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The Skinny on Weight Loss Surgery

When dieting is no longer enough

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Shelly is a 41-year-old mother of two who has always struggled with her weight. She was unable to lose any of the weight she gained during both pregnancies, even though she tried a number of diets. She would lose some weight with each diet she tried, only to gain it and more back. And, the heavier she got, the more difficult exercise became.

"I started suffering from chronic pain in my knees and ankles," she said. "I was embarrassed to talk about it because of course my joints hurt. I was carrying around so much extra weight." Shortly after she turned 40, Shelly was diagnosed with diabetes and high blood pressure. When she reached 342 pounds, she made an appointment with her family physician to discuss weight-loss surgery.

Obesity has reached epic proportions in America. In a 2002 survey by the National Center for Health Statistics (www.cdc.gov/nchs), 64 percent of American adults over the age of 20 were classified as overweight or obese. Physicians are now using a Body Mass Index (BMI) and obesity classifications (Class I, II or III) to determine how overweight patients are and whether they would be good candidates for weight-loss surgery. Class I has a BMI of 30 to 34.9, Class II is 35 to 39.9 and Class III (severe or extreme obesity, also known as morbid obesity) is a BMI of 40 and higher. The formula used to calculate a person's BMI is weight divided by height in inches squared multiplied by 703. Factors such as the patients' medical condition and willingness to change theirs lifestyle are also taken into account before surgery is even considered. Physicians use the following list of factors (www.thomsonhc.com) to determine if the benefits outweigh the risks:

•A BMI of more than 35 if the patient has possible life-threatening health problems such as heart disease, sleep apnea, high blood pressure or diabetes.

•The patient's obesity causes problems in his or her lifestyle, continuous movement (such as walking), or getting or keeping a job.

•The patient is willing to change eating habits and lifestyle needed to lose the weight and keep it off. The patient accepts the risks associated with this type of surgery.

•The patient is not a drug addict or alcoholic.

•The patient's obesity is not a glandular problem.

Shelly's BMI was 51. "I dreaded walking from the parking lot to work each day so much that I would occasionally call in sick to avoid it," she said. She was willing to change her lifestyle, she was not a drug addict and her obesity was not a glandular problem. Based on the criteria, Shelly seemed like a good candidate for surgery and made an appointment with Dr. James Valentine, one of five surgeons in the Treasure Valley area performing bariatric (weight-loss) surgeries.

Dr. Valentine has been performing bariatric surgery for about four years, and in that short time he has performed 252 of them. He said that about 80 percent of the people he sees are women and his surgical patients range in age from 21 to 70. "Sometimes patients are referred to me via their primary care physicians," he said, "but patients often find their way to me on their own. I determine if they are a good candidate for the surgery and then get them started on the program." The first step, Dr. Valentine explained, is telling the patients exactly what weight-loss surgery entails.

The American Medical Association lists two categories of bariatric surgery: restrictive and restrictive malabsorptive.

Restrictive surgeries limit the amount of food the stomach can hold and slow the rate of gastric emptying. There are two forms of this operation. One is the vertical banded gastroplasty (also called "stomach stapling"), where the stomach is partitioned by a line of staples to produce a 30mL pouch, which may then be reinforced with a strip made of Marlex mesh or Gore-Tex. The second option is a laparoscopic adjustable silicone gastric binding, where the stomach is stapled to form a small pouch. A band is then placed around the pouch and the pouch is connected to a reservoir implanted under the skin. Saline can be injected or removed from the reservoir to tighten or loosen the band, changing the diameter of the gastric opening.

Restrictive malabsorptive surgery gets it's name because food moves almost directly into the small intestine and therefore is digested very quickly, preventing the absorption of most calories. There are two procedures in this category. Roux-en-Y gastric bypass is the most commonly performed and accepted procedure. In roux-en-y, a 10 to 30 mL pouch is formed by stapling the stomach, causing food and liquid to go directly into the small intestine. The name refers to the y- shaped section of the small intestine created by the surgery. The second type of restrictive malabsorptive surgery, biliopancreatic diversion, is much more complicated and less commonly performed. Roux-en-y surgery is the most commonly performed because it is permanent, and overall, Dr. Valentine said, patients are happier with both the speed at which they see results and the end results themselves.

