Which surgery would a surgeon choose?

Question
QUESTION: Dear Doctor Pilcher,

I am 5'6'' and 314 lbs, and I have been unsuccessful in losing weight throughout my life.  Currently, I have heartburn, wrists that get painful when I lift anything of weight or do repetitive excercises (two years ago my wrists were very painful, even holding a section of a newspaper hurt and my pinkie and finger next to it often tingled and/or went numb - fortunately that's gotten much better), and I have plantar fasciitis, which I can't seem to get rid of.  The heel pain really prevents me from walking far, although all summer I swim every day at our cottage with fins (carefully).

My blood tests were normal, except my CRP was slightly high.  I am booked to see a bariatric surgeon next month.  I live in Ontario, Canada, and Lap-Band surgery is not covered by the government, but the Roux-en-Y and vertical sleeve are.

I guess I have 2 questions:

1. Would you recommend a Lap-Band for someone with so much weight to lose?  I can pay for the surgery.  Would you recommend another type of surgery?

2. Would you be concerned that I have a 'psychiatric history'?  I have been depressed since I was 12 (I'm 37), attempted suicide once (4 days in a coma), had about 170 ECTs (I stopped having them almost 2 years ago), and currently take psychiatric medications.  My family doctor refered me to the surgeon on the advice of the psychiatrist who prescribes my medications and whom has done so for about 14 years.  The pyschiatrist whom I talk to 4 x a week didn't at first support any operation, but has begun to change his mind when I talk about it: what I can't do at my weight, how much weight I should lose, and what I'd like to do if I lost part or most of the excess weight.

I don't believe that bariatric surgery will resolve my depression or give me normal self esteem, but I think that weight loss will help those issues and I have many things that I am looking forward to being able to do, even simple things like gardening, taking care of my mother's very large house (she has a very large benign skull base tumor (it was 7cm x 4.5cm, and they could only remove 50%), going for walks, biking, joining a no skills required hockey league, and maybe even becoming a SCUBA diver.  Doing any of these things would definitely lift my mood and elevate my self-esteem.

I just worry a lot right now that my psychiatric history might disuade a surgeon.  I am going to ask my psychiatrists to write letters stating that I am mentally stable and will be able to handle all the rigourous preparation and life changes I would need to make after the surgery.

Sincerely,

Jennifer.

ANSWER: Jennifer,
I think it is great that you are doing all this research and that you are taking action to improve your life.

Your history of depression (as you described it) would certainly be a factor that would increase the complexity of your care around surgery.  I would think of your psychiatric history as a "risk factor," similar to other risk factors like heart disease, diabetes, a bleeding tendency, etc.  My opinion is that risk factors need to be fully managed and controlled as well as possible, but only in extreme and poorly controlled cases do risk factors prevent bariatric surgery.

In other words, since you are being carefully treated, and since you have now recruited the support of your psychiatrist, and since you continue to see the psychiatrist regularly, I believe that most bariatric surgeons will seriously consider your for bariatric surgical intervention.

Best of luck!
Dr JP

---------- FOLLOW-UP ----------

QUESTION: Dear Dr. Pilcher,

Thank you again for you quick response and encouragement!  I was very relieved to read your answer.

I would like to know (if you can render an opinion with the information I can provide in an email format) which surgery might be most appropriate for me.

In Ontario, surgeons preform the Lap-Band surgery(which is not covered by the government), the Roux-en-Y type, and the vertical sleeve surgery.

I am about 314 lbs, 5' 6",37, female (I never want children), my bloodwork was essentially normal, and I may have sleep apnea (my 1st sleep test wasn't conclusive, as I "didn't sleep long enough" - a 2nd has been ordered.  I believe my BMI is just over 50.

Could you make a suggestion as to which type of surgery might be most appropriate based upon the above information?  Of course, your opinion would not take into account any unknown or unforeseen health problems.

Thank you again,

Jennifer.

ANSWER: Jennifer,
I think it is REALLY important for each patient to have a positive sense of conviction about the surgery they have done, so take my opinions with a grain of salt, research extensively yourself, talk to as many other patients as practical, and especially talk with your surgeon about his/her opinion.  Having said all that, I do have a couple of thoughts for you:

The Band is being recognized as clearly less effective than the other two operations.  Also, the Band requires a lot of the patient, full time.  That would be a concern for me if you suffer a bout of depression, in that you might not successfully keep up with your surgeon/physician recommendations.

The Gastric Bypass is the gold standard procedure.  It has been around for a long time and we know that it works well and it works for decades.  Having said that, there may be some question about the absorption of the multiple meds you take for your depression.

The Gastric Sleeve is the newest operation, and the weight loss with the Sleeve is not quite as good as the Gastric Bypass.  Nevertheless, the weight loss with the Sleeve is in the same ballpark as that for the Gastric Bypass and I suspect your medication tolerance would be more reliable with the Sleeve.

Thus, I would have a SLIGHT lean toward Sleeve in your case but I would certainly not be opposed to the Gastric Bypass if you or your surgeon believes that is better.  I would suggest for you to think of this as a choice between two good options.

