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Down sizing

More and more of the morbidly obese are turning to gastric bypass surgery to shed the pounds -- and save their lives

Tuesday, March 26, 2002

By Virginia Linn, Health Editor, Post-Gazette

The scene at Wal-Mart was typical.

Bill Cannata was listening to CDs through headphones in the store's music department, dancing a bit in the aisle.

A group of teen-agers came up. "I watched them point and laugh," said his wife, Pam.

"I tapped one on the shoulder and said, 'If you're going to make fun of someone fat, make sure his wife is not standing behind you.' "

Bob and Jen, eight months and three months, respectively, removed from gastric bypass surgery. Bob's weight at surgery was 313 pounds. Today it is 189. Jen is down from 293 pounds to about 240. (Bill Wade/Post-Gazette)

She's hoping those once-common spectacles are behind them. Both sought weight-loss surgery last year as a last-ditch effort to get thin and the pounds are melting off.

Bill, 34, with the help of family ties to Ventos pizza and Stagno's Bakery, had reached 540 pounds. But despite humiliating public encounters, it was watching Bill's mother die a slow death from obesity-related diseases that drove the Highland Park couple to surgery.

"Neither of us wanted to put that burden on each other," said Pam, 30, an administrative assistant who has dropped 130 pounds since her surgery last May.

Their stories are similar to those of the thousands of morbidly obese people locally who are turning to gastric bypass surgery after years of ridicule, unsuccessful yo-yo dieting and health problems including diabetes, high blood pressure, cardiovascular disease, arthritis, sleep apnea, chronic heartburn and a host of others.

A support group meeting held earlier this month by the Cannatas' surgeon, Philip R. Schauer, in UPMC Montefiore's large auditorium for patients and those curious about the surgery was standing-room-only. Demand is so high in this melting pot rated the ninth-fattest city in America that folks have to wait months for surgery in Schauer's practice. Other local doctors who perform weight-loss surgeries report increasing interest.

Most patients have what's called the Roux en-Y gastric bypass, which limits not only how much you eat, but how much is absorbed. It's the "gold standard" in weight-loss surgery and has been endorsed by the National Institutes of Health.

The field of bariatrics, which involves all types of weight-loss surgeries, logged a record 60,000 surgeries last year, said Georgeann Mallory, executive director of the American Society of Bariatric Surgery.

Jen and Bob Haller, in their 1997 wedding photo and before gastric bypass. Jen weighed nearly 300 pounds at the time, Bob, more than 310.
"The surgery has improved. Instead of being on the fringes or medicine, it's now a mainstream procedure," she said. The group represents 600 surgeons, up from 250 five years ago.

Schauer, 41, is nationally renowned for the laparoscopic Roux en-Y, a minimally invasive technique that results in fewer complications, less pain and scarring and faster recovery. He's done more than 1,000.

Roux en-Y got a huge boost when singer Carnie Wilson of the group Wilson Phillips had it in 1999 and lost 150 pounds.

The soaring rate of obesity in the United States, now at 27 percent of the population, also has boosted the procedure's popularity, with more insurance companies recognizing the enormous medical costs associated with obesity. The Rand Corp. earlier this month released a study showing that costs of treating of obesity-related conditions had eclipsed the health-care costs of either smoking or problem drinking. It's the second-leading cause of preventable death.

Patients receiving the Roux en-Y (pronounced Roo in Y) can expect to lose between 70 and 80 percent of their excess weight. Among bariatric surgeries, it has the highest short- and long-term success rates.

The surgery involves two steps. First, the stomach is reduced to the size of a thumb to hold about 2 tablespoons of food. Then a bypass is created from the new stomach pouch to a lower part of the small intestine so less food overall is absorbed in the body.

With the minimally invasive technique, the surgeon reaches the stomach and intestines through five or six buttonhole-sized incisions in the abdomen. A video camera on a probe magnifies the view of the organs on a TV monitor to guide him. Traditional open surgery leaves a 10- to 12-inch scar.

"The stomach reduction and bypass work very well for long-term control," Schauer said. "We've had folks lose less than their goal, but we haven't had anybody gain all the weight back. It's extremely rare."

But these results come with drastic trade-offs.

For the rest of their lives, patients can no longer eat large amounts of foods at a time. A few bites of chicken might be all they can handle for dinner. Some may not be able to tolerate sweets or other foods they loved. A steady regimen of vitamins is needed to avoid nutritional deficiencies that can lead to osteoporosis, anemia or metabolic bone diseases.

Dr. Lance Weaver, a surgeon at Allegheny General Hospital, did gastric bypasses in the 1980s, but has largely abandoned them because he started seeing long-term problems. Patients who weren't monitored by physicians several years out from surgery often developed severe B12 and iron deficiencies. He also saw the gastric bypass stretching and patients gaining weight. "The long-term wasn't giving us the results we liked."

