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Published: Sunday, 5/1/2005

Experiences show obesity surgery can be blessing, curse

BY LUKE SHOCKMAN
BLADE STAFF WRITER
Nancy Konopka, manager of Toledo Hospital's dietary department, holds a pair of pants that used to fit her before she underwent gastric bypass surgery. Ms. Konopka lost 125 pounds. Nancy Konopka, manager of Toledo Hospital's dietary department, holds a pair of pants that used to fit her before she underwent gastric bypass surgery. Ms. Konopka lost 125 pounds.
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Nancy Konopka and Rose Kemp both hated being fat.

Popping diabetes pills and worrying about dying early from an obesity-related heart attack was one thing. Going to a movie and squeezing into the seats, dreading the tight fit on a plane ride, and dealing with the stares and rude comments were all emotional blows that took their toll.

Diets? You name it, they tried it. Atkins, South Beach, Weight Watchers - none of them worked.

So like an increasing number of other Americans, the two women turned to a surgical solution known as gastric bypass in an attempt to shed weight. The results were startling: Ms. Konopka, 48, of Lambertville lost 125 pounds in nine months, while Ms. Kemp, 39, of Cincinnati lost more than 100 pounds in a year.

That, however, is where their similarities end.

Today Ms. Konopka is fit and energetic. With a radiant smile and a renewed zest for life, she's so thrilled with her surgery results she wants "to shout this from the rooftops I believe in it so strongly."

Ms. Kemp feels like shouting, too. In anger.

"My life has been destroyed," she said. "I would tell people don't get this surgery."

Ms. Kemp said surgical complications forced her to quit her job and she now fights nausea and diarrhea. She "lives" in doctors' offices as she waits for news on whether she can get the surgery reversed.

A godsend or a curse? Whatever the answer, doctors and hospitals nationwide and locally are rushing to meet the demand for obesity surgery, also referred to as bariatric surgery. St. Luke's Hospital in Maumee has offered a form of obesity surgery known as lap-band since 2002. Toledo Hospital started a gastric bypass surgery program in January and already has a waiting list. Medical College of Ohio is looking at restarting an obesity surgery program.

The number of bariatric surgeries nationwide has climbed from 20,000 10 years ago to more than 140,000 last year.The growth captures only a fraction of the market, according to Dr. Neil Hutcher, a surgeon who does gastric bypass procedures in Richmond, Va.

"That 140,000 represents less than 1 percent of those who might be eligible for the surgery," said Dr. Hutcher, president-elect of the American Society for Bariatric Surgery.

There are two main kinds of bariatric surgery performed in the United States: Gastric bypass and lap-band.

●Gastric bypass, sometimes referred as Roux-en-Y gastric bypass, is by far the most common procedure and can be done both surgically and laparoscopically. (The latter is a less invasive medical procedure in which doctors make small incisions to allow instrument access inside the body.) In a gastric procedure, a small pouch about the size of a shot glass is created from the top portion of the stomach, separating it from the rest of the stomach. Because of this smaller size, a patient feels full faster when they eat. Next, the first and second portions of the small intestine are bypassed. The intestine is connected to the pouch and food enters the intestine at a later point, a bypass which prevents much of the food from being absorbed.

●Lap-band is usually done laparoscopically and involves placing an inflatable band around the upper portion of the stomach. This restriction makes one feel fuller. None of the stomach or intestine is bypassed, so all food still goes through the entire digestive process. The procedure has fewer side effects and potential risks than gastric bypass, though some surgeons don't feel it's as effective.

It's easy to see why bariatric surgery is attractive to many Americans. Statistics from the federal Centers for Disease Control from 1991 show only four states with obesity rates of 15 to 19 percent, at the time the worst category. By 2003, however, it appeared as if the entire nation had plunked down on the couch with a bag of potato chips: 15 states had obesity rates of 15 to 19 percent, 31 states [including Ohio and Michigan] had rates of 20 to 24 percent, and four states reported more than one in four of their residents as obese.

The result? Obesity-related illness is one of the top 10 causes of preventable death in the country. With statistics like that, it makes sense for the medical community to embrace obesity surgery, according to Dr. Timothy Duckett, a surgeon at St. Luke's Hospital who performs lap-band bariatric surgery.

