No Magic Pill In Weight Loss Procedures

[Bom Chan 0]

Hello everybody,

This is Bom Chan of the BIB & LAP-BAND CENTER. A doctor recently emailed me to complain about his failures or poor results with the BIB (BioEnterics Intragastric Balloon) System. FAQs about the BIB System are available at www.totalobesitysolutions.com. I decided to post my response to his email on this forum because I believe this information may also be useful for patients who are deciding on or have undergone weight loss procedures or bariatric surgery.

What is in my email response is not something which one can refer to as “rocket science” or something that is written in stone. These are simply my observations and honest opinions of certain facts about weight loss. The BIB is an efficient weight loss tool but it is only a tool, just like the Lap-Band. A tool is something that helps or assists us in performing a certain task which may be difficult or close to impossible to perform. That is my layman’s definition of what a tool is and the BIB is nothing more than a tool, albeit a very good one, that may assist a patient in reaching his or her weight loss journey because losing weight is difficult. Why? Because of HUNGER, CRAVINGS, and OVEREATING coupled with INACTIVITY. We try to resolve HUNGER with an implant that creates early fullness, resolve CRAVINGS by inhibiting the production of the hunger hormone ghreline when an implant is present, resolve OVEREATING by Diet-Behavior Modification. INACTIVITY, this we try to resolve by encouraging patients to be more active by doing things and getting busy and not think only about food. Indulge in some form of physical activity like walking to and fro destinations that are 15 to 20 minutes away instead of using the car, doing house chores, watching less TV that comes complete with TV dinners and Snacks. Getting physical but not necessarily only going to the gym.

In recent years, there were a number of trends in bariatric surgery and one of them is the sleeve gastrectomy. Simply put, sleeve gastrectomy or sleeve resection involves stapling of the stomach to make it more like a tube rather than a bag in order to hold less food. I am not saying that sleeve gastrectomy is an inferior procedure but let us look at it in the proper perspective.

Proponents of the sleeve would say that if a person does not want an implant in the body (e.g. BIB or Lap-Band), then he should opt for the sleeve. I asked those doctors in a public forum how they define “implant.” They did not know where I was getting at so I told them that yes the BIB (ORBERA in certain regions) and the Lap-Band are implants but so are the rows of titanium staples that are used in sleeve gastrectomy. Whatever object that does not exist inside the human body, is not a part of the human body and is placed inside the human body is technically an implant. So sleeve gastrectomy uses implants in the form of titanium staples and also gastric bypass in the form of non-resorbable sutures.

With regard to the Lap-Band, the Lap-Band is long-term implant made of medical-grade silicone that is hypoallergenic and it interfaces with our physiology to act as part of our system. For example, when a person has a tooth cavity and the cavity is taken out and replaced with a dental filling, in time the filling which is an implant becomes the tooth and when a person bites into a sandwich, he does not make the distinction whether it is the tooth or the filling in the tooth that is mechanically breaking down the piece of food. That is what happens with Lap-Band, the Lap-Band restricts food intake and becomes like part of the stomach in its function.

That is not the case of the BIB. An intragastric balloon such as the BIB, which is a temporary implant that stays inside the stomach for 6 months, only occupies the space which is normally occupied by food.

A clinical study was made that compared the BIB System with Sleeve Gastrectomy. Fast forward – the winner is of course Sleeve Gastrectomy. The conclusion of the paper was that patients who had the sleeve lost more weight than patients who had the BIB. This is like saying a Ferrari is faster in 0-60 miles per hour than a bicycle. The Sleeve Gastrectomy is surgical and whether it is performed laparoscopically or minimally-invasive surgery, it is still surgery. The BIB is non-invasive. Only a gastroscope enters the mouth and down to the stomach and the BIB is placed in the stomach endoscopically without surgery. A 20 to 30 minute procedure which was originally indicated to size down super-obese patients before they undergo more invasive bariatric procedures or elective surgeries. Elective surgeries are surgeries that are important but are not emergencies therefore subject to choice or election by either the patient or doctor. An example being the surgical removal of the gall bladder, which is called a cholesistectomy, for the treatment of symptomatic gallstones.

There is no magic pill in bariatrics or weight loss procedures. There are patients who failed in the Lap-Band, primarily because of lack of follow up with the bariatric surgeon, and opted for the gastric bypass or sleeve gastrectomy. There are also patients who failed in the gastric bypass because the bypassed stomach increased in size over the years and the patient could tolerate more food; and, unlike the Lap-Band, the gastric bypass is not adjustable. Like Carnie Wilson, of the singing group Wilson Philips, who had a gastric bypass 12 years ago, lost the weight and gained it back, and is now having a Lap-Band. In relation to the sleeve gastrectomy where proponents claim that no follow ups are required; that is incorrect. There are risks involved with the sleeve gastrectomy like for example staple leaks and these should be detected under post-operative management. In several scientific studies, successes of bariatric procedures have a direct correlation with post-operative management and support.

