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Things they don’t tell you before WLS

Chapter 1

I wake up Sunday morning. I take a step. I cry out in pain from my big toe. I wobble down the hall and find myself thinking, oh no. Oh, fuck no. I do NOT have gout.

Side note: Gout feels like the most old-fashioned sounding medical term still used. Just me? Yeah, probably. Moving on.

I sit down to research. Symptoms: Nighttime onset with no prior trauma to affected area (check). Intense pain in the affected joint (check). Limited range of motion (I try to curl my toes and discover that only two of them move, so check).

But I don’t have the redness or swelling. There’s minor swelling. So I start to doubt gout.

Then I read about potential risk factors: Diet high in protein (check). Rapid weight loss (check).

Fuck. My. Life.

Never once did gout come up in a pre-op course I had to take. Nor was it mentioned in the post-op courses. The surgeon didn’t bring it up in our consult. But a few minutes of research taught me that gout can happen after bariatric surgery.

I try to get in to see my doctor, but he doesn’t have anything open before a follow-up I already had scheduled for Wednesday. So I wait. I start to worry it’s a break in one of the sesamoids. My doctor, however, confirms my original theory and says, at the same time as I do, overnight onset, rapid weight loss and high protein diet. Not kidding, we couldn’t have choreographed it better had we tried.

So he says, in an ideal world I’d put you on NSAIDS 3 times a day for a week, but with the sleeve they probably don’t want that. I confirm that they prefer us to avoid it. Instead he recommends Tylenol a few times a day, which I don’t bother with because it won’t do much to help the pain except mask it and it’s not worth the possible harm to my liver or the rebound headaches I sometimes get from regular acetaminophen usage.

Fast forward to this morning. We leave on Saturday for a road trip. For the first time in years I was planning to do some actual walking on this trip, thanks to the reduction of my lower back pain, which I’ve previously written about here. I was supposed to spend last week and this week walking daily to break in my new sneakers, but clearly that hasn’t happened as putting a show over that toe would be excruciating right now.

So I called the surgeon’s nurses. I left a message explaining the situation and asking about the NSAID usage. The nurse called me back and said the nurse practitioner cleared me to do the NSAIDs for no more than 4 days and with a proton pump inhibitor because of the increased risk for reflux. I already take Protonix thanks to the surgery (waking up with horribly sore throats sucks) so I just have to take it twice a day while I take the NSAID.

Then she asked, but Helene (the NP) wanted to know what your PCP prescribed for long term management. I said, uh nothing? He didn’t seem to think it was warranted given the presentation was fairly minor (even if it hurt like fuck — lemme tell you I never want a MAJOR presentation of gout). Oh, she said… well Helene would like you on something because this is quite common in post-op patients due to the rapid weight loss and high protein diet, and once it happens it will almost always keep happening (and what she left out there is that for people that have recurrent or chronic gout, the attacks tend to get progressively worse). We want to be sure you don’t have further attacks, so your PCP will need to prescribe a medication to help with that.

What. The. Actual. Fuck.

I feel my heart pounding as she tells me this, I feel the rush of anger driven adrenaline make my hands shake. I’m angry and I’m frustrated. What I was able to find online about gout and post-op WLS patients is clearly accurate (and shockingly, even for a skilled researcher like me, I still found very little).

Did they not think that maybe this might be something we should know could happen? I mean, I get they can’t cover every single possible complication, but if this is — as was described to me just now — seen fairly often in post-op patients, and on top of that, for them it typically does become recurrent… don’t you think that’s just maybe information they might want to know when they make their informed decisions?

After all, regaining some of my lost mobility was a HUGE factor in my choice to do something that is pretty much antithetical to all I believe in. So knowing I was risking developing a condition that could limit my mobility would’ve been nice, to say the least. There’s no informed consent when patients aren’t properly informed!

