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Frequently Asked Questions

Posted Jun 02 2009 4:40pm

FAQ About Gastric Bypass

(A) Preparation for Weight Loss Surgery

Q. How do I know if I qualify for weight reduction surgery
A. You qualify if:

» You weigh twice your ideal body weight or You are overweight by 100 lbs or more
» You have a BMI (body mass index) more than 40 or
» You have a BMI more than 35 with co-morbidities (illnesses related to being overweight).
» You are overweight for 5 years or more
» You have failed to lose weight or sustain weight loss under supervision
» You are willing to comply with lifestyle and diet changes

Q. How much weight will I lose ?

A. Roux-en-y gastric bypass is an effective tool in losing and maintaining weight. Weight loss depends on you and how well you follow a good diet and how often you exercise. On an average, people lose 65 – 70% of their excess weight at one year after gastric bypass. While an estimated 0-3% of patients with >100 pounds of excess weight will successfully lose weight through dieting, 80-85% of patients undergoing gastric bypass surgery will lose weight and more importantly, keep it off. After 10 – 14 years, patients have maintained 50 - 60% of excess body weight loss.

Q. What are the routine tests before weight loss surgery?

A. Certain basic tests are done prior to surgery. These include a complete blood count (CBC), urinalysis and clinical chemistry panel including serum TSH for thyroid gland function. Often a glucose tolerance test is done to check for Type 2 diabetes, a common condition in morbidly obese individuals. Adult patients will receive a chest X-ray and an electrocardiogram. Women may have a vaginal ultrasound to look for abnormalities of the ovaries or uterus. We also ask for an abdominal ultrasound to check for a fatty liver and gallstones and an upper GI Endoscopy to exclude hiatal hernia, peptic ulcers etc. Other tests, such as pulmonary functions, echocardiogram, polysomnography (sleep study) and cardiology evaluations may be requested when indicated.

Q. What is the purpose of all these tests?

A. An accurate assessment of your health is needed before surgery. The best way to avoid complications is to never have them in the first place. It is important to know if your thyroid function is adequate since hypothyroidism can lead to sudden death post-operatively. If you are diabetic, special steps must be taken to control your blood sugar. Because elevated blood sugar increases cardiac stress, your heart function will be thoroughly evaluated. Other tests will determine if you have liver malfunction, breathing difficulties, excess tissue fluid accumulation, electrolyte (salts and minerals) abnormalities or abnormally high levels of circulating fats in your bloodstream.

Q. Why do I have to have a GI Evaluation?

A. Patients with significant excess weight can have underlying problems such as a hiatal hernia, gastro esophageal reflux or a peptic ulcer without any symptoms. It is essential to know the presence of these abnormalities since we may have to modify our steps during surgery. In patients with acid reflux, up to 15% show early changes in the lining of the esophagus, which could predispose them to cancer of the esophagus. It is important to identify these changes so a suitable treatment program can be planned.

Q. Why do I have to have a Sleep Study?

A. The sleep study detects a tendency for abnormal cessation of breathing when asleep, called obstructive sleep apnea, which is associated with airway blockage when the pharyngeal and throat muscles relax. After surgery, you will be sedated and will receive narcotics for pain relief, which further depress normal breathing and reflexes. An undetected airway blockage would be more dangerous while under the effect of these drugs. It is important that your surgeon and anesthesiologist have a clear picture of what to expect so they and the nursing staff are prepared to prevent any post-surgical complications.

Q. What impact do my medical problems have on the decision for weight loss surgery, and how might they affect risk?

A. Medical problems, such as serious heart or lung problems, can increase the risk of any surgery. On the other hand, if the problems are related to the patient's weight, they also increase the need for surgery. Severe medical problems may not dissuade the surgeon from recommending gastric bypass surgery if it is otherwise appropriate, but those conditions will make a patient's risk higher than average.

