by Atul Gawande
Then, as he put it, “I started eating again.” Pizzas. Boxes of sugar cookies. Packages of doughnuts. He found it hard to say how, exactly. His stomach was still tiny and admitted only a small amount of food at a time, and he experienced the severe nausea and pain that gastric-bypass patients get whenever they eat sweet or rich things. Yet his drive was stronger than ever. “I’d eat right through pain—even to the point of throwing up,” he told me. “If I threw up, it was just room for more. I would eat straight through the day.” He did not pass a waking hour without eating something. “I’d just shut the bedroom door. The kids would be screaming. The babes would be crying. My wife would be at work. And I would be eating.” His weight returned to four hundred and fifty pounds, and then more. The surgery had failed. And his life had been shrunk to the needs of pure appetite.
He is among the 5 to 20 percent of patients—the published reports conflict on the exact number—who regain weight despite gastric-bypass surgery. (When we spoke, he had recently submitted to another, more radical gastric bypass, in the desperate hope that something would work.) In these failures, one begins to grasp the depth of the power that one is up against. An operation that makes overeating both extremely difficult and extremely unpleasant—which, for more than 80 percent of patients, is finally sufficient to cause appetite to surrender and be transformed—can sometimes be defeated after all. Studies have yet to uncover a single consistent risk factor for this outcome. It could, apparently, happen to anyone.
Several months passed before I saw Vince Caselli again. Winter came, and I called him to see how he was doing. He said he was well, and I did not press for details. When we talked about getting together, though, he mentioned that it might be fun to go see a Boston Bruins game together, and my ears pricked up. Perhaps he was doing well.
A few days later, he picked me up at the hospital in his rumbling six-wheel Dodge Ram. For the first time since I’d met him, he looked almost small in that outsize truck. He was down to about two hundred and fifty pounds. “I’m still no Gregory Peck,” he said, but he was now one of the crowd—chubby, in an ordinary way. The rolls beneath his chin were gone. His face had a shape. His middle no longer rested between his legs. And, almost a year and a half after the surgery, he was still losing weight. At the FleetCenter, where the Bruins play, he walked up the escalator without getting winded. Our tickets were taken at the gate—the Bruins were playing the Pittsburgh Penguins—and we walked through the turnstiles. Suddenly, he stopped. “Look at that,” he exclaimed. “I went right through, no problem. I never would have made it through there before.” It was the first time he’d gone to an event like this in years.
We took our seats about two dozen rows up from the ice, and he laughed a little about how easily he fit. The seats were as tight as coach class, but he was quite comfortable. (I, with my long legs, was the one who had trouble finding room.) Vince was right at home here. He had been a hockey fan his whole life, and could supply me with all the details: the Penguins’ goalie Garth Snow was a local boy, from Wrentham, and a friend of one of Vince’s cousins; Joe Thornton and Jason Allison were the Bruins’ best forwards, but neither could hold a candle to the Penguins’ Mario Lemieux. There were nearly twenty thousand people at the game, but within ten minutes Vince had found a friend from his barbershop sitting just a few rows away.
The Bruins won, and we left cheered and buzzing. Afterward, we went out to dinner at a grill near the hospital. Vince told me that his business was finally up and running. He could operate the Gradall without difficulty, and he’d had full-time Gradall work for the past three months. He was even thinking of buying a new model. At home, he had moved back upstairs. He and Teresa had taken a vacation in the Adirondacks; they were going out evenings, and visiting their grandchildren.
I asked him what had changed since I saw him the previous spring. He could not say precisely, but he gave me an example. “I used to love Italian cookies, and I still do,” he said. A year ago, he would have eaten to the point of nausea. “But now they’re, I don’t know, they’re too sweet. I eat one now, and after one or two bites I just don’t want it.” It was the same with pasta, which had always been a problem for him. “Now I can have a taste and I’m satisfied.”