He's switched mostly to vertical banded gastroplasty, which involves restricting the size of the stomach with staples and a plastic band to create a smaller stomach pouch. He does 400 of these a year.

Weaver acknowledged there's been a battle within the bariatrics field on which operation is better.

"Both of these operations work. But it's critical [to have] good follow-up."

Doctors also emphasize that both procedures are simply tools for losing weight. As with other diets, patients must incorporate healthy eating habits and exercise to keep weight off.

"You can do any operation like this on anybody, but if they eat too frequently, they'll beat it from day one," Weaver said. "It will fail if you have somebody who nibbles all day long."

A new view of morbid obesity

More doctors are recognizing that morbid obesity is not simply caused by a person's lack of will power, but, rather, by a complex interplay between genetics, behavior and the environment.

Most of these people were heavy as toddlers and have heavy relatives. Family activities were centered around food.

 
   

More stories

Some background on gastric bypass.

Profiles of bypass patients Bob and Jen Haller, Colleen King and Carma Cuzzupe, and Pam and Bill Cannata.

 
 

"We were created to withstand droughts and famine," said Paul Friday, chief of clinical psychology at UPMC Shadyside. "We weren't designed to eat chocolate-covered strawberries in February."

Unlike fist-sized normal stomach, the stomachs of morbidly obese people are stretched to the size of a head, and there's no lateral pressure telling their brains that they're full, Friday said. The brain, instead, gets the message that they're starving.

This can start at a very young age. "If you have an obese 4-year-old, their stomach is already stretched, so their brain is telling them if they don't eat they're going to die. It's not a case of willpower."

Schauer's patients heading to the OR for weight-loss surgery must get a psychological evaluation.

"I tell everyone that they'll experience many more emotional, social, sexual and psychological changes than they will physical ones," Friday said. "People who go into this think they'll be a smaller version of who they are, and they're not. They're going to be really very different."

Friday also looks at the impact on relationships.

Each patient in a marriage or long-term relationship rates his association on an 11-point scale. "We have found that the surgery, for those with high-quality relationships, tends to improve their relationships. Patients who have a low-quality relationship going into surgery tend to have these relationships deteriorate."

Barbara Thompson, 53, a librarian who lives in Upper St. Clair, has written a book about her experiences, "Weight Loss Surgery: Finding the Thin Person Inside You," which includes a chapter featuring her husband's reflections. She lost 125 pounds the first year after her gastric bypass in 2000, and travels the country telling her story.

Thompson, who praises her own family's support, emphasized that it's not just a one-person operation.

"It really touches everyone's lives in the family. With you as a component of a family, that family is altered as well. Some families have a difficult time dealing with that."

Laura Smolenak, 48, a bariatric nurse on Schauer's staff who had the gastric bypass in 1998 and lost 178 pounds, is one of the lucky ones whose 25-year marriage survived through "thick and thin."

Sixty-eight percent of marriages don't, she says.

Support for patients

Schauer, like a few other surgeons across the country, has put together a strong support network for patients that involves monthly group meetings, patient volunteers dubbed "angels" to help new patients before and after surgery, and follow-up monitoring.

In addition to Smolenak -- who lost 100 pounds three times on various diets before having the gastric bypass -- Schauer's staff includes two other bariatric nurses, Beth Klemm and Cheryl Grieco, and a researcher who all have had the procedure and can give patients first-hand information.

At the two-hour support meetings held the first Wednesday of each month, patients stand up and announce their losses, often to cheers and enthusiastic clapping. Others attend to learn about the process.

"The very first gastric meeting I went to, I cried my eyes out," recalls Colleen King, 34, who had the surgery in October and has already lost nearly 80 pounds. "This woman stood up and told her story about how her self-worth was very low. I felt her pain like it was my own."

Thompson, the local author, knows she's an inspiration. "That's one of the reasons I'm still going. Not only do I keep learning, I am there so people can look at me and they know there is hope for them."

More procedures coming

Researchers are exploring even less invasive procedures to promote weight loss.

The Food and Drug Administration last summer approved a new technique, the Lap-Band system, in which a silicone band is placed laparoscopically around the upper part of the stomach to create a small pouch.

A small opening between the pouch and lower stomach is left to allow food to pass, slowly, so patients feel full longer. The size of the band's opening can be adjusted and can be changed as weight is lost.

Clinical trials show that patients with the Lap-Band lose roughly 36 to 38 percent of excess weight -- far less than gastric bypass -- but the procedure is less invasive.

Many surgeons also are turning to younger patients as obesity becomes a growing problem in children. Schauer's youngest patient was 17, but he's seen children in their early teens carrying several hundred pounds.

He's hoping that more patients and doctors will recognize the seriousness of obesity and take action.

"What's underemphasized is obesity itself being a very dangerous disease," he says. Obesity shaves an average of 15 years off the normal life span. In fact, he's had a number of patients die while on the waiting list for surgery.

"The risk of not doing anything is great."

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