One such area of concern has been the depression and even suicidal tendencies seen in some cases after bariatric surgery. There are various case reports of depression and suicides after bariatric surgery in the literature ^1-4.

Recently a paper published in a reputed journal made an attempt to analyse this rather alarming problem ⁵. After critically analyzing these papers it was suggested that some papers suffered from methodologic problems such as small sample size, failure to use validated assessments of psychopathology and absence of appropriate comparison groups (for example , how many candidates were already depressed and having suicidal ideation before bariatric surgery).

One  study found out that many of the patients undergoing bariatric surgery already have psychiatric disorders in the form of anxiety , mood , and personality disorder ⁶. In another study the extremely obese subjects were found to experience increased suicidal ideation than their normal ­­­­weight counterparts ⁷. This may be partly responsible for the increased negative psychosocial effects seen in patients after bariatric surgery.

On the other hand, there are many papers  that suggest that Bariatric surgery is  associated with significant improvements in psychosocial status. Most psychosocial characteristics, including symptoms of depression and anxiety, health-related quality of life, self-esteem, a­­nd body image, improve dramatically in the first postoperative year.^8-13

Unfortunately, a minority of patients appears to struggle with numerous psychological issues postoperatively. Although the evidence submitted in the literature to prove the adverse psychosocial outcome arising as a direct result of bariatric surgery is far from convincing due to the reasons stated above, it is probably a good policy to involve a mental health professional in all cases before performing such surgery. ­­

References:

1.    Higa KD, Boone KB, Ho T. Complications of the laparoscopic Roux-en-Y gastric bypass: 1,040 patients–what have we learned? Obes Surg. 2000;10(6):509-513.

2.    Hsu LK, Benotti PN, Dwyer J, et al. Nonsurgical factors that influence the outcome of bariatric surgery: a review. Psychosom Med. 1998;60(3):338-346.

3.    Waters GS, Pories WJ, Swanson MS, Meelheim HD, Flickinger EG, May HJ. Long-term studies of mental health after the Greenville gastric bypass operation for morbid obesity. Am J Surg. 1991;161(1):154-157.

4.    Adams TD, Gress RE, Smith SC, et al. Long-term mortality after gastric bypass surgery. N Engl J Med. 2007;357(8):753-761.

5. David B. Sarwer,  Anthony N. Fabricatore, P et al. Primary Psychiatry. 2008;15(8):50-55

6.    Kalarchian MA, Marcus MD, Levine MD, et al. Psychiatric disorders among bariatric surgery candidates: relationship to obesity and functional health status. Am J Psychiatry. 2007;164(2)328-334.

7.    Dong C, Li WD, Li D, Price RA. Extreme obesity is associated with attempted suicides: results from a family study. Int J Obes (Lond). 2006;30(2):388-390.

8.    Bocchieri LE, Meana M, Fisher BL. A review of psychosocial outcomes of surgery for morbid obesity. J Psychosom Res. 2002;52(3):155-165.

9.    Herpertz S, Kielmann R, Wolf AM, Langkafel M, Senf W, Hebebrand J. Does obesity surgery improve psychosocial functioning? A systematic review. Int J Obes Relat Metab Disord. 2003;27(11):1300-1314.

10.    van Hout GC, van Oudheusden I, van Heck GL. Psychological profile of the morbidly obese. Obes Surg. 2004;14(5):579-588.

11.    Sarwer DB, Wadden TA, Fabricatore AN. Psychosocial and behavioral aspects of bariatric surgery. Obes Res. 2005;13(4):639-648.

12.    Herpertz S, Kielmann R, Wolfe AM, Hebebrand J, Senf W. Do psychosocial variables predict weight loss or mental health after obesity surgery? A systematic review. Obes Res. 2004;12(10):1554-1569.

13.    van Hout GC, Boekestein P, Fortuin FA, Pelle AJ, van Heck GL. Psychosocial functioning following bariatric surgery. Obes Surg. 2006;16(6):787-794.

What is done is that the greater curvature of the stomach is freed from the tissues attached to it (known as the gastrocolic omentum) using a vessel sealing device like the Harmonic Scalpel or the Ligasure. This is the first step of the sleeve gastrectomy procedure, as well.

