Roux-en-Y, The Easy Way Out

Most people will have the fortune of not having bariatric surgery. Those who happen to know what bariatric surgery is...surgery on the stomach and intestine to induce weight loss...and little knowledge beyond that may equate it with "stomach stapling." It's more complicated than that. There are actually several kinds of procedures that fall under the label of bariatric surgery.

The kind I'm scheduled for is called Roux-en-Y. Ironically I knew what roux was...basically fat and flour used as a base for certain recipes as a sauce. In this case it is a procedure named after the first surgeon to describe this type of operation. There are several variations of the procedure but for the most part if you diagram the end results your stomach and intestine are rerouted into a "Y" shape.

More drastic than the common gastric banding, Roux-en-Y combines calorie restriction - your stomach pouch is made smaller so it holds less food and makes you feel full sooner - with malnutrition; your intestine is shortened so it can't absorb as much nutrients (and calories) into your system.

The technicalities and all the pretty diagrams and pictures are readily available on the webbertubes via Google. If you're reading this because you're interested in the topic you no doubt already saw material describing the procedures; I started this to describe less about the technical aspects and more about expressing the emotional impacts and ramifications of the surgery.

In my research on the Internet I've run across references to people thinking that this surgery is a magic bullet fix. It's really not. Over and over it's reiterated: this is a tool to help you lose weight. It alters the way the brain perceives fullness. It alters your absorbtion of food. It punishes you if you "cheat" unless you stretch the pouch or start eating foods that are high calorie and slip readily through the pouch (milkshake, anyone?) (If you want to know about punishment, look up "dumping syndrome" related to gastric bypass surgery).

There are actually people that find ways to "cheat" their bypass surgery and there are a significant number of people who fail to lose weight after the honeymoon period following the procedure. Perhaps they just expect this to be a magic fix and ignore anything told to them to the contrary. Maybe they failed to address the underlying reason they overeat in the first place. I'm sure I'll have more thoughts on this after the surgery as I experience the emotions that follow the knife.

The underlying reason for overeating is a big problem, however. In my case I most likely eat because in part it is a comfort, an emotional hat rack on which to hang my problems. A very common response to the surgery is depression. Depression because of a variety of pressures but also because the primary emotional friend...the cheeseburger, the cupcake, the block of cheese...is no longer there to comfort the patient. The perception others have that this is an easy way out is yet another bit of baggage to lug around. It increases the self-perception that I'm a failure, that I wasn't "strong" enough to do this on my own.

I don't expect to change people's minds about this. They'll think what they will. But my reaction to other people's perceptions is something I do have some degree of control over. I've spent a lot of time thinking about the ramifications of what I'm about to do; if the things I will be facing post-operatively are considered the easy way out, then I guess they're right.

• I'll never be able to eat sugary foods unless I want to drown in nausea and diarrhea.
• I'll never be able to drink while eating.
• I'll never be able to drink alcoholic beverages. Okay, this isn't a biggie for me.
• I'll most likely be facing depression that may require treatment professionally.
• I'll have at least a month of enduring a "clear diet". Broth. Jello. More broth.
• I'll have to face my own fears of waking with tubes sticking out of my gut for several days. And a catheter. I'm squeamish about this.
• I'll have to change my routine and habits. If you don't understand Asperger's, you can't comprehend how difficult this is for me.
• I'll have to face the fear of food becoming "stuck". If I don't thoroughly...completely...chew food until it would fit into the pouch and through the opening into the intestines, let's just say what I've found isn't pleasant. At best I'll vomit. Next best I can try eating meat tenderizer. Worst case...surgery. Because of a stray bit of oversized chicken.
• I'll be on a permanent regimen of mutivitamins and probably calcium every day.
• I'll probably lose hair. Temporary, again not a biggie since I'm warned about it.
• I'll have to re-learn how to eat. Foods that "normals" take for granted can induce a dumping attack because of an aquired sensitivity to sugar. Something as innocuous as salad dressing at a restaurant could reduce me to a sweaty shivering heap on the floor. On the plus side I hear there's some people that experience a kind of delirium in the process so I guess that's a silver lining.
• I'll have to face psychological issues...ranging from the previously mentioned change in routine to depression to mood swings to coping with other people's reactions to my own fears about tubes in my gut and leaks where the surgeons reattach my innards and fears that a sneeze will forcefully expel my intestines from the front of my abdomen through the stitches like a birthday blowout party favor, only instead of making an annoying twitter of noise, I don't want to think about what flies out in this case.
• I'll have to survive the slim, but not nonexistent, chance that I won't be leaving that hospital if things turn for the worse. And the risk doesn't end there. The chance of dying from complications reduce as I'll heal, but that doesn't happen overnight. I'll be on embolism watch for at least a month.

