BMI » weight loss failure

MAKING THE MOST OUT OF LIFE AFTER BARIATRIC SURGERY

ramana — Sun, 08 May 2011 13:26:34 +0000

Those who undergo or contemplate bariatric surgery do so essentially as a second chance at life. I mean that the severely obese man or woman feels that he (or she) has lost out in life on multiple fronts. Here are a few examples:
Loss of body contour/beauty: you can’t forget how you were once before the fat started piling on.
Poor self image: you hate the thing you see in the mirror.
Poor quality of life: you can’t dance, surf, skip, run or walk without some kind of pain or discomfort. Going up one floor makes you breathless. You avoid holidays where you would need to walk, especially on hilly terrain.
Sexual issues: whether it is inability or unwillingness of one’s partner, sex life may take a back seat or even come unseated!
Health loss: you suddenly have been diagnosed to be having diabetes or heart disease (or anything else) and, suddenly, life sucks!
Social alienation: Even though there have never been as many obese people in the planet as the present, the morbidly obese individual catches everyone’s eye the wrong way. People make jokes, there is job discrimination, and even marriages get burnt!
The need for bariatric surgery serves as the wake-up call. What many people don’t realise is that bariatric surgery should not (and is not) a short cut. You cannot eat all you want and stay slim after the surgery. Therefore, if you look at the long term figures of weight loss after bariatric surgery, it may be as low as 40 to 50 percent, though the initial weight loss achieved may be 75%.
Obviously, we know weight regain is an issue for patients, and has to be addressed properly.
Even better is if you can program your life to prevent weight regain.
An unnamed BMI patient (we take our patients’ privacy seriously) writes to me:

Seems like such a long time ago that I was through surgery. I am still learning what I can and cannot do regarding food. I have a different attitude towards food now, which I never would have believed possible. I find the Paleo Diet hard to follow but have taken some of it on board and restrict foods, such as bread and potatoes to a bare minimum (a couple of slices of bread per week) and I haven’t eaten rice since surgery. I eat an egg for breakfast and sometimes mushrooms. The days of a full Ulster fry-up are long since gone, and dinner is served on a small side plate. I see the portions people eat and shudder. I have seen me ask for a children’s portion and still not finish it. I still have some milk in coffee and I eat natural yoghurt, which is not permitted but in general, my eating habits have really improved. Fresh fruit and veg, and some fish or chicken. I can only digest minced red meat and even then, only in small quantities, but nothing can equal how I feel.

(Eat This!)

(And This!)

As I keep saying, eat natural foods and avoid man-made food products.

(Stay strong when life tempts you!)

She reflects the pursuit of that kind of eating style (like primitive or Paleo man) that I teach. In addition, she has taken up kettlebell training and getting active in general. What does a lifestyle like this (without chips, pizza, cakes and bread on a daily basis) feel to the mind?

I can’t really explain the change which has occurred inside. I have my positive attitude back and feel I can tackle the challenges with more confidence than I have had in ages. The fact I am free of all medication is also a tremendous bonus.

And the bonuses keep coming to keep you motivated.

I saw my cousin today and she couldn’t believe how well I looked since the last time she saw me. I didn’t tell about the surgery, reasoning it was my business and she didn’t need to know. She congratulated me but then admonished me not to put it back on again. I assured her that wasn’t going to happen and left it at that.
I’m enjoying being normal and, for the time being, I am happy about that. I remember you saying that was a very low priority but for the moment, I am content. I now weigh what I did in 1995 and most people have never seen me this size so it comes as a bit of surprise.

Thank you, my dear (you know who you are): these words have inspirational content that mere doctors can only hope to provide!

All photos are original property of BMI.

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LIPOSUCTION TO LOSE WEIGHT: WHY NOT?

ramana — Mon, 02 May 2011 17:22:14 +0000

In the last two decades or so, people have recognised (mistakenly, as you will see) that surgery for weight loss means liposuction. It has become a tiresome but necessary ritual for us to explain to our patients that what we do is bariatric surgery, not liposuction. Liposuction is local removal of subcutaneous fat from a specific body part (like the belly or the thigh or butt). Bariatric surgery, on the other hand, is operating on the stomach and/or intestines to effect a reduction in one’s ability to eat food, reduce absorption of food and to promote fat-burning metabolism. Bariatric surgeons are not known to remove even an ounce of fat!

