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432
H. Tonelli and A. Minski
There are to date no studies designed specically to compare the efcacy of differ­ent psychotherapeutic approaches for patients undergoing BPDDS.Notwithstanding, insights from studies on the behavioral treatment of obesity may shed light on the alternatives available to such patients. Different psychotherapeutic techniques aim at providing a mental structure allowing one to reach the main goals of the treat­ment, i.e., losing and maintaining weight and/or controlling DEB.Such techniques employ different approaches for the goals to be achieved; for instance, psychoedu­cation techniques comprise interventions to change habits or lifestyles [5], while cognitive behavioral strategies aim at cognitive restructuring [5, 6], through the evaluation and modication of thoughts, beliefs, emotions, self- attributions, self­esteem, and self-efcacy related to weight loss [7]. Interpersonal psychotherapy (IPT) for obesity, in turn, is a therapeutic modality focused on interpersonal pro­cesses and aims at increasing social support, reducing interpersonal stress, facili­tating emotional processing in social contexts, and increasing social skills [8]. Therapeutic techniques based on transcendental meditation, such as mindfulness, have been increasingly employed for the treatment of obesity, helping to attenuate automatic eating as well as to improve reactions to cravings and impulsivity, in addition to regulating the relationship between negative emotions and emotional eating [9]. Additional psychotherapeutic approaches that have been increasingly studied include dialectical behavior therapy (DBT) and other techniques regarding emotion regulation (ER). Such techniques are based on the affect regulation model, according to which DEB are triggered by negative emotions and, in some patients, may be relieved through binge eating [10]. In this sense, ER-based techniques assist in the development of healthy strategies of ER and, consequently, in reducing DEB in patients with obesity.
47.2 Cognitive Behavioral Therapy (CBT)
A recent review of the literature on CBT for bariatric patients [11] found that the method is effective in promoting weight loss by reducing DEB and improving depression and anxiety symptoms, at least 2years after surgery. CBT techniques should be differentiated from interventions to change habits or lifestyles, although there is not always a clear distinction between them [5]. Habits/lifestyle change interventions comprise actions to stimulate dietary changes and physical activity [5], which may use behavioral approaches such as self-monitoring, goal setting, stimulus control, problem-solving, and relapse prevention [57]. CBT techniques, in turn, use such strategies associated with a cognitive component of the therapy aiming at cognitive restructuring [5, 6].
Self-monitoring is considered one of the pillars of the behavioral treatment of obesity [12]. Systematic recordings of diet, weight, and exercise seem to increase the awareness of behaviors leading to weight gain [13], predicting weight mainte­nance after bariatric surgery, along with the ability to control eating impulses [14]. Patients must be taught to set clear and tangible goals, since it directs attention and
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effort, minimizes the effect of distractors, as well as increases energy, motivation, and persistence for them to be achieved [15]. Goal setting is acknowledged as an evidence-based behavioral change strategy, due to its specic, measurable, and pal­pable characteristic [16]. DEB in people with obesity is inuenced by a phenome­non studied in animals, called cue-potentiated eating [17] or, in humans, unplanned eating, which is dened by a much more intense behavior of searching for food after an exposure to environmental food cues. Stimulus control interventions improve DEB by helping patients to identify and modify such cues [18]. Structured problem­solving techniques comprise, in essence, methods to assist patients in identifying personal problems underlying specic symptoms leading to DEB and, consequently, to weight gain and in developing suitable skills to solve these problems [19, 20]. The technique encompasses different phases, beginning with the delimitation of the problem, its clarication, and the elaboration of a plan to approach it, being comple­mented by a clear establishment of objectives, besides the encouragement to the description of available proposals targeting at the resolution of the problem [19, 20]. It is common for patients searching for obesity treatment to have very vague, unreal, or hard-to-solve problems, as well as poorly dened or intangible strategies to deal with these problems. Although controversial, the phenomenological similarity of DEB in obesity with substance use disorders seems frequently unescapable. Such similarity is supported by a series of neuroimaging ndings showing superposition of neural pathways in both conditions [21]. Thus, just as what occurs with substance addicts, individuals with obesity need assistance in order to avoid relapses and to learn to deal with loss of control. In this sense, it is essential to add that diets stimu­late a predominantly cognitive control over food, which is easily lost when one has to deal with a negative affect or an environmental stressor, leading to the abandon­ment of diets, when not to eating disorders [22]. Weeks to months before DEB emerge in an individual on a diet, dysfunctional emotions and cognitions may already sign that a relapse is on the way. Teaching patients to recognize and develop skills to deal with these negative mental states is the primary goal of relapse preven­tion. Signs of cognitive relapses include cravings and thoughts about places, people, and things associated with past substance or food uses, associated with minimiza­tion of the consequences of a relapse. Physical relapse, in turn, occurs when a patient has already engaged in DEB, with varying levels of lack of control. Loss of control over eating has been identied not only in major eating disorders, such as bulimia nervosa and binge eating disorder, but also in conditions such as grazing, nibbling, or snack eating, which could be considered subsyndromal eating disorders [23], where small amounts of food are recurrently consumed without planning between meals. It is important to keep in mind that many dietary programs endorse several meals per day or small low carb snacks between meals and that such orienta­tions might be subverted as subsyndromal eating disorders by some patients with obesity.
