The sea of fat drowns the external genitalia in the very obese, making them hardly visible. The men are unable to flaunt the male organ leave aside being able to penetrate. This lack of visibility sometimes occurs during erection too! An obese woman’s vagina may be visible only if one separates the entire fat covering it. Such physical disadvantage can even translate into difficulty in masturbation. At BMI, we have patients who have suffered psychological stress due to their inability to masturbate.
Attaining a normal intercourse in these individuals may require a lot of innovation by the partners – the right position and attitude- something that may not be easy on a regular basis. There is a lot of talk about the modification of various sex positions to facilitate the act in the obese. There is a male dominant position, female dominant position, rear entry position, Sim’s position, upside down position, T square position, X position, etc. The recommendation of various positions during sex in a fat individual is a testimony to the difficulty faced by the severely obese in performing the sexual act. As a rule, the bigger the individual, the bigger the problem. The lack of discussion on this highly sensitive topic- by the obese people and the society alike- is definitely of no help.
“I did not feel like having sex after some months because at 160 kgs I did not know how to do it. I was ashamed and even frustrated by my inability to satisfy my husband’s needs”, said Neha, one of our patients.
Interestingly, the most direct effect in dampening a sexual relationship in an obese couple comes from dieting. Prolonged semi starvation as an effort to reduce weight can itself dampen the libido!
The obese are also often beset with fears and prejudices. They may be more prone to doubt their partner’s sincerity because of their insecurity. Self-hatred manifests itself in a number of anti-erotic behaviors. Some women are reluctant to act seductively for fear of rejection and ridicule. Young women often have the desire to look ‘sexy’ and wear seductive clothes, but fear that men in particular will not appreciate them. It is also known that many obese people attempt to hide their bodies under cover of darkness, or keep their clothes on during sexual intimacy.

Bariatric surgery is one of the ways all this can be effectively addressed in a severely obese. Once these people start losing weight, one of the benefits that is immediately evident to the patient is that their genitalia becomes visible as a result of the fat melting all around it. Most patients after bariatric surgery have a sense of elation and this mood elevation also translates into greater libido. The positive benefit on the sexual life of an obese is one of the underrated but a key advantage after bariatric surgery.
In a nutshell, sexual difficulties among the obese are a more common problem than one would expect, and they deserve treatment, but everyone chooses to ignore the issue. As such it has become an elephant in the room. It can be addressed with the help of sex education, psychological counseling, weight loss either by diet and exercise or by more aggressive methods like bariatric surgery.

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Overview

When these situations arise, the surgeon has a lot of work to do. As starters, he or she needs to find out what caused it. Is it the technical failure of the procedure or is it the noncompliance of the patient to diet and lifestyle modifications? The patient can cheat too, you know.

On the basis of what is wrong, surgeons may recommend medical management in terms of dietary and lifestyle modification or another intervention (which is technically called revision bariatric surgery).

Common scenarios

The common bariatric procedures are – Lap Band, Lap Sleeve Gastrectomy and Lap Gastric Bypass. Most of the problems of inadequate weight loss are seen in Lap Band and Lap Sleeve Gastrectomy. This happens because these procedures work on the principles of only restricting the quantity of food and drinks. This makes it possible for the patient to eat and drink, however little in quantity, high calorie dense foodstuff (colas, chocolates, for example) and thus cheat. Obviously these subjects are not going to lose weight adequately. Also the Lap Band in particular has a high failure rate due to slippage, malposition and erosion of the band. The Lap Gastric Bypass is immune to this cheating as because the procedure makes the patient intolerant to sugary foods and also because it works by causing non absorption of ingested food, too. However, it is still possible to have inadequate weight loss after Lap Gastric Bypass if the pouch (small remnant of the stomach which is joined to intestine) is large sized or if the stoma (orifice joining the stomach and intestine controlling the speed of transit of food) is big.

What to do? Or not to do

The best thing to do in “cheaters” are to identify them before surgery and tell them politely that it is not going to work for them unless they are going to participate in the weight management process too. Even better, refer them to your friends. Why suffer with a poor reputation at the expense of a noncompliant patient. If identified after surgery, these patients need to be managed by counseling regarding food habits alone. Mostly they do not need surgery.

