Weight Loss Surgery: One Woman's Story

Learn how weight loss surgery changed one woman's life and what you should know if you are considering surgery for weight loss.

By Donna Rae Siegfried

Last holiday season, Paige Elliott, 42, Arthritis Today’s advertising coordinator, had a wish come true: She was approved for bariatric surgery, or weight loss surgery. Like so many of us, Paige has struggled for years to lose weight. As she saw it, her situation was dire and called for a drastic solution. As her weight went up, her health went down. Obesity was no longer just an insult to her vanity; it was causing grinding knee pain, escalating blood pressure and pre-diabetes symptoms, all of which she knew would get worse if she didn’t lose weight – a lot of weight.  And so she turned to surgery for weight loss.

While most of us were ringing in the New Year, Paige was recovering from the operation, and now, not quite a year later, she is 65 pounds lighter, much healthier and feeling just flat-out happy, she says.

Amazing. Impressive. Appealing. A means of weight loss that seems to work? But surgery? We wanted to know more. So we, her supportive yet skeptical coworkers, decided to investigate.

If, like Paige, you’re severely overweight, weary from failed diets and scared for your health, you might want to know more, too. As we dug in, our eyes were opened to the fact that there’s nothing easy about weight loss surgery. It takes courage and commitment – more so than any diet we’ve heard of – and it’s clearly not for everyone.

The Epidemic

How many people like the idea of losing 65 pounds in a year, with the realistic prospect of losing even more as time goes on? A lot. Obesity is pervasive in America. The Centers for Disease Control and Prevention (CDC) in Atlanta has been tracking its rise:  In 1990, 11.6 percent of people in this country were obese, and by 2002, an astounding 22.1 percent were.

What’s so alarming about this escalation is that nothing contributes to health risks like obesity. Excess weight raises the risk of arthritis – lower-body joints can’t endure the physical stress – plus a host of other serious and life-threatening diseases: cancer, type 2 diabetes, gallstones, heart disease and sleep disorders. And the risks for these diseases get worse as weight goes up.

As a result, weight loss has become a legitimate and prominent concern in the medical arena. Doctors are increasingly telling their patients to lose weight and backing that up with referrals for nutrition counseling, prescriptions for weight loss medications and, now, recommendations for bariatric surgery, which is where Paige ended up.

 

Health Consequences

For 15 years Paige’s weight has been a problem. Through high school, college and a few years beyond, her weight was normal – she had a very healthy body mass index (BMI - calculate your BMI) of 19 when she was 25 – then her weight started to creep up at a rate of five to 10 pounds per year when she took a desk job. Over 10 years, she gained 100 pounds, and by 2004, her health was in serious decline because her weight wasn’t.

Paige knew her health depended on losing weight, but she, like many people, had never been able to achieve permanent weight loss.

Within one year of losing weight, say experts, 30 to 35 percent of people regain it; and five years after losing, 50 percent or more are likely to have bumped back up to their starting weight. There’s no one answer to explain why that is, but research is showing that in some people, the complex interplay among genes, hormones and metabolism can make the body fight back against even the strictest weight-loss efforts. That means, according to the latest theories, that making lifestyle changes – even appropriate calorie restriction and intense, regular exercise – will not be effective for some people, even though it is for others.

Paige tried what seemed like everything – eating less, eating only certain foods, joining support groups and weight loss programs, following specialty diets, taking prescription weight loss medications and exercising. “I’d lose and regain, again and again,” she says. She started to feel obesity was her destiny.

In 2004, when Paige regained the weight she had recently lost and then some after stopping a prescription weight loss medication, she gave up and entered into a downward spiral. With her weight up to 256 and her body mass index at 39, the pain in her knees was excruciating when she walked up or down steps; osteoarthritis (OA) surely was developing. Walking to a nearby restaurant for lunch left her winded, and she had chronic heartburn. She developed sleep apnea; sleep studies showed her breathing stopped an average of 15 times per hour every night. Eventually, her cholesterol level and blood pressure got so high her doctor wanted her on medications to reduce her risk of heart attack and stroke, and they warned her she was in a pre-diabetic state. Because diabetes and heart disease run in her family, Paige knew she had to do something serious.

