Weight Loss Surgery If you've had it, or are considering it, share your discussions here

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Old 06-12-2002, 08:20 PM   #1  
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Default Article: Diabetes Forecast.. Gastric bypass. (for weight control)

Gastric bypass. (for weight control)
Date: 12-01-1994; Publication: Diabetes Forecast; Author: Gallagher, Sharon



* Are you more than 100 pounds over your ideal weight?
* Have you for years been caught in the "yo-yo" of weight cycling: You lose 10 to 20 pounds, gain it back, lose it, gain it back--sometimes with a little extra to boot?

* Have you tried supervised weight-loss programs, but were still not successful at losing enough weight?

* Are you about to give up?

Don't give up! Many people with medically significant obesity and diabetes can't control their weight through traditional programs. They then must look for another way to help them meet their goals.

One option is "bariatric" surgery, that is, surgical treatment of obesity. The type of surgery that we recommend is the gastric bypass. After this surgery, you can't eat big meals, and the food bypasses most of the stomach and part of the small intestine.

If you answered "yes" to the four questions above, you may want to talk to your doctor about gastric bypass.

Less Food, Less Fat

The average adult stomach can hold about 4 cups of food. In the stomach, food is partially digested. It then passes into the small intestine where more digestion, plus absorption of nutrients, takesplace.

In gastric bypass surgery, your stomach is made smaller. Four rows of stainless steel staples separate the stomach into two sections. Food passes into the smaller section, which is called the pouch. It then passes through a small opening (the outlet) into a section of intestine that is connected to the pouch.

The pouch holds only about a half cup of food, so you eat less than you used to at each sitting. Because the opening between the pouch and the intestine is so small, food takes a long time to leave, so you stay full longer. This helps reduce your appetite. In addition, food bypasses the first part of the intestine. This reduces your food absorption and helps with weight loss.

Scar tissue eventually forms at the stapled area, so the stomach' s volume is permanently reduced.

Most people lose from 50 to 100 pounds in the first year, depending on how much weight they needed to lose in the first place. Some people lose even more by continuing to follow their diets and keeping up with their exercise programs.

Better Than Diet Alone

Gastric bypass surgery has been practiced in the United States for more than 20 years, and it has been recognized as an effective way to achieve a healthy body weight.

More important, the surgery helps people maintain this new, healthy weight. Most people keep off about 60 percent of their excess weight for longer than 5 years after their surgery. That's a much higher success rate than what people get by dieting alone.

Research shows that gastric bypass surgery can be very helpful in controlling non-insulin-dependent (type 11) diabetes. Some studies show that in 90 to 95 percent of patients, symptoms of diabetes disappeared, and the people didn't need any diabetes medication. The rest were able to greatly reduce their dosage of medication.

However, the surgery did not do all the work. With the assistance of the surgery, people were able to change their eating habits. The resulting achievement and maintenance of healthy weight allowed these people to enjoy improvements in health, including a decrease in blood glucose levels and insulin resistance, as well as improvements in quality of life.

You may be wondering why your doctor hasn't mentioned surgery as a weight-loss option to you before. It may be that you aren't overweight enough to be a candidate for this type of operation. Or it may be that your health care professionals aren't that familiar with this surgery. It wasn't until 1991 that a panel of obesity experts from the National Institutes of Health promoted gastric surgery as a safe and effective treatment for severe obesity. Already, health professionals are becoming more familiar with the benefits of the operation. You will probably be hearing more about it in the future. In the meantime, we'll answer some common questions:

How does the surgery work?

The gastric bypass surgery helps you to control the amount of food you can eat at one time. Because the stomach is reduced in size to hold about 3 to 4 ounces, you'll feel full more quickly than before, and with smaller amounts of food.

You'll be advised to eat 3 to 4 small meals a day. You'd be very surprised to discover how satisfied you can feel with less food! Overeating after the surgery causes pain and perhaps vomiting, so you learn not to eat past the point of fullness.

