INTRODUCTION

Thank you for your interest in our Bariatric (weight loss) Surgery Program.  We offer a comprehensive medical approach to the treatment of obesity including both medical and surgical therapies.  We have been performing laparoscopic bariatric surgery since 1985 and most surgeries are done at the RMC in Vineland, New Jersey.  Our program is privately owned and managed by physicians.  We treat only obesity and related conditions in a setting designed to accommodate the special needs of our patients.

Our medical staff currently consists of five surgeons, Dr. Iqbal, Dr. Khan, Dr. Attia (weight loss specialists), Dr. Haq and Dr. Cooper.  Additional information about our medical staff is available at our web site and office.

We currently offer all types of bariatric surgery, the Roux-En-Y gastric bypass and the lap-band adjustable gastric banding.  All of the surgeries are performed laparoscopically and open as medically feasible.  Surgeries are performed at the RMC with a dedicated bariatric wing staffed by personnel knowledgeable in the core of bariatric patients and committed to their care.

What makes our center different?

• We offer a comprehensive program from the initial visit through surgery and offer long term follow up after surgery.
• Our staff includes surgeons experienced in advanced laparoscopic surgery and a physician who is a specialist in weight management.
• We provide personal and individual care. All of our visits are one-on-one; we do not perform seminar sessions to 20-30 patients at a time.
• Our practice is experienced and very successful with the insurance approval for bariatric surgery.
• We have an active support group to assist patients both before and after surgery.
• We are one of the few Bariatric Centers of Excellence within the state.

The following information is provided to introduce you to the surgical treatment of morbid obesity and our program.  It defines obesity and shows the impact on health.  The indications for surgery are discussed.  Next, the various types of bariatric surgery are reviewed including the risks and complications.  Finally, our program is discussed.

The decision to have bariatric surgery is very serious and life changing.  The amount of information you need to know about bariatric surgery can be overwhelming.  Please read this material thoroughly before your initial visit.  It will allow you to become familiar with our program to give you an opportunity to think of questions to be addressed at your visit.

OBESITY

Obesity Statistics

Obesity has reached epidemic proportions in the United States.  Over half of the adults in our country are overweight and 1 in 4 is classified as obese.  5-10 million Americans are considered to be morbidly obese.  Obesity is the second leading cause of preventable deaths second only to smoking.  It is responsible for over 300,000 deaths per year.  On the average, morbidly obese individuals die 10-15 years earlier than normal weight persons.

Definition of Obesity

Obesity is defined as excess fat tissue.  Obesity is recognized as a chronic disease, which can be treated but not cured.  Clinically obesity is generally defined two ways.  An increase of 20% or more above your "ideal body weight" is considered obese.  Typically insurance height-weight charts are used as references for ideal weights.  Another method of determining obesity is the Body Mass Index or BMI.  The BMI uses a person's height and weight to calculate a value that corresponds to the degree of health risk a person has.  A BMI of 30 or more is considered obese.

Medically, the word "morbid" means causing disease or injury.  Obesity becomes morbid when it reaches the point of significantly increasing the risk of developing serious or life-threatening conditions, which are known as comorbidities.  Morbid obesity is typically defined as being 100 pounds or more above ideal body weight or having a BMI of over 40 or higher.  Morbid obesity is also known as Clinically Sever Obesity or Grade III Obesity.

Health Implications of morbid obesity

Morbid obesity is associated with an increased risk for shorter life span.  The risk of an early death for people whose weight exceeds twice their ideal body weight is doubled compared to non-obese people.  Obesity causes or contributes to many serious health conditions known as obesity-related comorbidities.  The following is a partial list of some of the more common comorbidities.

Type 2 diabetes                                                                            Osteoarthritis

Heart disease                                                                               Gallbladder disease

Hypertension (high blood pressure)                                        Urinary stress incontinence

Hyperlipidemia (high cholesterol or triglycerides)               Lower extremity venous stasis

Sleep apnea//Respiratory problems                                       Menstrual irregularities

Pulmonary embolus (blood clot)                                              Infertility

Gastroesophageal reflux (GERD)/heartburn                          Polycystic ovarian syndrome

Depression

Treatment options for morbid obesity

There are many options available, both medical and surgical, for the treatment of morbid obesity.  However the success rate among the options varies considerably.  Most nonsurgical weight loss programs are based on some combination of diet/behavior modification and regular exercise.  Unfortunately these programs have not been effective in producing or sustaining a significant weight loss, especially in the morbidly obese population.  Weight loss surgery, however, has been the only method that has resulted in sustained weight loss in the morbidly obese.

Surgical treatment of morbid obesity

The use of surgery for weight loss has been performed in various forms since the 1950's.  Early methods, while effective, proved to have significant associated metabolic complications.  Bariatric surgery has gone through many evolutions since that time, which has resulted in the development of effective, safe surgical procedures.  As mentioned above, weight loss surgery has been shown to be the only effective method of weight loss for people who are morbidly obese.

Who is a candidate for weight loss surgery?

Undergoing surgery for the purpose of losing weight and improving comorbidities is obviously a drastic step.  It is only considered after more conservative methods have failed.  In 1991, the National Institutes of Health (NIH) developed guidelines for the selection of patients for bariatric surgery.  The American Society of Bariatric Surgeons (ASBS) has adopted these guidelines as well.

Criteria for Bariatric Surgery

• 1. Patients should exceed ideal body weight by 100 pounds or 100!, or have a BMI greater than 40.
• a. Patients with a BMI between 35-40 may be considered if there is a presence significant obesity related comorbidities.
• 2. They should have no known causative metabolic or endocrine causes for the morbid obesity (i.e. treatable causes).
• 3. They should have attempted weight loss through conservative methods and had been unsuccessful at sustained weight loss.
• 4. They should be capable to understand the full importance of the surgical procedure, including risks and complications.
• 5. Patients must be able to care for themselves and be willing to comply with needed long term follow up care.