Surgery for weight loss became a possibility, but she knew it was not a casual step to take. “I thought about bariatric surgery for a year and a half,” says Paige. “I read books, chatted online with those who had done it or were also considering it, and researched physicians.” Her decision to proceed was made neither lightly nor quickly.

Once she felt committed to weight loss surgery, she soon saw the decision wasn’t hers alone to make.

 

 

Necessary Hurdles

Surgeons who specialize in weight loss surgery and insurance companies that pay for it are highly selective about who qualifies for any of these dramatic operations. Approval is granted only if certain criteria are met, and the process is lengthy and arduous.

Paige spent nine months having blood tests and being evaluated psychologically to make sure she had realistic expectations and strong motivation. She met a number of times with a psychologist and filled out thick questionnaires. “The meetings and questions took four weeks total to determine that I did not have an unnatural body image or an eating disorder and that I did have the motivation to follow the instructions,” says Paige.

She consulted with a nutritionist, providing a detailed diet history of every plan she had ever tried, to make sure she understood how her eating habits would change. Although her doctors had given their okay, Paige’s fate rested in the hands of the insurance company.

Compliance is critical after bariatric surgery. Insurance companies may withhold a $30,000 weight loss surgery from a person they predict won’t stick with the program, explains Mohammad Jamal, MD, assistant professor in the division of gastrointestinal, minimally invasive and bariatric surgery at the University of Iowa Hospitals and Clinics in Iowa City. This is similar to the way organizations controlling organ recipient lists may withhold a liver from an alcoholic who would “abuse” the donated organ.

“A person who couldn’t comply with diet programs before surgery isn’t going to comply with what’s necessary after surgery,” he says.

Some surgeons have potential patients work with a nutritionist for the three to four months between the initial visit and surgery to follow a diet and exercise plan. “If they weren’t able to stick with the plan, then we must have a heart-to-heart discussion about lifestyle changes and postpone surgery,” he says.

“In my experience, only a few patients have been turned down for surgery, and some reconsider on their own,” says Dr. Jamal. Reasons include fearing the risk of potential complications, not wanting to go through the lengthy approval process or doubting their ability to adjust to the harsh realities of life after surgery.

“In a few cases, patients who go through the intense diet and exercise program during the approval process feel empowered and want to try keeping up those changes on their own before proceeding with surgery,” says Dr. Jamal.

 

Three Surgeries

Bariatric surgery, an umbrella term for several types of weight loss surgery, has evolved during the 50 years it has been available. No longer performed are the 1950s-era intestinal bypass, 30,000 of which had to be reversed due to liver failure and kidney stones, and the 1960s-era stomach stapling technique, which made bile back up into the esophagus.

When researching her options, Paige looked at three types of procedures currently available today: one that restricts the amount of food that can be eaten, one that alters the digestive process so that not all calories are absorbed, and one that is a combination of both. Although some procedures induce more weight loss than others, overall, people who have bariatric surgery lose an average of 62 percent of their excess weight, according to a 2004 review of 136 studies and more than 22,000 patients published in the Journal of the American Medical Association (JAMA).

All three procedures can be done laparoscopically, which requires only a few small incisions for the surgical tools, including a small video camera, to be inserted, giving the surgeon a close-up view on a video screen. Because there’s no need for a large abdominal incision with laparoscopic surgeries, there is less healing time and fewer infections and other complications. What were Paige’s options? Here’s an overview:

1. Laparoscopic adjustable gastric banding (lap-band surgery)

Type of procedure: Restrictive

How it’s done: An adjustable plastic band is placed around the top portion of the stomach, leaving a small golf-ball-sized pouch. A port lying just under the skin of the abdomen allows saline solution to be injected into or withdrawn from the band to tighten or loosen it. Restricting the size of the stomach requires people to eat far less than they normally would.

Risks: The band may slip or move, and the port may leak or twist, which could make another surgery necessary. The band may also grow into the stomach tissue, causing complications that require the band to be surgically removed. 

