- The Washington Times - Monday, August 2, 2004

One woman remembers the first time she could cross her legs. Another recalls the relief she felt at being able to see her toes again. A man is surprised he now can run.

All three are patients talking in a local doctor’s office about some positive results of gastric bypass surgery, an increasingly popular last-ditch effort by the morbidly obese to lose weight — especially if the excess weight is related to significant complicating medical problems.

The operation, one version of which often is called stomach stapling, is done either laparoscopically or by open incision. Stapling reduces the stomach size to a small pouch and shortens the digestive process by bypassing a section of the intestine.

It’s major surgery that later requires significant behavioral and dietary changes — smaller bites, more meals and longer chewing time — for the rest of a person’s life. Foods high in sugar or fat, including ice cream, are definite no-nos.

After surgery, a stomach that once held about 40 ounces, or five cups of food, now holds about 2 ounces, or one-quarter cup. In time, it may stretch to hold 5 or 6 ounces or three-quarters cup, notes dietitian Tanya Brackman in a 25-page list of nutritional guidelines given to patients of Dr. Joseph Afram at his Center for Obesity Surgery in Northwest.

Which is why failure to follow the recommended meal plan may result in little or no weight loss, she warns.

Although a person’s hunger is lessened, nutritional needs are no less. To maintain good health, a patient may be forever tied to prescription medicines to make up for reduced nutrients that comes with a reduced intake of food. Hence, monitoring is critical to prevent malnourishment, just as exercise is mandatory to keep off weight and condition the body. Even with exercise, at least half the patients undergoing the operation will need plastic surgery to remove excess skin and fatty tissue.

Another downside: As satisfied as formerly obese people feel when resuming a normal life, the immediate physical side effects of surgery can be unpleasant. They include diarrhea, vomiting and belching, any or all of which may continue, depending on how carefully a person observes the guidelines.

That can limit a person’s desire for group activity or normal social life, as Jason Jones, 20, discovered after undergoing the surgery by Dr. Afram in November.

Mr. Jones is a fully qualified volunteer fireman who works in construction, but was careful to stay close to home in the weeks following the surgery. It was six weeks before he tried solid food. Meanwhile, inches started dropping off his frame.

From a high of 645 pounds more than eight months ago, the 6-foot resident of Newburg, Md., now weighs 385 — a loss of 260 pounds. Also gone is a total of 141 inches from 20 areas of his body as measured by his mother, Brenda Jones.

“Now he has eyes,” she says.

Apnea, a serious sleep disorder, has disappeared, and Mr. Jones’ life expectancy, once estimated to be only 30 years, has increased dramatically.

Where he once could be weighed only at a feed lot store, he now can be checked at the doctor’s office, he noted proudly during a recent visit. He is on his way to having a normal life: being able to run, drive a truck, buy clothes, go out on a boat.

Dr. Afram gently reminded Mr. Jones that he has to get more exercise and would have to lose 70 more pounds before undergoing surgery to remove stretched and sagging skin.

Frank Pietrucha, a communications consultant on Capitol Hill, had the operation done laparoscopically in late October, but says he still gets sick from time to time. He is down to 225 pounds from a high of 352.

“You have to accept that you can’t eat certain things again,” he says. He still won’t touch spaghetti and is leery of steak. “If I have a martini or margarita, I feel the buzz instantly, because the alcohol goes straight into the bloodstream.”

As part of his rehabilitation, he works out in a gym six days a week.

“You let your body be your guide, learning what foods to tolerate,” says Connie Hrapla, of Crofton, Md., a registered nurse who lost 116 pounds in nine months following surgery performed by Dr. Afram. “I follow the rules,” she says. “You have to exercise self-discipline.”

In addition, she attends a support group at least once a month.

“Surgery is only part of comprehensive treatment [for morbid obesity],” says Dr. Afram with good reason.

Pre-operative and follow-up support in group or individual therapy, plus online chat rooms, are a necessary part of the regimen.

Then, too, the stomach pouch can stretch and weight can return, causing someone to have to repeat the operation. Figures vary on the number who manage successfully.

Where weight loss is concerned, Dr. Terrence Fullum, who does laparoscopic gastric bypass surgery at three area hospitals, expects an 85 percent success rate for weight loss alone.

A better marker is when related medical conditions such as cardiovascular problems and complications from diabetes are gone, he says.

“It’s when you get a 96 percent resolution [of these] and the weight stays off for five to 10 years.”

There are major emotional and psychological upheavals as well, as a person struggles to accept a new physique and self-image.

A woman in a follow-up support group at Dr. Afram’s Center for Obesity Surgery led by Mrs. Brackman and psychologist Maria Cohn complained aloud one day recently that she couldn’t accept having a scar from the incision, and even had trouble believing her weight had changed.

“It can take years before some people see what they are, because they have stopped looking at themselves,” says Ms. Cohn. Depending on a patient’s age and weight beforehand, “it may be a worse body image because of all the sagging skin,” she says.

“For most, food has become a way of coping — of numbing feelings. It’s difficult when they can’t go to food as a comfort item,” she says. “Some people never have experienced weight as a normal person. And people who have endured a good amount of weight have been through so much. … They are so brave, the ones that want to take [surgery] on. For some, it is almost having a delayed adolescence.”

Patients who take part in therapy groups for a year do best, she observes.

Living two hours away from the District keeps Mr. Jones from joining in the therapy, but he definitely has a supportive mother who is helping sort out the complications involved in paying for his medical procedures.

“The hardest problem is the insurance,” she says.

Dr. Arthur Frank, director of the George Washington University Weight Management Program, intends to start a post-surgical program in September that will not be affiliated with any particular bariatric surgeon or gastric bypass method.

“Unfortunately, there is a significant number of people either not losing weight or losing it and gaining it back,” he notes. “It’s not a sure cure.”

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