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BRITISH BROADCASTING CORPORATION
RADIO SCIENCE UNIT
CASE NOTES Programme no. 3 - Bariatric Surgery
RADIO 4
TX DATE: TUESDAY 13TH AUGUST 2008 2100-2130
PRESENTER: MARK PORTER
CONTRIBUTORS: SEVIM MOSTAFA
JANET BIGLARI
GUY SLATER
ANDREW KENDALL
PRODUCER: ERIKA WRIGHT
NOT CHECKED AS BROADCAST
YASMIN
I weighed 25 stone and have a picture of what I used to look like.
PORTER
Right this is you - wow - I mean you look completely different to me, if someone had shown me that and - I'd never pick you out of a line up.
YASMIN
People don't recognise me anymore, they walk right past.
PORTER
How tall are you?
YASMIN
Five foot two.
PORTER
Yeah 25 stone, I mean you're a shadow of your former self, quite literally aren't you. What did you do with all your clothes?
YASMIN
Give them to friends to make into curtains, pillowcases.
PORTER
I don't want to be rude but curtains - it looks like you're almost - I mean presumably you had to wear - where were you getting your clothes from?
YASMIN
Having them made.
PORTER
How do you feel looking back at - is that you?
YASMIN
I cant believe that was me, I've actually forgotten that used to be me. Funnily enough I just can't relate to that person anymore and I've been like that since the age of 23 and I'm 38 now.
PORTER
Yasmin who struggled with obesity all of her adult life. After more than a decade of trying every diet in the book, she managed to lose nearly 10 stone in nine months after having her stomach stapled. I have come to St Richard's Hospital here in Chichester to meet the team who operated on Yasmin to find out more about techniques like gastric banding and stapling. It's a controversial area, but there is a growing feeling among clinicians that this type of surgery - known as bariatric surgery - is much underused in the UK. In the ideal world obesity could be treated simply by encouraging a healthier lifestyle, but in practice the results from this sort of intervention are depressingly poor. And prescription-only slimming drugs don't seem to be much more effective either.
So how do the team at Chichester decide who is suitable for surgery, and who is not? Psychotherapists Sevim Mostafa and Janet Biglari help assess everyone referred here.
MOSTAFA
When we screen a patient we look at their eating behaviour. It's always a need to fill an inner emptiness with food and it's an emptiness that's an emotional emptiness and it'll never be filled with food. And that's what we come across. It's often anger, boredom, depression, loneliness and it's a vicious spiral because the more they use food the larger they become.
BIGLARI
Sometimes patients have got an addiction to food, as opposed to using it as a natural thing really. They're using food to suppress difficult emotions or difficult feelings that they're having. So by having a particular surgery like this would be taking away their coping mechanism.
MOSTAFA
Not many people see obesity as a psychological issue. So research suggests that about 70% of patients that go on to morbid obesity have actually suffered some form of abuse, be it physical, emotional, sexual abuse, those sorts of issues.
BIGLARI
Somebody doesn't become super morbid obese over a couple of years and this is why they do have a lot of psychological issues and deep rooted because that has kind of escalated from their childhood, adolescence into their adult life.
PORTER
Decades of ...
BIGLARI
Decades of increasing weight and increasing psychological issues.
MOSTAFA
And it's a spiral because when they get to that weight the mobility goes, they end up housebound, all they can do is sit and watch TV and eat.
PORTER
Do you think it's a problem that actually the first time they're likely to meet a psychologist about their eating behaviour is when they come for surgery which is sort of end stage treatment?
MOSTAFA
Absolutely, we say that all the time that - very often we sit down with a patient and we say what are your triggers and they've got no idea. And when we say but is it emotional eating, they've never actually had any form of counselling or psychotherapy so they don't know that it's an emotional issue.
PORTER
So you're saying the majority of your people that you see would have low self esteem, would be one of the major issues, so this sort of clichéd perception of people as being (in inverted commas) "fat and happy" is not true?
MOSTAFA
It's a complete myth. I would say the majority of our patients are depressed and have low self esteem.
PORTER
Because a cynic would say I mean you meet these patients but actually practically in the time that you have with them is there anything you can do about it because they're going to get surgery anyway?
