You know – the stuff that lists are made of – if you’re a WLS pre-op or post-op – you know – those lists…

1.  Cross your legs.
2.  Shop in a regular sized clothing store.
3.  See your toes!
4.  Touch your toes!
5.  Fly on an airplane and not need a seatbelt extender.

…stuff like that. You know – the stuff we only passingly consider a possibility when we’re MO – or SSSMO (’cause the extra S’s make you feel SO much better about yourself) – and then once we’re just ‘O’ or – heavens – even ‘N’ – we completely forget what a big deal they are. [In case you need a refresher: MO = morbidly obese; SMO = super morbidly obese; O= obese; N = normal.]

Stuff like…

…thighs that don’t rub together when you walk.

…feeling like you fit perfectly in your own skin.

…having arm pits.

…arms that hang down – not slightly projected out from your body.

…walking and not even thinking about the pain of each step.

…forgetting that the scale is anything other than an instrument to report information to you – not your nemesis!

…walking into any clothing store – anywhere – and finding your size on a rack, finding an item that you like (because it’s fashionable and cute and will look good on you), taking it to the fitting room, confirming that yep! It fits! And then buying it – affordably.

…not strategizing whether or not you can afford to participate in an activity because of the physical ramifications that it will cause your body to go through.

….not arriving at your destination completely winded, sweaty, heart palpatating, and trying hard to NOT look like you’re about to have a coronary and keel over.

…not feeling yourself judged by nearly every passer-by – judged of character, will, morality – all sorts of crazy stuff – based solely on your size.

These are the things that I’d forgotten about. Oh – not in theory – just in practical application.

I recall clearly saying – oh, somewhere around a year post-op and having lost 175 of the 245 pounds that I would eventually lose – maybe even a little flippantly…

“I don’t ever want to forget!”

You know – what it felt like – what it was like in practical application – to live the life of a super, super, super morbidly obese woman.

I didn’t ever want to lose my sense of empathy.

I didn’t ever want to be one of those “normies” who had nothing but disdain for the MO community. (Believe it or not – I know post-ops who would fall into this category!)

I didn’t ever want to discount the hell that those who were still MO lived through daily.

I didn’t ever want to lose sight of where I’d come from. You know – 365 pound wheelchair-bound, every co-morbidity in the book, BMI 66 – me.

I don’t know – maybe you’ve met one of them – yeah – them – one of those post-ops (of any of the many forms of WLS out there today) who have left their MO lives in the dust – and can’t be bothered with the MO community today.

I didn’t – and don’t – want to be a snot.

I didn’t – and don’t – ever want to be ungrateful.

I didn’t – and don’t – want to ever be unapproachable.

I didn’t – and don’t – want to ever take for granted the incredible blessings afforded me.

I believe – with every fiber of my being – that I have been blessed to be a blessing.

So – with all of that in mind, let me just say this.

…maybe I am a little bit of a snot…

It’s true – I don’t want to forget what it’s like to be SMO – but dang it! – I don’t want to be SMO – or MO – or even O.

I can and will admit it. I like normal! I miss normal!

Is that disingenous?

Now that I’m here – back at Morbidly Obese again – I can tell you with all sorts of confidence – it sucks.

For so many reasons that it’s really impossible to catalogue them – but suffice it to say, it’s no joy ride.

I guess I’m surprised. I’m surprised how distanced I’d become – emotionally, relationionally, practically – from the reality of the life of living with obesity. Thank God that I’m not back to BMI 66 me – but that I’m 18 BMI points higher than I was when I had that horrible surgery in February 2010 – scares the living snot out of me. What scares me more is that it’s not stopping – this horrific weight gain – day by day, week by week, month by month – my weight just continues to go up.

I think another thing that surprises me is that I had really lost sight of – okay – pretty much completely forgot about – that pervading sense of DREAD and sense of heart-sickness – over the seemingly un-winnable battle that is morbid obesity.

I’m remembering anew the sense of having been vanquished by a foe that is poorly identified, defined, or battled.

How thankful I am for Dr. Baltasar!

I continue to think back – and remember how dire the predictions were about my chances of surviving TO my DS in 2002 – much less through the surgery itself.

Of course, “they” didn’t know Dr. B. They didn’t understand his heart of compassion. His understanding – somehow – of how important the battle is – and the best weapons to bring to the fight.

So – big breath in…

Let it out slowly…

I leave for Spain a week from tomorrow.

I have a date with a wonderful Spanish surgeon by the name of Dr. Aniceto Baltasar.

I am a blessed woman.

XXL Patients

by John Kelly, IV, MD

From http://www.outpatientsurgery.net/

Our patients are getting bigger and bigger. Not only is the obesity epidemic to blame, but the abundance of food, protein shakes and the steroid craze are generating larger and larger patients. I worry when I do surgery on these behemoths because complications increase and exposures are truly more difficult.

See the remainder of this article here…  August, 2011 Cutting Remarks.

You’ll be required to sign up for a free membership to get access to the complete article – which I think EVERYONE do.  And then, after you’ve read it – and you’ve allowed the steam to clear – add a comment on just how irate you are about the content.

For those of us who have lived our lives as the MO or SMO sub-population – it’s no surprise when we encounter discrimination.  Maybe what surprises us more is when we DON’T encounter it.

So I want to know – when have YOU encountered discrimination because of your size/weight?  Let’s hear it!  Because honestly – I’ve heard more than once in the past few weeks that discrimination against the MO doesn’t happen any more – that it’s a thing of the past.  I’m pretty sure it isn’t, and I’d love you to help me prove a point.