CBT for patients with obesity employs all of the techniques discussed above associated with a cognitive component, which encompasses the evaluation and modication of thoughts, beliefs, emotions, and motivations regarding weight loss. Beliefs, the primary therapeutic target of CBT, can be dened as probabilities that a
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proposition about the world is true [24]. They are mental representations of expecta­tions about the world and things, have a predictive role, and need to be updated in order to increase their predictive and representational roles [24]. Therefore, the role of the CBT therapist in the treatment of obesity is to help patients update deeply rooted dysfunctional beliefs about eating and about their abilities to control eating impulses and lose weight. Dysfunctional beliefs like being thin are not for me, I do not deserve to be thin, or I will never be able to adhere to a physical exercise routine consolidated throughout a history of multiple attempts and failures in previous weight loss programs and can endanger the outcomes of bariatric surgery. They need to be properly evaluated and corrected (or updated). In this process of evaluat­ing and modifying false beliefs, patients should be taught to monitor their dysfunc­tional and automatic thoughts, apply corrections, create healthier alternative responses to them, value minor achievements, and react differently to any weight gain, hence increasing their self-efcacy [7]. Failures in previous treatments may favor erroneous beliefs about bariatric surgery, including BPDDS, such as the idea of a treatment that does not require any effort on the part of the patient, which usu­ally results in failure to achieve the expected goals.
H. Tonelli and A. Minski
47.3 Interpersonal Psychotherapy (IPT) forObesity
Eating behavior is strongly associated with feelings of pleasure, excitement, and happiness, as well as with relief from displeasure, anhedonia, or unhappiness, reecting a peculiar relationship between eating and emotion/affectivity, which is highlighted within interpersonal contexts. Indeed, patients with obesity frequently complain about feelings of loneliness, isolation, and not-belonging behind their DEB, which may be consequences of ostensive rejection, stigma, and social exclu­sion throughout their lives. IPT aims at increasing social support and social skills, reducing interpersonal stress, as well as facilitating ER in social contexts. Group IPT is comparable in efcacy to group CBT in the treatment of overweight patients with binge eating disorder. Studies have shown the efcacy of IPT in preventing weight gain in adolescents with high risk for obesity in adulthood [25]. Additionally, family-focused interpersonal approach helped overweight and obese pre-adoles­cents with loss of control over eating reduce psychological distress with a positive impact on eating behavior [26]. Although there are no studies on the efcacy of IPT in patients who underwent BPDDS, the results above suggest that it is very likely that this method particularly those patients with DEB.
