Gastric Bypass Surgery

Introduction

 

Gastric Bypass is a surgical procedure used in the treatment of Obesity. To learn more about this surgery, let us first learn about obesity and the normal digestive process.

Obesity is a condition in which the natural energy reserve, stored in the fatty tissue of humans, exceeds healthy limits. It is commonly defined as a body mass index (weight divided by height squared) of 30 kg/m2 or higher.Introduction
Gastric Bypass is a surgical procedure used in the treatment of Obesity. To learn more about this surgery, let us first learn about obesity and the normal digestive process.
About Obesity
What Is Obesity?
Obesity results from the excessive accumulation of fat that exceeds the body's skeletal and physical standards. According to the National Institutes of Health (NIH), an increase in 20 percent or more above your ideal body weight is the point at which excess weight becomes a health risk.
Obesity is a condition in which the natural energy reserve, stored in the fatty tissue of humans, exceeds healthy limits. It is commonly defined as a body mass index (weight divided by height squared) of 30 kg/m2 or higher.

History

What Is MORBID Obesity?

Obesity results from the excessive accumulation of fat that exceeds the body's skeletal and physical standards. According to the National Institutes of Health (NIH), an increase in 20 percent or more above your ideal body weight is the point at which excess weight becomes a health risk.

healthy person overweight person and obese person

Although obesity is an individual clinical condition, some authorities view it as a serious and growing public health problem. Some studies show that excessive body weight has been shown to predispose to various diseases, particularly cardiovascular diseases, diabetes mellitus type 2, sleep apnea and osteoarthritis.

What Is Morbid Obesity?

Obesity becomes "morbid" when it reaches the point of significantly increasing the risk of one or more obesity-related health conditions or serious diseases, also known as comorbidities. These comorbidities are conditions or diseases that result in either significant physical disability or even death. As you read about morbid obesity you may also see the term "clinically severe obesity" used. Both are descriptions of the same condition and can be used interchangeably. Morbid obesity is typically defined as having a Body Mass Index of 40 or higher.

Bariatric surgery is currently the only modality that provides a significant, sustained weight loss for the patient who is morbidly obese, with resulting improvement in obesity-related comorbidities.

Causes of Morbid Obesity

The reasons for obesity are multiple and complex. Despite conventional wisdom, it is not simply a result of overeating. Research has shown that in many cases a significant, underlying cause of morbid obesity is genetic. Studies have demonstrated that once the problem is established, efforts such as dieting and exercise programs have a limited ability to provide effective long-term relief.

Science continues to search for answers. But until the morbid obesity disease is better understood, the control of excess weight is something patients must work at for their entire lives. That is why it is very important to understand that all current medical interventions, including weight loss surgery, should not be considered medical cures. Rather they are attempts to reduce the effects of excessive weight and alleviate the serious physical, emotional and social consequences of morbid obesity.

The Health Threat Of Morbid Obesity

Morbid obesity brings with it an increased risk for a shorter life expectancy. For individuals whose weight exceeds twice their ideal body weight, the risk of an early death is doubled compared to non- obese individuals. The risk of death from diabetes or heart attack is five to seven times greater. Even beyond the issue of obesity-related health conditions, weight gain alone can lead to a condition known as ‘end-stage’ obesity where, for most part, no treatment options are available. Yet an early death is not the only potential consequence. Social, psychological, and economic effects of morbid obesity, however unfair, are real and can be especially devastating.

Significant Obesity-Related Health Conditions

Obesity-related health conditions are health conditions that, whether alone or in combination, can significantly reduce your life expectancy. A partial list of some of the more common conditions follows.

Obesity-related health conditions include:

Type 2 diabetes:

People with obesity develop a resistance to the insulin that regulates blood sugar levels. Over time, the pancreas becomes unable to produce enough insulin to overcome resistance. In type 2 diabetes, the initial effect of this stage is usually an abnormal rise in blood sugar right after a meal (called postprandial hyperglycemia). This effect is now believed to be particularly damaging to the body.

High blood pressure/heart disease:

Excess body weight strains the ability of the heart to function properly. The resulting hypertention (high blood pressure) can result in strokes, as well as inflict significant heart and kidney damage.

Osteoarthritis of weight-bearing joints:

The additional weight placed on joints, particularly knees and hips, results in rapid wear and tear, along with pain caused by inflammation. Similarly, bones and muscles of the back are constantly strained, resulting in disc problems, pain, and decreased mobility.

Sleep apnea/respiratory problems:

Fat deposits in the tongue and neck can cause intermittent obstruction of the air passage. Because the obstruction is increased when sleeping on your back, you may find yourself waking frequently to reposition yourself. The resulting loss of sleep often results in daytime drowsiness and headaches.

Gastroesophageal reflux/heartburn:

Acid belongs in the stomach and seldom causes any problem when it stays there. When acid escapes into the esophagus through a weak or overloaded valve at the top of the stomach, the result is called gastroesophageal reflux, and “heartburn” and acid indigestion are common symtoms. Approximately 10 to 15 percent of patients with even mild sporadic symtoms of heartburn will develop a condition called Barrett’s esophagus, which is a premalignant change in the lining membrane of the esophagus, a cause of esophageal cancer.

Depression:

People with weight-related conditions face constant challenges to their emotions: repeated failure with dieting, disapproval from family and friends, sneers and remarks from strangers. They often experience discrimination at work, cannot fit comfortably in theater seats, or ride in a bus or plane. No wonder that anxiety and depression may accompany years of suffering.

Infertility:

The inability or diminished ability to produce offspring.

Fatty liver or hepatic lipidosis:

Fatty liver disease is the accumulation of fat in liver cells. The greater the risk of developing liver inflammation, fibrosis, or cirrhosis (moderate or severe scarring of the liver).

Likeliness of Gallbladder disease:

Gallbladder disease is much more likely in obese individuals, being associated with formation of gallstones, usually composed of crystallized cholesterol, within the gallbladder. Although readily treatable by removal of the gallbladder (cholecystectomy), it may lead to life-threatening problems such as obstruction of the ducts from the liver, jaundice, and inflammation of the pancreas (gallstone pancreatitis).

Venous thromboembolic disease

Venous thromboembolic disease affects the legs, and causes swelling, thickening and discoloration of the skin, and ulceration of the skin. This condition begins with damage to the veins of the legs, associated with formation of blood clots (thrombophlebitis), often associated with an injury, a pregnancy (even use of birth-control pills or hormones), or a surgical operation. When a newly formed blood clot breaks loose, and floats through the veins to the heart and lungs, it is called a Pulmonary embolus, which may sometimes be fatal within minutes. More commonly, the blood clot remains in place locally, and heals by becoming a scar, which permanently damages the vein. Once damaged, the veins cannot fully function to return blood to the heart, and increased venous pressure in the legs causes swelling, impaired circulation in the skin, and sometimes skin breakdown. Obesity is a major risk factor in development of VTE, and may also aggravate the increased venous pressure in the legs.

Degenerative disc disease:

Degenerative disc disease is a progressive "wearing-out" of the cartilaginous disks between the vertebral bones of the spine. It occurs more often and earlier in life in obese persons, due to the markedly increased mechanical stress on the disks from the extra weight. Its most common sign is chronic low back pain, which may be disabling. This condition is also associated with sciatica, lumbar spondylosis, and spinal stenosis.

Skin breakdown:

Skin hygiene can be a significant problem for people struggling with obesity, as the layers of skin can rub against each other, causing skin breakdown and infection.

Swollen legs/skin ulcers:

Leg swelling is common and may be caused by blood clots in the leg veins. If untreated, skin breakdown can occur and the resulting wounds can be extremely hard to heal.

Urinary stress incontinence:

A large, heavy abdomen relaxes pelvic muscles, compounding the effects of childbirth. This weakens the valve on the urinary bladder allowing leakage when coughing, sneezing, or laughing.

Menstrual irregularities:

Morbidly obese individuals often experience menstrual disruptions, such as irregular or absent periods and increased pain during the cycle.

Cancer:

People suffering from morbid obesity are at an increased risk for some types of cancer eg., endometrial, gallbladder, uterine, cervical, ovary, and breast in females; colorectal and prostate in males.

Pulmonary embolus:

A pulmonary embolus is caused by a clot from the venous circulation. Most are caused from clots originating in the lower extremities, known as deep vein thrombosis (DVT). Because people with weight-related conditions are more susceptible to circulatory problems, their chances of experiencing a pulmonary embolus are higher.

 

Venous thromboembolic disease affects the legs, and causes swelling, thickening and discoloration of the skin, and ulceration of the skin. This condition begins with damage to the veins of the legs, associated with formation of blood clots (thrombophlebitis), often associated with an injury, a pregnancy (even use of birth-control pills or hormones), or a surgical operation. When a newly formed blood clot breaks loose, and floats through the veins to the heart and lungs, it is called a Pulmonary embolus, which may sometimes be fatal within minutes. More commonly, the blood clot remains in place locally, and heals by becoming a scar, which permanently damages the vein. Once damaged, the veins cannot fully function to return blood to the heart, and increased venous pressure in the legs causes swelling, impaired circulation in the skin, and sometimes skin breakdown. Obesity is a major risk factor in development of VTE, and may also aggravate the increased venous pressure in the legs.
Degenerative disc disease is a progressive "wearing-out" of the cartilaginous disks between the vertebral bones of the spine. It occurs more often and earlier in life in obese persons, due to the markedly increased mechanical stress on the disks from the extra weight. Its most common sign is chronic low back pain, which may be disabling. This condition is also associated with sciatica, lumbar spondylosis, and spinal stenosis.
Skin breakdown: Skin hygiene can be a significant problem for people struggling with obesity, as the layers of skin can rub against each other, causing skin breakdown and infection.
Swollen legs/skin ulcers: Leg swelling is common and may be caused by blood clots in the leg veins. If untreated, skin breakdown can occur and the resulting wounds can be extremely hard to heal.
Urinary stress incontinence: A large, heavy abdomen relaxes pelvic muscles, compounding the effects of childbirth. This weakens the valve on the urinary bladder allowing leakage when coughing, sneezing, or laughing.
Menstrual irregularities: Morbidly obese individuals often experience menstrual disruptions, such as irregular or absent periods and increased pain during the cycle.
Cancer: People suffering from morbid obesity are at an increased risk for some types of cancer eg., endometrial, gallbladder, uterine, cervical, ovary, and breast in females; colorectal and prostate in males
Venous thromboembolic disease affects the legs, and causes swelling, thickening and discoloration of the skin, and ulceration of the skin. This condition begins with damage to the veins of the legs, associated with formation of blood clots (thrombophlebitis), often associated with an injury, a pregnancy (even use of birth-control pills or hormones), or a surgical operation. When a newly formed blood clot breaks loose, and floats through the veins to the heart and lungs, it is called a Pulmonary embolus, which may sometimes be fatal within minutes. More commonly, the blood clot remains in place locally, and heals by becoming a scar, which permanently damages the vein. Once damaged, the veins cannot fully function to return blood to the heart, and increased venous pressure in the legs causes swelling, impaired circulation in the skin, and sometimes skin breakdown. Obesity is a major risk factor in development of VTE, and may also aggravate the increased venous pressure in the legs.
Degenerative disc disease is a progressive "wearing-out" of the cartilaginous disks between the vertebral bones of the spine. It occurs more often and earlier in life in obese persons, due to the markedly increased mechanical stress on the disks from the extra weight. Its most common sign is chronic low back pain, which may be disabling. This condition is also associated with sciatica, lumbar spondylosis, and spinal stenosis.
Skin breakdown: Skin hygiene can be a significant problem for people struggling with obesity, as the layers of skin can rub against each other, causing skin breakdown and infection.
Swollen legs/skin ulcers: Leg swelling is common and may be caused by blood clots in the leg veins. If untreated, skin breakdown can occur and the resulting wounds can be extremely hard to heal.
Urinary stress incontinence: A large, heavy abdomen relaxes pelvic muscles, compounding the effects of childbirth. This weakens the valve on the urinary bladder allowing leakage when coughing, sneezing, or laughing.
Menstrual irregularities: Morbidly obese individuals often experience menstrual disruptions, such as irregular or absent periods and increased pain during the cycle.
Cancer: People suffering from morbid obesity are at an increased risk for some types of cancer eg., endometrial, gallbladder, uterine, cervical, ovary, and breast in females; colorectal and prostate in males.

