Patient Articles -
Slimming Through Surgery
Patients Resort to Gastric Bypass Procedures. When Diets Fail, Obesity Threatens Health
By Lorraine Ash -- Daily Record
Laparoscopic surgeons worked in the darkened operating room at Morristown Memorial Hospital to change Holly Kapral's anatomy.
Doctors Alexander Abkin and Nicholas Bertha inserted their instruments through five half-inch holes in the 18-year-old's stomach, wending their way around her intestines and liver, bypassing layers of fat as they went.
The journey in the chilly OR was recorded in vivid color on a video screen above Kapral.
"Here is the stomach," Abkin explained, peering over his surgical mask. "Now watch what we do."
The top of the stomach had been their destination. They stapled a one-ounce pouch, the size of a shot glass, separating it from the rest of the 70-ounce organ below.
From this day forward, that pouch would be Kapral's functional stomach; the rest would not be used. The pouch would allow her to ingest a total of only 400 to 600 calories over the course of a day, in small portions. The limitation would help Kapral, who carries 348 pounds on her 5-foot-7-inch frame, to lose much of her excess weight.
The operation is the Roux-en-Y gastric bypass, now the gold standard in bariatric surgery, and some 500 have been performed at Memorial's 3-year-old Obesity Center. Since the surgery became available laparoscopically in 1993, hundreds of thousands of obese Americans have been opting for it as a last resort to finally lose their excess weight.
Obesity has become a national health problem in the United States. Sixty-one percent of American adults now weigh too much - 35 percent are overweight, meaning they carry at least 30 excess pounds, and 26 percent are obese, which means they carry at least 100 excess pounds, according to the National Institute of Diabetes and Digestive and Kidney Diseases.
Some 280,000 deaths in the United States are attributed to obesity every year.
The ebullient Kapral, a teen with glowing skin and a ready smile, had talked earlier that July 22 morning in her Jefferson Township home about the long journey that had brought her to the surgery.
"It started around the age of 5," she'd said. "My parents divorced and it was hard for me. I love both my parents so much. I'd see my dad and we'd go to fast food restaurants for dinner. We'd get ice cream. Plus, I have a history of weight problems in my family."
Her mother, Debbie Kapral, 45, had had a gastric bypass 14 months earlier and so far has lost 155 pounds. Inspired by her mother, Holly Kapral decided to go under the laparoscopes. She'd been through every diet plan from Weight/trimmers to Atkins to Slim-Fast, a diagnosis of depression, medications, and more diets.
While Holly Kapral had looked forward to the gastric bypass, she still was nervous about the hour-and-a-half surgery. The last time she'd had a procedure was when she'd had her tonsils and adenoids out a long time ago.
In the holding area of the OR just befrre surgery, she'd said to her mother, "You're so lucky. You could eat in five minutes. Have a cookie for me."
That morning she'd talked about how living next to a deli made it all too easy for her to indulge her cravings.
"At school kids would tease me. It just depressed me even more and made me want to eat more," she'd said. "I would eat if I was bored. I would eat if I was sad. I would eat if I was nervous. I would eat when I was happy."
Her face had brightened when she'd looked at her mother and remembered that the next day, when she was in recovery, her mother would be enrolling her for classes at County College of Morris in Randolph, where she's starting college in the fall.
"I'm starting a whole new life," she'd said. "A new school and everything."
Abkin and Bertha, two of five surgeons at Memorial who perform the laparoscopic gastric bypass, created a hole in Kapral's one-ounce pouch and then rerouted her small intestine, hooking it up to the pouch. Every stitch they made, every move of every instrument, was recorded on the screen.
The leakage rate of the bowel hookup is the most dangerous complication in the procedure - 3 percent to 5 percent nationwide, less than 1 percent at Memorial because of what the surgeons there do next. Abkin and Bertha pumped water into Kapral's body and looked, from the inside of the hookup through an endoscope, for air bubbles, which would give away a leak. They found none with Kapral, but if they had, they'd have sewn more sutures into her new abdominal configuration.
This Roux-en-Y hookup will help Kapral in two ways.
First, she'll be unable to consume many calories because she'll feel full after the little pouch is filled.
Second, her ability to absorb some fat and calories will be reduced because the foods she eats will bypass the digestive juices of the full stomach on their way out of the body. There's a downside to the second part: She won't fully absorb vitamins, either.
For the rest of her life, Kapral will need to drink protein shakes and take vitamin supplements with impeccable diligence, according to Mary Meola, nursing coordinator of the Obesity Center. A gastric bypass graduate, Meola had the operation four years ago, when surgeons still were mostly doing it as they had since 1969 - with open surgery. That approach can lead to more leaks, hernias and infections than laparoscopic surgery.