MOSTAFA
We try to give them coping strategies. We give them worksheets to work through, so that by the time they get to surgery they've actually thought through some coping strategies, thought through some of their issues.
BIGLARI
When they have surgery suddenly their coping strategies is taken away overnight, so they're not going to be able to manage that. What normally happens is a transferred addiction and a transferred addiction is they're replacing the food with something else and that could be shopping, alcohol, drugs - they need to find out what their triggers were, so you know when you're saying what do we do as psychotherapists we help them try to explore that in a shorter space of time by using CBT - cognitive behavioural therapy - for them to understand how they can move forward.
MOSTAFA
The other thing I would like to add is that we do also look for binge eating disorder.
PORTER
Is it important for you, from a psychological point of view, that they have tried and exhausted every other option?
MOSTAFA
I think you can so recognise what we call a burnt out yo yo dieter and you can see they've spiralled up and down for 20, 30 years.
PORTER
An all too familiar scenario to Yasmin - who we heard from at the beginning of the programme. She did have some success with diets, but it never lasted.
YASMIN
The biggest weight loss on those diets was about six stone.
PORTER
That's quite a lot.
YASMIN
And that was actually with a liquid diet. But it used to leave me feeling so much more depressed.
PORTER
And presumably the weight came back on?
YASMIN
And more - six stone I'd lose and then I'd gain about another four on top of the six.
PORTER
Within what sort of period?
YASMIN
Half a year.
PORTER
Where were you going wrong do you think?
YASMIN
I used to be secretly binging but I used to eat dinner at home as well. But mum used to always make healthy food and she never realised why I was gaining the weight. I was suffering from depression after I graduated because my parents had become ill - my father was very ill and my mother became ill as well. I used to go to the supermarket and buy bags of food and I'd bring it home and I'd hide it from my parents and I'd be eating and eating and eating continuously, robotically, and my parents would never even know that I was actually, you know, doing this in private. I'd go for a ride in the car, take my food with me so my mum and dad wouldn't know what I'm doing.
PORTER
Well you knew what you were doing wrong in your case - you were eating a lot - did you not think it wise to try and address that, to seek some help to try and control your eating rather than just diet and lose the weight, knowing that you still had the problem there?
YASMIN
No I didn't - I realised that I was eating a lot but that was the any thing that gave me the happiness.
PORTER
In 2002, when the National Institute of Health and Clinical Excellence - NICE - first appraised surgical treatments for obesity there were fewer than 10 specialists in the UK offering bariatric surgery, compared to around 200 in countries like France and Italy where obesity rates are significantly lower, and more like a thousand in the States.
The situation is improving here in the UK but not as fast as some experts would like. There are thought to be at least a million people across England and Wales who meet the criteria for bariatric treatment suggested by NICE yet just 3,000 operations are likely to be carried out by fewer than 30 surgeons during the current financial year. Guy Slater is one of them. He is consultant gastrointestinal surgeon at Chichester, and the man who operated on Yasmin.
SLATER
Patients are normally referred to us by their general practitioner and the criteria really determined on their size, which were defined originally by the National Institute of Clinical Excellence. And they use something called a body mass index which is really a measure of a patient's bulk and is determined by their weight and their height. So - because clearly a taller patient can sustain a higher weight without being obese. So a patient of over 40 without any illnesses related to his obesity would be considered for the surgery. And a patient of a BMI over 35, if they had obesity related illnesses, could also be considered.
PORTER
So for an average chap, roughly how much overweight would he be, of an average size?
SLATER
A typical patient of six foot tall would be about 170-180 kilograms - 30 stone.
PORTER
Heavy.
SLATER
Very heavy.
PORTER
Do they have to have tried conventional approaches through diet and exercise or medication?
SLATER
They - certainly the original guidance was very much that they should have gone through a specialist dietary clinic, tried the various medications that can help you lose weight and have shown to have really tried everything. In practice because none of those things really work now if their BMI is over 50 they can be considered for a direct referral to surgery.
MOSTAFA
One thing that we've found over the years is that the larger the patient the larger the psychological issues that are underpinning that. And so anybody that comes to us who has got a BMI of over 50 straightaway we know that they've got to have some psychological support.