Goals of surgery

The foremost goal of bariatric surgery is to improve or resolve obesity-related medical comorbidities.  The second is to prevent the development of new comorbidities.  Lastly, the patient's quality of life should improve as a result of significant weight loss and improvement of comorbidities.  The goal is not to make a person thin.

The normal digestive system

In order to understand how weight loss surgery works, it is important to understand how the gastrointestinal tract normally functions.  A simplified description of the gastrointestinal tract appears below.

• 1. The esophagus is a long muscular tube, which moves food from the mouth to the stomach.
• 2. The abdomen contains all of the digestive organs.
• 3. The stomach normally holds more than 3 pints (6 cups or 1500 ml) of food from a single meal. Here the food is mixed with acid and churned into smaller piece.
• 4. A muscle at the entrance to the stomach from the esophagus keeps food and acid from "refluxing back into the esophagus."
• 5. The pylorus is a small muscle located at the outlet of the stomach. When the pylorus opens, it allows food to pass into the first portion of the small intestine.
• 6. The small intestine is about 15-20 feet long and is where the majority of absorption of nutrients takes place.
• 7. The duodenum is the portion of bowel where food mixes with bile from the liver and digestive juices from the pancreas and further digestion occurs. This is also the region were much of the iron, calcium and B-vitamins are absorbed.
• 8. The jejunum and the .......
• 9. The ileum continues digestion and absorption of nutrients from the food.
• 10. Another valve separates the small and large intestine to prevent reflux of colon material into the small intestine.
• 11. In the large intestines, excess fluids are absorbed and a firm stool is formed.

How surgery causes weight loss

Bariatric surgery causes weight loss by altering the body's energy balance.  Energy balance is the relationship between how much food is absorbed and how much energy the body uses.  Excess energy is stored as fat and held in reserve until needed, at which time it is burned for energy.  When the amount of energy expended by the body exceeds the amount of energy eaten, the fat reserves can be used to meet your body's needs.  A reduction in food intake or absorption, or an increase in physical activity, can therefore result in weight loss.

There are two ways that surgery can alter the energy balance:

• 1. Decreasing food intake (restriction).
• 2. Decreasing food absorption (malabsorption).

Restrictive procedures

Restrictive weight loss surgery works by reducing the amount of food consumed at one time.  It does not interfere with the normal digestion and absorption of food.  This is accomplished by creatinine a smaller upper stomach pouch with an initial ½ - 1 ounce (15-30 ml) capacity.  The pouch connects to the rest of the stomach through an outlet (stoma).  The smaller pouch and narrowed opening caused early fullness with smaller quantities of food.

After the healing and adaption process, most patients can eat ½ to 1 cup of food before becoming uncomfortably full.  Patients must learn to eat slowly, eat less, and avoid drinking too many fluids, especially carbonated beverages.  Failure to follow these guidelines can defeat the purpose of the surgery by stretching the pouch and/or the outlet.  Snacking throughout the day and drinking high calorie liquids also reduces the effectiveness of restrictive procedures.

Malabsorptive procedures.

Malabsorptive procedures work by altering digestion, thereby causing food to be poorly digested and incompletely absorbed.  This is achieved by bypassing a portion of the small intestines, limiting the absorption of calories.  Because this type of surgery affects digestion, it also carries the risk of metabolic complications caused by nutritional deficiencies.  The risks of complications generally increase with the lengthening of the small intestine bypass.  Pure malabsorptive procedures do not restrict food intake; however, some procedures combine both restrictive and malabsorptive components.

Overview of types of weight loss surgery

Weight loss surgeries are categorized as either restrictive, malabsorptive, or a combination of the two.  The following section describes the different surgical procedures currently performed.  The advantages, disadvantages, risks, and results of each procedure are provided.  Later sections will review the two procedures, the Roux-En-Y gastric bypass and the lap-band, our clinic performs in great detail.

Vertical Banded Gastroplasty (VBG)

The vertical banded gastroplasty is a purely restrictive procedure.  In this procedure, the upper stomach near the esophagus is stapled vertically about 2 ½ inches to create a small stomach pouch.  The outlet from the pouch is restricted by a band or a ring that slows the emptying of food healing to create a feeling of fullness.

Advantages

• Relatively simple procedure
• Nutrient and vitamin absorption not affected

Risks

• Staple line disruption: This can cause leakages and/or infection. It may also lead to weight gain by allowing food to pass directly into the larger portion of the stomach.
• Obstruction of band or ring site.
• Stretching of pouch.
• Soft calorie syndrome. Due to the discomfort caused by eating solid food, many patients revert to eating soft high calorie foods which may cause weight gain.

Results

• 50-60% success rate. (40-50% of patients fail to lose half of their excess weight).
• Average weight loss: 35-40% EWL (Excess Weight Loss)
• 30% of patients reach IBW.
• 22-26% success rate at ten years after surgery.

Laparoscopic Adjustable Gastric Banding (Lap-Band)

An adjustable gastric band is a purely restrictive procedure in which a band is placed around the upper most part of the stomach creating a functional small pouch.  There is a balloon on the inner surface of the band that can be adjusted through a port attached to the abdominal muscle layer.  Food passes through the band area into the larger portion of the stomach and is digested in the normal manner.

Advantages

• No stapling or cutting of the digestive system
• Normal digestion
• More reversible
• Band can be adjusted to increase or decrease restriction
• Very low mortality rate

Risks

• Band slippage
• Band erosion into stomach wall
• Band, tubing, or port malfunction, which causes balloon to deflate
• Vomiting or acid reflux
• Pouch dictation

Results

• 75-80% success rate
• Average weight loss: 50-65% EWL over two years.