Q. What are the risks of gastric bypass surgery?

A. All efforts in preoperative evaluation are directed to identify high-risk patients. While all efforts are made to eliminate complications, still gastric bypass is a major surgery and is associated with certain complications. Some of these complications are as minor as draining a wound or difficulty in swallowing. More major complications include bleeding, intestinal blockage or obstruction, pneumonia, leaks that form abscesses, ulcers and hernias. One life threatening complication is a deep vein thrombosis. This is a blood clot in the leg that can travel up to the lungs (pulmonary embolism) and possibly cause death. Leakage from staple line is also a dangerous complication and may require surgery. Risks of Gastric Bypass Surgeries

Q. Is there anything I can do before surgery to reduce the risk of complications?

A. Certainly. You can reduce some risk by doing the following in the 4 weeks preceding surgery; Quit smoking, Quit drinking alcohol, Decrease 10 percent of your weight by taking high protein liquid diet. Doing this will not only decrease the risk but will also optimize your surgery.

Q. Will I have to stop smoking?

A. Patients are encouraged to stop smoking at least one month before surgery. Smoking increases the risk of lung problems and can reduce the rate of healing. It increases the rate of incisional hernia and leaks by interfering with the blood supply of healing tissues.

(B) Laparoscopic Gastric Bypass Surgery

Q. What can I expect when I wake up after surgery?

A. When your surgery is finished, you will be moved to the recovery room where you will wake up. The doctors and the nurses will be asking you to take deep breaths and monitoring your blood pressure and pain control. After you are awake and your pain and nausea is under control, you will be taken to your room. Dr. Kriplani will be in contact with your family while you are in the recovery room. Sometimes the anesthetist may decide to observe you more carefully for monitoring your respiration and blood pressure in the intensive care unit (ICU). Your family members can visit you in the ICU once a day.

Q. Will I have a lot of pain?

A. Every attempt is made to minimize pain after surgery to make it possible for you to move about quickly and become increasingly active which, in turn, helps avoid unwanted complications and speeds recovery. A major advantage of laparoscopic surgery is that it decreases pain significantly as compared to open surgery. Further, several drugs are used to help manage your post-surgery pain. While you are still in the recovery, your anesthetist may use a Patient Controlled Analgesia (PCA) apparatus, which gives you control over the frequency of pain medication delivery. Various methods of pain control are available.

Q. Will blood transfusion be required? Should I donate my own blood ?

A. Generally, blood loss after this surgery is not significant. Occasionally, unexpected bleeding during surgery may warrant blood transfusion. It is generally given during recovery. The down side of giving your own blood is that you have to wait for 2 weeks for surgery till your blood builds up.

Q. Does Laparoscopic Surgery decrease the risk?

A. The benefits of laparoscopic surgeries are typically less pain and discomfort, shorter hospital stays, earlier return to work and less scarring. By less pain and early ambulation, lung problems and deep vein thrombosis risk is decreased.

Q. What is done to minimize the risk of deep vein thrombosis (DVT) or pulmonary embolism (PE)?

A. Because a DVT originates on the operating table, therapy begins before a patient goes to the operating room. Often, patients are treated with sequential leg compression stockings and given heparin (a blood thinner) prior to surgery. Both of these therapies continue throughout your hospitalization. The third major preventive measure involves getting the patient out of bed and moving as soon as possible after the operation to restore normal blood flow in the legs. Please remember we are all working for one shared goal; to get you home as fast as possible. You are expected to get out of the bed the evening of your surgery. Use your incentive spirometer at least 4 to 5 times a day and walk around in your room. The next morning, you are expected to move out of your room in the lobby. It is very important for us to get your cooperation to achieve this goal.

Q. Will there be a drain in after surgery?

A. Most patients will have a small tube to allow drainage of any accumulated fluids from the abdominal space. This is done as a safety measure and is usually removed in two to three days. Generally, it produces no more than minor discomfort.

Q. Will my gall bladder be removed?

A. Your gall bladder will not be removed unless ultrasonography shows that it contains stones. However you will be given medication for 6 months after surgery to decrease the risk of developing gallstones due to rapid weight loss.