PORTER
And what are their principle motivators - is it health?
MOSTAFA
I would say it's more about trying to fit into life and to look better.
PORTER
They've wanted to do something about this weight for a long, long time.
MOSTAFA
Yes.
PORTER
There are two main types of operation used to treat obesity - both of which work by dramatically reducing the size of the patient's stomach so they feel full quickly and don't want to, or can't eat as much. Laparoscopic gastric banding - the lap-band - is probably the best known thanks to recent publicity surrounding celebrities who've had it done like Anne Diamond and Fern Britton. Guy Slater again:
SLATER
Well this is a model of a stomach with a gastric band round it and you place the gastric band very high up around the stomach using keyhole surgery, so that above the band there's just a small pouch of stomach, about 20 mils in volume, or the size of a very small yoghurt pot. The band itself is made of silastic, it's quite a rigid ring but inside has an inflatable reservoir and the inflatable reservoir is connected by tubing and it comes out through the patient's abdominal wall, under the skin to a port that's secured to the muscle on their left hand side of their abdomen. And by placing a needle through the skin and into the port and inject saline into the inflatable reservoir so that you can control the tightness of the band around the stomach.
PORTER
This is something you put in through a keyhole technique, I mean it's basically like a sort of jubilee - plastic jubilee clip....
SLATER
It's very similar to a jubilee clip.
PORTER
And why would you need to adjust it?
SLATER
You basically control a patient's food intake and their sensation of fullness by tightening the band. Fluids normally go through relatively easily, unless the band's too tight. The aim of the band really is to hold up food and solids and that's really important with patients that you educate them to eat the right sort of foods, anything that's very sloppy - crisps, chocolates, sweets, ice cream, alcohol - would go straight through the band and those calories would be consumed.
PORTER
Because the rest of the stomach remains intact.
SLATER
Absolutely normal.
PORTER
It's just this feeling of fullness that you're giving them essentially.
SLATER
Very much so. So digestion is unaffected and it's really controlling their appetite and giving them a sense of satiety.
PORTER
Now the other option involves surgery, involves doing things to the stomach, what operation do you use here?
SLATER
We use something called a gastric bypass which is a much more aggressive, much more radical operation and that involves - rather than putting a band round the stomach - stapling across the stomach to make a small pouch of stomach just above the staple line, again about 20 mils in volume. You then measure down the small bowel, making something called a by-pass, and you join the by-pass to the pouch using a hole that's about a centimetre in diameter and let them go back to recover.
PORTER
So effectively you've got this same pouch mechanism which gives them the feeling of fullness but there's actually a shortcut through the bowel as well.
SLATER
There is a shortcut through the bowel and I think some people feel that there's an element of mal absorption of fat that contributes to the weight loss. But I think actually the physiology behind it is very complex and there is actually an interference with the normal gut hormones that seems to have produced weight loss beyond what you'd expect from just the surgery. People can do equally well with the band or the bypass but the bypass is probably more reliable, it takes much less patient input to achieve a good result.
PORTER
You say patient input - I mean looking at this - having heard you explain those two techniques - it would seem that from the surgeon's point of view the lap band is the easier technique.
SLATER
Very much so. We've not lost anyone to date doing band surgery. For bypass the mortality rate is probably .5-1.0% ...
PORTER
Up to one in a hundred.
SLATER
One in a hundred.
PORTER
So how do you select which patients you put into which group?
SLATER
Certainly patients who are very good dieters, who can control the type of foods they eat will often do very well with the band, whereas people who have more disordered eating, less structured eating, I would tend to favour the bypass for them.
PORTER
So of the two the bypass is the (in inverted commas) "stronger treatment" as such?
SLATER
Very much so but it comes at a price.
PORTER
Guy suggested that Yasmin have bypass surgery, and she went under the knife last September after being referred by her doctor.
YASMIN
My GP was very supportive because he'd been supporting every diet that I'd ever done - I used to go and see my GP first. And the last resort was when I decided to have the surgery, my GP was very supportive. And my surgeon - the first thing he said to me - I have I think a 10% chance of living another five years if I carried on the way I was.
PORTER
Surgeons are pretty blunt aren't they.
