Dear Readers,

In the absence of any feedback or requests relating to my previous article, "Body Art: Tattoos and Piercings" (MT December 2008), I have decided to discuss an entirely different topic: bariatric surgery, sometimes known as "gastric bypass." This comes about because of an interaction with a particularly generous individual who willingly shared her experiences with me during a workshop. Since some of us are probably still recovering from holiday-related overeating, and since about 120,000 people will undergo some related procedure in the country this year, it seems timely and appropriate to take a closer look at how we can serve clients who have had bariatric surgery.

What Is It?

Bariatric surgery is a collective term for several different surgical options, all of which are designed to interfere with the uptake of nutrients in the gastrointestinal tract. Drastically limiting the capacity of the stomach reduces not only the amount of food a person eats, but also their capacity to digest what they take in. The result is typically massive weight loss.

In the United States, more than 60 percent of all adults are functionally overweight, and about 12 million people have a BMI of 40 or above; this is at least 100 pounds overweight for men and 80 pounds or more for women. When people experience this level of obesity their ability to reverse their situation becomes progressively more limited: knee and hip arthritis make exercise impossible, diabetes becomes resistant to treatment and fatty liver disease interrupts liver function. Patients become more vulnerable to secondary infections, certain kinds of cancer and early mortality.

At some point in this cycle, the safest, most effective intervention becomes surgically interfering with the volume of food that is eaten or the absorption of nutrients: bariatric surgery. When this is accompanied by improved eating habits and exercise, many of the illnesses associated with extreme obesity can be more manageable or even reversed.

Types of Surgery

Most types of bariatric surgery can be conducted laparoscopically, unless the patient has some specific limitations. This reduces the risk of secondary infection, and usually shortens recovery time.

Adjustable gastric band. This procedure places an adjustable band around the stomach. The size of the outlet can be controlled with a small balloon inside the band.

Roux-en-Y gastric bypass. In this procedure, food absorption is decreased by stapling the stomach to be about the size of a walnut and directly connecting it to the distal end of the small intestine.

Gastric sleeve. This surgery is often the first stage of another procedure called biliopancreatic bypass. This procedure removes much of the stomach, but leaves the intestines intact.

Biliopancreatic bypass with a duodenal switch. This surgery removes the lower portion (about 80 percent) of the stomach and connects the rest to the lower parts of the small intestine. It is extremely effective, but has a higher risk of complications than other surgeries.

Desired Outcomes

If a bariatric surgery is successful, a patient can expect to lose 50-60 percent of their excess weight within the first year after surgery. This weight loss can continue and stabilize if the patient is careful about diet and exercise. In addition, many of the disorders associated with obesity can be averted. The severity of osteoarthritis, type 2 diabetes, high cholesterol, high blood pressure, sleep apnea, and GERD (gastroesophageal reflux disease), which is linked to esophageal cancer, may all be reduced. Some research also indicates that bariatric surgery may reduce the risk of colorectal, breast and several other types of cancer for obese patients.

Complications

Bariatric surgeries are obviously not risk-free. Short-term problems include bleeding, leaking if intestinal sutures fail, infection, perforation of part of the gastrointestinal tract, and post-surgical blood clots that may cause pulmonary emboli. "Dumping syndrome" describes what happens when stomach contents move into the small intestine too quickly; this leads to nausea, vomiting, dizziness and sweating.

Longer-term issues include malnutrition and vitamin deficiencies, strictures (scarring in the GI tract), kidney stones, gallstones, and hernias: bulges that press through the surgical scar or through the mesentery - the fascia that suspends the intestines from the abdominal wall. Annoying but less threatening complications include hair thinning, feeling cold all the time, and dry skin. Finally, it is important to point out that about 10 percent of all bariatric surgeries are unsuccessful. In other words, patients do not experience adequate weight loss, or their weight loss is only temporary.

Massage and Bariatric Surgery

This article came about because I was involved in a class discussion on the benefits of abdominal massage even - or especially - for people who struggle with issues of body image and weight control. It was not surprising that most of the therapists in the class didn't make a habit of including abdominal massage. "Most people would rather just have extra time on their backs or legs" was a common comment. Nanette, one of the class participants, spoke up about her experiences receiving abdominal work in massage school several months after her roux-en-Y surgery:

"I felt horrible. It was unnatural, foreign. I felt anxious, nervous. Clockwise strokes on my abdomen made me feel sick. I wondered if somehow they had rearranged my insides with the surgery. I didn't feel safe. It spooked me."

Part of our job as massage therapists is to "in-corpor-ate" - literally help to weave together - our clients' bodies. For someone who doesn't feel connected to their belly, the experience (even if all it entails is a few unhurried breaths with warm hands on top of the sheet on the abdomen) can be an unusually powerful chance to experience that part of her body as positive, included, woven in. The students in Nanette's massage school were unable to help her do that, and after her initial experiences, she was unwilling to pursue it further.

Granted, Nanette's experience also included significant and painful post-operative complications, and although she lost more than 100 pounds, her general experience with the surgery was frustrating. Students (some of whom probably struggle with their own body image issues!) were not her best resource for abdominal work. But it is still an important goal for us to help our clients feel supported as full and beautiful whole beings, not as disintegrated, disconnected parts.

Massage is finding a place in many traditionally medical niches, including in the context of surgery. It is not unusual now to find therapists delivering pre-surgical massages for stress reduction, and post-surgical sessions for pain, improved sleep and general discomfort. Obviously modalities must be adapted to meet the resilience of the patients.

For clients who have had bariatric surgery, abdominal work clearly must be done with extra care. Nanette obviously needs a therapist with patience and expertise if she is ever to be comfortable with receiving even non-moving touch on her abdomen. Other clients will also appreciate the value of confident, sensitive, gentle strokes on their bellies.

Our unique ability to offer positive, therapeutic, nonjudgmental touch to our clients who do not fit our culture's expectations for normal size or appearance is an incomparable gift. Whether our clients consider bariatric surgery or not, we can provide a welcoming, accepting environment that will be much appreciated.

For next time: The floor is open, readers! Let me know, what's on your table? Until then, many thanks and many blessings.