COMPLICATIONS AFTER GASTRIC BYPASS SURGERY

Gastric bypass surgery (also known as RNY surgery) is a life-saving and enhancing operation for many severely overweight individuals who have failed to lose weight through other, less drastic means. For the vast majority of patients, gastric bypass surgery enables overweight patients to regain control over their lives and the many medical conditions associated with obesity such as diabetes, hypertension, sleep apnea and acid reflux.

There are, however, a substantial number of people, who through no fault of either the patient or the surgeon have significant complications and side effects of the RNY. These could include malnutrition because of the loss of absorption of protein, iron and vitamins induced by the operation as part of the mechanism by which the patients lose their excess weight. Malnutrition can occur even in patients who religiously take vitamins, iron and calcium tablets every day after RNY surgery. Malabsorption can also lead to overgrowth of bacteria within the gut, as manifested by symptoms such as chronic abdominal pain, fatty stools, diarrhea and embarrassing amounts of gas.

Patients can sometimes complain of excessive swings in blood sugar (glucose) levels after the RNY. This may be part of dumping syndrome, a normal reaction to the rearrangement of the anatomy of the stomach and small intestine after surgery. Dumping syndrome typically occurs if a RNY patient eats an excessive amount of sugary food or drinks an excess of liquids along with meals. Refractory hypoglycemia is a more profound drop in blood glucose level due to over production of insulin by the pancreas gland (the organ which regulates blood glucose levels in response to meals etc) after RNY. This condition can occur even with good dietary habits after RNY: it can occur quite unexpectedly and can lead to such drastic drops in blood glucose levels that patients can pass out until their glucose levels are restored to normal.

The connection between the small stomach pouch and the small intestine after RNY surgery has to be narrow, in order to ensure that patients feel full after only a small meal. Widening of the connection can lead to an ability to eat more and possible weight regain. Narrowing of the connection (either due to an ulcer or stricture/scarring) can lead to upper abdominal pain after eating, nausea and vomiting. These symptoms typically occur no earlier than 2-3 months after surgery and are seen more with the ingestion of solids than liquids. 90% of ulcers and strictures can be treated with medication or endoscopy (using a camera to identify the narrowing and dilate it with a balloon). Some patients with severe ulcers or strictures ultimately require surgery after medications and balloon dilatation fail to correct the problem.

I have been in surgical practice in New Jersey and New York for 8 years specializing in the surgical treatment of severe obesity. My particular interest is the correction of complications of gastric bypass surgery. I have operated on patients with such problems from Minnesota, Nebraska, Tennessee, Rhode Island, Connecticut, New Jersey and New York with great success.

Please look at my biography (see the "About Us" section of this website) and e-mail me any questions you may have about your particular case. My e-mail address is egoodman@chpnet.org.

My office telephone number is 212 844 1575. My fax number is 212 844 1581.

My main website is www.shedweight.com

Hope I can help you.

Yours,

Elliot R Goodman MD

IMPORTANT INFORMATION ABOUT A POTENTIALLY DEVASTATING LATE COMPLICATION AFTER GASTRIC BYPASS SURGERY:

March, 2006

To All   Post-Gastric Bypass Patients:

This message is for all of patients who have undergone gastric bypass (weight reduction) surgery.  It is to inform you that a small percentage of patients who have undergone this type of surgery will develop severe abdominal pain due to internal hernias.  This condition is called a Petersen’s hernia and must be treated surgically on an emergency basis. 

When patients lose a significant amount of weight, the fatty tissues in the abdomen decrease in size.  In some patients, the position of the intestine can shift within the abdomen and become twisted and obstructed. 

If you should develop abdominal pain you must seek medical attention immediately.  Petersen’s hernia can be successfully treated and full recovery is to be expected.  Time is of the essence however.  If there is a delay in diagnosis and treatment beyond a few hours, there is the potential for loss of a significant portion of the small intestine and even death. 

It is important that you be aware of this condition. If you develop abdominal pain, you must immediately seek medical attention and inform your physician that you have undergone gastric bypass surgery.  You should also tell them that you have been informed about the potential for a Petersen’s hernia and wish to be examined by a surgeon on an emergency basis. 

While the incidence of this condition is relatively low (less than 5% of patients who have undergone gastric bypass surgery), it is a serious development that must be treated very quickly.