This is hardly the only post-op side effect of surgery that wasn’t discussed and should’ve been. However, it’s the first one I’ve encountered where I didn’t know it was a potential complication from my own copious research. That’s likely because, from what I’ve learned since last Sunday, there isn’t a lot of research on this particular issue. I find that extremely problematic because one of the ways they promote this surgery is by discussing how much easier it will be to move afterwards! If you lose weight, after all, all of your pain is going to go away, once you’re thin, isn’t it (spoiler alert: probably not)?

You’ll be able to exercise more easily! You won’t have so much extra weight to carry around, so it will become a much easier thing to walk or do, well anything!

Until the morning you wake up with gout. Then you can’t move so easily.

Look, I get it. The surgeons have a vested interest in having to reveal as little as possible before surgery because it makes it more likely people will do it. Why mention something that hasn’t been that heavily researched, like gout? Even if you see it all the time in your own practice!

I don’t know, call me crazy, but maybe because it’s ethical to do so?

By the way, you’ll frequently see “obesity” listed as a risk factor for gout. Reminds me of the gallbladder issues caused by WLS (if you still have your gallbladder before surgery, the odds are good you won’t for long). Rapid weight loss causes gallstones. But they’ll also say “obesity” can cause it. I had mine out beforehand, so it was a non-issue for me, but I was surprised it wasn’t mentioned in the class discussions or my consult (maybe he’d already seen it was gone, Idk) as a potential complication of bariatric procedures. And the people I do know who had to have theirs removed post-op never had a single attack pre-op.

In other words, be wary of the things that surgeons/doctors tell you can be “cured” if you’ll only just lose weight. Why? Because some of these things happen to thin people anyway, and also because, in many cases, the “treatment” to make you thinner can actually cause the very thing they’re telling you that you need to lose weight for in the first place (this is especially true where oral weight loss drugs are concerned).

As for me, I’ve left my primary care a message so he can prescribe whatever other medication I need to add to my daily ritual of supplements, proton pump inhibitors and increased anxiety meds, all meds related to the surgery. I remember the nurse telling me before my surgery, while reviewing my meds, isn’t it going to be great when you don’t have all these pills to take? Being my skeptical self, I didn’t respond to her, not that time. After my surgery, I was able to come off some of my meds (notably the two I took for diabetes), at least for now (diabetes remission post-WLS is often temporary and not a cure). She asked me how great that was!

I was like, well I’ve added about 10 other pills, so it doesn’t really feel that great, to be honest. She was like, well yes, but those are VITAMINS! Isn’t that better?!

Uh, if you say so. I just kind of ignore her because I didn’t have anything to say she was going to want to hear.

The thing is not taking these supplements can make me really sick (vitamin deficiencies are no joke, and while bypass patients are at higher risk for those, it also happens to sleeve patients and these supplements will be necessary for the rest of my life). I have to remember to take them, which is sometimes problematic for me (yes, even with a pill calendar) so I don’t risk getting sick. Many vitamins/supplements are quite large and not to be taken on an empty stomach. That creates a challenge because I am not supposed to drink for 30 minutes after eating, and while there’s obviously still some food there at that point, it’s hard to — quite literally — fit some of these pills in when I’m still full from a meal. Especially considering they require more fluids to take them. Then there’s the part where a lot of them can impact how well my thyroid medication is absorbed, and that’s probably part of the cause of the thyroid shitstorm I’ve dealt with since the middle of March (first it was crazy hypo, then it went hyper… just last week it reached a normal level, finally).

So now I get to add another pill to my daily routine. Woohoo! So glad I was going to need less meds when I had WLS. Oh, wait…

Fortunately for me, I never really put much stock in those claims. But many do, and so not getting that result can be devastating. Not every post-op patient will be able to go off diabetes meds, for example. Even if they lose weight, they may still need them. For those patients who went into their procedure hoping for a cure, they may be very let down.

The bottom line here is, do your own homework before you consider any medical treatment, but especially one that has lifelong consequences. Don’t rely on medical staff to tell you about all the possible complications or outcomes. It shouldn’t have to be on you to due this research, but if you want to be able to ask informed questions, it’s definitely in your best interest.

Now, if you’ll excuse me. I’m off to read about famous people who’ve had gout.