The other situation of inadequate weight loss may be due to technical reasons like dilatation of the pouch/ remnant stomach after the primary bariatric procedure. This may be due to faulty technique (big pouch, inadequate removal of stomach especially the fundus) or due to gorging (excess food here acting as a dilator). The latter is because of binge eating disorder, something that should have been identified and eliminated before surgery. These patients will benefit from revision surgery.

What are the surgical options?

The following are the commonest options for bariatric revision procedures1:

1. Lap Band – an inflatable silicone prosthetic device that is placed around the top portion of the dilated left over stomach. This will slow down the passage of food from the stomach to intestine and decrease the eating. This procedure can be performed as a revision procedure for patients who have had a Sleeve Gastrectomy or Gastric Bypass surgery but have regained weight due to dilatation of the pouch/ remnant stomach.

2. Lap Gastric Bypass is a commonly chosen revision technique2 particularly in patients who have not been successful in meeting their weight loss goals after Lap Band or Sleeve Gastrectomy. Often the really really obese (super obese) may be offered this as a preplanned strategy as a two stage procedure. Here, the first operation is usually a Sleeve Gastrectomy and the second surgery in the form of Gastric Bypass is performed only after a modest weight loss has taken place. This reduces the risk of complications with a single shot gastric bypass that is a technically more demanding procedure especially in the super obese. The weight loss success rate after Gastric Bypass revision surgery is generally excellent.

3. StomaphyX is a new kid in the block. This procedure is a completely endoscopic procedure3. This obviates the need to perform any second surgery. Imagine, having an option where no scalpel (for the second time, for God’s sake!) is required. Here a stretched gastric pouch is made smaller by using internal sutures or fasteners through an endoscope. It may be used in patients who have had prior Gastric Bypass surgery and have a stretched stomach pouch.

Outcome of revision bariatric procedures

The revision procedures should not be taken lightly. They have their own share of problems despite their efficacy. In a recent article published in 2010, Dr Spyropoulos4 has published data regarding the outcome of revision bariatric surgery. As can be obviously guessed, it is way higher than with initial procedures. The anastomotic leak rate is (the most important complication as far as safety is concerned) is 13.1%. Compared to the standard leak rate of 0.5-3% after primary bariatric surgery, this is hell of a lot. Hernias, stenosis (narrowing of outlet orifice) and intestinal obstruction are also more frequently seen.

However, the benefits are also encouraging. The weight loss achieved in revision surgery is substantial (body mass index drops from a mean of 55.4 kg/m2 to a mean of 35 kg/m2 ) and most patients are satisfied with the results.

Take Home Message

The message is that these procedures should be done by experts with experience to make it as safe as possible.

I have always found convincing patients for second surgeries (after any surgery for that matter) a difficult task. The patient may take the entire previous exercise as a failure. The patient may lose confidence in the surgeon. However the patient would also need to understand that the only failure is in giving up. And there are now options available (even endoscopic) to rectify the primary surgery if desired results are not attained. Having said that, we at BMI believe that the most important management of inadequate weight loss after bariatric surgery is to prevent them by identifying the noncompliant patients and by meticulously performing first surgery. If however, the weight loss is not adequate, the Revision Bariatric Surgery should be taken with utmost regard given to case selection and safety.

REFERENCES:

1.Medical and surgical options in the treatment of severe obesity, Barry L. Fisher, M.D., Philip Schauer, M.D., American Journal of Surgery, Volume 184 • Number 6B • December 2002

2.The weight reduction operation of choice : vertical banded gastroplasty or gastric bypass, Capella JF et al. The American Journal of Surgery, ISSN 0002-9610, CODEN AJSUAB

3. The role of endoscopy in bariatrics, Shou- jiang Tang MDa and Don C. Rockey MDa, 2008 American Society for Gastrointestinal Endoscopy. Published by Elsevier Inc.

