Andrea Robenolt lives life out loud. But she wondered if she could keep going that way.

The 29-year-old mother of four has tried several traditional diets, including skimming off 40 pounds with the Atkins diet before gaining the weight back. She also tried a vigorous exercise regimen: spending her entire lunch break working out, working out before going to work and working out after coming home.

But as a working mom and wife, the three-times-a-day “me” exercise periods were taking away from her family life with husband, Ed, and her 12-, 10-, 5- and 1-year-old. And to see any weight loss results, Robenolt, of Lyons, Wayne County, needed to spend every one of those minutes exercising.

She found all that effort counterproductive when she was exercising to address her morbid obesity, “trying to live longer and be there for them, but I was spending all my time working on me. I didn't get to spend a whole lot of time with them,” Robenolt said. “When you have a family you can really only spend so much me time.”

So on Tuesday Robenolt took what some might consider a drastic measure: she had a very small stomach pouch surgically connected to her intestines, bypassing the rest of her stomach and the duodenum, the first part of the small intestine. Her stomach now holds only 1/4 cup of food.

More than 140,000 of these gastric bypass, or Roux-en-Y, surgeries were performed in 2005. Dr. Carl Weiss III, a bariatric and general surgeon, estimates he has performed 50 of these $12,000-$20,000 surgeries since joining Auburn Memorial Hospital in 2005. Dr. Chung Oh performed an older technique of bariatric surgery, vertical banded gastroplasty, at AMH for years.

But it was only a little over a year ago that AMH formalized the Fingerlakes Weight Loss Program with a surgical side directed by Weiss and a medically supervised weight loss side headed by Dr. Wendy Scinta, the only registered bariatrician in the region. There are 394 patients between the

surgical and medical sides of the program. Scinta's and Weiss' medical and surgical weight loss programs are designed to complement each other and keep both paths open for patients.

Critics of the surgery say bariatric surgery is taking the easy way out and that weight loss, or bariatric, surgery is not worth the risk of death. Proponents counter that scientific research has shown severely obese adults do not sustain long-term weight loss achieved by non-operative methods and that bariatric surgery offers an effective way to treat morbid obesity.

Individuals who are obese have a 50 to 100 percent increased risk of premature death from all causes of death in comparison to people of a healthy weight, according to the United States Department of Health and Human Services. There is 0.24-percent mortality rate related to bariatric surgery, according to the International Bariatric Surgery Registry of 2004-2005. Weiss estimates he has over 90-percent success rate of patients losing weight and keeping the weight off with support group participation and annual follow-up visits.

An estimated 22.1 percent of New Yorkers are obese, according to the Centers for Disease and Control National Center for Health Statistics. An estimated 31 percent of American adults are obese. Sixty-six percent of U.S. adults are either overweight or obese.

Morbid obesity, or clinically severe obesity, is defined as being at least 100 pounds overweight, having a body mass index over 40, or having a body mass index between 35 and 40 and having a severe medical condition like hypertension, sleep apnea or diabetes.

The Fingerlakes Weight Loss Program emphasizes changing behavior. Patients are told surgery is only a tool in a spectrum of life changes they must make to finally beat obesity, including development of better eating patterns and treatment of underlying emotional causes. Weight loss slows up after a year of steady loss of about 10 to 12 pounds a month. A healthy diet, continued exercise and participation in the program's support group meetings are a must to keep the gift of second life the surgery gives them, the program coordinators say.

Surgical candidates must demonstrate four to six months of supervised weight loss to satisfy most insurance company requirements. They must get medical and psychological clearance. They must attend support group meetings ahead of the surgery. They must complete their food diaries and show they are pursuing the steps of changing their living habits.

Patients are not allowed to undergo surgery if they are abusing substances, if they don't seem to understand what is involved or if they seem to have unrealistic expectations for the surgery, Weiss said. Red flags are “seeking surgery for reasons that don't sound sincere,” Weiss said: wanting surgery for physical beauty rather than out of concern for quality of life or future health risks.

