When the fat comes back

[Guest guest]

When the fat comes back

By Bergeron/ Daily News Staff

Tuesday, October 3, 2006 - Updated: 01:08 AM EST

FRAMINGHAM -- Trapped within a 500-pound body, Lucio Tomich desperately wants

another chance to escape the morbid obesity threatening his life.

I want help, " said the 45-year-old Framingham resident. " I’m ashamed. I cry

and cry. "

In 2001 Tomich had gastric bypass surgery at Brigham and Women’s Hospital

in Boston and lost 170 pounds in two years. Yet since 2003, the Brazil native

has regained every pound he lost -- at least partly due to poor eating habits

and heavy drinking -- and now suffers from high blood pressure, sleep apnea and

depression.

Tomich and his doctors only partially agree on why he regained everything

after losing a third of his body weight from an operation popularly called

" stomach stapling. "

Tomich blames his regained weight on the hospital’s inability to repair a

opening called a fistula between his new smaller pouch and old stomach. And he

believes a better post-surgical " support system " would have kept him on track

when he began regaining lots of weight.

" I wish I’d had more follow-up and counseling like other people, " he said.

Noting he lost weight consistently for nearly two years, Tomich insists

the unrepaired fistula is the primary cause of his regained weight.

But two doctors who treated him say Tomich hasn’t followed critical

dietary restrictions after surgery and appears to have resumed heavy beer

drinking, downing as many as a dozen beers a day.

Surgical solutions

On Aug. 17, 2001, Dr. B. Lautz performed a surgical procedure known

as roux-en-Y gastric bypass on Tomich. The most common surgery for obesity in

the United States, it involves fashioning an egg-sized pouch from the upper

stomach and linking it directly to the intestines.

Typically, the new pouch has a two-ounce capacity but, in time, often

stretches to double that.

Successful yet controversial, gastric bypass surgery has dramatically

reduced obesity for thousands of patients by restricting how much food they can

eat and reducing how much they absorb.

Lautz described Tomich’s present situation as " a relatively rare event, "

particularly since his regained weight wasn’t primarily caused by anatomical

problems following surgery.

The surgical director of Brigham and Women’s Hospital Weight Management

Program, Lautz has performed hundreds of gastric bypasses and considers the

operation " a tremendous success " in the national battle against morbid obesity.

Lautz said gastric bypass patients typically lose 50 percent to 75 percent

of their excess weight during the first two years. About 20 percent of

post-operative patients " regain a low amount of weight, " he said.

Tomich signed a release permitting his doctors to discuss his case.

Whatever the causes of Tomich’s weight gain, the medical consequences are

painfully obvious.

His feet and legs are grossly swollen and blotched from poor circulation.

He moves with lumbering slowness and loses breath after modest effort. A thick

strip of surgical scar tissue extends from his chest to his stomach.

" Now I hide from people. I have no desire to leave my apartment, " said Tomich,

social columnist for the Brazilian Times newspaper. " How can I go out? My

clothes don’t fit. Look how swollen my feet and legs are. I’m afraid I’ll lose

them. "

Tomich concedes he previously drank large amounts of beer -- up to 12

bottles daily at times -- but said last month that he’s stopped drinking.

Since surgery, he said he eats small portions of food as recommended but

eats often. He could not calculate his daily caloric intake.

" At this point, I can probably follow a diet. I’m living alone without

support, " said Tomich. " But it’s difficult when you have hundreds of pounds to

lose. "

A national epidemic

Whether self-imposed or not, Tomich’s weight regain raises questions about

why people become dangerously obese and the effectiveness of surgical

intervention. It also highlights as-yet unanswered questions about the nature of

hunger and why gastric bypass has been successful.

Lautz said bypass patients must embrace " profound " dietary changes

immediately after surgery, including eating significantly smaller portions and

exercising regularly.

Since food goes into a pouch of about 5 percent of the former stomach,

patients don’t experience the frequent hunger pangs that drove them to overeat.

Yet, Lautz said, doctors are still learning about the role of hormones that fuel

appetite.

Like most hospitals that perform bypasses, Brigham and Women’s weight loss

specialists evaluate patients at regular intervals following surgery. Lautz

said, " We see patients minimally two and six weeks (after surgery) and then

every three months for a year. Then we see them every six months or as needed.

After two years, we try to see them once a year perpetually. "

Tomich said he saw hospital staff at regular intervals for 18 months after

surgery but feels they were inattentive when he began regaining weight.

Over the last decade, the number of patients undergoing any form of

bariatric surgery has grown from 20,300 in 1996 to 177,600 in 2005, according to

the American Society for Bariatric Surgery, the largest medical group monitoring

such procedures.