However, unlike the sleeve, here we do not use the stapler to remove 80% of the stomach. We merely imbricate/plicate the stomach using running stitches from above downwards, layer by layer, till most of the stomach is pushed inwards, creating a narrowing of the passage, and a tunnel along the lesser curvature, just like the sleeve.

Lap Gastric Plication

In the same vein, if someone wants to reverse the procedure, the stitches may be removed by laparoscopy (making this a potentially reversible procedure like the Lap Band), though this would neither be a good thing nor a great experience!

Some patients have significant reflux symptoms after LGP, as after the sleeve, as we have discussed before.

It is possible that the stitches may give way later and hamper the weight loss, but preliminary results, as presented in the recent International Conference of Obesity in Stockholm, show good results akin to the sleeve.

More info later!

This article discusses these issues. Please buckle your seat belts!

First things first, who doesn’t know what a sleeve (as this operation will from now on be called) is and what it is for? Please refer to our Procedures page and also search this site for many other articles on this popular weight loss procedure.

Normally, the weight loss expected out of the sleeve is in the whereabouts of 50-80 percent of excess body weight. This is usually achieved in the vicinity of one year and may go on till three years, after which time there is usually no inherent weight loss from the surgery. This does not mean you will stop losing weight after that time. You could lose weight if your diet and exercise plans are on the spot. But in practice, weight loss plateaus in and around the third year. A recent study from India published in the journal SOARD reports a nearly 75 percent weight loss of the sleeve in three years.

(the stomach being stapled at BMI, Kolkata. Procedure done at Belle Vue Clinic)

So, the weight loss curve hits a plateau at a point in time. In itself, this is a benefit, as sleeve patients would shrink to oblivion otherwise! So, now that the weight loss plateau is upon you, what to do?

(the stapling process proceeds towards the direction of the foodpipe/esophagus)

Before we answer this, let us eliminate one important cause of weight regain* after the sleeve: a residual fundus. This means that the upper baggy part of the stomach, which is the source of the hunger hormone ghrelin, has not been fully removed by the surgery (usually a technical error). If this is detected, it is bad news.

*The definition of this is taken to be a weight regain of 10 kgs from the nadir (bottom) of the weight loss curve.

(the resected stomach being removed through one of the port sites)

In order to get the desired weight loss, re-surgery has to be undertaken. In such a case, we do one of the following:

1. Re-sleeve: using an endoscopic stapler, the extra fundus (the culprit) is excised. An option to create a narrower sleeve is also possible, but would mean more staplers, and higher cost.

2. Convert to a Roux-en-Y gastric bypass: especially if the patient is super-super-obese (BMI more than 60), where the sleeve is usually the first of a two-stage operative strategy. An alternative we can explore in the Western/Muslim/non-vegetarian super-super-obese patient is the Duodenal Switch (DS). The reason for this is that these patient classes usually eat enough proteins by way of meats. This is a very crucial consideration as the DS causes severe malabsorption of proteins and fats and can cause debilitating malnutrition in the vegetarian patient.

3. A banded sleeve. This adds an additional restrictive element to the sleeve, but has the disadvantages that a Lap Band normally carries (which is another full article). In short, high explantation rates, erosions, prolapse of gastric mucosa, esophageal dilatation, etc.

In a special section on sleeve gastrectomy published June 2010 in the journal Surgical Laparoscopy, Endoscopy & Percutaneous Techniques, I quote:

Similar to the banded gastric bypass, a band can also be placed in SG performed as ‘‘primary banded sleeve gastrectomy,’’ as published by Alexander et al. In this series of 27 patients, a band of 6 cm length made of biologic tissue (AlloDerm) was placed approximately 6 cm below the gastro-esophageal junction.

This is same, but different, compared to the former “secondary” sleeve banding described by Greenstein.