The surgery also helps you control the type of food you eat. Because the food bypasses some of the digestive process, eating high-fat and high-sugar foods results in intestinal discomfort followed by diarrhea. This discourages you from eating these types of food. Most people report that healthful foods, such as fruits and vegetables, are tolerated much better than junk food.

What should I expect from the surgery?

The surgery itself takes 2 to 3 hours. The incision is about 6 inches long, from naval to rib cage.

You'll be in the hospital for about a week. The first few days are quite uncomfortable, but people generally recover quickly and are walking around within 2 or 3 days. You'll be on a liquid diet for 2 to 3 weeks, followed by pureed foods for another 3 to 4 weeks, then solid food as tolerated. It's very important to let your stomach heal before you start eating solid foods again.

By the time you get home, you should be able to do many of your usual activities except lifting heavy objects. Most people go back to work in 6 to 8 weeks. There are no long-term restrictions on activities.

The total recovery period is about 2 months, and you should devote your full attention to it. This is a challenging time as you learn to adjust to a new way of eating and a different lifestyle. It's also an exciting time as you lose weight, improve your diabetes control, and feel better than ever before.

How safe is this surgery?

Gastric bypass surgery has its risks, as does any type of surgery. On average, about 3 percent of people who have this surgery experience complications. Each hospital's program has its own statistics on the rates of success and failure. Ask for this information at the institution that you're considering. It's important to find a good program and an experienced surgeon.

The risks of surgery can be divided into two categories: complications during, and immediately following, the operation; and long-term problems.

Possible complications during the operation or soon thereafter include: a clot forming in a lung artery, the incision in the abdomen bursting open, an infection developing in the incision or in the abdomen. There are also possible complications specific to gastric bypass surgery, such as the stomach staples coming apart, and the pouch or the outlet leaking. Programs will quote their own statistics on the likelihood of these things occurring.

There have been thousands of gastric bypass operations performed since the first one in 1966. Since then, techniques have improved and state-of-the-art medical care has helped to make the operation as safe as possible.

It's true that people have died during this surgery or developed complications afterward. You need to consider, though, that the same is true of all types of surgery. You should also remember that morbid obesity by itself raises your risk of premature death, and that diabetes further heightens that risk.

You may have heard of people who had problems after having this surgery. It's been our experience this is usually because patients didn't follow instructions after surgery. If you do what your treatment team asks of you, then you have an excellent chance of success after the surgery.

Am I home free after the incision heals?

No. Gastric bypass disrupts the normal flow of food, and you can' t fool with Mother Nature without expecting some backlash. You'll have to watch what you eat--even more carefully than you did before surgery.

If you eat too much carbohydrate or fat you'll experience the "dumping" syndrome: Too much undigested food gets dumped into your intestine. There, it can cause problems, such as pain, diarrhea, weakness, palpitations, and dizziness.

About 40 percent of people develop lactose intolerance. This means they can't easily digest the sugar in dairy products. If this happens to you, you may not be able to eat a lot of dairy products without getting diarrhea. However, enzyme pills are available to help you digest foods that contain lactose.

You may develop vitamin or mineral deficiencies. These can be corrected with a good diet and by taking supplements.

If you eat too much or too quickly, you'll get sick to your stomach and vomit. You'll need to eat slowly, pay close attention, and stop eating when your pouch is full.

Some people develop anemia or have short-term hair loss because they don't eat enough protein. Again, this is something you can control with a good diet.

Of course, it's best to catch problems early. You should make frequent follow-up visits to your surgeon or other doctor who is familiar with gastric bypass.

How do I know if I'm a good candidate?

The first criterion is your current weight. If you fit into the category of medically severe obesity (also called morbid obesity), that is, 100 pounds over your ideal weight, then you may be eligible.

In addition, most programs specializing in this surgery would ask you about any past attempts at dieting. It's important that you have at least tried some supervised form of conservative nonsurgical therapy first. The inability to lose adequate weight or to maintain that weight loss is called intractable obesity. If you can demonstrate that you suffer from this condition, then you are probably a candidate.

