BYPASS: LOSING WEIGHT THE SURGICAL WAY
By Mary Ann LittellMary
Arter had tried every
diet in the book and then some. She took FenPhen, Redux, and other
weight loss drugs. She tried Optifast, Slimfast, and any other "fast"
she could find. Nothing worked for her. Shed always had a weight
problem, going back to childhood. But at 255 pounds, her weight had really
ballooned out of control. A construction engineer, shed never been
employed in her field because she couldnt meet the physical demands
of the work. She told her internist, "Im going to be 40 soon,
and I dont want to be overweight anymore."Like thousands of
other Americans, Mary Arter researched her health problem on the Internet.
The solution she ultimately found was gastric bypass surgery. In this
procedure, a surgeon creates a small pouch at the top of the stomach with
staples and stitches. A portion of the small intestine is connected to
the pouch, bypassing the remainder of the stomach. The newly created pouch
holds only a few ounces of food, as compared to a regular-sized stomach
with a capacity of one quart. The patient feels full after eating small
amounts of food, resulting in reduced calorie intake and weight loss.
Many obese people are
turning to bariatric surgery, or surgery that facilitates weight loss. While
there are several types of bariatric operations, gastric bypass is the most
frequently performed and is considered the "gold standard." Gastric
bypass is not a new procedure, but it has been in the news quite a bit lately.
For years it was considered bizarre and drastic: a "quick fix"
offered by a handful of unorthodox surgeons. However, it is now gaining
acceptance among mainstream practitioners. Since 1996, the number of gastric
bypass procedures in the U.S. has doubled. Some 40,000 patients had the
surgery in 2000, and 50,000 procedures were projected for the year 2001.Mary
Arters surgery was performed by Joseph Kamelgard, MD, director of
The Obesity Treatment Center (OTC) at UMDNJ-University Hospital in Newark.
The OTC is a surgical program for patients with morbid obesity who have
been unable to lose weight through more conventional methods. "Typically,
our patients have a history of losing weight and gaining it back, of trying
new diets and being unsuccessful," says Kamelgard. "Bariatric
surgery is the course of last resort, when all other attempts to treat morbid
obesity have failed."Morbid obesity is the term used to describe someone
who is 100 or more pounds overweight or has a body mass index (BMI) of 40
or more. BMI, another measurement of obesity, is a ratio based on weight
and height. This obesity is called morbid because it contributes to life-threatening
health conditions, including diabetes, hypertension, cardiovascular disease,
and stroke. Mary Arter is not the only OTC patient to "log on"
to weight loss. "Most of our patients learn about us on-line,"
says Kamelgard. "This is the type of procedure people tend to research
thoroughly before making any decisions, and increasingly, patients are turning
to the Web."The surgeon says the many Web sites dedicated to bariatric
surgery have helped people learn more about the procedure. A popular one,
spotlighthealth.com, features celebrities, including Carnie Wilson, a member
of the singing group Wilson Phillips. When Wilsons gastric bypass
surgery was broadcast live over the Internet, some 250,000 viewers watched.
Wilson has since lost 150 pounds and speaks out enthusiastically about how
the surgery has improved her life.Before undergoing gastric bypass surgery,
every patient has nutritional counseling, a full medical workup, a psychiatric
evaluation, and even goes to physical therapy to learn exercises that will
keep the weight off.Kamelgard, who studied engineering before entering medicine,
has a keen interest in computers. He launched the OTC Web site(www. TheUniversityHospital.com/OTC)
in April 2000 to spread the word about the program. The number of people
who visit the Web site is monitored, and its growth has been impressive.
From October through December, 2000, it averaged 3,000 hits per month. In
early 2001, it received approximately 8,500 hits a month, and in one month
July 2001 there were more than 9,000 hits. The site includes
a video of a gastric bypass procedure produced by Kamelgard, as well as
an e-mail address where people can write for more information. He receives
100 to 150 e-mails a month. All inquiries receive a personalized e-mail
from the physician. Those who decide to come and see him start with a consultation,
where the surgical options are explained. He also gives group information
sessions, both in his office and as evening seminars. "The more informed
people are about the procedure, the more successful the outcome is likely
to be," he says.Gastric bypass surgery can be performed both as an
"open" procedure or laparoscopically. The open surgery involves
an 8 to 12 inch incision from the breastbone to the navel, while the laparoscopic
procedure is minimally invasive. A laparoscope is a thin, telescope-like
instrument attached to a tiny camera and specially designed surgical instruments.
