Authors: Atul Gawande
For the very obese, general anesthesia alone is a dangerous undertaking; major abdominal surgery can easily become a disaster. Obesity substantially increases the risk of respiratory failure, heart attacks, wound infections, hernias—almost every complication possible, including death. Nevertheless, Dr. Sheldon Randall, the attending surgeon, was relaxed—chatting with the nurses about their weekends, reassuring Caselli that things would go fine—having done more than a thousand of these operations. I, the assisting resident, remained anxious. Watching Caselli struggle to shift himself from the stretcher onto the operating table and then stop halfway to catch his breath, I was afraid that he would fall in between. Once he was on the table, his haunches rolled off the sides, and I double-checked the padding that protected him from the table’s sharp edges. He was naked except for his “universal”-size johnny, which covered him like a napkin, and a nurse put a blanket over his lower body for the sake of modesty. When we tried to lay him down, he lost his breath and started to turn blue, and the anesthesiologist had to put him to sleep sitting up. Only with the breathing tube in place and a mechanical ventilator regulating his breathing were we able to lay him flat.
He was a mountain on the table. I am six feet two, but even with the table as low as it goes I had to stand on a step stool to operate; Dr. Randall stood on two stools stacked together. He nodded to me, and I cut down the middle of our patient’s belly, through skin and then dense inches of glistening yellow fat. Inside his abdomen, his liver was streaked with fat, too, and his bowel was covered by a thick apron of it, but his stomach looked ordinary—a smooth, grayish-pink bag the size of two fists. We put metal retractors in place to hold the wound open and keep the liver and the slithering loops of bowel out of the way. Working elbow deep, we stapled his stomach down to the size of an ounce. Before the operation, it could accommodate a quart of food and drink; now it would hold no more than a shot glass. We then sewed the opening of this little pouch to a portion of bowel
two
feet past his duodenum—past the initial portion of the small
bowel, where bile and pancreatic juices break food down. This was the bypass part of the operation, and it meant that what food the stomach could accommodate would be less readily absorbed.
The operation took us a little over two hours. Caselli was stable throughout, but his recovery was difficult. Patients are usually ready to go home three days after surgery; it was two days before Caselli even knew where he was. For twenty-four hours, his kidneys stopped working, and fluid built up in his lungs. He became delirious, seeing things on the walls, pulling off his oxygen mask, his chest leads for the monitors, even yanking out the IV in his arm. We were worried, and his wife and daughters were terrified, but gradually he pulled through.
By the third day after surgery, he was well enough to take sips of clear liquids (water, apple juice, ginger ale), up to one ounce every four hours. On my afternoon rounds, I asked him how the sips had gone down. “OK,” he said. We began giving him four-ounce servings of Carnation Instant Breakfast for protein and modest calories. He could finish only half, and that took him an hour. It filled him up and, when it did, he felt a sharp, unpleasant pain. This was to be expected, Dr. Randall told him. It would be a few days before he was ready for solid food. But he was doing well. He no longer needed IV fluids. The pain from his wound was under control. And, after he’d had a short stay in a rehabilitation facility, we sent him home.
A couple of weeks later, I asked Dr. Randall how Caselli was getting on. “Just fine,” the surgeon said. Although I had done a few of these cases with him, I had not seen how the patients progressed afterward. Would he really lose all that weight? I asked. And how much could he eat? Randall suggested that I see Caselli for myself. So one day that October, I gave him a call. He seemed happy to hear from me. “Come on by,” he said. And after work that day, I did.
Vincent Caselli and his wife live in an unassuming saltbox house not far outside Boston. To get there, I took Route 1, past four Dunkin’ Donuts, four pizzerias, three steak houses, two McDonald’s,
two Ground Rounds, a Taco Bell, a Friendly’s, and an International House of Pancakes. (A familiar roadside vista, but that day it seemed a sad tour of our self-destructiveness.) I rang the doorbell, and a long minute passed. I heard a slow footfall coming toward the door, and Caselli, visibly winded, opened it. But he smiled broadly when he saw me, and gave my hand a warm squeeze. He led me—his hand on table, wall, doorjamb for support—to a seat at a breakfast table in his flowered-wallpaper kitchen.
