Though weight loss surgery has tremendous benefits, dealing with the aftereffects can also be very challenging
By Denise Mann
WebMD Weight Loss Clinic - Feature
Reviewed By Michael Smith, MD
Unlike past cruises, this summer as Susan Kochman, 57, and her husband, Ed, sail the Western Caribbean, she plans to spend significantly less time grazing the round-the-clock buffets and much more time touring Cozumel, Grand Cayman Island, and other ports.
Like growing numbers of Americans (including such famous folk as weatherman Al Roker and singer Carnie Wilson), Kochman, who lives outside Philadelphia, underwent weight loss surgery on Dec. 3, 2004, and has since lost 54 pounds.
"I have so much more energy," she says. "Before I had the surgery I needed to nap every day. I almost never nap anymore." What's more, she is off all of her heart failure medications and almost completely weaned off of her blood pressure medications.
"The surgery met my expectations, and I had high expectations," she tells WebMD. In fact, she says this past New Year's Eve was the first ever that she did not shed a tear for auld lang syne. "I was so happy and so looking forward to the next year."
But weight loss surgery isn't a quick fix or a free ride. It is a major surgery that involves shrinking the stomach size by sealing off most of the stomach and creating a small, thumb-sized pouch that greatly restricts food intake. The pouch also bypasses part of the small intestine to reduce the amount of calories and nutrients absorbed from food. And the surgery is often only the beginning.
What follows can include additional surgeries and severe lifestyle restrictions, and sometimes disillusionment.
Weight Loss Surgery a Last Resort
That's why for Kochman and many others, weight loss surgery is often a last resort. "After years and years of dieting and losing a little weight and then gaining more, I knew that I had reached a point where it was do this or concede that I was going to die early," Kochman says.
In 2004, about 140,600 people underwent weight loss surgery; a 36% increase from 2003. Preliminary estimates from 2005 suggest the number will increase even further, according to statistics from the American Society for Bariatric Surgery (ASBS).
This especially holds as more and more people are deemed acceptable candidates. For example, elderly patients can safely undergo weight loss surgery and can be expected to experience similar benefits from the operation as currently experienced by younger patients, according to a recent study in the Archives of Surgery.
Buoyed by the increasing popularity, surgeons are also honing their skills and refining their techniques. Today, the procedure can be performed minimally invasively via small incisions, and in some centers, such as Cedars-Sinai Medical Center in Los Angeles, it can even be done on an outpatient basis.
Like all major surgeries, weight loss surgery can have complications.
As many as 20% of patients need additional surgery to mend complications such as abdominal hernias. Because of malabsorption in the shortened digestive tract, roughly 30% of patients develop conditions due to malnutrition, such as anemia and osteoporosis, according to the National Institute of Diabetes and Digestive and Kidney Diseases. Some obese patients who have had weight loss surgery will also develop gallstones.
It's also not all that glamorous. The new stomach requires several tiny, nutrient-rich meals a day supplemented with additional vitamins and minerals. Eating too much or indulging in rich, sugary or fried foods can overload the pouch and cause dumping -- a term used to describe the sweats, chills, and nausea that result from food filling the pouch and overflowing straight into the small intestine.
"Initially after the operation, it's recommended that a person eat pureed foods to give the operation a chance to heal, but after that, behavioral modifications are key," says Harvey Sugerman, MD, emeritus professor of surgery at Virginia Commonwealth University in Richmond, Va., and president of the ASBS.
"You can't eat large volumes of food, and you get full more quickly," he says. But not indefinitely.
Regained Weight May Be an Issue
And that's why as time goes on, not all former weight loss surgery patients remain as pleased with the surgery as Kochman does right now, says Jacqueline Odom, PhD, the psychological director of the Beaumont Weight Control Center in Royal Oak, Mich.
"A year or two years out, patients are reporting struggling with weight regain because they are struggling with their old eating habits and may have not incorporated portion control and exercise," she says.
During the immediate aftermath of the surgery, people can only tolerate small amounts of food, she explains, but after a while they can eat more because the pouch opening gets stretched out. "Food cravings start coming back and medical problems can follow suit," she says.