Partly, it appeared that his taste in food had changed. He pointed to the nachos and Buffalo wings and hamburgers on the menu, and said that, to his surprise, he no longer felt like eating any of them. “It seems like I lean toward protein and vegetables nowadays,” he said, and he ordered a chicken Caesar salad. But he also no longer felt the need to stuff himself. “I used to be real reluctant to push food away,” he told me. “Now it’s just—it’s different.” But when did this happen? And how? He shook his head. “I wish I could pinpoint it for you,” he said. He paused to consider. “As a human, you adjust to conditions. You don’t think you are. But you are.”
These days, it isn’t the failure of obesity surgery that is prompting concerns but its success. For a long time it was something of a bastard child in respectable surgical circles. Bariatric surgeons—as obesity surgery specialists are called—faced widespread skepticism about the wisdom of forging ahead with such a radical operation when so many previous versions had failed, and there was sometimes fierce resistance to their even presenting their results at the top surgical conferences. They sensed the contempt other surgeons had for their patients (who were regarded as having an emotional, even moral, problem) and often for them.
This has all changed now. The American College of Surgeons recently recognized bariatric surgery as an accepted specialty. The National Institutes of Health issued a consensus statement endorsing gastric-bypass surgery as the only known effective therapy for morbid obesity, one able to produce long-term weight loss and improvement in health. And most insurers have agreed to pay for it.
Physicians have gone from scorning it to encouraging, sometimes imploring, their severely overweight patients to undergo a gastric-bypass operation. And that’s not a small number of patients. More than five million adult Americans meet the strict definition of morbid obesity. (Their “body mass index”—that is, their weight in kilograms divided by the square of their height in meters—is forty or more, which for an average man is roughly a hundred pounds or more overweight.) Ten million more weigh just under the mark but may nevertheless have obesity-related health problems that are serious enough to warrant the surgery. There are ten times as many candidates for obesity surgery right now as there are for heart-bypass surgery in a year. So many patients are seeking the procedure that established surgeons cannot keep up with the demand. The American Society of Bariatric Surgery has only five hundred members nationwide who perform gastric-bypass operations, and their waiting lists are typically months long. Hence the too familiar troubles associated with new and lucrative surgical techniques (the fee can be as much as twenty thousand dollars): newcomers are stampeding to the field, including many who have proper training but have not yet mastered the procedure, and others who have no training at all. Complicating matters further, individual surgeons are promoting a slew of variations on the standard operation which haven’t been fully researched—the “duodenal switch,” the “long limb” bypass, the laparoscopic bypass. And a few surgeons are pursuing new populations, such as adolescents and people who are only moderately obese.
Perhaps what’s most unsettling about the soaring popularity of gastric-bypass surgery, however, is simply the world that surrounds it. Ours is a culture in which fatness is seen as tantamount to failure, and get-thin-quick promises—whatever the risks—can have an irresistible allure. Doctors may recommend the operation out of concern for their patients’ health, but the stigma of obesity is clearly what drives many patients to the operating room. “How can you let yourself look like that?” is often society’s sneering, unspoken question, and sometimes its spoken one as well. (Caselli told me of strangers coming up to him on the street and asking him precisely this.) Women suffer even more than men from the social sanction, and it
’s no accident that seven times as many women as men have had the operation. (Women are only an eighth more likely to be obese.)
Indeed, deciding not to undergo the surgery, if you qualify, is at risk of being considered the unreasonable thing to do. A three-hundred-fifty-pound woman who did not want the operation told me of doctors browbeating her for her choice. And I have learned of at least one patient with heart disease being refused treatment by a doctor unless she had a gastric bypass. If you don’t have the surgery, you will die, some doctors tell their patients. But we actually do not know this. Despite the striking improvements in weight and health, studies have not yet proved a corresponding reduction in mortality.