In other words a few hours one day will forever change my life, gambling that the benefits will outweigh the drawbacks. I don't think this is the definition of an easy way out. Some other people might.

The Beginning of my Bariatric Journey

I've been overweight almost all of my life. I wasn't bullied as a child. I wasn't abused. I've come to believe that overeating was a comfort, a habit. There are a lot of reasons I could hypothesize were triggers or contributing factors to my current situation; sedentary lifestyle, emotionally coping mechanism, stress, among many others; in the end the causes of my obesity are not what are killing me. The obesity is.

For quite some time before that I had been diagnosed with a small stable of complications that the doctors seem to have come to expect from overweight patients: hypertension (high blood pressure), diabetes, high cholesterol, sleep apnea (that loud snoring during the night? Means they may not be breathing for periods of time, or actually getting into a restful state of sleep). I am on several drugs taken daily to control some of effects of these ailments.

I felt I was being treated well by my doctor in internal medicine in that she didn't sound like she had given up hope on me, but at the same time I was a typical patient in that I would listen to her but not really hear her. How many patients honestly hear instead of listen to the lectures they get from their doctors? Well, she referred me to a another doctor that was an endocrinologist/weight loss specialist.

I walked in to see him in his office. He appeared a few minutes later with my chart in hand. He sat down, looked through the chart, and began to rattle off the "symptoms" on my paperwork, the reason I was there to see him. Then he looked me in the eye and said I was going to die.

Okay, I thought. This guy doesn't waste time getting to the point.

"I'm going to refer to you a bariatric surgery office in (a town north of us)." That was it. I spent all of five minutes in his office and that was my ticket on the surgery express. Well, it wasn't much of an express train since it took about a year to reach this point, but that was still how I got on this track.

I had thought that the surgery could be done within a few months' time. Nope, that is most definitely not the case. I'm one of the small percentage of Americans with decent medical insurance, which, while covering this type of operation when my physician deems it necessary, also means that I have to follow their terms.

What followed was nearly a year of filling a checklist of requirements. I had a couple thousand dollars in a copay to raise (no doubt a tiny fraction of what the hospitals will end up paying). I had to meet with a nutritionist. I had to document previous weight-loss attempts. I had to take a special psychiatric exam called an MMPI which in turn said I was a depression risk, necessitating therapy.

As a matter of fact, the insurance company called and said that they weren't going to pay for surgery since I wasn't in therapy...even though they had been paying for over a month of therapy sessions already. The first bills of what I had to cover had arrived the day they told the surgeon's office that I was going to be turned down.

My attitude towards hospitals, insurance companies...anything involving bureacracies...can pretty much be summed up by that type of incident. For the year of work I was supposed to be putting in to prepare for surgery I waited for the ultimate denial from the insurance company. I expected a denial or another setback, and instead I got another hoop to jump through. Because of this I didn't put full effort into what was recommended I do; I hesitated to track my food intake. I hesitated to look into the implications of the surgery. Why waste the time?

Only in January did it look like things might fall into place, that I was in a home stretch. Only then did I start to take things really seriously beyond just reading information (which even then I took half-heartedly). I started tracking my weight and food intake because, well, the surgeon said that at that point if I didn't lose weight to the sub-450 range then the best they could do is refer me to another state's surgery center where they could handle larger patients. Ideally he wanted me less than 400.

Yes. That's right. In order to get weight loss surgery, you have to lose weight.

As of Christmas of 2008 I weighed approximately 458 pounds. Since then I've lost approximately 77 pounds. So far the only effect seems to be my blood sugar has noticeably fallen. I hope my blood tests will be more normalized, or at least improved, but that is something I get periodically from my physician in internal medicine, not every day like my blood sugar checks. I don't get too excited about this...I've had one person tell me that I look liked I lost weight so far, aside from my immediate family.

At any rate, I was called again a day or two after the insurance company said they were going to deny my surgery and told that I had been approved for the surgery. I had to make frantic calls to the psychologist's office and his office faxed information back and forth with the center doing the surgery on me and they faxed information to the insurance company until all of the paperwork was sorted out, and they approved it.

They actually approved it.

This was the culmination of a year of work. A year of thinking this wasn't going to happen. A year of not knowing, of completing some giant obstacle course to, as Randy Pausch of "Last Lecture" fame might have said, prove how much I wanted this...it was approved.

For now this will be my first post. An introduction, if you will. At this point I suppose you could call this the home stretch. Information on what I've learned, what I've observed, what I'm feeling...those can come a little later.