MM - BBGC - Life After WLS

12 year old gastric sleeve patient. I have no words.

From Dr. Alvarez, "Amazing "before and after" slideshow where Betsy, who had the gastric sleeve procedure at 12, shows her weight loss journey and results."

You bet I am torn about this.

I've met the surgeon who performed the surgery, several times... he's a lovely person with superb skill.  He's awfully cute as well.  (Of course I can't find the photo of us.)  BUT I DIGRESS.

However.  12 years old?  I can't get my 12 year old to shower on a predictable basis - how on EARTH would I get him to follow through with the long-term care and feeding of a bariatric surgery procedure?

Is it worth it to step in and thwart the long term effects of obesity at a very young age -- or are we screwing with an adolescents development?  

I am torn.  Very.

PS. I suppose I should mention? The little girl is the niece of her surgeon. Wait, what? Right. She's got a bariatric surgeon in the family -- whereas some of us can't get one on the phone.  Dr. A, will you adopt me?

Torn.  Very.

Should I have weight loss surgery?

It's a search I see often -- "should I have weight loss surgery?"  

It's a very personal decision, but people do ask the Google for advice.  Doing such, results in a page full of advertisements and opinions.  Certain pages should be obviously ignored, "LOSE WEIGHT THE EZ WAY!"   Um.  No.

Hunger Hormones May Be Dieters' Worst Enemy - in Primary Care, Obesity from MedPage Today

There could be a REASON why we fail diets. Or -- diets fail us.

One year after initial weight reduction, levels of the circulating mediators of appetite that encourage weight regain after diet-induced weight loss do not revert to the levels recorded before weight loss. Long-term strategies to counteract this change may be needed to prevent obesity relapse.

Ghrelin.  You may have heard of this evil little hormone.

Nature -

Do you follow?

*blink blink*  Wikipedia tells me --

Ghrelin  is a 28 amino acid peptide and hormone that is produced mainly by P/D1 cells lining the fundus of the human stomach and epsilon cells of the pancreas that stimulates hunger.^[1] Ghrelin levels increase before meals and decrease after meals. It is considered the counterpart of the hormone leptin, produced by adipose tissue, which induces satiation when present at higher levels.

In some bariatric procedures, the level of ghrelin is reduced in patients, thus causing satiation before it would normally occur.

Medical News: Hunger Hormones May Be Dieters' Worst Enemy - in Primary Care, Obesity from MedPage Today.

Hormones regulating when a person feels hungry or sated do not rapidly adjust to weight loss, which may be a factor in the yo-yo effect observed among dieters, researchers found.

One year after losing weight, levels of appetite-regulating hormones didn't revert to baseline levels, Joseph Proietto, PhD, of Heidelberg Repatriation Hospital in Australia, and colleagues reported in the Oct. 27 issue of the New England Journal of Medicine.

The findings suggest that the "high rate of relapse among obese people who have lost weight has a strong physiological basis and is not simply the result of the voluntary resumption of old habits," Proietto and colleagues wrote.

It's well established that heavy patients who lose weight dieting often fail to keep the pounds off, the researchers explained.

Studies have shown that restricting calories can lower levels of the hormones leptin -- which tells the brain that the body is full -- and ghrelin -- which stimulates hunger.

Doesn't this also help explain why some forms of weight loss surgery ... work better overall in the long term?  In certain types of WLS -- most of ghrelin producing factor -- is removed. 

Go DS.  Or not. It's up to you.  Surgery flame wars!

DSFacts.com -

Approximately 70% of the stomach is removed along the greater curvature, also called a vertical sleeve gastrectomy (VSG). The remaining stomach is fully functioning, banana shaped and about 3 - 5 oz in size which restricts the amount you can consume. The pylorus continues to control the stomach emptying into the small intestine; as a result patients do not experience "dumping". The upper portion of the duodenum remains in use; food digests to an absorbable consistency in the stomach before moving into the small intestine. This allows for better absorption of nutrients like vitamin B12, calcium, iron and protein when compared to gastric bypass procedures.

A benefit of removing a portion of the stomach is that it also greatly reduces the amount of ghrelin producing tissue and amount of acid in the stomach.

Ghrelin is the "hunger hormone" and by reducing the amount of the hormone produced the appetite is suppressed.

Study -

Sumithran P, et al "Long-term persistence of hormonal adaptations to weight loss" N Engl J Med 2011; 365:1597-1604.

Gastric Sleeve Gastrectomy

What is a "Sleeve Gastrectomy"?

Wikipedia -

Sleeve gastrectomy is a surgical weight-loss procedure in which the stomach is reduced to about 25% of its original size, by surgical removal of a large portion of the stomach, following the major curve. The open edges are then attached together (often with surgical staples) to form a sleeve or tube with a banana shape. The procedure permanently reduces the size of the stomach. The procedure is performed laparoscopically and is not reversible.

The following is from - Endobariatric.com - Dr. Alvarez

The sleeve gastrectomy is an operation in which the left side of the stomach is surgically removed. This results in a new stomach which is roughly the size and shape of a banana. Since this operation does not involve any "rerouting" or reconnecting the intestines, it is a simpler operation than the gastric bypass or the duodenal switch. Unlike the Lap Band procedure, the sleeve gastrectomy does not require the implantation of an artificial device inside the abdomen. 

Patients who should consider this procedure include:

1. Those who are concerned about the potential long term side effects of an intestinal bypass such as intestinal obstruction, ulcers, anemia, osteoporosis, protein deficiency and vitamin deficiency.
2. Those who are considering a Lap Band but are concerned about a foreign body inside the abdomen.
3. Those who have medical problems that prevent them from having weight loss surgery such as anemia, crohn's disease, extensive prior surgery, and other complex medical conditions.
4. People who need to take anti-inflammatory medications may also want to consider this. Usually, these medications need to be avoided after a gastric bypass because the risk of ulcer is higher.

It might also be a good option if patients have a problem with their lap band requiring revision, have already lost a lot of weight and don't want a full bypass. The weight loss seems to be a little better and more rapid than the lap band (60 - 70% EWL) over two years. There is still no long-term data.

What advantages does it have?

1. It does not require disconnecting or reconnecting the intestines (no dumping syndrome).
2. There is no malabsorption of nutrients therefore avoiding anemia, osteoporosis, protein deficiency and vitamin deficiency.
3. Only surgery that substantially removes the "hunger hormone" Ghrelin.
4. It is a technically a much simpler operation than the gastric bypass or the duodenal switch.
5. There is no foreign body inside of you.
6. It does not need adjustments or fills (adjustable band patients must come back for fills).
7. Preserves the pylorus (most patients should not get dumping syndrome).
8. It may be a safer operations for patients with a body mass index (BMI) more than 60. It may be used as the first stage of a 2-stage operation.