Q. How long will I stay in the hospital?

A. As long as it takes to be self-sufficient. Although it can vary, hospital stay (excluding the day of surgery) can be 3 to 4 days for a laparoscopic gastric bypass, and 5-7 days for an open gastric bypass. After leaving the hospital, you may be able to care for all your personal needs, but will need help with shopping, lifting and with transportation.

Q. How soon can I drive?

A. For your own safety, you should not drive until you are no longer taking narcotic medication for pain and can respond quickly to traffic. Usually this takes 7-14 days after surgery.

(C) Life After Weight Loss Surgery

Q. What will I eat after surgery?

A. You will be on intravenous fluids on the day of surgery. The day after we may do a swallow study to be sure there is no leak in the staple line. If there is no leak, you will be started on liquid diet 24 to 48 hours after surgery. Intake is limited to 1 or 2 ounces per meal so that the stomach can heal properly. If this is well tolerated, next day you will be advanced to blanderised soup. You will be discharged on liquid diet. We begin patients with liquid diets, moving next to semi-solid foods and about 4 to 6 weeks later, back to solid foods. This transition is necessary to allow time for your newly created stomach pouch to heal properly. Drink 2 liters or more of water each day. Water must be consumed slowly, 1-2 mouthfuls at a time, due to the restrictive effect of the operation.

Q. What's so important about exercise?

A. After weight loss surgery, you will lose weight because the amount of food energy (calories) you are able to eat is much less than your body needs to maintain itself (the basal metabolic rate). The difference or caloric shortfall has to be made up by burning (metabolizing) caloric reserves and the tendency will be to burn unused muscle before stored fat. If you do not exercise daily, your body will consume your unused muscle, and you will lose muscle mass and strength. However, daily aerobic exercise for 20 minutes shifts your metabolism away from muscle reserves and forces your body to burn fat instead.

Q. What is the right amount of exercise after weight loss surgery?

A. Exercise actually begins on the afternoon of weight loss surgery when you get out of bed and start walking. The goal is to walk further the next day and progressively further every day after that extending into the first few weeks at home. Patients are often released from medical restrictions and encouraged to begin exercising about two weeks after surgery, limited only by the level of wound discomfort, if any. The type of exercise is dictated by the patient's overall condition. Patients with arthritic knees, for example, can't walk well, but may be able to swim or bicycle. Most rehabilitation facilities offer water aerobics, which is an excellent form of exercise for patients with arthritis and degenerative joint problems. Many patients begin with low stress forms of exercise and are encouraged to progress to more vigorous activity as they are able to perform more.

Q. What if I have had a previous weight loss surgical procedure and I'm now having problems?

A. You should contact your original surgeon. He or she is most familiar with your medical history and can make recommendations based on knowledge of your previous surgical procedure

Q. What happens to the lower part of the stomach that is bypassed?

A. The stomach is left in place with intact blood supply. In some cases it may shrink a bit and its lining (the mucosa) may atrophy, but for the most part it remains unchanged. The lower stomach still contributes to the function of the intestines even though it does not receive or process food. It still produces the secretion necessary to absorb Vitamin B12 and contributes to endocrine hormonal balance and motility of the intestines in ways that are not entirely understood.

Q. How big will my stomach pouch really be in the long run?

A. This can vary by surgical technique and the bariatric surgeon. In the Roux-en-Y gastric bypass, the stomach pouch is created with a capacity of one ounce or less (15-20cc). In the first few months it is rather stiff due to natural surgical inflammation. About 6-12 months after surgery, the stomach pouch can stretch and will become more flexible as swelling subsides. Many patients end up with a pouch capacity of 4-6 ounces.

Q. What if I'm not hungry after weight loss surgery?

A. It's normal to have very little appetite for the first month or two after weight loss surgery. As long as you are able to take three meals with about 1000 calories, there is nothing to worry.

Q. How can I know that I won't just keep losing weight until I waste away to nothing?

A. Patients may begin to wonder about this early after the surgery when they are losing 10 - 20 pounds per month. Two things happen to allow weight to stabilize. First, a patient's ongoing metabolic needs (calories burnt) decrease as the body sheds excess pounds. Second, there is a natural progressive increase in calorie and nutrient intake over the months following weight loss surgery. The stomach pouch and attached small intestine learn to work together better and there is some expansion in pouch size over a period of months. The bottom line is that as long as there are no surgical complications, patients are very unlikely to lose weight to the point of malnutrition.

