Kiriakou’s gastrectomy was the operation in which John Kiriakou’s stomach was surgically removed in September 2022, undertaken to reverse an uncontrolled type 2 diabetes that had defeated every available drug. He no longer has a stomach. He has described the diabetes as running in two rounds, the first ending in a substantial weight loss and the second in the surgery, which reversed the disease and was followed by serious complications.
Type 2 diabetes
The desk job
He dates the onset to leaving the CIA. A case officer, in his account, gets a great deal of exercise — “a lot” — and the job he moved to afterwards was a desk job, on which he put on weight. Deciding he had to diet but not knowing how, he went to a nutritionist, and was diagnosed with type 2 diabetes at about the same time.[1]
The nutritionist’s regime was 2,000 calories a day, up to 200 grams of carbohydrate, up to 20 grams of saturated fat, and as much protein as he wanted within those limits. He cut out lamb and most beef in favour of turkey, chicken and tofu.[1][2] It took a year, and he lost 70 pounds — 32 kilos.[3]
The second round
The diabetes then slowed his metabolism, he says, and the weight returned little by little. By 2021 the disease was bad enough that his doctor put him on insulin — four injections a day, five at weekends, on top of the maximum dose of every diabetes medication available — and he ballooned, “fatter than I’ve ever been in my life.”[3][4]
When he returned to the doctor insisting he was barely eating, the explanation he was given was the insulin itself: starting it had brought his metabolism “almost to a stop”, which was why he could not burn fat.[4] His A1C at that point was 12.1, against a normal range he gives as four to six — a level he describes flatly as uncontrolled.[5]
Direction of cause
Pressed by his interviewer that the causation usually runs the other way — that weight drives diabetes rather than diabetes driving weight — Kiriakou accepted the general rule and defended the exception in his own case: “In the beginning I got fat, and that led to diabetes. The second round was the diabetes made me fat again,” because of what the treatment did to his metabolism.[6]
After the gastrectomy he reported the disease gone and his A1C normal.[7]
The surgery
The Lancet paper
The route to the operating table began with his doctor, who handed him a reading assignment rather than a prescription: an article from The Lancet written by a Scottish surgeon.[8] The surgeon had been treating a woman with stomach cancer who also had uncontrolled diabetes. Her stomach was removed for the cancer, and within twenty-four hours her pancreas began producing insulin again. Other surgeons, comparing notes, reported the same result.[5]
Three telephone calls
Kiriakou pursued it by telephone. He called the Scottish surgeon and made an appointment to speak with him, and was told: “It works. We don’t know why it works. We don’t yet fully understand the human body, but it works. And there’s almost no downside, no side effects.”[9] Asked whether anyone in the United States performed it, the surgeon named one in New York, who repeated the same formula — “We don’t understand why it works, but it works.”[9]
Kiriakou asked whether the operation was a bypass, a sleeve or a duodenal switch, and was told those do not work: “The stomach has to physically come out.” He was given the name of a single surgeon practising in Arlington, Virginia — where Kiriakou lives — Dr Jihad Salama, from Lebanon.[10]
The money
Salama’s first point was financial. Because the procedure is experimental, insurance would not cover it. The price was $17,000, including two nights in hospital. Kiriakou did not have it, so he went to a bank and took out a loan for the full amount.[11]
The operation
The surgery was performed in September 2022 and was robotic: the surgeon worked the toggles while the machine made “two little cuts”, still visible, through which the stomach was taken out.[12] Kiriakou had taken nothing but clear liquids for ten days beforehand, so that the organ was empty and had shrunk; it was cut, pulled out, and a pouch holding a quarter of a cup — “just enough to fit in the palm of your hand” — was constructed from his intestine.[12][13]
He took liquids for a further week, then moved on to pudding, purée and soups. Over the following nine months he lost 55 kilos and, he says, has kept all of it off.[13] The result he places above the weight is the disease: “I don’t have diabetes anymore. My A1C is normal. Everything’s normal.”[7]
The operation left him unable to eat certain foods at all. Asked about Greek lamb — “I’m Greek. I love arni, right? Who doesn’t?” — he said it is now too heavy, too dense and too fatty, and that he vomits as soon as he eats it.[14] It also placed him in the minority of patients who suffer serious complications.[15]
Complications
A sequence of failures followed the removal of his stomach. Kiriakou places himself in the roughly five per cent of patients for whom the operation goes wrong, and has required two follow-up surgeries; the first, he says, came after he almost bled to death internally and spent eight days in hospital.[15]
Eighteen months of vomiting
He vomited heavily from the first days after surgery and assumed it was the body’s response to trauma, “They took out my stomach. I’m throwing up. That’s just the way it’s going to be.” He mentioned it to his doctor only in passing, a year and a half later. The doctor’s reaction was that this was not normal: it should have stopped a week or two after the operation, not persisted for eighteen months. Blood tests showed he was malnourished.[16]
An endoscopy found extensive scar tissue, which the surgeon cut out during the same procedure. Kiriakou was discharged after four hours. He then travelled to Greece with his son, and the vomiting returned.[17]
The night on the kitchen floor
Two days after returning home he worked a Saturday from ten in the morning until ten at night and went straight to bed. At two in the morning he woke sweating, an experience he now associates with blood sugar falling too low rather than rising too high, and assumed he was having a hypoglycaemic episode.[18] He has no memory of going downstairs. He woke half an hour later on the kitchen floor, tried to stand, and fainted again; another half hour passed before he came round a second time.[19]
He shouted for help until one of the two lodgers who rent rooms in his house woke. It was three in the morning. Together the two men carried him to the couch, where he lay for another hour and was given a full-sugar Coca-Cola, which did nothing, the point at which he concluded the problem was not hypoglycaemia at all.[20][21] A final attempt to lift him into bed put him out again, and an ambulance was called.[21]
Of the hospital he remembers only a doctor shouting his name and telling him he was going straight into surgery.[22] He woke at ten the following morning to the explanation: “You had a massive blood clot sitting on top of a massive ulcer right at the surgical site.” His blood pressure on arrival had been 80 over 52, “50 is death. So I just made it”, and the surgeon told him another hour would have been too late.[23] The clot was removed and the ulcer sewn up.[24]
Asked why he had not noticed that he was bleeding, Kiriakou gave the answer that had hidden it: “I love ouzo and so I eat black liquorice all the time and so it’s always black.” He was told to stop, and did, “I never ate liquorice again.”[24][25]
The recurrence, and the trade
The following August he recognised the sensation returning in the middle of the night and told his girlfriend it was happening again; they drove to hospital and he was admitted straight into surgery with another blood clot.[25] The surgeon’s verdict was that he is among the five per cent in whom the operation leads to clots. Kiriakou’s own accounting is unsentimental: “I would rather deal with blood clots and be skinny than to be fat and diabetic.” He now takes a blood thinner.[26]