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November 20, 2007

Going for the knife

I've avoided this subject long enough.  Its time to talk about surgery.  Not for me....but for others.  Why not me?  I'll get into that later.  First let's look at what's available out there. 

There are 3 basic types of surgeries that we will look at today...

  1. Bariatric
  2. Liposuction
  3. Body Contouring

Bariatric surgery alters your digestive tract in different ways to reduce your food intake and/or make your digestion less efficient....so you don't absorb as many calories from the foods you eat.  Food ends up only partially digested.

NOTE:  The following information (just the stuff on bariatric surgery) was a straight copy/paste from www.weightlosssurgeryinfo.com .  I normally don't plagiarize quite so completely...but I thought their explanations were pretty good and didn't need any editing on my part.

There are a number of different bariatric surgeries....

Vertical Banded Gastroplasty (VBG) is a purely restrictive procedure. In this procedure the upper stomach near the esophagus is stapled vertically to create a smaller stomach pouch. The outlet from the pouch is restricted by a band or ring that slows the emptying of the food and thus creates the feeling of fullness


  • The primary advantage of this restrictive procedure is that a reduced amount of well-chewed food enters and passes through the digestive tract in the usual order. That allows the nutrients and vitamins (as well as the calories) to be fully absorbed into the body.
  • After 10 years, studies show that patients can maintain 50% of targeted excess weight loss.


  • Postoperatively, stapling of the stomach carries with it the risk of staple-line disruption that can result in leakage and/or serious infection. This may require prolonged hospitalization with antibiotic treatment and/or additional operations.
  • Staple-line disruption may also, in the long-term, lead to weight gain. For these reasons, some surgeons divide the staple-line wall of the pouch from the rest of the stomach to reduce the risk of long-term staple-line disruption.
  • The band or ring applied may lead to complications of obstruction or perforation, requiring surgical intervention.
  • Characteristically, these procedures, while creating a sense of fullness, do not provide the necessary feeling of satisfaction that one has had "enough" to eat.
  • Because restrictive procedures rely solely on a small stomach pouch to reduce food intake, there is the risk of the pouch stretching or of the restricting band or ring at the pouch outlet breaking or migrating, thus allowing patients to eat too much.
  • Around 40% of patients undergoing these procedures have lost less than half their excess body weight.
  • As is the case with all weight loss surgeries, readmission to a hospital may be required for fluid replacement or nutritional support if there is excessive vomiting and adequate food intake cannot be maintained.

Malabsorptive Procedures - Biliopancreatic Diversion

While these operations also reduce the size of the stomach, the stomach pouch created is much larger than with other procedures. The goal is to restrict the amount of food consumed and alter the normal digestive process, but to a much greater degree. The anatomy of the small intestine is changed to divert the bile and pancreatic juices so they meet the ingested food closer to the middle or the end of the small intestine. With the three approaches discussed below, absorption of nutrients and calories is also reduced, but to a much greater degree than with previously discussed procedures. Each of the three differs in how and when the digestive juices (i.e. bile) come into contact with the food.

Since food bypasses the duodenum, all the risk considerations discussed in the gastric bypass section regarding the malabsorption of some minerals and vitamins also apply to these techniques, only to a greater degree.

Biliopancreatic Diversion (BPD )

BPD removes approximately 3/4 of the stomach to produce both restriction of food intake and reduction of acid output. Leaving enough upper stomach is important to maintain proper nutrition. The small intestine is then divided with one end attached to the stomach pouch to create what is called an "alimentary limb." All the food moves through this segment; however, not much is absorbed. The bile and pancreatic juices move through the "biliopancreatic limb," which is connected to the side of the intestine close to the end. This supplies digestive juices in the section of the intestine now called the "common limb." The surgeon is able to vary the length of the common limb to regulate the amount of absorption of protein, fat and fat-soluble vitamins.

Extended (Distal) Roux-en-Y Gastric Bypass (RYGBP-E )

RYGBP-E is an alternative means of achieving malabsorption by creating a stapled or divided small gastric pouch, leaving the remainder of stomach in place. A long limb of the small intestine is attached to the stomach to divert the bile and pancreatic juices. This procedure carries with it fewer operative risks by avoiding removal of the lower 3/4 of the stomach. Gastric pouch size and the length of the bypassed intestine determine the risks for ulcers, malnutrition and other effects.

Biliopancreatic Diversion with "Duodenal Switch "

This procedure is a variation of BPD in which stomach removal is restricted to the outer margin, leaving a sleeve of stomach with the pylorus and the beginning of the duodenum at its end. The duodenum, the first portion of the small intestine, is divided so that pancreatic and bile drainage is bypassed. The near end of the "alimentary limb" is then attached to the beginning of the duodenum, while the "common limb" is created in the same way as described above.