Do you ever wonder why people are always so ready to spread unsubstantiated rumors?

Honestly – I’m asked one question in particular once a week – at least.

What’s that question, you ask?

“Is it true that Dr. Baltasar has retired?”

Or, alternatively, someone will say…

“So sad that Dr. Baltasar has retired, oh well, I heard from so-and-so that their surgeon is taking over in his place…”

So – in attempt to be definitive, I felt the need to set the record straight.

First…

NO, Dr. Baltasar has not retired.

He is, in fact, still doing surgery. He and his team – the group of incredible surgeons who have been a team for more than 30 years – continue to work together and make medical history.

If you didn’t hear, this past Spring Dr. Baltasar was one of four surgeons worldwide who were nominated for the incredibly prestigious ASBMS Foundation Outstanding Achievement Award. (You can see the notification letter here.)

The three surgeons that make up the powerful bariatric surgical team in Alcoy – Dr. Aniceto Baltasar, Dr. Rafael Bou and Dr. Marcelo Bengochea – continue to save and revolutionize lives.

Now in his mid-60′s Dr. Baltasar and his lovely wife do have an eye toward retirement in the coming years – they have grandbabies that they need to be loving on! J With the goal of more family time in mind, they have decided to try and ease their schedules that direction. (For those of you who may not know, Mrs. Baltasar – who is one of the sweetest, kindest ladies you will ever meet, is also the scrub nurse in the OR with Dr. Baltasar and team. I’ve heard him remark more than once what a blessing it is to have her working at his side!)

So yes, they are slowing down. Rather than doing two surgeries a day five to six days a week in his private bariatric practice – and juggling his responsibility of Chief of Surgery at Hospital Virgen de los Lírios, nowadays it’s more like one surgery 4 days a week in his private bariatric practice. (If you’re not familiar with healthcare in Spain – it is socialized, so pretty much all doctors/surgeons work for the state for part of the day and then conduct a private practice the balance of the day.) Dr. Baltasar has also stepped down from his Chief of Surgery position and retired from his position at the state-run hospital. It gives Mrs. Baltasar and he more freedom to pursue other interests – and actual free time – something that has been elusive for them for years given their extreme dedication to improving patients’ lives!

Sometime in the next 3 to 5 years, yes, he’ll probably retire – but his team will continue on, headed by the very capable Dr. Rafael Bou, who has been a key component of the wonder that happens in the OR with the team. J

Another question I get often is….

So – wait?! – You mean I could still have my surgery with Dr. Baltasar in Spain?!

Yes, of course!

Honestly – if I were a newbie checking out WLS and wanted a world leader in the field to do my surgery (and –um – hello?! – who wouldn’t?!), you better bet your sweet bippy I’d be writing my introductory email to Dr. Baltasar right this very minute!

How do you get in touch with him, you ask? Start by emailing him. Here are his email addresses:

a.baltasar@aecirujanos.es

and

44baltasar@gmail.com

Why two email addresses? Well – if you have a particularly crabby virus scanner/spam blocker, you may find that you’ll have problems with the internationally based first address. If you know you’ve got issues with that – then use the gmail email address. Heck – use both of them! Make sure he gets the email!

Just so you know – he’s FAST about responding. If you don’t have a response with 24 hours I’d be really surprised. That typically means 1) your spam blocker has diverted his email to your junk email folder as an unknown sender, 2) he didn’t get your email, or 3) he’s out of the country – he does travel quite a bit to teach, proctor new surgeons, etc. But – he checks email while he’s away, too – he just isn’t always able to respond quite as quickly sometimes if his duties while he’s abroad are particularly time-consuming.

If that’s the case, you can always drop me an email and see if I happen to know if he’s out of town or not.

Also – his new web site is being built as we speak – http://www.drbaltasar.es/index_en.html – right now the majority of it is in Spanish, but English is coming. Check back often to see progress!

Then there’s always….

So – it probably takes a really time to get a surgery date with Dr. Baltasar, huh?!

No. Not necessarily.

Depending on the time of year – and how many people are in the queue to have surgery, and the like – if there’s a cancellation or date adjustment – it’s possible to get a surgery date very quickly. Heck, I know one patient who decided on surgery, learned about Dr. Baltasar and had all of the pre-op questionnaire filled out and emailed out to Dr. B within about 24 hours; then, a last minute date adjustment came up and a date opened – within the coming week – and because this guy already had his passport in hand and his financing all lined up – he was in Spain recovering within a week! CRAZY! But it can happen.

Typically, however, most people can count on a surgery date within the coming 3 months. You should know that most summers Dr. Baltasar and team do not work during the latter half of the month of July and all of August – so needless to say, our teacher friends who are trying to get surgery dates for just after the conclusion of the school year tend to snatch those June/July dates up way ahead of time. Just saying…

Pretty much without fail, the next question will be…

But going to Spain is really only for rich people, right? I mean, who could afford that?!

Um – NO!

Hello?!

SO not rich! (Says the girl trying to figure out how to finance school clothes for the boys for this coming school year, not to mention just the regular day-to-day stuff!)

Did you know that the average cost of having a self-pay laparoscopic DS in the US is in the neighborhood of about $35,000? (Well, if you get a bargain…)

Did you know that the average cost of having a self-pay laparoscopic DS with Dr. Baltasar and team in Spain is 15,500€ (for hospital, labs, tests, surgeons fees, etc.) – which translates to $22,107.65 with today’s exchange rate. Yes, you’ll still need to factor in airfare, lodging, ground transportation (all of which are tax-deductible), and meals – but even with that – a pretty stinking good deal. One of the best surgeons in the world for a bargain! Especially when you consider it’s a completely lap procedure – not a hand-assist – the risk of hernia soooo much lower as a result.