Small incisions are made in the abdomen, through which the laparoscope is
inserted. The camera projects an image of the abdominal cavity onto a monitor
in the operating room so the surgeon can "see" inside the body.
While the results are the same for both procedures a 90 percent decrease
in the amount of food the stomach can hold there are some post-operative
differences. There is less pain with the laparoscopic method, and hospitalization
may be shorter. "Not everybody is a candidate for laparoscopic surgery,"
explains Kamelgard. "It depends on a variety of factors. We generally
do the open procedure on patients weighing more than 300 pounds, those who
have a BMI of 50 or more, those with an enlarged liver visible on ultrasound,
and those who have had other open abdominal surgery in the past."
Kamelgard received advanced
training in laparoscopic surgery at Baylor College of Medicine in Houston
before coming to UMDNJ in August 1998. Since then, public interest in gastric
bypass surgery has exploded. Even so, many physicians, including Mary Arters
internist, are reluctant to recommend the procedure to their overweight
patients. "My doctor said, What do you want to do that for? Try
another diet instead," she recalls.Kamelgard believes this attitude
stems from a lack of awareness. "Many physicians dont know that
much about it, and therefore dont think of it as an option,"
he says. "Others wont recommend it because they think its
too extreme." Some 20 percent of the procedures performed at the OTC
are laparoscopic. Mary Arters gastric bypass was one of them. She
had her surgery on February 19, 2001, and has since lost 90 pounds. Her
weight is now 148 pounds, and her ultimate goal is to get down to 135. She
still enjoys her food only much less of it and exercises for
at least a half hour each day. She left her job as an administrative assistant
and now works as an engineer in a construction firm. "I am much happier
now, and its great to be working in my field," she says. In order
for gastric bypass to be successful, says Kamelgard, many bad habits have
to change. Prior to surgery, every patient undergoes nutritional counseling,
has a full medical workup and psychiatric evaluation, and even goes to physical
therapy to learn exercises that will help keep the weight off. This way,
they will be prepared for what they have to do after the surgery. He does
not operate on smokers because the health risks are too great, but encourages
them to quit and then return for the surgery."Weight loss is not rocket
science," says Kamelgard. "The less you eat and the more you exercise,
the more successful you will be. But you have to do your part." The
average patient loses about two-thirds of the excess weight in one to one
and a half years. Its a significant loss but it may not be
enough to satisfy a patient who has unrealistically high expectations. "I
advise people not to aim for a size 2 dress, because thats probably
not going to happen," he states. "But they will feel better, look
better, and be within healthier range of their ideal weight." Success
is also measured by a reduction in other health problems. For instance,
many Type II diabetes patients blood sugar levels return to normal
following gastric bypass surgery.Patients need to carefully follow specific
eating guidelines after surgery. If they try to resume their old eating
habits, some experience what is known as a "dumping syndrome,"
where high-calorie foods pass too quickly from the stomach to the intestine.
Fluid rushes into the stomach to dilute high concentrations of sugar, and
the patient may feel faint and nauseous and experience stomach cramps and
diarrhea. In some cases, vomiting results if food is not chewed thoroughly.
Patients will also need to take daily vitamin and mineral supplements to
compensate for deficiencies resulting from the surgery. Most insurance companies
cover gastric bypass surgery. "It is not considered a cosmetic procedure,
but one designed to lower the risk of conditions associated with obesity,
including high blood pressure, Type II diabetes, back pain, and sleep apnea,"
says Kamelgard. The surgery is not without its risks: among them infection
at the surgical site, leaking of the newly formed pouch, and intestinal
blockage. In addition, after significant weight loss, many patients require
reconstructive surgery to remove excess skin and tissue from the stomach.
The procedure, called a paniculectomy, is performed by a plastic surgeon.
In some cases, patients will benefit from breast reduction surgery and removal
of excess skin from arms and thighs. Only about 25 percent of patients proceed
with the plastic surgery, because it is not typically covered by insurance.Despite
the risks, most patients who have had gastric bypass surgery are very glad
they did. "Morbid obesity carries with it psychological burdens as
well as physical ones," says Kamelgard. "Most of the patients
I see have some degree of depression. They wouldnt seek out this type
of elective surgery if they were content." The depression lifts after
they have the surgery and begin losing massive amounts of weight. Many speak
enthusiastically about being able to give up blood pressure medications,
of having more energy, of fitting on one seat in an airplane rather than
having to book two, of walking the golf course rather than having to ride
Weight before surgery: 255 pounds.
Weight post surgery: 148 pounds.