Q. Is there a difference in the outcome of weight loss surgery between men and women?

A. Both men and women generally respond well to this surgery. In general, men lose weight slightly faster than women.

Q. Will I be miserably hungry after weight loss surgery since I'm not eating much?

A. Most patients say no. In fact, for the first 4-6 weeks patients have almost no appetite. Over the next several months the appetite returns, but it tends not to be a ravenous, "eat-everything-in-sight" type of hunger. Small pouch results in a very early sense of fullness followed by a very profound sense of satisfaction. Even though the portion size may be small, there is no hunger and no feeling of having been deprived. When truly satisfied, you feel indifferent to even choicest of foods. Patients continue to enjoy eating, but they enjoy eating a lot less.

Q. What if I am really hungry?

A. This is usually caused by the types of food you may be consuming, especially starches (rice, pasta and potatoes). Increasing protein intake is helpful. There may also be a psychological problem with lack of food in your life “head hunger”. Be absolutely sure not to drink liquid with food since liquid washes food out of the pouch.

Q. Is sexual activity restricted?

A. Patients can return to normal sexual intimacy when wound healing and discomfort permit.

Q. Will I be able to take oral contraception after surgery?

A. Most patients have no difficulty in swallowing these pills.

Q. I am thinking about getting pregnant. Will I be able to have children after weight loss surgery?

A. Many women have had successful pregnancies after weight loss surgery. There is nothing per se that would prevent pregnancy. Infact, bariatric surgery enhances fertility in those who have had difficulty in conceiving. We recommend, however, that you wait until your weight loss is complete before becoming pregnant. This may take a year or more. The effect of rapid and prolonged weight loss on the developing fetus is unknown but it could have dire consequences and pregnancy is not recommended until a stable weight has been attained.

Q. Is there any difficulty in taking medications?

A. Most pills or capsules are small enough to pass through the new stomach pouch. Initially, It is suggested that medications be taken in liquid form or crushed.

Q. Will I have to change my medications?

A. Your doctor will determine whether medications for blood pressure, diabetes, etc can be stopped when the conditions for which they are taken improve or are eliminated after weight loss surgery. For medications that need to be continued, the vast majority can be swallowed, absorbed and work the same as before weight loss surgery. Usually no change in dose is required. Two classes of medications that should be used only in consultation with your surgeon are diuretics (fluid pills) and NSAIDs (most over-the-counter pain medicines like aspirin, ibuprofen, naproxen, etc.). NSAIDs may create ulcers in the small pouch or the attached bowel. Most diuretic medicines make the kidneys lose potassium. With the dramatically reduced intake experienced by most weight loss surgery patients, they are not able to take in enough potassium from food to compensate. When potassium levels get too low, it can lead to cardiac problems.

Q. Will there be any hair loss?

A. Hair loss can accompany rapid and significant weight loss. The most common reason for this is poor intake of protein. Lack of mineral zinc can also lead to hair loss. Patients who have not been eating enough protein will usually show some hair loss between four and six month after surgery. Consistent intake of protein at mealtime is the most important prevention method. Also recommended are a daily zinc supplement and a good daily volume of fluid intake. Happily, most patients experience natural hair re-growth after the initial period of loss.

Q. What can I do to prevent excess hanging skin?

A. The amount of excess skin depends on the age, skin elasticity, total weight loss and how much the skin was stretched. Many people, heavy enough to meet the surgical criteria for weight loss surgery have stretched their skin beyond the point from which it can "snap back". Some patients will choose to have plastic surgery to remove loose or excess skin after they have lost their excess weight.

Q. Will exercise help with excess hanging skin?

A. Exercise is good in so many other ways that a regular exercise program is recommended. Unfortunately, most patients may still be left with flaps of loose skin.

Q. What will the staples do inside my abdomen? Is it okay in the future to have an MRI test? Will I set off metal detectors in airports?

