Gastric-bypass surgery increasing in popularity
By Paula Rath
Advertiser Staff Writer
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| RoseMary Calasa followed a behavior-modification plan to lose weight after surgery. Click on the photo for details.
Advertiser photo illustration/Deborah Booker • The Honolulu Advertiser |
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Photo courtesy of RoseMary Calasa |
"That's the stupidest thing to say. If they can do what I do for one day and not go crazy, they get a gold star," Calasa said.
What she does every day is live with a stomach about the size of an egg. Into that stomach she can put about eight mouthfuls of food at a time. Any more and she will throw up.
While it has not yet attained the "trend" status of Botox injections, cosmetic tattooing or liposuction, there have been notable increases in the numbers of gastric-bypass operations performed in recent years.
Certainly the surgical weight-loss successes of singer Carnie Wilson, NBC anchor Al Roker and TV personality Sharon Osbourne have hit the headlines and raised awareness of the procedure.
We talked to three Island women who have undergone the surgery in the past year or so. Each woman has different reasons for having gained the weight and different reasons for wanting to lose it in the most drastic way possible: surgically reducing the size of her stomach.
It's been a struggle. In talking about the process, the women sometimes fought back tears.
When asked if she would do it again, especially in the first weeks and months after their surgery, the women sometimes weren't sure. Now, however, months later, each woman is pleased with the results.
"I would do it again in a heartbeat," Calasa said.
Her comments reveal some of the painful experience that prompts the obese to seek gastric- bypass surgery: "People are very prejudiced against overweight people. I am so much more acceptable because of the weight loss, and I find that very sad."
Prepping for surgery
Before a man or woman is considered for gastric-bypass surgery, physicians typically screen them for certain preconditions:
- They are 100 or more pounds over ideal body weight.
- The patient has tried other means to lose weight, such as medically supervised diet and exercise.
- Body Mass Index, or BMI, a measure of weight in relation to height, is more than 40, considered the level for morbid obesity. BMI can be calculated in two ways: by dividing weight in kilograms by height in meters squared, or by multiplying weight in pounds by 703 and then dividing by the height in inches squared. For example, a person who is 5 feet 7 inches and weighs 150 pounds would have a BMI of 23. A person of the same height who weighs 200 pounds would have a BMI of 31.
- If life-threatening complications of obesity, such as sleep apnea, diabetes, high blood pressure or respiratory problems exist, a man or woman with a BMI of 35 to 40 will be considered for surgery.
Preparations begin months before the surgery. Beforehand, patients learn about nutrition and behavior modification, and most are encouraged to start an exercise program, even if it's a modest one.
In many cases, there is plenty of time to prepare, as most establishments providing gastric-bypass surgery have a long waiting list.
Kathleen Jones, who had her surgery in August 2002, experienced months of pre-op anxiety. "There was a lot of wondering — Am I going to fail at this? This is the end — my last chance — the last resort. Will it work for me?"
The months of waiting for gastric-bypass surgery are not wasted. "We do psychological testing and counseling. The education pays big dividends," said Dr. John Balfour of Straub Clinic & Hospital.
To prepare, physicians and nurses require patients to quit smoking, and to attend educational sessions, bringing the family member or friend who will help care for them after the surgery.
Afterward, there are a new set of challenges.
In spite of extensive psychological counseling, Calasa said, she experienced an emotional roller-coaster ride after her surgery.
"No one can prepare you for what it will mean to you when food is ripped out of your life," she said. "You're up, you're down, up, down — you know what's happening, but the emotions do just have a mind of their own."
Post-operative care is critical, requiring at least a week of full-time care. Liquids and pureed foods must be measured exactly. A bite too much and vomiting will occur. The patient can't drive for at least a month, or carry anything heavy for about three months.
Tahiti Fernandez went through months of eating a bite too much, causing her to vomit. Finally, she said, "I understand the space I have," and she can manage her food intake without disastrous results.
"It's hard when the reality hits you that you can't use food as a tool to make you feel good or relieve stress or boredom," Fernandez said. "I had to find outlets for the release food used to give me. Now I take a bath or listen to music or draw."
