Introduction

[Note: The entries in this diary appear last in first out, after this Introduction.]

This is my diary of my experiences with weight loss surgery. I use this general term, because there are two (actually more) types of weight loss operations: gastric bypass or lap-band. But, I am getting ahead of myself. Click to see more...

[Note: in the rest of this blog, you will see the "Click to see more..." message at the end of each posting. Many times,there is actually nothing more. So, at the end of those posts, I have proceeded the "more" link with "End of post, so don't ...".]

Friday, September 26, 2008 I had my first set of appointments in the preliminary examinations for Weight Loss Surgery. Here are the facts:

• Weight: 343lbs (350lbs with clothes on, but I will use 343 as it seems to be my body weight set point)
  
• Height: 5' 11"
• Body Mass Index: 47.8 (non-overweight BMI: 18.5-24.9)

(go to BMI Calculator to figure out yours)

The standard qualifications for WLS patients are a BMI > 40 and an age between 18 and 65. I qualify.

I had an electrocardiogram which was judged OK, but there was one little dip where there should have been a rise and so, since I am 61 I am scheduled for a stress test to make sure everything is OK.

The subject of the appointments I will have, ending with a meeting with my chosen surgeon, are:

• Two seminars on Weight Loss Surgery
  
• Blood work
• Introductory meeting with Bariatric nurse
• Introductory with director of WLS program at BIDMC
• Ultrasound to determine if I have gallstones
• Stress test
• Nutritionist
• Psychologist
  
• Exercise physiologist
  
• Surgeon

i.e., extensive.

On my application to the Bariatric Surgery Program at Beth Israel Deaconess Medical Center, my answer to the final question of "Tell us about yourself..." was:

My primary reason for wanting to get control of my eating and consequently my weight is because I am fearful of all of the adverse health conditions that have accumulated in my body due to being significantly overweight in the last 15 years. Yes, there are many activities that I no longer can do because of my excessive weight. Things like walking, hiking, enjoying the adventurous aspects of traveling. Then there is the self-loathing that results from my lack of discipline to "just eat less" and my appearance.

I'm pretty smart and that has worked against me. Although I was very successful in loosing weight in Overeaters Anonymous, after a while I started to fail because I started to ignore the advice that "Thinking is not on of the tools of OA". And indeed it has taken me several years to fill out this form, because after I investigated everything there was to know about weight loss surgery, I thought "Why go through that? I can always exercise the discipline that you will need after the surgery and loose weight without going through the surgery." The only problem is that I never got around to exercising the discipline, and so the weight stay on. I have finally realized that all of this intellectualization has resulted in me weighing 350 pounds and on the verge of diabetes, the third or fourth medical condition due to my obesity. My biggest fear is how to deal with the stress I currently relieve by medicating myself with overeating. Then, of course, there are the unknowns about what it will feel like after the surgery, and the well publicized surgery complications.

Having said all of this, I want you to know I am both enthusiastic as well was watchful about what I am going to do. Please wish me luck.

Harry

P.S. Why did I choose the name "Reboot" for this blog? Well, in computers when the machine starts to perform badly because of the accrual of lots of junk, mismanaged memory, rogue processes, etc., the best thing is to reboot the machine and start from scratch. I find this a metaphor for what I am about to do regarding my eating: lots of bad habits, reasons for eating, out of control behaviors. The best thing is to start again with learning how to eat and WLS surgery is the only 100% foolproof way to do this. -- HF

So, How are things going?

Just an update on how things are going. There have been some big changes -- but not necessarily in the weight department. Rather, in the exercise department. Marsha and I have been in Florida since Feb 1 and we both are getting a lot of regular exercise -- bicycle riding, kayaking and swimming. This time of year in Naples is wonderful for exercising -- temperate days (75°-80°) cool nights and mornings (60°-65°).

The net effect is that we have both been getting a lot of exercise and it feels good.

Next week I return to Boston for 2 days and an appointment with my weight loss team where my surgeon will inject saline into the port for the first "fill" of the gastric band. Right now, I feel no change in my appetite, but expect that after the fill, I will experience a sense of being full faster at meal time. This is the effect we are after, and I know that it may take several attempts to get the right amount of saline so that I am feeling full after eating the right amount. So, patience is the word here -- and I appreciate that the slow, deliberate approach is being taken here. I don't want any mistakes...

