Operation: weight loss

By Beverly Creamer
Advertiser Staff Writer

Ehnes is seen before her surgery at the wedding of her daughter, Jennifer Salima.

After her surgery, Ehnes no longer needs to wear size 30-32 pants. Deborah Booker • The Honolulu Advertiser

"I've lost 85 pounds," says the Kaiser Permanente nursing supervisor whose weight has dropped from 310 to 195 pounds since October from a combination of surgery and medication.

For the first time in years, men have started to notice her. And she has bought her first bona fide "little black dress." Now her face, not her stomach, is the first thing people look at, though some people she has known for years don't recognize her.

"I'm 55. It's the last resort," Ehnes said. "I wish I had this in my 20s, instead of being obese all my life. I couldn't walk from my office to the cafeteria without getting short of breath and having to sit down. I have diabetes and was on insulin. I was on high blood pressure medication and had trouble with my knees. I wore 5X tops."

For all of those reasons, Ehnes went ahead last October with surgery that bypassed several feet of her small intestine, stapled much of her stomach closed and left her with a small pouch in its place. Called gastric bypass, this form of bariatric surgery (from the Greek, "baros," meaning weight) produces a 50-100 pound weight loss or more, but means patients could face nausea and vomiting if they push meals beyond a few bites, especially in the first few months after surgery.

As in any surgery, there are risks – that something could go wrong, and that it won't last long-term. While statistics have shown that the majority of patients sustain a major weight loss, the surgery isn't foolproof. Without making major lifestyle changes, including radically changing eating habits, adding exercise and delving into deeper psychological problems, patients can stretch their new stomach and regain the weight.

"People have to recognize they're not going to be able to go to a restaurant and sit down and enjoy it the way an ordinary person would," said Dr. Carlos Weber, the general surgeon who initiated the bypass procedure at Kaiser Permanente and has performed it on about 40 patients. "That's something they have to be ready to give up."

That was a small sacrifice for one of his patients, whose weight was in the mid 400s before surgery.

"He had his surgery three months ago and he's already lost about 100 pounds," Weber said. "He's well on his way to losing in excess of that. Another patient, a year after his surgery, was wearing a shirt he hadn't worn in 30 years."

Changing her eating habits was also a small sacrifice for Ehnes, whose weight has gone below 200 pounds for the first time in 30 years. Although she's not yet within striking distance of her 140-pound goal, she's on a downward slide so rapid she sometimes slips right past sizes without having time to buy the clothes.

"It does have complications," she said, "but none are as bad as being 200 pounds overweight and what that does to your body. But it's serious, major surgery. The doctors liken it to cardiac bypass.

"I didn't do this to be skinny. Or save my looks," she continues. "I was trying to save my health. I wasn't going to see my granddaughter get married if I didn't lose some of this weight. A lot of us say our birthday is the day we had surgery."

Ehnes had the bypass – and six months of preparatory sessions with nutritionists, doctors, physical therapists, a support group and a behavioral health professional – at Kaiser, but this operation is also performed at Straub Clinic & Hospital.

But Ehnes was one of the first to have it done laparoscopically, without the major abdominal incision usually required. That means only small openings need to heal.

In the past two years, gastric bypass has received new attention partly because of National Institute of Health approval of two surgical techniques as safe for weight loss, and because of singer Carnie Wilson's choice to talk publicly about her procedure. She's the daughter of Beach Boy Brian Wilson.

But bariatric surgery "mills" have also sprung up on the Mainland, Ehnes said, and patients don't always get the kind of follow-through Kaiser provides; this follow-up is a crucial component of success.

"Once we do the operation, that's really just a small part of what has to happen," Weber said. "The rest of the work that goes into losing weight and maintaining the loss is their responsibility. People come in and say 'Thank you for saving my life,' and I turn around and say 'I did my part, but you're doing the rest of it.'"

Each patient is required to go through an extensive three to six month preparation period, which includes counseling with nutritionists, doctors, exercise physiologists, behavior therapists and psychologists, and then making a lifetime commitment to the support group.

"Because weight loss and weight management is a lifestyle change, it just made sense to us to have all the players on board," said Candyce Ka'ai'ai, the behavioral health professional who offers counseling. "Many of the people I work with will tell you they use food in some ways to comfort themselves so I help them learn different strategies to replace food in their lives.

"It's so complex and we see a lot of people who have some depression," Ka'ai'ai said. "They feel different, misunderstood. They feel people misjudge them, that there's a lot of prejudice because they're heavy. It's very much like seeing someone with a stalled car holding up traffic: you almost want to say 'Hey I didn't do this on purpose.' I think a lot of people with a weight problem want to say that too."

Support is the backbone of success, said Dr. Sasha Stiles, who leads the ongoing weekly group that draws as many as 30 patients.

"Prospective patients are watched (during the preparatory period) to see if they have the physical capacity, as well as the mindset to go through this surgery," said Stiles, the "doctor champion" for weight management services at Kaiser.

"You have to do your own 'brain' surgery because this surgery is only the tool. What it does is give you six months to a year where you could experience massive weight loss, where you could reclaim your body and your life. But then the hard work begins. Basically, you have to know what triggers you to eat. Why you ate in the first place. It gives you the impetus to learn how to eat differently.

"If you lose 100 pounds, you begin to realize the pleasure of having a body you can work in. So when the surgery stops working they have the behavioral structure in place to have the courage and the will to continue."

Stiles said those who are "morbidly obese" – more than 100 pounds overweight, or having a Body Mass Index (BMI) of above 40 – may have deep psychological issues to face. "Often they are women who try to do everything for everyone else and in the little time left for themselves, they eat," she said. "Or sometimes it's protection against sexual predators. Or sometimes that's how families were: You laugh, you eat; you cry, you eat. And sometimes there are deeper issues such as abuse in childhood."

Stiles contends that sustaining the loss comes from understanding those deeper reasons for the weight gain, and ending that psychological control over your eating habits.

Ehnes agrees that the pre- and post-surgical support are crucial. "People were failing because they didn't have enough information or support. They would eat too much and not exercise. It's a wonderful thing but if you don't do it right you'll gain the weight back."

Yet Weber notes the surgery also offers new views of overweight.

"We're being trained to view obesity as something like high blood pressure. It's a disorder of the body's regulatory system, which we don't understand all that well. But we're getting to the point where we're not blaming the patient anymore, we're trying to think of ways we can treat it, reverse it and deal with the consequences, just like high blood pressure."

When Ehnes went into surgery she knew there was the possibility of infection, or of the pouch closing up. There was a chance that the staples could rip open if she ate too much. And there was the possibility that she wouldn't be able to follow the rather stringent guidelines for success.

"Before you go and do this to your body, you better have a real good understanding of what it is and how you're going to eat for the rest of your life," she said. "I feel like I'm really eating normally for the first time."

Diana Orr is finding the support system a lifeline though her surgery is two weeks away. "I'm excited and scared all at the same time," admits the 51-year-old licensed practical nurse who weighs 209 pounds, but is normally heavier.

"I know what can happen: death, infection, bleeding, complications like the pouch closing, nausea, vomiting, losing your hair, drying skin. What's great about the support group is people who have gone through all of these have shared it with us.

"One lady decreased her fat intake so much her skin became really dry. You can't cut out fat. It's necessary for your cells. Another person lost a lot of hair because she didn't eat enough protein.

"That's what's so great about the support group. I see what to avoid from those who've been there."