Complications of Obesity

Psychosocial

  • Eating disorders
  • Poor self-esteem
  • Body image disorder
  • Social isolation and stigmatisation
  • Depression

Pulmonary

  • Exercise intolerance
  • Obstructive Sleep apnea
  • Asthma

Gastrointestinal

  • Gallstones
  • Gastro-oesophageal reflux
  • Non-alcoholic fatty liver disorder

Renal

  • Glomerulosclerosis

Musculoskeletal

  • Ankle sprains
  • Flat feet
  • Tibia vara
  • Slipped capital femoral epiphysis 
  • Forearm fracture

Neurological

  • Pseudotumour cerebri
    (idiopathic intracranial)

Cardiovascular

  • Hypertension
  • Dyslipidaemia
  • Coagulophathy
  • Chronic inflammation
  • Endothelial dysfunction

Endocrine

  • Insulin resistance
  • Impaired fasting glucose or glucose intolerance
  • Type 2 diabetes
Ankle sprains Flat feet Tibia vara Slipped capital femoral epiphysis
Forearm fracture
Ankle sprains Flat feet Tibia vara Slipped capital femoral epiphysis
Forearm fracture

Treatment available for Morbid Obesity

For anyone who has considered treatment for weight loss, there is certainly no shortage of choices. In fact, to qualify for insurance coverage of weight loss surgery, many insurers require patients to have a history of medically supervised weight loss efforts. Most non-surgical weight loss programs are based on some combination of diet/ behavior modification and regular exercise. Unfortunately, even the most effective interventions have proven to be effective for only a small percentage of individuals. It is estimated that less than 5 of individuals who participate in non-surgical weight loss programs will lose a significant amount of weight and maintain that loss for a long period of time. According to the National Institutes of Health, most people in these programs regain their weight within one year. Sustained weight loss for patients who are morbidly obese is even harder to achieve. Serious health risks have been identified for people who move from diet to diet, subjecting their bodies to a severe and continuing cycle of weight loss and gain known as "yo-yo dieting."

The fact remains that morbid obesity is a complex, multifactorial chronic disease. Weight loss surgery, when compared to other interventions, has provided the longest period of sustained weight loss in patients for whom all other therapies have failed.

For many patients, the risk of death from not having the surgery is greater than the risks from the possible complications of having the procedure.

Patients who have had the procedure and are benefiting from its results report improvements in their quality of life, social interactions, psychological well-being, employment opportunities and economic condition.

In clinical studies, candidates for the procedure who had multiple obesity-related health conditions questioned whether they could safely have the surgery. These studies show that selection of surgical candidates is based on very strict criteria and surgery is an option for the majority of patients.

Appropriate candidates for weight-loss surgical procedures?

 

In general, the indications for surgical treatment established by the 1991 National Institutes of Health Consensus Development Conference Panel include a BMI greater than 40 or a BMI greater than 35 in combination with life-threatening cardiopulmonary problems or severe diabetes mellitus. Nonetheless, strict absolute weight determinants should serve only as an overall guide, especially in regard to third-party payers. For instance, few thoughtful physicians would argue that a 40-year-old man with hypertension, type II diabetes mellitus, severe degenerative joint disease in his knees and lower back area, and sleep apnea who has a BMI of only 33 does not have morbid obesity. Thus, all patients with severe, direct weight-related morbidity may be considered, but each patient should be considered individually.

For some patients who have a history of failed conservative treatments and a BMI of approximately 35, a trial of pharmacologic appetite suppression might be the next reasonable choice, especially if the weight-related morbidity is not severe. Substantial and prolonged weight loss (greater than 50% of excess body weight), however, would be distinctly unusual with this approach, and thus this type of regimen should not be expected to be successful in most patients with morbid obesity and severe comorbidities due to weight.

The overall guidelines should be as follows. Patients who fulfill the absolute weight criteria and have active weight-related morbidity or younger obese subjects (older than 20 years of age) who have a family history of weight-related morbidity but who have not yet experienced any complications should be considered preliminary candidates. Chronologic age, previous abdominal operations, or previous bariatric procedures that are functionally ineffective are not necessarily contraindications. In contrast, active substance abuse and psychiatric disorders (for example, schizophrenia, borderline personality disorder, active suicidal ideation, or uncontrolled depression) should be considered absolute contraindications.

The Gastrointestinal System

 

The gastrointestinal system is essentially a long tube running through the body with specialized sections that are capable of digestive material put in the mouth and extracting any useful components from it, then expelling the waste products from the anus.

Food after ingestion undergoes three types of processes in the body:

  • Digestion
  • Absorption
  • Excretion

The entire GI system is under hormonal control with the presence of food in the mouth triggering a cascade of hormonal actions. When food reaches the stomach, different hormones activate acid secretion, increased gut motility, enzyme release etc.

Nutrients from the GI tract are not processed on- site but instead will be absorbed and taken to the liver through the blood circulation to be broken down further, stored, or distributed.

Esophagus

Once food is chewed and mixed with saliva in the mouth, it is swallowed and passes down the esophagus.  The esophagus has a stratified squamous epithelial lining (SE) which protects the esophagus from trauma.  The submucosa lining (SM) secretes mucus from mucous glands (MG) which aid the passage of food down the esophagus.  The esophageal wall muscle layer helps to push the food into the stomach by waves of motion called peristalsis.

Stomach

The stomach is a ‘J’-shaped organ with two openings- the esophageal and the duodenal- and four regions- the cardia, fundus, body and pylorus. Each region performs different functions including mixing of the food with digestive enzymes and strong acid. The layer of mucus produced prevents the stomach from digesting itself.

The stomach’s major functions are:Temporary food storageControl the rate at which food enters the smallintestine

  • Acid secretion and antibacterial action
  • Fluidization of stomach contents
  • Preliminary digestion with pepsin, lipases etc.

Small intestine

The small intestine is the site where most of the chemical and mechanical digestion is carried out, and where virtually all of the absorption of useful materials occurs.The whole of the small intestine is lined with an absorptive mucosal layer, with certain modifications for each section. The intestine also has a smooth muscle wall with two layers of muscle; rhythmical contractions force products of digestion through the intestine (peristalsis). 

There are three main setions to the small intestine:

The duodenum forms a ‘C’ shape around the head of the pancreas. Its main function is to neutralize the acidic gastric contents (called ‘chyme’) and to initiate further digestion; Brunner’s glands in the submucosa secrete alkaline mucus which neutralizes the acidic chyme of the stomach and protects the surface of the duodenum.

The jejunum and the ileum are greatly coiled parts of the small intestine, and together are about 4-6 meters long; the junction between the two sections is not wll-defined. The mucosa of these sections is highly folded (the folds are called plica), increasing the surface area available for absorption dramatically.

Large intestine

The large intestine is the last part of the digestive tube and the location of the terminal phases of digestion. It is the part of the digestive tube between the terminal small intestine and anus. Within the large intestine, three major segments are recognized:

The cecum is a blind-ended pouch that in humans carries a worm-like extension called the vermiform appendix.

The colon constitutes the majority of the length of the large intestine and is sub-classified into ascending, transverse, and descending segments.

The rectum is the short, terminal segment of the digestive tube, continuous with the anal canal.

Functions of the Large Intestine

Recovery of water and electrolytes from digested food:

A considerable amount of water and electrolytes like sodium and chloride remain and must be recovered by absorption in the large intestine. This is what goes wrong when you have diarrhea and constipation

Formation and storage of feces:

As digested food passes through the large intestine, it is dehydrated, mixed with bacteria and mucus, and formed into feces.

Microbial fermentation:

Fermentation is the enzymatic decomposition and utilization of foodstuffs, particularly carbohydrates, by microbes. The large intestine does not produce its own digestive enzymes, but contains huge numbers of bacteria which have the enzymes to digest and utilize many substrates.

 

 

 

The duodenum forms a ‘C’ shape around the head of the pancreas. Its main function is to neutralize the acidic gastric contents (called ‘chyme’) and to initiate further digestion; Brunner’s glands in the submucosa secrete alkaline mucus which neutralizes the acidic chyme of the stomach and protects the surface of the duodenum.
The jejunum and the ileum are greatly coiled parts of the small intestine, and together are about 4-6 meters long; the junction between the two sections is not wll-defined. The mucosa of these sections is highly folded (the folds are called plica), increasing the surface area available for absorption dramatically.

About Gastric Bypass Surgery

History of Gastric Bypass Surgery

Weight loss (Gastric Bypass Surgery) surgery is a unique field, in that with one operation, a person can be potentially cured of numerous medical diseases including diabetes, hypertension, high cholesterol, sleep apnea, chronic headaches, venous stasis disease, urinary incontinence, liver disease, and arthritis. Gastric Bypass Surgery is the only proven method that results in durable weight loss. This proven surgical approach, combined with the dismal failure of dieting, the marked improvement in quality of life and the quick recovery with minimally invasive techniques, has fueled the surge in the number of Gastric bypass procedures performed annually over the last 10 years.

The first operations designed solely for the purpose of weight loss were initially performed inthe 1950s at the University of Minnesota. The jejunoileal bypass (JIB) induced a state of malabsorption by bypassing most of the intestines while keeping the stomach intact. Although the weight loss with the JIB was good, too many patients developed complications such as diarrhea, night blindness (from vitamin A deficiency), osteoporosis (from vitamin D deficiency), proteincalorie
malnutrition, and kidney stones. Some of the most worrisome complications were associated with the toxic overgrowth of bacteria in the bypassed intestine. These bacteria then caused liver failure, severe arthritis, skin problems, and flulike symptoms. Consequently, many patients have required reversal of the procedure, and the procedure has been abandoned.

This led to a search for better operations.

Modifications in the original procedures and the development of new techniques have led to 3 basic concepts for Gastric Bypass Surgery, as follows:

  • Gastric restriction by gastric banding (verticalbanded gastroplasty and adjustable banding)
  • Gastric restriction with mild malabsorption (Roux-en-Y gastric bypass)
  • A combination of mild gastric restriction and malabsorption (duodenal switch)

Is Bariatric Surgery Right for You?

For people who are morbidly obese, trying to lose weight without surgery isn’t as effective when it comes to achieving significant long-term weight loss. The majority of morbidly obese people who try to lose weight without having weight loss surgery regain all the weight they’ve lost over the next five years. Surgical treatment is the only proven method of achieving long-term weight control.

So how do you know you’re morbidly obese? In general, individuals are considered morbidly obese if their weight is more than 100 pounds over their ideal body weight. But a more common way to define morbid obesity is to use the body mass
index (BMI).

Below is a chart to help you figure out your BMI. If your BMI puts you in the morbidly obese category, you may be a candidate for weight loss surgery. If your weight is lower, but you have other health problems related to obesity; if you’ve tried to lose weight and failed; and if you’re aware of all the risks and rewards of weight loss surgery, weight
loss surgery may be the solution for you. But there are many factors to consider—physical, emotional, practical, and financial—when deciding whether it's the right choice for you.

Calculating your BMI

The first thing your doctor might do as he or she decides if you are a candidate for weight loss surgery is to determine your body mass index (BMI). Body mass index (BMI) is a measure of body fat based on height and weight that applies to both adult men and women. This number is calculated by dividing a patient’s mass ( in kilograms) by his or her height ( in meters, squared). A normal BMI is considered in the range of 18.5 - 24.9 kg/m². A BMI of 25 - 29.9 kg/m² is considered overweight. A BMI of 30 kg/m² or greater is classified as obese; this classification is further subdivided into class I, II, or III obesity.

Calculating your BMI
BMI = Weight (Kg) / Height x Height
Category BMI
Underweight < 18.5
Normal 18.5 - 24.9
Class I 30 - 34.9
Class II 35 - 39.9

Bariatric surgery is most appropriate for people with a BMI of 40 or more or who also have serious health complications related to obesity.In general, weight loss surgery is considered for people with Class II obesity if they have obesityrelated illnesses and Class III obesity with or without related illnesses.

How Affective Is Bariatric Surgery?

The actual weight a patient will lose after the procedure is dependent on several factors. These include:

  • Age
  • Pre-surgery weight
  • Overall health
  • Surgical procedure
  • Ability to exercise
  • Commitment to diet, exercise and follow-up care
  • Motivation
  • Cooperation of family, friends and associates

Successful Weight Loss

Weight loss surgery is considered successful when a patient loses 50% or more of excess body weight (the "overweight") and keeps the weight off for at least five years.