Roux-En-Y Gastric Bypass (RYGBP)

The Roux-En-Y gastric bypass is considered a combined restrictive and malabsorptive procedure.  It is the most commonly performed weight loss surgery in the United States.  A small (15 to 30 cc) pouch is created by stapling and dividing the stomach.  The outlet of the pouch empties directly into the lower portion of the jejunum, bypassing the duodenum, and reducing calorie absorption.  This is done by dividing the small intestine just beyond the duodenum and constructing a connection with the new, smaller pouch.  The bypassed portion of the intestine is then reconnected to the jejunum.

Advantages

• Faster and typically greater weight loss then purely restrictive procedures.
• Studies have demonstrated long term weight loss maintained after 10-14 years.
• Dumping syndrome may help patients avoid high calorie sweets.

Risks

• Leakage or surgical connections, though uncommon, may occur.
• Because the duodenum is bypassed, lower absorption of the minerals, iron, and calcium can occur. The absorption of certain B vitamins may also be affected. This can lead to deficiencies of these nutrients, which in turn can predispose patients to medical problems such as anemia and osteoporosis.
• Dumping syndrome can result in unpleasant side effects.
• The lower part of the stomach can no longer be easily visualized after surgery.

Results

• 75-80% success rate.
• Average weight loss: 70% EWL
• 1/3 of patients reach IBW.

Malabsorptive Procedures

The Biliopancreatic Diversion (BPD) and the Biliopancreatic Diversion with "Duodenal Switch" are considered malabsorptive surgeries.  Although the stomach size is typically reduced in these surgeries, the pouches are usually much larger than with other procedures.  The main goal of these procedures functions is to alter the normal digestive process.  The bile and the pancreatic digestive juices are diverted so they meet the ingested food closer to the middle or end of the small intestines.  With all three of the approaches discussed below, absorption of nutrients and calories is reduced, but to a greater degree than with the previously mentioned procedures.

Advantages

• Often result in high degree of patient satisfaction because patients are able to eat large meals than with other procedures.
• Can produce the greatest excess weight loss due to providing highest levels of malabsorption.

Risks

• A period of intestinal adaption when bowel movements can be very liquid and frequent. This condition may persist for life.
• High incidence of nutritional complications due to malabsorption.
• Close lifelong monitoring for protein malnutrition, anemia, bone disease, and nutritional deficiencies is highly recommended.

Results

• Success rate > 80%.
• Average weight loss: 75-85% EWL.

The three most common malabsorptive procedures are the Distal Roux-En-Y Gastric Bypass, the Biliopancreatic Diversion, and the Biliopancreatic Diversion with  "Duodenal Switch."  They are discussed below.

Distal Roux-En-Y Gastric Bypass

The Distal Roux-En-Y Gastric Bypass is a variation of the Roux-En-Y Gastric Bypass in which the segment of bypassed small intestine is much longer in the standard procedure.  This creates a greater malabsorptive effect on nutrients.

            (see Roux-En-Y figure, above)

Biliopancreatic diversion (BPD)

The classic Biliopancreatic Diversion (BPD) completely removes ¾ of the stomach, retaining the natural stomach outlet, to produce both restriction of food and reduction of acid output.  The small intestine is then divided and one end is attached to the stomach pouch to create what is called an "alimentary limb."  All of the food moves through the segment, but very little is absorbed.  The bile and pancreatic juices pass through the "biliopancreatic" limb:  which connects to the side of the intestine near its end to form a "common limb."  The nutrients are then absorbed through the short common limb.

Biliopancreatic Diversion with Duodenal Switch

This surgery is a variation of the BPD.  In this procedure, only the outer margin of the stomach is removed, leaving a sleeve of stomach with the pylorus and the beginning of the duodenum intact.  The duodenum is divided so that pancreatic and bile drainage is bypassed.  The near end of the "alimentary limb" is then attached to the beginning of the duodenum, while the "common limb" is created as described before.

Open versus laparoscopic

A laparoscopic operation is performed with the aid of a small camera inserted into the abdomen.  The camera and surgical instruments are inserted through incisions made in the abdominal wall.  This approach is considered less invasive but our open procedure is done with a small 4-5 inch incision.

All of the surgeries discussed above can be performed both laparoscopically and in the "open" manner.  The results and side effects have been shown to be similar.  In fact, laparoscopic procedures have a much lower incidence of abdominal wall hernias (20% open vs. 2% lap) and wound infections (30% open vs. 1% lap).  Postoperative pain is commonly lower with laparoscopic surgeries.  Also the period of time before returning to work after laparoscopic surgery is typically one-third to one-half that of open surgeries.

Benefits of weight loss surgery

There are numerous benefits as a result of weight loss surgery.  They can be measured in terms of weight loss, resolution, or improvement of the medical problems related to obesity and quality of life.  Studies have shown that is currently the only effective method of long term weight loss in the morbidly obese population.

More importantly, the operation can cure or control many of the serious diseases that accompany morbid obesity.  The following statistics demonstrate the affect gastric bypass surgery has for patients one year after surgery.

                        Percentage of comorbidities resolved after one year

                                    Type 2 diabetes mellitus                          82%

                                    Sleep apnea                                          74%

                                    Hypercholesterolemia                              63%

                                    Hypertriglyceridemia                               57%

                                    Hypertension                                        70%

                                    GERD                                                  72%

                                    Urinary incontinence                              44%

Most patients experience significant improvements in their quality of life after bariatric surgery.  Improved self esteem and confidence help in fighting depression.  Patients are able to socially interact with family, friends, and coworkers in ways that were not possible before surgery.

Risks and complications of weight loss surgery

While the benefits of weight loss surgery can be very dramatic, every surgical procedure carries risks and complications.  It is important to understand these risks and complications in order to make an informed decision about weight loss surgery.  Some risks and complications apply to any abdominal surgery.  Others are more specific to particular procedures.  Unfortunately, being morbidly obese in itself places patients at higher risk for any surgical procedure.  It is the act of having an operation not the particular operation which is done, that causes most of the risk.

