Monday, March 05, 2007

Gastric bypass surgery

This weekend I had a small job I picked up through RentACoder to record a TV show and do a transcript of the show, which entailed watching it several times. The show is called Action Hero Makeover, and it turns out it's about a relatively new variation on gastric bypass ("stomach stapling") surgery, as it was performed on Gil Gerard.

If you don't know me, you should know that I'm extremely obese, with a BMI in the 75 range. Most of the typical complications and correlated illnesses, however, have not been a problem for me. I've never had high blood pressure, and my cholesterol has generally ranged from acceptable to very good (with the exception of HDL which I just can't get to go up). I've shown no signs of heart disease.

In recent years I've been diagnosed with type II diabetes. However, I've also shown that it's possible for me to control it, even without meds. I've also shown that I can fail to stay in control. This progressive failure is mostly because of my own failures of willpower, but it's certainly true that my weight contributes: it's hard to be active and exercise when my weight itself is an obstacle so often, in the form of knee pain and general soreness at even modest activity, the difficulty of getting started, the cost of equipment that can hold up to me, and the general low level of energy I have.

Generally speaking I believe that it's possible to be "fit and fat", and that the medical community has assisted in perpetrating a number of fallacious ideas about overweight, the most pernicious being that if there are poor health conditions associated with overweight, that losing weight is invariably a means to solve them.
  • First, correlation in the public at large doesn't mean correlation in any individual; for instance, my lack of blood pressure problems at my size is unusual, but it doesn't hint at a hidden problem.
  • Second, correlation isn't causation; many of the ill effects associated with overweight are effects of a common cause, not effects of overweight itself, and trying to prevent them by eliminating overweight can be like trying to avoid sickle-cell anemia by bleaching your skin.
  • Third, even when a health problem can be reduced or eliminated by losing weight, that doesn't always mean the health effects of attempting to do so aren't worse. Though rarely publicized, the ill effects of almost all forms of dieting are well-proven, and it's clear that dieting is not only rarely effective but usually counterproductive.
That said, I wouldn't mind not being fat one bit. There are lifestyle reasons; one feels petty talking about the thousand discomforts of being in a world that refuses to fit me, and one feels like arguing with the world and insisting it accomodate me rather than "giving up" and adjusting to fit it, but despite that, it'd sure be nice to be able to fit on planes and in cars, not have to apologize every time I try to pass someone in a restaurant, and be able to buy clothes cheap and easy. And there are health reasons like back and knee pains I wouldn't mind missing.

But the best reason is to be rid of diabetes. Yes, rid of diabetes. This is something I've really thought of as impossible, and that's what really struck me about that show I was transcribing from. Before the surgery, Gil was a very out-of-control diabetic, with fasting blood glucose numbers in the 300 range; we weren't told if he was doing anything to treat it, and it's possible he wasn't because other, more serious health concerns he was dealing with would preclude most forms of treatment. After the surgery, his fasting blood glucose was in the 100 range -- entirely normal, with no diabetes treatment at all. It's commonly said that once you're diagnosed diabetic you can only be "in control" or "out of control" but you can't ever not be diabetic, but even the doctors described Gil unequivocally as no longer diabetic.

I've known about variations on "stomach stapling" for years, but they were very dangerous and not terribly effective. Before I was diagnosed diabetic, I didn't give them much thought; clearly they were a lot of risk to solve not very much. (It didn't help that my father died on the table in exactly this kind of procedure; though it probably didn't hurt as much as you might think, given that my father was never very close to me, and that I am not the kind to obsess and worry and get wrapped up in fear because of something like that.)

Even after my diagnosis, I still didn't think much about them because they still seemed too risky, and I didn't think they'd make that big a difference: maybe they'd cure the discomfort of airplane seats, but not diabetes. I always had a general sense that one day the risk would be reduced to near nil, the efficacy improved to highly reliable, and the option would become far more accessible; and then I'd have to re-evaluate. But I didn't think that day was anywhere near yet.

