The patient was a 16-year-old girl of Puerto Rican descent who presented for bariatric surgery to a large comprehensive bariatric surgery program in an academic medical center early in April 2007. Her weight was 325 1b, and her BMI was 64 kg/m2. At her initial evaluation with the bariatric surgery program, she had the following co-morbidities: hypertension, asthma, pseudotumor cerebri, severe scoliosis, obstructive sleep apnea (requiring bi-level positive airway pressure treatment), narcolepsy, previous gallstone disease (treated by laparoscopic cholecystectomy), ophthalmic convergence excess, and gastroesophageal reflux disease. She also had menstrual irregularities and various food allergies.
The patient had been born and raised in Puerto Rico. She had grown up in what can best be described as difficult conditions. Her parents both had had substance abuse problems and reportedly belonged to a satanic cult. Her father left the family in 2000 and her mother had hypertension, diabetes type 2, and obesity. She was also diagnosed with schizophrenia and, in 2005, was considered legally incompetent to care for the patient or her siblings. Soon after, the patient moved to the United States to live with her aunt, who became her legal guardian and has since adopted the patient.
The patient reported that her excessive weight gain started at the age of 6. Although her mother had been extremely obese, the patient also reported poor dietary habits and a general lack of physical activity as a young girl. When she arrived in the United States, she indicated that she had frequently consumed large-portion sizes of calorically dense foods, such as ice cream, candy, cookies, and fast food. She would also binge eat and engage in purging behaviors several times weekly. In 2006, her aunt had her treated for bulimia at an intensive day treatment program with good results. Later in 2006, she was in an inpatient weight management program for approximately 2 months that resulted in a 15-lb weight loss. Since then, she reported that she had also seen a nutritionist on an outpatient basis with little effect on her weight. At the time she presented for surgery, she reported typically eating 2–3 meals, as well as several snacks, each day. She denied any binge eating or purging since 2006.
The patient initially presented for surgery while finishing her sophomore year of high school. She reported receiving B’s and C’s on her last report card. Since being in the United States, she had also been engaged in mental health treatment, not only for her bulimia, but also for depression, post-traumatic stress disorder (related to her childhood abuse and neglect), and generalized anxiety disorder. Her outpatient mental health professional reported that the patient was making good progress in her treatment.
After her initial evaluation by the consultants with the bariatric surgery program in April 2007, the recommendation from the team was to continue the mental health treatment and remain psychiatrically stable for a period of 2–3 months. It also was recommended that she engage in some additional nutritional counseling with the dietitians from the bariatric surgery program to teach the patient more about the postoperative diet requirements.
The patient returned for another evaluation 3 months later in July 2007. She had lost approximately 4 lb with help from a dietitian, had initiated a fitness program, and had continued her psychotherapeutic treatment. Her outpatient therapist stated that she believed the patient to be psychiatrically stable and had made good progress in managing her mood and anxiety levels. At that time, she was deemed an appropriate candidate for bariatric surgery.
The patient underwent laparoscopic gastric bypass with Roux-en-Y anastomosis in August 2007. At surgery, she weighed 302 lb and had a BMI of 59 kg/m2. The surgery was performed without complications.
During the first postoperative year, the patient struggled with the transition back to a regular diet of solid foods. At several of her postoperative visits with the surgeon and program dietitian, she reported stomach pain, dizziness, sweating, and shaking soon after a meal. She also reported several episodes of diarrhea each week. These episodes were attributed to her continued reliance on high-sugar and high-fat foods. It took close to 1 year for the patient to be able to eat solid foods without these untoward gastrointestinal events.
Approximately 13 months after surgery, the patient was hospitalized for approximately 5 weeks secondary to a return of her eating disorder symptoms. The patient’s aunt reported that the patient was starving herself and sometimes purging in an effort to expedite the weight loss after the surgery. After the hospitalization period, the patient was doing better and maintained healthy eating habits, which allowed for slow and steady weight loss. She also had undergone a sleep test, which revealed no sleep-disordered breathing and, hence, no need for additional bi-level positive airway pressure therapy. However, she continued to use this therapy to treat the headaches she experienced in the mornings. Additionally, the patient had insomnia. She was scared of the nightmares she was having after the trauma she had experienced while living with her biologic parents and also feared that she might choke or die in her sleep. The patient was referred to cognitive behavior therapy to help her manage her sleeping problems.
The patient was last seen for follow-up with the bariatric surgery program at 18 months postoperatively. Her weight was 219 lb (BMI 43 kg/m2), representing a weight loss of approximately one third of her initial body weight. She reported feeling “Great!” and added, “You guys changed my life.” She was making healthy food choices, eating every 3–4 hours, and could tolerate a regular diet without nausea or vomiting. Her blood pressure was normal without antihypertensive medication. She reported a reduction in her headaches (which were believed to have been precipitated by her pseudotumor cerebri) and had undergone successful back surgery to treat her scoliosis. She continued to be engaged in outpatient psychotherapy and attended a support group for bariatric surgery patients on a regular basis.