In some cases, improper eating (large feeds, drinking colas and binge eating) can cause the gastric tube (sleeve) to become dilated. Though the initial surgery may have been perfect, the end result is similar to that of a residual fundus after primary surgery: inadequate weight loss, or an early weight loss plateau. This is the reason it is critical to screen patients before surgery for eating disorders and psychiatric conditions that make for unreliable post-op compliance (which means we don’t want to operate on patients who won’t listen to us, and are likely to screw up the results of surgery and give us a bad name).

Let’s get back to the originally asked question. If you underwent a gastric sleeve surgery, and there were no operation-related problems and you lost 70-75% of your excess body weight in, say, three and a half years, BUT you put back 5 kgs in the last few months, what to do?

First, we evaluate the stomach: is it dilated? Is there a residual fundus?

If there is no surgically significant problem, we must get back to basics.

Our strategy is simple:

1. Motivation: talk, talk and more talk. Help the patient understand how results should be the focus, not eating.

2. Eliminate processed foods, sugars, sweetened beverages, alcohol, and other such temptations.

3. Reserve grains as a cheat meal, not as a daily component of the diet.

4. Put some patients on a low-carb diet.

5. Careful food journaling and monitoring of nutritional intake. An online journal may be kept for free at www.fitday.com (or similar sites).

6. Fish oil capsule supplements: 1.8 to 3 grams daily (around 6-8 caps daily).

7. Activity guidance: walk, cycle, play, climb, skip. Don’t sit, slouch, drive, ride.

8.  Exercise: strength training with cardio, both HIIT and long-slow cardio.

Once we hit the system with renewed vigor, you will soon be back on track with weight loss!

References:

1. Revisional bariatric surgery for inadequate weight loss. Gumbs AA, Pomp A, Gagner M. Obesity Surgery, Sept 2007.

2. Re-sleeve gastrectomy. Baltasar, et al. Obesity Surgery, Nov 2006.

3. The Spanish study on sleeve gastrectomy outcomes. Obesity Surgery, Sept 2009.

4. French prospective multicenter study: results at 1 and 2 years. Nocca, et al. Obesity Surgery May 2008.

5. LSG with minimal morbidity. Rubin, et al. Obesity Surgery Dec 2008.

6. Greenstein’s article link in SOARD.

7. Banded Sleeve Gastrectomy. Alexander et al. Obesity Surgery, Sept 2009.

(even men go crazy over hair loss!) Pic credit: here.

But who is man enough to tell a lady that her hair loss is not serious?

Though it is not possible to discuss the physiology of hair loss in any kind of detail in this platform, we should have a working knowledge of how and why this happens.

Hair follicles are the living part of hair, the latter being keratin strands without inherent blood and nerve supply. When hair follicles get less nutrition or blood supply, the hair falls off. The important things to understand here are that:

1. The hair follicle itself is capable of recovering fully and regenerating hairs, and

2. The hair loss that the patient notices is a reflection of the insult suffered by the hair follicle several weeks beforehand.

So, in practice, what happens is that a patient notices clumps of hair coming off in the bathroom or during sleep, three or more months after the gastric bypass. A panic appointment is made, and we take time to assuage the panic. Usually, women being women (please forgive the unintended sexism), the reassurance wears thin, as the hair loss continues. In the meantime, the visible scalp areas elicit comments in the patient’s family and circle (“OMG! What is wrong with you? My aunt had something like this, and they later said it was cancer!!” is one of the comments you may hear), and the panic washes up once too often (“But, doctor, you never told me about this!”).

True, as surgeons, while we dwell at length about leaks, thromboembolism, weight loss plateaus and other such major issues, we may not harp much on the hair loss thing. One of the reasons is that this is a reversible phenomenon. Once the weight loss is achieved and the patient’s nutritional intake comes to near normal, the hair loss stops and the regrowth is established.

Anecdotal reports of benefits exist for various supplements, including biotin, primrose oil and flaxseed oil and horsetail extract, among others. It is all up to you to experiment and find out which one would work magically for you!

One thing we do strongly advise is not to go for hair transplants and other major interventions like this. After all, there is such a thing called common sense: why over-think something that is self-correcting?

For a nice overview of nutritional and metabolic complications after bariatric surgery, read this article in Diabetes Care.

We need to now examine why these leaks occur. Is it the make of the stapler?