Caregivers need to understand that this surgery requires a lot of introspection and "me-ism" after the procedure. Some patients become completely self-absorbed during the first few months.
There's another downside for caregivers: They often gain weight, eating all the leftovers from the patients' meals.
Sometimes a husband, boyfriend or girlfriend becomes estranged after the weight loss. Partners can have difficulty accepting a loved one's new shape — and habits, such as spending time at the gym.
Obesity is a chronic disease
According to the American Society of Bariatric Physicians (specialists in treatment of obesity), obesity is a chronic medical disease with serious health implications. It is the second-ranked cause of preventable death, surpassed only by cigarette smoking. In addition, it is a major risk factor for heart disease, diabetes and hypertension.
Gastric-bypass surgery is not a simple procedure. It requires months of pre-operative preparation, several hours in the operating room, anywhere from three to eight days in the hospital and at least 1 1/2 years of post-operative care and follow-up visits.
The surgeon reduces the size of the patient's stomach and reroutes part of the intestine, reducing the stomach to a 30-cubic-centimeter pouch — about the size of an egg, though the stomach can expand over time after surgery.
For six weeks, the patient can only eat pureed foods and liquids. Eating and drinking must be separated by more than an hour.
"Perhaps the hardest thing they have to learn is to eat very slowly, because the stomach doesn't register being full for 20 minutes, so by the time the brain gets the message, you've already vomited," Balfour explained.
Every surgery comes with risks. According to the American Society of Bariatric Physicians, the death rate for gastric-bypass surgery is 3 in every 1,000 patients. Potential complications include malnutrition, abdominal infection, vitamin and calcium deficiencies, gallstones and internal bleeding.
This surgery is not for the very young. It is known to limit calcium absorption by the body, so to perform the surgery when the bones are still forming brings additional risks.
"I would recommend this surgery as long as all other methods have been exhausted," said Jones.
Turning lives upside down
"In a short operation I'm going to turn their lives upside down. What's going to replace food for them?" asked Dr. Brandt Lapschies of Kuakini Medical Center, adding, "We don't operate on their head; we operate on their body."
"You have to realize that this is not an end-all and be-all procedure. It's a tool to help people lose weight. There's still a significant amount of work and dedication required from the patient to achieve ultimate success. It's not a magic bullet," said Maj. Stan Zagorski a doctor at Tripler Army Medical Center.
The nation has seen a dramatic increase in gastric-bypass operations. The American Society of Bariatric Physicians reports that in 1995, 18,100 surgeries were performed in the United States. In 2001, that number rose to 47,200, in 2002 to 63,100, and this year, 100,000 surgeries are anticipated. The American Society for Bariatric Surgery reports similar numbers (see graphic).
It's harder to get a handle on statistics for Hawai'i. The Hawaii Health Information Corp. reports that 872 gastric-bypass operations were performed in 1995 and 1,000 last year.
Balfour, who is credited with being the first surgeon to perform surgery for obesity in Hawai'i, in 1973, limits his practice to two gastric bypasses a week. His waiting list for consultations is five to seven months, and for surgery, an additional six to eight months.
Zagorski limits himself to three to four a month. His waiting lists are about the same as Balfour's. He estimates that there are "80 people for every space in the operating room."
Lapschies performed 50 operations in 2002 and 40 in the first six months of 2003. He is planning to expand his practice to Queen's, Kapi'olani and Pali Momi.
At Kaiser Permanente Medical Center, three surgeons performed 58 gastric-bypass surgeries in 2002 and 42 in the first six months of this year.
Balfour and Zagorski attribute the increased demand for gastric- bypass surgery to many factors.
"We are becoming a fatter and fatter nation," Balfour said.
"This procedure has become more accepted by the medical community, so more physicians are referring patients to us," added Zagorski.
In addition, surgical techniques have improved. And most insurance companies pay for the procedure, because they recognize that it costs more to treat the diseases of a morbidly obese person than to pay for the surgery.
A $25,000 operation
The procedure costs around $25,000. Follow-up care, support groups, psychologists and plastic surgery (to rid the body of excess folds of skin) are usually additional costs.