I asked him how things were going. “Real good,” he said. He had no more pain from the operation, the incision had healed, and, though it had been only three weeks, he’d already lost forty pounds. But, at three hundred and ninety, and still stretching his size 64 slacks and size XXXXXXL T-shirts (the largest he could find at the local big-and-tall store), he did not yet feel different. Sitting, he had to keep his legs apart to let his abdomen sag between them, and the weight of his body on the wooden chair forced him to shift every minute or two because his buttocks would fall asleep. Sweat rimmed the folds of his forehead and made his thin salt-and-pepper hair stick to his pate. His brown eyes were rheumy and had dark bags beneath them. He breathed with a disconcerting wheeze.
We talked about his arrival home from the hospital. The first solid food he had tried was a spoonful of scrambled eggs. Just that much made him so full it hurt, he said, really hurt, “like something was ripping,” and he threw it back up. He was afraid that nothing solid would ever go down. But he gradually found that he could tolerate small amounts of soft foods—mashed potatoes, macaroni, even chicken if it was finely chopped and moist. Breads and dry meats, he found, got “stuck,” and he’d have to put a finger down his throat and make himself vomit.
It troubled Caselli that things had come to this, but he had made peace with the need for it. “Last year or two, I’m in hell,” he said. The battle had begun in his late twenties. “I always had some weight on me,” he said. He was two hundred pounds at nineteen, when he married Teresa (as I’ll call her), and a decade later he reached three
hundred. He would diet and lose seventy-five pounds, then put a hundred back on. By 1985, he weighed four hundred pounds. On one diet, he got all the way down to a hundred and ninety. Then he shot back up again. “I must have gained and lost a thousand pounds,” he told me. He developed high blood pressure, high cholesterol, and diabetes. His knees and his back ached all the time. He had only limited mobility. He used to get season tickets to Boston Bruins games, and go out regularly to the track at Seekonk every summer to see the auto racing. Years ago, he drove in races himself. Now he could barely walk to his pickup truck. He hadn’t been on an airplane since 1983, and it had been two years since he had been to the second floor of his own house, because he couldn’t negotiate the stairs. “Teresa bought a computer a year ago for her office upstairs, and I’ve never seen it,” he told me. He had to move out of their bedroom, upstairs, to a small room off the kitchen. Unable to lie down, he had slept in a recliner ever since. Even so, he could doze only in snatches, because of sleep apnea, which is a common syndrome among the obese, thought to be related to excessive fat in the tongue and in the soft tissues of the upper airway. Every thirty minutes, his breathing would stop, and he’d wake up asphyxiating. He was perpetually exhausted.
There were other troubles, too, the kind that few people speak about. Good hygiene, he said, was nearly impossible. He could no longer stand up to urinate, and after moving his bowels he often had to shower in order to get clean. Skin folds would become chafed and red, and sometimes develop boils and infections. “Has it been a strain on your marriage?” I asked. “Sure,” he said. “Sex life is nonexistent. I have real hopes for it.” For him, though, the worst part was his diminishing ability to earn a livelihood.
Vincent Caselli’s father had come to Boston from Italy in 1914 to work in construction. Before long, he had acquired five steam shovels and established his own firm. In the 1960s, Vince and his brother took over the business, and in 1979 Vince went into business for himself. He was skilled at operating heavy equipment—his specialty
was running a Gradall, a thirty-ton, three-hundred-thousand-dollar hydraulic excavator—and he employed a team of men year-round to build roads and sidewalks. Eventually, he owned his own Gradall, a ten-wheel Mack dump truck, a backhoe, and a fleet of pickup trucks. But in the past three years he had become too big to operate the Gradall or keep up with the daily maintenance of the equipment. He had to run the business from his house, and pay others to do the heavy work; he enlisted a nephew to help manage the men and the contracts. Expenses rose, and because he could no longer make the rounds of city halls himself, he found contracts harder and harder to get. If it hadn’t been for Teresa’s job—she is the business manager for an assisted-living facility in Boston—they would have gone bankrupt.
Teresa, a pretty, freckled redhead (of, as it happens, fairly normal weight) had been pushing him for a long time to diet and exercise. He, too, wanted desperately to lose weight, but the task of controlling himself, day to day, meal to meal, seemed beyond him. “I’m a man of habits,” he told me. “I’m very prone to habits.” And eating, he said, was his worst habit. But, then, eating is everyone’s habit. What was different about
his
habit? I asked. Well, the portions he took were too big, and he could never leave a crumb on his plate. If there was pasta left in the pot, he’d eat that, too. But why, I wanted to know. Was it just that he loved food? He pondered this question for a moment. It wasn’t love, he decided. “Eating felt good instantaneously,” he said, “but it only felt good instantaneously.” Was it excessive hunger that drove him? “I was never hungry,” he said.