Sincerely,

Elliot R Goodman MD

Beth Israel Center for Obesity Surgery

Caution on Pregnancy on Heels of Obesity Surgery

Doctors find it can have deadly complications for mom, baby

WEDNESDAY, Aug. 11 2004 (HealthDayNews) -- Pregnancy after obesity surgery is by-and-large safe, but doctors warn that occasionally there could be deadly complications. A letter in the Aug. 12 issue of the New England Journal of Medicine details the case of a pregnant woman who died 18 months after she had undergone gastric bypass surgery. The woman, and her baby, died as a result of an internal hernia that occurred as a complication of the gastric surgery. The hernia, which wasn't diagnosed in time, caused a large section of the woman's bowel to become infected and die. "This complication is something that can happen after [gastric bypass surgery]," said one of the letter's authors, Dr. Edward Whang, an attending surgeon at Brigham and Women's Hospital in Boston. "It's probably more difficult to diagnose in a patient who is pregnant because some of the symptoms, such as nausea and vomiting, are symptoms that also happen in pregnancy." The 41-year old woman was 31 weeks pregnant at the time she started feeling ill. She was admitted to a community hospital complaining of abdominal pain, nausea and vomiting. The problem, Whang said, is that along with symptoms similar to those of pregnancy, all of the standard tests can come back normal even as the problem is occurring. "There is no perfect way to diagnose this condition without an operation. Of all of the tests that are available, CT is the best one, but the results could be normal and you could still have this condition," he added. She was transferred to Brigham and Women's after spending 48 hours at the community hospital. "When she came to our hospital, she was already nearly dead," Whang said. Surgeons at Brigham and Women's removed a large section of the woman's diseased bowel, and they also performed a Caesarean section to deliver the baby, who was already dead. Three hours after the surgery, the woman, who weighed 440 pounds, died of cardiac complications. Whang noted that the gastric bypass surgery, prenatal care and initial evaluation of the woman's symptoms did not occur at his hospital. Dr. Daniel Herron, chief of bariatric surgery at Mt. Sinai Medical Center in New York City, agreed that surgery is the only way to definitively diagnose such a complication. But, he added, "If a patient who has had weight loss surgery has abdominal pain, they should be quickly identified and evaluated by a bariatric surgeon." That's because bariatric surgeons are familiar with such a complication and can probably diagnose it faster. And, he added, time is of the essence in diagnosing this problem. Herron also noted that this complication should become less common because of new methods of bariatric surgery. There are two or three spaces in the abdomen where hernias can occur after many types of abdominal surgery, he said. After gastric bypass surgery, fat starts to disappear, allowing the intestines to become more mobile. If the hernia spaces exist, hernias are more likely to occur. That's why bariatric surgeons now suture those spaces closed, which should substantially decrease the likelihood of an internal hernia, he said. Herron said that, based on other studies, he doesn't believe that pregnancy after gastric bypass is generally associated with bad outcomes. He does, however, advise all of his female patients to wait at least one to two years before becoming pregnant to give their body time to heal and adjust to its new nutritional needs after surgery. Pregnancy during this time, he said, generally isn't good for a fetus because the mother's body is in a near-starvation mode, and can't supply proper nutrition to a developing baby. In this case, the woman became pregnant about 10 months after her surgery. The authors of the letter wrote that their concern is that more and more women are having this procedure. In 2003, 103,000 gastric bypass operations were performed in the United States, according to the letter; 84 percent of those patients are women and most are of childbearing age. As these women lose weight, they may increase their sexual activity. And, weight loss often triggers a rise in fertility, the letter authors said. The dramatic rise in the number of gastric bypass surgery hasn't caught the attention of only the letter's authors. On Aug. 4, the Massachusetts Department of Public Health issued new guidelines for weight loss surgery programs. Along with detailed guidelines for health practitioners, the expert panel recommended that anyone who is having gastric bypass surgery should select a hospital that does more than 100 such surgeries a year, as well as a physician who does 50 to 100 cases annually, because they'll be less likely to have complications from the surgery. More information Visit the Massachusetts Office of Health and Human Services to learn more about weight loss surgery. SOURCES: Edward Whang, M.D., attending surgeon, Brigham and Women's Hospital, and assistant professor of surgery, Harvard Medical School, Boston; Daniel Herron, M.D., chief of bariatric surgery, Mount Sinai Medical Center, New York City; Aug. 12, 2004, New England Journal of Medicine Article from link: http://www.medicineonline.com/conditions/article.html?articleID=3014&catID=40

Recent article from New York Magazine (May 16, 2005) on the psychologic effects of massive weight loss after bariatric surgery:

My Life as a Thin Person

People like Lisa Marie Sohr, who lose 100 pounds or more with stomach surgery, find that with their new bodies often come new friends, new spouses, new lives. But happiness is not a foregone conclusion.

By Jennifer Senior

Photo Caption: Lisa Marie Sohr After (Photo Credit: Danielle Levitt)

To see her now—hips framed by low-slung pants, navel shot through with a $500 belly ring—it strains the imagination to envision Lisa Marie Sohr, a resplendent Long Island hottie, as an obese woman. She moves with the insouciance of someone who has always been 120 pounds, except when she stands up, when she looks a bit as if she’s been fired from a slingshot. (“It’s like, whoa—I’m used to going for the big lunge.”) Yet Sohr can recall the day her weight became not just an unsupportable physical millstone but a metaphysical one: It was her 33rd birthday. The New York City Police Department had just forced her into early retirement. And, at five foot four and 236 pounds, she had recently taken to climbing the stairs of her Baldwin home on her hands and knees.

In July 2002, Sohr threw herself a combination housewarming-birthday- retirement party. A week later, she went to Long Island Bariatric Center. And on August 7, in a five-and-a-half-hour laparoscopic procedure, a surgeon removed her gallbladder and cinched a gastric band around her stomach, making it very difficult for her to eat large portions of food at a time. Within a year, Sohr lost almost half her body weight, the equivalent of an entire person.