Did you know that the average length of time for a Lap DS with Dr. Baltasar and team is less than 4 hours on the surgical table. In fact, most Lap DS’s are more like in the 2 to 3 hour range (the fastest to date was 1 hour 7 minutes – super fast!).

And Lap Sleeve – seriously fast – like an hour is all it takes.

Know what happens when you get the Maserati of WLS with one of the best surgeons in the world? Amazing recovery times. Wonderful long-term outcomes. Fabulous quality of life.

Okay? We all on the same page now?

So my question for you – if you’re a pre-op thinking it’s time to get serious about WLS.

Whatcha sitting there for? Email Dr. Baltasar!

Rather than the Thursday that we traditionally meet, it’s been decided to move our dinner this month until SATURDAY, AUGUST 13th, 2011 at 5:00 pm.

Be sure to check out the Facebook invite for additional details and/or to RSVP there.

————————————-

Hey guys!

Sorry for the late notice – but well, details kinda slipped through the cracks.

We are so fortunate – we’ve been extended a really generous invitation for our group to Audrey & John’s place in Tualatin for a Potluck/BBQ.

Here are the details from Audrey:

People can bring their own meat (we have a BBQ) and a side dish to share.  We’ll serve up some homemade lemonade, water, salad and a side dish as well as paper plates, cups, utensils, etc.

Location: Close to I-5 and 205 in Tualatin, OR 97062 – when you RSVP we’ll get you the address

Time: Any time after 5pm. until ????

If you know you are coming, a head count would be great for seating, beverage, and utensil planning.

Please feel free to RSVP here in the comments, to Audrey on the DS-Oregon Yahoo Group, or on Facebook.

Inviting, huh?

So – why don’t you come join us for dinner for our July get together? We’re definitely gonna sign up early for a table on the patio!

Place: Manzana Rotisserie Grill, 305 – 1st Street, Lake Oswego, OR 97034 (Jill – here’s your map!)

Date: Thursday, July 14, 2011

Time: 7:00 pm

RSVP: by 9pm Tuesday, July 12, 2011 please.

Please RSVP to me here (under the comments), via email (dinacmcb@comcast.net), on Facebook, or phone or text me at 503-887-6147. (Please feel free to RSVP early – we keep a list! )

Who can come?

Any WLS pre-op or post-op – or even if you’re just trying to figure out what WLS is all about – come join us!

Any support person of the above.

What do we do?

We share a meal, laugh, talk, hang out, kick back and relax.

There’s no agenda.

There are no time constraints.

If you have questions or just need to hang with someone who gets what it’s like to be a post-op – this is the group for you!

Hope to see you there!

Thanks To Joanne Minnerly Bathalon for providing the transcript.

Hi, I’m Dr Mitchell Roslin, Chief of Bariatric Surgery at Lenox Hill Hospital in NY and Northern Westchester Hospital in Mt. Kisco, NY. The title of this talk is, “Revisions – Does the Patient Fail the Procedure or Does the Procedure Fail the Patient?” This is a copy of a talk that I gave at the ASMBS in Orlando in 2011 and I was asked by many of the attendees at the session to see if I could record the talk and place it online. The purpose of the talk is to try to explain some of the physiology behind bariatric procedures and weight regain or inadequate weight loss following bariatric surgery.

When I started doing bariatric surgery 17 years ago I really thought it was simple. I thought when we did a gastric bypass what we did is that we made the stomach smaller so that people were forced to eat less. Then we added an intestinal bypass so that some of what was eaten was passed into the fecal stream. I now know that bariatric surgery is far more complex. The stomach is far more than just a storage organ, it actually produces certain hormones that regulate hunger and satiety. As a result I think concepts like restriction (making the stomach small) or malabsorption (bypassing part of the intestine) are rather simplistic and instead we need to think of bariatric surgery as gastric and intestinal. What I’ve learned is that one of the major aspects of the gastric part of the operation is suppression of hunger, especially through the reduction of the hormone ghrelin. In addition, instead of a malabsorptive component probably what the intestinal component of the operation does is it increases the work of digestion therefore increasing the metabolic rate. Frequently, patients who haven’t done well with the various bariatric procedures have been labeled as non compliant, or not following directions. One of the things we have to realize is that if it were simple to follow eating directions nobody would have ever required bariatric surgery. Another thing that we have to realize is that obesity is not a single disease. Obesity occurs where there is inadequate regulation or inadequate balance between the amount of energy taken in and the amount of energy that is expended. As a result, the defect can be anywhere in the process, so that any no two patients that we see may have the same defect, yet we all treat them similarly. So when somebody doesn’t do well with an operation we tend to say that it’s because they haven’t followed the directions, or they’re noncompliant. An alternative explanation is that the operation doesn’t change or alter the physiology that caused their obesity and is not effective in their particular case. I think that if we’re going to take credit for bariatric surgery causing weight loss and being the most effective treatment of obesity, when patients regain weight the operation also has to be a part of the burden. We have to realize that there may be a physiological reason for weight regain, not just behavioral changes and lack of compliance. The purpose of this talk is to try to explain what we’ve seen in the two most common procedures performed in bariatric surgery – laparoscopic adjustable gastric banding and gastric bypass.

