The title was actually decided on by the publisher and was designed to include every imaginable “keyword” that might be used to search the Internet for a book on gastric banding. I wasn’t exactly enamored with the title but accepted the wisdom of those who are in the business of selling books. I preferred the title I had used when submitting the manuscript, “Stepping out of the Shadow of Obesity – A Comprehensive Guide to the Adjustable Gastric Band.” To me, this spoke to what I believe is the heart of the issue of weight loss surgery; individuals taking the initiative to actively “step-out” from under the destructive effects of a lifetime of being over-weight.

At the time I wrote the book I was performing Lap-Band^® exclusively for my obese patients, because I believed it to be the safest option available. While I still believe the Lap-Band^® has a place in surgical weight management, over the last few years I have witnessed a number of long-term problems with the band. Chief among the complications is displacement or slippage. Over time the band can “slip” down on the stomach causing dilation and partial obstruction of the upper gastric pouch. This can occur despite the fact that the band is sutured in place. The telltale signs are chronic heartburn, chest pain, spontaneous regurgitation, failure to lose weight and even aspiration pneumonia.

When I first encountered the problem of a slipped band, I naturally believed the best treatment was to surgically reposition and re-suture it back in place. The results from these re-do procedures were acceptable, at least for a while, but several patients showed up with a second slip within a few months despite my best efforts. That’s when I decided to try something different, the gastric sleeve.  The sleeve was a very new procedure and involves removing about three quarters of the stomach pouch, but unlike the gastric by-pass there is no re-routing of the intestines. Around 2005 some of my colleagues had started to use the sleeve as a primary obesity operation, but I thought it made more sense as a “rescue procedure” for patients with a slipped Lap-Band^®.

I began converting patients with slipped bands to the gastric sleeve about four years ago and the results were truly amazing. Not only did the problems of heartburn, chest pain and regurgitation improve, these patients actually started losing weight again. It’s a well-known fact that most band patients lose about half of their excess weight and then just seem to hit a wall. But after conversion to the sleeve, many of my patients seemed to get back on track, losing up to 75 to 80% of their excess weight. Invariably they would tell me that the biggest difference they noticed was they weren’t hungry any more. The theory is hormones released from the stomach cause us to feel hungry, and since much of the stomach is physically removed during the gastric sleeve procedure, those hormones are also dramatically decreased. Without the constant feeling of hunger, gastric sleeve patients are better able to stick with their weight loss programs. In fact, most of my sleeve patients tell me they have to remind themselves when its time to eat. The sense of hunger does return after about six months, but never to the same degree they’d experienced before. Universally, my conversion patients tell me they wish they’d gone with the sleeve to start with. While hindsight is always 20/20, the fact is the gastric sleeve is still a relatively new option.

As a result of the success I saw in patients converting from the Lap-Band^® to the gastric sleeve, in early 2008 I started using the sleeve as the preferred option for most obese patients seeking weight loss surgery. Somewhat ironically this was about the same time my Lap-Band^® book came out in print. I’ve learned that writing a book, which takes a year or more to produce, is probably a waste of my time. So, given the fast paced world of Internet communication, I’ve decided to stick to writing this blog, which allows me to make changes “on the fly.” Currently, it is my opinion that the gastric sleeve, combined with a comprehensive weight management program, offers the best option for over-weight individuals interested in “Stepping Out of the Shadow of Obesity.” Its also the best option for those who have fallen off the Lap Band Wagon. 

As a surgeon I sat and watched the events unfold on television last Saturday and I was struck by how efficiently the emergency medical system responded to this major disaster. This was not some pre-rehearsed disaster drill, rather this was the real thing! On just another lazy Saturday morning I’m certain the emergency department at the University of Arizona Medical Center was in the process of seeing a few minor injuries, a couple of children with fever, and perhaps an elderly gentleman with chest pain. Suddenly, they were in the middle of what must have felt like a war zone. Helicopters and ambulances were arriving one after the other with critically injured patients including Congresswoman Gabriel Giffords. To describe such a scene as chaotic would be an understatement.