Sohr says she didn’t have outsize expectations of her surgery. But she says she did expect her husband, an auto mechanic in Glen Cove, to show a renewed sexual interest in her and was disappointed when he didn’t. She also noticed that a lot of the female company she’d kept, many of them women who’d struggled with their weight their entire lives, suddenly made themselves scarce. So she found herself a newer, younger, mostly male crowd. She started going out. She started acting out. She went to the local bar and played darts until seven in the morning. If she came home earlier, she’d sit in the car and wait until she saw her husband leaving for the garage, just to cross his path. It didn’t have the desired consequence. In September 2003, he asked her for a divorce.

“My ex was your typical awkward-rocker guy,” she says today, sitting on the sofa of her Tudor home, a cigarette dangling from her hand. “Long hair, ripped blue jeans, T-shirts with dragons on them, glasses. Very geeky, played Dungeons & Dragons on his computer. But when I was heavy, I thought he was all I was ever going to get, and my mother convinced me I wasn’t getting any younger—that if we didn’t marry, I’d be fat and alone and miserable. But there was no spark. All the way up the aisle, I was saying to myself, ‘Oh, my God, what am I doing? Oh, my God, what am I doing? I can’t even run, because my dress will get stuck on a nail.’ ”

Back then, Sohr needed a five-pound steel-boned corset to cinch her 39-inch waist into her custom-made gown. That wasn’t the case this past month, when she remarried, rising up through the floor of the Chateau Briand wedding hall in an Ian Stuart size 6 (“which is like a size 4 in human terms”). Her new husband, a 32-year-old Israeli hunk named Bari, was her own version of Florence Nightingale: He sold her her first bikini in ten years.

Lisa Marie Sohr Before

“My ex,” she continues, “is a self-conscious girl’s guy.” She points to Bari, whose long curls are gelled back into a perfect seashell. “This is a wild woman’s guy. Before, I was, like, on pause. And when you’re on pause, you’re willing to tolerate a lot. But when you’re not, you grow out of people.”

Sohr’s ex-husband, Paul Ruppert, doesn’t necessarily take issue with this interpretation, but frames it differently. He sees a woman who, after reacquiring the body of her late adolescence, started to relive it. “She lost a whole person,” he says, “and became someone different.”

It’s hard to think of anyone in American life who gets the freak sociological privilege of abrupt, overwhelming wish fulfillment. There are the impoverished kids who sign NBA contracts, perhaps, or cafeteria workers who win the lottery; on television, there are the lucky contestants who are selected for extreme-makeover shows.

Yet for the morbidly obese, the possibility of rapid and radical change, of a near-existential reorganization of life, is becoming increasingly common: Last year, the number of patients who underwent weight-loss procedures was an estimated 140,600, according to the American Society for Bariatric Surgery, more than double that of 2002.

Most people who undergo this procedure are not doing it to look pretty. They’re doing it to not die young, to save their knees, to be able to walk to and from the grocery store without gasping for breath. Yet the procedure often has striking aesthetic consequences, making conventional beauties of people whose self-images were previously organized, at least in part, around the very principle of invisibility or unsightliness. For them, losing weight turns out to be the least of their transformations. They don’t just have new bodies; they have new narratives, new public identities. “Many patients greatly underestimate just how significant the psychological transformation is,” says Warren Huberman, a clinical psychologist who evaluates prospective bariatric patients at NYU Medical Center. “I ask what they anticipate—and what changes they think will be unpleasant. They look at me like I’ve got three heads. They can’t imagine anything will go badly if they’re thin.”

In the annals of obesity literature, this is not a topic that’s received a ton of attention. But attend any bariatric support-group meeting, and this much is clear: One has to learn to be skinny. Even the smallest adaptive behaviors take years to shake—buying clothes too big, deeming a subway seat too small, refusing to be first through a crowded bar. “I had a man come to me a month ago,” says Christine Ren, a bariatric surgeon at NYU. “He’d started out at 525 pounds. Now he’s 250. And he says, ‘Doc, I don’t know what to tell people. Am I man who lost 275 pounds? Or who needs to lose another 60?’ ”

Gloria Cahill lost 140 pounds. (Photo credit: Danielle Levitt)

In some ways, answering this question is just the beginning. Dramatic weight loss has a way of exposing not just the architecture of people’s bodies but of their lives—the subtle economies of power in their relationships, the suitability of their work, the limits of their own strength—and that architecture may not look nearly as lovely. A woman may discover that her marriage of twenty years was predicated on a dynamic of disrespect and condescension, or that her best friend since childhood required a sidekick who didn’t threaten her somehow. Then again, she may also discover that the man she’s been married to is made of even kinder, sturdier stuff than she ever imagined, and that her friends have a capacity for generosity more profound than she’s ever known. It simply depends. Results, as they say in diet commercials, may vary.

“There was a night—this was maybe a year and a half ago—when a really gorgeous twentysomething Frenchman spent the bulk of a party sitting on the coffee table in front of me, just listening. That was fun.”

This is Gloria Cahill, 46, director of NYU’s Office of Community Service. She had gastric-bypass surgery four years ago.

