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Bariatrics

If there were one surgery that was the best, with the most weight loss, lowest risk, and least side effects, there would not be any others. As it is, though, each of the operations we currently do have their pros and cons. The more you can educate yourself on each surgery, and the more insight you have into your own wishes and values, the easier it is for your surgeon to discuss and make a plan with you.

We do not perform bariatric surgery to make people dependent on protein shakes and vitamin mixes. You will return to eating solid food, at regular mealtimes, with perhaps a healthy snack between meals. The meals are smaller, no question. But if, by “normal”, you mean the standard American, no-hold-barred, giant steakhouse platter of fried and calorie-oozing slop, then no, that kind of “normal” is a thing of the past for you. And good riddance! Be prepared, take a cooler everywhere you go with drinks and food that you can have.

The quick answer is that most patients have some hair thinning or loss in the 3 to 9 month period, and in almost all cases, it stops and reverses after 9-12 months. Any kind of rapid weight loss will cause the hair follicles to go dormant; surgeries that yield greater weight loss have greater risk of hair thinning. Conversely, surgeries that yield less weight loss have less risk of hair thinning or loss.

Bariatric surgery is major surgery and carries risk. This fact should not be minimized, but each patient should also remember that morbid obesity carries significant risk also. The decision about which risk to take is highly personal, and only you can decide that.

The internet is full of information — good, bad, and dangerous. Chat rooms or forums can be helpful in showing other patients’ experience, but remember that those patients are in a different program, with different surgeons, different expectations, and different risk factors all contributing to their ultimate outcome. Reputable major university surgical programs (such as the Mayo Clinic, Vanderbilt University, or others) will often have reliable information. Our own website at Optum is designed to be a resource for patients desiring more information. Take what you read on the internet with a grain of salt, but don’t let it discourage you from doing research. The more informed you can be, the better.

We still believe that the risk of osteoporosis is significant, and encourage our patients to take their supplemental calcium. There is no evidence to suggest that this increases risk of kidney stones. There is some data to suggest that kidney stones may form due to not enough calcium in the diet. Some patients may have kidney stones that form after bariatric surgery due to certain compounds in protein supplements, or from the changes in metabolism that occur after bariatric surgery.

No, you must quit smoking for six months prior to surgery.

Generally, the criteria for surgical weight loss procedures is a Body Mass Index (BMI) of 40 or greater; or, BMI of 35 or greater if they have associated medical conditions that are related to obesity.

Check-ups with your doctor are a normal and very important part of surgery follow-up. Many surgeons see their patients weekly or biweekly during the first month and every four to twelve weeks for the first year. Adjustments are performed during some of these visits. It is typical for follow-up visits to be scheduled every three to six months during the second and third year, depending on the individual case.

• Leakage from intestinal connections or suture lines – The stapling and re-routing involved in gastric bypass entails creation of a connection between stomach pouch and small intestine, and between small intestine and small intestine.  This kind of bowel connection is called an “anastomosis.”  These connections can occasionally fail (around 0.5–2% in most studies), causing intestinal contents like food and digestive enzymes to leak into the abdominal cavity.  This would usually happen within the first two weeks after surgery, and is one more reason why strict adherence to your surgeon’s instructions about liquid diet must be followed.  A leak usually means one or more re-operations, a longer hospital stay, and an increased risk of other life-threatening complications.  The most important connection in the gastric bypass is the one between the stomach pouch and small intestine.
• Narrowing of intestinal connections – When an intestinal connection scars down to be too narrow for solid food to pass through, this is called a “stenosis” or “stricture.”  Around 5% of stomach pouch to small intestine connections will narrow enough to require treatment.  Treatment usually involves passing a flexible scope down the mouth, under sedation, and using a balloon to stretch the connection.  This is termed “dilation,” and may be required one or more times.  This complication usually shows up within the first 1–6 months after surgery.
• Ulcer formation – A special kind of stomach ulcer, called a “marginal ulcer”, can form after gastric bypass right where the stomach pouch connects to the small intestine.  This can occur at any time after gastric bypass: months or even years later.  Marginal ulcers may cause pain, bleeding, or even rupture and leakage into the abdominal cavity.  The two most important causes of marginal ulcer to avoid are: smoking and use of NSAIDs.  NSAIDs are “nonsteroidal anti-inflammatory drugs”, such as aspirin, ibuprofen (Motrin®, Advil®), naproxen (Aleve®, Naprosyn®), ketorolac (Toradol®), and COX-2 inhibitors (Mobic®, Celebrex®).  Patients who have had gastric bypass should never, ever smoke cigarettes for the rest of their lives.
• Internal hernia or intestinal blockage – Because of the unique re-arrangement of the intestinal tract after gastric bypass, patients may be at risk for blockage caused by scar tissue or a special type of intestinal blockage called “internal hernia.”  The main thing to remember is this: abdominal pain after gastric bypass is not normal, and should prompt you to see your doctor.  Once the surgical pain is gone after gastric bypass, a return of abdominal pain could signify intestinal blockage or an ulcer, as described above.