YASMIN
Oh yes, very blunt. I was worried about the complications but also the fact that food would be taken away from me because I had such a love/hate relationship with food. It was so easy to be that big obese person sitting in her four walls at home and just existing and not living.
PORTER
But on the other side was the prospect of a new you and a new life.
YASMIN
And that was much more difficult for me to handle.
PORTER
How did you feel in the sort of few days before you were coming into hospital to have the operation done, knowing this was your - if you like - your last opportunity to eat the way that you had been?
YASMIN
I was absolutely petrified.
PORTER
While Guy Slater was preparing to operate on his next patient - 25-year-old Sara - I had a quick chat with her on the ward. Like Yasmin, she's had her ups and downs with her weight.
SARA
Pretty much from about 14 years old onwards really I've sort of struggled. I was okay as a child, I was always a big girl but hitting adolescence it sort of packed on and it's sort of been a struggle since then really.
PORTER
And how heavy are you now?
SARA
I'm 19 stone 7.
PORTER
And you're sitting here in your theatre gown about - literally about to go downstairs to have stomach surgery, what sort of operation are you having?
SARA
I'm having the gastric bypass.
PORTER
What are you looking forward to most about having a smaller stomach?
SARA
I'm looking forward to not eating because if you was to cram what I've eaten in my life into years I'd be an old lady because that's just how it's been.
PORTER
To get back in control?
SARA
Yeah that's it, I've had - I've not had control for a while and this is the first thing that I'm sort of doing for myself that is taking control.
ACTUALITY IN THE OPERATING THEATRE
PORTER
Guy, why have you gone for the gastric bypass in this case?
SLATER
This young lady was very interesting. Originally when I saw her in clinic she was quite well informed and I went through the options really, discussing gastric band and gastric bypass with her and the pros and cons. And then I sent her off with some internet sites to do some further research and it was really after she'd spent some time researching and comparing her own sort of eating behaviour with the sort of requirements of each surgery that she actually rang me up and said I've really changed my mind, I think the bypass would be much more effective for me.
PORTER
And she thought it would be more effective because of what?
SLATER
I think she felt that given her eating behaviour and knowing her weaknesses with her diet she felt that this would be more reliable for her, that she felt there was a significant chance of her cheating with the band. It's said that if you're a sweet eater or favour ice cream and chocolate and so forth that the band isn't good for you. I wouldn't say that's an absolute rule. At the moment we're just going down through the skin of this abdominal incision, it's quite a small incision but as you can see the abdominal wall fat is quite thick in this lady, about five or six centimetres from the underlying muscle.
PORTER
And that's another physical challenge of doing this sort of surgery as well, you're operating at the bottom of quite a deep hole aren't you.
SLATER
Yeah there's no doubt that it is physically and technically very demanding surgery and it's high risk - if things don't go to plan, if you encounter a mistake during the operation or afterwards, the patients do badly, so you have to be technically quite able and the operations need to go well.
PORTER
So given that this sort of surgery's been approved for people with high BMIs by NICE, if you fulfil the NICE criteria do people have a right to get funding for this sort of operation?
SLATER
No they don't have a right and I think that's the thing about the National Institute of Clinical Excellence is it's only a recommendation and it's up to the primary care trust to fund what they choose to fund. And to be fair to them I have some sympathy, certainly at the levels set by the National Institute of Clinical Excellence, obesity is so - there's so much of it at that level that it's unaffordable.
PORTER
But bariatric surgeons like yourself are few and far between in the UK, I would imagine what there's 20 or 30 of you in the country.
SLATER
I think of that sort of order.
PORTER
What do your colleagues think of you - I'm thinking of the traditional surgical approach to well these people just need to eat less and do more?
SLATER
I think there is certainly an uninformed view within surgery and there's no doubt that many surgeons do hold prejudices but certainly in my opinion it is an illness, it's working with it for so long that's made me realise that and I probably had a similar attitude previously.
PORTER
Consultant anaesthetist Andrew Kendall is helping Guy with Sara. Andrew, these must be very difficult patients from an anaesthetic point of view?