As far as I could tell, Caselli ate for the same reasons that everyone eats: because food tasted good, because it was seven o’clock and time for dinner, because a nice meal had been set out on the table. And he stopped eating for the same reason everyone stops: because he was full and eating was no longer pleasurable. The main difference seemed to be that it took an unusual quantity of food to make him full. (He could eat a large pizza without blinking.) To lose weight, he faced the same difficult task that every dieter faces—to
stop eating before he felt full, while the food still tasted good, and to exercise. These were things that he could do for a little while, and, with some reminding and coaching, for perhaps a bit longer, but they were not, he had found, things that he could do for long. “I am not strong,” he said.
In early 1998, Caselli’s internist sternly told him, “If you cannot take off this weight, we are going to have to do something drastic.” And by this she meant surgery. She described the gastric-bypass operation to him and gave him Dr. Randall’s number. To Caselli, it was out of the question. The idea of the procedure was troubling enough. No way could he put his business on hold for that. A year later, however, in the spring of 1999, he developed bad infections in both legs: as his weight increased, and varicosities appeared, the skin thinned and broke down, producing open, purulent ulcers. Despite fevers and searing pain, it was only after persistent coaxing from his wife that he finally agreed to see his doctor. The doctor diagnosed a serious case of cellulitis, and he spent a week in the hospital receiving intravenous antibiotics.
At the hospital, he was also given an ultrasound scan to check for blood clots in his legs. Afterward, a radiologist came to give him the results. “He says, ‘You’re a lucky guy,’ ” Caselli recounted. “I say, ‘Did I win the lottery? Wha’d I do?’ He says, ‘You don’t have blood clots, and I’m really surprised.’ He says, ‘I don’t mean to break your bubble, but a guy like you, in the situation you’re in, the odds are you’re gonna have blood clots. That tells me you’re a pretty healthy guy’ ”—but only, he went on, if Caselli did something about his weight.
A little later, the infectious-disease specialist came to see him. The specialist removed his bandages, examined his wounds, and wrapped them back up again. His legs were getting better, he said. But then he added one more thing. “ ‘I’m going to tell you something,’ ” Caselli recalls the man saying. “ ‘I’ve been reading your whole file—where you were, what you were, how you were. Now you’re here and this is what’s going on. You take that weight off—and I’m not telling you this to bust your ass, I’m
telling
you—you take
that weight off and you’re a very healthy guy. Your heart is good. Your lungs are good. You’re strong.’ ”
“I took that seriously,” Caselli said. “You know, there are two different doctors telling me this. They don’t know me other than what they’re reading from their records. They had no reason to tell me this. But they knew the weight was a problem. And if I could get it down . . .”
When he got home, he remained sick in bed for another two weeks. Meanwhile, his business collapsed. Contracts stopped coming in entirely, and he knew that when his men finished the existing jobs he would have to let them go. Teresa made an appointment for him to see Dr. Randall, and he went. Randall described the gastric-bypass operation and spoke with him frankly about the risks involved. There was a one-in-two-hundred chance of death and a one-in-ten chance of an untoward outcome, such as bleeding, infection, gastric ulceration, blood clots, or leakage into the abdomen. The doctor also told him that it would change how he ate forever. Unable to work, humiliated, ill, and in pain, Vincent Caselli decided that surgery was his only hope.
It is hard to contemplate the human appetite without wondering if we have any say over our lives at all. We believe in will—in the notion that we have a choice over such simple matters as whether to sit still or stand up, to talk or not talk, to have a slice of pie or not. Yet very few people, whether heavy or slim, can voluntarily reduce their weight for long. The history of weight-loss treatment is one of nearly unremitting failure. Whatever the regimen—liquid diets, high-protein diets, or grapefruit diets, the Zone, Atkins, or Dean Ornish diet—people lose weight quite readily, but they do not keep it off. A 1993 National Institutes of Health expert panel reviewed decades of diet studies and found that between 90 and 95 percent of people regained one-third to two-thirds of any weight lost within a year—and all of it within five years. Doctors have wired patients’ jaws closed, inflated plastic balloons inside their stomachs, performed
massive excisions of body fat, prescribed amphetamines and large amounts of thyroid hormone, even performed neurosurgery to destroy the hunger centers in the brain’s hypothalamus—and still people do not keep the weight off. Jaw wiring, for example, can produce substantial weight loss, and patients who ask for the procedure are as motivated as they come; yet some still end up taking in enough liquid calories through their closed jaws to gain weight, and the others regain it once the wires are removed. We are a species that has evolved to survive starvation, not to resist abundance.