Weiss likens the program to the Alcoholics Anonymous model of intervening in addictive and dysfunctional behaviors. “Behavior that's thought about can be changed,” Weiss said.

Local residents have heard the criticism from loved ones and from acquaintances that the bariatric surgery is a cheater's way to weight loss. But the patients interviewed for this story said they made their decision to have the gastric bypass surgery after battling with weight their entire lives. They have memories of parents whose lives or good health were cut short by the same health problems assailing the quality of their lives. They want to be around for their children and their grandchildren.

It's been 20 years since Karen Twomey, of Fleming, had her gastric bypass surgery done by Oh. The watershed moment for her was the invitation her 3-year-old daughter received to go to a roller skating party. She felt horror that she might not be able to safely strap on skates to join her daughter.

“I was 30 and I felt like was 50. I was not living. I was existing,” Twomey said.

Patty Pierleoni, of Elbridge, recently looked at her 11-year-old son and decided she wanted to be alive when he had children. She said it was hard to not fit into roller coaster or airplane seats.

“It makes you shrivel inside,” Pierleoni said. “It makes you feel you don't fit in the world.”

The substitute teacher had her surgery May 8.

“I'm not doing this to be skinny,” Pierleoni said the week before her surgery. “I'm doing this to be healthy. This is not a cure. ... This is not the easy way out. This is not the lazy man's way out.”

“People who do this put their lives on the line,” said Sam Giangreco, of Auburn, who had his surgery April 17. “Vanity was not a reason to do it.”

Some patients do regain the weight because their dietary and exercise habits don't change. They didn't make the mental preparations. Jessica Herron, the program's bariatric dietitian, doesn't just tell patients what they should be doing. She tells them what dietary choices will defeat their digestive reconstruction.

“We understand this has been a lifelong struggle,” Herron told a recent meeting of the bariatric support group. “You've been on a lot of diets. You wouldn't be here with if us if you had success in conventional ways. ... Make this a lifestyle, a lifelong change.”

On Tuesday morning prior to her surgery, Robenolt joked with her husband as nursing staff came to wheel her to the operating room.

She visited with Pat Baran, a registered nurse in AMH's operating room and the facilitator of the weight loss program's support group. Baran underwent bariatric surgery 14 years ago and she makes it a point to visit with every bariatric patient before they go in for surgery.

“They're like my kids. I'll fight you to the wall for them. They can count on me for anything,” Baran said.

At 8:49 a.m., the first incision was made in Robenolt's stomach. She was now undergoing a much less invasive form of bariatric surgery than was possible 15 years ago.

The first surgeries conducted for weight loss kept the stomach intact and bypassed most of the intestines, according to the American Society for Bariatric Surgery. Weight loss resulted, but patients developed serious complications from vitamin A and D deficiency and bacteria growth in the bypassed intestines. The bacteria caused liver failure, arthritis and other problems.

Weight loss surgery is still commonly known as having one's stomach stapled, but the surgery has developed beyond the vertical banded gastroplasty technique in which part of the stomach, near the esophagus, is stapled to create a pouch and the pouch outlet is restricted to slow the emptying of food.

Gastric bypass, or Roux-en-Y, surgery advanced on vertical banded gastroplasty by providing two mechanisms - one of restriction and one of malabsorption - for weight loss. The surgery reduces stomach volume and the amount of food that can be eaten by constructing a new small stomach pouch. The surgery also bypasses the first part of the small intestine and reduces the amount of calories and fat that can be absorbed. Other forms of bariatric surgery that reduce stomach size are still in use but not as popular.

Weiss has performed an estimated 300 of the open gastric bypass surgeries and the more technically challenging surgeries of laparoscopic gastric bypass surgeries. The first laparoscopic gastric bypass surgery was documented in 1994, according the American Society for Bariatric Surgery.

