Patients in Despair: Weight Regain after a Primary Bariatric Surgery Procedure

by Robin Blackstone, MD, FACS;
David Engstrom, PhD;
and Lisa Rivera, MPH

INTRODUCTION
Bariatric surgery is achieving increasing acceptance for the treatment of obesity. Obesity-and its role as the central paradigm of modern disease- is slowly penetrating into the consciousness of affected people, and they are increasingly hopeful of remission or cure from their medical problems through bariatric surgery. Primary care doctors, convinced by the positive results they see in patients treated with surgery, are more likely to refer their patients. Finally, payers at all levels are slowly beginning to appreciate there may be some long-term health and financial benefits. It is expected that the Medicare decision to cover surgical treatment for the indication of morbid obesity in their national coverage decision of February, 2006, will create additional pressure on payers and employers to cover these procedures. The publicity surrounding the laparoscopic gastric bypass on Carnie Wilson, widely publicized in People magazine in 1999, has also helped fuel an exponential growth in the number of procedures. The American Society for Bariatric Surgery (ASBS) has estimated that over 177,000 bariatric operations were performed in 2006.

One of the most difficult problems in the specialty is working with the patient who has failed to achieve control of comorbidities or weight through a primary bariatric procedure. An average of 15 percent (5–40%) of primary bariatric surgical patients, or 21,000 per year, will require a revision.1 Some reports suggest these patients will encounter more complications than a primary bariatric patient, and the results of surgery seem to indicate that their excess weight loss and resolution of comorbid diseases may be less than primary patients.2,3 However, only a small volume of detailed data regarding this group of patients is available. As programs and surgeons begin to work with patients seeking a revision, they will realize that in most regions of the country specific procedures were performed commonly in that area. After the first few patients are evaluated for revisional surgery, common causes of failure begin to emerge and an understanding of the specific anatomy is gained. Overall, an understanding of the history and development of the restrictive and malabsorptive procedures is essential to working with this patient group.4

This population of patients includes those who have a serious medical complication of a previous surgery, patients who fail to lose the weight necessary to achieve resolution of their comorbid disease, and patients who have regained their weight after an initial weight loss. Patients seeking revision due to a serious medical problem related to their procedure are usually more urgent than other categories of patients. Malnutrition in low weight patients who cannot keep any food down due to severe stricture, marginal ulcer with recurrent gastrointestinal bleeding, and slippage of the adjustable gastric band are a few of the issues that demand more urgent attention. In general, these patients seem to be at or below goal weight. Complex psychological issues may still exist but take a secondary role to evaluation and treatment of these more serious medical problems. Often these patients need to be seen for follow- up, but are reluctant to seek care because they fear regaining weight. If the patient has not lost a significant amount of weight since the primary surgery, then the immediate problem should be treated and the patient referred to the bariatric center for a formal evaluation.

The evaluation of a patient seeking revision of a primary surgery includes a complete history and physical exam, an extensive evaluation for psychological symptoms and psychosocial stressors, and dietary evaluation for patterns of behavior in regards to food. Further studies based on this initial evaluation as well as a defined plan of approach for the patient should be developed from this information. Obtaining the previous operative record and discharge summary is very helpful if it is available.

PSYCHOLOGICAL EVALUATION
It is important not to minimize the profound emotional and behavioral impact that bariatric surgery has on an individual. Lifelong eating habits must be suddenly altered and the effects of rapid weight loss on body image and psychosocial adjustment are dramatic. Certain aspects of the personality inevitably change and all relationships are affected by these changes. Historically, the idea that psychological factors might adversely affect surgery outcomes is based on several outdated but widely held assumptions that: 1) being obese is somehow psychologically beneficial to an individual (e.g., avoidance of close relationships) and 2) overeating leads to emotional satisfaction. It follows by this logic that if obesity is treated without addressing and resolving these psychological factors, any treatment, surgical or otherwise, will be compromised.5 Despite nearly 15 years of research on the psychology of bariatric surgery, there is still no consistent evidence that specific personality patterns or diagnostic categories lead to weight regain following surgery. In fact, investigators6 found that there was no association between preoperative psychiatric diagnosis and postoperative outcome. In another study7 where binge eating severity and depression level were assessed, it was found that both binge eating behaviors and depression levels actually improved following surgery. Beyond the purely psychological aspects of surgery outcomes, it has been found8,9 that some unsuccessful patients discover that frequent consumption of small amounts of liquid or soft foods “allow them to feel satisfied but avoid intolerable fullness or dumping.” This behavioral habit of eating many small meals throughout the day, commonly known as “grazing,” may shed light on some of the behavioral dynamics of unsuccessful surgery outcomes. Not much is known about the presence of these behaviors in patients who are candidates for surgical revision.

