Roanoke Times
Copyright (c) 1995, Landmark Communications, Inc.
DATE: MONDAY, March 22, 1993 TAG: 9303220036
SECTION: VIRGINIA PAGE: A-1 EDITION: METRO
SOURCE: By Carolyn Click/Staff writer
DATELINE: LENGTH: Long
HOPING FOR SECOND CHANCE
AT 375 POUNDS, Maxie Ayers is running scared and running out of time. But Virginia Medicaid officials say they can't fund an operation for the Roanoke man because the procedure is still in the experimental stages.
Maxie Ayers has heard enough fat jokes to last a lifetime.
"You know, you see people out of the corner of eye, poking each other and saying, `Look at that guy.' "
But the 375-pound Roanoke man has never quite made peace with his widening girth.
Sidelined from his job as a trucker because of a bad back in 1984, the 5-foot-11 Ayers settled into a disturbing routine that included more eating and less and less exercise.
"Everything I ate turned to fat," he said. Once a hearty but manageable 230 to 250 pounds, Ayers could no longer lift weights or exercise enough to stave off the creeping poundage.
As his weight ballooned, his mobility decreased. With the extra pounds came a plethora of health problems - hypertension, cardiac disease, depression. Doctors told him time and time again that, if he did not get his weight under control, he would die a young man.
Ayers, 36, admits his poor eating habits have contributed to his limited lifestyle. He is virtually housebound, unable to take more than a few steps without the debilitating back pain that was exacerbated by a 1988 car accident.
"I don't know what it is like to play with my kids in the park or go shopping for my own clothes," he said.
The simple act of tying his shoes is an ordeal. The things that other people take for granted, like going to the movies, are off-limits because he simply can't fit into the seat.
Ayers said he has tried to lasso his weight and bring it under control. He has made the rounds of at least 50 doctors, listened to their lectures and embarked on dozens of diets with no success.
So when a Duke University surgeon offered last year to perform an innovative operation that would enable Ayers to slim down to an almost unimaginable 180 pounds, Ayers believed his fat days were over.
But because Ayers is on disability and his wife does not work, he had to win approval for the surgery from the Virginia Department of Medical Assistance Services, which handles Medicaid claims.
And that's where the hefty Ayers ran into an even more formidable force.
The operation that Dr. John Grant wants to perform, called a jejunocolostomy bypass with intravenous home nutritional support, is still in the experimental stage. The state has a policy that it does not fund any operation that is not considered standard acceptable medical practice.
Grant, an associate professor of surgery, understands the decision and is reluctant to get into a shouting match with Virginia officials.
They are, he said, making a legitimate medical decision based on evidence in the current literature. They are not withholding medical treatment, having cleared Ayers to have either of two standard procedures, the vertical banded gastroplasty or a Roux-en-Y gastric bypass.
Because of his past surgical experience, Grant said he is no longer willing to perform those traditional "stapling" operations on people of Ayers' size.
Ayers, like other patients who have had or are awaiting the surgery, are classified medically as super obese, meaning they are 225 percent over their ideal weight.
While any weight loss for extremely overweight people is good, Grant believes the standard procedures don't go far enough. Weight is reduced by about 75 to 100 pounds, but for people who tip the scales at between 300 and 500 pounds, that merely places them in a morbidly obese category, he said.
"They have got him in a Catch-22," Grant said. "They are perfectly right in saying they [the Roux-en-Y and vertical banded gastroplasty bypass] are the approved ones. But they won't work at his level of obesity.
"What I told them [Virginia Medicaid] is, the worst thing they can do is to authorize an operation that will be ineffective," Grant said.
Issue not cut and dried
Virginia Medicaid officials don't quite see it in such black-and-white terms.
"There are some very effective traditional methods of treatment," said Bruce Kozlowski, director of the Medical Services Assistance Department. "The issue is not cut and dried in the context that some researchers make it out to me."
While he declined to comment on the specifics of Ayers' case, Kozlowski said all requests for third-party payments are approved based on lengthy reviews by medical consultants inside and outside the department. They must review the available medical information and make a decision "predicated on the efficacy of the procedure and the outcome of the experience.
"At some point in time, there may or may not be enough experience and data to reach a different conclusion," he said. "At this point, it doesn't exist."
Grant said he hopes his own soon-to-be published manuscript on the operation will clear the way for insurance companies and Medicare/Medicaid providers to set apart the super obese from other categories of the overweight.
He said West Virginia and North Carolina medical officials are also weighing the benefits of the operation.
Dr. Edward Schirmer, a University of Virginia surgeon who has operated on dozens of obese patients, says he would not dismiss the two standard operations out of hand for a person of Ayers' size.
"I would say the vertical banded is least likely of the techniques to produce results simply because a lot of people in the super obese category eat a lot of sweets," Dr. Edward Schirmer said.
Although both standard operations reduce the size of the stomach, the Roux-en-Y allows food to go directly into the intestine.
If a patient eats high concentrations of sugar, a "dumping syndrome" often occurs, creating severe nausea.
It takes only one candy bar for the super obese person to swear off sweets.
So far, Grant has performed the jejunocolostomy bypass on eight people, including two Virginians, waiving his professional fees in all cases.