While Hawai'i surgeons generally are conservative in their selection of patients for this surgery, the morbidly obese — and more and more commonly, obese people who are not facing imminent health risks from their additional weight — are being actively recruited in many Mainland cities. We found a Web site, www.belighter.com, offering a drawing for a free operation by "a surgery team in the USA and Mexico." Those interested simply fill out a form online to be entered in the drawing for a November surgery.
Calasa, Fernandez and Jones have not yet had the true test of success of their surgery and subsequent weight loss. That comes after two years or more. By then, the body can become extremely efficient and may stretch to accommodate more food, allowing the patient to go back to eating normal amounts of food and, subsequently, gaining back the weight.
Balfour describes it this way: "You can learn to out-eat the operation." We're betting these three motivated women won't.
Reach Paula Rath at prath@honoluluadvertiser.com or 525-5464.
On the Web
- www.asbs.org — Web site of the American Society for Bariatric Surgery, with a list of board-certified surgeons in Hawai'i
- www.asbp.org — Web site of the American Society of Bariatric Physicians, who specialize in the nonsurgical treatment of obesity
- www.gastricbypasshawaii.com — Dr. Brandt Lapshies' Web site, including a fill-in-the-blanks chart to calculate your own BMI
- www.nih.org — National Institutes of Health, with information on surgery, outcomes, baseline data and criteria
- www.obesityhelp.com — AMOS (American Morbid Obesity Society), a peer-support group. It schedules surgeon and nurse chat sessions.
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RoseMary Calasa
- Age: 51
- Profession: Registered nurse
- Lives in: Upcountry Maui
- Height: 5-feet-1
- Weight before surgery: 225
- Present weight: 124
- Former jeans size: 24
- Present jeans size: 4
- How the weight came on: Although she was thin most of her life (she was a 102-pound bride), she began gaining weight after a 1992 car accident that required complete bed rest. "My metabolism went to hell, but my eating habits didn't change. Then I just got lazy."
- Health problems related to obesity: Diabetes, sleep apnea.
- Weight-loss methods tried before: "Every over-the-counter drug possible for weight loss — Jenny Craig, Weight Watchers, Adkins, the grapefruit diet, the cabbage soup diet — I tried 'em all."
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| September 3, 2003: 170 pounds
"The hardest thing is the mind adjustment. I still see a heavy person when I look in the mirror. Maybe it has to do with being female." — Tahiti Fernandez |
Tahiti's transformation (graphic)
- Age: 22
- Profession: Regional retail manager, MAC Cosmetics
- Lives in: Kailua, Kona, Big Island
- Height: 5-feet-5
- Weight before surgery: 268
- Present weight: 170 (her goal is 150)
- Former jeans size: 24
- Present jeans size: 14
- How the weight came on: "My mom said I was born an insatiable eater, even when I was a baby, breastfeeding. My body could never tell my brain, 'Hey, you're full! Stop!' "
- Health problems related to obesity: Family history of diabetes, heart disease and strokes. Her maternal grandmother weighs 400-plus pounds and is in a wheelchair; her uncle weighs 350 pounds.
- Weight-loss methods tried before: "I've been on a diet since I was 10. I tried medically supervised drug therapies, Jenny Craig, low carb diets, Weight Watchers — everything."
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- Age: 40
- Profession: Diagnostic Laboratory Services information specialist
- Lives at: Pearl Harbor
- Height: 5-feet-3
- Weight before surgery: 303
- Present weight: 135
- Former jeans size: 26
- Present jeans size: 8
- How the weight came on: Started with childbirth and the implantation of birth control device.
- Health problems related to obesity: Pseudo-tumor cerebri, which elevates pressures in the brain's canal system, leading to near blindness caused by pressure on the optic nerve, hypertension, gastro esophageal reflex disease, sleep apnea and a family history of diabetes. She was on 24 medications daily. Now she is taking none.
- Weight-loss methods tried before: "Every diet known to man — I've probably gained and lost upwards of 800 pounds in the past 20 years — Optifast, Slim Fast, Jenny Craig, Weight Watchers (16 times)."