• Leakage from stomach suture line – The stapling and removal of a portion of the stomach in sleeve gastrectomy means that a long staple line needs time to heal.  Like in gastric bypass, this staple line can occasionally fail and rupture (around 0.5–2% in most studies), causing intestinal contents like food and digestive enzymes to leak into the abdominal cavity.  This would usually happen within the first four weeks after surgery.  A leak usually means one or more re-operations, a longer hospital stay, and an increased risk of other life-threatening complications.
• New onset or worsening of gastroesophageal reflux (GERD) – Because sleeve gastrectomy alters the anatomy of the stomach with relation to the esophagus, some patients can experience new or worsened gastroesophageal reflux symptoms, such as heartburn, “gurgling” in the chest, asthma exacerbations, hoarseness, or regurgitation of fluid or food into the mouth.  These symptoms have been studied and found to decrease following the first year after surgery, but some patients may require continued medication or revisional surgery.
• Narrowing of stomach tube – Despite the use of a sizing tube when constructing the sleeve gastrectomy, occasionally the stomach tube (sleeve) scars down after surgery to be too narrow for solid food to pass through.  This is called a “stenosis” or “stricture.”  Around 5% of sleeve gastrectomies will narrow enough to require treatment.  Treatment usually involves passing a flexible scope down the mouth, under sedation, and using a balloon to stretch the affected area.  This is termed “dilation,” and may be required one or more times.  This complication usually shows up within the first 1-6 months after surgery.

• Band erosion – Rarely, the band device that is wrapped around the outside of the stomach can end up wearing a hole into the inside of the stomach.  This can happen at any time after implantation of the band.  This requires removal of the band, and only later can another operation for weight loss be considered.  Often, an infection of the port under the skin is the first sign of this complication.
• Band slippage – If the band slips down around the thick part of the stomach, the channel for food becomes so tight that no food or drink can pass.  The patient most commonly experiences nausea, vomiting, abdominal pain, or new onset of acid reflux symptoms.  Occasionally, the band is so tight on the stomach that a part of the stomach can die.  A band slip requires removal of all of the fluid from the band, followed by surgical correction of the slip.
• Stretching of the stomach pouch or esophagus – An overly tight band, if not loosened but  allowed to stay tight, will eventually cause the stomach pouch to stretch, which can lead to some weight gain.  If the situation continues and is not addressed, eventually the esophagus can stretch and stop working properly.  Patients most commonly report new onset of acid reflux symptoms as the first sign of this overtightening.
• Device failure requiring additional surgery – The adjustable gastric band is the only one of these procedures that involves an implanted device.  As with all manufactured products, some of these devices will not function as intended and may require removal and replacement or revision.  Tubing kinks, tubing breakage, injection ports that twist or fail, and balloon deflation are all examples of mechanical failure.

That is not always the case. As a rule, plastic surgery should not be considered for at least a year or two after the operation since sometimes the skin will mold itself around the new body tissue. Give the skin the time it needs to adjust before you decide to have more surgery.