Sunday, February 15, 2009

Gastric bypass surgery’s complications can be devastating for some patients

Modesto, CA
Sandi Krueger of Turlock, Calif., dropped 120 pounds with weight-loss surgery, but she is hardly a success story.

The 2002 surgery led to chronic malnutrition and anemia. As the pounds melted away, so did her life.

With a sunken face and protruding collar bones, she is too weak to work and spends most afternoons on the couch wrapped in a blanket.

She has thoughts of giving up, but wants to be there for 12-year-old daughter Megan and 19-year-old son Dustin.

“It’s not acceptable leaving me like this,” said the 103-pound Krueger, who at 38 looks closer to 50. “I’ve gone to doctor after doctor and basically they don’t help me.”

According to studies on bariatric surgery, patients with long-term complications are in the minority and disastrous outcomes such as Krueger’s are rare. But with 200,000 weight-loss surgeries being performed each year, she and other patients believe the long-term complications deserve more attention.

Looking for hope

Krueger’s options appear to be running out. Her anemic blood hasn’t been responding to iron shots and she was told last month that she can’t have the gastric bypass reversed.

“This isn’t a life,” said Robert De Kasha, her brother. “If she doesn’t find an answer, she is just going to fade away.”

Spurred by a national epidemic of obesity, bariatric surgery has become a standard of care for people with weight-related health issues. It has improved the lives of people who suffered from diabetes, high blood pressure, sleep apnea and other issues, experts say. No one is sure why some bariatric patients fare better than others.

The stomach-shrinking surgery has risks, such as leaks that can cause life-threatening infections, hernias and bowel obstructions. After the surgery, patients are expected to follow nutritional and lifestyle guidelines to achieve weight loss and avoid trouble with their altered digestive tracts.

Most patients will have “dumping syndrome” at some point, when food passes too quickly from the tiny stomach pouch into the small intestine. Because the stomach hasn’t broken down the food, the person gets a rush of blood sugar, rapid heartbeat, sweating and nausea.

Other patients may have iron and vitamin B-12 deficiencies years after surgery. All bariatric patients need to take vitamin supplements for life.

A nationwide study released in 2006 concluded that bariatric surgery complications are common. By examining insurance claims for 2,522 surgeries, researchers with the federal Agency for Healthcare Research and Quality found that 40 percent of patients had complications in the six months after surgery, about double the rate in previous studies.

The complications ranged from the minor to the severe, including dumping syndrome, problems with the bariatric connections, hernias, infections and pneumonia. Post-surgery problems sent 18 percent of patients back to the hospital, some for costly readmissions or corrective surgery.

The agency contends that surgical advances recently have lowered the complication rate to 30 percent, still high for an elective procedure, said William Encinosa, lead author of the study.

“Anytime you can cut into the intestine, you have a risk of complications,” he said. “Clearly there are benefits for people who are morbidly obese, but these patients need to know what they are getting into.”

Live longer

Less is known about complications years after the surgery, although a 10-year Swedish study found many patients kept the weight off and had increased longevity.

Krueger, who once worked two jobs as a nursing assistant, sought treatment for an injured back in 2002. A specialist suggested that the 5-foot, 250-pound woman lose weight through bariatric surgery to deal with the back problem, she said.

She had what’s called a Roux-en-Y gastric bypass at Doctors Hospital of Manteca, Calif. To perform the common procedure, surgeons create a small pouch from the stomach and make a connection between the bottom of the pouch and a section of small intestine.

Most of the stomach and part of the intestine are bypassed, so the person feels full after a few bites of food and the intestine absorbs fewer nutrients.

Krueger, weighing 219 by the time of surgery, lost weight quickly as dumping syndrome made her sick for months. When she went to the doctor with complaints, he urged her to stick with the dietary instructions and take supplements, she said.

Bariatric surgeries were discontinued at Doctors Hospital of Manteca, so Krueger sought help from specialists at University of California at San Francisco Medical Center. In 2004, surgeons there corrected a problem from the initial surgery and, as her strength returned, she got up on water skis for the first time.

She gained 22 pounds, then her troubles returned and she bottomed out at 98 pounds.

With her body starved of nutrients, her blood sugar dropped so low she was admitted to Emanuel Medical Center for a week of monitoring, she said.

Tests have shown that her pouch no longer holds food but dumps it directly into the small intestine. Even if she eats five times a day, she doesn’t get the protein and other nutrients she needs.

She’s tried protein bars and countless other foods and even finds that fish is hard on her digestive tract. Daughter Megan brings her toast and crackers because she knows those are easy on her stomach.

Krueger said it’s heartbreaking for her daughter to see her tired and faint all the time. She has lost hair, her teeth are decaying, and she’s often out of breath.

