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Bariatric Surgery: Losing Weight and Discovering a New Life - 11/01/2006

Imagine for a moment that you can’t get on an airplane, go to a restaurant, run after your child, or even bend over to pick up a pencil. Imagine you can’t do these things because you are obese. Other routine indignities include sidelong looks, giggles, and cruel remarks.

More than 60 million Americans know this reality all too well. During the past 20 years, obesity among adults has risen significantly in the U.S. According to the latest data from the National Center for Health Statistics, 30 percent of adults 20 years of age and older — over 60 million people — are obese. Overweight children and teens, aged 6 to 19 years, now number about 9 million.

Those who come to The Hospital of Central Connecticut for weight loss surgery — also known as bariatric surgery — can’t lead normal lives. Their lives are threatened by the diseases and health conditions that often accompany obesity, including hypertension, type 2 diabetes, heart disease, stroke, gallbladder disease, osteoarthritis, sleep apnea and respiratory problems, and some cancers.

Obesity is more complex than overeating. For some, it’s caused by a lifelong pattern of dysfunctional eating behavior, perhaps exacerbated by a life change or trauma. Families and social patterns can also play a role. Some people have a genetic predisposition for obesity. For others, there is an underlying medical condition, such as hypothyroidism. And research continues to see how other factors, including bacteria and viruses, may contribute.

Whatever the cause of an individual’s obesity, the solution is the same — learning to eat less and exercise more.

Changing Behavior
Along the continuum of clinical weight loss programs at The Hospital of Central Connecticut known as “Weigh Your Options,” bariatric surgery is the most “aggressive option,” says Dino Costanzo, director of health promotion. “Our center includes a wide range of services for individuals looking to lose five pounds and manage their cholesterol, to those who are morbidly obese and need to lose more than 100 pounds.”

“The first thing I tell everyone considering bariatric surgery is that it is not a magic cure,” says surgeon Dr. David Giles, surgical director of bariatrics. “It is a last resort for the morbidly obese.”

Dr. Giles and every member of the multi-disciplinary bariatric surgery program emphasize the patient’s active role in his or her recovery and weight loss.

“It changed my life,” says Yvonne Roche, 42, of her gastric bypass. Roche, practice manager for Grove Hill Pulmonary in New Britain, lost nearly 140 pounds in the year since her surgery.
Roche’s story is typical of many who become obese — by definition, having a Body Mass Index of 30 or more. “I was always on the heavier side,” she says, but didn’t consider her weight a problem until college. She yo-yoed up and down on diets. But after gaining 100 pounds during her second pregnancy in 1993, she couldn’t get it back under control.
“I tried everything,” she says, rolling her eyes. “Every diet you can imagine from cabbage soup, to diet pills… It happens cumulatively. You gradually change your way of doing things. To avoid being embarrassed, you stop doing things like shopping. The discrimination is not always overt, but you hear the remarks and giggles behind your back.”

A trip to Ireland was the “last straw,” Roche says. The airplane seat was unbearable; negotiating the aisles was awkward. While others enjoyed sight-seeing, she struggled to keep up, and by the end of the day was utterly exhausted. Roche had heard about bariatric surgery, and so, soon after returning from Ireland, she contacted Dr. Giles. “It’s like having a new lease on life.”

Manny Makiaris is an outgoing 65-year-old Greek man with a generous smile. Sitting in their oceanside home in Niantic, Manny and Irene Makiaris, married 41 years, exude vitality and a love of family. Being active is very important to them.

Before he had his gastric bypass surgery in April 2005, Manny weighed 362 pounds. He is down to 216 and is ecstatic.
“She loves to dance and I couldn’t anymore,” he says. “I always used to have to scout places we wanted to go, to make sure Manny would be able to sit down,” Irene says. “Now everything has changed. We’ve all totally changed our eating habits… Now we travel, we dance.” And, Manny interjects, he can enjoy his “favorite hobby” again — his three grandchildren, Carson, Davis, and Jamie.

