Helen Koehling lay on the operating table, head tipped to the right, belly exposed.

After a winter of diet and exercise she still weighed 372 pounds. She wanted help, needed it.

Lights dimmed in the room. Her heart monitor offered a steady blip, blip, blip. A surgical team made six tiny incisions.

Over the next four hours Dr. Padiath Aslam stapled and stitched her stomach to the size of a thumb.

“We have to change our eating habits now,” said her husband, Charlie, outside the waiting room at MaineGeneral Medical Center in Augusta.

“About that much” – he pulled a few coins from his pocket – “and she’ll be full.”

Koehling’s gastric bypass surgery in early February was a year in the waiting. The night before she was anxious, and hungry, but ready.

She wanted to fit on roller coasters again. To go back to work.

To be 35 and have a life.

More than 500 people had gastric bypass surgery last year in Maine.

Five years earlier fewer than 100 were done.

The surgery has been available for decades but only since 1998, with the advance of laproscopic surgery – quicker healing time, smaller scars – has it taken off. Celebrities like singer Carnie Wilson, “American Idol” judge Randy Jackson and Ozzie’s wife, Sharon Osbourne, have lent credibility and cachet. A culture of monster portions and rampant inactivity supplied clients.

Some 22,600 people in the state, 2 percent of Maine adults, were considered morbidly obese, at least 100 pounds overweight, when the Bureau of Health checked in 2002.

By the state’s best estimate only 1 percent were morbidly obese 10 years ago.

“Mother Nature designed us for fast, not for feast, and we’re surrounded by feast,” said Dr. Gregory D’Augustine. The Lewiston doctor has performed gastric bypass since 1985.

For the past six months he’s been trying to recruit a second doctor to his practice to do more. “The need is there,” he said.

Only a dozen or so surgeons do the procedure in Maine. In the last year, a Bangor practice added two doctors, Portland one and Augusta one.

As the number of surgeons, as well as demand, has grown hospitals have also adapted, to better accommodate large people. Jeannie Coulter, executive director of the Web site ObesityHelp.com, remembers when Aslam started operating at MaineGeneral 10 years ago. He had a 531-pound patient and there wasn’t an operating table, bed, wheelchair or shower big enough for the man. Coulter says after walking the whole hospital they finally did find a shower.

“Guess where it was? In the morgue.”

‘It’s not vanity’

Gastric bypass involves cutting off a small portion of the stomach and creating a new stomach the patient will have for the rest of his or her life. The small intestine is then attached to the new stomach. The new stomach feels full fast so patients eat less.

Stomach capacity shrinks from about 5 cups to 2 tablespoons.

The remaining stomach keeps making gastric juices but doesn’t feel hunger pains.

Different doctors have slightly different prerequisites for surgery.

There’s typically two categories of patients: those 100 pounds or more overweight and those 75 pounds overweight with a serious weight-related side issue like high blood pressure, sleep apnea or diabetes.

D’Augustine’s waiting list is a year long. In Bangor, at Eastern Maine Medical Center, it’s closer to six months.

Patients visit a dietitian, psychologist, physical therapist and attend support group meetings before surgery, said Lynn Bolduc, clinical coordinator of the surgical weight loss program at EMMC. The hospital has a partnership with Northeast Surgery.

The average client is a 40-something woman, but she is starting to see more men.

“If you ask they’ll tell you it’s thanks to Al Roker,” said Bolduc. The NBC weatherman went public with his surgery last summer.

Her program’s goal: lose 70 percent of excess weight the first year. Most gastric bypass patients keep off at least 50 percent of their excess weight after five years.

“Our patients don’t become Barbie and Ken when they’re done,” Bolduc said, but they do usually get rid of the serious side issues, like high blood pressure.

“It’s almost never vanity,” she added. “If these people don’t have surgery they will die 10 to 15 years sooner than their counterparts.”

Gastric bypass is a procedure with risks. In his literature, D’Augustine warns of a 3 percent chance of wound infection or pneumonia, a 1 percent chance of leaking around stomach stitches, and, after surgery, a chance of gallbladder disease and iron deficiency.

Nationally, the mortality rate is between 0.5 and 1 percent. Bangor had two deaths last year. Portland and Augusta had one each.

“It doesn’t make anyone immortal,” said Aslam, who runs the Aslam Bariatric Treatment Center in Augusta. “It’s a complicated procedure.”