General Surgical Risks/Complications

Bleeding

• Heparin effect

Heparin is a blood thinner used during and after surgery to prevent blood clotting and pulmonary embolus (see below).  Each individual has a different sensitivity to this medication; therefore, delayed bleeding may occur after surgery in some persons.  This is monitored closely during your hospital stay.

• Hemorrhage

When surgery is performed, blood vessels must be cut.  Bleeding is stopped by either typing the ends of the vessels with suture or using an electrocautery devise that coagulates the blood and seals the ends.  Sometimes, a blood vessel may escape, and then begin to bleed again several hours later.  Occasionally, this may require a return to the operating room to correct the problem.

• Transfusions

When significant blood loss occurs, it may cause the blood pressure and pulse to become unsteady.  This may necessitate a blood transfusion.  Although blood banks have very high quality standards, there is still a very small possibility of contracting Hepatitis or HIV through blood transfusions.  It is very uncommon to need a blood transfusion with bariatric surgeries.

Surgical problems

• Possible injury to nearby structures

The spleen and liver are large solid organs that are in the same region as the upper stomach.  They need to be retracted or moved during surgery to provide access to this area.  Occasionally, tears may occur which need to be repaired.  Rarely it is necessary to remove the spleen because of bleeding.

• Perforation of stomach and/or intestine

There is a small risk of the stomach or intestines tearing during surgery.  This can usually be corrected at the time of surgery and does not interfere with the outcome.

• Rejection of staple or suture material

The materials used for surgery are hypoallergenic and rarely cause any problems.  There is, however, always a rare possibility that the body will react to a foreign substance that it is exposed to.  The staples used during any abdominal surgery remain there for life and do not pose any problems with any future radiological tests.

Bowel obstruction

Bowel obstruction can occur after any abdominal operation due to scars called adhesions.  Adhesions can cause symptoms ranging from discomfort to blockage of the bowel requiring surgical intervention.  They can occur from weeks to months or years after surgery.

Infection

• Abscess.

An abscess is a collection of infected fluid that can occur anywhere in the body.  After an abdominal operation, a pocket of fluid may develop and become infected if there are bacteria present.  The treatment of an abscess is to drain away the fluid and kill the bacteria with antibiotics.  To prevent abscesses, a drain is often inserted during surgery to prevent fluid buildup.

• Wound infection

A wound infection is a type of abscess and treated in much the same way.  Major wound infections are uncommon with laparoscopic surgeries in comparison to open surgeries.

• Pneumonia

Pneumonia is an infection in the lungs.  Precautions to prevent pneumonia include using good anesthesia and respiratory treatment.

• Urinary tract infection

Urinary catheters are frequently inserted at the time of abdominal surgeries.  In rare cases this can lead to an infection of the urinary tract, which can typically be cleared through the use of antibiotics.

Lung problems

• Atelectasis

Atelectasis is a partial collapse of the tiny air sacs in the lung.  It can occur after surgery due to not taking full deep breaths.  It can cause a fever after surgery and lead to pneumonia.  The best prevention is to take deep breaths after surgery and perform any lung exercises given.

• Pulmonary edema

Pulmonary edema is a buildup of the fluid in the lung that can cause respiratory difficulties.  This can usually be treated with medications but may require keeping the breathing tube in place or replacing it until the problem is corrected.

• Pulmonary embolism

A pulmonary embolism is a concern with any surgical procedure.  Because people are not moving during surgery and very little after surgery, it is easier for blood clots to form in the legs.   Obese people are also more prone to develop blood clots in general.  If a blood clot breaks off and travels through the veins to the lungs, a pulmonary embolus may occur.  This can be a life threatening situation.  Several precautions are taken to prevent pulmonary emboli.  Foremost the length of the surgery is kept to a minimum.  Heparin, a blood thinner, is used at the time of surgery.  Compression devices are placed on the legs to assist blood flow.  Lastly we encourage all patients to get out of bed and walk as soon as possible after surgery.

Cardiovascular problems

• Myocardial infarction (heart attack)/Congestive heart failure

The heart is required to do extra work around the time of any surgery or stress.  Bariatric surgery is a major stress.  If the patient's heart is not able to keep up with the increased demands, fluid may back up into the lungs causing congestive heart failure.  If a patient already has compromised circulation to the heart, the increased demand could cause a heart attack.

• Arrhythmias

The increased workload on the heart may cause heartbeat irregularities.  Anesthesia can sometimes make a patient more prone to develop these irregularities.

• Stroke

If blood flow to the brain is significantly affected at the time of surgery, usually from heart irregularities, it could result in a stroke.

Kidney and Liver

• Acute kidney failure
• Liver failure

Anesthetic problems

Airway control may be difficult in morbidly obese patients due to the amount of fat tissue surrounding the neck.  Anesthetic agents may be metabolized differently in this group as well.  These factors can present problems for anesthesiologist.  The hospital that we perform bariatric surgeries has excellent anesthesiologists well experienced in dealing with bariatric patients.

Death

Although death is rare following surgery, it can and does still occur.  Currently, the risk of death for gastric bypass surgery in the United States is approximately 1 in 200 to 1 in 300.  The risk of death for the lap-band procedure is approximately 1 in 10,000.

Roux-En-Y Gastric Bypass Surgery Risks/Complications

In additional to the general risks of abdominal surgery discussed above, the Roux-En-Y Gastric Bypass operation has other, more specific risks and complications.  While most of these are uncommon, it is important to understand that they may occur and affect the post-surgical course.

Anastomosis leak

When a surgeon connects bowel to bowel, or bowel to stomach, the connection is called an anastomosis.  If a complete seal does not form, fluid can leak from the bowel into the abdominal cavity.  This is called an anastomotic leak.  It is potentially one of the most serious complications that can occur after surgery.  Fortunately, it is very rare with a less than 2% occurrence.  It can lead to peritonitis, which is an infection of the abdominal cavity.  Leaks almost always require surgical repair, sometimes involving an "open" technique.  Leaks are tested for during surgery as well as a few days after surgery before allowing a patient to eat or drink by mouth.