47.4 Mindfulness
Automatic and unconscious thoughts, emotions, and motivations often lie behind intrusive ruminations about the future, the past, and other people [27], leading to dysfunctional psychological and behavioral styles. Mindfulness meditation
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addresses these mental states through the cultivation of a non-judgmental psycho­logical state centered in the present, in which every thought, feeling, or sensation that arises in consciousness must be accepted as it actually is [28]. Some encour­aged attitudes in mindfulness meditation include an impartial witnessing stance of one’s own experiences, avoiding thoughtless conclusions and not falling into the temptation of trying to anticipate things, being open to new possibilities, and accept­ing how things are here and now. Such a stance involves, from the neuropsychologi­cal point of view, psychological operations of reconguration of attentional processes, corporal consciousness, and cognitive reappraisal of reality [28]. In the treatment of obesity, mindfulness techniques seem very effective in attenuating automatic eating present in many obese patients, as well as in improving reactions to cravings and impulsivity, in addition to regulating the relationship between nega­tive emotions and DEB, resulting in better control of weight [9]. Although research ndings on the effectiveness of mindfulness meditation on weight reduction are promising, there is still little evidence that such favorable results are long-lasting [9].
47.5 ER-Based Methods
Recent studies have shown that ER, dened as the repertoire of cognitive strategies used to inuence emotions in ourselves or others [29], plays a crucial role in the emergence of DEB.Anger, loneliness, and other emotions, particularly those related to interpersonal experiences, are important components in the origin and perpetua­tion of DEB in individuals with obesity [30, 31], particularly those with ER decits. Ultimately, such individuals would be more prone to eat palatable foods in order to minimize the expression of aversive emotional states arising from their social environments.
ER incorporates intrinsic and extrinsic psychological processes such as monitor­ing, appreciating, and changing the magnitude of the emotional reactions [32]. One of the most studied ER models encompasses two mechanisms, cognitive reappraisal and expressive suppression [33]. The former, considered the most adaptive, involves the cognitive effort of modifying the emotional potential of a given condition, rede­ning it in non-emotional terms, while the latter covers the modulation and control of the behavioral emotional response. Both strategies require some ability to per­ceive and reect on one’s own emotions, a capacity that is not evenly distributed among the general population [34]. Recent ndings show that DEB, as well as restrictive eating behaviors present in anorexia nervosa, result from maladaptive alternatives to regulate or suppress unpleasant emotions [33]. In the same way as individuals with eating disorders, individuals with obesity seem to have greater dif­culty in identifying and describing their own feelings, in addition to presenting an externally oriented thinking, which is characterized by a style of perceiving and thinking disconnected from emotions [35], typical of alexithymia, a transdiagnostic condition encompassing difculties in identifying and describing one’s own emo­tional states [36]. Alexithymia seems to result from interoceptive decits disrupting the appropriate interpretation of internal signs of hunger, proprioception, tiredness,
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and temperature [36]. Interoceptive decits in alexithymia may derive from inam­mation secondary to obesity affecting the brain [37]. Thus, patients with obesity scoring high in instruments assessing alexithymia would nd it difcult to differen­tiate anger from tiredness, hunger, or fever. Impairments of one’s emotion identi­cation present in alexithymia interfere with the accomplishment of emotional regulation strategies such as cognitive reappraisal and affective suppression, leading to emotion regulation with food, addictive substances, gambling, shopping, or por­nography, for instance. Such impairments also disrupt the adequate processing of social information, damaging the social regulation of emotion.
DBT is an integrative intervention originally developed to tackle dysregulation in highly suicidal, self-injurious individuals with borderline personality disorder (BPD) [38]. Due to being successful in ER in such patients, it has been applied to comorbidly diagnosed individuals with BPD and DEB, with promising results [38]. DBT combines CBT strategies with techniques from other orientations such as mindfulness [39] and may be delivered individually or in group, as well as associ­ated with phone coaching and therapist consultation [40]. The technique comprises four modules of skills to be developed: distress tolerance, ER, mindfulness, and interpersonal effectiveness [40]. Regarding ER, many adaptive strategies may be rehearsed by a trained DBT therapist assisting patients with ER decits, some of them were discussed in details above. DBT’s programs include reappraisal, problem­solving, and acceptance, the latter addressed in mindfulness. Such strategies, which are considered protective against psychopathology, including DEB, contrast with non-adaptive ER strategies comprising expressive and thought suppression, avoid­ance, and rumination [41].