“We were in a room full of people, and a lot of them were the kind of girl-woman who used to be the bane of my high-school existence—beautiful, self-confident, not above the occasional fat joke,” she continues. “They were all looking on, wanting to know who he was and, probably more to the point, who the hell I was. That was satisfying. At the end of the evening, all I could think was, ‘This is a new approach to parties.’ I went from being a wallflower to . . . I don’t know. A bouquet.”

Warm, sensitive, and brimming with opinions, Cahill has a lively knack for describing the effects of her operation. She’s actually 200 pages into writing a book about it, part of a collaborative effort with her surgeon, Mitchell Roslin, who helped operate on Al Roker at Lenox Hill. In one chapter, she likens her new body to a cereal box whose contents have settled.

“She lost a whole person, and became someone different.”

“Oh, and then—” she remembers. “This was maybe two years ago. At a local benefit. I was wearing high heels and a slinky black dress with a slit up the side. And a very attractive man parked himself at my table, smiled a bit mischievously, and declared, ‘I’m very partial to redheads.’ ”

In the history of pickup lines, that one probably wasn’t the most deft, I admit. But it wasn’t the worst—

“Yes, but it wasn’t my hair he was looking at,” she says, then bursts out laughing. “He said it two or three times, as if it were meant to be charming. I had never experienced that kind of misguided flattery. It was the construction worker’s wolf whistle in stockbroker’s clothing.”

Until her surgery, Cahill had spent almost her entire life as a fat girl—shopping at the “Chubby Shop” section of Lane Bryant, attending her first Lean-Line meetings in eighth grade. She finally decided to have her operation after her mother, also morbidly obese, died in 2000. At the time, Cahill was 275 pounds, and her sister, roughly the same weight and ten years her senior, was already struggling with horribly debilitating medical problems. Cahill was terrified she was staring into a crystal ball.

Today, Cahill is 135 pounds. She blazes up stairwells; hikes up mountains; twists herself into yoga poses, luxuriating in the sensuality of her corkscrew limbs. Adjusting to her new contours took time—a few months after the surgery, Cahill said “excuse me” to her own reflection before running into a mirror—but she also had a premonition: “Before I lost the weight, I had this sneaking suspicion I bore a resemblance to Annette Bening,” she says. “I never, ever, would have said it out loud—I’d have been laughed out of the room—but since I lost the weight, so many people have said it.”

Under the circumstances, you’d think Cahill would be catnip to men. But her social life is more complicated than that. Like many people who’ve been heavy, Cahill missed some of the crucial rites that demystify the dating process. (Doctors often talk about this phenomenon: “They’ve never gone through that teenage thing of holding hands,” says Alfons Pomp, a surgeon at New York-Presbyterian Hospital/Weill Cornell, “so they meet someone in a bar and wind up in Europe for the weekend.”)

Photo Caption: Gloria Cahill (Photo Credit: Danielle Levitt)

“Men notice me more now,” admits Cahill. “But the thing is, when you’re obese and relationships don’t go well, you could blame it on, Well, nobody loves a fat girl. If you’re thin and can’t find a boyfriend, what do you blame it on? A friend of mine set me up on a date with a terrific man recently. We got along wonderfully . . . and yet I never heard back from him.” She gives a bewildered shrug. “Before, I was never any good at recognizing men who were interested. But now, when I think I recognize men who are interested in me, I’m completely flummoxed, because they don’t do anything.”

Today, Cahill often views the positive attention of strangers with wariness rather than unalloyed delight. “There’s a part of me,” she says, “that thinks, One hundred pounds ago, if I’d sat next to you on this bus, you wouldn’t have been this nice.”

You can hear it in her voice—how strange, and not a little bittersweet, it is to discover that the basic decency of strangers is a conditional thing. She takes a sip of coffee. We’re in a café in the Village, where more than a few male patrons have admired her, dressed as she is in a green V-neck sweater and plaid skirt that shows off her legs. Cahill seems not to notice. “This is profoundly difficult for me to talk about,” she confesses. “I was amazed . . . I’m still amazed.” She stops, puts down her cup. “It just amazes me to see how much power comes with prettiness.”

Ask Cahill what she misses most about being fat, and she’ll launch into a thoughtful riff about knowing who her friends were, about depths meaning more than surfaces. Ask Sohr, 35, and her answer’s much more straightforward: “My boobs.”

The bright, sunny day Sohr picks me up at the Baldwin train station, her cat-green eyes are concealed by giant sunglasses and her new frame is swaddled in a coat of brown mink. She’s tough. Frank. Sublime, in her way. Her observations are unvarnished, and her accent is pure Fran Drescher, a merry substitution of aws for every or (gawgeous, New Yawk).

Sohr has always lived in her body, which may, in part, explain her uncomplicated feelings of elation now. As a child, she was a tomboy, climbing trees and chopping wood; in the late eighties, when she was still thin, she was a promotional model for Bloomingdale’s, sporting more tube tops and acid-washed casualwear than a girl could dare to dream. At her heaviest, she still had boyfriends (“I probably dated, like, 200 guys”), participating in medieval fairs so that she could still wear elaborate, corseted costumes that made her feel sexy.