In a study of successful patients, defined by weight loss, reduction in medical comorbidities, and improved quality of life10 it has been reported that successful outcomes are related to 1) the absence of grazing behaviors, 2) a strong social support network, and 3) high self-motivation and self-efficacy, in that order. Again, personality patterns and psychiatric syndromes had very weak relationships with success. Further clinical outcomes research focusing on these and other psychosocial factors may help in describing differences between successful versus unsuccessful patients, as well as those who may require revision. Despite this complex and sometimes contradictory research, the psychological evaluation of patients who regain weight must be extensive and very individualized. Although the number of these patients is quite small, we have observed individuals in this category to suffer from postoperative depression and emotional eating, to be socially isolated either by choice or circumstance, or to fail to adhere to the basic behavioral rules, such as no liquids during mealtime and no between-meal snacking. Any thorough evaluation must include the patient’s entire psychosocial and behavioral history, both before and after surgery.

MEDICAL AND DIETARY EVALUATION
A determination of patient weight and comorbid disease is essential. The Ali-Wolfe comorbidity scale can be excellent at pinpointing the exact stage of comorbid status.11 If at all possible, an operative report and discharge summary and a detailed history of any complications that took place around the primary surgery will help the surgeon and team plan any further intervention. The team will need to determine whether the failure of the primary procedure is psychological, mechanical, or a combination of both. Once the primary procedure has been identified, an initial formulation of the problem can direct the subsequent workup. Patients may have a dilated gastrojejunal anastomosis, dilated pouch, or breakdown of a previous staple line as a mechanical cause of the weight regain. Choices for evaluation include endoscopy, computed tomography scan, and esophageal swallow/UGI. In our experience, the esophageal swallow is not as useful for estimating the dilation of the gastrojejunostomy or size of the pouch, and endoscopy is more helpful. It should be observed or performed by the surgeon. It is helpful if the patient can bring a food journal with them to the initial evaluation. The dietary evaluation will expose specific eating patterns that may have contributed to dilation of the pouch or gastrojejunostomy.

SPECIFIC REVISION PROBLEMS
Many surgeons start their revision cases doing open laparotomy. This allows them to understand the anatomy of the local variations and defends criticism by the hospital surgery committee when complications are encountered. Eventually, as the primary laparoscopic case load grows and an understanding of the anatomy and work involved in a revision are realized, the surgeon may safely begin to choose selective cases for a laparoscopic approach, depending on their level of laparoscopic expertise.

EVALUATION OF THE PATIENT WITH A PRIMARY ADJUSTABLE GASTRIC BAND (AGB)
Overall, the literature from outside the United States has established reasonable efficacy with very low complication rates for the adjustable gastric band.12-14 In a recent randomized control trial, Australian surgeons, led by Paul O’Brien15 seem to have outstanding success at weight loss with the band (87% EWL in the BMI group 30-35), which may reflect that these patients have much less weight Blackstone.qxp 3/28/2007 1:42 PM to lose or may represent the influence of the public health system or cultural tendencies of that patient group. The United States data is still very young, but recent four-year outcomes seem to verify that the band has a significant role to play in the treatment of morbid obesity. There is still some skepticism over whether the longterm results from AGB, which is also a restrictive procedure, will be better long term than vertical banded gastroplasty (VBG), which showed a 35-percent long-term excess weight loss at 10 years of follow-up.16 Even a 35-percent excess weight loss is advantageous to the patient but may not result in resolution of all comorbid disease. Conversion of a previous AGB is usually to a gastric bypass, which is a predominantly restrictive procedure. Conversion to a duodenal switch (DS) or biliopancreatic diversion (BPD), both of which are malabsorption- based, requires a different educational process be made available. 16 Few surgeons in the US, approximately 50, perform DS at this time.

The weight loss period with a band can extend to at least 24 months. During this period of time, the patient should be coached and additional methods of behavior control should be used. If a patient has failed to achieve the weight loss necessary to control major comorbid diseases after 24 months, we believe it constitutes one of the strongest indications for conversion.

EVALUATION OF THE PATIENT WITH A GASTROPLASTY
Gastroplasty procedures proliferated during the late 1980s and early 1990s. Many have a local variation, which may be named after the local surgeon. Usually these patients present with vomiting and show a breakdown of the staple line. The esophageal swallow may be very helpful in identifying staple line breakdown. Most of these patients will be converted to a gastric bypass with complete excision of the previous staple lines and are not usually amenable to banding because of the mechanical effect of the staple line breakdown.

