An unusual case of weight regain

Focus on Bariatric surgery

A 43 year old female presents for an opinion on weight loss

She had a “stomach stapling” procedure in Queensland two decades earlier, which worked
very well however over the last twelve months she has lost her sense of satiety and has gained a worrying 10kg. She generally eats freshly prepared home cooked meals but her portion sizes have increased.

Her BMI was 37.1, which puts her in the range of class II obesity. Her only comorbid condition is depression for which she takes Cipramil. On examination there was a long midline laparotomy scar.

Fortunately, the patient had kept records of her previous procedure. It was in fact a biliopancreatic diversion with duodenal switch (BPD-DS), a powerful malabsorptive operation that produces excellent weight loss and comorbidity resolution but is rarely performed in the southern hemisphere anymore because of the high risk of severe protein-energy malnutrition if patients are not compliant with vitamin supplementation and a high protein diet. The surgery consists of a reduction in the size of the stomach and an anastomosis from the duodenum to the ileum.

A comprehensive nutritional assessment was made. The patient was getting adequate protein in her diet. In addition to the usual iron studies, Vit B12, calcium, and Vit D, we also ensured her other fat soluble vitamins (A, E and K) were normal. Her micronutrients Zinc, Selenium and Copper were also checked and were normal. Liver function testing was likewise normal. The patient passed up to four soft stools per day.

A volumetric gastric CT scan was performed (affectionately known as a CT Fizzogram because of the effervescent contrast material that distends up the stomach). This estimated the gastric volume at 380cm3, which is greater than the volume of a typical modern sleeve gastrectomy.

Gastroscopy was performed, excluding Barrett’s oesophagus, hiatus hernia and H.Pylori infection. The patient then proceeded to laparoscopic surgery. Despite the previous surgery, adhesions were minimal.

The distance from the distal anastomosis to the caecum was 180cm, which is adequate to avoid malabsorption. The residual stomach was dissected and a sleeve gastrectomy performed to further reduce the size of the stomach. The small bowel anatomy was left undisturbed.

The patient was discharged home after an overnight stay in hospital, and made an uneventful recovery.

At the three-month post-operative mark, the patient had lost 12kg, her bowel function was unchanged and she had no reflux. The importance of lifelong regular nutritional follow up
was stressed.