"My patients don't have to go through what I did," said Meola, who with her staff shepherds patients through the center's extensive program - from initial support and informational meetings through extensive preparatory counseling, preoperative checkups with a host of specialists and postoperative follow-through that doesn't quit.
Patients who have eaten addictively can't be left suddenly bereft, without their longtime crutch, or they may turn to other addictions. They need to know how to eat well and cope well.
Meola is a hand-holder, confidante, advocate, information source and expert. Of the 600 weight loss patients at Memorial's Obesity Center, more than 500 have had gastric bypasses, an operation that made headlines when pop singer Carnie Wilson had one done by Dr. Alan Wittgrove, father of the laparoscopic form of the surgery, which has patients back home two days after surgery.
Four hundred people, from those thinking about surgery to those who've had it, attend the obesity center's monthly information and support meeting at the hospital's Malcolm Forbes Amphitheatre.
Some 60,000 bariatric surgeries - including vertical banded gastroplasty and laparoscopic adjustable gastric banding, for patients who don't want or who anatomically can't tolerate a gastric bypass - are performed annually in the United States, according to the American Society for Bariatric Society.
There are 10 times as many candidates for obesity surgery now as there are for heart bypasses, according to the much-discussed article "The Man Who Couldn't Stop Eating" in the July 9, 2001, issue of The New Yorker.
The surgery is so popular, there are more patients who want it than surgeons to provide it, according to Meola, who says the ratio is 1 to 30,000.
The reason for the demand is clear: Obesity is an epidemic and, in the midst of it, gastric bypass surgery is the one thing that seems to work. Ninety percent of the people who get it lose their weight and keep it off. The other 10 continue eating, despite the "dumping syndrome" that eating too much or too fast brings them - nausea, pain and a bloated feeling. The operation also can be defeated by drinking high-calorie drinks.
The bypass is serious surgery with risks and potential complications. (See accompanying box.) One of 200 patients dies as a consequence of the surgery, as have five at Memorial.
Many opting for a bypass - who must have unsuccessfully tried everything else, at least at Memorial - probably are otherwise looking at a premature death, primarily because of the comorbidities that go with their obesity, which tend to cumulate with age.
"Obesity can kill you," said Dr. John Edoga, another laparoscopic gastric bypass surgeon at Memorial who practices with Dr. Edward McLean and Dr. David Ward. "Obesity can kill you rapidly and kill you miserably because of a lot of the illnesses associated with it - high blood pressure, diabetes, breathing problems, sleep apnea, sudden death syndrome. A lot of people just drop dead. Nobody knows why."
The operation is no quick fix, though, he said. Patients don't wake up the next day looking like Twiggy.
"If we operate on you, there are digestive and absorptive limitations that the surgery places on your body. You will not absorb vitamin B12 the way you used to. The same with iron. If you don't take your vitamin B12, you can hurt yourself. The vitamin B12 deficiency creates a terrible anemia. A vitamin B1 deficiency can lead to paralysis."
But patients who religiously follow the post-operative nutritional rules, he said, absorb sufficient calories to live a long, healthy life. Many, who walk into his office taking 10, 12 or 15 different medications for blood pressure, diabetes, arthritis, knee problems, hip problems and back problems, walk out six months later on no medications except their vitamins.
Holly Kapral had no medical problems, at least not chronic ones. She got the surgery at a young age to stave off the onset of chronic problems. She had trouble walking up stairs and staying on her feet for long periods. A cashier job at a toy store put her in great pain.
She'd squat at the register to relieve pressure on her feet.
"What can I do?" she said. "You have to stand for a lot of jobs, at least the ones kids get nowadays. I'm looking forward to being able to stand for a long time. There's so much I'm looking forward to. Walking up hills and not being tired. Getting up stairs without huffing and puffing. Going to a Mets game and being able to sit in the bleachers, or going to a movie theater and being able to sit in a seat nice."
Although gastric bypass patients at Memorial have ranged in age from 18 to 70, McLean said he's always delighted to see young people come in for the surgery.
"My feeling is that the younger patients, the ones that take charge of themselves at age 22, are some of the best results," he said. "They really want to fix themselves before they get into their 30s."
Obesity is an ubiquitous problem, the subject of increasingly more studies and news stories. The New Jersey Supreme Court in April ruled morbid obesity (defined as obesity that causes other medical problems) is a handicap protected under the state's antidiscrimination laws, according to media reports.