The show made me wonder if maybe the time is nearing after all. Dr. Rutledge's technique, Mini-Gastic Bypass (MGB), offers some very compelling advantages even over the "state of the art" techniques now being done all over the country. The risk of dying on the table is now comparable to everyday surgeries like appendectomies. Other complications are very rare for the most common procedures, but for MGB they're far lower still, almost negligible. MGB also costs a good deal less, since it's a laparoscopic technique with a recovery time measured in hours, not weeks. I'm not just reciting the TV show's points; most of these comparisions between MGB and other bariatric procedures weren't mentioned in the show. But I've been doing a bunch of reading, and MGB simply becomes a more compelling option the more I read. Not merely by comparison to other bariatric surgery options, but more generally, as something that maybe I should seriously considering doing.

However, there are two big snags.
  • Requirements: All forms of bariatric surgery require you to demonstrate extensively to the surgeons that you have spent years and years sincerely trying other methods of losing weight, and failing. While I have done "diet and exercise" for years, and it's easy to show I haven't lost weight and kept it off, I would have to lie to suggest I was trying to lose weight. Apart from the discomforts like back pain and difficulty finding clothes that fit, I haven't minded my weight; it's my diabetes I have minded, and I found that my control over that and my weight were barely correlated, if they were correlated at all. I did lose weight during my "in control" years even though I wasn't really trying to; but sometimes I gained it back, and my control didn't track my weight really at all. Would my attitude towards my weight be considered by the surgeons and therapists to be "unhealthy"? Would they refuse to consider me because I hadn't tortured myself enough with diets and done enough damage to myself before coming to them? Maybe I could parley my struggle with diabetes into something, but I'm doubting that could really live up to the kind of onerous requirements I'm seeing.

  • Insurance: It'd be easy to prove to an insurance company that, if someone's going to be on their insurance for a long time, it'll make far, far more sense in the long run to let them get surgery like this than to wait for insurance to have to pay for the ongoing treatment of a chronic problem like diabetes, then deal with the complications. It's a no-brainer: $17,000 now versus tens, hundreds of thousands, maybe millions over the course of a life. But what's this, logic, in a paragraph that started with the word "Insurance"? What was I thinking? No doubt the insurance company is hoping that my employer will change insurance companies before then, or failing that, that I'll be hit by a bus. Or perhaps they still think that everyone who is overweight is so because they're evil. Either way, they don't cover procedures like this. Could one wangle an exception based on "medical necessity"? Uncertain. But given how it took months of stress-inducing, health-eroding arguing with them just to cover a better blood sugar meter, one can't help wonder if the cost they'd exact in sheer agony wouldn't make surgery seem like recreation by comparison. This is a doubly interesting question to ask right now since our long-time primary care physician is moving away, so we don't even know who our new doctor is yet. Who knows how sie will feel about us? Or how good sie will be at dealing with the insurance company, even if sie decides this is worth fighting for?
Yet through all of this haze, the image keeps haunting me of the idea of not being diabetic anymore. If this is going to happen, there's a lot of thinking, research, planning, struggle, and perhaps outright fighting, and a lot of time, in between me and it. I guess maybe it's time to start preparing to start prepare to decide whether I'm going to start preparing to do it. Maybe.


The Wife said...

and of course... what if we both do it?

When would we do it? not at exactly the same time, perhaps... so that we're not both in recovery at the same time but maybe a few weeks apart? So we're in similar dietary situations?

I just... it's all so big...

But like you, the idea of being free of diabetes is very very compelling to me.

The Wife Again said...

You know, I think that the real thing they're trying to get at is a demonstrated ability to make changes in your situation that are necessary for your health.

I think our two plus years with our BG less than 6.0 must count for -something- in that regard.

I can't see us being completely noncompliant post-op. That's just not us. Is it? Am I deluding myself?

Charles said...

I have been considering this for the last 2 years. Sadly the only thing our insurance covers is getting the Stapling, least thats what their determination was a year ago. The one I found interesting was a surgery that calls Gastioplasti(yeah you know me I can't spell). They use a balloon and put that into your stomach. This has the advantage of, should complications arise, its easily removed. Recovery is the same, somewhat, hours from the surgery and a couple days/weeks to get used to it and the meals. If you all go for it, I might as well too. I get to the point of depression some times.