Even her first significant weight gain, she says, started as a conscious decision, inspired by the shame of letting a perp slip away during her first year on the NYPD—when she threw herself on top of him, he tossed her off like a horse shaking loose a fly. “I thought I was gonna be this tank and take him down,” she says. “But I wasn’t heavy enough. I got teased mercilessly by all the cops because I got my ass handed to me on account of being so small . . . ” She trails off. “Now, I have a big ego, and I’m a second-generation cop. There was no way anybody was going to get away from me again. And nobody did. I used to run up behind ’em, put my wrist up against their Adam’s apple, lift my feet up off the ground . . . ” She beams, remembering. “Try holding 190 pounds up in the air on your throat and see how fast you go—right down to the floor! I choked off their oxygen supply!”

Of course, Sohr didn’t intend to reach 190 when she set out to gain weight. The tendency toward obesity ran in the family—her father died at 51, morbidly obese, and her mother, 57, is awaiting approval for the same surgery her daughter had. Ultimately, the pounds turned out to be a problem for Sohr. Her knees, weak before she joined the force, got even weaker, and tussling with criminals made them weaker still. “I was always getting hurt,” she says. “I had to be the moron who was first through the door.”

Then, on patrol at a traffic accident, Sohr was hit by a woman in a Jaguar. The event left little mobility in Sohr’s right hand and wrist, forcing her into early retirement. Then she had knee surgery. Then she got into a car accident. With each successive injury, Sohr spent more and more time on the couch, staying up all night watching the SciFi Channel and drinking two-liter bottles of soda. Her weight soared to 236.

But even before reaching her peak, Sohr says it was distressing going through so many weight fluctuations as a female cop. “When you first join the Police Department and you’re skinny, you’re like the lamb chop,” she says. “When you start getting heavier, they’ll flirt occasionally, but they kind of stop. But when you’re really heavy, you start to hear whispers behind your back.”

“And there was this girl,” she adds, “who came into the precinct when I was heavy. Gave me this attitude like she was Miss Thing. Before I retired, I said to her, ‘Sweetheart, everybody has their day in the sun. Everybody gets older; everybody’s figure changes. So don’t be mean to the people who are here for a while, because when you turn into this, you’re not going to have any friends.’ ” Recently, Sohr went to a function thrown by her old Brooklyn precinct and ran into this woman. “I see this girl in the bathroom, and she’s like this.” Sohr expands her arms. “At least six sizes bigger than me now. I just looked at her and said, Nice dress.”

She pumps her fist.

In the final chapter of Fat Boys: A Slim Book, the historian Sander Gilman gives a startling time line of the various attempts to do away with fat via the knife: Pliny the Elder described a “heroic cure for obesity” that involved surgical intervention in the first century; in the twelfth century, a surgeon sliced open Count Dedo II of Groig to reduce his gut. In the twentieth century, the first attempts at stomach stapling were first done on animals, then on people (in the late sixties). Surgeons today rely primarily on three methods: gastric bypass, in which a small pouch is created out of the top of the stomach and reconnected to the small intestine; the duodenal switch, in which two-thirds of the stomach is removed and two-thirds of the intestine is bypassed; and gastric banding, in which an adjustable silicone ring is looped around the stomach, then attached to a port sewn directly into the abdominal muscles. To tighten it, the doctor injects saline directly into the port, constricting the ring like a blood-pressure cuff.

Alison Show lost 130 pounds. (Photo credit: Danielle Levitt)

If competently done, all three of these methods boast reasonably good long-term success rates. A comprehensive survey in the October 13, 2004, issue of The Journal of the American Medical Association reports dramatic reductions not just in weight but diabetes, hypertension, cholesterol, and obstructive sleep apnea; attend any support-group meeting, and you’ll also hear story after story about the restoration of simple dignity: being able to fly without seat-belt extensions, shop in any old store, tie one’s shoes, cross one’s legs, pick oneself up after falling down. One woman, a patient of Ren’s, described the first time she was able to wrap and tuck a hotel towel around her body. It’s hard, here, to replicate the mixture of incredulity and gratitude in her voice.

But all bariatric surgeries also require a lifetime of vitamin and mineral supplements, which some patients ignore. Sensualists should be warned: Some people can never eat meat again; others can’t tolerate pasta or bread. And some replace one form of addiction with another. Cynthia Buffington, the director of research at U.S. Bariatric in Fort Lauderdale, says that about 30 percent of its patients convert a penchant for overeating into alcohol dependence.

Perhaps most critical, bariatric surgeries are high-risk. Most responsible surgeons won’t even countenance the idea unless a patient is 100 pounds too heavy or more. One in 200 patients dies within 30 days of gastric-bypass surgery, by far the most common procedure; one in 100 dies from the duodenal switch, the most radical. Gastric banding, the least mutilating procedure, is by far the safest, with a mortality rate of just 0.1 percent. Unfortunately, it also seems to be the least effective. Gastric-banding patients can tolerate liquid foods far more easily than others, making ice cream a tempting alternative when little else goes down.