Even when the surgery goes off without a hitch, life’s never the same again.

Recovery, motivation

Stephanie Soosman had a gastric bypass last February. She’s lost 104 pounds, down from 294.

“Learning to eat afterward is a major ordeal,” she said.

Soosman can’t eat and drink at the same time. Drink would push the food through quickly and expand her tiny stomach. For that reason, she avoids spicy, hot foods and if she really needs water, chews on a piece of ice.

What little she does eat – mostly proteins, then vegetables, rarely pasta – she chews really, really well. She eats three small meals and three snacks a day, plus a protein shake and vitamins.

“You get in tune with your body. You learn, OK, I can’t take that next bite,” said Soosman, 42, of Bowdoinham.

Each person’s reaction to food is different. Some can’t eat steak again, others rice, said Georgeann Mallory, executive director of the American Society for Bariatric Surgery,

Patients with gastric bypasses are warned that sweets can trigger “dumping syndrome”: dizziness, heart palpitations, sweating.

Not eating right or exercising after surgery is a recipe for stretching out the stomach and gaining the weight right back.

Soosman tried all sorts of diets before resorting to surgery: Weight Watchers, Slim Fast, Atkins, grapefruit diets, appetite suppressants from her doctor. Nothing worked with lasting results. She had arthritis in her lower back, shortness of breathe, acid reflux and was looking at a family history of heart disease.

“You just carry yourself so much better when you feel better about yourself,” she said. She has another 40 pounds to go, but, “If I never lost another pound I would still be happy.”

Carrie Palmer started thinking about surgery two years ago. The last straw: taking her nephew to the dentist.

“I wasn’t able to fit in one of the seats and wait for him. I sat in the car,” Palmer said. She told herself: “Whatever I have to do, this is going to stop.”

Palmer said she went through several stages awaiting surgery, getting excited, then hesitant, then disappointed in herself. “The whole failure concept came out, ‘This is ridiculous. I have to go to this extreme?'”

And when the Lewiston nurse moaned to a friend about never eating Oreos again, her friend told her, “You can Carrie, you just can’t eat the whole row.”

She had surgery Jan. 20. Two weeks into her recovery, she was walking 1.5 miles a day in the mall with her mom.

She’d lost 27 pounds.

“My biggest thing, I want to be able to go out in public, to a theater, to a play, to a dentist’s office and not be concerned ‘Am I going to fit?'” Palmer said.

Paying the price

Palmer and Soosman had insurance through their jobs that covered surgery. Helen Koehling had approval through MaineCare, coverage Gov. John Baldacci had threatened to drop last month when he went looking for budget cuts.

The Bureau of Insurance has gotten a handful of complaints from people whose insurance companies don’t want to pay for the surgery, a $15,000 to $35,000 cost.

Gastric bypass isn’t a mandated benefit in Maine, as is newborn care and treatment for alcoholism.

Insurance coverage nationally “was improving. As of this year it seems to be going the other way,” said Mallory. In her state, Florida, a major insurer just issued a letter saying it won’t cover the procedure even when medically necessary.

“In Maine, and L-A in particular, that’s a rare patient that can say, ‘Oh, I don’t care if insurance covers it or not,'” said D’Augustine.

It’s an issue that could heat up this year when members of the American Society of Bariatric Surgery meet in Washington, D.C. in May and consider lowering the weight requirements for patients, presumably increasing demand.

The morning of her surgery Koehling said she thought she knew what to expect. She’d seen the operation on the Internet.

Her kids were excited. “We’re going to raid each other’s closets now,” said Regina Forgrave, 12. Her mom, she said, was already eyeing a pair of her pants.

Koehling’s procedure, because she was 250 pounds over her ideal weight, was difficult, Aslam said. There was a lot of bulk to navigate around.

During recovery in the hospital Koehling got pneumonia. She believes she didn’t move around soon enough after surgery. She stayed on oxygen for five days and was in lots of pain.

She said she felt lucky to have the hospital staff: They helped her understand what was going on, “they didn’t care that I asked a gazillion different questions.”

Eight days after surgery, she was home in Wiscasset getting nutrition from a feeding tube – part of Dr. Aslam’s routine while the stomach heals. She didn’t like being in the same room while people ate.

“The biggest thing in my day is I get to swish and spit water,” Koehling said.

She hadn’t stepped on a scale yet. She wasn’t ready.

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