"You'll save more lives with bariatric surgery than you will with cardiac surgery," he said. "That's a bold statement, but it's true."

If anyone knows how to eat right, it's Nancy Konopka. A former chef, she's been manager of Toledo Hospital's dietary department for eight years, a job that daily requires her to oversee feeding hundreds of patients nutritious meals. But being so close to food every day was also a temptation.

"I know nutrition. I know what to eat. I just ate too much of the wrong stuff," she said. "I have a low metabolism. I'd have a friend go on a diet with me and she'd lose 10 pounds and I'd lose two. I'd lose the weight and then regain it, and usually with interest."

Then in 2002 she was put on insulin for her diabetes.

"When you have to give yourself a shot every day, that's an eye-opener," she said.

A dietician at the hospital told her that Dr. Patrick White, a Toledo surgeon and medical director of the hospital's bariatric program, was doing gastric bypass procedures. She did some research and discovered that gastric bypass surgery is not without risks. Some studies have found 1 in 200 people die from it. More recent studies suggest that number could be as high as 1 in 50, depending on the experience of the surgeon. In addition, 15 percent of patients develop minor to serious complications.

"But the way I looked at it, I was going to die if I didn't get it," Ms. Konopka said.

She had the surgery in the fall of 2002 at St. Vincent Mercy Medical Center, which no longer has an active bariatric surgery program. She said she is thrilled with the results.

"Almost immediately, my diabetes and sleep apnea disappeared," she said, enabling her to stop her insulin and diabetes medications.

Two years later, she's kept all the weight off and "people still don't recognize me."

Just as importantly as her improved health, she said, "I've got a smile on my face now When I could shop in a regular clothing store, it brought tears to my eyes."

This happiness doesn't come without hard work. Like all gastric bypass patients, she must take vitamin and mineral supplements to make up for the nutrients lost because a lot of food doesn't get absorbed normally. She also must be careful about how much food, and what type, she eats. Patients who don't follow these instructions will vomit, though Ms. Konopka stressed she no longer has problems like that. Finally, keeping the weight off requires exercise, though she said it's easier to exercise after having lost so much weight.

Her surgeon, Dr. White, said he carefully screens patients to avoid those who only want to lose a few pounds. The surgery is only recommended for those who are 100 pounds or more over their ideal body weight.

Dr. White, who has performed 106 gastric bypass procedures, said he enjoys helping patients like Ms. Konopka. "I had one 30-year-old guy who couldn't keep up with his 4-year-old daughter and now can. These patients tell me they get their life back."

Dr. Duckett and his partner, Dr. Thomas Oweis, have performed 220 lap-band procedures and have experienced the same kind of reaction.

"I ask my patients, 'Was it worth it?' and 98 percent say, 'Absolutely, I wish I would have done it 10 years ago,'●" Dr. Oweis said.

Tracy Micks-Harm, a 44-year-old nurse living in Monroe, said she had worked very hard to lose weight, "but I just couldn't get it off." She worried because her family has a history of weight-related problems.

"You never see a fat person at 90. Fat people do not live the life of a thinner, healthy person," she said.

Fearful of the possible side effects of gastric bypass, she had lap-band surgery at St. Luke's in 2003 and is happy with her new look. She dropped from 230 pounds to 147 and has kept it off. She said those critical of obese patients who turn to bariatric surgery should ease up.

"Thin people don't understand the psychological torture it puts on that person and the way society treats them," she said. "I get treated way different now than I did when I was heavy."

Rose Kemp wouldn't hesitate to trade her newfound thin body for the chance to be heavy again. The Cincinnati woman had been overweight for much of her life, so when she heard about gastric bypass surgery, she jumped at the chance.

The first year after her 2003 surgery was a joy. After dropping 100 pounds, she was beginning to enjoy life.

But last year she began to develop problems related to her surgery. Her body is breaking down, she said, because it is simply not getting the nutrients it should. She said she has nausea all the time and is so weak she had to quit her job.

"I did everything right. I took all the correct vitamins, all the right food. I was the model patient and my body still ended up in the sewer," she said.