"Surgery is not a cure for obesity, it's only a tool," she says. "One has to have the mindset or resolve that lifestyle changes are inevitable. A lot of people have been disappointed in surgery long term because they really thought it would cure obesity and it hasn't." Odom runs a monthly support group for patients considering the surgery as well as those who have undergone it.
Nothing Tastes as Good as Thin Feels
"The significant weight loss that occurs within the first year is a very big motivator, but food urges start coming back and people get scared and have to learn to cope with food urges without acting on them," Odom warns.
Kochman believes she has this part covered. "When it came to dieting all my life, I always felt like a failure, but now my capacity is different and that's the tool that I have been given," she says. "Between that tool and the changes in my own head, I feel like a success."
In other words, "it's more important to feel good about myself than to have a cookie," she says.
Another issue that some former weight loss surgery patients face is that they think surgery will improve everything in their lives, and it doesn't. "A difficult marriage before surgery will be a difficult marriage after surgery," she says.
For Kochman, the only major change in her marriage is that "now I am a cheap date," she quips.
When she and her husband dined out the other night, "I ate a hamburger without the roll, got half way through it and was so full," she says.
Decrease in Medication Aids Motivation
Other motivators are the reduced dependence on medications and freedom from the lifestyle restrictions of obesity.
"The data are pretty strong that patients who have the surgery have a lower mortality risk than those who did not have surgery, and clearly there are dramatic improvements in comorbidites of obesity such as diabetes, hypertension, and obstructive sleep apnea," says Sugerman.
In a recent review of 136 studies published in The Journal of the American Medical Association, weight loss surgery reversed diabetes in 77% of obese patients, eliminated or improved high blood pressure in 78%, and improved cholesterol in at least 70%. In addition, obstructive sleep apnea resolved in 86% of patients.
The New You
When a person loses a large amount of weight in a short period of time, particularly after weight loss surgery, they may have large amounts of extra skin that requires some significant nipping and tucking.
"Different people present with different degrees of deformity," says Al Aly, MD, a plastic surgeon in private practice in Iowa City, Iowa, and a spokesman for the American Society for Aesthetic Plastic Surgery (ASAPS).
Most weight loss surgery patients who undergo body contouring will have a minimum of two and as many as three to four surgeries following weight loss, he says. And as the trend toward weight loss surgery increases, plastic surgeons are learning how to best sequence these surgeries.
"The most common thing is the lower trunk [which comprises] the belly, hips, waist, sides, and buttocks," he says. "Essentially the tummy is the area that bothers people the most, so it is often one of the first things addressed," he says. "The upper arms and thighs are two other areas that are quite problematic for massive weight loss patients as are the area from the neck down to just below breasts," he says.
The excess skin and the amount of follow-up surgeries can come as a surprise to massive weight loss patients, he says.
"People are not told what is going to happen when they lose weight," he says. "In the average person when they lose weight, especially massive weight, their skin is not going to contract down," he says. "If your skin is a balloon that's blown up pretty extensively for an extreme period of time, when you take the air out, it doesn't go back to same shape."
Most Would Do It Again, Despite Obstacles
As Al Roker said in November 2004, about two and a half years after his surgery: "For anybody who thinks that this is a magic bullet, you do this and it's done, you're making a mistake. It's not."
Sugerman agrees. "Some people go into it thinking it's a free ride, and we try to make it clear it's a procedure designed to help them help themselves," he says.
And despite the fact that this is a major surgery involving a whole host of often-difficult lifestyle changes and the potential for even more follow-up surgeries, Kochman would do it again -- in a "New York minute."
That holds for the vast majority of weight loss surgery patients, says Sugerman. "I have had patients 18 years out who control weight and are extremely grateful."
Published Feb. 25, 2005.
SOURCES: Jacqueline Odom, PhD, psychological director, Beaumont Weight Control Center, Royal Oak, Mich. Al Aly, MD, plastic surgeon; spokesman, American Society for Aesthetic Plastic Surgery. Harvey Sugerman, MD emeritus professor of surgery, Virginia Commonwealth University, Richmond, Va.; president, American Society for Bariatric Surgery.
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