Now, everyone knows that bariatric surgery is a serious undertaking for the patient with its potential for complications (about which much has been written by us in this website). Everyone also knows that liposuction is a simple way of removing body fat without any complications. Some plastic surgeons or slimming centers may encourage this line of thinking by being effusively positive and optimistic about the benefits of the procedure.
The ethical and responsible plastic surgeons (and we know several) clearly know the place of liposuction in the management of the obese patient.
They explain the potential complications of liposuction as including infection, embolism and skin complications. They reserve it largely for spot reduction, a cosmetic indication, avoiding the obese patient who needs more than spot reduction of a few pounds of fat.
Additionally, I have always suspected that post-liposuction, the patient (whose lifestyle usually goes unchecked) puts on more fat that accumulates in other body parts, leading to an unsightly obesity. Today, my suspicion stands vindicated.
As the New York Times reports:

…fat came back after it was suctioned out. It took a year, but it all returned. But it did not reappear in the women’s thighs. Instead, Dr. Eckel said, “it was redistributed upstairs,” mostly in the upper abdomen, but also around the shoulders and triceps of the arms.

However, the human mind likes gratification, even if it lasts all of one year (heck, even one minute of a sweet treat is irresistible), and so the study shows that the women still were happy with the results of the liposuction, in spite of more belly fat than before. Irony.

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GASTRIC BYPASS: CHOOSING THE STOMA

ramana — Thu, 21 Apr 2011 00:00:49 +0000

Weight loss after the lap gastric bypass is a well known fact. What is less known is that there is a certain degree of weight regain in some patients in the long term.

Before we proceed, do you know what is a lap gastric bypass all about?

An important factor to be considered by every patient/doctor involved in a gastric bypass is how the stoma for the pouch would be created, as it is one of the known factors leading to weight regain.

The stoma is the opening we create between the gastric micro-pouch and the upper small bowel (jejunum). Too big a stoma will lead to food exiting the pouch quicker and resultant weight regain. Too small a stoma would lead to obstructive symptoms and misery.

So what is the ideal stoma size: 12 mm, 14 mm, 18 mm, or 25 mm? And how would we create this stoma? Does the stoma size stay that way all life at the same size?

Easy, tiger, easy. One thing at a time!

Ideal stoma size:
Different people seem to be using different sizes. A popular way of creating the stoma is with the EEA circular stapler and the OrVil device. The stoma created is either 21mm or 25mm in size.
The stoma is a little big but it is known to contract in size later. The risk of stenosis being highest in the circular stapler group, it is perhaps better to keep stoma size around this level. A smaller stoma may stenose and cause obstructive symptoms. The incidence of stenosis is less than 3 percent.

The hand-sutured technique (my personal favorite) is known to stenose the least in the long term. Here the stoma size is 12 mm/36 Fr. In case you are wondering how we can measure in millimeters in lap surgery, we pass a 36 Fr gastric tube through the mouth into the pouch. The anastomosis between the pouch and the jejunum is fashioned over this tube.
A stoma can be created with the Linear Stapler. This leaves the anterior (front) walls open, and need hand-suturing to complete the process. The stoma also tends to be excessively wide, in my experience. Therefore, at BMI, we don’t favor this method, preferring the hand-sewn and EEA techniques instead.
So the keen patient here would be wondering, “Which is better or best?”
Like most things in life, it depends. Each method of stoma creation has its pros and cons.
The EEA circular stapled method is quick and mechanised, so suturing is not a major issue. The stoma is reliably and safely created, with minimal leak rates. However, it is expensive, needs the surgeon to be familiar with the device, and has the highest stenosis rates. On top of that, technical disasters are not unknown (study in colorectal context).

The hand-sewn method (best demonstrated by Kelvin Higa) is also safe, reliable and avoids mechanical stapler failures and disasters. It needs the highest level of skills in the surgeon, and is more time consuming in most hands. Experts, however, can complete this quickly.

The Linear Stapler method is easy for most surgeons, but has very little to recommend it.

One final issue with the stoma: do we need stoma to be buttressed, or glued? It may by nice to do and for us to see in the operating room, but it probably does not reduce leak rates significantly. In the high-risk patient we may choose to use it. Some studies do report significant benefits in reduction of bleeding, leaks and stenoses.

The bottomline is to ask your surgeon how he would create the stoma, and what he prefers. Then make up your mind to go for it. You have more to gain by that decision: that one thing that will transform your life.

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WEIGHT LOSS PLATEAU AFTER SLEEVE GASTRECTOMY: WHAT NOW?

ramana — Wed, 30 Jun 2010 16:09:41 +0000

Weight loss plateaus may occur in certain patients who have undergone a sleeve gastrectomy as a primary bariatric procedure. What are the causes? What is the next step?
What is the prognosis for these patients?

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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