Beyond Change

 

Obesity Surgery Journal

Beyond Bariatric Surgery ...

Complications We Fail to Address

Jacquelyn K. Smiertka, RN, CBN

Auburn Hills, Michigan, USA

 

Introduction

 

In a recent Obesity Surgery journal, Dr George Cowan
addressed the future of bariatric surgery, offering a

prediction that the time will come when the lay and
medical communities realize bariatric surgery is the
conservative approach to treatment for the morbidly
obese. 1 He presented a challenge to those who work
in what still remains a controversial field of medicine.
He states that we must demonstrate the appropriate-
ness of bariatric surgery, that treatment is effective
and safe and that non-surgical treatment is ineffective
in the long-term. Even in the light of favorably
published statistics and research, our progress in ac-
complishing this task has been slow.

 

Surgery has, for a number of years, been docu-
mented as a viable treatment when other weight loss
modalities have failed.2 Significant research indicates
that with long-term weight loss, made possible by
surgical treatment, medical anomalies such as diabetes,
asthma, hypertension, sleep apnea and other co-mor-
bidities can be resolved or ameliorated. 3 Statistics are
revealing fewer perioperative as well as postoperative
complications, shorter hospital stays, decreased mortal-
ity and morbidity rates and long-term weight loss.4
With so much that is positive, why should contro
versy over the surgical treatment of morbid obesity
still exist?

 

If we look at the literature of the past and present,
we find repeated emphasis on the goal of achieving a
'successful surgical outcome', while in our research we
seem to forget that it is actually the patient who is
the determinant of that success. Ultimately the quality
of the surgical procedure is meaningless if it does not
provide an improved quality of life for the patient.
Should patient follow-up only include sporadic office
visits or should it include monthly or biweekly patient
support group meetings? Are we failing to address
what could be the most serious postoperative compli-
cations? Are we ignoring the possibility that the
emotional adjustment to bariatric surgery is as equally
important as the physiological adjustment?

 

When the patient has achieved their desired thin-
ness, we are often made aware that this has not

assured the patient of their desired happiness, either
with themselves or with their surgical procedure.
When patients are lost to follow-up, is it because they
have become disenchanted with themselves, with the
surgery, or both? Based on this suspicion it seems
even more imperative that we publish information
indicating, not only sufficient weight loss statistics,
but also the methods used to help the patients become
adjusted to their surgery, to the weight loss process
and to their acceptance back into society.  Brolin et al 5
reported that nearly all of the published reports of
results of obesity operations are deficient either in
terms of providing follow-up, or the duration of
follow-up. It is clear then that the patient is in need of
close assessment after surgery, but equally clear that
we need the patient for our assessments. To help us
prove the appropriateness and effectiveness of baria-
tric surgery, postoperative follow-up should be
intensified.

 

What We Already Know

 

Despite all the new developments in understanding of
obesity, the basic premise still pertains: obesity occurs
when there is excessive caloric intake and insufficient
energy expenditure for that individual.6 Surgically our
goal is to decrease caloric intake and secondarily to
increase energy expenditure. We accomplish this by
restricting the stomach size, and in many cases, by
also creating a system that results in malabsorption.
We are all aware that with any procedure, the patient
still has the capability of consuming excess calories,
affecting the efficacy of the outcome. This would
indicate a need for continued educational reinforce-
ment of the necessity of certain dietary restrictions.

 

We know that long-term weight reduction in the
disease of obesity provides the resolution of a great
number of co-morbidites. Some physicians have re-
ported a 49% cure of asthma, 98% cure of diabetes,
81% cure of hypertension. 7-9 We also recognize the
need for more documentation of the cost-effectiveness
of surgical weight loss, which is enhanced by the
resolution of these illnesses. Michigan insurance com-
panies and their new systems of 'managed care' have
a tendency to relate more interest to the 'managed
dollar' as opposed to concern of the improved well-
being of the patient. In our practice, we have encour-
aged patients to write to their insurers, expressing
their appreciation of having had surgery for obesity
and relating the effect it has had on their once
exorbitant medical expenses. This has proven benefi-
cial in that at least two companies are now providing
much quicker response to requests for authorizations.