4. Spyropoulos C Arch Surg. 2010;145:173- 177.

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1. Pories WJ et al. Who would have thought it? An operation proves to be the most effective therapy for adult onsat diabetes mellitus. Annals of Surgery 1995; 222:3

2. Henry Buchwald et al. Bariatric Surgery: Systematic Review and Meta-analysis. JAMA 13 2004; 292(14): 1724-37.

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Since the last couple of years, however, it has become commonplace to do tight sleeves over bougies 32-36 Fr. The idea is that a tighter sleeve is more restrictive in terms of stomach capacity and would give faster and better weight loss.

This article examines the truth.

Gagner et al had published an article in Obesity Surgery in 2008 showing better safety profile in their own series for patients who had 60 Fr sleeves compared to those who had narrower 40 Fr sleeves. Today, however, we are talking of much tighter sleeves. The question, therefore, could be “Does a sleeve twice as tight as a conventional 60 Fr sleeve give better results?”

Recent studies have shown that tight sleeves have shown good results. In fact, many of us in India have no regrets doing tight sleeves, with equivalent weight loss in the short term and 85-100% resolution of diabetes mellitus.

At BMI, we use around 34 Fr or 38 Fr, but end up with a slightly tighter sleeve because of meticulous oversewing of the staple line.

The most important consideration in designing a tight sleeve is to ensure that there is no narrowing at the level of the incisura (the sag-point of the stomach where the organ turns horizontally towards the right of the patient). A narrowing will cause a leak at the GE junction or lead to persistent vomiting later, necessitating invasive treatment later. All in all, a highly regrettable outcome could ensue, so it is wise to leave a wider incisura than make it too tight.

Some new thoughts are also currently being aired on improving outcomes after the sleeve. Could the gastric tube, detached from its greater curve attachment of gastrocolic (“greater”) omentum, get coiled up later and impair emptying of the organ? Would it be wise to re-anchor the omentum to the stomach tube?

We really don’t know yet. Interesting possibilities abound, but the truth is by no means established.

In recent times, several studies have reported no increase in complications  when the staple line is not reinforced with stitches. In fact the last one I read talked of zero leaks in  more than 500 cases. At BMI, we have now switched from ”meticulous suturing of the staple-line” above to stitches placed at the junction of adjacent staple lines.

And, so far, we are free from the disaster of leaks (knocks on wood).

So, if we create tighter sleeves with a narrow bougie (between 32 and 36 Fr) would we have a higher rate of strictures? No. In a recent article in a journal, Zundel et al have reported a 0.26 % stricture rate. The cause of stricture may be:

1. A hematoma (blood clot) causing compression

2. Stitch causing narrowing

3. Ischemia due to inadvertent vascular injury to branches of the left gastric artery.

4. Kinking of the gastric sleeve (due to stitches, stapling technical errors, etc). This can occur regardless of sleeve size.

5. Fistula: the associated inflammation causes narrowing.

6. Band removal cases, usually associated with much fibrosis.

7. Mucosal edema and food impaction can also cause acute blockage.

References:

1. Gagner M, Deitel M, Kalberer TL, et al. The Second International Consensus Summit for Sleeve Gastrectomy, March 19-21, 2009. Surg Obes Relat Dis. 2009;5:476–485.

2. Frezza EE, Reddy S, Gee LL, et al. Complications after sleeve gastrectomy for morbid obesity. Obes Surg. 19:684–687.

3. Lalor PF, Tucker ON, Szomstein S, et al. Complications after laparoscopic sleeve gastrectomy. Surg Obes Relat Dis. 2008;4: 33–38.

4. Zundel, et al. Strictures After Sleeve Gastrectomy.

Surg Laparosc Endosc Percutan Tec, Volume 20, Number 3, June 2010

5. DE Bellanger, FL Greenway. Laparoscopic Sleeve Gastrectomy: 529 cases without a leak.

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1. Hagedorn, J., Encarnancion, B., Brat, G., & Morton, J., “Does gastric bypass alter alcohol metabolism?”. Surgery for Obesity and Related Disease 3: 543–548.

2. Maluenda F, Csendes A, De Aretxabala X, Poniachik J, Salvo K, Delgado I, Rodriguez P. Alcohol absorption modification after a laparoscopic sleeve gastrectomy due to obesity. Obes Surg. 2010 Jun; 20(6): 744-8.

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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.

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