After meeting, Dr. Valentine and Shelly both agreed that weight-loss surgery was the right choice for her. She was required to attend a general information seminar and to undergo a psychiatric evaluation, which according to the American Bariatric Society, should assess such things as "behavioral, cognitive/emotional and developmental state of mind, current life situation, motivation and expectations."

And, weight-loss surgery is very expensive. Even though a patient's life may be on the line, health insurance seldom covers the costs. Shelly's insurance was no exception. She said, "I told my husband that this surgery was for me what rehab is for a heroin addict. It would be my rehab. So, we took out a second mortgage on our house."

Within a couple of months of meeting Dr. Valentine, Shelly went to the hospital where the surgery would be performed, filled out the preliminary paperwork and handed over a check for $10,000. Three days later, at 6:30 a.m., she was lying on clean, crisp white sheets being prepped for surgery. The surgery was performed laparoscopically (where several small incisions are made as opposed to a laparotomy, where one large incision is made) and Shelly was sent home a few days later. She is expected to lose 70 to 75 percent of her body fat, most of it very rapidly. For example, a person who weighed 300 pounds at the time of surgery can expect to lose around 150 pounds within six months. Because Shelly's procedure involved several small incisions instead of one large one, her physical healing is well on its way. Still, according to Dr. Valentine, it is the emotional and psychological healing that takes time.

"One of the biggest issues for patients, is that [with this surgery] we take away their coping mechanism: food," Dr. Valentine said. "They have to learn other ways to deal with their problems. Food has always been their friend, and after the surgery, that's no longer the case."

Shelly knew recovery wouldn't be easy, but it's been harder than she expected: "I'm depressed, I'm hungry and it's hard to see everyone around me eating. I'm so sick of broth!" Unfortunately, broth and sugar-free gelatin will be the staples of her diet for a while. She will be on a liquid diet for as long as six weeks. When she can have solid food, she has to learn to stop eating when she's full, regardless of how much food is still on her plate. She drink with meals, because liquid will fill her up, leaving no room for food. She has to choose foods for their nutritional value, not for how they make her feel. If she eats too much food, or the wrong kind, that food can quickly become her enemy. If she eats too fast without chewing properly, food may cause her to choke or vomit or it may get stuck in her stomach or intestines. She may have to deal with "dumping syndrome," which is a common problem for people who have recently gone through gastric bypass surgery. High-sugar and high-fat foods and fluids move too rapidly into the intestines. Dumping can cause sweating, dizziness, increased heart rate and/or stomach cramps. People with dumping syndrome should avoid candy, cookies, fried foods and fatty meat. They should eat more raw vegetables and lean meat. As obvious as that command seems, if it were just that simple, there wouldn't be much of a need for weight-loss surgery at all. Patients are given the tools to deal with their physical needs after the surgery, but what about their emotional needs?

Dr. Valentine said a good support system--co-workers, friends and family--and sanctioned support groups can be paramount for a successful recovery.

"Four to six months after the surgery is when psychological issues come up," Dr. Valentine said. "Patients often face serious interpersonal problems." They often feel reborn with their new bodies and thus behave differently. "Spouses and significant other often become jealous and find ways to sabotage the healing process."

It has been two weeks now since Shelly's surgery. Several of her problems will vanish in the next four to six months: Her diabetes is likely to clear up, her joints may stop aching, it will be easier for her to breathe and she will find she has more stamina. The one thing that won't go away in six months, though, is the problem or problems that caused her to gain the weight in the first place. And, more importantly, she will face a whole new set of problems. She will no longer be the "fat girl." Along with 100-plus pounds of weight, she will lose her identity, her security and her coping mechanism. She may face obstacles put before her by the very people who love her most.

Even at this stage, would she do it again? "Absolutely," she said. "I know I have a long, hard road ahead of me but I think the results [better health, higher self-esteem] will make up for what I'm going through now."

For more information on obesity and weight-loss surgery, go to the American Obesity Association's Web site at http://www.obesity.org, or visit the Web site for the American Society of Bariatric Surgeons at www.asbs.org.

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