Duke University Medical Center, which urged Grant to set up a surgical program, picked up the cost for the first five because officials there were interested in Grant's outcome.
One patient paid for the operation herself. The Travelers insurance company agreed to pick up expenses for another, the first insurer to approve the operation. The eighth patient is still seeking insurance approval, Grant said.
In developing a surgical procedure that would help the super obese, Grant coupled an intestinal bypass process developed in the 1960s with more recent technological breakthroughs.
In 1963, Dr. J.H. Payne intentionally shortened the intestine, attaching about a foot of the jejunum, or middle part of the small intestine, directly to the transverse colon of 10 super obese patients. All 10 lost weight rapidly, but the resulting diarrhea upset the metabolic and electrolyte functions of the patients severely, placing them all at great risk.
In the 1970s, that procedure was virtually abandoned for the Roux-en-Y and vertical banded gastroplasty operations, which emphasized decreased dietary intake and delayed gastric emptying rather than diarrhea and malabsorption of calories.
Grant, whose initial work focused on providing intravenous nutrition to patients who had lost their intestines, figured intravenous support could be the answer to the problems Payne had encountered three decades earlier.
Doctors could regulate the formula to provide needed vitamins and minerals - but eliminate the calories of carbohydrates and fats.
Once Grant performs the jejunocolostomy bypass, he places the patient on a home intravenous regimen that can take up to 30 months for the patient to complete. The I.V. generally runs at night, allowing patients to go about their daytime activities. After an initial rapid weight loss, the patient loses one to two pounds a week.
During that time, the patients can eat as much as they want, but because food intake is accompanied by constant diarrhea, caloric consumption gradually tapers off.
"The food goes out of the stomach, goes into about a foot of the small intestine and then dumps into the colon," he said.
Over the period, Grant has watched as patients who normally consume 3,500 calories a day eat about 500 calories a day, with most of that not absorbed into the body because of the shortened bowel.
"We thought that [diarrhea] would be the Pavlovian stimulus to make them stop eating," he said. "If they eat a cookie, they get diarrhea. Then they stop eating the cookie."
So far, his research since 1988 shows that the behavior modification works.
Five of the patients who have completed the program have maintained their ideal weight. One has gained about 20 pounds, and two are progressing through the weight-loss phase.
"At the end of the weight reduction, I really have to encourage them to eat again," he said.
Once the desired weight is achieved, Grant then reverses the operation and creates a vertical banded gastroplasty to help prevent any weight gain.
"That's another thing Medicare/Medicaid doesn't like," he acknowledged.
The elaborate procedure is expensive, but as in the other cases, Grant has agreed to waive his own professional fees for Ayers if Medicaid officials will relent.
Then, the state would be responsible for picking up the tab for Ayers' hospital stay and aftercare, a cost that would likely run about $150,000 to $200,000 over a two- to three-year period.
The standard procedures are far less expensive, with the Roux-en-Y gastric bypass and the vertical banded gastroplasty costing about $10,000 for the operation and hospital care followed by another $15,000 in follow-up treatment, Grant said.
Productive again
Ayers, who is appealing the decision, has also taken his case to the court of public opinion. He has written Gov. Douglas Wilder and elected officials in Washington in hopes of winning a reversal.
His situation also caught the attention of Hillary Rodham Clinton. An aide telephoned Ayers last week asking him to serve on a health-care panel and possibly testify before Congress.
But Ayers had to decline. Traveling is difficult for him, he said, and he could not afford the travel expenses.
If he were given a second chance - the opportunity to watch his children, 3-year-old Brittany and 5-year-old Anthony, and his 15-year-old stepson, Raymond Shortt, grow up - he believes he would muster the willpower to keep the weight off forever.
"It might be that I could become a productive citizen again," he said.
He figures the state, which now pays his medical bills because he is poor, would save money in the long run because many of his health problems would disappear along with his weight.
He was hospitalized recently at Community Hospital for nearly a week after doctors removed a golf-ball-size growth under his arm.
"I realize I brought a lot of this on myself," said Ayers, who has overcome an alcohol problem but still smokes cigarettes.
But, for him, Medicaid's denial has become the equivalent of a death sentence.
"The only thing I didn't have was 12 people and a judge to set my date of death," he said.
Grant's case histories also suggest the super obese patient can escape the prison of fat that has so many locked into lives of despair.
His first patient, a 28-year-old woman, became so obese doctors had to perform a tracheostomy to help her breathe. After the operation, she began dating, eventually married and had a child. She continued to do well until she was strickened with acute leukemia and died.
Another, a 425-pound radio station operator, had developed hypertension and sleep apnea and feared being fired because he could not perform some of his tasks. After the operation, he regained full activity, including some participation in sports.
For now, Grant is counseling patience to Ayers and five other super obese people who are wrangling with insurance carriers over the validity of the operation.
If his manuscript is published by a prestigious medical journal, if officials in surrounding states begin to approve funding for the procedure, and if his success rate continues, Grant believes it will only be a matter of time before Virginia will also move the operation onto its standard list.
But Grant says patients like Ayers feel those are too many ifs.
"They are running scared and do not think they have that kind of time," he said.
Keywords:
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