Discover 3

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VALERII__DEX/SHUTTERSTOCK

Sometimes I’m called upon to look
for and treat problems after bariatric
surgeries. Rebecca’s weight gain
suggested that a complication had
developed from her procedure.
I threaded a flexible fiber-optic
camera down through her esophagus
and into her stomach pouch. I
discovered a hole, or fistula, between
her pouch and the rest of her stomach.
Food was leaking through the fistula
into the larger stomach, then passing
through her entire small intestine. She
was able to eat much more than her
pouch would have allowed, and her
body was absorbing everything she ate.
Her weight gain made perfect sense.
The procedure to fix the problem was
performed the next day. Using tools
passed through the endoscope and into
her stomach, I closed Rebecca’s fistula
with metallic clips.
Then we did the leak test. In the
radiology department, she drank a
special liquid visible under X-ray. The
liquid flowed through her pouch and
intestines in real time on the X-ray
screen. There was no leak. I discharged
Rebecca with instructions to follow up
as needed.

FAT REDUX
Two months later, she was back and
more anxious than before.
Rebecca had gained 15 pounds since
I last saw her. Assuming my closure
of her fistula had come undone, I did
another endoscopic investigation. I
found no fistula, so I arranged to have
Rebecca drink the X-ray-visible liquid
to find any other structural problems
that could explain her weight gain.
I found nothing.
A week later on a follow-up visit,
Rebecca was still upset and had gained
3 more pounds.
“Are you sticking to your bariatric
diet?” I asked.
“Yes, for sure,” she told me.
“Are you still exercising like you have
been?”
“I go for a long walk every day.”

After bariatric surgery, patients

need to follow a highly regimented diet

with appropriate vitamin supplements.

Most of them eat significantly less than

people who haven’t had the surgery.

They might consume 800 to 1,

calories per day, with many averaging

about 1,000 calories a day. (Typical

adult women consume about 2,

calories a day to maintain weight.)

This enables them to stay at their lower

weight. Patients must avoid high-fat

and calorie-dense foods, which include

most junk foods.

Despite her denials, I remained

concerned that Rebecca was way off

her diet plan. She had told me during

earlier visits that binge eating was one

way she dealt with stress when she was

younger. I instructed her to keep a

food journal and scheduled a follow-up

in a month.

MILKSHAKE RENDEZVOUS

Two weeks later, on a Saturday, I was

at a local shopping mall with family.

We were standing in line at an ice

cream vendor in a food court when I

spotted Rebecca a few people ahead.

I overheard her order a chocolate

milkshake. After paying, she turned

and saw me. I nodded, and she

quickly averted her eyes, visibly upset.

When it was my turn to order, I asked

the counter person how many calories

were in the milkshake. I was stunned:

over 1,300.

On Monday, Rebecca showed up at

my clinic. In tears, she revealed that the

weight gain caused by her fistula had

triggered behaviors from years ago,

before her bypass surgery. She felt she

was losing control over her body and

appearance. Her anxiety drove her to

binge eating.

First, she overate solid food, but

it caused her to vomit because her

stomach pouch couldn’t hold it all.

Then she got creative. Rebecca learned

she could eat high-fat and high-calorie

foods that were either liquid (such as a

milkshake) or that melted in her mouth

(such as cheese puffs). Her stomach

pouch could handle them.

After talking with Rebecca,

checking an online calorie counter and

making several back-of-the-envelope

calculations, I deduced that most days

she was consuming over 3,500 calories.

This clearly explained her weight gain.

I made appointments for

Rebecca with a nutritionist and a

psychotherapist. With time and hard

work, she was able to resume her

healthful post-bariatric diet plan. The

pounds started dropping off.

Bariatric surgeries can truly change

people’s lives. But there is more to

losing weight than going under the

knife. “I’m very disappointed with

myself,” she told me. “I never thought

I would be in this situation again. But

I’m glad I’m back to losing weight.” D

Douglas G. Adler is a professor in the

Department of Internal Medicine at the

University of Utah School of Medicine. The

cases described in Vital Signs are real, but

names and certain details have been changed.

She felt she was

losing control

over her body and

appearance.

Vital

Signs