A 1991 study in The American Journal of Surgery also contains some interesting data about the mental-health effects of bariatric surgery. In the first six months, patients reported they were ecstatic. But after two years, most were back to where they started, at least in the aggregate. The crude explanation for this, says Walter Pories, one of the study’s authors and a surgeon at the Brody School of Medicine at East Carolina University, is that real life once again begins to reassert itself, and the trials of real life aren’t always things that skinniness can cure: bad jobs, neglectful spouses, rebellious children, faces and bodies that turn out only ho-hum. The more interesting mental-health discovery he and his colleagues made, Pories says, were the effects the surgery had on people’s marriages. “If the woman married when she was thin, had kids, became obese, and then had the surgery, the marriage almost always got a lot better,” he explains. (An estimated 75 percent of all bariatric patients are female.) “But if the woman married someone while she was obese and then became pretty . . . well, then she found a job. Got her colors done. Felt better about herself. And almost every one of those marriages ended in divorce.”

“Here I am in Anything Goes,” says Alison Show, flipping through a pile of photographs from recent summer-stock productions. “And this is me in Oklahoma . . . ”

The day I first speak to Alison Show, Deborah Voigt, the international opera star, is smiling on the front page of the New York Times, admitting she had gastric-bypass surgery. It’s a funny coincidence. Though a musical-theater freak in college, Show chose to major in opera, precisely because it was the one medium in which her five-foot-two, 260-pound frame wouldn’t be held against her. Then, at 23, she was cast as the lead in Massenet’s Cendrillon. Her costume arrived and didn’t fit. The director was furious. She called her mother that night, telling her she’d decided to have bypass surgery. Today, at 26, she’s half her old weight and living in New York, attempting to become an actress.

“When you’re obese and relationships don’t go well, you could blame it on, ‘Well, nobody loves a fat girl.’ If you’re thin and can’t find a boyfriend or get married, what do you blame it on?”

“And here I am as Sarah Good in The Crucible,” she continues. “These are all of the opportunities I never would have had as a heavy person.”

Yet in speaking to Show, one wonders if opera was still the more forgiving medium. “When I go to auditions for musicals,” she says, “I look at myself compared to these girls. They all have huge boobs, they’re all a size 4, they all put on their leotards and bounce around. And I’m thinking, I’ve waited three hours for this cattle call, and there are 300 people in this room who are younger than me, look better, and can sing and act as well as I can.”

Nor does Show, a boop-a-doop cutie with a strong jaw and perfect forties hairdo, yet have any conception of how to play ingenues and temptresses, the main staples of the Broadway stage for 26-year-olds. She harks back to college, when she was cast as the lead in The Magic Flute. “There was no way to conjure any kind of sexual emotion within me,” she says. “I’m just starting to realize the power of sex and that kind of persona—from getting free drinks to just getting someone to let you walk into the subway ahead of them.”

Show says she enjoys the attention. But she also happens to be married—to a 130-pound pianist and composer she’s known since grade school. “It’s been hard,” she says. “My husband and I are still making adjustments. I used to be funnier in social situations. I used to be more academically focused. Now, working out is very important to me, whereas my husband does very little exercise. My image is a priority. Going out and experiencing life in the evening is a priority.” She stops herself. “I am a completely different person from the person he fell in love with.”

So what’s the glue?

“Our parents knew each other,” she says. “We had the same circle of friends. Our upbringing was very similar; we both try to keep Christ at the center of our lives.

Alison Show (Photo credit: Danielle Levitt)

“I do get a lot of Catholic guilt,” she says, after a moment. “It feels sinful that I’m aware of sexuality. I feel guilty for rediscovering myself. It’s almost . . . vanity.” She pulls out a picture of herself at a 5K race. “Like, I’ll be running. I love running—I think I chose it because it’s the antithesis of being fat, because fat people cannot run—and in the back of my mind, I’ll hear God telling me: You’re worshipping your body. I’ll feel guilty because it’s just a vessel, it’s not my soul. And instead of nourishing my soul, I’m taking such a vested interest in what I look like.”

She flips to an old photo of herself. “God. I feel like my nose was heavier in this picture. I feel like my forehead’s fat.”

Recently, Show also went for reconstructive surgery to tighten the skin around her new, smaller frame. This is a frequent, nearly inevitable by-product of bariatric surgery: the sudden presence of excess skin, shapeless as an oven mitt, surrounding the stomach, arms, and legs. It’s a source of huge embarrassment, a chronic reminder to the patient of the body that was. Usually, its removal is not covered by insurance. And in Show’s case, the operation wasn’t even successful. The procedure often involves the re-creation of a belly button. But Show’s old belly button reopened. Now she has a crater in her tummy about one inch deep.

A few months ago, the various pressures of Show’s new life began to catch up with her, and she began to see a therapist, Jude Milner, who’s had bariatric surgery, too. “The problems actually started maybe a year after my surgery, when I was cast in a show where I was an adagio dancer,” Show explains. “The guy had to lift the girls up. At that time, I was 157 pounds, and all I could think was, This guy is going to break his back.” She’s quiet for a second. “That’s when I started. The vomiting and purging. That’s when I realized how easy it was to develop that habit.” Within two weeks, she’d gotten her weight down to about 145 pounds.

“I used to think that if I were thin, I’d be so much happier, and my life, from that moment on, would be perfect,” she says. “But it’s almost as if I’ve created other ways to be unhappy.