Clinical studies show that, in general, patients:

  • Lose weight for 18-24 months after the procedure
  • Lose 30-50% of excess weight in the first six months and 77% of excess weight within 12 months of surgery
  • Maintain a 50-60% loss of excess weight 10-14 years after surgery
  • With higher initial BMI’s lose more total weight
  • With lower initial BMI’s lose a greater percentage of excess weight and come closer to their ideal body weight
  • With Type 2 Diabetes lose less excess weight than patients without Type 2 Diabetes
  • Very few people reach their ideal body weight this is not the goal of bariatric surgery

Potential benefits of gastric bypass

Patients who have gastric bypass surgery often lose more weight, lose weight more quickly and keep more weight off for longer periods of time than those who have other forms of bariatric surgery. However, individual results depend on many factors, including the type of procedure performed and the commitment of the patient to making the necessary dietary and lifestyle adjustments. Age, gender and initial weight at the time of the surgery may also play a role in the outcome.

Patients often report higher self-esteem and better general health, including having more endurance to carry out daily tasks. Gastric bypass surgery may also lengthen a patient’s lifespan and help improve symptoms of conditions related to obesity, including:

  • Hyperlipidemia is corrected in over 70% of patients.
  • Essential hypertension is relieved in over 70% of patients, and medication requirements are usually reduced in the remainder.
  • Obstructive sleep apnea is markedly improved with weight loss, so that most patients are asymptomatic, and often do not even snore, within one year.
  • Diabetes mellitus type 2 is reversed in up to 90% of patients, usually leading to a normal blood sugar without medication, sometimes within days of surgery.
  • Gastroesophageal reflux disease is relieved from the time of surgery in almost all patients.
  • Venous thromboembolic disease signs such as leg swelling are typically much improved.
  • Low back pain and joint pain are typically relieved or improved in nearly all patients.

A recent study in a large comparative series of patients showed a 89% reduction in mortality over the 5 years following surgery, compared to a nonsurgically treated group of patients. There were accompanying decreases in the incidence of cardiovascular disease, infections, and cancer. Concurrently, most patients are able to alter their
lifestyle, to consume "healthier" foods, exercise more regularly, and to enjoy greater participation in family and social activities. Bariatric surgery is the most effective treatment for morbid obesity, and can markedly improve health and lifestyle.

What lifestyle changes will you have to make?

In order to make the most of your weight loss surgery, you’ll need to change your lifestyle after the surgery. Here are some changes you’ll need to make:

  • You’ll need to restrict your diet and take supplements. Because the size of your stomach has effectively been reduced to about the size of 1 cup or less, your meals will be in smaller portions. You’ll have to eat more frequently throughout the day, and you’ll need to make sure you chew your food slowly and thoroughly, so it doesn’t become stuck and so it’s properly digested. You’ll need more time to eat than you used to, but you’ll also notice you feel fuller with less food. You wont drink any beverages with your meal - your stomach will be too small to hold both. If you had gastric bypass surgery, you’ll be absorbing fewer nutrients than you did before the surgery, so to prevent deficiencies, you’ll need to commit to a regimen of vitamin supplements for the rest of your life.
  • You’ll need to exercise regularly. Exercise is even more important to the weight loss surgery patient. After surgery, you’ll be losing weight very rapidly. When this happens, your body will burn stored fat and muscle. Exercise as well as eating more protein are important in countering this by building muscle, burning fat, and increasing your metabolism. Exercise will also be crucial in helping you maintain your weight loss and health lifestyle for the long term.
  • You’ll need to work through any psychological and emotional issues. Many people mistakenly assume that weight loss surgery will be a quick fix to all their problems. You have your own issues going into the surgery, and chances are you’ll still have them after surgery. Weight loss surgery will affect most aspects of your life, including your family, career, social life, and self-esteem. You’ll be faced with a lot of changes, most of them good. But any change - good or bad - causes some degree of stress and anxiety. Participating in a support group or getting professional help through a counseling will be helpful in overcoming these and the many other challenges that you’ll experience along your journey.

Points to Consider

  • Are you ready to make a lifelong commitment to improved health?
  • Am I convinced I can't lose weight any other way? Have I tried every other option?
  • Have I researched all aspects of bariatric surgery?
  • Am I committed and willing to lose weight and improve my health? Will I stick to my dietary guidelines? Exercise regularly?
  • Can I manage how my life will change after surgery?
  • Will I be able to eat small, healthful meals and chew each bite thoroughly and slowly?
  • Do I understand the risks of potential complications?
  • Will I maintain a regular schedule of doctor appointments for the rest of my life?

Weight loss surgery is major surgery. You should only make the decision after careful evaluation and consultations with an experienced bariatric surgeon. Here are some important considerations to keep in mind and discuss with your doctor:

  • Weight loss surgery should not be considered cosmetic surgery.
  • The surgery does not remove fat (like liposuction does).
  • Your current health risks must be weighed against the risks of surgery.
  • Bariatric surgery is not meant to be reversible.
  • Weight loss surgery can only be successful with long-term changes in diet, exercise, and lifestyle and strict follow-up care.
  • Problems can arise that require re-operations.
  • Bariatric surgery should only be considered after all other less invasive options, such as medically-supervised weight loss programs, have been tried to exhaustion.
  • Weight loss surgery will dramatically alter your life-physically, emotionally, financially - and relationships with people and food.

What other factors are used to determine if a person is a good candidate for bariatric surgery?

For most people, BMI is the most important factor However, your doctor needs to carefully consider your current physical and emotional health as well. For example, if you have recently had cancer treatment, major surgery, a heart attack, or a cardiac procedure, your doctor may feel that you should wait a period of time before considering bariatric surgery. With regard to emotional health, people with a history of anorexia nervosa are generally not considered good candidates for this surgery. Likewise, uncontrolled bulimia is generally a contraindication for bariatric surgery. If you have had an eating disorder in the past but have been well controlled for a long time, your doctor may consider you a good candidate.

Finally, if you have long-standing psychiatric difficulties such as schizophrenia or manic depression you are unlikely to be a good candidate for weight loss surgery. I would like to emphasize that these criteria are simply rules of thumb; nothing is in stone. Each person has a unique set of circumstances. The final decision is ultimately up to you, your personal physician, and your bariatric surgeon.

Understanding the gastrointestinal tract

To better understand how bariatric surgery works, it i s important to understand how your gastrointestinal tract functions. As the food you consume moves through the tract, various digestive juices and enzymes are introduced at specific stages that allow absorption of nutrients. Food material that is not absorbed is then prepared for elimination. The major functions of the GI tract are ingestion, digestion, absorption, and defecation. A simplified description of the gastrointestinal tract appears below.

  • The esophagus is a long, muscular tube that moves food from the mouth to the stomach.
  • The abdomen contains all of the digestive organs.
  • A valve at the entrance to the stomach from the esophagus allows the food to enter, while keeping the acid-laden food from “refluxing” back into the esophagus, causing damage and pain.
  • The stomach, situated at the top of the abdomen, normally holds just over 3 pints (about 1,500 ml) of food from a single meal. Here, the food is mixed with an acid that is produced to assist in digestion. In the stomach, acid and other digestive juices are added to the ingested food to facilitate breakdown of complex proteins, fats, and carbohydrates into small, more absorbable units.
  • The pylorus is a small, round muscle located at the outlet of the stomach and the entrance to the small intestine. It closes the stomach outlet while food is being digested into a more easily absorbed form. When food is properly digested, the pylorus opens and allows the contents of the stomach into the first portion of the small intestine.
  • The small intestine is about 15 to 20 feet long and is where the majority of absorption of the nutrients from food takes place. The small intestine is made up of three sections: the duodenum, the jejunum, and the ileum.
  • The duodenum is the first section of the small intestine and is where the food is mixed with bile produced by the liver and with other juices from the pancreas. This is where much of the iron and calcium is absorbed.
  • The jejunum is the middle part of the small intestine extending from the duodenum to the ileum; it is responsible for absorption of nutrients.
  • The last segment of the intestine, the ileum, is where the absorption of fat-soluble vitamins A, D, E, and K and other nutrients occurs.
  • Another valve separates the small and large intestines to keep bacteria-laden colon contents from flowing back into the small intestine.
  • In the large intestine, protein and excess fluids are absorbed and a firm stool is formed.

Types of bariatric surgery

The three types of Bariatric Surgery

Restrictive procedures

Vertical-banded gastroplasty and adjustable gastric banding

In restrictive surgery, the size of the stomach is dramatically reduced. This type of surgery makes a person very full, very fast. Overeating results in a very unpleasant feeling and often vomiting. After a restrictive procedure, weight loss is the result of not being able to consume calories. 

 

Malabsorptive procedures with some restriction 

Biliopancreatic diversion with duodenal switch

In malabsorptive surgery, a large portion of the small intestine is bypassed, making food you eat pass through only a part of the small intestine. Weight loss following this type of procedure is the result of an inability to absorbed calories. This is because food does not come in contact with the bypassed portion of the small intestine. Although malabsorptive surgery can result in tremendous weight loss, it does have some drawbacks.
more about restrictive gastric bypass surgery

Restrictive procedures with minimal malabsorption

Roux-en-Y gastric bypass

The most popular weight loss surgery, Roux-en-Y procedure, is both restrictive and malabsorptive and will be discussed a little later.

Bariatric surgery can be performed by both an open technique and a laparoscopic technique. The laparoscopic technique has currently become the more popular approach.

Gastric Banding

Gastric banding, also known as lap band surgery, uses an inflatable silicone band to divide the stomach and create a very small stomach pouch.

Read more about Gastric Banding

Vertical-banded gastroplasty and gastric banding

Vertical-banded Gastroplasty and Gastric Banding are purely restrictive procedures. In vertical-banded gastroplasty, the stomach is stapled fairly close to where the esophagus (food tube) meets the stomach. The staples are placed in a vertical fashion and a polypropylene (plastic) band is placed near the bottom of the staple line. The stapling results in a very small stomach while the band restricts how quickly food can leave this reduced pouch.

Vertical-banded Gastroplasty

Vertical-banded gastroplasty advantages

  • No dumping syndrome
  • No nutritional deficiencies/malabsorption

Vertical-banded gastroplasty disadvantages

  • Needs strict patient compliance to diet
  • High fiber foods and foods with a more dense, natural consistency can become very difficult to eat, while highly refined foods cause little discomfort. Most people who regain any weight lost after surgery do so because choosing "healthier" foods are harder to digest, while "junk" food pass easily.
  • VBG is in no way a magic bullet or pill. It must be emphasized that lifestyle changes, i.e. diet Vertical-banded Gastroplasty and exercise, are absolutely imperative for weight loss to occur and be maintained. Realistic expectations are imperative.
  • Reversal of a VBG requires a much more complex and intensive surgical process than getting the VBG. When removal of a polyurethane band is involved (polyurethane was predominantly used in the 1980s and 90s), it likely has built substantial scar tissue that must also be removed, depending on how long ago the VBG took place. Removal of the staples involves stitching the previously separated parts of the stomach back together. For these reasons, a reversal should only be considered if there are serious medical complications.
  • Vomiting and severe discomfort if food is not properly chewed or if food is eaten too quickly.
  • As with any surgical procedure, there are risks of complications. It has been observed that approximately one in every hundred patients undergoing VBG die within a year. There may also be other medical complications down the road, but the risk is relatively low
  • Not adjustable

Long term

Although restrictive operations lead to weight loss in almost all patients, they are less successful than malabsorptive operations in achieving substantial, long-term weight loss. About 30 percent of those who undergo VBG achieve normal weight, and about 80 percent achieve some degree of weight loss. Most studies have suggested that 10 years after surgery, only 10% of patients maintain a minimum weight loss of at least 50% of their total excess weight at the time of their initial surgery.

Some patients regain weight. Others are unable to adjust their eating habits and fail to lose the desired weight. Successful results depend on the patient’s willingness to adopt a long-term plan of healthy eating and regular physical activity.

Does vertical-banded gastroplasty result in any vitamin or mineral deficiencies?

In the stomach food comes in contact with gastric acid. Iron found in foods such as spinach, raisins, and red meat requires contact with gastric acid to covert it from the ferrous form, which is not readily absorbed adequately, anemia can result. The stomach also contains something called intrinsic factor, which aids in the absorption of vitamin B12.