 

We know that our morbidly obese patients have
tried a myriad of weight loss techniques with near
universal long-term failure. Consequently, they ap-
proach bariatric surgery as their last desperate attemp
at weight loss. It is little wonder that this population
is willing to undergo major surgery with its attendant
risks, in search of relief from the psychological and
medical consequences of grossly excessive weight. 10
These individuals believe themselves to be at a desper-
ate stage in their lives, having tolerated discrimination.
having tried countless diets, and suffering a variety of
medical problems. They cannot walk without hurting
breathe without laboring, or face the public without
being humiliated. To them, the idea of surgery as a
radical and drastic measure seems minor compared to
existing in a body that is plagued with physical and
emotional restrictions. To this patient, surgery is the
conservative approach to weight loss.

 

We know that the patient who is a statistic of a
revisional or failed procedure is one who seems to
appear on talk shows. He/she is distressed and more
than happy to reveal their displeasure for the sake of
sensationalistic journalism. Complaints of repeated
trips to the operating-room are perhaps necessary, as
postoperative complications and revisions are occasion-
ally necessary for any surgeon doing any type of
bariatric procedure. Although it has been frequently
suggested that surgical failures in many cases are due
to psychological factors rather than surgical technique
or complications to the lay public, the disgruntled
patient is a certification that surgery is risky and
ineffective.

 

What We May Never Know

 

We may never know what will be considered the best
bariatric procedure available to the morbidly obese
patient. Perhaps it will be up to the surgeon who is
able to document and publish the highest patient
follow-up, the majority of whom will be successful
and free of comorbidities, 10 or 20 years past surgery.
Presently, each surgeon believes his/her procedure
to be the best. While this is admirable and perhaps
praiseworthy, one should question if the doctor's
patients believe their surgery to be the best? Do the
restrictive procedures that severely limit the ability to
enjoy food, infringe on the patient's quality of life?
Does the malabsorption procedure require more
compliance with vitamin therapy than the patient is
capable of doing in the long-term?

 

We may never know how to select the best patient
population as candidates for bariatric surgery. Sur-
geons, psychiatrists and other members of the bariatric

team currently do not have the ability to accurately
predict who the recalcitrant patients will be, nor have
they been able to reliably identify those patients who
will have an unsuccessful outcome.6  Although predic-
tors of a successful outcome have yet to be estab-
lished, a comprehensive and careful assessment of the
bariatric patient should be done preoperatively and
continue throughout the postoperative process.

 

It is known that eating is a human behavior, en-
dowed with multiple meanings, and that 'learning'
how, what, and how much to eat occurs early in life
and aids in establishing life-long eating habits. The
developmental and psychological dimensions of this
behavior cannot be ignored in the total evaluation of
these patients.6 We should not expect the complica-
tions of this particular human behavior to be reme-
died by surgery alone. We must not mislead the
patient into believing this, either.

 

The Responsible Patient

 

In a recent study by Gentry et al.12 on the preoperative
psychological assessment of the morbidly obese pa-
tient, it was emphasized that patients must understand
their own role in the production of their obese state.
They must also be actively involved in their care, in
order to produce the maximum desired effect during
the postoperative period. Getting the patient to become
actively involved and responsible for their own well-
being is an imperative and challenging process.

In our practice, each new patient is assigned a
'sponsor' who has, at a post-operative stage of 6 months
or longer, been known to be responsible and compliant.
Interaction between the two patients is encouraged and
monitored closely. This method has proven to benefit
both patients. One has become the educator, while the
other has the opportunity to feel guided and supported
on a more personal level. Each patient must sign a
contract prior to surgery which requires them to attend
biweekly postoperative educational and assessment
classes for a period of 18-24 months. This well
established 'buddy system' has allowed each new
member to feel an integral part of the group that
averages 65-70 participants, including patients, as well
as significant others. Acceptance of these new and
generally apprehensive group members is clearly made
the responsibility of the 'seasoned' patients.