All over the world, surgeons use either the Ethicon stapler (called Echelon) or the Covidien product (the legendary endo-GIA). In our experience, while both are world class products, the mechanical problems arise with reuse of the stapler guns. In India, not many patients want to pay for a new gun. Surgeons also tend to give lower packages in an effort to be patient-friendly, thereby giving short shrift to a new gun (something that may cost nearly 20,000 to 30,000 INR, or in the vicinity of 400-500 USD).

If you reuse a gun beyond its shelf life, you can have misfirings during the operation. This is a ghastly experience which no surgeon should have. I have even had occasions where the stapler failed to unlock after firing! Clearly, no surgeon should allow a situation like this to happen, but how can he prevent it? After all, the stapler gun doesn’t say, “Don’t use me now, I am gonna die!”

What I say now may be controversial, but this is my humble experience of using laparoscopic staplers over a decade. The Covidien gun tends to work better with reuse, while the Echelon stapler works best when new. If I use the latter product in a case, I make sure I buy a new gun and throw it off (after all, these products were not meant to be reused!) after the case. Obviously, this pushes up the cost of the operation, but what can we do except to hope that the patient understands the reasons?

To come back to the point, reusing staplers is a tricky and potential troublesome issue. I have found no evidence in the scientific literature linking leak rates with reuse, but I suspect that there may be a relationship in some cases, at least.

In a personal communication with the authors of the Chilean paper I referenced in Part One, they opine that leak rates may be related to thermal injuries. This means that when we seal off and divide the blood vessels of the stomach, we may cause some heat injury to the wall of the organ. If such a part is left behind (rather than removed as part of the specimen) it may leak in the post-op period.

Another mechanism of leak: if the gastric tube is too narrow at the region of the body ( a point called the incisura) the resultant increase in pressure in the upper part of the stomach tube may lead to a blowout at the most vulnerable part above. This is usually at the junction of the food pipe and the stomach (the GE junction). This is borne out in clinical practice. The commonest site of a leak is the GE junction.

Another site of a leak could be the junction between adjacent staple cartridges. This is why it is considered important to oversew these junctions.

Does oversewing the staple line prevent leaks? We all think it  does, which is why practically all of us do so. However, as this Czech paper says, it may be unnecessary in most cases.

How do we detect leaks?

During the operation, we check the staple line by pushing in methylene blue dye into the stomach. A leak will be seen if present. Some people use an endoscopic verification of the staple line.

After the operation, a contrast (dye) study usually done just before liquid diet is started may be done, especially if intraoperative checks were not done, or a leak was detected and corrected at that time.

Does using staple line reinforcement reduce leaks? As this literature review says, no.

Which patients are more prone to leaks?

While the heaviest middle-aged male smokers are the stereotypical ‘bad’ patients, those who undergo revision surgery (for example, a sleeve with a band removal) are more liable to leaks.

How is a leak managed?

1. Ensure drainage of the peritoneal cavity (percutaneous, CT-guided drainage versus laparoscopic surgical placement of a drain)

2. Endoscopic stent to cover the leak, though a stent may migrate and be unsatisfactory in a given situation.

3. Suture closure of the leak after re-exploration of the abdomen.

4. Parenteral or enteral nutrition.

5. Mere observation in given patients

In most instances, the leak takes several weeks to dry out fully, and this results in prolonged hospitalisation and increased costs as well.

The important thing about leaks is to detect it early, as clinical examination in the severely obese is notoriously unreliable.

Useful references:

1. ASMBS position paper on Sleeve Gastrectomy 2009

2. Canadian overview on Sleeve Gastrectomy

3. World Journal of Gastroenterology 2008 Editorial

We as surgeons tend to counsel patients according to our own perspectives. I have never failed to acknowledge that, while I can place in a Band as well as another Johnnie, I have a distinct distaste for it. My counseling tends to betray this bias. I am objective enough to acknowledge this, while many others would put an evidence-based spin to their own colored viewpoint.

