"How to choose surgery when you don't want surgery"

choosing the sleeve gastrectomy

The surgeon asked me to google "sleeve gastrectomy." I did, there is a substantial amount of information out there about it, and I read what I could find. Essentially, it is the removal of most of the stomach, leaving a sleeve-like conduit between the esophagus, which connects the mouth to the stomach, and the pylorus, which connects the stomach to the small intestine. About the size of a banana, the remaining stomach-sleeve holds about 100cc of food. Think half a cup.

The part of the stomach that is removed is the stretchy part, and it also contains cells that secrete substances that regulate (by increasing) hunger. You retain the pyloric valve, the natural passageway between the stomach and small intestine. You do not place a large foreign body, as you do with a lap-band.

The most important difference for me between a sleeve gastrectomy and a gastric bypass is that anatomy is not rearranged with the sleeve gastrectomy. Also important is that this is surgery that we have a long history of experience with. It has been used to treat stomach cancer and ulcer disease long before bariatric surgery became common. We know what happens to people years and years post-op.

Some of the most interesting developments in bariatric surgery have come about because of accidental discoveries of the role of various substances secreted by parts of the gut that are intentionally removed or bypassed in procedures designed to induce mal-absorption. As happy an accident as that is, to be sure, Type-II Diabetes can be almost reliably cured with one type of these procedures, this also reveals our collective ignorance of the role and importance of these substances secreted by the gut.

image of the sleeve gastrectomy

Because of that ignorance, I am more uncomfortable with deliberately inducing malabsorption by intestinal bypass than deliberately surgically limiting intake. Sleeve gastrectomy involves no bypass. Further, if bypass should become a good idea later on, that is, if situations changed to the point that I became comfortable with bypass, it can still be done after a sleeve gastrectomy. In fact, that's how this procedure was "discovered."

drawing of a duodenal switch

The sleeve gastrectomy is esentially half of another procedure called a duodenal switch, which like gastric bypass, involves both a restrictive and malabsorptive intervention. The restrictive part is the sleeve (in this image called the pouch). The food coming from the stomach, which passes through an intact pylorus, bypasses the small intestine for some distance (via a duodenal bypass, the so-called alimentary limb) and then re-joins the bypassed-by-food part of the small intestine down-stream, which is still draining digestive juices coming from the biliary tree (the B-P limb). This means a much shorter distance of the small intestine (the common channel) is available to absorb food, this creates the mal-absorptive portion of this proceudre.

In very high risk surgical patients (read: very fat and sick people), they would do the sleeve gastrectomy part first, laparoscopically, and then go back and do the bypass when the patient was a better surgical risk (because they had lost some weight). They discovered that is some number of the cases the bypass was never necessary. So, the sleeve gastrectomy became a stand-alone intervention.

So, this was a good compromise for me. Ironically, as bariatric surgeons discovered their God-like power to completely cure Type-II Diabetes with intestinal bypass they signaled to me that they didn't know what the hell they were doing. There was a lot going on the gut endocrinologically that was a mystery to them until they stumbled upon their happy accident. The mechanical part of restricting intake and inducing fullness with less food volume was straightforward enough for everyone to understand. I was comfortable with that, but waving the feathered stick of bypass over me, with the accidental discovery of the role of peptides secreted in the stomach in Diabetes, as a "Wow, cool this seems to work!" kind of intervention smacked of surgical hubris. I've worked with too much idiocy in health care over the years to accept this. It wasn't that long ago that we figured out that ulcers were a bacterial infection--an important distinction also discovered by accident. How many people got their stomachs removed to treat an ulcer when an antibiotic would have done the trick?

Even though it resembled the voodoo of intestinal bypass, I was relatively comfortable with removing parts of the stomach that contain cells which secrete the hormones which modulate hunger because I knew we've been doing partial stomach removals (for other reasons--cancer and ulcers) like this for a long time. Further, it seemed to "fit" for me because my problem with maintaining weight loss (I'm quite good at losing weight) has always been hunger, physical hunger. I've always had this notion that something is out of whack in that feedback system in my case. Other people don't seem to get hungry like I do. Other people seem to be able to get full on a lot less food than I need.

The icing on the cake of this decision was that my surgeon also advised me that the lap-band is falling out of favor in Europe (where they've had about 15 more years of experience) because it so often requires replacement, revision, removal or adjustment. It is beginning to not be seen as a permanent solution. This is a permanent problem, I needed a permanent solution.

Finally, the sleeve gastrectomy procedure would be done laparoscopically, which is also well-known to shorten recover time and dramatically lower peri-operative risks. It still involved general anesthesia, which was my biggest fear, but at least it didn't involve fileting me like a fish.

So, surprisingly (to me, most of all) I found myself sold on the gastrectomy after speaking with my surgeon for about 20 minutes. I understood everyone's assertion that the lap-band would not be therapeutically powerful enough to address my problem. It wasn't that I was unconvinced of that, it was that I was fundamentally uncomfortable with losing my pyloric valve and I was intractably resistant to rearranging my intestines. While the lap-band procedure doesn't rearrange anything, it is an internal appliance, a foreign body left inside the body and I wasn't crazy about that idea either.

The sleeve gastrectomy seemed to be a reasonable compromise between the "not doing enough" of the lap-band and the "messing with things we clearly don't understand" of the gastric bypass. I couldn't believe I was doing it, I couldn't believe the words were coming out of my mouth, but I looked Dr. Daniel Rosen, my surgeon, in the eye and said "Ok."

next - The operation