A. The staples used on the stomach and the intestines are very tiny in comparison to the staples used for skin incision closure. Each staple is a tiny piece of titanium: so small it is hard to see other than as a tiny bright spot. Because the metal (titanium) is inert (not chemically reactive), most people have no reaction to them. The staple materials are also non-magnetic which means that they will not be affected by the magnet in an MRI. They will not trigger airport metal detectors.

(D) Diet

Q. How long will I be off solid foods after weight loss surgery?

A. Most bariatric surgeons recommend a period of four weeks or more without solid foods after weight loss surgery. This is the time required for adequate healing of the staple line. During this period, a regimen of liquid diet followed by pureed food is recommended. We will provide you with specific dietary guidelines for the best post-surgical outcome.

Q. What will my long term diet be like ?

A. Eat three small meals a day.

- Keep a record of your dietary intake. Include everything you eat and drink: the date, time and amount of each meal. Start keeping this record (food diary) from one week after the surgery so if you begin having problems with vomiting, diarrhea or malabsorption. we can review your food record and make recommendations.

· Not only is there an adjustment to make about the quantity but also quality of food you should eat. When you are able to eat solid foods again, eat food high in protein. Protein foods are very important for the healing of staple line of your pouch. Protein in the form of lean meats (chicken, turkey, fish) and other low-fat sources should be eaten first. These should comprise at least half the volume of the meal eaten. Foods should be cooked without fat and seasoned to taste. Avoid sauces, gravies, butter, margarine, mayonnaise and junk foods. Hair loss is one effect of not eating enough protein.

  • You will also have to learn to eat slowly and chew your food thoroughly. Food not chewed properly will not pass through the narrow stoma and may cause vomiting.
  • Stop eating as soon as you feel full. If you do not stop, you may have vomiting and it will put strain on the staple line.
  • Do not eat sweets! This includes sweetened chewing gum, candy and regular sodas. Beware of hidden sweets (cereals with honey or sugar coatings).
  • You may be unable to tolerate certain foods, especially those containing fat and sugar. A balanced diet of 1000 – 1200 calories a day is recommended.
  • Drink 2 liters or more of water each day. Water must be consumed slowly, 1-2 mouthfuls at a time, due to the restrictive effect of the operation.
  • Never drink water or any fluid with the meal. Drink fluids thirty minute to an hour after meals. Taking fluids before or at meal time may cause bloating, low food intake, vomiting, or dumping syndrome. It will also flush the food through the stoma and you will feel hungry again.
  • Do not drink flavored beverages, even diet soda, between meals
  • Exercise aerobically every day for at least 20 minutes (one-mile brisk walk, bike riding, stair climbing, etc.). Weight / resistance exercise can be added 3-4 days per week.
Q. What are the best choices of protein?

A. Vegetarian : Legumes (dried beans), low-fat cheese, low fat cottage cheese, tofu, low fat yogurt with artificial sweeteners, oatmeal and cream of wheat made with skimmed milk, non-fat dry milk powder, skimmed or 1% milk.
Non-vegetarian : Poultry, eggs, fish and other seafood.

Q. Why drink so much water?

A. When you are losing weight, there are many waste products to eliminate, mostly in the urine. Some of these substances tend to form crystals, which can cause kidney stones. A high water intake protects you and helps your body rid itself of waste products efficiently, which in turn, promotes rapid weight loss. Water also fills your stomach and helps to prolong and intensify your sense of satisfaction with food. If you feel a desire to eat between meals, it may be because you did not drink enough water the hour before.

Q. What is the Dumping Syndrome?

A. Eating sugars or other foods containing many small particles when you have an empty stomach can cause dumping syndrome in gastric bypass patients. Your body handles these small particles by diluting them with water, which reduces blood volume and causes a shock-like state. Sugar may also induce an insulin reaction due to the altered physiology of your intestinal tract. The result is a very unpleasant feeling. You break out in a cold clammy sweat, turn pale, feel "butterflies" in your stomach, and have a pounding pulse. Cramps and diarrhea may follow. This state can last for 30-60 minutes and can be quite uncomfortable. This syndrome can be avoided by not eating the foods that cause it, especially on an empty stomach. A small amount of sweets, such as fruit, can sometimes be well tolerated at the end of a meal.