“I was thinking about this on the ride over here,” she concludes. “I’m not really any happier,” she says. “I’m just different.”

Show isn’t alone in having a panicked reaction to keeping her weight off. Sohr, at one point, dipped all the way down to 106 pounds. Her doctors insisted she regain ten. “I was hysterical,” she says. “I started to cry. I felt fat. But my girlfriend who’d been through the surgery, she understood—Oh, my God, you gain a pound, you’re going to go back. It was cool to have her around.” She thinks. “But my other girlfriend who’s always been tiny, she doesn’t bother with me anymore. Another went on a diet. She had marital problems, so she’s trying losing to keep him around.”

We’re sitting in Sohr’s living room, still a frilly wonderland of bridal paraphernalia. “Every girl who knows me from before is on a diet right now,” says Sohr. “And everyone reports to me how much weight they lost.”

Did she tell these people that she’d had surgery to achieve her lovely new results?

“Yeah,” she says. “but they were never heavy enough to qualify for the surgery. Everybody was like, ‘You don’t need to lose weight, you’re wonderful the way you are,’ da da da da da da. But seeing me go from so heavy to so small, they’re all freaked, I think.

“I don’t have any girlfriends now,” she adds. “I had my fiancé’s cousin in my bridal party because I don’t have any girlfriends. My mother was my matron of honor. All my friends are guys.”

She reflects on this for a moment. “I was told by one of them that guys always approach fat chicks because they’re easier,” she says. “That really hurt. That shocked me. It made me rethink everybody I ever dated. Was I a target because of my weight, maybe? It just made me wonder.”

Is it easier being intimate with men, at least? “I still feel uncomfortable with my body,” she says. “A lot of my confidence came from my chest. People always raved about it. Now I look at myself, and I don’t think I have anything sexy anymore. But now people say, ‘It’s the whole package that’s sexy; you don’t need to focus on one thing.’ ”

Yet her clothes, Sohr admits, are far sexier; she no longer dresses in busy patterns or like the girl next door. (“Though my favorite thing was just buying a white shirt,” she says. “Fat girls can’t wear white. You look like you’re wearing a tent.”) She’s invested in two-piece lingerie. She has a closet full of bikinis, a drawer full of thongs. And she marvels at her newfound sexual freedom. “Before, I couldn’t really go on top of someone,” she says. “To be funny-graphic about it, my thighs were so big I couldn’t get a grip on the bed. And there were goofy things—you watch TV, and you think, I wish I could do that. Now Bari tosses me around like I’m a powder puff. And you can’t get close if you’ve got fat in the way, so you don’t get a lot of satisfaction. I’m more sensitive now.

“But you know,” she adds, “I think my favorite sensation is being touched on my hips. Before, I had awful hips. Saddlebags. And now they’re smooth.

“Yeah,” she says, after a second. “I like my hips. I always envisioned the hip being a sexy point on a woman, like an hourglass. So now I have a tendency to lay on my side. The first time Bari put his hand there, I thought, Wow.”

Because bariatric surgery is serious and high-risk, some doctors refuse to keep before-and-after photos in their offices. Like Roslin at Lenox Hill. “If you show pictures,” he says, “the only thing patients see are those pictures. They won’t hear anything else you’ve said. And I’m in the health-care business, not the cosmetics business. Morbid obesity is a serious medical disease.”

Gloria Cahill was Roslin’s patient. She went through a grim odyssey of complications and mishaps after her surgery in March 2001—strictures in her esophagus, blockages in her bowel. It took three endoscopies, two more hospital visits, and three months before her recovery could begin in earnest. She found the ordeal so traumatic she decided she wouldn’t proselytize when it was over, even though she had no doubt, once her health had stabilized, that the surgery had really improved her life. She made just one exception: her sister, Susie. The two of them were very close, both in adulthood and growing up, raised by a widowed mother in a tough neighborhood of Jersey City.

Even though Susie’s health was unraveling—grave back problems, severe diabetes, high blood pressure, eroded knees—the procedure was not an easy sell. She was nervous about giving up her old eating habits, and she’d just watched her sister go through a long, painful recovery. Cahill didn’t push. But as Cahill began to shed pounds and move with more confidence through the world, Susie’s interest began to wax. She and her husband had just bought a new condo, and Susie could barely climb the stairs. And then she had a heart attack.

Susie decided to start attending support- group meetings with Cahill. Eventually, she booked doctors’ appointments. “I’ll never forget the day she went for her consultation with the nutritionist,” says Cahill. “She was struggling to walk. When we got to the middle of the block, there was a railing. She held on to it, started to cry, and said, ‘My biggest fear isn’t the surgery; it’s having them telling me I’m too sick to have it.’ ”

She was told nothing of the sort. On June 13, 2002, just fifteen months after Cahill had her own operation, Susie checked into Lenox Hill, whose reputation in the field of bariatrics is among the finest and whose mortality rates are among the lowest.