Her message to those considering a bariatric procedure is simple: "Don't get the surgery."

"Find another way. That's not easy for me to say because I did everything else and I know our options are limited. But the grass is not always greener on the other side. I've lost 155 pounds and continue to lose against my will. I understand that those people 500 or 600 pounds might have to, and at that point maybe you want to go ahead. But those 100 pounds overweight, they need to find another way. Because this can benefit some, and be a curse to others."

Paul Ernsberger, a nutrition professor and obesity researcher at Case Western Reserve University in Cleveland, has heard from hundreds of patients like Ms. Kemp. He said that while short-term results are often good, long-term bariatric surgery patients sometimes develop serious complications because their bodies aren't absorbing nutrients naturally.

He says what's really driving the issue is the lucrative nature of bariatric surgery. Lap-band can easily cost $20,000 or more, while gastric bypass can cost $35,000 or more. Insurance may not cover it. Some local insurers cover it in limited situations, including Paramount and Medical Mutual, the area's largest providers. Other insurers cover the procedure only in extreme circumstances or not at all.

"Surgeons want you to believe it's a medical emergency if you're fat, but it's not," Mr. Ernsberger said.

Blue Cross and Blue Shield of Florida, the largest insurer there, stopped covering bariatric surgery in January because of the company's concern over "safety and efficacy," according to Dr. Barry Schwartz, a vice president at the insurer.

"What's driving this is money. This has been seen by many folks, both hospitals and surgeons, as a cash cow," he said. "I promise you, this is a very serious surgery with very high complication rates."

Dr. Hutcher of the American Society for Bariatric Surgery angrily disputes claims like that.

"There is no justification on a medical, moral, or economic basis to deny someone bariatric surgery," he said.

"If you're diabetic and have bariatric surgery, you have an 87 percent chance of not being a diabetic anymore," Dr. Hutcher said. "Well, the cost per year of life to treat a diabetic is almost $34,000 a year. This [surgery] saves money. So when someone says we can't afford it, it's bull."

Dr. Philip Schauer, director of Cleveland Clinic's bariatric surgery program, said he was recruited there in December to "dramatically" expand the clinic's bariatric surgery program. He said many studies have found the surgery works well and is usually safe. In addition to safety concerns, another key issue is effectiveness. For those like Dr. Schauer, there's no question: "There's nothing that compares to surgery in terms of the magnitude of weight loss."

Earlier this month, the Annals of Internal Medicine, a medical journal put out by the American College of Physicians, released a review of 147 obesity surgery studies. The review is meant as a guide for physicians when talking to their patients. Their conclusion? There are few reliable studies available, but evidence so far shows surgery is more effective than nonsurgical treatment for weight loss in severely obese patients. More data are needed to determine the effectiveness of surgery in less obese people.

The study authors caution that because there are few good studies available, they can't say whether obesity surgery is effective long-term. There's never been published a complete "randomized control trial" evaluating obesity surgery, which is considered the gold standard of medical studies.

As to the safety question, the authors said it appears the old adage is true: The more surgeries a surgeon does, the better the outcome. Surgeons who did 20 or fewer surgeries had mortality rates as high as 5 percent compared to surgeons who did 250 or more with a 0 percent mortality rate.

Dr. Hutcher points to a recent effort by his bariatric surgery society to certify "centers of excellence" for such surgery programs that would ensure only those with high quality standards get the group's seal of approval. Nearly 500 hospitals out of the nation's 5,000 have applied so far.

At the end of the day, the message for people considering bariatric surgery is perhaps best summarized by Dr. Steve Wagner, who specializes in treating digestive disorders. The Toledo doctor has treated obesity surgery patients who had problems with their surgeries. But he also doesn't think surgery should be dismissed as a method of dealing with the deadly epidemic of obesity.

"It's wonderful when it works," he said. "I only stress to patients who come to me that they need to go into it with their eyes open and recognize there's no 100 percent-effective operation with no complications. As long as a patient has a good understanding of the benefits and risks, I don't object to it being done."

Contact Luke Shockman at:

lshockman@theblade.com

or 419-724-6084.



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