The average person approaching bariatric surgery endures a lot before coming to Benefis’ Bariatric Institute in Great Falls. Diets of every description, from extremely restrictive to dangerous to just plain ineffective. Worsening health. A cycle of decreasing mobility. Discrimination: people dread simple actions like grocery shopping or going out to eat, because other people watch what they put in their carts and on their plates. JoVonne Ketterling, Bariatric Nurse Coordinator, knows. She’s been there. Before her surgery five years ago, Ketterling weighed 307 pounds. “I’d do it again in a heartbeat,” she said. Ketterling was close to becoming insulin dependent before surgery. “I’ve not had to get on insulin, I was able to get off high blood pressure meds and my sugars have been perfect.” Ketterling’s weight loss is within the typical range of sixty to eighty percent of excess weight. “It’s so much fun being able to do things with my family. We are avid roller coaster freaks. All these things are perks of having a healthier life,” she pointed out.

Each bariatric surgery candidate gets assigned a nurse at the first visit, either Ketterling or another of the staff nurses, who goes over all the details and risks of the procedure. Then the patient chooses a surgeon n Dr. Mortenson or Dr. Rohrer. The next visit is often a long one; the patient sees the dietician for a diet evaluation, the social worker for a psychiatric evaluation, and the doctor. The Institute schedules the visits this way for the convenience of the many patients who drive long distances.

Dr. Dale Mortenson, General Surgeon, said the main benefit people experience from the surgery is improvement in co-morbid conditions. “These are associated illnesses that occur from obesity, like diabetes, high blood pressure, congestive heart failure and increased risk of malignancies, sleep apnea, and degenerative disc and joint disease n which isn’t reversible, but losing weight makes it possible to walk much more easily,” he said. “For all those reasons, there’s an indication for weight loss surgery. Once people get to a BMI of 40 or more, the chance they’ll lose enough weight and keep it off is less than 1%.”

National Institute of Health guidelines say all patients with a BMI of 40 or more without health problems or a BMI of 35 or more with one or more serious health conditions are candidates for bariatric surgery.

Along with the serious health concerns, there’s a social component, said Dr. David Rohrer, Bariatric Surgeon. “They are discriminated against. I have each patient write an essay” about their hopes. Their goals are modest. “It’s something as simple as being able to buy something off the rack or fit into a regular seat belt on a plane,” Rohrer said. After surgery, he said “a lot of day-to-day discrimination improves and they really get a new life.”

Next, patients schedule a tentative surgery date. “Then we do more education,” Ketterling said. Patients get diet education from the dietician, go through pre-admission, and see the social worker, who is trained in addictions counseling.

Darla Black, RN Manager of Surgical Unit of the Bariatric Institute, said before surgery, people are most afraid of the major lifestyle changes. “You’re afraid and excited all at the same time,” she said. “Most of our patients have thought of this for a long time before choosing to do it. Many have been heavy all their lives. A person can truly become a different person and it’s taking away at some times part of their identity.” The support groups and on-going counseling help patients get through this.

“What we like about this program is that it’s comprehensive; they see the same nurse for consultation and preadmission,” Ketterling said. “I try to see them in the hospital. After surgery, we see them at a week, three months, six months, a year, a year and a half and then every year after that for five years. So once a surgeon takes on a bariatric patient, they are kind of married to them because they do follow them forever.”

Patients are so appreciative and grateful about their success, Ketterling said. However, she said the surgery itself is only a tool. “They have to have ownership in their surgery, it’s all about them changing their lifestyle and getting healthier. The tool is the surgery. You have to learn how to choose correctly n have fruit instead of a candy bar.”

Dr. Rohrer agreed. “How well they do with it is how well they use the tools. If the person is really involved, takes advantage of the weight loss, reads labels, exercises, they will do well with either procedure. People who want a silver bullet will have trouble with weight gain or problems with malnutrition if they don’t follow their plan.”

“What we look at as a success is if they lose 50% of their excess body weight,” Black said. “It’s not that you are ever going to be a Twiggy; we look at the quality of life and the health changes more than what they look like; people not having to take as much medication and can walk for fitness, that’s success n more so than fitting into a size 4.”

“Patients usually have several co-morbidities which are alleviated if not cured; some people have been known to get off their c pap machines for sleep apnea, their insulin, and/or high blood pressure meds. This surgery alleviates mobility problems, too,” Ketterling said. “It lets people get into life.”

There are two procedures a patient may choose; the traditional Roux-en-Y procedure or the Adjustable Laproscopic Banding (Lap Band). In Roux-en-Y, doctors close off part of the stomach, which sends food to the small intestine sooner. In the Lap Band, an adjustable band is placed on the upper part of the stomach reducing the amount that can be consumed.

The first week after surgery, the patient stays on liquids then moves to pureed foods for about a month. “Whatever your family is eating, put it in the blender. It won’t look pretty but it’ll taste fine,” Ketterling said. Then patients go to soft foods. “Eventually they get to eat normal foods,” Black said, “but it’s going to take them longer and they won’t be able to eat as much.” At the beginning, patients often find it hard to take in the right amount of fluids and protein. They may be only able to take in a few teaspoons of food at a time at first.

“What people have the hardest time with is the high processed sugars; we recommend they eat their proteins before eating sugars.” The Institute recommends each patient take in 60 to 80 grams of protein every day for life.

By six months post-op, patients live on 600 to 800 calories. “You live off the fat stores that you have at the same time you’re adding a lot of protein,” Ketterling said. Patients take multivitamins, calcium and B12 which promotes digestion and energy. At one year post-op, patients take in 800 n 1000 calories and at 18 months, 1200 to 1800 calories.

The Bariatric Institute is a Medicare-approved site as well as a Center of Excellence, which means the Institute goes through reviews by and reports patient outcomes to the Surgical Review Corporation. They do more than 125 surgeries a year and each surgeon does more than 50. Dr. Rohrer has done over 800 surgeries since 2000. On a personal level, Black said, “we have been doing this for many years. We’re used to heavier patients. We have a non-judgmental atmosphere.”

Dr. Mortenson advises patients to get good information. The Bariatric Institute offers free consultations, nutrition classes, counseling, and support group meetings. “If someone is a good candidate for [surgery], we can look at their med list and illness list and figure out their BMI. If they think it’s a good option, they owe it to themselves to get more information. The surgery can be done safely and it’s the only truly effective means for long-term weight loss.”

“It’s very rewarding when patients come back and they feel you’ve changed their lives for the better,” Dr. Rohrer said.