2. The “duodenal switch” procedure

Type of procedure: Malabsorptive

How it’s done: This procedure changes the stomach from a pouch-like structure to a tube and connects the duodenum, the first part of the small intestine, to the lower part of the small intestine. With this procedure, more food can be eaten than with gastric banding; weight loss occurs because food bypasses a portion of intestine, causing malabsorption. Of the three procedures, this one can cause the greatest weight loss.

Risks: Chronic malabsorption means blood levels of nutrients, such as protein, and minerals, such as iron and calcium, must be monitored for life to prevent muscle loss, anemia and osteoporosis. 

3. The Roux-en-Y (“roo-on-Y”) gastric bypass 

Type of procedure: Combination of restrictive and malabsorptive

How it’s done: A portion of the stomach is removed and, using staples or a plastic band, a small pouch is created at the top of the stomach that is then connected to the middle of the small intestine, bypassing the duodenum altogether. Not only is less food eaten, but also less of the intestine is available to absorb nutrients, so weight is lost.

Risks: Anemia, bone disease or osteoporosis may occur if the patient does not take vitamin and mineral supplements. Intestinal irritation or ulcers may occur. Diagnosing an ulcer or bleeding can be difficult because parts of the stomach and intestines aren’t visible by X-ray.

 

 

Facing the Risks

The risk of death from weight loss surgery is low, but severe complications can and do occur. Bariatric surgery carries a mortality rate of about 0.5 percent – equivalent to rates associated with total knee replacement surgery. That means one in 200 people who have bariatric surgery will die within three days of the operation. Although the cause could be directly related to the surgery, it also could be related to the patient’s obesity. People who are obese are more likely to have blood clots after surgery, regardless of what kind of surgery they undergo.

Complications may occur long after the patient leaves the hospital, too. A recent study by the U.S. Department of Health and Human Services’ Agency for Healthcare Research and Quality showed that within six months of undergoing bariatric surgery, up to 40 percent of people experience complications as varied as hernias, infections, pneumonia, leakage of gastric juices and dumping syndrome – an unpleasant phenomenon usually triggered by the consumption of too much food or sugar. The contents of the stomach are rapidly released, causing diarrhea, nausea, sweating and weakness.

A more serious long-range complication includes the formation of scar tissue around the band used in lap-band procedures, says Dr. Jamal. “Any time you put a foreign body inside a human, the body may reject it over the long term,” he says. “Removing the band can be difficult because sometimes it erodes into the stomach’s tissue, and when the scar tissue is removed, it doesn’t heal well because it doesn’t have a good blood supply, so infection may occur.”

“Bariatric surgery may also necessitate future plastic surgery to remove excess skin left behind after a massive weight loss. Most often this is necessary in older patients who have less elasticity in their skin, or those who were morbidly obese and had more weight to lose,” says Dr. Jamal.

Change in Attitude

The medical community is becoming more accepting of weight loss surgery due, in large part, to that 2004 review paper published in JAMA. Its extensive review of studies found that those morbidly obese people who don’t respond well to dieting and medications do respond well to surgery.

In 2005, a group of surgeons from Virginia Commonwealth University Health System, Richmond, led by Dr. Jamal, studied the impact of both obesity-related problems and bariatric surgery–related complications. They concluded that the risks associated with obesity are far greater than the risks associated with the surgery. The result? Physicians are more likely to approve surgery so that the life-threatening complications caused by obesity can be eliminated.

Insurers have come along more slowly than the medical community, to be sure, but the industry’s willingness to pay the costs of surgery for weight loss is changing.

“Insurance companies are realizing obesity is a disease and that bariatric surgery is a treatment, not a cosmetic operation,” says Dr. Jamal.

 

 

The Tempting Part

Paige’s thorough research left her no doubt about the risks she’d face, but she wanted to hear about the potential benefits, too. And she liked what she learned.

Several studies show that surgery for weight loss can produce a number of major health improvements, including easing the sometimes excruciating pain caused by extra stress on joints.

