by Tracy Martinez, RN, BSN
Ms. Martinez is Program Coordinator of Wittgrove Bariatric Center, La Jolla, California.
Morbid obesity is a chronic disease for which we have no cure. However; bariatric surgery is the most effective and powerful intervention currently known in medicine. Postoperative weight gain, however, is possible and will be seen by every practitioner in every program.
Weight loss results are individual, but different bariatric surgical procedures have ranges of expected weight loss. Laparoscopic adjustable gastric banding (LAGB) weight loss is 61.6 percent, standard gastric bypass is 68.2 percent, and biliopancreatic diversion is 70 percent. Weight loss is also dependent on patient selection, education, and long-term follow-up.1 (Figure 1. The Clinical Pathway at Wittgrove Bariatric Center.)
Patient selection includes patients who have been cleared by a trained psychologist to insure that there is no untreated or uncontrolled psychological disorder that may impede their success. Medically, patients need to be cleared to make sure there are no endocrine (thyroid) abnormalities or medications such as long-term steroid use that can affect acceptable results.
Education of the patient—and the patient’s willingness and compliance to be educated—on how best to manage his or her disease after surgery from a nutritional, physical exercise, and commitment to follow-up visits and lab surveillance is imperative for success.
A question for debate among clinicians is not only how do we define success after surgery, but—for purposes of this article—how we define weight gain and failure? Is it body mass index (BMI)? Percentage of weight regain? Return of comorbidities? Patient’s perception? Or a combination of all of these?
I believe most practitioners would agree that BMI and return of comorbidities are red flags and should be considered serious. Intervention is indicated if and only if the patient is willing and committed.
One question that should be asked once weight gain has occurred is who failed whom. Did the surgery fail the patient or did the patient fail the surgery?
How Does the Surgery (or Program) Fail the Patient?
There are several reasons why this can occur. First it may be due to lack of appropriate preoperative assessment. This can include a patient who is at higher risk for noncompliance. Appropriate and thorough preoperative psychological evaluations by a trained psychologist with knowledge of bariatric surgery can often prevent this from occurring during the patient selection process.
Was there inadequate informed consent and preoperative teaching? If so, the patient may not understand or be willing to adapt to the postoperative guidelines necessary for success. These guidelines include the importance of protein intake; restricted smaller portions; vitamin replacement; support group attendance; daily exercise; and close follow-up. Adequate protein intake during weight loss plays an important role in long-term weight loss success because it prevents muscle mass loss, therefore preserving lean muscle mass. Losing too much muscle mass during weight loss can adversely compromise an individual’s basal metabolic rate.
Technical problems that occur either at the time of surgery or after surgery can lead to failure. Some of these technical problems include large pouches or fistulas with gastric bypass, band erosion, or improper placement of the band, which can leave a large reservoir and therefore limit weight loss or make it much more challenging. Although there is no proven study or data to support that one procedure is more beneficial over another for any one specific patient, would a known sweet eater benefit as much with a LAGB versus a gastric bypass?
Why Does the Patient Fail the Surgery?
This answer can be very complex. It seems the most significant reasons may be that the patient is not following the postoperative guidelines by snacking and/or making bad nutritional choices. Additionally, lack of exercise can slow weight loss, but more importantly, exercise plays a very important and potent role for weight maintenance.
The importance of support group attendance in long-term success and compliance should not be underestimated. Several studies have demonstrated evidence of the importance of the support group in the scientific arena. There have been documented studies on better medical outcomes with individuals who regularly attended support group versus those who did not.
Poor follow-up often leads to poor results. Scheduled follow-up allows the clinician the opportunity to provide education on where the patient may be getting off track early in the weight regain phase. Reemphasizing hydration, vitamins, exercise, protein intake, and other nutritional guidelines continues to reinforce necessary lifestyle changes for long-term success. This opportunity is diminished with minimal or no follow-up. Accountability seems to play a significant role long-term.
Revision Versus Behavioral Modification
Revision bariatric surgery should be considered only when the surgery has failed. The failure should be evidence based—in other words, well documented by upper gastrointestinal, endoscopic, and other diagnostic studies. A thorough medical workup and a specialized informed consent should be completed.
When diagnostic studies have demonstrated that the primary surgery has kept its integrity, behavior modification and education need to be implemented. It is important that your program designs a “back on track” process. This should include the following:
• Request the patient fill out a questionnaire that reviews daily dietary intake and food choices, hydration, snacking habits, vitamin compliance, and exercise activity.
• A step to reeducate and review all postoperative guidelines and reasons for each one.
• Get the patient back on track with regular follow-up visits and lab
• Review the importance of adequate (64 oz.) water intake, appetite control, and ability to gauge whether they are hungry or thirsty. It seems the body can not tell the difference between hunger and thirst. Keeping the body well hydrated allows better assessment of hunger.
• Stress exercise as imperative for weight maintenance. Review the importance of aerobic and anaerobic exercise as a key for success.
• As adequate protein intake in the form of lean proteins allows longer satiety, reinforce the importance of limiting simple carbohydrates to control hunger.
• Patients need to control snacking. They must be told that snacking is the saboteur of bariatric surgery. The hope is that with the improved mindfulness of increased hydration and protein intake, snacking can be minimized. If patients are hungry, educate them to choose a lean protein instead of a snack food that is commonly a simple carbohydrate.
• Reinforce how and why simple carbohydrate snacking fuels hunger and continues the cycle of eating. If the patient is psychologically hungry as opposed to physiologically hungry, psychotherapy should be considered. Psychotherapy can be extremely beneficial to those individuals who disclose (or are suspected of) emotional eating. Having a well trained specialist that understands both bariatric surgery and eating disorders can best serve the patient and your program.
• Adequate vitamin replacement is important for overall health as well as prevention of serious deficiencies. Vitamin deficiencies can increase hunger and decrease metabolic rate. Reinforce the importance of complying with vitamin supplementation guidelines.
• Support group attendance is important to build momentum and accountability and should be incorporated into all postoperative processes.
• A food intake and exercise diary can be a great teaching tool for patients to be aware of habits. Meals and exercise become more mindful activities when recorded. Becoming cognizant of one’s eating behaviors helps the patient toward long-term significant change. Writing down food intake allows the patient to be aware of foods consumed and allows the clinician to counsel the patient on better choices.
• Pharmacology support may be considered.
The reeducation process can be very time-consuming; therefore, programs should consider “back on track” classes for individuals who have experienced weight gain that is not due to surgical failure. A Powerpoint presentation with written supportive literature reinforces multidisciplinary key guidelines. The multidisciplinary team should participate by presenting topics within the realm of their respective specialties. The course may consist of two or three classes to provide in-depth education, and may be offered quarterly, depending on your patient load. Charging a course fee should be considered.
In summary, all bariatric programs should have a method to treat patients with weight gain. This process should be organized and include a multidisciplinary team approach. We realize that morbid obesity is a chronic disease and surgery is a powerful tool. Teaching patients to work with their tool (and not against it) to keep this chronic disease at bay is the goal.
The best way to treat weight regain is by prevention. Certainly the operation needs to be done precisely. Beyond that, we should try to stimulate our patients to be committed to a new lifestyle through education and example.
Remember, there are some patients who cannot be effectively managed by the program alone but are better managed individually by a psychologist or psychiatrist. Lastly, welcome all seekers without judgment and congratulate them for seeking help. Have a detailed and organized educational plan supported by a clinical pathway to insure thoroughness.
1. Buchwald H, Avidor Y, Braunwald E, et al. JAMA 2004;292(14):1724–37.
Category: Patient Management Perspective