As mentioned, obesity occurs when there is any breakdown in the negative feedback system that controls energy balance. Human energy intake is mainly controlled by hormonal factors. There are several key hormones that control hungry, satiety, as well as early energy and long term energy requirements. Ghrelin which is produced primarily in the stomach is considered the hunger hormone. PYY which is produced mainly in the intestine is considered the satiety or fullness hormone. Insulin is the short term energy hormone and it works along with GLP. Leptin is the long term energy hormone and is mainly produced in fat cells. But even this is relatively simplistic and leptin and insulin actually complete sometimes for binding in the hypothalamus of the brain. As a result a lot of patients who are insulin resistant also have excess leptin but leptin can’t tell the brain that you already have too much fat tissue. So there is a breakdown in that regulation. As opposed to the input for energy intake which is mainly hormonal, the output is mainly through the nervous system. When the body wants to conserve energy it increases the tone of the parasympathetic system, reducing the heart rate and the metabolic rate. And this is what occurs when people try to reduce their caloric intake. When the body wants to produce more energy it activates the sympathetic system. The bottom line is that energy balance is a rather complex process and a deficit anywhere either in the input or the output or the afferent or efferent system or as well as in the brain or central nervous system and the hypothalamus can cause obesity because of the energy imbalance.

After watching the previous video of the patient who struggled with the Lap Adjustable Gastric Band, and has done so well with the Duodenal Switch, it’s obvious that there different physiologic factors that occur following the bariatric surgical procedures As mentioned the input for human energy intake is mainly hormonal. Laparoscopic adjustable bands don’t reduce ghrelin or increase PYY thus it’s not surprising that a number of patients are still hungry following lap adjustable banding. Thus instead of giving patients labels like noncompliant, or suggesting that the patient failed the operation because they didn’t work hard enough we need to understand the physiologic differences that our operations cause. And in addition we need to begin to gain insight into why the particular patient is obese and what their particular deficit is in energy imbalance. Unfortunately we’re not able to do that at the present time and we continue to treat patients with these broad operations. But it’s really important to realize that failing one bariatric procedure doesn’t mean that you’re going to fail another bariatric procedure, and there is a lot more than just restriction and malabsorption. The most important thing that we can offer our patients in bariatric surgery is hunger suppression.

While Lap-Band appears to be an attractive alternative for many patients it also has many limitations. The advantage of banding is the fact that the operation is relatively simple. The complications and the risk of serious early complications are lower than other bariatric or stapling procedures. The disadvantage of lap adjustable banding is the results are more variable and approximately 20-25% of patients, if not higher, will be dissatisfied with their weight loss. A major reason is because that while can always increase the work of eating, making you chew more and eat slower, it frequently doesn’t make patients less hungry. I often say a Lap-Band is a diet with a seatbelt, and what I mean by this is that the band doesn’t affect ghrelin levels, doesn’t increase PYY hormone or PYY levels, and as a result really functions similar to a diet accompanied by a restrictive device. Many patients do well with the band and patients who are most likely to do well are also those that are most likely to do reasonably well on a diet. They’re younger, they’re more active, and they have lower BMI’s, or are in the lower part of the morbid obesity scale. Patients that seem to do less well with Lap-Bands include older patients, patients that have a BMI that approaches or above super morbid obesity, and there is now a suggestion from George Washington University that there may be ethnic differences, and African Americans seem to have lower overall weight loss as well as a higher failure rate. Thus patients that are determining what bariatric procedure they want to undergo need to understand the probability that they have a higher chance of having inadequate weight loss with a Lap-Band or a Realize-Band, as well as a higher chance of requiring reoperation and extraction of the band. This is offset by a lower early serious complication rate. But people have to understand that not all patients that have a Lap-Band have hunger suppression and in fact a significant amount never ever have any reduction in hunger, or for that matter, satiety.

