Saturday, June 21, 2008

Band vs. Sleeve

When I first started this blog, I was looking into getting a lap band, aka Adjustable Gastric Band. As I started doing more research into it, I discovered that there are TONS of weight loss surgeries, not just Gastric Bypass and Lap Band. I looked into them all but at the time I was still afraid of doing any sort of permanent thing to my insides and they all seemed too extreme or too experimental.

I looked into the new VBLOC but it's only in clinical trials and I didn't meet the qualifications because of my past blood clot. Also, it's not clear if it is that effective. They are thinking something like 20% Excess Weight Loss (EWL) with it, which is about the same as diet pills.

Then I heard about something called Duodenal Switch. I had no idea what it was. I looked into it and said NO WAY. They cut of a piece of your stomach and reroute your intestines. Afterwards, if you eat certain foods, like carbs, you get really scary farts -- the kind people get fired from their jobs from! I am against malabsorption surgery on principle anyway. So no DS.

The last surgery I looked at was the gastric sleeve, aka Vertical Sleeve Gastrectomy. In this operation, most of the stomach is cut away leaving a sleeve like a banana. The basic stomach is still there -- you have a normal opening on each side -- and all your intestines are still there. So the only difference between you and a normal person is that you can't eat as much at any one time. As an added bonus, the portion of the stomach that generates ghrelin, the hunger hormone, is gone. So you don't feel hungry all the time and you can't eat big portions, but you absorb all your food and you don't get stuck.

Sounds like a great surgery, right?

But I wasn't ready for it at the time. I watched a sleeve surgery on OR-live and when I saw them cut off the stomach and throw it away, I freaked out. What if I changed my mind? What if I was one of those people who did poorly with WLS and wanted it reversed? What if I developed a leak and died?

Since then, I've been hanging out at a lap band site while waiting for the Fall to have my surgery. During that time I have noticed something:

-most of the people on the site talk as if they are on diets; most of them are on diets, in fact. A significant minority of them live like bulimics and talk like people with eating disorders

-lots of people have trouble finding their sweet spot. They can't get tight enough to control their hunger and still be able to east normally

-after a few years, generally 2-3, a significant minority start having problems that require the removal of their bands

If I wanted to be on a diet, I could do that without having surgery. I don't think being "on a diet" is a healthy way to live and I don't want to get into that destructive pattern of behavior. I was sure that I could have a lap band and not be one of those people though. The same with becoming a bulimic. My plan was to keep myself fairly loose so that I could eat most foods without getting "stuck" leading to having to burp up my food because it wouldn't pass through the band.

But all the talk started to get to me. What if I never found my sweet spot? It wasn't just the crazies who never found it. Plenty of people who make good choices never get that way. The fickleness was a big turn-off too. I didn't want to be a slave to my band, only eating what it would let me at certain times of the day or month.

But the big turn-off was the complications rate. The mortality rate for the lap band is negligible. The erosion rate varies but seems to be mostly a factor of surgeon skill. I knew I could pick a good surgeon. Then we get to slippage.

Slippage is somewhat under the control of the patient. Take your time moving back to solid food and good adhesions will form so that your band is locked in place. Don't overeat in the early days when scar tissue if forming. These are things that lead to slippage. But even if you do that, the world-wide slippage stat is something like 3% ... and it's growing every day in the US where doctors seem in a hurry to get their patients onto solid food. Three percent is a VERY BIG NUMBER for a complication that requires re-surgery.

It seems like the lap band is the sort of surgery that require a re-surgery after some time has passed. The longer you have it, the more chance something will go wrong. At 10 years out, the re-operation rate is some where between 20 and 40% depending on what study you read.

In the meantime, my attitude towards a "permanent" surgery started to change. Lap band is touted as reversible and, compared to a sleeve, it most certainly is. But you don't go back to what you had before. You have scar tissue to deal with. You may have esophageal problems too. These may or may not be restored to normal once your band is removed. Most likely, you will be okay once the band is removed, but it's not like you can get a band and just change your mind later and everything goes back to the way it was.

I have begun to see that if I choose to go this route -- WLS -- that I need to be totally committed. I can't pick a surgery based on how easy it is to reverse. I have to look at the big picture and part of that big picture is long-term quality of life and after care. What kind of complications you have and how common they are is a big part of the picture.

I believe that the sleeve, when you look at the big picture, is a better surgery for me than a band would be. This is particularly true now that I have to pay for the darn thing myself! With a band, I will continue to struggle with the insurance issues. I'll have to pay for adjustments (aka fills) for the rest of my life. If I get erosion or slippage, I'll have to pay for the band to be taken out. With a sleeve, once my staple line heals over and, if I don't develop a stricture early on, I'm pretty much home free. I won't be paying for re-surgery unless I'm unhappy with my weight loss and want to get revised to a bypass or DS. I won't be paying for adjustments for the rest of my life.

Partial gastrectomies have been done since the 70s for patients with severe ulcers and stomach cancer and we know the long-term effects. These people go on to live normal lives and don't have late-term complications. Their chance of getting ulcers and stomach cancer is less than normal. They can eat pretty much what anyone else eats, but just in smaller quantities. They have normal hunger.

In fact, the big win for me with the sleeve though is hunger control. Hunger control with a sleeve is guaranteed. Long-term studies show that over time your body learns how to make more ghrelin. But only as much as a normal person has. Getting hungry every 1-2 hours will only happen if my hunger is not real, but manufactured in my head.

Since I'm pretty sure that 90% of the time, it is real hunger, I am very happy with my chances for success with the sleeve.
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