Seroma/infection

In all patients, some of the fat tissue under the skin liquefies after surgery.  The body usually reabsorbs this fluid over the course of a few weeks.  In some patients this fluid finds its way to the outside at the incision sites.  A large amount of yellow/orange drainage may occur.  Usually nothing needs to be done other than covering the spot to protect clothes.

Sometimes, bacteria colonize the fat tissue under the skin during the operation and develop into an infection.  We have found that this usually occurs at the large incision at the left side of the abdomen between 4 and 7 days after surgery.  Signs include a red tender bulge at the site, which may drain a yellowish, malodorous liquid.  The infection is treated by draining the site and placing the patient on oral antibiotics.  This can usually be done in the office.  Our experience has shown that this condition can occur in 5-8% of our patients after surgery.

Stoma stricture

The stoma is the outlet from the stomach pouch to the small intestine.  The hole is deliberately made small, slightly smaller than a dime, to prevent food from emptying too rapidly from the pouch.  As healing occurs, this area may scar and contract causing the opening to become too small.  Food has difficulty passing through, which causes repeated vomiting.  Stoma strictures occur in approximately 8-10% of our patients.  It usually develops 3-4 weeks after surgery.

The stricture is both diagnosed and treated by performing an endoscopy or EGD which is the same test that was done before surgery to evaluate the stomach.  A balloon is used to stretch the stoma.  One treatment corrects this problem in most people:  However this procedure occasionally may need to be performed a few times until the stoma stays at an acceptable diameter.  The EGD is performed as an outpatient procedure.

Internal hernia

Recently, there have been reports of patients developing small internal hernias in the abdominal cavity.  It is estimated that it may occur in up to 2-3% of patients.  It is usually seen after a patient has lost a significant amount of weight.  This type of hernia is not the same as a hernia involving the abdominal wall.  It is felt that as fat is lost within the abdomen; the bowel may slide through small defects in the tissue supporting the bowel causing a hernia.  This problem can be hard to diagnose because the symptoms can be vague.

Gallstone formation

Any rapid weight loss increases the risk of developing gallstones.  This applies to gastric bypass surgery as well as other forms of rapid weight loss.  Approximately 30% of patients develop gallstones after gastric bypass surgery and require surgery.  The use of a medicine called ursodiol, or Actigall, for six months after surgery has been shown to decrease this to 3%.  The use of this medication may be discussed with you.

Dumping Syndrome

Dumping syndrome is a phenomenon seen after gastric bypass surgery due to the altered digestive process that occurs as a result of the surgical changes.  It is caused by the way that simple carbohydrates (sugary foods) are processed by the digestive system after surgery.  Dumping syndrome is usually divided into "early" and "late" phases.

Early dumping is caused by the high osmolality of simple carbohydrates in the small intestine.  When a simple carbohydrate enters the intestine from the pouch it will quickly "suck" a significant amount of fluid into the bowel.  This causes cramping and subsequent vomiting or diarrhea.  It also activates nerve responses, which cause symptoms including palpitations (heart racing), dizziness, nausea, sweating, and skin flushing.  These symptoms can occur in as little as 10-15 minutes after eating.

Late dumping has to do with the high blood sugar.  The small intestine is very effective at absorbing sugar, so that the rapid abortion of a small amount of sugar can cause the blood glucose level to spike upward.  The body responds by releasing more insulin to process the sugar.  However by the time the insulin surge occurs, the blood sugar levels cause the person to feel weak, sleepy, and profoundly fatigued.  The hypoglycemia also stimulates appetite, thus causing a cycle of hunger and eating every few hours.

The best way to avoid dumping syndrome is to avoid surgery, simple carbohydrate foods.  Some people are more prone to dumping syndrome than others.  Most people like having this "backup" as a way to avoid foods that could interfere with their weight loss.

Marginal Ulcers

There is a small possibility of developing ulcers at the margin of the pouch and small intestine connection.  Avoiding medications known to possibly cause ulcers can prevent this problem.  This includes the use of anti-inflammatory medications called NSAIDS, which include aspirin and ibuprofen.

Vomiting

Most vomiting that occurs after gastric bypass surgery is related to eating habits.  Eating too much, too fast, or not chewing food sufficiently can cause vomiting.  Stoma strictures can also be a cause of vomiting (see above).

Nutritional deficiencies

Nutritional problems are rare after gastric bypass surgery and can usually be avoided by the use of proper vitamin and mineral supplements and by eating a healthy diet.  A great deal of time is spent educating patients about proper eating habits and the importance of vitamin/mineral supplementation.

• Protein Deficiency

Protein provides the building blocks to repair and replace tissue.  It is an essential nutrient that the body needs to constantly replace.  A deficiency of protein will prevent the body from functioning optimally.  It can also weaken the immune system placing people at a higher risk of contracting illnesses.  The amount of protein consumed also affects how the body loses weight.  If there is an insufficient amount of protein consumed, the body will "steal" protein from other sources such as muscle.

Gastric bypass surgery reduces the amount of protein that can be consumed at one time.  It also may affect how much of that protein is actually absorbed by the intestines.  Therefore, it is important to eat an adequate amount of protein following surgery.  This may include using protein supplements until you are able to consume enough protein through your food intake.

• Vitamin Deficiency

Vitamins play an important role in the body and deficiencies can cause medical problems.  Vitamin deficiencies can occur following gastric bypass surgery for two reasons.  First, the amount of calories consumed during the first year after surgery do not provide a sufficient amount of vitamins to meet the body's needs.  Secondly, the bypass portion of the surgery affects the absorption of certain vitamins that can cause problems such as anemia and neurological problems.  We therefore recommend that patients take a high potency multivitamin for the rest of their life after surgery.