There are legitimate grounds for being wary of the procedure. As Paul Ernsberger, an obesity researcher at Case Western Reserve University, pointed out to me, many patients undergoing gastric bypass are in their twenties and thirties. “But is this really going to be effective and worthwhile over a forty-year span?” he asked. “No one can say.” He was concerned about the possible long-term effects of nutritional deficiencies (for which patients are instructed to take a daily multivitamin). And he was concerned about evidence from rats that raises the possibility of an increased risk of bowel cancer.
We want progress in medicine to be clear and unequivocal, but of course it rarely is. Every new treatment has gaping unknowns—for both patients and society—and it can be hard to decide what to do about them. Perhaps a simpler, less radical operation will prove effective for obesity. Perhaps the long-sought satiety pill will be found. Nevertheless, the gastric bypass is the one thing we have now that works. Not all the questions have been answered, but there are more than a decade of studies behind it. And so we forge ahead. Hospitals everywhere are constructing obesity-surgery centers, ordering reinforced operating tables, training surgeons and staff. At the same time, everyone expects that, one day, something new and better will be discovered that will make what we’re now doing obsolete.
Across from me, in our booth at the grill, Vince Caselli pushed his chicken Caesar salad aside only half eaten. “No taste for it,” he said, and he told me he was grateful for that. He had no regrets about the operation. It had given him his life back, he said. But, after one more round of drinks and with the hour growing late, it was clear that he still felt uneasy.
“I had a serious problem and I had to take serious measures,” he said. “I think I had the best technology that is available at this point. But I do get concerned: Is this going to last my whole life? Someday, am I going to be right back to square one—or worse?” He fell silent for a moment, gazing into his glass. Then he looked up, his eyes clear. “Well, that’s the cards that God gave me. I can’t worry about stuff I can’t control.”
Part III
Uncertainty
Final Cut
Your patient is dead; the family is gathered. And there is one last thing that you have to ask about: the autopsy. How should you go about it? You could do it offhandedly, as if it were the most ordinary thing in the world: “Shall we do an autopsy, then?” Or you could be firm, use your Sergeant Joe Friday voice: “Unless you have strong objections, we will need to do an autopsy, ma’am.” Or you could take yourself out of it: “I am sorry, but they require me to ask, Do you want an autopsy done?”
What you can’t be nowadays is mealymouthed about it. I once took care of a woman in her eighties who had given up her driver’s license only to get hit by a car—driven by someone even older—while she was walking to a bus stop. She sustained a depressed skull fracture and cerebral bleeding, and, despite surgery, she died a few days later. So, on the spring afternoon after the patient took her last breath, I stood beside her and bowed my head with the tearful family. Then, as delicately as I could—not even using the awful word—I said, “If it’s all right, we’d like to do an examination to confirm the cause of death.”
“An autopsy?” a nephew said, horrified. He looked at me as if I were a buzzard circling his aunt’s body. “Hasn’t she been through enough?”
The autopsy is in a precarious state these days. A generation ago, it was routine; now it has become a rarity. Human beings have never quite become comfortable with the idea of having their bodies cut open after they die. Even for a surgeon, the sense of violation is inescapable.
Not long ago, I went to observe the dissection of a thirty-eight-year-old woman I had taken care of who had died after a long struggle with heart disease. The dissecting room was in the sub-basement, past the laundry and a loading dock, behind an unmarked metal door. It had high ceilings, peeling paint, and a brown tiled floor that sloped down to a central drain. There was a Bunsen burner on a countertop, and an old-style grocer’s hanging scale, with a big clock-face red-arrow gauge and a pan underneath, for weighing organs. On shelves all around the room there were gray portions of brain, bowel, and other organs soaking in formalin in Tupperware-like containers. The facility seemed run-down, chintzy, low-tech. On a rickety gurney in the corner was my patient, sprawled out, completely naked. The autopsy team was just beginning its work.