The complications started from almost the moment she entered the operating room. Some were routine; others were not. (The hospital, for legal reasons, will not elaborate.) For seventeen nights, Cahill sat beside her sister’s hospital bed, talking to her, playing her music, reading to her from Jane Goodall’s Reason for Hope, even though her sister was in a coma. “I kept saying, ‘If you can hear me, I know this is probably annoying you, and you want me to shut up about the monkeys,’ ” says Cahill. Then she laughs. “But I’m sorry. It’s a wonderful book. It’s about the challenge of being a person of science and faith.”

On the eighteenth night, Cahill, a practicing Catholic, went to the church by the hospital, where she’d already spent a great deal of time those last two weeks. “The words ‘Thy will be done’ are a covenant,” says Cahill. “You better not pray that prayer unless you’re ready to deal with it. That night, when I knew Susie was dying and I said ‘Thy will be done,’ it was probably the most heartfelt prayer I’ve ever said.”

After losing weight, some bariatric patients develop almost an angularity to their personality. It’s not just their jaws and cheekbones that leap out, but a certain sharpness and assertiveness of character. Not Cahill. There’s something about her aspect that remains, to me anyway, very round. It’s the softness of her personality, surely, that accounts for some of it. But one wonders if the rest has to do with a deep identification with her sister. Three years later, Cahill says it’s still difficult to succumb to the awful logic of the situation—that if she hadn’t lost the weight, there’s a chance her sister may not have died right then. “This is the thing I’ll probably carry to the grave,” she says. “Even though it’s not rational, even though I know that if Susie were sitting here, she’d say, ‘Get over it. And don’t give yourself that much credit. I make my own decisions.’ ” She sips some of her coffee.

“The day she went for her consultation,” she continues, “the doctor said, ‘I want you to understand that you’re not going to come out of this looking like Gloria. I can’t promise you’re going to be a size 8.’ And that was fine. She was not doing this to get skinny. And yet . . . when I see myself at 135 pounds, I see part of what Susie died for. By no means all of it. But part.”

Cahill’s crying now, discreetly but steadily. “It would be very easy for me to say, ‘This surgery killed my sister, and it’s the worst thing in the world,’ ” she says. “And her last moments of consciousness may have been imbued with terrible fear . . . ” She looks away. “But also hope,” she resumes, looking directly at me. “This gave my sister hope, and nothing else did.”

She takes her cloth napkin, wipes her eyes, and in the process of setting it down, grazes her blazer across her plate. She laughs it off, declaring the thing indestructible.

“It just amazes me to see how much power comes with prettiness.”

Meanwhile, Sohr’s mother awaits approval for her own gastric band, a far less dangerous procedure, though one not without risks. She seems prepared to take them. Few things have thrilled or inspired her more than watching her daughter’s transformation. In fact, before Sohr made her grand entrance through the floor of the Normandy Room, wearing that Ian Stuart dress and a tiara on her head, she exchanged vows in her mother’s old wedding gown. “To see her, at 35, fit into a dress I wore at 20 . . . that was a very awesome thing for me,” says her mother, Linda Bajada. “The beautiful young girl who once was had come back.”

Sohr met Bari in February 2004, while on vacation in Fort Lauderdale. Her third-to-last day, she popped into a beachfront store to buy a bikini, figuring her body deserved it. A handsome salesman approached and asked if he could be of assistance. She said he could, and he was. As she yo-yo’d in and out of the dressing room, they struck up a conversation. He asked if she’d been out dancing in the area; she mistakenly heard him ask if she wanted to go dancing with him—a mistake that only a woman with renewed confidence in her body would probably make. “Is that an invitation?” she asked. “Sure,” he said, figuring, Why not?

“I gotta be honest with ya,” says Sohr. “I thought he was gonna be a one-night stand.”

It wasn’t, as we all now know. She spent the next 72 hours with him and left on February 12. On Valentine’s Day, Bari spent all day on the phone with his future wife. Six days later, she caught a midnight flight back to Florida and found an apartment with Bari. In May, they moved back to New York. This April, they got married. Almost the entire staff of Long Island Bariatric Center attended, as did her surgeon.

I ask Sohr if she thinks Bari would have considered dating her when she was heavy.

She releases a long stream of smoke. “He’d have been nice to me,” she says. “He’s got friends who are heavy. But dated me? Probably not.” Bari opens his mouth to protest. She waves him off. “Let’s face it, the guy could be a GQ model. He is gorgeous”—gawgeous—“but during that period, I was different—very down, very drab personality. I wouldn’t have talked to myself.”

Bari doesn’t buy it. “I just saw the eyes,” he says. “That’s why I married her—so I could look into those eyes for the rest of my life. The body, it’s just the outside. What’s it gonna be twenty years from now? What I look for in a woman is a good personality and a friend.”

Sohr still keeps a picture of her old self in her wallet. It’s “a really gross one,” as she calls it. She wants everyone in the world to know that a similar transformation is available to them. “Anyone I see who’s overweight, I start a conversation about it,” she says. “I never forget where I came from.”

She also shows me a picture of herself in the bikini she bought from Bari. She looks staggeringly skinny in it. She says she’s gained weight since.

“But I was a size zero once in my life,” she says. “I hit my goal. I blew past my goal. I was there.”

Bari pipes up. “And I didn’t like it,” he says. “There was nothing to grab. Nothing! No meat.”