What Happened?

From maniacworld.com

Into every life a little rain must fall.

Frequent music lyrics from a number of artists.  And, apropos for a patient who came in for a post op visit last week.

In the course of an unusually predictable day, I had a patient that I had seen a number of times in the past, and was in the office for her post op Sleeve Gastrectomy visit, closing in on 1 year post surgery.

She had a pre op history of HTN, OSA, Asthma, T2DM, and Depression.  Her start weight was 249 with a BMI of 45.5.

One of her ongoing issues from previous visits was the scarcity of her weight loss, and resultantly, the lack of significant positive change in her comorbidities .  At her visit last week, she had lost only a few pounds more than previous visits, had a history of a few pounds up and down in past visits, and her weight loss total, (including her 15# loss preoperatively) stood at a net of 0. 

That is, she was back to her pre operative weight.


How can that happen?


This issue, and this patient example, fortunately is not a common finding.  It is actually quite rare for a patient within their first year to lose very little, or actually start to gain at some time, already working against their expected mounting weight loss after their surgery.

As you can imagine, is is usually a neon red flag that something is up.

We had interactive, ongoing discussions from her previous visits, and the lack of her post op weight loss did have a cause.  She was going through some very rough times psychologically, with depression and having binge eating issues in response.  Some of the stress was likely brought on by her surgery, at least indirectly, but she also had new and significant stressors at home to deal with.

She fully admitted her issues, and her awareness about it's impact on the lack of success thus far from her surgery.  She was embarrassed and saddened about it, but was actively engaged in counseling and was slowly on the road to getting better in the mental health area.

A few key points.

Interesting, how most patients have a degree of "automatic" weight loss after surgery, most seeing the expected 60-80% loss of excess weight loss within that first year, but on occasion they do not.  Of those that do not, there are some practical prognostic signs can give us a tip off that something is up.

The amount of weight loss at post op visits varies widely, patient to patient.  There is no 'normal' so to speak, but lack of meaningful weight loss at earlier visits post op (1 mos, 3 mos, 6 mos), or weight gain often requires us to delve more into the history to see if there is a behavioral or dietary issue.

Specific and detailed questioning about portion sizes, junk food / empty calories, lack of protein, snacking, etc. may yield some clues.  A thorough exercise / activity review also is needed.

This being said, I also have a low threshold to call a patient out on a self-reported glowing history of bariatric lifestyle adherence, when it's in the face of fair to poor weight loss.

In the case of this patient, fairly superficial questioning allowed her to explain her psych issues, diet issues, and her understanding about the interaction between those factors and her lack of weight loss. Somewhat refreshing, actually, as I have had patients in the past with admittedly less obvious lack of weight loss, who have a hard time admitting to any correlative behavioral issues that may be at cause.

I did bring back this patient more frequently than our usual Q3 mos visits, in an effort to try and stay in touch with her, offer encouragement, and review proper lifestyle changes that were needed for better weight loss.

Sometimes you can only do what you can do.

We will continue to work with her, and support her as we can, and hopefully get her on track to realize some of the benefits she anticipated from her referral to us in the first place. Both for the weight and comorbidity benefit.

The honeymoon phase of 12 mos after the surgery is now nearly gone, but there still is hope if she can start to consistently use her 'tool' of her Sleeve the proper way long term.