• Mineral Deficiency

Mineral deficiencies can also occur after gastric bypass for the same reasons as with vitamins.  The two minerals most commonly affected are iron and calcium.  Our recommended multivitamins contain minerals in ample amounts.  However, we also recommend daily use of calcium to prevent osteoporosis, and many patients, particularly women, will require extra iron supplementation.

Lap-Band Risks/Complications

Because the lap-band surgery is a purely stricture surgery, it does not carry the same risk of nutritional complications as the gastric bypass.  It also does not carry the risks of leaks because the stomach and intestines are not cut.  The lap-band does, however, have the risk of certain complications unique to this type of surgery.  Currently, is estimated that there is a 5-10% change that one of the following complications could arise, which may require further surgery to correct.

Band slippage

The band is placed in a very high specific place and secured with sutures.  In rare cases, the stomach can slip up through the band creating a large pouch that empties poorly.  This can lead to indigestion or vomiting after eating.  Reoperation is necessary to correct this problem.

Band erosion

It is possible that over time the band can erode into the stomach.  This does not cause illness, but leads to a sudden increase in food intake.  Advances in surgical technique have significantly reduced this risk.  Correction of this problem requires surgery to repair the hole.  The bad may or may not be able to be replaced at the same time.

Food intolerance/Vomiting

A very small group of people develop intolerance to food after surgery.  This may require removal of the band and conversion to a different type of surgery.

Tube or reservoir problems

It is possible that the tube or reservoir (port) may develop a leak.  The ability to adjust the band is lost when this occurs.  It usually requires the replacement of the band to correct the situation.

Port infection

Anytime the skin is punctured, there is a risk of infection.  Cleansing the skin with antiseptic liquid and using sterile technique minimize this risk.  Rarely an infection can occur in spite of taking these precautions.  If a port infection occurred, it could travel to the band site and cause further complications.  Treatment of port infections may include removing the port and/or band until the infection is resolved.

What are the steps before surgery?

The process from inquiring about bariatric surgery to having surgery performed involves a number of steps.  It takes time to undergo the proper evaluations and testing necessary before surgery.  Insurance approval for the procedure can also take time and require documentation, which must be collected.  Also due to the overwhelming demand for the laparoscopic approach to this type of surgery and the relatively few surgeons who perform the surgeries in this manner, there can be a delay caused by the sheer numbers of patients requesting surgery.  It is not unusual for a period of 4-6 months to pass between the initial evaluation and the surgery date.  Some centers have waiting periods longer than one year just for the initial visit.  Our clinic understands and empathizes with our patients' desire to more forward as soon as possible after deciding to undergo bariatric surgery.  Please understand that we will move you through the process as quickly as possible under the above constraints.

Patients frequently request if their surgery date can be sooner than the anticipated date.  The only reason we will move someone's surgery date up is for medical reasons.  Patients who have severe medical problems requiring more urgent care will obviously have surgery as quickly as possible.  We cannot move a surgery date due to insurance coverage deductibles and/or changes of work schedules.  Please understand that this is not fair to other patients who are also waiting for surgery.

Our staff will contact you throughout the pre-surgical process. Although you are anxious about getting surgery, calling the office repeatedly for updates prevents the staff from being able to process patients and may cause delays in surgery.  We ask that you be patient so that everyone may benefit.

Initial evaluation

Prior to your initial evaluation, you will have received a packet, which includes this material as well as a patient questionnaire and other forms.  This information is used to help determine if you are an appropriate candidate for bariatric surgery.  It is very important to complete this information prior to your visit.  Failure of completing the forms demonstrates a lack of commitment needed to succeed with this type of surgery.

During the initial evaluation, you will meet with the medical director of the clinic.  The evaluation will consist of reviewing the collected information as well as taking measurements.  The doctor may request further information or testing if needed.  Surgical options will be discussed including risks, complications, and weight loss expectations.  If you are deemed an appropriate candidate and decide that you would like to proceed with surgery, you may begin the process for surgery.  This process involves many steps.  The time from your initial evaluation to surgery can be 4-6 months.

Consultation with surgeon

The next step is meeting with the surgeon who will perform your operation.  The surgeon will discuss the surgical details with you and determine if there are any factors present that may affect the surgical course.  Laparoscopic surgery becomes more difficult from a technical standpoint if your BMI is over 60.  If your BMI is over 60, the surgeon may suggest weight reduction prior to surgery.  After meeting with the surgeon, you will be scheduled for any tests needed prior to surgery.

Insurance approval process

It is usually necessary to obtain approval from your health insurance carrier in order to have the surgery covered by the insurance company.  Bariatric surgery is an area where there is a great deal of variability in regards to insurance coverage and requirements.  Some policies may exclude weight loss surgery totally.  Most companies require that you meet their list of criteria to consider approval.  Our staff will advise you about the requirements your particular insurance carrier may have.

We understand that once you have decided to proceed with surgery you are anxious to begin this new phase of your life.  However, getting insurance approval for weight loss surgery is different than approval for other procedure and can take as long as a month.  Also most insurance companies request that we only submit forms within a certain time frame before surgery.  This may mean waiting until closer to the anticipated surgical date before seeking approval.

Preoperative testing

Certain tests are required before surgery to lower the risks of complications.  This allows the opportunity to correct problems that may affect your surgical outcome or to discover problems that might place you at too great of a risk to undergo surgery.

Esophagogastroduodenoscopy (EGD)

Patients who are undergoing gastric bypass surgery have their stomachs evaluated by endoscopy.  This is an outpatient procedure performed at the hospital or surgical center.  After patients are given I.V. sedation, the physician evaluates the stomach with a flexible scope.  Biopsies may be obtained if there is significant inflammation.  The doctor may prescribe medication to heal any abnormalities from the EGD.

Gallbladder Ultrasound

Patients who are undergoing gastric bypass surgery have their gallbladder evaluated by an ultrasound exam to determine if gallstones are already present.  If gallstones are present, the surgeon will discuss the possibility of removing your gallbladder at the time of the gastric bypass surgery.