  • These operations often result in a high degree of patient satisfaction because patients are able to eat larger meals than with a purely restrictive or standard Roux-en-Y gastric bypass procedure.
  • These procedures can produce the greatest excess weight loss because they provide the highest levels of malabsorption.
  • In one study of 125 patients, excess weight loss of 74% at one year, 78% at two years, 81% at three years, 84% at four years, and 91% at five years was achieved.
  • Long-term maintenance of excess body weight loss can be successful if the patient adapts and adheres to a straightforward dietary, supplement, exercise and behavioral regimen.


  • For all malabsorption procedures there is a period of intestinal adaptation when bowel movements can be very liquid and frequent. This condition may lessen over time, but may be a permanent lifelong occurrence.
  • Abdominal bloating and malodorous stool or gas may occur.
  • Close lifelong monitoring for protein malnutrition, anemia and bone disease is recommended. As well, lifelong vitamin supplementing is required. It has been generally observed that if eating and vitamin supplement instructions are not rigorously followed, at least 25% of patients will develop problems that require treatment.
  • Changes to the intestinal structure can result in the increased risk of gallstone formation and the need for removal of the gallbladder.
  • Re-routing of bile, pancreatic and other digestive juices beyond the stomach can cause intestinal irritation and ulcers.

Laparoscopic Adjustable Gastric Banding

A Laparoscopic Adjustable Gastric Band procedure is a purely restrictive surgical procedure in which a band is placed around the upper most part of the stomach. This band divides the stomach into two portions, one small and one larger portion. Because food is regulated, most patients feel full faster. Food digestion occurs through the normal digestive process.


  • Restricts the amount of food that can be consumed at a meal.
  • Food consumed passes through the digestive tract in the usual order allowing it to be fully absorbed into the body.
  • In multiple studies involving over 3000 patients, excess weight loss ranged from 28-87%, with a minimum of 2 year postoperative follow-up.
  • Band can be adjusted to increase or decrease restriction.
  • Surgery can be reversed.


  • Gastric perforation or tearing in the stomach wall may require additional operation.
  • Access port leakage or twisting may require additional operation.
  • May not provide the necessary feeling of satisfaction that one has had enough to eat.
  • Nausea and vomiting.
  • Outlet obstruction.
  • Pouch dilatation.
  • Band migration/slippage.

Next there's liposuction.  While the techniques have improved over the years, the concept is still the same and is surprisingly simple. Liposuction is a surgical technique that improves the body's contour by removing excess fat from deposits located between the skin and muscle. Liposuction involves the use of a small stainless steel tube, called a cannula (from the Latin word for reed, tube, cane). The cannula is connected to a powerful suction pump and inserted into the fat through small incisions in the skin. Fat removal is accomplished as the suction cannula creates tiny tunnels through the fatty layers. After surgery, these tiny tunnels collapse and thus result in an improved body contour.

I'm not going to get into all the different options for liposuction.  It really depends on what your needs are and how your body stores fat.

Lastly, body contouring or loose skin sculpture is a way of shoring up all that loose skin you have after either conventional weight loss or weight loss from a bariatric surgery.  You see, the skin will stretch when you put on weight but it doesn't snap back into place if you lose weight too quickly or have lost a great deal of weight.  And as you get older the harder it is for the skin to recover.  This can leave your body looking 'deflated'. 

There is some debate on how much the skin will actually be able to snap back after weight loss....I can't say for sure who's right.  However, one of the reasons I chose to lose weight at a slower speed is that I want my skin to have time to recover at each step of the way.  And so far that is working for me. 

Do I recommend any of these procedures? No...no I don't.

I'm not in a position to recommend surgery to anyone.  I'm not a doctor....and the situation for each of you is different.  For example bariatric surgeries are the only way that some of the morbid obese can ever hope to recover to a point that they can get back to an active lifestyle.  Since I 'was' morbidly obese when I started, I can understand how hard it is to lose weight the conventional way when your joints are all crying out in pain just moving your body around...not to mention the stress on the lower back.  It was a slow road. 

My opinion is that bariatric surgery isn't for me....and it probably isn't for you either.  Same goes for liposuction.  My biggest problem with these surgeries is that it doesn't fix the problem...it just fixes the symptom.  The problem ISN'T the fat...it is the diet.  A fat person that loses weight with a quick fix like surgery hasn't really learned how to keep it from happening again.  They haven't learned how to fix their diet.  And until they do that, the knife is just fixing the fat issue....not the real problem.

That leaves us with the loose skin issue.  Would I get body contouring to take care of the problem?  Maybe.  But I'll let you in on my overall weight loss plan...and maybe that will put it in perspective for you.

  • Year 1 - Drop 50 pounds (done)
  • Year 2 - Drop additional 50 pounds
  • Year 3 - Give skin time to recover
  • Year 4 - Decide if I'll do body contouring

I'm not going to worry about it for now.  I'm strengthen my body and reducing my fat.  Those are the most important things to me right now.  If a year after my weight loss stops I'm still walking around with lots of loose skin...I'll decide then.  


Now THAT is some loose skin!









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