“It is not uncommon for obese patients with OA to come in for bariatric surgery in a wheelchair because of pain, failed joint replacements and lack of mobility – all due to excess weight – and within a year walk free of even a cane,” says Walter Pories, MD, chief of the Metabolic Institute at East Carolina University in Greenville, North Carolina, and one of the authors of the 2004 review published in JAMA.

Losing weight via bariatric surgery may also help resolve chronic inflammation associated with rheumatoid arthritis (RA), diabetes and heart disease. Studies performed over the last several years by researchers in Austria show that the level of C-reactive protein (CRP) and other cytokines linked closely to inflammation decrease significantly after bariatric surgery.

Within a matter of weeks after the operation, the body begins to produce and appropriately absorb insulin and manage glucose more effectively. Indeed, in a study of 608 morbidly obese people with diabetes who had weight loss surgery, 99 percent of them were able to normalize their blood glucose level. 

“We don’t yet know exactly why the body responds so well to bariatric surgery, but it does,” says Dr. Jamal.

Reality: Surgery and Beyond

When preparing patients for life after bariatric surgery, Dr. Jamal and Dr. Pories make sure patients have realistic expectations.

“Bariatric surgery patients do not become ‘normal,’ thin people; they become lighter, healthier people. A patient who weighs 300 pounds won’t get to 110 but may get down to 200 and eliminate or decrease their need for medications to treat diabetes, high cholesterol, high blood pressure and arthritis pain,” says Dr. Pories.

Paige says she was realistic. “I knew having surgery would not be taking the easy way out.” She knew radical and challenging lifestyle changes were part of the deal.

On December 29, 2005, Paige’s surgeon made five incisions on her abdomen and placed a restrictive plastic band at the top of her stomach.

After a one-night stay in the hospital, she was home and on a full liquid diet for two weeks. She could take in only about four liquid ounces per meal. “I could eat anything that melted in my mouth, like gelatin or yogurt. After a while, I was going crazy for something even semi-solid. I would have been happy to chew anything.” After the first two weeks, she was free to eat anything that could be pureed in a blender – and you’d be amazed at how much can be pureed, she says.

Six weeks after the surgery, Paige returned to the doctor for her first “fill,” a saline injection through the port in her abdomen to tighten the band. “It feels a little weird but is not painful or uncomfortable,” she says. Adjustments are made every six weeks. Surgeons will tighten a patient’s band if she is not losing four to five pounds per month, and it’s loosened if the patient is not able to eat one-half cup of food at a time. Since her surgery, Paige has had four “fills,” or procedures, to tighten her band.

“I’ve had major surgery amounting to mechanical portion control that will alter the way I will eat for the rest of my life,” says Paige. “I can take in only one-half to one cup of food at each meal.”

She has learned to be patient when eating. “I have to chew food until it’s nearly gone,” she says. “If I don’t, or if I eat too much, the food stays above the band, in the esophagus. It’s really uncomfortable for a while.”

Paige doesn’t drink liquids during her meals, otherwise she feels full immediately and isn’t able to take in any nutrition. “But I do drink hot tea or have some warm soup before every meal, to soften the band a little and make it more comfortable. Then I make sure I eat protein first. If I have room, I eat some veggies and then carbs. Desserts and treats are out,” she says. “There’s just no room to splurge on foods that don’t provide real nutrition, and I no longer crave them.”

 

Control, At Last

Two months after her surgery, Paige had declared, “I officially love my band.” Over the next months she took joy in the many signs that she and her body were really changing: She bought an XL (not an XXL) coat, no longer cared what the scale read, and no longer felt incessant hunger – she actually had to remind herself to eat.

Nearly a year after her surgery, Paige is careful to follow her doctor’s orders: She takes her vitamins and exercises regularly. She has lost enough weight to bring her BMI down out of the obese range (from 39 to 29.9). Her sleep apnea improved just six weeks after the surgery, so she no longer snores. And about three months after her procedure, her blood pressure improved and her knees stopped hurting. Now, she says, she has more energy and looks forward to going to the gym instead of dreading exercise.

“The nicest surprise is that I keep losing. I’m so much healthier. If I could have just one other wish come true, I’d wish I had done it sooner. After years of thinking nothing will work, I finally feel like I can control my body and my life,” she says.