A class-action lawsuit was filed two weeks ago in New York State Superior Court contending that the Big 4 fast food chains - McDonald's, Burger King, Wendy's and KFC - are at least partly responsible for obesity and should pay.
How did Americans get themselves into such a state?
In New Jersey, where more than 50 percent of adults are overweight and diabetes has increased more than 28 percent since 1995, according to state figures, everything from air conditioning to the New Jersey State Plan have been blamed, the latter because many communities have been designed around cars, promoting inactivity.
But the problem is larger than that. Obesity is a consequence of the sedentary television and computer age, the prevalence of poor packaged food choices, and high stress levels leading to emotional eating.
Additionally, how appetite works still is a scientific mystery.
It's known that in some people the hypothalamus in the brain doesn't register satiety as it does in others.
It's known that some people will develop diabetes at 200 pounds and others won't at 300. But why? To what extent genetics is a factor is not known.
"Everybody's out there looking for the magic bullet. That magic pill is 30 years away," Meola said. "You take what we currently have medically available - diet, exercise, behavior modification, the old push yourself away from the table and eat a little bit less. That has about 98 percent failure rate in our patient population.
"They do diet. They do exercise. They do everything in their power. They have tried it all. Hypnosis. I've had people come into the office who have had acupuncture. They still have staples in their ears that have been in there for two years, because that was a weight loss technique and they couldn't find anyone to remove the staples. One of the first things I do is take the staple out of their ear.
"Patients will have their jaws wired shut. Using al l of these methods, our patients fai l over and over and over again."
Obesity is a moneymaker, Meola said, because it is an epidemic and because everyone wants to find that elusive magic bullet.
What's clear, Edoga said, is that no one can any longer afford to blame the victim and do nothing because doing so would drag down the economy. Obesity now consumes 12 percent of the national health care budget, he said.
"Unfortunately, we're headed the wrong direction. People are getting bigger for their frames instead of smaller," he said. "If we keep going the way we are, by 2004 almost one-quarter of Americans will be morbidly obese."
American children are the third fattest in the world, according to Meola, who says only Malta and Germany have a more obese child population.
Kapral had been attending programs since she was a youngster but to no lasting benefit. She'd lose weight to gain it back and then some. One week after her bypass operation the energetic teen went to the obesity center for a checkup and to have her staples removed. When Abkin weighed her, she discovered she already was 13.4 pounds lighter than she'd been a week earlier.
She clapped and giggled.
"I'm so happy," she said. "Plus, before the operation I lost 20 pounds, so in total I lost 33 pounds. I'm sure I lost the 20 because I stopped the soda before surgery. I used to be such a big soda drinker and I knew I needed to stop because after the surgery, if I went for soda, it'd mess up my own stomach and I'd be hurting."
She effused about being able to wear the clothes, in all sizes, that fill her mother's closet. Debbie Kapral bought a new wardrobe whenever she dropped another 30 pounds.
Holly Kapral said the "positive air" at Memorial's obesity center is what keeps her upbeat. At no other place has she felt so buoyed by empathy and encouragement. At no other place, in no other program, has she felt so understood.
Her new life will include exercise - she already was walking more, to avoid post-operative blood clots - and a new way of eating. One week after the operation, on Aug. 1, she was subsisting on the meager diet on which all gastric bypass patients start. In her case, that included a lot of water, a little juice and sugar-free Carnation Instant Breakfast for protein.
"My stomach hasn't really liked my drinking the third shake of the day," she said. "I get nauseous. I had half a bow l of yogurt the other day and I was so stuffed. I couldn't eat anymore at all. It's amazing and it's strange at the same time. I used to be able to eat a whole cup of yogurt, maybe two, and I can't even eat half a cup. It's a radical change and I don't really comprehend it."
Her taste buds already are different, she said. Before the surgery she found a brand of diet iced tea she liked and asked her mom to buy a lot of it so she could drink it after the operation.
"I really liked it. It was really good," Kapral said. "I drank some yesterday and I was like, 'This is the most nasty stuff I ever tasted. What's wrong with me?' I don't know if it's because of the sugar, but it doesn't agree with my stomach."
For the first time in her life, Kapral was not only happy but eager to step on the scale and get weighed by Abkin.
"The scale is my biggest fear. I hated it. Every year at school you had to get your height and weight done and I'd have to talk to the nurse and ask, 'Can you do this in private 'cause I don't want anybody to know what's going on?'" she recalled. "This morning I couldn't wait to go on the scale to find out how many pounds I have lost. It's exciting."