Thus the major issue with Lap Adjustable Banding is inadequate weight loss. Another thing that frequently occurs s that we make the band tighter hoping to achieve restriction and force a smaller amount to be eaten and patients to be less hungry. And what we’re successful in doing is creating a high pressure zone where patients don’t get hunger suppression and they continue to eat and we see dilation in the esophagus and changes in the motility of the esophagus itself. So when you look at the X-ray on the left side of this diagram you see tremendous dilatation of the esophagus above the level of the band. When fluid is removed you can see that the esophagus becomes smaller and the band wide open but there are still these scalloping figures in the esophagus which is a signal of a motility disservice. What you realize is that when you make the band tighter you make it harder to eat, you also make the esophagus work harder and you take the risk of having permanent motility disorders to the esophagus, but you don’t necessarily make patients less hungry. The patient in this picture here actually came to me with the picture on the left because he started to regain weight because he was storing food in that large esophagus. So it’s very, very important to understand the role of fills in Lap Adjustable Banding. The role of fills is to create some level of restriction but if that pressure gets greater than what the esophagus can pump, then there can only be harmful side effects to the esophagus. And just making bands tighter does not make all patients less hungry. Frequently on the internet we see something called the Green Zone, which is a place where people who have bands eat less and are less hungry. Unfortunately, on diagrams the Green Zone always exists, but clinically it’s often very, very difficult to find a therapeutic window where patients eat less, are less hungry, and where we don’t create a high pressure system that has an adverse effect on the esophagus. Whereas inadequate weight loss or extraction are the main problems of Lap Adjustable Banding, gastric bypass is an outstanding weight loss operation. What I’m not convinced of is that it’s a great operation for the maintenance of weight loss. An increasing problem in bariatric surgery is the number of gastric bypass patients that have regained weight 3-10 years following the operation. We’ve done an awful lot of research on this topic and are beginning to form an understanding of why we believe this occurs. Over the course of time what we see happening is food, or in this case contrast as shown in this diagram, passing immediately from the esophagus into the small gastric pouch, and then going straight into the intestines. The food doesn’t remain in the pouch long because there is no restriction left between the gastric attachment and the intestinal bypass that was created. As a result as soon as the patient eats the food goes into the intestine. With this you get a rise in satiety factors followed by a rapid fall. Thus what we believe happens following gastric bypass is there’s a return of inter-meal hunger so that when you actually question patients what you find is that while they can still eat less than they did prior to the operation but the problem is that they’re hungry one to two hours after eating. If they eat foods that are higher in the glycemic index, or simple carbohydrates what happens is they have a very rapid insulin response followed by a low sugar, and this makes patients develop a maladaptive eating pattern. So what we are seeing is numerous patients with gastric bypass that have lost a considerable amount of weight, but approximately 30% of our post bypass patients we’re seeing regain a significant amount of the weight that was originally lost. Thus we believe the major problem in gastric bypass surgery is weight regain with a return of inter-meal hunger. As a result it’s been our hypotheses that better bariatric procedures would have a valve at the end of the gastric pouch. And we believe that the best vale is the pyloric valve which is the normal valve of the stomach which controls emptying of food in the normal stomach. There are two operations that now exist that allow us to preserve the pyloric valve. They’re the Sleeve gastrectomy and the Duodenal Switch. In order to test this hypothesis we have designed a prospective trial that we received grant for that examines the weight loss as well as response to glucose challenge in sleeve gastrectomy, gastric bypass, and duodenal switch. This is the first 6 month data from that perspective trial. And you can see that all of the operations cause effective weight loss, with duodenal switch causing the most weigh loss in the first six months. The purpose of the study though, was to compare the effects of a glucose challenge on the various operations that we perform. This shows data when glucose is given both preoperatively, as well as 6 months following from surgery. And what we do following the glucose challenge is we measure the insulin levels. What we can see is a vast difference between the different operations. With gastric bypass what happens at six months is that the insulin level goes down, but when challenged with glucose the insulin level actually goes up so high that it exceeds its preoperative value at six months. We don’t see this in sleeve gastrectomy and duodenal switch. When you get such a rapid rise in insulin what happens next is a rapid fall in the sugar. And we believe this rapid rise in insulin followed by the rapid reduction in sugar glucose level leads to inter-meal hunger. Because we know when people become hypoglycemic in order to relieve the symptoms of the low sugar they become hungry and forced to eat. So we believe what is happening in gastric bypass is that since there is no valve there’s rapid emptying and when there is rapid emptying there s rapid rise in the factors that determine fullness such as insulin as well as the other gut hormones, followed by a rapid fall. And when that rapid fall occurs patients become hungry. What is really fascinating is that we don’t see the same response in duodenal switch which also has an intestinal bypass.

This diagram shows the 6 month results for insulin levels. You can see that all the operations cause a reduction in fasting insulin level, which is very important and demonstrates an improvement in metabolic function. However, gastric bypass causes a rapid rise when stimulated with glucose, much greater than sleeve gastrectomy or duodenal switch. We believe that this rapid rise in insulin is a hallmark of a rapid emptying of food as well as the rapid distribution of nutrients to the intestine, and that this rapid emptying then leads to a rapid fall in glucose level and causes the inter-meal hunger that we think is responsible for a significant amount of weight regain following gastric bypass.

This diagram shows results that were determined in the RESTORE trial. The RESTORE trial was the first multi-center trial to look at endoscopic treatment for weight regain following gastric bypass. The idea was to try to reduce the anastomatic size so that patients could regain restriction. Unfortunately to date none of the endoscopic trials have been shown to be effective to provide long term weight loss. There are some suggestions that short term weight loss could be achieved. When we went back and looked at all of the data from patients that were eligible for the trial, and this means by definition that they have to have normal pouch following gastric bypass, no evidence of fistula, and an anastomatic size that was >2CM, which we estimated approximately 70% of post bypass patients would have. We found that the most significant factor that would determine weight regain was the time from surgery.. Thus we felt that this was evident that the weight regain was physiologic, and was steady and progressive over time, especially in patients that have an anastomatic size >2CM. When surgery is first done the anastomosis is made approximately 1.5CM, or slightly less. Unfortunately what we’re finding in time is that in time the anastomosis spreads to a greater size. What we found looking at the data from the RESTORE trial is that once it got to 2CM, it didn’t make a difference if it was 2CM or 3CM, there was already a loss of restriction and weight gain was steady and progressive. We believe that means that this is going to be very, very difficult to treat by an endoscopic procedure. While weight regain following gastric bypass is becoming a much more common clinical problem, with the average patient regaining approximately 30% of the weight they lost and approximately 20-30% regaining a significant amount more, the options for patients remain limited. They include:

1. Obviously dietary adjustments but many patients feel that we’re kind of like Indian Givers, because at one point in time they had no hunger, they had early satiety and now they’re hungry all the time.
   
2. An increasingly investigated option is endoscopic suturing but there is no long term data.
   
3. Band over bypass works for certain patients, but has many of the same problems that primary banding has.
   
4. The most aggressive option is to convert the operation to a Duodenal Switch but this is a rather large operation, requires multiple anastomosis, and is an option that we reserve to patients that have considerable problems because of their weight regain.
   

