Obese people say results of bariatric surgery are worth the risks

The earliest weight Julius Tresch remembers is 225 pounds. He was in the sixth grade.

This year, at 44, he was carrying 445 pounds. He has congestive heart failure, type 2 diabetes, a failed hip joint and a fear that obesity will kill him.

Last Tuesday, the Lewistown man had surgery for obesity - called bariatric surgery - at St. Patrick Hospital. It left him with a 2-ounce stomach and a rerouted small intestine. He was terrified, he said Thursday in the hospital. But he was desperate.

"I've been going this direction a long time," he said. "I don't know if it'll work for me. But you've got to get a handle on it. You can't keep doing diets and ending up 50 pounds heavier after each one. You'll end up here anyway."

Kristine Peterson was obese for more than 20 years before deciding on bariatric surgery 16 months ago. Beginning to see that she could reach 500 pounds, the 43-year-old Polson woman couldn't go to movies because the seats weren't wide enough, and she couldn't go to her child's concert at school because she couldn't get up the stairs. Down 214 pounds, she is not slim.

"But every day I live with joy that I can get out of bed," she said. "I have hope for the first time in 20 years."

"I just want to walk down the street and have fat not be the first thing you see about me," she said. "I just want to be average."

Les Wood of Plains comes from a family of obese people. They all die in their 50s, he said, his mother at 56. He's 62 now. He had bariatric surgery last August, 87 pounds ago.

"My knees were giving out, I had sleep apnea, I had to have a cane," he said. "I was afraid I was going to die. … I had four sons. I only have three left. I wanted to make sure they could carry me in the coffin."

"I don't want to fail," he said. "I've invested too much."

Renee Williams' feet hurt while she was working her shifts as a nurse in Day Surgery at St. Patrick Hospital. She went to a podiatrist, and he told her the truth: The bones in the top of her feet were broken by the stress of her weight. She studied bariatric surgery programs around the country before settling on the one at home because of its lengthy follow-up program. When she brought her mother to a meeting of post-surgery patients before she herself had the surgery in December, Renee cried.

"I don't think she realized how unhappy it made me," she said. "Being obese is hard. People are cruel."

In her work as coordinator of the Montana Center for Surgical Treatment of Obesity at St. Patrick's, Connie Hanson hears these stories every day. Obesity, she said, is a miserable disease.

"It is the last bastion of incredible discrimination," she said in an interview last week in her office, where the chairs are extra wide. "There's not a comic who doesn't have a joke about a fat lady. You wear the disease on your sleeve."

Hanson had firsthand experience for decades. Just more than two years and 125 pounds ago, she had bariatric surgery herself in Salt Lake City. A registered nurse for 27 years, she was co-director of Camp Mak-A-Dream for about five years before going to work for the new center in Missoula.

"You wouldn't believe how different I'm treated," she said. "People think I'm smarter. They want to listen to me."

But Hanson, though so much happier at a smaller size, is no Pied Piper of bariatric surgery, she said. It's incredibly hard for the patient. It fosters weight loss in about 85 percent of people who have it. It can have complications of blood clots, pulmonary troubles, excessive vomiting and dehydration, peptic ulcer disease, depression, even death. It costs nearly $17,000 without complications, and health insurance covers it only about 50 percent to 60 percent of the time. It requires a lifetime of follow-up and a complete change in the patients' relationships with food: Forever, they can eat no more than about 1 cup of food three times a day, and they live on 600 to 900 calories a day.

"Sometimes I forget to say, because it's so good, that it's a change," Hanson told a group of surgery hopefuls last Thursday evening.

Since St. Patrick's program began last August, surgeon Brad Pickhardt has operated on 35 patients. Pickhardt, who works as the program's medical director, comes from 10 years of general surgery in Missoula, with specialties in breast cancer surgery and trauma. He did some bariatric surgery during his residency in Denver in the late 1980s and came to believe in it because he is moved by the suffering of the patients. He went for extensive training and became a member of the American Society for Bariatric Surgery.

"I like it because it's important," he said. "It's the last vestige of discrimination in this country. You can turn people's lives around. It's neat, and it's scary at the same time."

The bariatric surgery candidate is more than 100 pounds overweight, has a body mass index of more than 40 and has a history of trying to control weight by medical means. The patient has related life-threatening conditions such as heart problems, type 2 (adult-onset) diabetes, sleep apnea and hypertension.

"We're talking about morbidly obese people," Pickhardt said.