Q. What about milk and dairy products?

A. Milk contains lactose (milk sugar), which is not well digested. This sugar passes through undigested until bacteria in the lower bowel act on it producing irritating by-products as well as gas. Depending on individual tolerance, some persons find even the smallest amount of milk can cause cramps, gas and diarrhea.

Q. Why can't I snack between meals?

A. Snacking, nibbling or grazing on foods, usually high-calorie and high-fat foods, can add hundreds of calories a day to your intake, defeating the restrictive effect of your operation. Snacking will slow down your weight loss and can even lead to weight gain.

Q. Why can't I eat red meat after surgery?

A. You can in time, but it should be avoided for the first several months. Red meats contain a high level of meat fibers (gristle) which hold the piece of meat together and will require you to thoroughly chew each piece. Even so, the gristle could plug the outlet of your stomach pouch and prevent anything from passing through making you very uncomfortable.

Q. How can I be sure I am eating enough protein?

A. 40 to 65 grams a day are generally sufficient. Check with your dietician to determine the right amount for you.

Q. Is there any restriction of salt intake?

A. No, your salt intake will be unchanged unless otherwise instructed by your primary care physician.

Q. Will I be able to eat "spicy" foods or seasoned foods?

A. Most patients are able to enjoy spices after the initial 6 months following surgery.

Q. Will I be allowed to drink alcohol?

A. You will find that even small amounts of alcohol will affect you quickly. Alcohol is high in calories and will significantly alter your calorie balance. It is suggested that you drink no alcohol for the first year. Thereafter, you may have a glass of wine or a small cocktail for social purpose not more than once a fortnight.

Q. Will I need supplemental vitamins?

A. Most surgeons recommend a daily multivitamin for the rest of your life. Vitamin B12 injections are sometimes suggested once a month for the first year and every six months thereafter. It may also be taken orally or sublingually (under the tongue) by many patients.

Q. Is it important to take calcium, iron or trace elements?

A. It is strongly advisable and most patients require these supplements.

Q. Will I get a copy of suggested eating patterns and food choices after surgery?

A. We provide patients with materials that clearly outline their expectations regarding diet and compliance to guidelines for the best outcome based on your surgical procedure and prior health status. After surgery, health and weight loss are highly dependent on patient compliance with these guidelines. You must do your part by restricting high-calorie foods, by avoiding sugar, snacks and fats, and by strictly following the guidelines set in the book for optimal results.

(E) General

Q. What is the youngest age for which weight loss surgery is recommended?

A. Generally accepted guidelines from the American Society for Bariatric Surgery and the National Institutes of Health indicate surgery only for those 18 years of age and older although surgery has been performed on younger patients. There is a real concern that young patients may not have reached full developmental or emotional maturity to make this type of decision. It is important that young weight loss surgery patients have a full understanding of the lifelong commitment to the altered eating and lifestyle changes necessary for success.

Q. What is the oldest patient for whom weight loss surgery is recommended?

A. Patients over 65 require very strong indications for surgery. The risk of surgery in this age group is increased while the benefits in terms of reduced risk of mortality are reduced.

Q. Can weight loss surgery prolong life ?

A. There is strong scientific evidence that if you have type 2 diabetes, heart disease, osteo-arthritis or several other serious, obesity-related diseases, are at least 100 lbs. over your ideal body weight and if you are able to comply with the permanent lifestyle changes (daily exercise and low-fat diet), then weight loss surgery may significantly prolong your life.

Q. Can weight loss surgery help other physical conditions ?

A. A recent comprehensive clinical review of bariatric surgery data showed that many patients who underwent a weight loss surgery procedure experienced complete resolution or improvement of their co-morbid conditions including diabetes, hyperlipidemia, hypertension, and obstructive sleep apnea*.

Via: www.obesitysurgeries.com
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