In regular gastric bypass surgery, a surgeon opens a long incision in a patient's abdomen to access the digestive system. But in the laparoscopic version, five or six incisions are made in a patient's abdomen. In the open bypass surgery, patients face a 20-percent rate of incisional hernias and eight percent rate of wound infection. The minimally invasive laparoscopic surgery reduces convalescence of four to six weeks to just a couple of weeks.

A team of six assisted Weiss on Robenolt's surgery, including Dr. Deborah Geer, a fellow surgeon. Surgical tech William Ladd was the right-hand man handing surgical tools and color-coded staples to Weiss. Physician's assistant Bahgat H. Abdelaziz operated a small video camera inserted into Robenolt's abdomen revealing bubblegum pink and melon orange tissue on two high-definition screens that magnify at a scale of 2.5 times.

Instead of looking down directly at a body cavity opening, Weiss was looking at camera screens. “We could see everything beautifully,” he said later.

Robenolt's abdomen was filled with carbon dioxide, creating space within to operate. The room was mostly quiet as he sliced stomach tissue before stapling off the upper part of her stomach to create a new small stomach pouch.

“There we go. Look at that,” Weiss said after constructing a new miniature stomach for Robenolt.

He put in five to six staples toward the top of the pouch and one below to partition it from the rest of the stomach. The construction of the small pouch is the swiftest part of the surgery.

Weiss then constructed a new 1.5 to 2-centimeter outlet for the pouch using a crescent-shaped needle and black silk thread. “It can't be too big or too small,” Weiss said.

If it's made too big, patients won't have a sense a fullness. If it's too small, patients can begin to lose too much weight too quickly. At 9:20 a.m., Weiss was heading for the homestretch of reconstruction. Dissolvable white thread was used in the interior, and black silk thread was used in the exterior.

Robenolt's new digestive system was flushed with water to make sure there were no leaks. At 10:06 a.m., the surgery was officially safely concluded.

Weiss left the O.R. to report to Robenolt's family of a safe surgery. Abdelaziz closed the incisions with stitches. He washed blood off and put medical tape over the incisions.

The surgery helps obese patients achieve dramatic weight loss because the small stomach pouch eliminates the feeling of deprivation of food. The “dumping syndrome” also creates an averse reaction to eating fatty, greasy and sweet foods or eating too much. The fast passage of food into the small intestine makes bariatric patients feel light-headed, flushed or weak and experience abdominal pain, nausea, sweating and diarrhea.

“You get immediate feedback. You can't take a day off,” Weiss said.

The fast weight loss in the first year improves or eliminates health problems people had because of their weight: arthritis, incontinence, hypertension, sleep apnea, diabetes and high cholesterol.

Weiss is not always able to do a laparoscopic surgery. Men must undergo open surgeries more often because of a larger amount of intra-abdominal fat that impedes the minimally invasive form of surgery.

According to the International Bariatric Surgery Registry in 2004-2005, 87.2 percent of patients had no complications 30 days after their surgery; 9.5 percent had minor complications and 3.4 percent had major complications. There were a total of 93 deaths of 38,501 patients from cardiac arrest, gastrointestinal bleeding, gastrointestinal leak, pulmonary embolism, respiratory arrest and small bowel obstruction.

Most common major complications included gastrointestinal leaks at 0.73-percent and gastrointestinal bleeding at 0.44-percent and small bowel obstruction at 0.44-percent.

Because the surgery bypasses the duodenum part of the small intestine - where most of the absorption of calcium and iron takes place - anemia and osteoporosis are life-long complications. Patients must take multivitamins, including for Vitamin B 1 and Vitamin B 12, Herron said. Massive weight loss can strip Vitamin D from the bone, so that is also supplemented, she said. Liquid protein supplements are always used to try to keep patients on a nutritional even keel, Herron said. The lack of protein during rapid weight loss can lead to ketosis, with the temporary effects of bad breath and taste changes. Patients' hair can also thin. But these last problems ease as the weight loss slows down, Herron said. With the dramatic weight loss, patients sometimes need plastic surgery to remove excess skin.