 

The Responsible Bariatric Team

 

Successful bariatric surgery requires a commitment
which should begin when the patient first contacts

the office. The overall goal is to educate and assess
this individual, helping them to become knowledge-
able of the surgical process and of what their respon-
sibilities will be to make this a successful venture.
Extensive preoperative assessment should focus on a
thorough evaluation of premorbid psychologic status,
sources of family and personal support, and expecta-
tions for emotional change after surgery.13 This is the
responsibility of the complete bariatric surgical team,
which includes the surgeon, psychologist, exercise
physiologist, dietitian, nurse, and other support person-
nel. This multidisciplinary team should be accessible
to the patient throughout the preoperative and post-
operative experience.

 

Psychological evaluation is important and support-
ive to the patient who anticipates a successful surgical
outcome, and for the surgeon who will be reassured
of the emotional stability of this individual. The
primary goal of the psychiatric consultation is to
establish whether the patient has evidence of a diag-
nosable psychiatric illness, especially one which might
influence the decision to not perform surgery.6  Since
postoperative dietary compliance has been shown to
be critical to the success of the operation, psychiatric
and psychologic stability might also be inferred to be
related to the degree of weight loss.12

 

A supportive family and social structure also proves
beneficial to the successful outcome of the surgery. In
a study done by Waters et al.,13  it was found that, of
the psychological testing done on their patients,
mental health scores reverted back to the preoperative
levels after 24 months. With no significant weight
regain at that time, they could only hypothesize an
explanation to this disturbing trend. It was felt that
possibly these patients depended on medical and
emotional support from their clinic visits to improve
psychologically. They concluded that as the frequency
of support decreases, so do the improvements. Upon
completion of the study it was suggested that it may
prove beneficial to begin a patient support group,
with the hope that perhaps some of the emotional
problems encountered would diminish.

 

Emotional changes postoperatively can be noted
within the first 3 months. Two separate groups of
patients, including those of Dr Alex Macgreagor and
those of our patient population were given question-
naires regarding their personal concerns at intervals of
3, 6 and 12 months past surgery. Of the 59 respond-
ents, 17% were at 3 months, 35% 6 months and 48%
were at the stage of I or more years. At 3 months
past surgery, 54% expressed their most difficult adjust-
ment was that of learning what and how much to eat
and how to consume it properly. The 6 months time
interval indicated 50% had difficulty coping with

rapid body change, social adjustment, still having to
limit various foods, and continuing to view themselves
as being fat. At 12 months, the concerns seemed to
escalate, indicating that 37% were still learning to
accept body changes, distress over weight loss plat-
eaus, not having developed what they had thought
would be a 'normal' looking body, and finally that
weight loss alone did not make everything in life as
great as they had originally anticipated. Of these
patients, 56% believed they were still experiencing a
preoccupation with food, acknowledging difficulty in
being able to replace what they considered a love of
food with a love of something else. The remaining
number of this group found hobbies and exercise a
suitable replacement. Each one of these patients admit-
ted to attending behavior modification groups on a
faithful basis, with 98% stating that if it had not been
for the peer support, they would not have tolerated
these 'postoperative complications' as well as they
had. From these respondents, 100% never regretted
having had surgery and would do it again without
question. The reasons given were: overall health im-
provement, enhanced self-awareness and elevated
self-esteem, all of which provided them the ability of
being able to enjoy a new life. Interestingly, 69%
believed that having their significant other attend
the same support meetings was beneficial to their
outcome, as it also gave needed support to the
significant other. It was further suggested that spouses
would be more likely to understand the physical and
emotional changes related to weight loss, if they were
involved with the same support process. Although
these statistics seem to appropriately advocate the
need for support groups, a comparison of patients
not provided this type of follow-up would be
enlightening.