KENDALL
They tend to as they get very large with BMIs over 50, and we've done patients with BMIs up to 109 so far, have problems with airway collapse. They certainly have a blunted respiratory drive and a lot of the patients here have what's called sleep apnoea. So if you give them normal analgesic drugs like morphine they simply stop breathing on you. So we have had to develop a different anaesthetic technique, just to give them decent analgesia while not blunting that respiratory drive.
PORTER
So that's the pain relieving part of the anaesthetic - you're knocking them out and you need to give them pain relief on top.
KENDALL
And you need to give them pain relief afterwards because of course the classic thing with anaesthetics was if you have a lot pain, especially in the upper abdomen, which is where we're doing the operation, then people tend to try to restrict their breathing at the end. So we've developed what's called a [indistinct words]block of local anaesthetic to make sure they take deep breaths.
PORTER
The other problem is of course that these patients just aren't obese, they're often going to have diabetes, high blood pressure, other problems that might present a bit of a challenge to you.
KENDALL
Indeed. One reason we do the operation isn't to make them look slim and beautiful, it's actually to improve their quality of life in the future and stop them having things like heart attacks in the future. So yes you do get patients with the older ones who've already got into those problems and the younger ones who are very obese you have to look out for some of the other co-mobilities which might come like heart failure, which they don't recognise apart from swelling of the ankles but it gives us all sorts of problems.
PORTER
What about recovery after the operation?
KENDALL
Well probably the major medical advance we have is we have these special beds which you can see out here, which they can sit bolt upright. So at the end of an operation instead of lying flat on their backs and some of these patients can't lie flat on their backs and haven't done so for sometimes tens of years, we have them sitting bolt upright so that they are actually able to take that first deep breath which is always so important.
PORTER
So literally the effects of gravity when they're lying flat on their back stops them breathing?
KENDALL
Yeah and a lot of these patients have either been sleeping with five or six pillows or some of them have learnt to prone themselves, because your pulmonary mechanics work differently if you're lying on your stomach and they actually wedge themselves up but lie on their fronts and that way they can breathe more efficiently.
SLATER
This lady's quite challenging because she's quite short and quite small, so although she's quite overweight there's a very small person underneath.
PORTER
I noticed that it's not a very big wound either, what four to six inches, you only just get your hand in.
SLATER
Certainly if we keep the incision small patients do seem to recover quicker, have less pain and go home quicker.
PORTER
The device you're using to close off the bottom part of the stomach there is - I mean is - essentially is that a normal staple?
SLATER
It is a normal stapler that we use in other areas of surgery.
PORTER
And those bits of metal in there they'll stay in forever presumably?
SLATER
The staples stay in place permanently. The patients aren't aware of them. They don't cause any symptoms or any side effects.
PORTER
What sort of regime will Sara have to be on when she gets home?
SLATER
Initially she'll be on a very strict regime in terms of what she can eat and she'll eat three or four very small meals a day, literally each meal consisting of two or three teaspoonfuls of food. And initially that would be pureed vegetables and fruit. And with time she'll be able to eat more.
PORTER
And presumably she'll never be able to go out and eat a meal with people, she'll always be eating little and often?
SLATER
By about six months to a year after the surgery patients can lead a fairly normal lifestyle. If they were to go out to dinner they may find that they can't manage a main course but perhaps they can manage two starters. But if there's somebody who can't manage meat they may look down the menu and think oh I'm really short of choices so it is really very limiting on their lifestyle and that's something you need to explain to them.
PORTER
If Sara manages to lose her target of - I think she was talking somewhere between six and eight stone, which she ideally would like to lose what's going to happen to her skin, because she's been overweight for quite a long time, although she's young it's not going to recover fully is it?
SLATER
There's no doubt that that is a concern for particularly ladies who tend to wear their fat on the outside, so with weight loss they do get quite marked folds of skin, particularly around their upper arms, across their abdomens, around their thighs and backsides and it is a real issue. The NHS is very clear that they won't fund plastic surgery to remove that excess skin except in exceptional circumstances. So it's one of the things I have to run through with patients making sure that their expectations are realistic and that they understand how they will look physically afterwards.
PORTER
Once Sara gets home at what stage will you be seeing her again for follow up?