Thus it’s important to realize that…

1. Our operations have limitations and that inadequate weight loss and weight regain can’t just be blamed on the patient. Bands have no effect on Ghrelin, PYY, or GLP.
   
2. Gastric bypass has no valve and this can lead to inter-meal hunger.
   
3. The fact that the weight gain is steady and progressive over time I think is indicative that it is physiologic.
   
4. We believe that increased insulin secretions after glucose challenge in bypass is indicative of the rapid emptying that occurs and the cause of inter-meal hunger. Additionally, failing one operation should not preclude consideration for another bariatric procedure.
   
5. Obesity is a chronic disease and therefore we’re going to have to be prepared to treat our patients on a long term basis and realize that bariatric surgery is not a cure for obesity but merely a control mechanism. We need to critically analyze our procedures.
   

My opinion is that pyloric preserving procedures such as the sleeve gastrectomy and especially the duodenal switch, and maybe future variations of these procedures will replace gastric bypass as standard.

This lady was in drastic need of some honest assessment of her lifestyle AND a good round of probiotics.

She looked at me blankly when I asked, “Have you tried probiotics yet?”

She really wasn’t even sure what they were, and why the heck she ought to try them.

So we talked some more, and we came to an understanding.  She was willing to adjust her lifestyle a bit AND try a round of probiotics.

I heard back from her the other day.  She was a little weepy – as in, with GRATITUDE.  She couldn’t believe what a huge difference those little adjustments made and wanted to know why more post-ops didn’t know about probiotics and how to take them.  I promised her I’d post something here on the blog about them.

Here’s the thing – you don’t have to be in intestinal hell to consider making some healthier adjustments and incorporating more probiotic-rich foods in your diet.  It makes a lot of sense, actually.

So there are some basic things to understand.  Like – there are different types.

Yeah, I know a total ‘duh’ for some – but it wasn’t that many years ago that I didn’t know that.

Yes, there are many different strains in each TYPE of probiotic as well.

You may need one TYPE of probiotic.  You may need a specific strain of a particular type of probiotic.

Yes – a lot of people find great success with one brand or the other.  Just because it doesn’t work for you doesn’t mean that you should write off probiotics altogether.

There are dairy TYPES of probiotics (reuteri, culturelle, etc.).

There are soil TYPES of probiotics (Primal Defense Ultra, and another that I can never consistently find, so I won’t even mention it!).

There’s an interesting theorem out there that if you were a vaginally born breast-fed baby that you have a lesser need in general for supplemental probiotics.

Also interesting, the fact that most of the soil based probiotic in the United States has been obliterated by the chemically based farming that has been going on for so many decades.

So why would you need probiotics to even begin with?

There are these great little microorganisms in your gut – bacteria, actually.  Some of ‘em are good, some of them not so good.  If you get an imbalance it can seriously mess up your gut (and world).

Reasons the bad bacteria might gang up and try to take over the world?

• A course of antibiotics may well eliminate the healthy colonies of intestinal flora in your gut.
  
• Chronic dehydration often plays a starring role in this – supports just the type of environment the bad bacteria love.
  
• Sugars and processed/refined foods (aka simple carbs) feed the bad bacteria.
  
• Insufficient dietary fiber intake.
  

…to name a few.

So – if you need to restore order to your gut there are some basic things you can try doing.

• Cut out all sugars and simple carbs.  Yeah, I know – not easy.  But is restoring order worth it to you?
  
• Get and stay hydrated.  That means you should be getting in somewhere in the neighborhood of 80 to 120 oz of non-sweetened fluids daily.  That means no artificial sweeteners.  That means no “natural” sweeteners.  That means NO sweeteners of any kind.  You want iced coffee?  Sure, why not.  You want iced tea?  Go for it.  You love iced water with a slice of lemon in it?  Perfect.  This is a super, extremely, monumentally important part of getting everything set to rights.
  
• Consider adding some probiotic-rich foods into your diet:  Greek yogurt, kombucha, water kefir, fermented and cultured vegetables, etc…
  
• Add in one or both types of probiotics to your world.
  

Here’s the thing with adding in probiotics… there’s a “better” way of getting there….

Start with adding one of the dairy based probiotic first thing in the morning every day for a week.  If everything is going fine, then….

Add in one soil based probiotic at bedtime every night for a week.

If that is going well, but you still feel like things have not “righted” then move to the next step.

Add one additional dairy based probiotic each morning – for two total each morning, every morning for a week.  If everything is going fine, then…

Add in one additional soil based probiotic at bedtime every night for a week.

If that is going well, but you still feel like things have not “righted” then move to the next step.

Add one additional dairy based probiotic each morning – for three total each morning, every morning for a week.  If everything is going fine, then…

Add in one additional soil based probiotic at bedtime every night for a week – for a total of 3 at bedtime.

Sense a trend there?

Here’s the thing – it requires that you do something that most of us have been trained NOT to do:  LISTEN TO YOUR BODY.

This is not a quick fix.  BUT – most of the patients that I work with on this DO find a happy place and then find a good maintenance level.

I’ve got one post-op that works up to taking EIGHT probiotic a day to get things “righted” – and then comes the work of tapering off…  It’s pretty much just the same as taping up, just in reverse.  Assuming it took getting up to 4 of each type of probiotic to get things straightened out…

First week – take 4 dairy based probiotic in the morning, take 3 soil based probiotic at night.

Second week – take 3 dairy based probiotic in the morning, take 3 soil based probiotic at night.

