The Gastric Bypass Operation

Introduction

Well, it’s done. As I write, it’s Saturday, day five post-op, and I have some time to reflect and compile. I had bariatric surgery done. It was a big step, and it will mean a lifetime of changes, hopefully the gross majority of which will be for the better. So, how did I get here? What happened? Well, I will start almost 30 years ago.

The Issue

I’ve been big almost my entire life. I’m currently 32 years old. As a small child, I was a healthy size and active. Then, at age 4, I broke my right tibia and fibula. This was in the era before boots-for-breaks, so I was stuck in a cast for quite a while. I couldn’t go out and play, work off the natural energy. I was forced to learn to be content being still, doing activities like reading or watching television. Also, I was in a lot of pain, and I lived in a society where “comfort food” is a byword. The two combined, I learned a lot of bad habits which I was never quite able to break (not for lack of effort) and set me on a path to obesity.

Fast forward through an obese childhood, adolescence, and adulthood filled with various diets, cures, methods, tricks, books, exercises, groups, plans, supplements, drugs, machines, deprivations, and suggestions from well-meaning supporters, all which failed, to my current state. At the beginning of this part of the journey, late August this year, I was about 530 pounds. I’ve been measured as high as 550, though I may have gotten higher at points. I wear t-shirts in a 6XL. Dress jackets necessitate a 72/74 inch chest size, and shirts require a 24 inch neck. Pants require a size 62, though the actual size is larger due to vanity sizing. I have a 23 inch inseam, and I’m severely knock-kneed, my legs having adapted to support my immense weight. At 5’11”, my BMI was 73.9, well into the NIH’s “morbidly obese” range. One might even say it was a “DAYUM!” on the Iglesias Scale. Something had to be done.

Why Surgery?

In short, it was the last option. As I said before, I tried a very wide variety of methods to try and lose the weight. However, there was at the center of all those techniques two inextricable components: my willpower and my physiology. One worked for my goal, and the other worked against.

I had willpower and desire to lose the weight. Anyone who knows me knows that I can be more stubborn than a tree stump. Push me too hard, and I will push back simply out of spite. If willpower alone was the only independent variable in the equation, I would have licked this years ago. Unfortunately, they body has a say in the matter, too.

The human body, through evolutionary design, wants to be fat. I know this sounds strange, but consider: human beings evolved as hunter-gatherers for millions of years before the agricultural revolution. Prior to that, we ate what we got when it was there to be gotten. The body stored any excess for when food wasn’t as available as body fat. As such, the ancestors who responded more readily to this desire to stock up and store had a greater likelihood of surviving periods of famine to pass on their genes. They responded in this manner because the body adapted incentives to encourage the behavior: namely, sugar and fat, those concentrated sources of calories, TASTE GOOD. They trigger all kinds of feel-good chemicals in the brain when consumed to the point of fullness and satiety. These incentives and responses occur completely independent of rational human thought. Therefore, humans have a natural tendency to consume fat and sugar whenever it’s readily available and stomach space exists.

Fast forward to modern times. We no longer live in the feast/famine world that our bodies evolved to survive. You can get a quarter-pound cheeseburger at 3am on any Sunday in the middle of winter, and that cheaply. You can get bread and cakes and confections just as easily. Science has made leaps and bounds over the last hundred years or so with regards to preservation and transportation, making “out-of-season” almost a thing of the past. Yet, fat and sugar still taste good. For many, our bodies have not yet adapted to dampen the evolutionary impulses to stock up. This may be one explanation for the obesity epidemic: everything’s too available.

This is a lot of exposition, but I wanted to be clear in my reasoning as to why the body worked against the goal of weight loss. As to my current situation, my willpower, while strong, was unable to override millions of years of genetic programming. I needed something to counteract the body that didn’t depend on my willpower.

Notice earlier I said that the desire to consume was dependent on stomach space being existent. It turns out, doctors know what causes the feeling of fullness/satiety. There is a nerve at the top of the stomach, where it joins the esophagus, that, when contacted, imparts a “full” signal to the brain. For a feeling of long-term (about 6 hours) satiety, this nerve needs to be continuously triggered for 25 minutes. This makes sense: when you have eaten enough, the food bounces around as the stomach churns and digests it, constantly hitting the nerve. The solution to overriding the body’s desire to overconsume, therefore, lies in triggering that fullness feeling sooner. Enter gastric bypass.

The Operation

Bariatric surgery comes in a couple different flavors, with varying degrees of risk and effectiveness. Each one has the same goal: to reduce the amount of food necessary to contact the fullness nerve by reducing the amount of available space in the stomach. One of the more popular ones is the lap-band. Simply put, an inflatable band is attached around the stomach near the base of the esophagus. This is fairly low risk, reversible, and adjustable post-op, but also relatively low results. Next is the sleeve, where a section of the stomach is simply cut out and removed. Better results, but it’s riskier and irreversible. Third is the most effective and the first developed: the Roux-en-Y gastric bypass. For this, the bulk of the stomach and upper small intestine is cut away and sealed shut. The small remaining part of the stomach, which is still attached to the esophagus, is connected directly to the small intestine, bypassing the duodenum. See http://www.webmd.com/diet/weight-loss-surgery/gastric-bypass-surgery-for-obesity for a picture.