To treat her anemia, she’s had a blood transfusion and three rounds of iron infusions. A reaction to the last infusion caused her blood pressure to plummet and nurses to come to her aid.

Second thoughts

Last year, she was considered for having the gastric bypass reversed at UCSF, but doctors told her in December that it was too dangerous. They were concerned that her remaining stomach would have inadequate blood flow and would rot, she said.

“That day was hard for me,” she said. “I don’t know what is ahead. I feel my life has been taken from me.”

Dr. Guilherme Campos, director of bariatric surgery at UCSF, said about 1 percent to 4 percent of the center’s patients suffer from nutritional deficiencies over the long term. The UCSF center has dieticians and other staff to work with patients with malnutrition. Reversal operations are major procedures and are done as a last resort, he said.

The surgeon contended that bariatric surgery is an effective way to treat morbid and superobesity, the main reason university hospitals have adopted the treatment in recent years.

“The benefits by far outweigh the risks that are associated with the procedure,” he said.

While many patients sing the praises of weight-loss surgery, including television personalities Al Roker and Star Jones, some patients say they’ve had a tough time.

Donna Sellers, 61, of Modesto, said four members of her family had weight-loss surgery with mixed results. Her husband and younger daughter lost weight with no complications. But Donna shed weight too fast and suffered from dumping, malnutrition and dehydration the first year after her 2004 surgery at Memorial Medical Center.

Attempts to eat made her feel sick and sweat profusely, even though she followed the guidelines to eat pureed food and take small bites, she said. She went from 246 pounds to 123 in six months and landed in the emergency room, where she was treated for dehydration for several hours, she said.

She finally discovered she could eat chicken and Swiss cheese, and force-fed herself. To deal with the hot flashes of dumping syndrome, she laid on the cold floor tiles of her kitchen to eat meals, she said.

Five years after the surgery, she still is forcing herself to eat and is relying on her nursing training to maintain her weight in the 130s.

“I eat three or four bites and then wait 10 minutes and eat some more,” she said. “I eat a scrambled egg for breakfast, and tomorrow a scrambled egg makes me sick.”

She said one of her daughters had the same post-surgery troubles, as well as a calcium deficiency resulting in dental problems.

A 2001 surgery in Southern California saved Alycsha Bostic of Merced, Calif., from sleep apnea and asthma attacks. But she developed hernias requiring two operations and iron deficiencies that cause headaches and dizziness.

Losing 160 pounds boosted her fertility and she got pregnant twice despite being on birth control, she said. Doctors put a port in her chest to feed iron into her blood during pregnancy. Her ferrous levels are a third of normal since her second child was born in 2007.

Bostic, 34, hopes doctors can figure how to get more iron into her system — and she needs another hernia operation.

“I am so tired of having surgery,” said Bostic, who talks with other bariatric patients with complications. “We’ve all had hair loss. I still get dumping syndrome. If I don’t chew my food 50 times, it collects at the bottom on my esophagus and I throw up.”

More than 3,000 weight-loss surgeries have been performed at Memorial Medical Center in Modesto since 2003.

Deana Chiarchianis, health center manager, said the post-surgery complications at the hospital are far lower than the numbers in the AHRQ report. The study considered data before widespread use of laparoscopic techniques, which have reduced problems such as surgical wound infections and hernias, she said.

The hospital tries to ensure good outcomes by evaluating and educating surgical candidates, including a psychological assessment of their ability to cope with the surgery. It also stresses post-surgery guidelines such as teaching patients to prevent dumping through the proper choice of foods.

“They need to understand that the surgery is a tool and the patient is responsible for complying with the recommendations for follow-up, nutrition, exercise and behavior change,” she said.

Dr. Kelvin Higa, a Fresno, Calif., surgeon and past president of the American Society for Metabolic and Bariatric Surgery, said it’s important for patients to have lifelong follow-up with their surgeons. Usually, there are surgical options for patients with severe complications such as Krueger’s.

“Any patient that has those problems should not be sitting there. They should seek help,” he said. “Almost invariably we can take these patients and adjust their anatomy to take care of their nutritional issues.”

Krueger said her poor health has taken a toll on family life. No longer does she take Megan to cheerleading and dance classes. She and her husband have postponed their dream of building a home.

Krueger worked as long as she could at Emanuel Medical Center last year to keep her health benefits, but ran out of strength. Her primary care doctor is trying to line her up with a nutritionist or hematologist who accepts Medi-Cal.

A feeding tube could be next if she loses more weight, which reminds her of a 32-year-old bariatric patient at a care facility where she worked.

“She had a feeding tube and it really bothered me,” Krueger said. “If I don’t get better, I know my organs will take a toll. If they would put me on the operating table to take me back to 250 pounds, I would do it.”

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March 18, 2009 3:41 AM  

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