Vitamin B12 deficiency can result in a condition called pernicious anemia. Vertical-banded gastroplasty can result in a deficiency of both iron and vitamin B12. Although this is generally not a major problem, supplements of both iron and vitamin B12 are usually necessary. Because of the potential for vitamin and mineral deficiencies following gastric bypass surgery, it is crucial for you to maintain regular follow-up with the nurses, doctors, and dietitians at your gastric bypass
center.

Do people keep their weight off following vertical-banded gastroplasty?

While initial weight loss is quite good with verticalbanded gastroplasty, long-term maintenance is poor. Unlike most other forms of gastric bypass surgery, following vertical-banded gastroplastymost people are not troubled by eating sweets, and as a result they may consume excessive amounts of sweets. This behavior has been linked to poor long-term weight loss. At ten years this procedure has an 80 percent failure rate (meaning much of the initial weight lost is regained). In addition 15 to 20 percent of people who have this procedure require a re-operation due to blockage of the
polypropylene band or reflux of stomach acid into the esophagus. Because of these difficulties, it is unlikely that your doctor will suggest verticalbanded gastroplasty.

The Roux-en-Y gastric bypass procedure

Gastric bypass is the favored bariatric surgery in the United States. Surgeons prefer this surgery because it's safer and has fewer complications than other available weight-loss surgeries. It can provide long-term, consistent weight loss if accompanied with ongoing behavior changes.

Gastric bypass isn't for everyone with obesity, however. It's a major procedure that poses significant risks and side effects and requires permanent changes in your lifestyle. Before deciding to go forward with the surgery, it's important to understand what's involved and what lifestyle changes you must make. In large part, the success of the surgery is up to you.

How is Roux-en-Y gastric bypass surgery done?

Surgical techniques

Laparoscopic surgery is performed using several small incisions, or ports, one of which conveys a surgical telescope connected to a video camera, and others permit access of specialized operating instruments. The surgeon actually views his operation on a video screen. The method is also called limited access surgery, reflecting both the limitation on handling and feeling tissues, and also the limited resolution and two-dimensionality of the video image. With experience, a skilled laparoscopic surgeon can perform most procedures as expeditiously as with an open incision — with the option of using an incision should the need arise.

The Laparoscopic Gastric Bypass, Roux-en-Y, first performed in 1993, is regarded as one of the most difficult procedures to perform by limited access techniques, but use of this method has greatly popularized the operation, with benefits which include shortened hospital stay, reduced discomfort, shorter recovery time, less scarring, and minimal risk of incisional hernia.

Before gastric bypass, food enters your stomach and passes into the small intestine. After surgery, food is redirected so that it bypasses most of your stomach and the first section of your small intestine (duodenum). Food flows directly into the middle section of your small intestine (jejunum), limiting absorption of calories.

In gastric bypass (Roux-en-Y gastric bypass) the surgeon creates a small pouch at the top of your stomach and adds a bypass around a segment of your stomach and small intestine.

The surgeon staples your stomach across the top, sealing it off from the rest of your stomach. The resulting pouch is about the size of a walnut and can hold only about an ounce of food. The pouch is physically separated from the rest of the stomach. Then, the surgeon cuts the small intestine and sews part of it directly onto the pouch.

This connection redirects the food, bypassing most of your stomach and the first section of your small intestine, the duodenum. Food enters directly into the second section of your small intestine, the jejunum, limiting your ability to absorb calories.

Even though food never enters the lower part of your stomach, the stomach stays healthy and continues to secrete digestive juices to mix with food in your small intestine. Because of its low complication rate and high degree of success, the Roux-en-Y is generally accepted to be the best and safest bariatric procedure.

Some surgeons perform this operation by using a laparoscope — a small, tubular instrument with a camera attached — through short incisions in the abdomen (laparoscopic gastric bypass). The tiny camera on the tip of the scope allows the surgeon to see inside your abdomen.

Recent studies show patients who have had laparoscopic weight loss surgery experience:

  • Less pain after surgery
  • Easier breathing and lung function
  • Fewer wound complications such as infection or hernia
  • Quicker return to pre-surgical levels of activity What happens if the operation cannot beperformed or completed by the laparoscopic method?

In some patients the laparoscopic method does not work effectively. Factors that may increase the possibility of choosing or converting to the "open" procedure may include:

Roux-en-Y gastric bypass procedure

A history of prior abdominal surgery causing dense scar tissue

  • Inability to visualize organs
  • Bleeding problems during the operation

Roux-en-Y gastric bypass procedure If bariatric surgery is performed laparoscopically and complications occur during the operation, your doctor may choose to perform open surgery.

The decision to perform the open procedure is a judgment decision made by your surgeon either before or during the actual operation. The decision to convert to an open (conventional) procedure is strictly based on patient safety.

Risks And Complications Of the Roux-en-Y Procedure

As with any major surgery, there can be complications. One of the most common in the Roux-en-Y procedure is blood clots in the legs. This occurs in about 0.2 percent of people undergoing the Roux-en-Y procedure. The clots have the potential to travel to the lungs, where they can have serious consequences. In order to prevent this you will be given blood thinners following surgery. You may also be asked to wear compression stockings. These are very tight stockings that have been proven to reduce blood clots in postoperative patients. Your doctor will want you to get up and walk as soon after surgery as possible. Early ambulation has also been proven to reduce the risk of blood clots. Finally,
although the risk of blood clots is highest in the days immediately following surgery, if you notice unexplained swelling in your legs or sudden shortness of breath once you are home from hospital, contact your physician and get yourself evaluated. Another risk is that occasionally food or liquids will leak out of the stomach instead of traveling directly into the jejunum. While this can be a serious complication occurring in about 1 percent of procedures, it can generally be
corrected. If this happens to you, you will need to return to the operating room. In general, one day after your gastric bypass surgery you will go down to the radiology department and drink something called gastrographin (this is a liquid that will show up on an x-ray). After you drink the gastrographin you will have an x-ray to make sure there is no leakage. If there is a problem, it can be addressed immediately.

Complications of Roux-en-Y gastric bypass

Early complications:

  • Anastomotic leak (1-3%)
  • Pulmonary embolism, deep vein thrombosis (<1%)
  • Wound infection (more common with open approach)
  • Gastrointestinal hemorrhage, bleeding (0.5-2%)
  • Respiratory insufficiency, pneumonia
  • Acute distention of the distal stomach

Late complications:

  • Stomal stenosis (20%)
  • Bowel obstruction, small bowel obstruction (1%)
  • Internal hernia
  • Cholelithiasis
  • Micronutrient deficiencies
  • Marginal ulcer
  • Staple line disruption
  • Ventral hernia formation ( more prevalent after open approach)

Weight loss with the Roux-en-Y procedure

Weight loss with the Roux-en-Y procedure is quite good, with most people losing between 65 to 75 percent of their excess weight within the first year. While some people do gain a considerable amount of weight back over the following three to five years, most do not. The first six months after the surgery is known as the rapid weight loss phase.

Immediately following surgery your stomach will be quite swollen and you simply will not be hungry. At this stage you will be taking in liquids only and your weight will fall dramatically. As you begin to eat real food weight loss slows a little, but you can expect very steady and substantial weight loss for the first six months. At about six months many
people find that their appetite returns. Nonetheless weight loss generally continues for another six months, but at a slower rate. In general, after about a year, further weight loss becomes more difficult without real effort. By a year most people will have lost about 65 to 75 percent of their excess weight. This means that in order to achieve their ideal body weight they need to continue to lose. Unfortunately, at about a year a person’s new stomach will have stretched a bit, making it much easier to consume larger portions.

At this point food choices and exercise help determine if a person will achieve his or her ideal body weight.

Within the first two years of surgery, you can expect to lose 50 percent to 60 percent of your excess weight. If you closely follow dietary and exercise recommendations, you can keep most of that weight off long term.

In addition to dramatic weight loss, gastric bypass surgery may improve or resolve the following conditions associated with obesity:

  • Type 2 (adult-onset) diabetes
  • High blood pressure
  • High blood cholesterol
  • Obstructive sleep apnea
  • Gastroesophageal reflux disease (GERD)

The improvements observed in type 2 diabetes, high blood pressure and high blood triglycerides may significantly decrease the risk of cardiovascular events in people who have undergone gastric bypass surgery compared with those people who did not have surgery. Also, gastric bypass surgery may reduce the risk of dying of diabetes, heart disease and cancer. The surgery has also shown to improve mobility and quality of life for people who are severely overweight.

Gastric banding

Gastric banding, also known as lap band surgery, uses an inflatable silicone band to divide the stomach and create a very small stomach pouch. While the diameter of the band is generally about five centimeters, the surgeon can adjust the
diameter by pumping saline into the band from a reservoir implanted under the patient’s skin. Just as with vertical-banded gastroplasty, blockage of the band can be problematic, and unfortunately the reservoir implanted beneath the skin doesn’t last forever. Consequently, weight regain with this method can also occur. In general gastric banding
is no more successful than vertical-banded gastroplasty, and it too can result in iron and vitamin B12 deficiency. Laparoscopic gastric banding requires more frequent visits for band adjustment.

Complications of the adjustable gastric band procedure

Early complications:

  • Injury of the stomach or esophagus
  • Bleeding
  • Food intolerance
  • Wound infection
  • Pneumonia

Late complications:

  • Band slippage
  • Food intolerance or noncompliance to band
  • Pouch dilatation
  • Band erosion into the stomach
  • Port complications
  • Re-operation rate (2-41%)
  • Esophageal dilatation
  • Failure to lose weight
  • Port infection, band infection
  • Leakage of the balloon or tubing
  • Mortality rate

Biliopancreatic diversion bypass

The biliopancreatic diversion bypass is performed through open surgery with one long incision, leaving a permanent scar. It is less common and more complicated than the Roux-en-Y-gastric bypass. In the biliopancreatic diversion, portions of
the stomach are removed and the bypass is attached to the distal illium. This procedure is not widely used, because there is more risk of nutritional deficiencies.

The pancreas and gall bladder have ducts that carry digestive juices and enzymes to the duodenum. These enzymes and digestive juices allow for the breakdown of the food we eat. Once food is broken down it can be absorbed in the
duodenum and jejunum of the lower intestine.

Since this procedure prevents the digestive juices and enzymes in the duodenum and jejunum from making contact with food until almost the end of the ileum, calories from food are simply not absorbed effectively. This allows dramatic weight loss to occur, but it also results in a number of complications.

Complications of the Biliopancreatic diversion with duodenal switch

  • Fat malabsorption results in diarrhea and foulsmelling gas in approximately 30% of patients.
  • The potential nutritional deficiencies mandate frequent follow-up visits, with close monitoring and supplementation of multivitamins and minerals.
  • Malabsorption of fat soluble vitamins (vitamins A, D, E, and K)
  • Vitamin A deficiency, which causes night blindness
  • Vitamin D deficiency, which causes osteoporosis
  • Iron deficiency
  • Protein-energy malnutrition (may require a second operation to lengthen the common channel)

The Process: Before, during & after Surgery

Before gastric bypass surgery

Persons considered for surgery must be carefully evaluated. Studies are performed to assess the health of the patient’s cardiovascular, pulmonary, and endocrine systems. A psychological evaluation is considered essential by most physicians to determine a potential patient’s response to weight loss and change in body image and ability for permanent lifestyle change. Nutritional counseling is also a must before surgery.

Your Consultation

  1. Bring to the appointment a list of prescription pharmaceuticals, over-the-counter drugs and herbal or vitamin supplements you are taking.
  2. Prepare to review your medical history, providing the names and phone numbers of physicians you are seeing or have seen recently.
  3. Tell your surgeon about any anesthesia complications that you or a family member has experienced. For example, some people may inhale food or liquids into their lungs as a result of the suppression of the normal throat reflexes that general anesthesia can cause. This is one of the reasons your surgeon will tell you to avoid eating and drinking within a certain period of time before surgery.
  4. Obtain directions to the surgical facility.
  5. Request a list of preoperative and postoperative instructions, which can include:
  • Discontinuation of certain medications
  • Showering recommendations
  • A list of medications that must be taken before the procedure
  • When to stop eating and drinking before the procedure
  • A list of supplies that you will need after the procedure
  • Which medications should be crushed after
  • surgery and which can be taken whole

6. Find out what kind of support the surgeon's practice offers throughout recovery.
7. Request emergency contact phone number

Psychological evaluation

All our patients undergo a psychiatric evaluation to assess their psychological status prior to the Gastric Bypass. It is a requirement for a patient to see a psychologist in preparation for the surgery.