Bariatric patients' tolerance for the richest foods can return. The dumping syndrome and reduced appetite sometimes is not enough on its own to prevent weight gain.

Some patients were binge eaters in a rush; some were grazers throughout the day and some were just “unskilled eaters” without a good sense of what to eat and how to eat, Herron said.

The ultimate tool is an effective community built around a support group.

The program has a monthly weigh-in for all participants the first Wednesday of every month. The support group on the weigh-in night is a free-for-all as a group of 60 mingle in chaotic conversation. On other nights of the month, fewer people show up and the conversation is more focused.

“They're excited,” said Becky Grandger, Weiss' office manager. “Something is finally happening. Finally the first thing they're working toward in life is working for them.”

All have been on a million diets that didn't work. Some are self-described food addicts. All feel assaulted by the overabundance of bad food around them. They've struggled with depression, anxiety and low self-esteem.

They share recipes for bariatric-friendly food. They share tips. And they share triumph at dropping weight and taking their lives back from social stigma. They come for a circle of stories that inspire them.

Patients “get their last laugh,” Scinta said. “Whenever you become beautiful, you become beautiful from the inside. It's like a wedding glow.”

During the program's one-year anniversary party earlier this month at the Sunset Restaurant, 29 patients received certificates for losing more than 100 pounds and 26 patients received certificates for losing 50 to 99 pounds.

Christy Van Ostrand, the Fingerlakes Weight Loss Program coordinator, and Scinta's office manager, Jen Avery, have, respectively, lost 30 and 50 pounds by following the diet and exercise management the program calls for. Avery started off as a patient and now is an employee. They say their weight loss helps them identify with patients.

Herron advises patients to eat three nutritionally balanced meals every day at 30 minutes a time. Patients are told to drink water a half hour before and a half hour after having a meal. They are told to eat slowly and stop eating when they aren't hungry anymore. It's a simple formula of reducing the amount they eat and increasing the amount they exercise, but it goes against the grain of a culture that says plates should be cleaned of every last piece of food, patients say.

Pierleoni said she has been like a dizzy kid spinning and the group was the ground for her. She had success losing weight before the surgery following the medical side of the program.

“Yes, I've done good. This is the tool,” she said. “There's a chance of slipping back in the mode and I don't want that to happen.”

Twomey's secret to keeping off the weight after 20 years has been to reward herself for keeping her body half the size of what it was before her surgery. She also sets a mental threshold of what is acceptable for her body and what is not.

She gained some weight at first after her surgery, but that weight gain motivated her to keep up her exercise for the last 20 years.

She asked Dr. Oh to undo the surgery 10 years ago because she thought she did not need it anymore, but he told her she shouldn't undo it because of how her system had atrophied. Now, she says it's one of the best things she has ever done.

Every year she adds something to her life's to-do list. Still left: hot air balloon ride, kayaking to the other end of Owasco Lake, taking a trip to Italy. One check on her list was buying a sports car.

“I'd rather live like other people than eat like other people,” Twomey said.

Robenolt went home from the hospital Thursday. Except for some nausea, she feels alright. She expects to return to her job keeping payroll and accounts payable for Catholic Charities in a couple of weeks.

She has a plan to keep on track with her weight loss. Her mother is her neighbor, her exercise partner and has joined Robenolt as a bariatric surgical candidate.

Robenolt is teaching her eldest daughter, who helps more and more to take care of her younger siblings, how to cook more healthy foods with lower sugar, grease and fat.

She jokes she wants to drive her husband crazy for the rest of her life.

“I'll take thin. That's a nice side effect. I want to be around,” Robenolt said.

Staff writer Amaris Elliott-Engel can be reached at 253-5311 ext. 282 or at amaris.elliot-engel@lee.net