You may think that you're not a candidate for surgery because of your diabetes, but in fact the opposite is true. Having diabetes is actually a reason to have this surgery. Just as nonsurgical weight loss improves diabetes control, so does weight loss through surgical means.

But don't think of this surgery as the easy way out. Gastric bypass is not a magic solution for obesity. The surgery offers an additional component to your diet and exercise program. It's not intended to replace the basic sound principles of healthful eating habits and regular exercise.

You'll still need plenty of willpower to eat a healthy diet, especially with the diet restrictions you will have after surgery. Consider the pros and cons of surgery carefully, and know what the surgery can and can't do for you.

Will my insurance cover the surgery?

Your doctor may need to write to your insurance company to document the medical necessity for the surgery along with evidence of intractable obesity. In our experience, many insurance companies and Medicare will cover the cost of the operation and the related expenses. It may take several phone calls, but it's worth the effort.

How do I find the right program?

You need to find an established program with a surgeon who specializes in obesity surgery. Most general surgeons have not performed the operation and are unfamiliar with the kind of care that is required during the recovery period.

You can check with the American Society for Bariatric Surgery, 633 Post St., Box 639, San Francisco, CA 94109, (415) 753-6029. They can give you names of surgeons in your area who do various bariatric surgeries, including gastric bypass. You still need to do your homework: Check out the success rate of the program you're considering.

It's also important to find a surgeon involved with a program that offers a full range of services, including nutritional therapy, psychological counseling, and peer-support groups. We encourage you to explore surgery as an option for obesity treatment. It may be the best decision you ever make.

"People Don"t Recognize Me"

Helen Roccia weighed 270 pounds when she went to a surgeon to talk about having a gastric bypass done. But that wasn't her top weight; she had dieted down from 287--"just out of embarrassment"--in preparation for the visit.

The 5-foot-6-inch Roccia had always been a successful dieter--successful on grapefruit diets, liquid diets, doctor-supervised diets. With one weight-reduction program, she lost 114 pounds in 9 months. Then she gained 135 over the next 6 months.

"That's what I did constantly," she says. "I'd join programs with the very best intentions. In the first 2 weeks, I'd lose 11 pounds. The third week I'd gain 2. The fourth week, gain 3. All of a sudden, I'd be back to my original weight and then start gaining on the program."

At age 38, at a weight of 244, she was diagnosed with non-insulin- dependent (type 11) diabetes. She controlled it with diet and exercise at first. "But, of course, I didn't adhere to it," she says. "I ended up on insulin within a year and, without a doctor's permission, was altering the dose as I kept eating. If I ate a dozen candy bars, I just took a little more insulin."

She knew the risk she was taking. She is a geriatric nurse, and her husband had died at age 49 of complications of insulin-dependent (type I) diabetes.

"But your compulsion to eat supersedes any fears," she explains. "And I was the type of diabetic that if I cut out the refined sugars for a few days and watched certain foods, my glucose levels would fall considerably. That was my cop-out: I'm not a true diabetic.' " She eventually got up to 70 units of insulin a day and a weight of 287.

"I had reached the saturation point. I just started eating, and I didn't give a dam, because for every weight loss that I was successful with, was very unsuccessful keeping it off. If I lost a pound, I gained a pound and a quarter back. And the older I got, the more I gained. I couldn't combat it. I said, OK, I'm defeated.' I knew I needed some intervention and it wasn't another diet or program."

Roccia had been considering a gastric bypass for years; a nurse friend had had one. She finally decided to explore the option. "I was approaching my 50th birthday. This was my birthday present to myself."

Down 100

Roccia went to support groups to learn about the surgery and what to expect. "I knew how sick I might be, how intolerant of foods I might be."

She felt prepared for the worst and decided to go ahead. She had more than a few days of wishing she hadn't.