The psychiatric evaluation in preparation for surgery is recommended.

An evaluation by your usual medical doctor will not fulfill these criteria. The patient should have a routine psychiatric evaluation to rule out significant eating disorders or other major psychiatric illnesses that may affect the results of surgery.

Patients with inadequately treated depression need to be appropriately diagnosed and treated prior to surgery. Alcohol and drug abuse are also relative contraindications to surgery. The patient must not have unrealistic expectations of the outcome of surgery.

Nutritional evaluation

You’ve probably dieted for years, and you may even know so much about nutrition that you could write a book. Why do you need to see a dietitian?

Well, denial is a part of recovery. A dietitian identifies the type of eating behavior you have.

She can instruct you on the major changes you need to make after surgery. As you describe your eating pattern and verbalize your relationship with food, you help to identify potential danger zones after the surgery.

Most people turn to food for support, stress relief, comfort, and many other reasons. Right after the surgery, your emotional or situational triggers cannot be relieved with large quantities of food.

Your surgeon will refer you to a dietitian who is familiar with weight loss surgery patients. This person is a valuable source of information for what you can expect and the amount of food you can eat after surgery. She has a wealth of information on what other patients have experienced with their diets. So be sure to pay attention during this evaluation. The dietitian will give you helpful tips on what types of food to eat throughout the entire course of your recovery. She can also tell you how to eat after the surgery, how much to chew, and what to avoid.

With time, you may be able to eat more and turn to food for all the wrong reasons. A dietitian can help not with therapy but with good food choices and eating behavior tricks to prevent yourself from regaining weight after your surgery. The bottom line with weight loss surgery is that healthy choices keep your caloric intake to a minimum, and this is an important component of maintaining your weight loss.

When you reach a plateau in your weight loss, the dietitian may have tips on how to kick-start your weight loss again.

Keep a food log for several days and be perfectly honest. Include not only the foods you ate, but the quantity as well as the time you took to eat it. Go over this with your dietitian and identify areas that need work. Remember:
You’re a work in progress, and you should call in consultants when you need them.

Lab Studies

Preoperative laboratory evaluation should include a complete blood count (CBC), a complete chemistry panel, liver function tests, thyroid function tests, a lipid profile, coagulation tests, serum iron and total iron binding capacity (TIBC), vitamin B-12, folic acid, blood typing, and urinalysis.

Imaging Studies

  • Chest radiography
  • Ultrasonography of the gallbladder

Diagnostic Procedures

Upper endoscopy is performed to rule out intrinsic upper gastrointestinal disease, because, after gastric bypass surgery, the ability to nonsurgically visualize the distal stomach and the duodenum could be a challenge.

Medical therapy

A preoperative trial of weight loss is beneficial to ensure patient compliance with the postoperativediet protocol. Also, a preoperative liquid diet can shrink the liver, thus facilitating the surgical procedure.

Medications

Medications you are taking may interact with bariatric surgery or with medications that your surgeon will prescribe before and after your procedure. Be sure to tell your surgeon about any medications you are taking or plan to take throughout recovery. Vitamins, minerals and herbs can also interact with medications, so tell your surgeon about them as well.

Here are some examples of how surgery and surgery-related medications can interact with normal medications or food supplements:

  • Aspirin, Coumadin, Plavix and vitamin E can increase the risk of bleeding at the time of surgery.
  • Estrogen hormone medications such as birth control pills can increase the risk of blood clots.

After surgery, your stomach or the outlet of your new stomach will be smaller. Pills may irritate your new stomach pouch and cause nausea or pain, so you may be asked to crush your tablets for several weeks. You should check with your surgeon about which pills to crush and for how long. Some medications can't be crushed because they are "sustained release" and may need to be changed to a non-sustained release form.

In the Weeks and Days Before Your Procedure

  • Purchase any supplies that you will need for recovery.
  • Follow your surgeon's instructions regarding medications.
  • Recruit an "escort" — a close friend or relative — who can drive you home after surgery and possibly stay with you for several days afterward. The after-effects of anesthesia will likely impair your ability to drive and perform normal functions such as meal preparation, personal hygiene and even walking. You may also need emotional support as your incisions heal and you become accustomed to your new body.
  • Fill any postoperative prescriptions.
  • Stop smoking for at least 30 days before bariatric surgery. Smoking can make the lungs more sensitive during surgery and may possibly lead to pneumonia. Smoking can also slow the healing process by narrowing the blood vessels and thus restricting the flow of blood to the healing sites. Many surgeons will not operate on patients if evidence exists that they are smokers and even go so far as to require blood or urine testing for nicotine levels before surgery.
  • Inform your surgeon if you become sick the day before surgery.
  • Refrain from alcohol use for at least 48 hours before bariatric surgery.
  • Have a support group in place to help with your aftercare needs.

The Night Before Your Procedure

  • Pack your bag with any personal items you might need.
  • Remove credit cards and other valuable items from your wallet or purse.
  • Leave all jewelry at home.
  • Bring a container to hold your eyeglasses or contact lenses.
  • Bring comfortable clothes to wear after the procedure.
  • Bring all educational materials that your surgeon and nutritionist gave you. This often contains information and instructions about postoperative care.
  • Follow your bariatric surgeon's instructions regarding avoidance of eating and drinking before surgery.

The Day of Your Procedure

  • You will receive a list of discharge instructions, as well as medication instructions.
  • You will receive emergency contact information.
  • Be certain to have someone stay with you for the amount of time that your surgeon recommends.

During Surgery

What can you expect during the surgery?

Patients are placed under general anesthesia, which means they are not awake for the the procedure and feel no pain. A tube is inserted through the nose and into the upper stomach and connected to a suction machine, which will help in the healing process following surgery.

During the procedure, the stomach is made smaller by dividing it into a smaller upper section and a larger lower section. The surgeon uses surgical staples to seal off the upper part of the stomach from the remainder of the stomach. This creates a small pouch at the top of the stomach that is about the size of a walnut and is able to hold about 1 ounce (30 ml) of food.

The surgeon then cuts the small intestine and sews part of it onto the pouch. This arrangement allows food to bypass most of the stomach and the first section of the small intestine, known as the duodenum. Instead, the food travels from the surgically created pouch through the new connection (known as a Roux limb) and directly into the second segment of the small intestine, known as the jejunum. This limits the amount of calories absorbed into the body.

Step 1: Step 2: Step 3:

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Step 6:

 

In rare cases, the gallbladder may also be removed (cholecystectomy) during a gastric bypass to prevent formation of gallstones that sometimes result from rapid weight loss. However, this is more often achieved through medications that dissolve these stones.

Gastric bypass surgery usually takes about four hours to complete. The incisions will be closed with stitches or surgical staples and then covered with a sterile bandage. The patient will have the stitches or staples removed at a later time during a follow up visit.

Life After Surgery

What can you expect after gastric bypass surgery? Immediately after surgery, for at least eight weeks, you will be required to follow a special eating plan.

This will be planned and discussed with you by our obesity specialist dietitian.

With your stomach pouch reduced to the size of a walnut, you'll need to eat very small meals during the day. In the first six months after surgery, eating too much or too fast may cause vomiting or an intense pain under your breastbone. The amount you can eat gradually increases, but you won't be able to return to your old eating habits.

If you experience any problems after surgery it is important that you contact us directly as soon as possible. You will be given contact details for us on your discharge from hospital. There are a number of other things that you will also need to consider:

Lifelong commitment

As in all treatments for obesity, successful results will depend on your motivation and the actions you take. Our specialists will support you along the way and you will be required to attend regular follow-up appointments for the rest of your life to ensure that your weight loss is maintained and to monitor your general health and wellbeing, as well as to pick up any potential problems early.

Monitor your diet

All treatments for obesity require a lifestyle change. Our staff will provide you with after-surgery guidance to ensure you maintain your diet and nutrition plans, this will reduce the risk of any problems occurring after surgery and will maximise your weightloss. It is important that you follow our recommendations to manage your diet and stick to the recommended food portions, so that you do not experience any unpleasant side effects. Our dietitian will advise you on how to manage your eating habits.

Take regular supplements

If you have had obesity surgery, especially bypass surgery, you will be required to follow a wellbalanced diet and take nutritional supplements and medications for the rest of your life. Some bypass surgery patients develop nutritional deficiencies such as anaemia, osteoporosis and metabolic bone disease – although these can be avoided if a balanced diet and daily vitamin and mineral supplements are taken. Our specialists will closely monitor you to ensure that any potential problems are picked up early.

Our specialists will discuss with you the impacts of surgery with you before a decision about whether to operate is made. You will also have a contact point within the hospital to ensure that any problems you have are dealt with as quickly as possible.

You may experience one or more of the following changes as your body reacts to the rapid weight loss in the first three to six months:

  • Nausea
  • Body aches
  • Feeling of tiredness similar to flu
  • Feeling cold
  • Dry skin
  • Hair thinning or hair loss
  • Mood changes
  • Changes in bowel movements
  • Constipation
  • Loss of muscle mass

Patients should contact their physician if they experience any of the following:

  • Fever
  • Chills
  • Redness or swelling at the incision site
  • Bleeding or other drainage from the incision site
  • Increased pain at the incision site

Physicians monitor gastric bypass patients closely for several years after surgery. Continued attention to weight loss and diet is essential for a successful outcome, and the patient is likely to consult with a registered dietitian or other dietary expert in planning appropriate meals. Patients may participate in support groups or use other methods to help adjust to their new lifestyle.

As people lose weight over the next one to two years they may develop excess skin. These patients may benefit from plastic surgery aimed at correcting the condition.

Lifestyle Changes

Living with gastric bypass

Weight loss surgery is not a guaranteed cure for obesity or the disabilities that may occur as a result of obesity. Instead, the surgery helps diet and exercise to finally work, by controlling your appetite and making you feel full with smaller amounts of food. Because obesity may have affected your psychological well-being, you will be referred for counseling to help you adjust to life after surgery.

Postoperative dietary changes (including vitamin, mineral , and possibly liquid protein supplementation), exercise, and lifestyle changes should be reinforced by counseling, support groups, and the patient’s family physician.

Gastric Bypass Recovery and Aftercare

After gastric bypass surgery, many patients spend two to three days in the hospital, or one to two days for the laparoscopic procedure. On average, most people require two to five weeks of recovery before returning to normal activities. For a number of days, the abdomen will be swollen and sore, and the patient often feels discomfort. Your doctor can prescribe medications to help you manage the discomfort.

Aftercare treatments typically include a dietary plan, regular exercise, behavioral-modification therapy, and vitamin supplements. Your weight loss surgeon might require the use of a dietician, an exercise program, and possibly a psychologist for an extended period of time to assist you in your recovery.

Going home

Be sure to arrange to have a ride home from the hospital. As much as you’re looking forward to going home. the trip can be uncomfortable experience. You’ll be dealing with seat belts, the abdominal strain of getting in and out of the car, and the inevitable bumps along the way. You also may feel dizziness and nausea from anesthesia.

If you live near by the hospital, here are some tips to make going home a bit more bearable:

  • Wear very loose clothing.
  • Time your pain medication so you take a dose just before leaving the hospital.
  • Have a pillow with you in the car so you can hold it against your abdomen for support.
  • Take a bottle of water with you so you can sip all the way home.
  • Do ankle exercise by flexing your feet back and forth and then rotating each foot in a circle.

Your Diet and Eating Habits

You will need to adjust your diet because of the changes that were made to your stomach during surgery. It is very important to adhere to your surgeon's diet recommendations. Some common recommendations include:

  • Chew your food slowly and thoroughly, to reduce it to very small pieces. You may want to grind your meat before eating it.
  • Wait two to three minutes between bites.
  • Drink fluids at a time other than when you are eating, to avoid a premature feeling of fullness that may make you feel like vomiting.
  • Avoid eating foods high in sugar and fat, such as non-diet soda, juices, high-calorie nutritional supplements and milkshakes. Eating many of these foods can lead to dumping syndrome, a rapid emptying of the stomach into the small intestine that causes considerable discomfort.
  • On the other hand, you should prioritize foods that contain high amounts of proteins, such as fish, dairy products, meat, beans and legumes.

You should also try to eat plenty of fresh vegetables and fruits.