So our pre-op counseling tends to favor the sleeve. I do try to attract the patient to the benefits of the bypass, but I am careful when doing so. An inappropriate procedure in an unsuited patient can be a miserable experience. As I was saying before interrupting myself for the nth time, we tend to portray the sleeve as the safest procedure for the patient, with very negligible leaks and problems like bleeding. We tend to convey the impression that the expected complications are more likely to be those of any procedure in the severely obese patient, like embolism, pneumonia, infections, etc.

Now, if I can be brutally frank about this, we are not being entirely factual. Why? Because even an operation as safe as sleeve gastrectomy does have a specific leak rate in the literature. How much? If you look at a recent prospective study from the famous Chilean University Hospital known for the great surgeon Atilla Csendes, they had seven leaks in 214 patients, around 3 percent. This is higher than other papers like this one from Cleveland Clinic, where the leak rate was 0.7 percent. However, on the whole, a figure of 2.7 percent is an accepted leak rate arrived at from 24 studies covering over 1700 patients. To our surprise, we find that the leak rate of the sleeve may be more than after the bypass, an operation generally acknowledged as having more complication rates (Nguyen et al).

There are several major issues of import here:

Are the leaks stapler related?

Are these leaks reduced by staple line reinforcement methods like suturing or Seamguard?

Can we identify a subset of patients who are more susceptible to leaks?

How do we manage these leaks?

For all these and more, stay tuned for Part Two.

(B, a young patient who was 165 kgs, before surgery)

The same applies to ‘morbid obesity’. We call this ‘Clinically Severe Obesity’ now. Allegedly because the term ‘morbid’ is negatively prejudiced against the obese. Some time soon, they will replace the term ‘obese’ and call it ‘adiposely challenged’ or something, I have no doubt!

All said and done, what does it change? Does it change the fact that obesity kills more people than most other diseases today? If you want to know why obesity is not considered being healthy, have a look at this list of diseases associated with it. The term we use is ‘co-morbidity’.

(from Gen Surg News)

If you have had bariatric surgery and are now having reflux, what now?

(Are you worried about your reflux? Pic source: here)

We need to see what procedure you had. If you had a Band, tough luck! Because, as we mentioned before, the Band does cause reflux and also esophageal dilatation. Now, many surgeons will quickly accuse me of bias here. To which I plead guilty. I have always maintained that the Band is not exactly my favorite operation. While I maintain that it causes reflux in a lot of patients, there are conflicting reports worldwide.

For example, in Dixon’s study, they have found fantastic results after the Lap Band in terms of reflux symptoms and otherwise, too. Ten years later, the Australians reported excellent results in this paper.

(your favorite antacid may help. Pic: here)

After sleeve gastrectomy, reflux is temporary but may be distressing. If you have this problem, here is a list of what to do:

* Chew your food slowly or drink your liquids slowly.

*Avoid processed carbs

*Stay away from coffee, alcohol and tea

*Stop smoking, really stop it, will you?!

* Walk around after dinner

* Take an hour or two (or more) to sleep after dinner

* Keep the head end of the bed elevated

* Take PPIs as prescribed. PPIs are drugs that banish acid secretion.

* For short term burning sensation, drink  little cold water and have some preparation like Mucaine gel or Xylocaine viscous (local anesthetic).

* Contact the bariatric team for further advice.

After sleeve, reflux may be distressing and persistent in a small subset of patients. As this recent paper says, there may be an association between a wider proximal stomach tube and a narrower distal tube. This means that the upper part of the stomach tube is wider than the lower part. However, this is not related to the size of the bougie (the rod like thingie that is used as a sizer for the tube prior to stapling). Whether 3 cm or 6 cm of the lower part of the stomach (the antrum) is left behind has no relationship to the severity of reflux. Most of these patients also respond well to medical treatment.

Well, that should wrap up the subject pretty much for you! Please get in touch with us if you need more information.

So let us now assume that you are awaiting bariatric surgery and have reflux symptoms. So how does your reflux have an implication on your surgery? Will bariatric surgery (after all, we are operating on the stomach) make your reflux worse or better?

Let us take this procedure by procedure:

The Band: The band produces a mechanical obstruction right below the junction of the food pipe and the stomach. While this produces a barrier for the downward descent of food and accounts for the restriction in food intake after its placement, it does just the reverse for acid reflux. In other words, it tends to make reflux symptoms worse. Not to waste too many words on this, the Band is out if you have reflux.