Best wishes,
Dr JP



---------- FOLLOW-UP ----------

QUESTION: Dear Dr. Pilcher,

Thank you for answering my two previous questions.  I have no other bariatric surgeon whom I can pester with questions until the end of next month.  I hope you will answer another question for me please.

You didn't recommended the Roux-en-Y/gastric bypass, but leaned slightly towards the sleeve, because absorption of my psychiatric meds wouldn't be effected as much.

Would it make a difference if I could get most of my current meds in liquid, or sublingual form, or by depot injection?  Would liquid and sublingual meds be easier/more reliable to take with a gastric bypass or sleeve, or could I simply take a larger dose of meds in a crushed format?  Crushed meds would probably be cheaper and I have no insurance.

I know my prescribing psychiatrist will work to 'finesse' the dosages I might need post-op (he was the one who first mentioned getting bariatric surgery).  That psychiatrist is the head of 'drug-prescribing' for psychiatric patients whose regular psychiatrists can't help at a major, well-respected Toronto hospital.  He specializes in prescribing drugs for patients who have not responded to conventional drug therapy for depression, etc., and has done so for decades.

I will list my current meds and ask that you keep in mind that I have been depressed now for over 25 years and I have previously tried 33 different actual antidepressants, either alone or in combination with various adjuncts and they didn't work; however, for years I have taken most of the following:

Xanax - 0.5mg x 4/day
Clonazepam - 2mg x 1/day

Imovane - 7.5mg x 2/day

Concerta (aka Ritalin ER) - 54mg/day

Lupron Depot - 1 7.5mg IM injection/month

Tecta/Pantoprazole Magnesium) 40mg x 1/day

Abilify - 2mg/day

I believe that the Xanax and Clonazepam could be replaced by equivalent doses of some sublingual benzodiazapine at staggered intervals during the day (but mostly at night).

Ritalin is available in liquid form in the US (I'm not sure about Canada).  I could take a smaller non-extended release dose twice a day, perhaps crushed?

Lupron Depot will cause me no problems as it's an IM injection.  I do get my bone density measured about once a year.  I take it both because I have endometriosis and because I get very, very depressed around the end of my cycle.

Tecta/Pantoprazole Magnesium - I don't think I will need to take that for very long, maybe another month.  I had about $9,000.00 worth of dental work done recently (1 root canal, 5 crowns, a few cavities, etc.) and I took the maximum dose of Ibuprofen whenever I was awake for too long, and got nasty heartburn, but I think now that my teeth almost never hurt, and now that I haven't taken Ibuprofen for months, I will be off Tecta by next month, when I see the bariatric surgeon.

Abilify - My doctor and I don't think it's doing anything for my mood at all, so I think he will tell me to stop taking the drug when I see him next week.  We were discussing doing this the last time I saw him.

I have never been psychotic, but he did try using anti-psychotics as adjuncts to antidepressants, as is recommended for patients who don't respond to antidepressants alone.  That is also why I am taking Concerta, as stimulants are also recommended as adjuncts to antidepressants: however, I find Concerta does help me get up and get out and about during the day.  It does not produce any sort of 'high', it's like having a strong cup or two of coffee.  I could stop taking it if necessary, I've forgotten to take it once or twice and it made me extremely somnolent for about a day.

Imovane - I'm not sure what liquid or sublingual medication could replace this, perhaps it could be crushed, rather than replaced?

Except for adding a second Imovane pill and increasing the dose of Concerta, and the short-term use of Abilify and Tecta, I've been on the same drugs, at the same doses for about seven years.  I don't want you to think I'm abusing my prescriptions!  I want to use less of them, rather than more!  However, when I was thinking about having my wisdom teeth removed under sedation (at my dentist's suggestion), my psychiatrist said I could not be taken off my meds, so I know he doesn't want to take me off the meds that have kept me stable and kept me from feeling suicidal for years.

I talked to my other psychiatrist, my psychoanalyst, and he will write a letter stating that not only am I mentally stable, but that I can also handle the rigors of preparation for surgery and the life changes afterward, and that bariatric surgery would very likely improve my depression and self-esteem greatly.  I have seen him for about 7 years (since his predecessor retired).  My "drug psychiatrist" (whom I've seen for about 14 years) will also write a letter to the same effect.

I apologize if I have written too long a question or have repeated myself in a paragraph.  Having bariatric surgery is very important to me, and I wanted to present an unvarnished, full history for your consideration as an experienced bariatric surgeon.  I appreciate your time and your replies beyond measure.

Sincerely,

Jennifer.

Answer
Jennifer,
I have a lot of respect for the careful research that you are conducting.  In my prior answer I did mention a potential difference between absorption in the case of gastric bypass vs. sleeve, but in practical reality the difference will be small between the operations.  I looked at all the medications that you listed, and I can tell you that I've had patients on each of those meds with gastric bypass and with sleeve and they have done well.

You asked about using crushed or liquid form of the meds.  This is very likely to be useful in the time period close to surgery because crushed or liquid meds will go down more easily in first month or so.  In the long run you may need some dose adjustment of your meds with either operation, and the need for dose adjustment will be just as like based on weight change as on change in absorption.

Now, I am going to gently withhold further advice because I don't want to interfere with the decision making that you and your surgeon will do together.  I really think you will do well, and I wish you the best of luck!

Dr JP

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