Sandi Krueger feels better than she has in almost seven years.
The 38-year-old Turlock mother lost too much weight after a 2002 gastric bypass surgery.
After surgeons reduced her stomach to a small pouch and bypassed much of her small intestine, every bite of food made her sick, in time causing her weight to drop from 219 to 98 pounds and reducing her to a gaunt shell.
Since her story ran in The Bee in January, a patient from Oakdale who had the same wasting syndrome — and survived — brought Krueger to a surgeon in Delano in Kern County.
Dr. Ara Keshishian implanted a gastrointestinal tube through Krueger's side, so nutrients could be fed into her emaciated body at home. She has gained 30 pounds and tests show the hemoglobin, iron, vitamins and other vital minerals in her blood have risen from dangerous levels.
She's able to take her 13-year-old daughter, Megan, to do volunteer work and cheer for her 20-year-old son, Dustin, at his motocross races.
The tube feedings are intended to build her strength so she can undergo surgery to reverse the gastric bypass. Krueger also awaits an OK from the Medi-Cal program for coverage of the surgery.
"Right now, I am as happy and healthy as I can be," Krueger said. "When I wake up in the morning, I don't have the feeling, 'Is this the day I am going to die.' That has completely gone away."
Krueger is part of the small percentage of weight loss surgery patients who suffer from severe malnutrition. It is a sad outcome for 1 percent to 4 percent of bariatric surgery patients, which can leave them with severe anemia, the inability to walk and difficulty performing simple tasks.
With more than 200,000 of the surgeries performed each year in the United States, doctors are seeing a growing number of these patients.
Keshishian, a bariatric surgeon, said that each month four to six patients come to his office for revision or reversal of gastric bypass procedures. About half complain of weight gain or inadequate weight loss; others have nutritional deficiencies, persistent nausea and vomiting, ulcers, malnutrition or dehydration.
Some, such as Krueger, have struggled for years.
"The question we ask is, 'Are they healthy enough to continue living with gastric bypass and the downside or better off taking the risk of another surgical intervention,' " the surgeon said. "In general, revision or reversal surgeries carry a higher risk than the primary procedure, but for some of these patients the alternative is not an option."
Various reasons are given for poor outcomes: The patient didn't comply with dietary regimens or medical instructions after surgery, the surgeon didn't perform the bypass to specifications or bariatric surgery simply carries the risk of complications.
Physicians across the country are seeing a gap in follow-up care for bariatric patients.
"From talking to patients who have problems, it seems they are afraid to seek follow-up," said Dr. John Husted, a former Modestan and bariatric surgeon in Kentucky who was featured in Discovery Channel specials on bariatric surgery and adolescent obesity. "They felt that being overweight was their fault, and it's their fault they didn't have a successful outcome from gastric bypass."
Husted said he is seeing more bariatric patients with severe nutritional deficiencies, which he attributes to the large number of weight loss surgeries being performed.
Laura Martinez of Modesto had a gastric bypass in 2006 at Memorial Medical Center to address her diabetes and back pain. As she lost weight and her health issues disappeared, she spoke at seminars for people considering bariatric surgery.
About two months after the surgery, she started having trouble keeping food down. Soon, she had persistent vomiting. Drinking water gave her the dry heaves, she said. Starting at 274 pounds, she kept losing weight rapidly and eventually got down to 106 pounds.
"The doctors, to this day, don't know what caused it," she said. "My body just didn't react well to the surgery."
She was in the hospital for weeks with her potassium level so low she was at risk of a stroke, she said. At home, she was so weak she couldn't take care of her two sons. Her husband resigned his correctional officer job to care of the children, while she moved in with her parents.
"I had to live with my mom just so she could bathe me," Martinez said. "I was 28 years old and could fit into my niece's clothes, the size 10-12 clothes for kids."
She had a reversal surgery last year at Memorial. As her weight has climbed to 155, she worries about weight gain and the possible return of diabetes.