 

Where We Go From Here

 

In this challenging field of medicine there will always
be a great deal more to learn. We will continue
to learn from that which has been published, from
research soon to be published and through clinical
experience and observation. Nevertheless, we should
not forget that our most valuable source of informa-
tion will always be our patients. We must study and
clarify why some individuals fail and why so many do
so well. The most effective way to accomplish this
appears to be by way of patient follow-up, preferably
through support groups and regular postoperative
visits. Patients must continue to learn from us and
trust that we have their best interest at the core of all
new developments. We can learn from them what life

is really like, what it means to breathe again, to walk
without pain, and even what it means to be able to
wear pantyhose for the very first time, or buy clothes
from a 'regular' store. In so many ways the patient
willingly holds us responsible, believing that we are
the reason they have been given a chance to enjoy an
improved quality of life. We gladly accept this respon-
sibility. For the patient who holds us responsible for
their failure to do well, we must also accept respon-
sibility. What did we miss? Assessment? Teaching?
Failed procedure? Follow-up? Unacceptable surgical
candidate?

 

Where we go from here is back to the patient.

Patients are predominantly pleased and anxious to
assist in demonstrating to the lay and medical commu-
nities that surgery is the most appropriate and effec-
tive treatment for morbid obesity. Patients do impress
the medical community when revealing that they
have been cured of diabetes or hypertension. Surgery
will become known as the conservative treatment of
morbid obesity and testaments of our satisfied patients
will play a significant role, if we are wise enough to
use this resource.

 

Conclusion

 

Surgery may appear to be a radical treatment for
morbid obesity to the lay and medical communities,
but to the patient who chooses this approach, it is
usually the last attempt at achieving a better quality
of life. We are responsible for proving that it is the
conservative, successful approach. To Dr Cowan it
must be said that you are right, 'It really ain't over till
the fat lady is thin, then she really sings'. Then we
must add that 'It really ain't over till she sings the
praises, that bariatric surgery is the reason that she is
able to sing.'

 

 

References

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2. National Institutes of Health Consensus DevelopmentConference Statement.

Gastrointestinal Surgery forSevere Obesity. March 2, 1991, 25-7.

3. Halverson JD, Koehler RE. Gastric bypass; analysis ofweight loss and factors determining success. Surgery1981; 90: 446-8.

4. Halverson JD, Scheff RJ, Gentry K, et al. Jejunilealbypass. Late metabolic sequelae and weight gain. Am ]Surg 1980; 66: 618-21.

 

5. Brolin RE, Kenler HA, Gorman, et al. The dilemma outcome assessment after operation for morbid obesity. Surgery 1989; 105: 337-46.

 

6. Charles Sc. Psychiatric evaluation of morbidly obese patients.  Gastroenterol Clin North Am 1987; 16: 415-33.

 

7. Macgregor AM, Greenberg RA. Effect of surgicallyinduced weight loss on asthma in the morbidly obese.Obesity Surg February 1993; 3: 15-21.

 

8. MacPherson BH, unpublished data.

 

9. Bourdages H, Goldenberg F, Nguyen P, el al. Improve-ment in obesity-associated medical conditions follow-ing vertical banded gastroplasty and gastrointestinalbypass. Obesity Surg 1994; 4: 227-31.

 

10. Bull RH, Engels WD, Engelsmann F, el al. Behavioral
changes following gastric surgery for morbid obesity:

 

11. Mason EE. Surgical Treatment of Obesity. Philadelphia:  WB Saunders, 1981,449

 

12. Gentry K, Halverson JD, Heisler S. Psychologic assessment of morbidly obese patients undergoing gastricbypass: a comparison of preoperative and postoperativeadjustment. Surgery 1983; 95: 215-19.

 

13. Waters GS, Paries WI, Swanson MS, et al. Long-termstudies of mental health after the Greenville gastricbypass operation for morbid obesity. Am]. Surg 1991;143: 417-29.

 

(Received 8 June 1996; accepted 27 June 1996)

Obesity Surgery, 6, 1996 381