The Gastric Bypass: This is the ultimate anti-reflux operation. It has a nearly 100 percent success in banishing reflux. After all, the pouch is separated from the stomach, where most of the acid is produced. What more, the small gut (jejunum) that is connected to the pouch acts to drain the acid away from the food pipe downwards. The special “Roux-en-Y” way in which we attach the jejunum to the pouch is the key to banishing reflux disease.

Sleeve Gastrectomy: Sleeve gastrectomy converts the stomach into a straight tube. In addition, it removes the part of the stomach from where muscle fibers go as a sling to loop around the LES (Lower Esophageal Sphincter). So it is possible that this operation weakens the sphincter and enhances reflux. In fact, clinically, most patients tend to have some degree of reflux after the sleeve, but this is self-limited and resolves soon. Once weight loss is begins, reflux also tends to reduce and go away.

In patients with a lax esophageal hiatus (the gap in the diaphragm through which the food pipe enters the abdomen) or with hiatus hernia, the sleeve can be done along with a repair of the hiatus (a procedure known as cruroplasty). This is also an accepted modality of treating reflux in the bariatric patient.

So the sleeve is a good bariatric procedure with a fairly good tolerance for the patient with some degree of pre-existing reflux symptoms.

The Duodenal Switch: This operation does not do much more than the sleeve for reflux. Indeed, the sleeve gastrectomy is the first part of the DS operation.

To sum up, if you are looking at bariatric surgery and you have symptoms and evidence of reflux esophagitis, then you should NOT consider the Band. If reflux is making your life miserable, then a bypass will be the best operation for you. If you don’t want the bypass for any reason, by all means consider the sleeve procedure.

In Part Three, we will examine the rest of the reflux story.

While a detailed discussion on the why’s and how’s of acid reflux are outside our syllabus in today’s class, it is important to just get an idea of the basic reasons why gastric acid gets up (against the tide) into the food pipe (esophagus).

The normal junction between the esophagus and the stomach is marked by a whorl of muscle fibers of the two organs that functionally works as a valve. This valve, called the LES (Lower Esophageal Sphincter) allows food to pass from the food pipe into the stomach, but not the other way. If it weren’t for this, we would keep burping up food into the mouth like infants. Now that wouldn’t impress our girl friends, would it?

(diagrammatic representation of the area of our interest. Pic source: www.chw.org)

In certain circumstances, the function of the LES is impaired, and the net result in the reverse entry of gastric acid into the food pipe (a place that is not adapted to acid pH). This happens if you eat too much, or oily/spicy/processed food, drink too much coffee or alcohol, or if you smoke. I am not even scratching the surface here.

In cases where the pressure within the abdomen is very high (as in advanced pregnancy or severe obesity) the excess pressure on the stomach overcomes the resistance of the lower esophageal sphincter and causes reflux. The food pipe gets inflamed as a result of the acid attack (reflux esophagitis).

In many instances there is a condition called hiatus hernia that causes severe reflux. This condition occurs when the junction between the food pipe and the stomach slides up into the chest cavity, as a result of which the positive intra-abdominal pressure pushes up the acid from the stomach into the esophagus, which is located in a negative (low) pressure zone inside the chest cavity.

With this background, we need to understand that most obese patients, specially those being considered for bariatric surgery, are chronic sufferers of reflux. However, it is important to understand that many upper abdominal or digestive symptoms (like pain after eating, vomiting, “gas”, for example) are due to associated gallstone disease.

Obviously, each of this is deserving of treatment on its own merit.

When we see patients, we evaluate the patient’s symptoms and consider reflux as a clinical diagnosis. The diagnosis is documented by other studies like upper GI endoscopy, barium study and esophageal manometry.

An ultrasound is always done to exclude gallstone diseases and to see the state of the liver. Fatty liver is almost always a given in the bariatric patient before surgery.

Now that we know what reflux is, how it occurs in the obese patient and how we detect it, we need to know what to do about it.

That will be Part Two.