Third week – take 3 dairy based probiotic in the morning, take 2 soil based probiotic at night.

Fourth week – take 2 dairy based probiotic in the morning, take 2 soil based probiotic at night.

Fifth week – take 2 dairy based probiotic in the morning, take 1 soil based probiotic at night.

Sixth week – take 1 dairy based probiotic in the morning, take 1 soil based probiotic at night.

Seventh week – take 1 dairy based probiotic in the morning, take NO soil based probiotic at night.

Eighth week – no more probiotics.

On the taper down, if you find that you hit a point in time when things go wild again, then go up to the week prior and hold there for a couple of weeks and then try going down again on the taper.

The goal is to get things righted – and then live a lifestyle that doesn’t require the use of probiotics except occasionally.  (i.e., like after a round of antibiotics, or a particularly stressful season in life, or a total junk out, etc.)

OF COURSE – there are some folks who find that life for the most part is gonna include probiotics on a daily basis.  Ideally, they should come from healthy food choices.  In the event that doesn’t work for you – then find your maintenance level and live there.  That’s real life.

So – think about it.  Consider getting real with yourself about your lifestyle, and decide if maybe adding some probiotics into your daily diet isn’t maybe something you should give a whirl.

We make fun of those lines that society has heard so many times – they’re funny placed appropriately in a script. But they’re not so funny if they’re a part of your day to day life – no matter what the addiction is – if it’s an addiction that is detrimental to your health – be it emotional, physical, spiritual, etc.

My addiction?

People laugh and think – yeah, right. Like that’s a problem.

Well – it is – if you’re a girl who was diagnosed with osteoporosis at age 36.

Big problems with Coke – it has HFCS (evil stuff) and carbonation – both things that block calcium absorption.

Here I am a malabsorber with osteoporosis – taking boatloads of calcium, D3, and magnesium – and knocking it back with a swig of Coke.

DUH.

And – if I’d been having one Coke – oh, like every week or two, that would be one thing. But more like six or eight of them a day? Yeah, not so good.

So – four years ago today – May 29, 2007 – I gave up Coke.

FOUR YEARS.

TODAY!

I’m so proud of me.

I don’t know if I can adequately explain to you how much I STILL love Coke – and how deeply committed I am that it never pass these lips again.

Having bones has so much more importance to me, you know?

Not only have I not had a Coke in 4 years – no carbonation and no HFCS have passed these lips, either.

Not a single soda.

Have I mentioned how proud I am of me?

‘Cause honestly – it’s not like you give up a lifetime addiction on whim. At least I don’t.

And when I say lifetime – I mean lifetime.

Coke in a baby bottle is the great Southern cure for Colic.

I was a colicky baby.

Yep – I got Coke in my baby bottle.

LIFETIME, people, lifetime addiction.

And – I should just take a moment to thank our friends at Starbucks for making it all possible. I honestly don’t think I could have done this without Tazo Zen and Awake. (‘Cause honestly – it took a plan – and I had to have something on hand as a substitute.) If they happen to you know, give me stock in thanks for the many – I’m sure – thousands of dollars I spent in the drive-through over the past 4 years for my Venti Iced Tea, No Classic, with Extra Ice Please – well, I’d be okay with that.

The Blue Olive NW, 500 NW 21st, Portland, OR 97209

You can find their menu online here.

Date: Thursday, June 9th, 2011

Time: 7:00 pm

RSVP: Before Wednesday June 8th, please.

Please RSVP to me here, via email (dinacmcb@comcast.net), on Facebook, or phone or text me at 503-887-6147. (Please feel free to RSVP early – we keep a list! )

Who can come?

Any WLS pre-op or post-op – or even if you’re just trying to figure out what WLS is all about – come join us!

Any support person of the above.

What do we do?

We share a meal, laugh, talk, hang out, kick back and relax.

There’s no agenda.

There are no time constraints.

If you have questions or just need to hang with someone who gets what it’s like to be a post-op – this is the group for you!

Hope to see you there!

You walk in – everyone looks – then tries not to look – then looks again as surreptitiously as possible – then tries not to look. As conversation progresses you note glances here, there – as brief as can be – but glances nonetheless.

There is this myth – this attitude or belief – that has perpetuated itself in the DS post-op (and to a certain extent – the pre-op) community. If you’ve been on the various online groups at all you’ve heard it in varying degrees, undoubtedly. (Well, unless you’ve been completely oblivious.)

Statements like:

“50 pounds gone forever.”

“I’ll never regain any weight. It’s impossible with the DS.”

“You can eat whatever you want and still lose your weight!”

And following those statements all sorts of disparagement for those who have done the unthinkable in the DS community – regained weight. Any weight.

And let me just say here and now – I believe wholeheartedly that the DS, in the right hands – is THE surgery that can give hope to the morbidly obese, and particularly the super morbidly obese, community. Don’t get me wrong. It’s not supposed to NOT work. Granted, you have to factor in surgeons who don’t get it and do more harm than help because of it in the name of giving someone a rocking form of WLS. (:sigh: If only there were some way we could clone Dr. Baltasar and his kind, compassionate, caring, empathetic heart and amazing world-leader skills so that ALL pre-ops could be given THE best chance of kicking their obesity to the curb!)

We (post-ops) all (should) know (and typically say), “Expect a bounce. It should be in the range of 10% of the excess weight you needed to lose. If you go back to the basics, you can lose it.” You will see all sorts of posts from people who are there – experiencing the bounce – and praying to God that’s all it is.