SLATER
I'll see her about a month after surgery and then I'll see her regularly through the first year. And at about a year by that time we're confident their weight loss has stabilised and they're not going to lose too much weight, at that point we discharge them.
PORTER
And the sort of weight loss you'd be looking for on average?
SLATER
Again it varies very much from person to person. But I think Sara's expectations of six to eight stone are realistic for her. Bigger men may lose anything between 12 and 15 stone.
PORTER
Do you notice a big difference in your patients pre and post operatively from a psychological point of view?
SLATER
Yeah, no there's no doubt that when they come back, not necessarily the first visit but often the second visit, they're amazingly happy. They often say that their lives have been turned around, have not saved, and they're really pleased. And I think it's that happiness that most struck me when I first started doing the surgery.
PORTER
Sara's stapling and bypass went very well and she's now home, but her operation is just one step in a long journey. Psychotherapists Janet and Sevim again.
BIGLARI
Our patients lose a huge amount of weight, so not only are they losing a sense of themselves a new self is coming through which they don't know and they're only going to manage that transition if they've got the support, it's not just about losing the weight, it's about once they've lost the weight and all these other issues are coming up for them.
PORTER
Do you talk to them about how other people might see them once they've lost five, six, seven, eight stone because they're going to look very different, I mean to their partners?
MOSTAFA
They're very different and then there's a huge incidence of relationship breakdown after surgery because people become different, totally different people.
BIGLARI
It's very common and what we tend to do within our assessments is we ask them - what are the gains for them to lose weight and what are the losses? - and that's really quite enormous for them, that they look at the gains and the gains is only, you know, a few but the losses is that it's huge because they're losing a huge sense of themselves, they now might have to go out and interact in society. This weight may have been a coping mechanism or it may have been something else. And that's really being taken down - their barriers...
PORTER
Something quite literally to hide behind.
BIGLARI
Absolutely. Overnight - because overnight, within three or four months, that's when the largest weight loss is - you know you could see the results then.
MOSTAFA
There's often fear, there's a lot of fear that will they be able to make those changes, are they going to be the one patient that it's not going to work for?
BIGLARI
This is something that they'll be doing for the rest of their lives.
MOSTAFA
Some people just find it completely difficult to re-engage with life because they've been stigmatised for so long that they become very anxious, they become very fearful of entering the world again.
PORTER
But you must see quite a lot - I mean if it works for them and they're losing the weight you must see a lot of very happy people as well.
MOSTAFA
It's wonderful, it's wonderful. When you see someone who's lost weight and they're healthy with it, it's just the most amazing feeling. And to be part of that is just incredible.
PORTER
Although Yasmin's surgery has been a great success, and she's lost around 10 stone since her operation in September, it was a struggle at first.
YASMIN
After surgery emotionally I still felt very low because I was told that my stomach was the size of like a little petite filou carton and I couldn't handle it, I was just like miserable.
PORTER
So how were you eating, what were you told about how you should eat and drink then?
YASMIN
I was told that initially I'd be eating very small amounts, like teaspoons of pureed food, I'd never be able to eat and drink at the same time, I'd have to have a half hour gap between food and drink. For breakfast, for example, I'll have half a Weetabix and that's it.
PORTER
And you can eat that in one go?
YASMIN
It takes time, about 15 to 20 minutes, very, very slowly.
PORTER
What about things like a cup of tea?
YASMIN
Again I can have tea but have to sip very slowly and that could take about 20 minutes to drink one cup of tea.
PORTER
Did you make a smooth recovery afterwards?
YASMIN
Yes I did, I was quite surprised at how quickly the recovery was. I thought the pain, the sickness and everything would last forever but luckily it didn't but a month at least.
PORTER
There was a month before you felt back to normal?
YASMIN
I'll never be normal, I mean what I used to be, I'll never be that person again. I've had to totally change myself.
PORTER
And you look fantastic, and you look very happy.
YASMIN
Yeah I am very happy because of the fact that I didn't have to think - for the first time in my life - I never had to think about food.
PORTER
Looking back now right across your whole experience has it been one that you're pleased you went through?
YASMIN
Hand on heart I can say this that after 10 years of thinking whether I should have it or not and arguing with my whole family to have this done I would recommend it to anybody but only as a last resort.
ENDS
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