"They were not whistlin' Dixie. It was absolutely brutal. I've had two major surgeries since that were nothing as painful as the bypass."

She was in the hospital for 9 days, and says it took her 2 months before she "felt human again."

The weight didn't melt off, but after 3 months Roccia noticed she had dropped a few sizes. In the first year, she lost over 100 pounds- -and did a lot of shopping.

"I got my ears pierced, I bought $300 worth of make-up, I had my hair styled. I used to wear polyester pants and polyester smock tops because they fit. I'd never been able to buy a designer outfit. My first full outfit was a designer outfit. It was the thrill of my life, because it was not a plus size."

Still A Struggle

Today, 6 years after the surgery, she weighs 150. She hasn't taken insulin since the day of her surgery. She doesn't check her blood glucose anymore; yearly tests done by her doctor show that her blood glucose levels are normal. "I'm not conscious of it any more," she says of the diabetes. "If I want to eat candy, I eat candy, but I' m not eating 5-pound boxes anymore."

Although she can eat bigger meals now (the pouch stretches some with time), there are still foods she can't tolerate. "I don't do lots of meat or dairy products. Animal fats and refined sugars act as irritants. I have a better tolerance of pastas and salads."

Even though the surgery forces her to eat healthy foods, keeping weight down is still a struggle. "The surgery is great for a year, " Roccia says. "It gets 100 pounds off--it's almost a guarantee, if you adhere to the program. But it's only a working tool.

"Your appetite does increase as you get further away from the surgery. After about a year, you can suddenly tolerate a banana, popcorn, small meals. That's when you have to be watchful.

"The surgery corrects the size of your stomach, but it doesn't stop the brain from all the craving. I still like food--I don't think you' re going to take 50 years away from me."

She has found substitute pleasures. She and her son-in-law go to a gym two or three nights a week to work out with weight machines, and she walks a lot.

Mind And Body

She does wish she had been more mentally prepared for the period following surgery. "The surgery is great, but you really need some support afterwards. And not just a little group of us sitting together comparing notes on who has an intolerance for chicken. You need more therapeutic counseling.

"You never believe you're small. Once you're fat, you will always be fat--you're always critical of yourself.

"I still have fat days. I look in the mirror and check: Does this dress look good? No, I look like I should lose some weight.'

"If you beat yourself up, you're going to become that fat person again. You'll look at yourself and say, Ah, I'm still fat--what the ****, I'll eat that candy.' This is what you need to combat."

Despite the brutal days after the surgery and the continuing struggle to maintain her weight, Roccia says the surgery was worth it. "I would do it again. It's awful to say, but I feel like a normal person because I'm normal size. I can go to regular-size stores and buy clothes, I fit in bus seats and airplane seats, I'm not embarrassed by my size anymore.

"Isn't that terrible that we judge people by size and looks? But I see pictures of myself at almost 300 pounds and I feel bad for that person.

"Some people don't recognize me; I really get a kick out of it. They say, Keep talking, I recognize the voice.' Finally, I'll tell them who I am, and they say, You are not.' That's kind of nice. But I didn't do it for anybody else, I did it for myself. I've always wanted to be thin."

Sharon Gallagher, MEd, RD, CDE, is the coordinator and dietitian for the Surgical Obesity Program at Deaconess Hospital in Boston,Mass.

R. Armour Forse, MD, PhD, is director of the Surgical Obesity Program and chief, Division of General Surgery at Deaconess Hospital. Dr. Forse is also an associate professor of surgery at Harvard Medical School.

Gallagher, Sharon; Forse, R. Armour, Gastric bypass. (for weight control). Vol. 47, Diabetes Forecast, 12-01-1994, pp 52(6).
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Old 07-05-2002, 12:07 PM   #2  
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Hi Suzanne,

Thank you sooooo much for posting unbiased, honest information about WLS. Certainly, it is not the answer for everyone, but definitely for some of us with extreme weight and health issues. Thanks again!!!! Robin
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