Before we forget, my email response to the doctor goes as follows:

Dear doctor,

Thank you for your response. I fully understand what you mean. In relation to the BIB, there are successes and failures because of a numberof things. We had a BIB patient (here in the Philippines) who was 25 pounds overweight and she was happy with the BIB which made her lose the 25 pounds in 6 months, after then she had consecutive BIBs to maintain her desired weight. (Asians have higher levels of body fat as compared to Caucasians. At certain BMI levels which are considered as “Overweight” for Caucasian patients, the same BMI levels may well be “Obese Class 1” already if it were for Asians. It would have been more cost effective for the patient just to go straight for the Lap-Band, but she refused to undergo any kind of surgery.)

We had one case where the patient lost 72 pounds and she maintained the weight loss after BIB removal. We had an American patient who lost 102 pounds in 6 months which was one of our best results locally. After the removal he regained 25 pounds but was still quite happy with the end results. We also had a strange case where the patient complained that she did not lose weight (this was a BIB workshop subject/patient) but claimed that her hypertension and diabetes type 2 went into remission and were controlled. She also lost the aches and pains in the back and on the knees and ankles. Perhaps she did lose some weight. But when the workshop was held some time in 2004, the focus was more on the technical or gastroenterology side of BIB placement and the patient did not follow up with the doctor.

We had 2 cases of failures like early removal of the BIB after one week because the patient could not tolerate the discomfort and a case where a patient lost 45 pounds but gained all the weight back after the BIB was removed. I always make it a point to tell our patients that after they lose the weight, they have to realize that at a lower BMI, they do not need as much food to sustain bodily functions so they should try to adhere to eating less food. All in all, I would say that quite a big majority of patients who had BIBs got what they expected and were happy with the results.

The BIB System is not a magic pill that will make an obese patient lose weight even though he forces himself to overeat even when he is full. We should be honest to our patients and not give them false hopes. While we are still waiting for the magic pill to be invented, if there is indeed one, we believe that the BIB is still one of the best weight loss tool or option for temporary weight loss (after weight is lost, the patient has to rely on good eating habits and physical activity to maintain normal weight). It would be best if the patient who wants a BIB discuss the matter thoroughly with the doctor and the doctor explains to the patient what to expect. What we are aiming to achieve is a "Diet-Behavior Modification" or change in behavioral patterns of eating. But if patient still overeats even when he if full, he vomits and therefore making it a "Forced Behavior Modification", meaning if the patient is full, he should be cautioned not to continue eating otherwise he would feel sick. A patient with the BIB should be given a hypocaloric diet composed of 1,200 calories a day which is manageable. That is the only time the body will revert to stored fat, both peripheral and subcutaneous, as fuel for energy. Patient education and follow up is advisable to get good results.

If we place a BIB that is too small, like 450cc, the patient may not feel any discomfort but it may also not make him full. If we put a BIB that is too big, like 700cc, the patient may lose a lot of weight but it may be an awful experience, which feels like indigestion, and the patient may want to have it removed immediately. We had a patient who wanted to have the BIB removed after 1 week because of no apparent reason. She did not complain of pain or discomfort but immediately after the BIB was removed, she went straight to a restaurant and ordered a big bowl of noodle Soup, dumplings and the works because she just wanted to enjoy eating a lot. This leads us to think about the questions that bariatric surgeons should ask their patients (and for us to introspect) : 1.) How serious and dedicated are you in wanting to lose the weight? 2.) How important is it for you to lose the weight? 3.) Do you envision yourself living a healthy lifestyle even before you have reached your ideal normal weight?

Some doctors put 600cc to all patients as part of their protocol. Preferably, the fill volume depends on the size (and shape) of the stomach and the balloon should touch the anterior and posterior part of the stomach inside. It should be big enough because the stomach has stretch receptors that give signals to the brain that the

patient is full; a signal to stop eating. We have placed BIBs as big as 700cc (of saline solution volume ) in some patients who had very big stomachs. And it is also the weight of the saline solution, the heaviness, that creates early fullness. Same reason why intragastric balloons filled with air has never been proven to be successful. The design of the BIB is a perfected design after groups of medical practitioners following a convention held in Tampa Springs, Florida years ago concluded that unlike the old Garren-Edwards Bubble (air-filled) which gave unsuccessful results, the design of the ideal intragastric balloon (BIB System) should be perfectly round, adjustable in

size (400cc to 700cc), able to last for 6 months, made of high-grade medical silicone, filled with saline solution for the weight, and have a radiopaque self-sealing valve.

A BIB doctor once told me that what he does is to make the BIB large enough to create some sensation close to discomfort but not excessively uncomfortable and he manages it with a little PPI (proton pump inhibitor) only when necessary. His patients lose 20 pounds to 70 pounds depending on the excess weight of the particular patient and adherence to protocol.

I hope that this would give some insight to your practice and contribute to more successful results with your patients to come.

With kind regards,

Bom CHAN

Head of Obesity Solutions

BIB & LAP-BAND CENTER

Email: bom@aemed.biz

Website: www.totalobesitysolutions.com

Thanks for reading!!!

P.S. A patient who used to be a plus-size model with a pretty face asked me what would happen if she had a bariatric procedure. I told her 3 things:

1. She may lose a lot of weight, and if she does,
   
   
2. She will lose her job as a plus-size model and may not qualify as a fashion model because she may not meet the criteria,
   
   
3. She will live a healthy normal life and enjoy doing things that she could not do when she was severely obese.
   

She replied: “Sounds good! So when do we start?”

[Rojasanoll 920]

good writing!