There’s often an underlying hostility toward those with other surgeries – you know, NOT the DS – who have had weight regain. In fact, there’s this level of dismissal – a little bit shockingly, really – of the person as a whole.

Assumptions are made.

Broad sweeping judgments adopted. (Adopted = chosen, embraced as your own.)

Weak moral character.

Weak mental capacity.

Pity.

Belittling is done.

Nasty attitudes and words are dispensed freely.

(Funny how we as a WLS post-op community as a whole are so good at shooting our wounded!)

“Well – if you were dumb enough to have X surgery instead of the DS, then well – there you go….”

I think what bugs me most is that oftentimes these statements are made by relative babies. You know, post-ops who are still infants, really – less than a year post-op. Or toddlers – 1 to 2 years post-op. Preschoolers. Kindergarteners. When you’re a pre-op it feels OLD – really OLD to make it to those amazing post-op milestones – one year post-op, three years post-op, five years post-op. Now those are milestones! What I want to hear is from those who have made it to TEN years post-op. Those are the post-ops who are soundly in the middle of elementary school and are starting to wake up a bit to the world around them – and please dear Lord – have attained some empathy for post-ops for ALL procedures hopefully on some level.

But heaven forbid you are a DS post-op who has regained more than an acceptable bounce amount.

Any of you old timers out there? Do you remember what we used to say? (…and I still believe wholeheartedly to be true!)

“YOU haven’t failed. Your SURGERY has failed you!”

I find myself at this place that is difficult for me to process – on pretty much any level.

There is no way to explain what it’s like being just shy of 9 years post-op and have gotten to goal – something I really believed would never be attainable – a normal BMI and finally understood what it truly felt to feel at home in your body…

…and then….

THIS

Where I am right now.

Or maybe I should say: Back where I am right now.

Obviously – not back to where I started (BMI of 66 at 365 lbs, wheelchair bound, every co-morbidity in the book).

But where I never dreamed I’d be again.

When you head into WLS you have some thoughts – and it’s not that unusual for them to be undisclosed – i.e., very, very private – because – hello!? – who wants to be set up for failure yet again – of where you:

1. Realistically believe you will “land” after you’ve lost what your surgery can afford you.
2. Where you sort of hope you’ll land.

and

1. Where – in your heart of hearts – you long to land.

For me – 125 pounds was where I longed to land.

Not only that – when I was there it was just so RIGHT.

Yes, it was where I needed to land orthopedically speaking. But – really and truly – that’s where I longed to be in my wildest dreams. 135 was my where I hoped I would land. Realistically – even clinically (see Dr. Baltasar’s recently published paper on this – it’s great!) – a sound, realistic expectation would be to land somewhere below 200.

I remember saying to myself, and even aloud. “If only I could get to the place where buying clothes isn’t so hard. You know, where I could open a catalog and find something in a 14 or 16.” (Not the 6X I was in at that time.)

These are the things that you think on when you find yourself HERE….

…back standing on the scale, looking down and seeing that the first number is a 2.  The much dreaded number 2.

Somewhere I hoped – okay – I’ll admit it – BELIEVED – I’d never be again.

Oh, it breaks my heart to see it.

Worse – it’s doing horrible things to my mobility, my pain level, my ability to function, stamina, and self-esteem.

I feel fairly confident that I can say this without any reserve: I hate it.

Worse – I’m back to feeling resoundingly like this big, huge, monumental failure.

It makes me want to NOT update here. I mean no one talks about THIS. No one tells what it’s like to go through it. ‘Cause it’s not supposed to be able to happen, right?

Granted – honestly, it does… sometimes. There are reasons, mitigating factors, etc. But sometimes, it’s true – you’ll meet or hear of a DS post-op who finds themselves much in the same place.

If nothing else this experience has taught me to have a completely new level of empathy for/with post-ops (of ANY surgery) who have gone through it, are going through it, will go through it. My heart is breaking for all of us.

And if we’re going to speak the truth here (and why speak at all if not to be brutally honest, right?) – thinking back to that elephant in the room, I feel a bit of empathy for those who encounter me (those of us) who have gone through this. It has to be shocking if someone hasn’t seen me since, oh, December. In December, I weighed 173. Today I weigh 202.

Sometimes I think I should just blurt out, “Yes, it’s true. I have gained a lot of weight. Yes, in just a little bit of time. Yes, it is shocking. Okay – so, what was it you wanted to talk about?” You know – get it out of the way. But why make it all about me? Yes – I think about it at each greeting – but I don’t think it’s always necessary to say the words out loud for the most part.

Here’s the thing – I KNOW in my head that it’s because my DS got killed. (Or as Lisa so aptly said today – I’ve been un-DS’d.) But it doesn’t stop me from feeling as if it’s my fault… somehow. I find myself thinking – more often than not without even realizing that my thoughts had followed that meandering trail – what I could, should, or would have done differently. Logically – I know the truth. My DS got taken down – without my consent – and not only was I super, super, super morbidly obese as a pre-op, I’m the descendant of a whole bunch of folks who were as well. My DS was the first and only time I was able to lose weight and keep it off – ever. Should it shock me or surprise me now that it’s not that there all I have to do is breathe to gain weight? No. But it does. Inexplicably, it does.

So – I’m going to try and do better – to actually say out loud what it’s like to go through this. There are some things on the horizon that could potentially be interesting. I won’t say anything out loud yet, because my heart is just a little bit afraid to hope at this juncture. But – suffice it to say – one more reason to keep current with and to keep my heart open and honest before God.