Because I was already so far overweight, my doctor immediately set aside any notion of a sleeve or lap-band: the results would be insufficient, and the risks of the bypass have been mitigated through experience. So, we set about for a full bypass.

The Process

This was not a short thing. I didn’t show up to the doctor’s office on Friday and have an appointment for the following Monday. As I said before, this portion of it started back in late August. I say “portion” because I’ve had this decided in my mind for several years: I’ve just never had the wherewithal to see it done until now. (Thank you, federal benefits!!) I’ve done copious research on the whats, whys, and hows, of this whole thing. Indeed, I started on it during the second year of my dissertation at Missouri. I attended seminars, read journal articles, and generally did my homework. I decided then that it was the right course of action for me. Unfortunately, grad-student insurance sure as hell wasn’t going to cover it, and the cost of doing this procedure sans-insurance is prohibitive: about $15,000. I attempted a crowd-sourcing thing through Facebook (Indiegogo wasn’t a thing, yet), but failed to raise a single dollar. So, I decided to carry on and bide my time. In the meantime, I graduated from Missouri, moved back home, got a job in D.C., moved again, and here I am.

Once I took a little time and got settled in, I decided that I had waited long enough. I first checked out the doctors in my area. There were a few close to home, so I dug deeper and checked credentials. The guy I chose, Matt Fitzer, was a bit of a drive away in Reston. But, he had the creds: thousands of operations performed, numerous awards, and a fellowship at Missouri with the doctors I originally scoped to do mine while there. I found out later that he was derby-girl approved, having worked with Dethblok of the CoMo Derby Dames. After I decided who would do it, I sat down with him and laid things out. He had me watch a couple webinars detailing the process and answering questions. Then the other shoe dropped: I had to lose 25 pounds to get this done.

Dafuq?

I thought the whole point was to have this done so I didn’t have to diet, to pit mind versus body in yet another failing battle. Turns out, he needed the room to work. The procedure is done laparoscopically, with instruments inserted through small incisions doing the work. This drastically cuts down recuperation time. To enable him to get the tools in and have them move around, I needed to shed some layers, make a little working room. So, he put me on caffeine pills.

In the meantime, I met with his nutritionist to go over the post-op diet. More on that later. I also had to get a cardiac clearance, bloodwork clearance, and general primary-care-physician clearance. Fortunately, my ticker’s fine, my blood is clean, and the doc was happy. Dr. Fitzer also generally includes a psych eval as part of the process, but, I think he decided it wasn’t necessary given my own credentials and through discussions with me.

In addition to all this, I still had to get clearance through my insurance. Fortunately, I had inadvertently fulfilled all their requirements already. They wanted a six-month nutritionist/registered dietician/doctor supervised dieting period to have occurred in the last two years. Also, they wanted three months of dieting overseen by the surgeon himself immediately before. I saw a nutritionist while I was at Mizzou. I got a letter from MU Student Health detailing the dates, and sent it off to Aetna. Dr. Fitzer’s office handled the rest, and I was go for launch, almost.

Things on the weight loss side were a little sketchy at the end. See, I knew I would have to be on a clear-liquids diet for three days pre-op. So, the fourth day, I said my goodbyes to big meals by having one last go: a nice filet mignon done medium rare, fried shrimp, steak fries, baked potato soup, and a slice of chocolate cake to top it all off. I figured the pre-loading would help me stick to the clear liquid diet better. It also pushed me a bit further away from goal. Fortunately, I was close enough on the day of surgery to proceed.

Surgery Day

The day itself went like most surgeries under general anesthetic, insofar as I don’t remember most of it. But, there were standard things like getting to the hospital way too early, meeting with the anesthesiologist and the doctor, getting hooked up to an IV, and putting on the gown that leaves your ass hanging out the back.

After surgery itself, they kept feeding me narcotics for pain relief, since anti-inflammatories would cause stomach upset, which we really didn’t want. I finally got them to stop that nonsense and just give me straight Tylenol, so my head could de-fog. I met with the doc’s assistant a few more times while there, and they held me for two nights for observation, making sure I could drink enough to be sent home without getting dehydrated. Now I’m home, and working on getting back to living normal life.

The New Norm

Now that the surgery is done, I have a new way to approach eating. I’ve got a very strict diet to follow for the first two months after surgery, to ensure I heal properly. More clear liquids for the first week, followed by toothless-person food (grits, oatmeal, applesauce, cottage cheese) the second. Tuna, scrambled eggs, and toast are added in the third. Starting week four, I begin to really start getting back into real food: eggs, fish, cooked veggies, soft fruits, beans, and oh-thank-God-finally pasta. At week seven, the leash comes off and I can start adding things in, experimenting. Everything will be in very small portions, and there are four basic rules to follow.

1) Spread meals out over 25 minutes, and eat three meals a day. No skipping.

2) No drinking anything 15 minutes prior and 45 minutes after a meal.

3) Make the majority of the meal a protein source.

4) Avoid sugary liquids.

There are other things, and countless minutiae, but I will save you from those.

I want to thank everyone who has offered prayers, well wishes, or even just kind words on my journey to this point. I think this will change me for the better once it all pans out. As it stands, I am hopeful for the future.

D.J./Hayek