weight loss she was promised (despite her being a model patient) but also has caused numerous NEW comorbidities which are difficult to impossible, to treat? I bet not one person who has treated my friend ever asked these questions. :(

By the way, the Junkfoodscience blog has an excellent analysis of the latest study suggesting that bariatric surgery (weight loss surgery) is more cost effective for insurance companies than treating obesity. I love her title "
No evidence that bariatric surgeries save healthcare costs or save lives" Seems this study has more holes in it than swiss cheese. Bravo to this blog and its author for exposing these um...less than scientifically sound (how's that for politically correct) studies!

Finally by way of news, the young lady who made the headlines a while ago for getting a lap band (after lipo suction etc) in her early teens, appeared on the new show, "The Doctors". Seems she (not the parents!) is looking to get more plastic surgery. "I want my arms done," she told those watching the show, pinching a small bit of skin under her arms. She admitted she wanted a few other procedures also. I found myself wondering whether she, like so many of us, is getting into the "hooked on plastic surgery" thing. Of course, this attitude seen in many American women, keeps plastic surgeons in business, but so often the bottom line is the inner feeling that "I will never look good enough" a possibly correllary of which is "I will never BE good enough". Many people who get WLS are also motivated by looks and highly disappointed with the results when they don't come out looking like the air brushed models in the magazine with totally flat abs etc, even if the surgery produces a weight loss close to the so called "ideal". This young lady, now at the age of 15, remains a lovely naturally good looking young lady who, because of societal pressure, may well not be enjoying what nature gave her, and just the exhilaration of being young with her life ahead of her, instead looking for happiness in places where perhaps happiness may not be found. Should she be looking for inner happiness which may make her feel a lot better than yet-more surgery?

Friday, September 12, 2008

WLS providers misrepresent - who loses?

Occasionally (ok not so occasionally) I listen to an interview with a weight loss surgery provider which misleads from start to finish. And this upsets me and I think it upsets the many providers out there who truly care about their patients and try to follow up and make themselves available. It upsets everyone because it could give folks a very bad impression of providers in general. Folks tend to make decisions based on very limited contact. That is, _if_ their limited contact is a provider like the following one, it could lead to not only bad decisions but also a bad name for the industry.

I actually came across this provider whom I will call DR X, because one of his patients wrote to me and she is not a happy camper. She had a gastric bypass 3 years ago and has been ill ever since and worse yet, she hardly lost any weight from it. This provider who told her it was easily reversed and that he would be there for her, immediately dropped her with his last communication being several rude comments about how she had broken the "tool" and all her illness was her fault. She now is looking for a provider to give her a take-down so she can have some quality of life again and not be so ill.

I am not blaming the surgeon for her illness - it could be that her body just really objected to having her innards so drastically rearranged - many bodies do object to having the stomach cut in two pieces and most of it bypassed and the gut cut into three pieces and put back together in a very different manner than it came from the factory (despite the fact that the media hype tries to convince us that it's a total "walk in the park" and the "weight falls off" etc).

What I do fault the surgeon for, is not supporting her when she did become ill and also she told me that the surgeon really did not give her any detailed instructions on how to manage, what supplements to take, B12 shots and a myriad of other facts gastric bypass patients should be in possession of, before they take the big plunge. To be sick and without a provider who understands can be one of the loneliest positions one can be in and yet, I have met quite a few ill gastric bypass patients in this exact position.

In the radio program I listened to, this provider made the following comments:

When asked if a gastric bypass wasn't a really extreme solution, he answered that living with a BMI of 43 was much more extreme than having a gastric bypass.

I think picking that BMI was an unfortunate choice for him. I lived with a BMI of 44 for quite some time and found that it wasn't extreme at all and that even being in my 60's I was totally not ill or even mobility impaired as he suggests. He never dealt with the fact that the gastric bypass has a 2 in 100 risk of death within 30 days of surgery (report delivered to the College of surgeons in Oct 21, 2003.[Study title: The Impact of Bariatric Surgery on Patient Survival: A Population-Based Study]) and a 2-4 percent risk of dying within the first year plus a 20 percent reoperation rate and a 34 percent risk of gaining all or most of the weight back within 10 years. (Annals of Surgery. 244(5):734-740, November 2006. Christou, Nicolas V. MD, PhD; Look, Didier MD; MacLean, Lloyd D. MD, PhD) Now that's extreme!

But the comments were about to get better or more um..misleading...