While bariatric surgery is a life-saving option for some, “Weigh Your Options” offers a full spectrum of other weight loss plans. “We also specialize in medically complicated weight management,” says Dr. Thomas Lane, medical director of the clinical weight loss center. “Our patients range in weight from about 250 to 600 pounds, so their weight loss goals differ greatly.” Dr. Lane personally manages patients in the very low calorie diet (VLCD) program, which is used on its own, but also often prior to surgery to lose 30 to 50 pounds to lower risk factors.“A core piece of the program is psychological,” says Dr. Lane. “We teach coping skills,” he says noting that everyone has some “coping issues” and uses food at one time or another for comfort.

That’s where counseling comes in. Steve Moore, Ph.D., behavioral psychologist, says, “One of the most important behavioral aspects of weight loss is identifying one’s own eating behavior. So much of that is automatic. Simply recognizing what, when, and why you are eating is a key part of changing your behavior about food.”

A Five-Month Program — Not a “Magic Cure”
“Our bariatric surgery program is comprehensive and requires a lot from the patient,” Dr. Giles says. The program includes education, nutritional and behavioral counseling, and exercise, provided by a multi-disciplinary team of professionals who form a partnership with the patient that begins before surgery and extends long after.

“Before a patient has their actual surgery, we have them well prepared,” says Janice Heiner, RN, a bariatric nurse. “After surgery, it is very important that patients have continued educational and medical support.”

Before being accepted for the program, patients must meet specific criteria, which include being over age 18, having tried other diet methods, and being a non-smoker. Most significantly, to be considered for surgery, they must have a Body Mass Index (BMI) of 35 or more, “morbidly obese.”

The three commonly performed types of bariatric surgery are gastric bypass (Roux-en-Y gastric bypass), biliopancreatic diversion (in which part of the stomach is removed), and lap-banding (laparoscopic stomach band). All procedures are accepted surgical practice; patients’ individual situations dictate which procedure is best suited for them.

Dr. Giles performs the gastric bypass primarily. It is a permanent procedure in which the size of the stomach, normally 40 ounces, is reduced to the size of an egg (about 2 ounces). A section of the bowel is also bypassed to reduce the absorption of fat.

Dr. Carlos Barba, co-medical director of bariatric surgery, specializes in the lap-banding procedures, but has performed all types. The lap-banding procedure, as the name indicates, involves banding part of the stomach to reduce its capacity. It is adjustable and reversible.

Once a patient is accepted as a candidate for surgery, the five-month program begins with meeting between the patient, registered dietitian, bariatric nurse, surgeon, and behavioral psychologist. A 12-week educational program begins. The patient begins nutritional counseling, is asked to change their diet, lose weight, and begin to exercise. Concurrently, the patient undergoes thorough medical and psychological tests as needed (e.g. sleep, cardio-pulmonary, and psychiatric evaluations).
After surgery, close and careful supervision of a patient’s diet and health is especially important. Patients are first on a liquid diet, and transition slowly to small portions of “regular” food. Patients typically miss about three weeks of work.

“Patients’ protein and fluid intake are closely monitored,” says May Harter, RD, one of three registered dietitians that work with bariatric patients. “When the quantity of food intake is so drastically reduced, it’s important to ensure that patients are getting all the sustenance/nutrition that they need.”

Patients typically experience their most dramatic weight loss in the first six months after surgery. In addition to having access to the staff at any time, a monthly bariatric support group meets once a month.

A Gift
“The surgery has been a gift,” says Phyllis Rulewicz, a 34-year-old legal secretary who had her gastric bypass in spring 2005. She weighed 255 pounds, which, at 4-foot, 11-inches, made her morbidly obese. Having lost 120 pounds, Rulewicz has met her goals and feels healthy, but still wants to lose a few more pounds.

Rulewicz describes the pleasure of simple things she can now do: shopping and being able to walk up three flights of stairs. “It has changed my life. That’s not to say that I don’t work hard at it every day… This program is different. It’s the interaction with the staff and the quality time they spend with you. It’s easier to do something when you have good people behind you.”