  • Daily vitamin and mineral supplements at higher than normally recommended doses are a must, because you will not receive adequate nutrition from the small amounts of food you eat. You may wish to use vitamins in liquid or chewable forms, because they cause less discomfort than swallowing large solid vitamin pills.
  • B-complex vitamins, iron and calcium require special attention if you have had a Roux-en-Y gastric bypass, because of the changes to your digestive system.
  • Vitamin B-12 is particularly difficult for your body to absorb after surgery, and you should look into taking it in forms other than a pill.

Insufficient intake of vitamin B-12 will cause you to become fatigued easily.

  • Likewise, you should take calcium (as the citrate) in large amounts, to avoid early osteoporosis, a disorder in which the bones become porous, brittle and easily fractured.
  • Be careful with alcohol. It is absorbed and metabolized much more rapidly after surgery. In addition to the risk of rapid and unexpected intoxication, alcohol consumption can cause ulcers in your stomach pouch or intestine.
  • Plan meal times, and avoid snacking. You should eat several small meals per day because of your stomach's smaller capacity.

Activities After Weight Loss Surgery

Before you leave the hospital after surgery, you will be asked to stand up and move around a bit. You will also be directed to try to walk around the house several times throughout each day, over the course of your recovery.

It is important to remember that you will require assistance leaving the hospital and at home for a period of time after surgery. Everyone recovers at a different rate: some people require assistance for a day or so, but others need help for several weeks. The type of assistance you will need includes driving you home from the hospital and driving you for a few days or weeks after that. It also includes meal preparation, medication assistance and dressing.

The type of pain management program you and your surgeon select may also impact the duration and severity of the recovery period. If you receive local anesthesia, you may require less assistance, and for a shorter duration, than if you have general anesthesia or require narcotic pain management.

Patients can usually drive within two weeks after surgery and can return to normal activities within six to eight weeks. These times may vary, depending on the type of surgery, your general health and the type of activities you performed
before surgery.

Your Medications After Weight Loss Surgery

Your pain management medication might be in the form of a local anesthetic that can be administered in the surgical area, such as around the incision.

You may need narcotic medications to manage your pain. You may also cont inue your maintenance medications, such as for high blood pressure or high cholesterol, but the need for these medications will be monitored, and sometime after surgery your doctor may decide to change them.

Because nutritional deficiencies may occur after certain weight loss surgeries, you may be monitored for low levels of iron, calcium, folate and vitamin B-12, and you may need to take supplements. This pertains specifically to Roux-en-
Y gastric bypass, biliopancreatic diversion and duodenal switch.

If you are a woman of child-bearing age, you may be advised to use birth control for 18 to 24 months postsurgery.

Physicians advise against pregnancy during the period of maximum weight loss, due to intrauterine restrictions and possible nutritional deficiencies. You will be able to get pregnant sooner after surgery if you have a gastric band operation, because weight loss tends to be more gradual, without the risk of nutritional deficiencies.

Regardless of the operation you have, multivitamins with iron, folate and B-12 are imperative during pregnancy.

Going Back to Work

Your ability to resume pre-surgery levels of activity will vary according to your physical condition, the nature of the activity and the type of weight loss surgery you had. Many patients return to full presurgery levels of activity within six weeks of their morbid obesity procedure. Patients who have had a minimally invasive laparoscopic procedure may be able to return to these activities within a few weeks.

Birth Control & Pregnancy

It is strongly advised that women of childbearing age use the most effective forms of birth control during the first 16 to 24 months after weight loss surgery. The added demands pregnancy places on your body and the potential for fetal damage make this a most important requirement.

Long-Term Follow-Up

Although the short-term effects of weight loss surgery are well understood, there are stil questions to be answered about the long-term effects on nutrition and body systems. Nutritional deficiencies that occur over the course of many
years will need to be studied. Over time, you will need periodic checks for anemia (low red blood cell count) and Vitamin B12, folate and iron levels.

Follow-up tests will initially be conducted every three to six months or as needed, and then every one to two years.

Follow-up is recommended for life.

Risks and Complications

Complications of abdominal surgery

As with any surgery, there are operative and longterm complications and risks associated with weight loss surgical procedures that should be discussed with your doctor. Possible risks include, but are not limited to:

  • Bleeding
  • Complications due to anesthesia and medications
  • Deep vein thrombosis
  • Dehiscence
  • Infections
  • Leaks from staple line breakdown
  • Marginal ulcers
  • Pulmonary problems
  • Spleen injury
  • Stenosis

Any major surgery involves the potential for complications — adverse events which increase risk, hospital stay, and mortality. Some complications are common to all abdominal operations, while some are specific to bariatric surgery. A person who chooses to undergo bariatric surgery should know about these risks.

Infection

Due to poor circulation or underlying diabetes, many overweight people have difficulty healing wounds. Therefore, it is not surprising that between 1 and 5 percent of people develop wound infections at the site of surgery. The risk of wound infection is greatly reduced if surgery can be performed using a laparoscope ( a small instrument with a light on the end). In such a procedure, there are generally six very small incisions sites sites instead of one large one. As a
result hospitalization and recovery time are reduced. In general, a person’s size and whether or not he or she has had previous abdominal surgery are the deciding factors for determining if the laparoscopic approach van be used. The larger the person the less likely he or she will qualify for laparoscopic surgery. Laparoscopic surgery is much more technically demanding than the traditional procedure, but if you qualify for it, it definitely makes recovery quicker and less painful.

Infection of the incisions, or of the inside of the abdomen (peritonitis, abscess) may occur, due to release of bacteria from the bowel during the operat ion. Nosocomial infect ion, such as pneumonia, bladder or kidney infections, and
sepsis (bloodborne infection) are also possible. Effective short-term use of antibiotics, diligent respiratory therapy, and encouragement of activity within a few hours after surgery, can reduce the risks of infections.

Hemorrhage

Many blood vessels must be cut in order to divide the stomach and to move the bowel. Any of these may later begin bleeding, either into the abdomen (intra-abdominal hemorrhage), or into the bowel itself (gastrointestinal hemorrhage).

Transfusions may be needed, and re-operation is sometimes necessary. Use of blood thinners, to prevent venous thromboembolic disease, may actually increase the risk of hemorrhage slightly.

Hernia

A hernia is an abnormal opening, either within the abdomen, or through the abdominal wall muscles.

An internal hernia may result from surgery, and rearrangement of the bowel, and is mainly significant as a cause of bowel obstruction. An incisional hernia occurs when a surgical incision does not heal well; the muscles of the abdomen separate and allow protrusion of a sac-like membrane, which may contain bowel or other abdominal contents, and which can be painful and unsightly.

The risk of abdominal wall hernia is markedly decreased in laparoscopic surgery.

Bowel obstruction

Abdominal surgery always results in some scarring of the bowel, called adhesions. A hernia, either internal or through the abdominal wall, may also result. When bowel becomes trapped by adhesions or a hernia, it may become kinked and obstructed, sometimes many years after the original procedure. Usually an operation is necessary to correct this problem.

Venous thromboembolism

Any injury, such as a surgical operation, causes the body to increase the coagulation of the blood.

Simultaneously, activity may be reduced. There is an increased probability of formation of clots in the veins of the legs, or sometimes the pelvis, particularly in the morbidly obese patient. A clot which breaks free and floats to the lungs is called a pulmonary embolus, a very dangerous occurrence.

Commonly, blood thinners are administered before surgery, to reduce the probability of this type of complication.

Pneumonia

After any abdominal surgery pneumonia is a risk.

This is because it hurts to take a deep breath. When a person fails to breathe deeply a portion of the lung may collapse, setting the stage for pneumonia. Approximately 0.1 percent of people undergoing the Roux-en-Y procedure develop
pneumonia. Simply breathing deeply following surgery reduces this risk. In order to facilitate deep breathing the hospital staff will tach you to use a handheld plastic device called an incentive spirometer. You will be instructed to inhale deeply with your mouth around the tube attached to the incentive spirometer. The more air you take into your lungs, the more you will move the little ball inside the spirometer.

Death

Death occurs in about 0.5 percent (one in every two hundred) of people who undergo this procedure. While the risk is low, it is not zero.

This is about the same risk as any other major abdominal surgery. But this is elective surgery.

Making the big decision to have bariatric surgery may feel like taking a big risk. You are right, it is a big risk, but there are things you can do to reduce it. For example, quitting smoking, losing some weight, and developing an exercise program (even a little walking) before surgery can reduce your risk of major complications and death following surgery.

Complications of gastric bypass

Anastomotic leakage

An anastomosis is a surgical connection between the stomach and bowel, or between two parts of the bowel. The surgeon attempts to create a watertight connection by connecting the two organs with either staples or sutures, either of which actually makes a hole in the bowel wall. The surgeon will rely on the healing power of the body, and its ability
to create a seal like a self-sealing tire, to succeed with the surgery. If that seal fails to form, for any reason, fluid from within the gastrointestinal tract can leak into the sterile abdominal cavity and give rise to infection and abscess formation. Leakage of an anastomosis can occur in about 2% of gastric bypass procedures, usually at the stomach-bowel
connection. Sometimes leakage can be treated with antibiotics, and sometimes it will require immediate re-operation. It is usually safer to reoperate if an infection cannot be definitely controlled immediately.

Anastomotic stricture

As the anastomosis heals, it forms scar tissue, which naturally tends to shrink ("contract") over time, making the opening smaller. This is called a "stricture". Usually, the passage of food through an anastomosis will keep it stretched open, but if the inflammation and healing process outpaces the stretching process, scarring may make the opening so small that even liquids can no longer pass through it. The solution is a procedure called gastroendoscopy, and stretching of the connection by inflating a balloon inside it. Sometimes this manipulation may have to be performed more than once to achieve lasting correction.

Gallstones

Before surgery you will undergo an ultrasound of your gallbladder. If you have existing gallstones then your gallbladder will be removed at the time of surgery. The reason this is done is that the rapid weight loss you will experience following gastric bypass can increase the risk of developing symptomatic gallstones. If you already have gallstones the risk is high enough that preventive removal of your gallbladder is warranted.

Dumping syndrome

Dumping syndrome happens in response to the presence of a high carbohydrate load entering into the intestine. After gastric bypass surgery, if you eat sweets it may sometimes be “dumped” into the intestine instead of being released gradually, in small amounts.

Symptoms: Abdominal fullness, nausea, crampy abdominal pain followed by diarrhea within 15 minutes after eating. As a result, you may feel warm, dizzy, weak, faint, have an increased pulse rate, and break into a cold sweat.

Follow these four rules to help avoid dumping syndrome:

  1. Eat slowly
  2. Chew thoroughly
  3. Do not consume liquids with solids
  4. Avoid sugar

Tips:

  • Your diet should below in simple carbohydrates, low in fat, and high in protein.
  • All food and drink should be moderate in temperature. Cold drinks can cause gastric distress.
  • If “dumping” is a problem, it may be helpful to lie down 20 to 30 minutes after meals, or even up to an hour.
  • Pectin, a dietary fiber found in fruits and vegetables, may be helpful. It delays gastric emptying, slows carbohydrate absorption, and reduces the glycemic response. (Consume fruits and vegetables according to Stages)
  • Read food labels and avoid foods high in added sugar. To identify sugar, look for ingredients ending in ose (example: dextrose, sucrose, and fructose). Other forms of sugar are corn syrup, honey, and molasses.
  • Sugar, or a form of sugar, listed in the first three ingredients on the ingredient list should be avoided.

Look for foods labeled sugar-free or no addedsugar. Foods labeled dietetic, may not be sugar free.

Nutritional deficiencies

Hyperparathyroidism, due to inadequate absorption of calcium, may occur in over 30% of GBP patients. Calcium is primarily absorbed in the duodenum, which is bypassed by the surgery. Mostpatients can achieve adequate calcium absorption by supplementation with Vitamin D and Calcium Citrate (carbonate may not be absorbed - it requires an acidic stomach, which is bypassed).

Iron frequently is seriously deficient, particularly in menstruating females, and must be supplemented.

Again, it is normally absorbed in the duodenum.

Ferrous sulfate can cause considerable GI distress in normal doses; alternatives include Ferrous fumarate, or a chelated form of iron. Occasionally, a female patient develops severe anemia, even with supplements, and must be treated with parenteral iron.

Vitamin B-12 requires intrinsic factor from the gastric mucosa to be absorbed. In patients with a small gastric pouch, it may not be absorbed, even if supplemented orally, and deficiencies can result in pernicious anemia and neuropathies. Sublingual B-12 appears to be adequately absorbed.

Thiamine deficiency (also known as beriberi) will, rarely, occur as the result of its absorption site in the jejunum being bypassed. This deficiency can also result from inadequate nutritional supplements being taken post operatively.