Medical Clearance

Every operation places a patient at a certain level of risk of complications.  Morbidly obese patients are considered to be at a higher risk for any surgery.  Patients must be evaluated and medically cleared for surgery.  Sometimes, your primary care physician may do this.  In some cases, you may need to be cleared by a specialist such as a cardiologist.

Psychological Evaluation

Some insurance companies require that patients undergo a psychological evaluation as a part of the approval process.  We do not generally refer for psychological testing unless the patient's insurance company requires it or there are reasons a patient might benefit from this type of evaluation.  Research has demonstrated that currently used psychological tests do not predict which patients are successful with bariatric surgery.

Nutritional Evaluation

An evaluation of your dietary habits is performed during your initial evaluation.  However, some insurance companies require patients to undergo formal evaluations as part of the approval process.

Maintaining Current Weight

As mentioned many times earlier, bariatric surgery is a tool used to aid weight loss.  It is not a cure.  Successful results require a commitment to healthy eating habits and activity.  If patients are unable to maintain their weight through the pre-operative process, they may have difficulty adhering to post-operative recommendations.  Patients who gain a significant amount of weight during this process may be deemed poor candidates for surgery.

Nutritional counseling

Hopefully at this point you have had all of the preoperative testing completed and been approved for surgery by your insurance company.  Before having surgery, patients are seen at the clinic for a preoperative visit.  During this visit, the physician will review any medication changes needed before surgery and any instructions for the day of surgery.  You will also receive counseling about the postoperative period after surgery.  This includes a comprehensive nutritional program to get the most benefit from your surgery.

Support group

The American Society of Bariatric Surgeons states that every weight loss surgery program should include a support group.  Our clinic has an active support group that usually meets twice a month.  We also offer a newsletter for circulation as well as an E-mail support group.  We strongly encourage patients to attend support group meetings both before and after surgery.

Hospital course

Gastric Bypass Surgery

Gastric bypass patients typically have a 3-4 day hospital stay.  Patients receive fluids through IV lines and are allowed only small amounts of ice chips by mouth.  Most patients will have a drain inserted into the abdomen, which is removed before you go home.  Usually on the third day after surgery, you will have an x-ray procedure done to test for leaks.  If this test is satisfactory and you are tolerating liquids, you are discharged from the hospital.

Lap-Band

The lap-band procedure requires an overnight stay after surgery.  The next morning, patients undergo an x-ray procedure to ensure proper positioning of the band and the absence of a blockage.  Patients are then discharged from the hospital.

Long term follow up after surgery

Our clinic provides long term follow up and care to all of our patients after surgery.  Patients are usually seen around one week after surgery.  Gastric bypass patients are typically seen at 1, 3, 5 and 12 months after surgery and then yearly.  Lap-band patients are typically seen 4-6 weeks after surgery.  Future follow ups vary depending upon the need for adjustments.  Lap-band patients are usually seen every six weeks for the first six months, then every three months for the first two years, then yearly.

Life after surgery

Activity

Most patients recover quickly after laparoscopic surgery.  Gastric bypass patients usually return to work two weeks after surgery.  Lap-Band patients can sometimes return in as little as one week after surgery.

Diet

There are dietary transition stages for both gastric bypass and lap-band surgeries.  This is to allow healing and to prevent complications.  However both surgeries are only tools to aid in weight loss and do not replace healthy eating habits.  Dietary recommendations are reviewed in detail during the pre-operative visit.

Medications

Most medications are well tolerated and absorbed after surgery.  There may be expectations that require adjustments in the form or dose of a medicine.

Exercise

Exercise is a key component to any long term weight loss program.  Bariatric surgery is no exception.  Exercising helps to prevent muscle loss and reduction of metabolism.  Most patients find they can exercise much easier after a significant weight loss.

Recommended Reading:

NIDDK.  "Gastric Surgery for Severe Obesity."  www.niddk.gov/gastric.

Boasten, Michelle.  Weight Loss Surgery:  Understanding and Overcoming Morbid Obesity.

Thompson, Barbara.  Weight Loss Surgery:  Finding the Thin Person Hiding Inside You.

References:

American Society for Bariatric Surgery.  Surgery for Morbid Obesity:  What Patients Should Know.

National Institute of Health.  "Gastrointestinal Surgery for Severe Obesity."

Illustrations:  Ethicon Endo-Surgery, Inc.  "The Facts About Weight Loss Surgery."

Appendix A

Table 1:  Ideal Body Weights for Men and Women

Weight Criteria Modified from the Metropolitan Life

Insurance Company Height/Weight Tables, 1983

Table 2:  BMI Table

DISCHARGE INSTRUCTIONS

If vomiting occurs, patients should immediately stop drinking and eating until the feeling of nausea passes.  After the nausea disappears, the patient should resume drinking liquids before attempting to eat solid foods.  Repetitive vomiting to the point where liquids cannot be retained is potentially dangerous and any patient experiencing this should immediately contact the operating surgeon or go to the hospital emergency room.

DISCHARGE INSTRUCTIONS - ACTIVITY

Following discharge from the hospital, patients should not drive for one to two weeks and should not attempt any strenuous activity, particularly heavy lifting, for approximately six weeks.  Patients may walk as much as they wish, climb stairs as they need to, and take baths or showers.  Some patients with sedentary-type jobs have returned to work as soon as three weeks after the operation.  Patients with physically demanding jobs should wait six to eight weeks before returning to work.  It is not uncommon to feel weak and tired immediately after discharge from the hospital.  The body is still recovering from the stresses of a major operation and the feeling of weakness may be somewhat prolonged because weight loss is occurring during the recovery period.

POSTOPERATIVE FOLLOW-UP

Postoperative follow-up after gastric reduction operations is extremely important for several reasons.....