He dismissed all the "bad stories" about gastric bypass comparing pregnancy to gastric bypass "everyone gives them the horror stories. People in general want to share your misery."

I don't have to comment about this one except the least this comment is, is highly insensitive to those folks for whom the WLS does not work or makes them ill. Of course, there is every evidence that this surgeon drops patients who are not happy campers so he may not really be concerned with anyone but those who are happy with the surgery.

And of course, pregnancy is a very natural condition whereas the gastric bypass is a very unnatural condition. That's kind of a no brainer.

Next comment....

He pointed out that all WLS patients had tried dieting and failed but then, made another unfortunate analogy. He stated that "you don't buy a car without taking walks, getting rides from friends, taking the bus and riding a bicycle"

In case Dr X didn't know, most people never try out bikes etc before buying cars - indeed, a large percentage of teens already have cars and use them to drive as short a distance as 1 mile to school which would be a walk for me! And actually, most ill patients have told me that they really didn't give dieting as hard a try as they gave WLS, so perhaps his analogy while unfortunate for proving his case, may have been more correct than he meant!

Finally to make his point which was obviously to go buy a bariatric surgery, hopefully from him he made the classic comment of all times. I quote him here:

"It isn't extreme. I'd much rather have bariatric surgery than being obese. I'd rather have AIDS than diabetes. I know that people don't die from AIDS in the USA anymore..."

Excuse me? People don't die from AIDS anymore? What planet does he live on, I wonder. Has he ever seen a terminal aids patient? There is nothing quite so bad as that. Diabetes while not a walk in the park, is totally no comparison to Aids and I really wonder how a physician can make such a bad error without making it on purpose, hoping the public is extremely ignorant.

Physicians like this scare me because people believe them and can get very hurt by their misrepresentations.

In the course of the discussion, it turned out this surgeon, Dr X, had gained 70 lbs at one time in his life and had lost it by exercise and extreme eating. In other words, some of his judgmental attitudes definitely resemble the ex-smoker who is intolerant of everyone who has not yet given up smoking.

He is not the first surgeon I have encountered who is fat phobic - actually I have over heard remarks from a few WLS surgeons which are extremely disparaging (to say the least) about the patients who provide their bread and butter. One surgeon, for example (who is retired now) told the nurses to not pick up a bariatric patient if they fell. "Just leave them on the floor and call the paramedics and let them deal with it" he told the nurses, an attitude which annoyed even very slim nurses. He was the one who laughed when he said "Oh, if they overeat after surgery, it WILL come up!" I think the vomiting after gastric bypass isn't a laughing matter by any stretch of the imagination. Not withstanding his assumption that all fat people are that way from stuffing themselves which in my observation simply has no relationship to reality.

In the as yet unpublished Russell Williams studies, he asked several caterers who had catered NAAFA conventions where the average BMI is well over 40, how the amount of food consumed compared to those conventions attended by a cross section of the public, many at so called "normal weight". He found that 3 caterers said the fat folks had consumed about the same amount of food as the so called normal weight folks and the other three caterers said that the fat folks had consumed less food than the slimmer folks!

So we wonder does a surgeon's fat phobia spill over to his/her performance in the OR? One would hope not and frankly, I had never considered the possibility, until I watched a "Whipple procedure" which is done for pancreatic cancer and much less invasive than a gastric bypass. The surgeon refused to do it laparoscopically (he said it was too delicate and too much might be injured), he took 5 hours to do it, doing most of the anastomosis with sutures and not with staples and painstakingly, avoided injuring organs, causing a lot of bleeding and not connecting blood vessels. The Whipple procedure provides for cutting a section of the pancreas and a section of the duodenum, the first section of the small bowel which is a small percentage of the digestive tract which is cut and rearranged in a gastric bypass. So I really wondered how they can do a gastric bypass in 30-90 minutes when there is a lot more cutting involved? Is it because fat people considered disposable in our fat phobic society? I was shocked to say the least but in thinking about it, it's logical that fat phobia would carry over, at least in some cases, as does any bias.

If you are considering any of these procedures particularly the gastric bypass (RNY) or duodenal switch/bileopancreatic diversion (DS/BPD), take your time. Get your information from informed consent documents or from a gastroenterologist. Someone who does not stand to profit if you decide to go ahead with it. That's only common sense. Sadly, we often take a lot more time and care, buying a car than we do, buying a surgery.