Protein malnutrition is a real risk. Some patients suffer troublesome vomiting after surgery, until their GI tract adjusts to the changes, and cannot eat adequate amounts even with 6 meals a day. Many patients require protein supplementation during the early phases of rapid weight loss, to prevent excessive loss of muscle mass.

Other potential complications of gastric bypass surgery include:

  • Vitamin and mineral deficiency (iron deficiency anemia, vitamin B-12 deficiency and vitamin D deficiency)
  • Dehydration
  • Bleeding stomach ulcer
  • Intolerance to certain foods
  • Kidney stones
  • Low blood sugar (hypoglycemia) related to excessive insulin production

Nutrition

The Pre-op Nutritional Consult

Have no fear. This is your easiest consult. We only ask questions and educate! It is recommended to see your dietitian as early in the process as possible so you can learn some good techniques to practice before surgery.

The idea is to start being healthy before surgery.

The following are common questions you will be asked during your interview. Think about these questions before you have your appointment to increase communication between you and your dietitian.Diet

  • Height, weight, age, sex, body frame
  • Past medical history
  • Prescribed medications as well as anything over the counter or herbal
  • Compliance with medications
  • Special dietary needs (Kosher, vegetarian…)
  • Intolerances or allergies to foods
  • Daily meal patterns and food preferences
  • Fluid intake
  • Preparation of meals (homemade, dining out, fast food…)
  • Eating habits (daily meals consumed, daily snacks…)
  • Alcohol consumption
  • Weight loss history (age onset, diets, medications…)
  • Family history (obesity, diabetes…)
  • Personal experience with an eating disorder
  • Activity/ Exercise
  • Occupational physical limitations
  • Support system
  • Desired goal weight

Once you and your dietitian have discussed the above topics, she will go through the education portion of your consult. You will learn the guidelines that are required for you to follow after surgery.

Pre-operative Nutrition

You all come from different backgrounds of eating difficulty. Your relationship with food and the years of trying to deal with it vary. You have now selected a surgeon and together have decided on which surgery is right for you. Your surgeon may have their own requirements for you before surgery.

Some may require pre-op weight loss, others may want you on a liquid diet before the big day. You might ask your surgeon about their specific protocols.

You can do many things in preparation for your surgery to promote good health. The following are general guidelines for you to follow in the time you have, once you have committed to have the surgery, up until your surgery date. Make smart choices from every food group:

  • Eat good, quality protein. Select lean protein from different sources to incorporate into your meals (animal, plant, legumes, dairy, fish, poultry, eggs, and nuts).
  • Eat foods low in saturated fats, trans fats, cholesterol. Eat fats that are polyunsaturated and monounsaturated. Keep your total fat intake between 20-35% of total calories.
  • Limit sugar. If sugar is one of the first three ingredients on the list, don’t eat it.
  • Use the food label. Check the serving size and calories. Look to see how many servings you are actually consuming. Look at the %DV. If you are limiting something in your diet make sure it is 5% or less. Trying to increase fiber- select foods that are 20% or higher. How easy is that to identify the healthy foods?
  • Snack on fruits. Pick different colors. Make it interesting. Try one that you have never tried before.
  • Eat three meals a day. No skipping! Emphasize eating fruits, vegetables, fat-free or low fat dairy products, and whole grains (fiber).
  • Increase drinking water.
  • Increase daily physical activity. This needs to be discussed with your doctor. Different weights require different physical activity in order to be safe.
  • Maintain or lose weight. Do not gain weight prior to surgery.

Now that you have made some healthier food choices, maybe lost a few pounds, now you can walk into your surgery knowing that you are ready!

Interesting fact: If you eat 100 more calories a day than you burn, you will gain about 1 pound per month. That is about 10 pounds a year!

Post Operative Diet

Stage I Diet (Liquids)

The only liquids you will consume are clear, sugar free liquids. You will usually receive a liquid diet and a protein supplement after surgery. Now it is very common to be afraid to take those first few sips, but remember, the sooner you tolerate your foods the quicker you get to go home. Your tray may vary from hospital to hospital, but it will generally have some water, clear broth, diet jello, and some sugar free juice or decaffeinated tea.

The portions may be regular size, but you will be given a small medicine cup to drink out of. Usually, the standard is you can consume about ½ cup (4 ounces) every waking hour. This gradually improves with time. There will be no straws on your tray. Using straws post-operatively can increase gas problems and make you more uncomfortable.

We recommend that you try to sip small amounts of your liquids, because your health care team want to see that you are able to tolerate it. Once it is decided by your surgeon that you can advance to the next stage, you will receive Full Liquids. This includes fat free cream soup, pudding, cream of wheat cereal or oatmeal and sugar free plain yogurt (no fruit). Take your time. Be persistent.

Follow what your surgeon and nurses advise you to do and you will be discharged home. Many surgeons will send you home once you have tolerated a stage I diet. Other surgeons may keep you on liquids for awhile longer. The stages will be discussed in the next section . The recommendations for progression are individual by surgeon.

Stage II Diet (Soft, mushy and/or pureed)

This next stage can only start once you have successfully tolerated Stage I. You will only be allowed to consume foods that are NOT solids for the next 4-6 weeks (may vary by surgeon). Your goal is to eat approximately 550-700 calories a day and at least 60 grams of protein. Your new stomach pouch can only handle 1-2 ounces (the size of 1-2 ice cubes) at a time. It is up to you to try and eat a variety of foods and concentrate primarily on proteins. The following are good examples of food choices:

  • Cottage cheese
  • Yogurt
  • Egg whites beaters
  • Tofu products
  • Ricotta cheese
  • Soft cheeses
  • Hummus
  • Soft flaky fish
  • Tuna
  • Ground meats
  • Oatmeal Skim or 1% milk Pudding

These foods should meet the 5% rule for carbohydrates and fat. Some patients for convenience try jarred baby foods (meats). A general rule is to avoid red meats for the first 3-6 months. They are not easily tolerated. Ground meats such as turkey, chicken or veal should be tried, depending on your preference. Other foods that fit into this consistency are soft bananas, pureed melons, and overcooked vegetables. We do not enforce those types of foods, because they do not provide substantial protein.

Stage III (Regular)

Once again, you can only advance to this stage once Stage II has been completely tolerated.
Regular solid foods should not be tried prior to 4-6 weeks after surgery. Remember, no liquids with meals! Continue Stage II foods and slowly introduce solid foods each day. Experiment with caution and slowly so you can easily tell which
foods are tolerated and which ones are not. You should aim for three meals a day with one or more protein supplements as needed to reach your goal of 60 grams of protein daily. This stage encourages lean protein. Fruits, vegetables, whole grains, fat and sugar continue to be limited.

Tips For Beginning a Regular Diet:

  • Avoid “cheap calories” such as fats, high calorie liquids, sweets, ice cream, junk foods and cookies.
  • Remember, because the quantity of your intake is very small, it is crucial to eat highly nutritious foods.
  • Cut up each piece of meat to the size of an eraser on the end of a pencil.
  • Chew up each piece of meat individually, before swallowing.
  • Remember no liquids with meals!
  • High calorie liquids should be avoided. Consume only calorie free liquids.
  • Each meal should take an average of 30 minutes to consume. Eat slowly.
  • When in doubt about a new food, try it.
  • At least ½ of each meal should be high quality protein.
  • Quit when you are full. Do not challenge the capacity of your stomach pouch, to avoid stretching.
  • Do not smoke.
  • Do not use carbonated beverages, and avoid alcohol.

You may not feel hungry, so plan your meals by the clock to maintain adequate nutritional intake throughout the day. This will also make it easier to plan your fluid intake. Nutritional changes take place throughout the first year, and individual meal planning may be necessary with your dietitian.

Amino Acids

Amino acids are the basic structural building blocks of proteins. Your body can produce 10 of the 20 amino acids your body needs to live. The other 10 are called essential amino acids because you can only obtain them by eating food. If you miss even one amino acid your body needs, your body won’t function properly. Your body does not store excess
amino acids for later use as it does for fat and starch. Therefore, you must consume them everyday in the foods you eat. The following are two very popular amino acids that are always talked about when it comes to weight loss and
maintenance.

Arginine - This is an essential amino acid that is important for growth and proper functioning of the immune system It is one of the three building blocks of creatine. It is needed for the formation of proteins such as collagen and elastin, and the vital substances such as hemoglobin, insulin and glucagons.

I mention this in particular because with the amount of weight that you are about to lose, you want your skin to look as healthy as it can. We have all heard of collagen and elastin in lotions that you may use. The following foods are rich in arginine which will help in forming these important proteins. Peanuts, cashew nuts, walnuts, piyal seeds, and most vegetables especially green and root vegetables. It also exists in a free state in garlic and ginseng. Remember to make sure that the foods you are eating are stage appropriate.

Glutamine - This is the most abundant amino acid found in muscles. It helps to build and maintain muscle tissue, helps prevent muscle wasting, increases brain function and mental activity, helps keep the digestive tract healthy, alleviates fatigue and depression, and decreases cravings for sugar and alcohol. You can understand the need for this
amino acid with the intensity of your pending weight loss. Foods rich in glutamine are: beef, fish, poultry, eggs and dairy. Vegetarians can get glutamine by consuming legumes, hemp seeds, chia seeds, raw cabbage and beets.

Vegetarianism and Protein

Just to reassure those of you that are contemplating WLS and are practicing vegetarians of different degrees, it is easy for you to get quality protein too! Foods such as beans, grains, nuts, vegetables, beans, soy, tofu and tempeh are great examples. Plant based proteins also contain healthy fiber and complex carbohydrates. It is a great idea to consume many types of proteins because too much animal protein has been linked to formation of kidney stones and has been associated with colon and liver cancer.

Interesting fact: The human body can absorb 92% of protein found in meat and 91% of protein in soybeans. It is worth discussing the topic of soy for those of you that either do not know what it consists of, or are on the fence with the
controversy surrounding it.

Soy - Soybeans contain natural isoflavones.

Isoflavones are studied in relation to the relief of certain menopausal symptoms, cancer prevention, slowing or reversing of osteoporosis and reducing the risk of heart disease. These positives are talked about so often because they can potentially help a wide range of people. This article does not encourage or discourage the use of soy. It is purely informative in helping you to understand this topic and make an informed decision of your own.

Soy also has many negatives. Over 90% of soy is genetically modified and it also has one of the highest percent contamination by pesticides of any of the foods we eat. Soy can also block the body’s uptake of essential minerals like magnesium, calcium, iron and zinc. Soy can also block the uptake of enzymes which the body needs for protein digestion. This can cause gastric distress, reduce protein digestion, and cause problems with amino acid deficiencies. As previously mentionedthe best diet regimen is one that is varied and does not depend on one specific type of any food group as it‘s main source. The jury is still out and research is ongoing in the soy matter. Stay tuned for further updates.

Frequently Asked Questions

Q: At What Point is Gastric Bypass considered successful?

A: Gastric Bypass is a success when half of extra weight is lost and the loss is persistent for up to five years. A patient who is one hundred pounds over their ideal weight ought to lose fifty pounds or more. That weight loss should be maintained for five years. It is interesting to note that Ninety-five percent of Gastric Bypass patients are considered successful after Gastric Bypass surgery. 85% of Gastric Bypass recipients continue to lose twothirds or more of their extra mass.

Q: After the Gastric Bypass, are there any restrictions?

A: After the operation, particularly while taking any pain medication, we advocate that you refrain from driving. Lifting may be limited, based on how well you are recuperating from the Gastric Bypass.

During the first two weeks after the Gastric Bypass most people are not sufficiently comfortable to lift heavy objects.

Q: Is it possible to have a leak that is not identified by the gastrographin x-ray study?

A: Yes, sometimes it is difficult to identify a leak.

Signs and Symptoms of a leak may include rapid heart rate, rapid breathing, left shoulder pain, and anxiety. While these signs and symptoms may seem quite vague, they are not normal and certainly would prompt your doctor to investigate fully.

Q: Why do I need to follow a diet before and after surgery?

A: Prior to surgery it is expected of you to lose between 7-10% of your body weight. The main goal of the bariatric program is to teach you to make a healthy lifestyle change – it could take quite some time to make a successful lifestyle change. By placing you on a healthy diet prior to surgery you are taking the first step in making that change.