While there is no national clearinghouse for bariatric surgery data, the

ASBS reports gastric bypass patients on average lost 48 percent to 74 percent of

their excess weight. In one study of 600 gastric bypass patients, average weight

loss exceeded 50 percent after 14 years.

Appetite for disaster

At first Tomich appeared to be another success story.

Dr. Simpson of the South End Community Health Center in Boston,

who’d initially recommended Tomich for bypass surgery, said his weight had

dropped from 500 to 330 pounds by March 2003, 17 months after surgery.

But Tomich’s success story began to unravel for reasons that remain in

dispute.

In March 2003, Tomich visited Simpson’s office seeking to have a " large

flap of abdominal skin " removed after his weight loss but his insurance company

refused to pay for the procedure because it was considered cosmetic and not

medically necessary.

Over the next four months, Tomich regained about 20 pounds and appeared

depressed, said Simpson.

According to Simpson’s records, Tomich regained the weight in bursts,

possibly stimulated by a combination of depression and beer drinking. He was up

to 427 pounds in May 2004 and by July 6, 2006, Tomich weighed 490 pounds. " Lucio

(Tomich) didn’t have immediate complications after surgery for two years. He

seemed to be recuperating well. At first, he kept most of his weight off, "

Simpson said.

Asked what caused Tomich to regain his weight after a good start, Simpson

cited a combination of personal and social factors.

He attributed the national epidemic of obesity to " a toxic nutritional

environment where there’s so much good tasting, high-calorie food available. "

Yet Simpson identified " social isolation " as part of Tomich’s problem.

" He needs to get out and get around. He doesn’t take care of himself, " he

said.

Before surgery, Simpson said, another doctor questioned whether Tomich was

a " good candidate for surgery because he hadn’t demonstrated any weight loss in

the previous 20 years. "

Yet Simpson agrees with Lautz that another surgery carries significant

risks with a lower rate of success. Both would prefer to see Tomich lose weight

by limiting his caloric intake, including beer.

Tomich agrees he began regaining weight in 2003 but complains the hospital

didn’t do enough to repair his fistula or provide long-term counseling.

When his problems intensified in 2003, he said the hospital’s weight loss

staff " didn’t seem to have time for me. "

Lautz said it’s critical to understand obesity’s complex origins and not

blame overweight people or attribute their weight to " a lack of willpower. "

" The really important thing is we don’t know what’s causing obesity. There

has to be a shift in how we perceive obesity. It’s truly a disease. It’s a

killer, " he said. " ...When people come for help, they’re not saying ’I want to

look great.’ They want to live to see their grandkids. "

After performing hundreds of bypass surgeries, Lautz said post-operative

patients respond " in very individual ways " to dramatic changes to their appetite

and ability to digest certain foods.

Some adjust easily to smaller portions while others can’t stomach meat or

foods they used to enjoy.

Lautz said, " It’s unpredictable. For some people, (gastric bypass) surgery

stops them from overeating. There are profound changes in the way food tastes

and their drive to eat. "

Yet Lautz acknowledged certain post-operative complications can undercut

patients’ progress.

He said one of the " most common " anatomical problems occurs when the

" outlet " to the new, smaller pouch expands, allowing food to move into the

intestines without letting the patient feel full.

" The name of the game is relief from the hunger drive. If food goes directly

to the intestines, there’s less of a sense of satiety, " he said.

If patients regain weight, Lautz typically orders tests to look for

anatomical complications such as dilated openings in the pouch.

When that problem is diagnosed, Lautz said doctors can " tighten the

connections " between the pouch and intestines with arthroscopic surgery down the

patient’s mouth without reopening the stomach.

" In most cases, there’s something (physically) wrong. It’s not necessarily

the patients’ fault. If there’s anatomical problems, we can get them back on

track, " he said. " If there’s nothing for me to fix, we refer them to surgical

counseling. "

But Lautz added, if there are no physical problems, " significant weight gain "

often results from " major dietary problems. "

Tomich underwent such a procedure in 2003 to repair his fistula but said

it didn’t resolve his problem. " I feel like I have two stomachs, " he said.

While agreeing Tomich has a fistula in his pouch, Lautz reiterated his

belief his weight gain resulted from dietary " noncompliance. "

Lautz said he’d " be happy to see " Tomich but believes again he needs to

get his diet and drinking under control as a first step to battling obesity.

Tomich said he recognizes his current weight jeopardizes his health and

even his life. As his depression mounts, he said he’s considering seeking

surgical help for his fistula in his native Brazil despite any risks.

" I’m not afraid of dying. I really don’t care at this point. All I can say

is that I’m looking for help, " he said.

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