• 1. The success of these operations is not determined at the time of discharge. Weight loss after stapled gastroplasty generally occurs over a nine to twelve month period, while weight loss after gastric bypass occurs for as long as 18 months after the operation.

• 2. Counseling by the nutritionist, who is experienced in counseling patients after gastric reduction operations, is important in making the transition from liquids to soft foods. The nutritionist will emphasize the important of making appropriate food choices in order to maintain a balanced diet and to avoid high caloric liquids and soft foods which can defeat the purpose of the operation. All gastric reduction operations can be defeated by consuming too many calories. This is particularly true of the gastroplasty operations.

• 3. The follow-up visits are also very important in recognizing vitamin and iron deficiencies in the early stages so that appropriate treatment can be given. Gastric bypass patients who miss their regularly scheduled follow-up visits along with the necessary postoperative blood tests can eventually develop severe vitamin and mineral deficiencies.

• 4. The best weight loss generally occurs in patients who regularly keep their follow-up appointments.

SCHEDULE OF POSTOPERATIVE VISITS

• 1. First visit three to four days after discharge, then every 2 weeks.

• 2. Visits at six week intervals during the first three months after the operation.

• 3. Visits at approximately three month intervals for the first year after the operation.

• 4. After the first year, follow-up visits are scheduled at six to twelve month intervals for an indefinite period of time.

The operating surgeon and nutritionist meet together with all postoperative patients at each visit.

LONG-TERM OUTLOOK

Weight loss after gastric reduction operations is gradual and occurs at the greatest rate during the first several months after the operation.  Over the long term, consistency rather than rapidity of weight loss is stressed.  After a few months the rate of weight loss will gradually decrease.  This is because the weight which is lost is fat (adipose tissue) rather than lean body mass (muscle).  Hence, the more fatty tissue that is lost, the less remaining fat there is to be lost.  Few patients will reach ideal body weight.  Patients whose weight stabilizes within 50 percent of their ideal body weight are considered successful.  The main reason for poor weight loss after gastric reduction surgery is bad food choices and frequent snacking.  Patients may "loss track" of their eating pattern and redevelop some of the bad eating habits which caused their obesity in the first place.  In almost every case, these bad habits can be corrected by minor changes or substitutions in the diet.  This is why regular follow-up visits are so important after this type of surgery.

Obesity-related medical problems may improve with a modest degree of weight loss after gastric reduction surgery.  Blood pressure is routinely monitored at each follow-up visit, as is blood sugar (glucose) in patients with hyperlipidemia.  Patients are encouraged to see their own medical doctor at regular intervals after the operation, particularly for adjustment in their medications.  With steady weight loss, patients often require lower doses of medication for diabetes and high blood pressure.  Patients may not require any medications for these problems after achieving a substantial amount of weight loss.

All gastric reduction operations are potentially reversible.  Reversal requires an operation of the same magnitude and risk as the original operation.  Reversal of gastric reduction operations is uncommon.  In the long term, changes in the original configuration of the operation can occur.  Disruption (pulling out) of the staples is now an uncommon problem and usually does not occur beyond six weeks from the time of surgery.  Stretching of the upper part of the stomach may occur to some degree, but is rarely a reason for inadequate weight loss.

GASTRIC STAPLING SUPPORT GROUP

A support group of patients who have had gastric reduction operations at South Jersey Healthcare Regional Medical Center has been formed and holds regular meetings.  These meetings are held on a monthly basis.  The primary goal of this group is to serve as a means for exchanging information among patients who have had this type of surgery and also to provide information for individuals who are considering gastric reduction surgery as a possible solution for a serious weight problem.  Many prospective patients have been reassured by speaking with someone who has previously undergone the surgery.  Several members of the support group have volunteered to discuss their experience by telephone with interested patients.  More information about the support group can be obtained from either the operating surgeon or the nutritionist.

GUIDELINES FOR BARIATRIC SURGERY

            When the patient calls for the initial consultation, we advise them that they had to be on a diet and exercise program and they should still be on one.

            When our patients come in for an initial visit we have a group meeting in our office.  However, if they cannot attend the group office meeting we will give them an individual appointment and we go over the same thing.  At our group meeting we explain the entire procedure to the patients.  We advise them of the risks and benefits.  We go over with the patients the things that they must do for the rest of their life, such as taking in adequate vitamins and minerals daily, regular exercise, maintaining a healthy diet, surgeon and physician follow up, and monthly support group meetings.

            After we complete our group meeting all patients meet privately with the doctor.  He will then go over their height, weight and BMI.  A complete history and physical is taken.  The doctor will then decide based on the information obtained if the patient is a candidate for surgery.  If the patient is a candidate we will then advise them what is required prior to surgery.

• 1. Patient must complete and pass a psychological evaluation.
• 2. Patient must go the nutritionist (possibly three visits if the nutritionist and the insurance company feel it is necessary).
• 3. Patient must attend three Behavioral Modification/Support Group
• 4. Patient must complete a Sleep Study, if needed.
• 5. Patient must follow up with their primary care physician and obtain medical clearance.
• 6. Patient must obtain any additional consultation such as cardiac and pulmonary if needed, and clearances.
• 7. EGD is done before surgery.
• 8. All lab work, chest x-ray and EKG is to be completed.
• 9. Patient must also go to the hospital for a pre-surgical class.

Patient will then come back to surgeon's office to go over all the test results and to make sure that if the patient has any additional questions they are answered.

If no abnormally exists, we proceed with surgery.

After surgery patients are followed very closely by the surgeon.

• 1. The average hospital stay is 3-4 days.
• 2. The surgeon sees the patient for follow-up within one week, and then again in one week, than in three weeks. Then every two months for a year if all is ok.
• 3. We will repeat labs every six months.
• 4. We encourage the patients to attend the Gastric Bypass Support Group Meeting.
• 5. Appropriate consultations obtained as needed post-op.