For these people, said the National Institutes of Health in 1991, surgery is the only answer.

"For morbid obesity, nothing else works," Pickhardt said. "Unfortunately, not all patients and not all doctors know this. They think, 'Can't you just get on the treadmill?' "

Though science has yet to identify why, people with the disease of obesity are different, said Pickhardt and Hanson. Their metabolisms are remarkably efficient, they said, getting the most out of everything they eat with plenty left over to store. Calorie-cutting just makes them more efficient. During surgery, Pickhardt said, it's apparent that their tissues are even constructed differently. The cause could be genetically linked. It could be hormonal.

"We don't know. It's multi-factorial," Pickhardt said. "They're just different. They're wired different. And even the smartest people in the world can't figure that out."

The most common thread among them is an inability to achieve satiety, the feeling that a meal has been enough.

"Most of our patients, they say, 'I never feel full,' " Pickhardt said. "That's the most common thing. It's not willpower. It's the way they're wired."

Achieving that feeling of satiety is also important to success post-surgery, and the patient has to learn to manage food with a reduced stomach size.

Surgery for obesity was first tried in the 1950s. In the 1960s and early '70s, the surgeries bypassed most of the small intestine.

"People lost a lot of weight, but they had some awful side effects - kidney failure, liver failure," Pickhardt said. "People died. And it gave the field a bad name."

Today's obesity surgeries fall into two basic procedures. Restrictive surgery reduces the size of the stomach using bands or surgical staples and reduces the outlet from the stomach; the aim is to achieve fullness early and to delay emptying of the stomach.

The other type of surgery is restrictive/malabsorptive surgery. The type Pickhardt does at St. Patrick's is the most common of this type, called the Roux-en-Y; it accounts for about 85 percent of the bariatric surgeries done in the United States. In the technically demanding surgery, which takes about two hours, Pickhardt partitions the stomach. He sizes the part that is to remain connected by inserting a balloon inflated to 25 cubic centimeters. The functional stomach becomes a small "gastric pouch" that holds 2 ounces at first and eventually expands to hold one-half to one cup. Then, downstream, he removes about 125 to 150 centimeters of the small intestine and reattaches the end.

The combination of the two seems to lead to the most success, said Pickhardt and Hanson. The missing intestine - the average person has at least 18 feet to start - reduces nutrient absorption a bit and also seems to play a role, not yet understood, in satiety. The "stomach stapling"-only treatments of the 1980s caused patients to lose weight, but most regained it in two years, Pickhardt said.

Other effects that have yet to be understood is an almost universal reversal of hypertension and of type 2 diabetes. Almost all patients lose their need for insulin in about a month.

The ultimate success of patients depends on their abilities to manage food in new ways, and that's where Hanson and the follow-up program come in. Before and after, she and St. Patrick nurse Williams, who works part time for the program in addition to her work in Day Surgery, help people eat in new ways. They teach three small meals a day, each about half protein. No carbonated drinks, ever again. Certain foods, especially fatty or sugar-laden foods, can cause a post-surgery phenomenon of "dumping," in which the food hits too quickly and causes nausea, sweating and shaking. Milkshakes can produce severe reactions.

"These people, I see them the rest of their life, make sure they're not getting anemic, getting any vitamin deficiencies," Pickhardt said. "They get follow-up the rest of their life."

St. Patrick's bariatric surgery program established a new "center of excellence" for the hospital. Because the surgery is elective, it is always paid for before it's done and so can help offset the hospital's money-losing areas. Hanson helps patients make cases to their health insurance companies, but about half pay cash, taking out second mortgages or saving for the surgery.

In Montana, St. Patrick's is the only full bariatric surgery program. The surgery is available in Great Falls, and a Ronan surgeon may start offering it.

According to the Centers for Disease Control and Prevention, the incidence of obesity in the United States rose by more than 50 percent in the past seven years. About 33 percent of Americans are overweight. More than 300,000 deaths can be attributed to obesity each year, at a cost of more than $100 billion. The U.S. weight-loss industry is valued at more than $30 billion a year.

In Montana, according to February figures released with a warning from the state medical officer, just more than 50 percent of people are overweight, and 16 percent qualify as obese.

Many overweight people can find help in healthy eating and exercise. But the numbers show a niche for bariatric surgery.

"It isn't something trendy," Hanson said. "It's not to take off 40 pounds for your reunion. It's to treat people who are dying of a disease."

Reporter Ginny Merriam can be reached at 523-5251 or at gmerriam@missoulian.com.

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