Surgical procedures can be grisly, but dissections are somehow worse. In even the most gruesome operations—skin grafting, amputations—surgeons maintain some tenderness and aestheticism toward their work. We know that the bodies we cut still pulse with life, and that these are people who will wake again. But in the dissecting room, where the person is gone and only the shell remains, you naturally find little delicacy, and the difference is visible in the smallest details. There is, for example, the simple matter of how a body is moved from gurney to table. In the operating room, we follow a careful, elaborate procedure for the unconscious patient, involving a canvas-sleeved rolling board and several gentle movements. We don’t want so much as a bruise. Down here, by contrast, someone grabbed my patient’s arm, another person a leg, and they just yanked. When her skin stuck to the stainless-steel dissecting table, they had to wet her and the table down with a hose before they could pull her the rest of the way.
The young pathologist for the case stood on the sidelines and let a pathology assistant take the knife. Like many of her colleagues, the pathologist had not been drawn to her field by autopsies but by the high-tech detective work that she got to do on tissue from living patients. She was happy to leave the dissection to the assistant, who had more experience at it anyway.
The assistant was a tall, slender woman of around thirty with straight sandy-brown hair. She was wearing the full protective garb of mask, face shield, gloves, and blue plastic gown. Once the body was on the table, she placed a six-inch metal block under the back, between the shoulder blades, so that the head fell back and the chest arched up. Then she took a scalpel in her hand, a big No. 6 blade, and made a huge Y-shaped incision that came down diagonally from each shoulder, curving slightly around each breast before reaching the midline, and then continued down the abdomen to the pubis.
Surgeons get used to the opening of bodies. It is easy to detach yourself from the person on the table and become absorbed by the details of method and anatomy. Nevertheless, I couldn’t help wincing as she did her work: she was holding the scalpel like a pen, which forced her to cut slowly and jaggedly with the tip of the blade. Surgeons are taught to stand straight and parallel to their incision, hold the knife between the thumb and four fingers, like a violin bow, and draw the belly of the blade through the skin in a single, smooth slice to the exact depth desired. The assistant was practically sawing her way through my patient.
From there, the evisceration was swift. The assistant flayed back the skin flaps. With an electric saw, she cut through the exposed ribs along both sides. Then she lifted the rib cage as if it were the hood of a car, opened the abdomen, and removed all the major organs—including the heart, the lungs, the liver, the bowels, and the kidneys. Then the skull was sawed open, and the brain, too, was removed. Meanwhile, the pathologist was at a back table, weighing and examining everything, and preparing samples for microscopy and thorough testing.
> For all this, however, I had to admit: the patient came out looking remarkably undisturbed. The assistant had followed the usual procedure and kept the skull incision behind the woman’s ears, where it was completely hidden by her hair. She had also taken care to close the chest and abdomen neatly, sewing the incision tight with weaved seven-cord thread. My patient seemed much the same as before, except now a little collapsed in the middle. (The standard consent allows the hospital to keep the organs for testing and research. This common and long-established practice has caused huge controversy in Britain—the media have branded it “organ stripping”—but in America it remains generally accepted.) Most families, in fact, still have open-casket funerals after autopsies. Morticians employ fillers to restore a corpse’s shape, and when they’re done you cannot tell that an autopsy has been performed.
Still, when it is time to ask for a family’s permission to do such a thing, the images weigh on everyone’s mind—not least the doctor’s. You strive to achieve a cool, dispassionate attitude toward these matters. But doubts nevertheless creep in.
One of the first patients for whom I was expected to request an autopsy was a seventy-five-year-old retired New England doctor who died one winter night while I was with him. Herodotus Sykes (not his real name, but not unlike it, either) had been rushed to the hospital with an infected, rupturing abdominal aortic aneurysm and taken to emergency surgery. He survived it, and recovered steadily until, eighteen days later, his blood pressure dropped alarmingly and blood began to pour from a drainage tube in his abdomen. “The aortic stump must have blown out,” his surgeon said. Residual infection must have weakened the suture line where the infected aorta had been removed. We could have operated again, but the patient’s chances were poor, and his surgeon didn’t think he would be willing to take any more.