By following a healthy diet prior to surgery we assess whether it is possible for you to stick to a diet. If you are successful at losing a small amount of weight preoperatively, the chances are that you are likely to do well post-operatively as well, when you are only able to consume tiny amounts of food at a time. If you do not follow the postoperative diet, complications could set in.

Most obese patients tend to have an enlarged liver. By following a healthy preoperative diet with enough protein, you can shrink the liver and reduce some of the abdominal fat. This will make it much easier for the surgeon to see your internal organs and perform the surgery safely. After surgery the reasons to follow a diet is much more obvious. The most important reason is to ensure that you do not get complications. The diet will also help to prevent you from getting dumping syndrome. Dumping can occur due to food passing too quickly from the small stomach pouch into the jejunum.

By meticulously following the diet will alsohelp prevent dehydration.

Q: How will my diet change in the long term?

A: Three months after surgery you will be on a normal diet. After your stomach have healed, you may eat most foods that won’t cause you discomfort. It is necessary that your food intake consist of six to eight small meals a day in order to
maintain an optimal nutritional status. After three months your stomach pouch can tolerate one, to one-and-a-half cups of food at a sitting (equivalent to a very small plate of food). If you do not follow these guidelines, there is a risk of becoming deficient in certain vitamins and minerals. By three months postoperative most patients can tolerate most types of food in moderation. In some cases it can take a patient a bit longer to tolerate foods like tough meats, alcohol and bread. Dumping symptoms is usually most prominent during the first postoperative year. Although it never completely goes away, it certainly becomes less of a problem over time. When you follow a healthy diet you should not experience dumping symptoms. Annual follow-ups are recommended after the 6 month diet program.

Q: How much weight can I expect to lose?

A: That depends on each individual. The first six months after surgery is known as the rapid weight loss phase. During the first three months after surgery you can expect an average weight loss of ten kilograms per month. Thereafter weight loss generally levels of for the next one to two years.

One tends to lose 80% of ones excess body weight in the first year, and the remaining 20% in the second year after surgery. A regain of up to 10% of your excess body weight is possible after 2-5 years.

Q: Why do I need to take vitamins for the rest of my life?

A: Vitamin and mineral deficiencies can develop following any gastric bypass procedure. This is very unlikely to occur if you take supplemental Iron, Vitamin B12, Calcium and a good multivitamin.

Vitamin D is also important for people who live in areas where winters are long and sunlight scarce. In sunny areas people can go out in the sunlight during the winter time and make their own vitamin D. Your dietitian or surgeon will recommend specific amounts of these supplements. With your annual follow-up you will go for blood tests to determine if your vitamin and mineral levels stays optimal.

Q: What will the pre- and postoperative diet consist of?

A: The preoperative diet consists of two main phases. The first phase is a healthy eating plan to help patients to start losing weight and in most cases reduce insulin levels. The second phase is a preoperative preparation diet to prepare the
stomach for surgery. The preoperative preparation diet consists of four phases and takes the following transition: It begins with clear liquids; followed by full liquids; puréed food; and lastly soft food, before going over to a normal healthy eating plan.

Q: Can I eat whatever I want after the Gastric Bypass?

A: Fats and sweets, when consumed above advised levels, can lead to abdominal cramping, sweating and lack of energy.

Q: What is "dumping syndrome?"

A: Gastric bypass surgery causes food to be moved from the small stomach pouch straight into the small intestine. Sweets and foods high in fat can irritate the small intestine and produces an unpleasant feeling. If you eat while drinking fluids, the same affect is produced. You should wait half an hour between drinking and eating.
 

Q: What other foods have a high glycemic index and might cause the dumping syndrome?

A: Foods such as white rice, white bread, some breakfast cereals including high-sugar cereals and, surprisingly, cereals such as cornflakes may also cause dumping syndrome.

Q: What will exercise be like after Gastric Bypass?

A: It is best to begin walking as soon as you can after the Gastric Bypass operation. You should also get some exercise on a daily basis. Exercise will lead to a healthy body and you will lose more weight. Walking is a good exercise that significantly speeds up weight loss. It is recommended that you take a nice long walk every day after you have fully recovered from your Gastric Bypass.

Q: After Gastric Bypass surgery, when do I follow up with the doctor?

A: During your recovery you will see Prof. van der Walt on a regular basis. There will usually be a follow-up visit after two weeks, and again six weeks your Gastric Bypass operation. Follow-up visits occur every three months to help your weight stabilize and to make sure that you are comfortable with your new lifestyle. After your weight is stable, you'll have regular yearly follow-up visits.

Q: Can I reverse my Gastric Bypass?

A: Gastric Bypass surgery can be reversed, but turnaround operations are usually more problematic than the original Gastric Bypass. The only patients that would be considered for reversal are those who experience noteworthy long term
problems. It is significant to note that any person who has their Gastric Bypass reversed will probably recover any weight loss seen after the first surgery.

Q: Who should not have Gastric Bypass Surgery?

A: Choosing to have a Gastric Bypass surgery is evidently a very serious choice. People who suffer from depression, bipolar disease, or schizophrenia should consult and be under the care of a psychiatrist before Gastric Bypass. Weight loss can exaggerate these conditions. To qualify for a Gastric Bypass, you'll need to be medically categorized as "morbidly obese". Click here to check your body mass index, which will tell you what category you fall into.

Q: What will my hospital stay be like?

A: The hospital stay is usually three days unless a complication from the surgery develops.

Q: When can I resume normal behavior?

Weight Loss Surgery Terms
Absorption: Process by which digested food is absorbed by the lower part of the small intestine into the bloodstream.
Adipose: Fatty; pertaining to fat
Anastomasis: Surgical connection between two structures
Bariatric: Pertaining to weight (from the same root as in barometer — measuring the “weight” of air) Bariatric surgery may be performed by bariatric surgeons. Bariatric physicians are usually internists who specialize in non-surgical weight management.
BMI: Body mass index. One of the anthropometric measures of body mass. A formula for standardizing the extent of overweight.
Clinically severe obesity: The newer term for morbid obesity. Body Mass Index of 40 or more, which is roughly equivalent to 100 pounds or more over ideal body weight; a weight level that is life risking.
Cardiovascular: Pertaining to heart and blood vessels.
Co-Morbid: Associated illnesses (i.e, arthritis, hypertension) and disabling conditions associated with clinically severe obesity or obesityrelated health conditions.
Colon: Large intestine beginning at the end of the small intestine and ending at the rectum.
Contraindications: Any symptom or circumstance indicating the inappropriateness of an otherwise advisable
treatment (i.e., alcoholism, drug dependency, severe depression, sociopathic personality disorder)
Criteria: Defines potential candidate for surgery
Digestion: Process by which food is broken down by stomach and upper small intestine into absorbable forms.
Dilation: Process of enlargement a passage or anastomosis
Disease: Process injurious to health and/or longevity
Duodenum: First 12 inches of small intestine immediately below stomach. Bile and pancreatic fluids flow into duodenum through ducts from liver and pancreas, respectively.
Gastric: Pertaining to stomach.
Dumping syndrome: Whereby stomach contents move too rapidly through the small intestine. Symptoms include nausea, weakness, sweating, faintness, and, occasionally, diarrhea after eating, as well as the inability to eat sweets without becoming so weak and sweaty that the patient may have to lie down until the symptoms pass.
Esophagus: The tube that connects the pharynx (throat) with the stomach. The esophagus lies between the trachea (windpipe) and the spine. It passes down the neck, pierces the diaphragm just to the left of the midline, and joins the cardiac (upper) end of the stomach. In an adult, the esophagus is about 25 centimeters long. When a person swallows, the muscular walls of the esophagus contract to push food down into the stomach. Glands in the lining of the esophagus produce mucus, which keeps the passageway moist and facilitates swallowing. Also known as the gullet or swallowing tube. From the Greek oisophagos, from oisein meaning to bear or carry + phagein, to eat.
Gastric Bypass: Operation designed to make nonfunctional a portion of the stomach.
Gastrointestinal: Pertaining to stomach or intestine.
Gastric banding: In this procedure, a band made of special material is placed around the stomach near its upper end, creating a small pouch and a narrow passage into the larger remainder of the stomach.
Gastrojejunostomy Anastomosis: Upper connection of the gastric bypass operation
Obesity: Pertaining to excessive weight or adipose tissue
Obsruction: Narrowing of an anastomosis or segment of gastrointestinal tract that retards normal passage of food or waste materials
Extensive gastric bypass (biliopancreatic diversion): In this more complicated gastric bypass operation, portions of the stomach are removed. The small pouch that remains is connected directly to the final segment of the small intestine, thus completely bypassing both the duodenum and jejunum.
Although this procedure successfully promotes weight loss, it is not widely used because of the high risk for nutritional deficiencies.
Gastroplasty: Operation for morbid obesity that reshapes the stomach.
Hernia: The protrusion of a loop of an organ or tissue through a weakened opening. Ten to 20 percent of patients who have weight-loss surgery develop a hernia.
Hypertension: High blood pressure
Ileum: Ten feet of small intestine responsible for absorption.
Intestinal bypass (no longer done): This procedure has evolved and improved since it was first introduced some twenty years ago. In the early days, intestinal bypass — which is totally different from gastric bypass — had some very serious complications.
Compared to the intestinal bypass, gastric bypass is relatively safe with fewer complications.
Jejunum: Ten feet of small intestine; the part responsible for digestion.
Open: Making an incision to do the operation; opening the abdomen.
NIH: National Institutes of Health
Preop: Before surgery (Pre Operation). The time/events prior to surgery.
Postop: After surgery (Post Operation). The time/events after surgery.
Periop: Surrounding surgery (Peri=“around”, as in periscope [“around-looking”]).
The time/events before, during and after surgery.
Panniculectomy: The removal of the tissue and skin from the abdomen; a tummy tuck. (Never use the term “tummy tuck” when communicating with an insurance company. They like to deny this surgery!)
Pouch: The new small stomach created during most bariatric surgeries.
Malabsorption: Impaired intestinal absorption of nutrients, causing food to be poorly digested and absorbed.
Morbid: Pertaining to disease, illness, increased risk of death.
Morbid Obesity: Severe obesity in which a person's BMI is over 40. This is generally equivalent to having 100 or more pounds to lose.
Mortality: Pertaining to death
Multidisciplinary: Team approach to evaluation and treatment of clinically severe obesity; includes surgical, internal medicine, nutrition, psychiatric, and exercise physiology, assessment, and treatment
Psychotherapy: Evaluation and treatment of mentally related disorders.
Kilogram: Measure of weight equal to 2.2 pounds.
Laparoscopy: Method of visualizing and treating intra-abdominal problems with long fiber-optic instruments.
Psychotherapy: Evaluation and treatment of mentally related disorders.
Pulmonary: Pertains to lungs.
Restriction operation (weight-loss surgery):

Restriction operations are the surgeries most often used for producing weight loss. Food intake is restricted by creating a small pouch at the top of the stomach where the food enters from the esophagus. The pouch initially holds about 1 ounce of food and expands to 2-3 ounces with time. The pouch's lower outlet has a small opening. The small outlet delays the emptying of food from the pouch and causes a feeling of fullness.

Restriction operations for obesity include gastric banding and vertical banded gastroplasty.

Both operations serve only to restrict food intake. They do not interfere with the normal digestive process.

Roux-en-Y gastric bypass (RGB):

This operation is the most common gastric bypass procedure. First, a small stomach pouch is created by stapling or by vertical banding. This causes restriction in food intake.

Next, a Y-shaped section of the small intestine is attached to the pouch to allow food to bypass the duodenum (the first segment of the small intestine) as well as the first portion of the jejunum (the second segment of the small intestine). This causes reduced calorie and nutrient absorption The procedure is more extensive than the VBG (below). Some people prefer it because of a a sick feeling that results (called “dumping”) when post op patients overeat. This can be a powerful feeback/learning mechanism whereby people lose their interest — at a “gut instinct” level — in eating excessive carbohydrates.

Staples: Surgically sterile devices for connecting tissue; usually permanent and made of stainless steel or titanium.
Strictures: Narrowing of anastomosis or section of intestine; often related to scarring or ulcers.
Therapy: Treatment
Type 2 diabetes: A disorder of glucose and insulin metabolism.
Vertical banded gastroplasty (VBG): This procedure is becoming the most frequently used restrictive operation for weight control. It is less extensive than the RNY (above). Both a band and staples are used to create a small stomach pouch. The procedure works best on individuals who are not binge
eaters.