EVALUATION OF THE PATIENT WITH A ROUX-EN-Y GASTRIC BYPASS (RYGB)
Based on early and intermediate outcomes, Bessler et al., have observed that patients with a dilated gastrojejunostomy are amenable to adjustable gastric banding.1 These data have not been substantiated by additional peer-reviewed literature, but anecdotal reports from surgeons seeing revision patients confirm that this approach is being considered. Further reports would be helpful to determine the success of this approach. Since the band is placed anatomically above the lesser curve, it is a relatively clean plane. If the original surgery was performed with a laparoscopic approach, few adhesions may have formed. Patients may have stretched out or have an enlarged pouch. This particularly applies to patients from the era prior to the 15–20cm pouch. Patients with an early stricture may have dilated the pouch in response to chronic overeating; nevertheless, the pouch can be revised. In our experience, it has rarely been necessary to revise the length of the Roux limb. The combination of adequate restriction with behavior modification can usually result in successful outcomes.

PLANNING
Once the initial evaluation period is complete, a specific plan for the patient should be developed. The patient needs to understand if a mechanical component is involved and its mechanism of action. In addition, surgeons need to convey the impact that specific behaviors are having on their outcomes. Psychological stressors should be discussed and a plan of therapy or support needs to be accomplished prior to revision.

Steps to educate the patient about nutritional choices and eating behaviors are essential. Specific dietary habits may need to be worked on prior to revision, even if the patient has a specific anatomical loss of restriction. We usually require a significant demonstration of medical weight loss working with the registered dietitian and psychologist prior to any revision surgery. The amount of weight loss required can help determine a patient’s commitment to the behavior that will be necessary to achieve weight loss after surgery. We have found that many patients were operated on in an era of surgery where education and programmed support were absent. Many of these patients benefit from the education and support that makes up a part of the standard bariatric program in 2007.

Occasionally, a patient will fail to achieve the demonstrated commitment to behavioral change that is requested. This means the patient has failed to achieve behavioral change during the initial procedure as well as in the period leading up to a possible revision. We have chosen not to offer surgery to these patients. We feel that revision surgery is usually the last surgical opportunity for the patient to lose weight, and their inability to change their behavior will herald subsequent failure.

Obtaining insurer preauthorization will be required and can be difficult. Some insurers and employers are putting lifetime maximums in place. This may force the patient to pay out-of-pocket for a potentially complicated procedure. This should be clearly discussed and the patient be made aware through the informed consent process about the potential risk of paying for a revision procedure in cash.

EDUCATION/SUPPORT
The cornerstone of a successful revision must be based on the patient’s accountability for his or her own outcome. Patients who regain weight after their primary procedure will inevitably feel frustrated and may adopt the belief, “The surgery let me down.” Blaming the previous surgeon or team may signal a failure of understanding of the patient’s role in the successful outcome of surgery. The use of a specific plan for the patient’s educational and psychological support allows the team to interact and build a patients’ confidence in their own ability to contribute to their successful outcomes.

Many of the patients currently seeking a revision did not have a chance to participate in a programmed approach to success. They may have had their procedure in much the same vein as an appendectomy or elective cholecystectomy. In those patients, education provides the opportunity to have a more successful outcome of their revision.

PROGRAM GOALS
Bariatric programs are committed to providing the educational, technical, and psychological support that, coupled with a clear understanding of the patient’s own accountability, has the maximum chance of achieving success in weight loss and comorbid disease resolution. Some failures will occur regardless of the commitment of the program team or the quality of the technique. The more connected patients are with the bariatric program, the more comfortable they will be in returning if they start to regain their weight.

Three elements the program can provide that may help patients who experience weight regain are the following: • Establishing a supportive community of providers of care to facilitate a patient’s return to a blameless environment. • A directed and monitored longterm follow-up program to facilitate getting patients back into care as early as possible. • Primary care physician education on the expected results of surgery, so they can refer their patients back into the bariatric program.

CONCLUSION
Clearly, weight regain after a primary bariatric surgery procedure is complex and multifaceted. Working with patients seeking revision surgery can be frustrating and difficult for the entire team. Patients sometimes have a feeling of desperation which translates into unrealistic expectations of the team. Receiving these patients into the program should be done only after a significant experience in primary bariatric procedures exists and should be performed in a tertiary bariatric Center of Excellence, where senior bariatric surgeons have extensive experience with providing intensive care to complicated patients.

Category: Past Articles, Review