It’s truly remarkable how a civilian hospital and the personnel who work there were capable of shifting gears, becoming a major disaster management center in just a matter of minutes. It’s my understanding that 10 separate gunshot victims arrived at the University Medical Center, and all but one of them survived. The lone exception was nine-year-old Christina Green who had been shot in the chest. Regrettably, nothing could be done to reverse the mortal wound she suffered. As for the others, including representative Giffords, they were quickly and expertly transported into operating rooms where life-saving care was administered.

Over the last three and a half decades I have spent countless hours in hospital emergency departments caring for a variety of sick and injured patients including victims of trauma, and I can assure you that the remarkable actions of the trauma team in Tucson did not occur by accident. Trauma teams across the nation train regularly for such events and stand ready to deal with them whenever and wherever they may occur. So, if there is one thing positive that should come out of this tragedy, it is the realization that physicians and nurses and a variety of support personnel are ready and capable of dealing with even the most horrific acts of human violence or natural disaster. The results may not always be perfect, in fact sometimes an injury or illness is simply irreversible, but with God’s help the tireless efforts of dedicated individuals can, and often do, produce phenomenal results. 

One final point: Over the last several years the national discussion surrounding health care in the United States has consistently pointed to various statistics suggesting that we have less than quality care at a higher price than elsewhere in the world. Personally I reject that notion and would point to the events of January 8, 2011, in Tucson, Arizona as proof of the exceptional standards of American medicine.

The most powerful of the modern GERD drugs are known as proton pump inhibitors, or PPIs. They include Prilosec and Zegerid (Omeprazole), Protonix (Pantoprazole), Prevacid (Lanzoprazole), Aciphex (Rabeprazole), Nexium (Esomeprazole) and Dexilant (Dexlansoprazole). If you look at the generic names of each of these drugs they all end in prazole, referring to that chemical component responsible for stopping acid from being produced by the stomach. While some patients get better results from one than they do from another, the fact is they all work pretty much the same way. Interestingly it is not uncommon for one drug to work well for a period of time only to become ineffective. Changing to a different PPI may prove effective, assuming your insurance will pay for it; but that’s a whole different discussion.

For two decades the PPIs have been widely prescribed for both proven as well as merely suspected reflux. During that time there was little mention of potential side effects other than the fact that they occasionally cause cramping abdominal pain, diarrhea or constipation and excess gas, as well as a known interaction with the blood thinner Plavix®, But if you look more closely at the long-term effects of eliminating stomach acid there is a concern over what this does to Calcium absorption by the intestinal tract. Recently, the FDA reported on its review of a number of studies that demonstrated an increased risk of osteoporosis and pathologic fractures in patients who have been on PPI’s more than one year. This risk appears to be greatest in women over the age of 50 and increases with prolonged use of these medications. Calcium is simply not well absorbed when there is no acid in the stomach.

Certainly neither I nor the FDA are suggesting that everyone should stop taking PPIs; that is not at all practical. But if you are one of the millions of people who take medicine everydayfor heartburn you should know there are minimally invasive surgical procedures that can stop your reflux and thus the need for medications altogether. Perhaps the most exciting news in recent years has been the introduction of an incisionless surgery option for treating chronic reflux. The Transoral Incisionless Fundoplication (TIF procedure) can be used to strengthen the muscular valve between the esophagus and the stomach, and is performed entirely through the mouth, requiring no incisions. It is truly the definition of minimally invasive surgery.

While operations for reflux can provide some patients permanent relief from symptoms, they are not indicated for everyone. Prospective patients must first be properly evaluated, which includes an upper GI endoscopy to look for associated problems like hiatal hernia, esophageal stricture and other associated conditions. Additional tests may also be needed to not only prove the diagnosis of reflux, but also to help determine whether surgery is an appropriate alternative to a lifetime of pills.

If you’re interested in learning more about gastroesophageal reflux disease and its surgical treatment options go to www.robertsewellmd.com. There you’ll find videos explaining reflux as well as the available surgical options along with a number of patient testimonials.