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Latest developments in Weight Loss

Thanks to my relative Jeff Blaustein, here is a video summarizing an article that reports on two new techniques for controlling the amount of food metabolized by a severely obese person. The article appears after the "Click to read more..." break.



I imagine surgeons who have carefully built up a practice in one form of weight loss surgery have to constantly look over their shoulders to see which new techniques are being developed. If not, the entire fast moving world of weight loss intervention might blow on by them.

http://www.newscientist.com/article/mg20126936.300-gastric-condoms-could-help-obese-avoid-surgery.html

Gastric 'condoms' could help obese avoid surgery
by Peter Aldhous

GASTRIC surgery is a last resort for people who are dangerously obese. But there may soon be a gentler option in the shape of a removable device inserted into the gut though the mouth.

The EndoBarrier, developed by GI Dynamics of Lexington, Massachusetts, is an impermeable sleeve that lines the first 60 centimetres of the small intestine. In animal experiments and preliminary human trials, it reduces weight and rapidly brings type II diabetes under control.

Given the rising tide of obesity across the developed world, new treatments are a matter of priority. In the US alone, more than 15 million adults meet the criteria for gastric surgery because they have a body mass index of more than 40, or a BMI of 35 plus a complication such as diabetes.

While the operations do cause dramatic and sustained weight loss, their high cost and concerns about the risk of dying on the operating table mean only a fraction of those who might benefit go on to have the surgery. According to the American Society for Metabolic and Bariatric Surgery, around 220,000 people in the US had gastric surgery for weight loss in 2008.

GI Dynamics is not the only company working on alternatives (see "Wired for weight loss"), but its approach is appealing for its simplicity and low cost. The device, enclosed in a capsule, is inserted via the mouth using an endoscope. Once in place below the base of the stomach, the capsule releases a small ball that with the help of a catheter pulls a flexible sleeve made of the slippery polymer PTFE through the intestine. The ball is jettisoned and the sleeve fixed in place by releasing a spiked attachment made from the shape-memory metal alloy nitinol (see diagram).

The entire process takes less than half an hour, and the EndoBarrier can also be removed in less than 10 minutes by tugging on a drawstring to collapse the attachment device and pull out the spikes. The EndoBarrier is then pulled back out though the mouth.

At the Massachusetts General Hospital in Boston, a team led by gastroenterologist Lee Kaplan has shown that a miniature version of the sleeve causes weight loss in rats equivalent to a popular form of gastric surgery in humans, where food intake is restricted by an adjustable band placed around the top of the stomach (Obesity, vol 12, p 2585).

"We aren't doing anything to the stomach, so the patient can still eat normally," says Stuart Randle, president of GI Dynamics, who adds that some patients given gastric bands find ways to fulfil their cravings for more calories. "They can do a lot of creative things - basically putting food into blenders," he says.
We aren't doing anything to the stomach so the patient is still able to eat normally

Kaplan's team also found that the device caused a rapid reversal of type II diabetes, even before the weight loss kicked in, thought to be the result of changes in neural and hormonal signals sent from the gut. This also happens in patients given a gastric bypass, in which the gut is replumbed to miss out a large part of the stomach and part of the small intestine.

The weight loss triggered by the device is larger than can be explained simply through reduced absorption of nutrients, Kaplan adds. So that, too, seems to be driven mainly by changes to gut physiology.

Around 150 people have tested the device, with similar effects to those seen in rats. Randle says the total cost of the EndoBarrier, including installation and removal, will be around $7500. This compares to $15,000 or more for inserting a gastric band, or at least $20,000 for a gastric bypass.

More extensive trials will be needed to ensure the device is effective and can safely be left in the gut for long periods, says David Flum, who studies the outcomes of gastric surgery at the University of Washington in Seattle. "We don't really know what the implications will be."

But if the studies prove successful, many more obese people could have access to potentially life-enhancing weight loss treatment.


Wired for weight loss

BEFORE doctors knew peptic ulcers were caused by a bacterial infection that can be treated with antibiotics, one approach was to cut the vagus nerves to reduce the release of stomach acid. This had an interesting side effect: many patients lost weight.