Suddenly, a weakling
The same thing happened to Rae Ellen Sweeten, 39, of Denair. An avid horsewoman, she once could bench-press 160 pounds and toss hay bales into the back of her truck, she said.
Today, her weight hovers around 110 pounds, down from 286, and she never has the urge to eat.
Sweeten admits that a svelte body was her motivation for undergoing the surgery six years ago in Fresno.
"Now, I am this scrawny person with old person skin who couldn't change a flat tire," she said. "I made a judgment call. I paid my money and took my chances, and it didn't turn out very well. Eventually, it is going to kill me."
She has been in the hospital several times in the past year, where she was given nutrients intravenously and required a blood transfusion. She said a doctor has told her nothing can be done for the scar tissue in her esophagus and her shriveled pouch, which makes it difficult to eat.
Three other local bariatric patients told stories of severe weight loss and malnutrition.
Stomach-shrinking surgeries have been performed since the 1970s, but after the issuance of National Institutes for Health guidelines in 1991, weight loss surgery became a primary treatment in response to the obesity epidemic in this country.
Where dieting, drug therapy and exercise have failed, bariatric surgery is considered a proven method of losing weight for people facing obesity-related conditions such as diabetes, heart disease or liver disease.
By stapling off a small pouch from the stomach and bypassing part of the small intestine, gastric bypass serves to restrict food intake and the body's absorption of nutrients. But the treatment doesn't stop there.
Patients are expected to commit to lifestyle changes after the surgery. They must change their eating habits, exercise and take vitamin supplements the rest of their lives.
With such an invasive procedure, experts say, several things can go wrong soon after the surgery, such as leaks in the staple lines, intestinal obstructions, bleeding or infection.
Other problems may occur years later. Iron deficiencies are common and patients regularly are tested for vitamin B-12, folic acid, thiamine, vitamin D and calcium deficiencies.
Other complications may include gallstones, ulcers, hernia, narrowing of intestinal passages, band erosion or reflux disease.
Dr. Anton Decker, as assistant professor of medicine at the Mayo Clinic in Arizona, said patients considering the surgery need to know it's a major procedure.
"After the surgery, it's important that the patients not be left alone," he said. "They need to have their nutritional profile checked from time to time and need to see doctors who care about them to get on these complications quickly."
Tests have shown that Sandi Krueger's golf-ball-sized pouch no longer breaks down the food she eats, but dumps it directly into her small intestine. Before the feeding tube, her attempts to eat caused nausea and she often had dumping syndrome, a reaction when certain foods pass too quickly into the intestine, resulting in sweating, rapid heart beat and weakness.
Her journey began in 2002 with a gastric bypass at Doctors Hospital of Manteca, which later closed its bariatric program. She had constant dumping and severe weight loss, had a falling out with her surgeon and went to the University of California at San Francisco for corrective surgery in 2004.
Her condition improved for several months and then her condition gradually deteriorated. She stopped working as a nursing assistant last year and then UCSF rejected her request for a reversal surgery.
Repairs are complex
She's made the 165-mile trip to Delano because Keshishian accepted her Medi-Cal coverage and he specializes in revising or reversing gastric bypasses. A reversal has some of the same risks as gastric bypass; in addition, the surgeon must deal with scar tissue that grows between the left side of the liver and upper part of the stomach.
"You have to peel the stomach away from the liver," Husted said. "It's tricky and can take a long time."
Many patients who aren't absorbing enough nutrients can improve with counseling and treatment, experts say.
Until her surgery is scheduled, Krueger will stay with the tube- feeding routine — 44 ounces of water mixed with a formula of protein, vitamins and other stuff costing the family $549 a month. With her husband drawing unemployment, it strains the family budget, but at least she feels healthy.
"It is nice to be a mom again," she said. "It feels like I have missed six years of my life."
Bee staff writer Ken Carlson can be reached at firstname.lastname@example.org or 578-2321.