Although DBT has been studied extensively in individuals with DEB, be they obese or not, only three studies recently addressed the efcacy of DBT in bariatric patients. Delparte et al. [39] found that a brief DBT skills training group as an adjunctive intervention to traditional interventions in a bariatric pre-surgical pro­gram could aid in minimizing DEB as well as that bariatric patients receiving DBT may have a better weight loss trajectory than those receiving only traditional inter­ventions. Gallé etal. [42] found that DBT was more effective than usual treatments in reducing both weight loss and comorbidities in patients showing BPD traits and DEB, who underwent gastric bypass or laparoscopic adjustable gastric banding. Himes etal. [43], in turn, studied a group intervention utilizing both CBT and DBT techniques, showing that the intervention helped patients who underwent gastric bypass reverse their pattern of weight regain. At the time this chapter was written, there were no published studies on DBT in patients undergoing BPDDS.
47.6 Final Considerations
Psychotherapeutic treatment options for patients undergoing BPDDS are still poorly studied; for this reason, techniques for which there is more evidence of efcacy for the treatment of obesity should be preferentially adopted in this population. To date,
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psychotherapies based on CBT, IPT, mindfulness, and DBT were the most studied, with studies showing its effectiveness, particularly in patients presenting DEB.However, it is important to keep in mind that methodological limitations of many studies make it difcult to generalize the results. Obesity should be seen as a multidimensional phenomenon, where behavior is only one of its many variables, whose complexity increases the challenge imposed on whichever professionals are involved in their understanding, treatment, and prevention. DEB in bariatric patients, possibly their most studied psychopathological issues regarding risk of weight regain, may be explained as trait-dependent or state-dependent conditions. This means that obesity directly causes behavioral deviations, through several neuro­physiopathological mechanisms, such as low-grade systemic inammation, (state­dependent) processes that might affect the brain, damaging neurotransmission systems regulating mood, impulsiveness, and behavior. Such processes can be reversed with weight loss, as shown by some studies on the effects of bariatric sur­gery on the central nervous system [44]. However, trait-dependent conditions such as temperament, personality, and individual coping styles lie behind the various ways obesity indirectly alters an individual’s behavior. Thus, certain temperamental characteristics may increase the odds of DEB in patients with obesity [4], dening, likewise, the chances of therapeutic success. For instance, conscientious and self­controlled individuals may adhere better to post-surgical routines; otherwise, neu­rotic, impulsive, and reward-sensible individuals, personality traits related to increased impulsivity and, consequently, increased risk of DEB, have higher chances of unfavorable outcomes [4]. Further studies on psychological treatment for patients undergoing BPDDS need to be performed, for instance, to clarify which psycho­therapeutic techniques are most effective and safe, both on short and long term, as well as whether they are best done when performed individually or in group.
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Chapter 48
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Surgical Management ofLeaks
ArielShuchleib, MarioShuchleib, andEliasChousleb
48.1 Introduction
Bariatric surgery is the most efcient therapy for weight loss and management/reso­lution of multiple medical comorbidities.
Without a doubt, the biliopancreatic diversion with duodenal switch (Fig.48.1) or one of its variants with a single anastomosis (Fig.48.2) is the most powerful bariatric surgery in terms of weight loss and resolution of comorbidities [1, 2]. Despite its great efcacy, this procedure and its derivatives are not even 1% of the total bariatric surgeries performed worldwide according to the IFSO global reg­istry [3].
We believe that two of the main reasons why this procedure is seldomly per­formed are that, even with the single anastomosis, the duodenal switch is more technically challenging to perform than other bariatric surgeries. Secondly, and more relevant for this chapter, it is due to the fact that short- and long-term compli­cations are higher with these procedures.
Before we begin to talk about the management of a complication, it is important to understand how often it presents, in order to be able to appreciate the magnitude of the problem.
In a large multicenter study led by a group from the bariatric medicine institute in Utah with over 1300 patients in whom a primary SADI was performed, they
A. Shuchleib (*) Department of General Surgery, American British Cowdray Medical Center, Mexico City, Mexico
M. Shuchleib Department of Internal Medicine, Hospital Angeles Lomas, Mexico City, Mexico
E. Chousleb The Bariatric and Sleeve Gastrectomy Center at Jackson North, Miami, FL, USA
© The Author(s), under exclusive license to Springer Nature Switzerland AG 2023 A. Teixeira et al. (eds.), Duodenal Switch and Its Derivatives in Bariatric and Metabolic Surgery, https://doi.org/10.1007/978-3-031-25828-2_48
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