Now EnteroMedics of St Paul, Minnesota, aims to treat obesity using an electronic device that blocks vagus nerve signals to the gut. This seems to suppress appetite, inhibit the expansion and emptying of the stomach, and reduce the secretion of digestive enzymes. "It allows patients not to feel as hungry and to feel fuller much sooner," says EnteroMedics president Mark Knudson.

The vagus nerves descend from the brainstem, branching out to organs including the heart and the larynx, as well as the gut. The EnteroMedic device blocks signals to the gut by electrically stimulating the nerves just below the diaphragm at a frequency of 5 kilohertz. The electrodes are connected to a controller implanted beneath the skin above the ribs. Radio signals both program the device and recharge its battery.

When the vagus nerves are cut the body tends to adapt so in time shed weight can pile back on. To prevent this, EnteroMedics' device blocks signals for 5 minutes, shuts down for the next 5 minutes, and repeats this cycle throughout the day. It is also switched off at night.

The cost of device, now being tested in some 300 obese patients, will fall somewhere between a gastric-band operation and the costlier, more radical gastric bypass.

© Copyright Reed Business Information Ltd.

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3 Week Checkup 1/29/2009

Last Thursday I had my 3 week checkup, and all went well. Everything seems to be healing and working as intended.

First, I met with Dr. Henry Lin -- a surgical fellow at Beth Israel Deaconess. Dr. Lin came by when I was in the hospital and is very thorough young doctor who came in my room with a small team of, I am going to guess, residents/interns.

After making sure I was progressing as needed, he started to ask me questions about what I had done in the past. There is no better way for a doctor to flatter a patient than for them to change the topic of conversation to something special to the patient, different from the medical reason being addressed. I remember my father being flattered when his doctor asked him for investment advice.

Apparently Dr. Schneider told Dr.Lin about our conversation about my early involvement in the Internet and Dr. Lin introduced me to his team as someone who was involved in the early days of the Internet and proceeded to ask me a lot of questions about those experiences. Nice bedside manner.

In any case, in the 3-week checkup appointment, Dr. Lin asked me a lot of questions about how I was doing. One interesting piece of advice he gave me was to leave the dining area after 20 minutes. The issue is that at about 20 minutes of slow eating I will sense fullness -- but this too will pass and if I am still around food, there will be a desire to satisfy hunger. He warned me to avoid grazing because this can defeat the purpose of the band. Obvious once you hear it, but very good advice.

No one was surprised by my lack of sense of change in either my hunger or any sense that anything was different: in fact, this was the desired effect and I had indeed healed properly from the operation. Initially, I did feel some increased sense of being full after eating small amounts of food, but this was because there was swelling around the site of the placement of the band. Gradually as this healed, the swelling went down, and my food passages returned essentially to their pre-surgery dimensions. The prednisone that I was taking for my attach of gout also contributed to the cessation of swelling.

This effect can be seen in my weight loss graph to the right. For the 3 months prior to the operation (actually more accurately one month prior) I lost weight the old fashion way: by will power alone. Then I had the operation and my esophagus and upper stomach where the band was placed was swollen, constricting the flow of food to my main stomach. So, I lost weight at an increased rate. Then, when the swelling went down, my food passages were as they were before the operation, I am hungrier than immedately after the operation, and consequently I ate more and the weight loss slowed down -- it hasn't stopped, but is more gradual. So, I would expect to see this small rate of weight loss due to choice of diet, not hunger attenuation, increase at the end of February when I get my first "fill" -- when the surgeon injects the first amount of saline solution into the band. It will take a couple of visits before we get the exact right amount so that I do not feel hungry while still eating a reduced amount.

The bottom line is that now I have an "implant" -- the band -- that is ready to be activated at my next appointment at the end of February.

I next went up to radiology where I had a test to make sure that everything was working properly. I drank a liquid containing Barium which provided a high contract liquid that a continuous xray could follow the flow down into my stomach. This all proved that there were no leaks and that the band was in the right position. I was even able to see the band -- although it was much fainter than the liquid.

Finally, I met with Kelly Moore, the bariatric nutritionist who went over the Stage 4 eating plan, which introduces a number of new choices and textures.

This was all over in about an hour and 15 minutes, which was fine with me: with the positive review of my surgery, I was eager to move on to our next adventure, leaving for Florida the next day. End of post, so don't ...

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