This is a very important question that nearly every bariatric surgery patient asks. Let me fist explain to you that weight loss from a gastric bypass or a gastric sleeve occurs over about 1 year following surgery.
The operation will help you maintain your weight but will not help you loose weight after about a year. (A patient with an adjustable gastric band is on a different schedule and will be discussed in a separate posting on this blog). So it is very important that you put your best effort into doing "all the right things" in that first year and continue them thereafter. Therefore it is important that you are truly ready for surgery and get help for problems, (such as binge eating or unresolved emotional trauma, or stress eating), that may keep you from being successful even before you have surgery and you should lose as much weight as possible before surgery so you arrive at a weight near ideal weight at the end of the year after your operation.
So what are "all the right things" to do in the first year after surgery and thereafter?
1). Do not drink your calories. I find that this is one of the most frequent errors people make. Although for the first 8 weeks or so you are likely to need to take liquids since most other things will not go through the connection between the gastric pouch and intestine, once you are able to eat solid food I would strongly suggest you avoid calorie containing liquids. This includes avoiding milk, (even skim milk since it still has sugar calories ). cream soups. ice cream, fruit drinks and all soda products. Drink liquids like crystal lite, tea with sweetener instead of sugar and water. I once had a patient that was upset that she was not losing as much weight as she was expecting. She said her main fluid intake was only coffee and she would drink several coffees a day. She even brought in a "coffee" with her into the exam room and it was a large cafe latte with regular milk! Of course the amount of milk she was consuming was blunting her weight loss! You should start your meals with solid food especially your protein and drink only between your meals.
2). Avoid eating too much carbohydrate such as mashed potatoes, junk food or other carbohydrates.
3). Establish a "NO FLY ZONE" for foods that are too tempting for you and are foods that trigger overeating. Just tell your family and anyone also that come onto your property that your home is a "NO FLY ZONE" for pizza, cookies or what ever you have difficulty with and these items won't fly here. Also make strategies for eating out or going to social gatherings such as which foods you will and will not eat or how you might tell the server you are 'eating light and please bring a container to the table with the food" so you can take some of the food off the plate before you start eating. These are great suggestions from "Exodus From Obesity" by Paula Peck and you can probably get her book on Amazon.com.
4). Be aware of your portion size and listen to your body. Use your eyes and brain to determine how much you should consume at any one time. Do not expect to have your operation tell you you have eaten too much. If you do you probable have already exceeded what you should have eaten. Most patients will be able to eat about 1 cup, (pressed down), of food at any one time. Eating more than this with keep you from being successful.
5). Get in an exercise program using an exercise therapist or personal trainer and work out 3 to 5 times a week. In our program this is an integrated portion of the overall program and our offices are even in the McConnell Heart Health Center which is a medically oriented fitness center. Only tell you this to reinforce how important I think this component of your recovery really is. You will be losing muscle mass while you loose fat mass after your bariatric surgery. A great exercise therapy program will help you to build muscle, lose more weight and look better as you fill out some of the space with muscle that used to be filled with fat mass. You also may me less likely to need plastic surgery!
I find that if patients in my practice are following these directives they will lose on the average about 20 lbs. per month for the first 3 months and then a little less each month. Therefor they have lost about 60 lbs. in the first month and about 80 % of their excess weight at 1 year. The most frequent BMI I record for our patients at 1 year is a BMI of 28. I let them know this is their goal at the end of a year and that way they can "shoot" for that goal. The great thing is almost everyone in our practice reaches that level of weight loss and it is very infrequent to have one of them regain significant weight back. I don't tell you this to brag, although I am very proud of the work our patients and the staff put in, but to give you some bench marks to try to make happen in your own life.
Please feel free to leave other suggestions you have found helpful by clicking on "comments" at the end of this posting and may you experience all the success you deserve as you travel this jouney to better health.
Saturday, February 27, 2010
Wednesday, February 24, 2010
A patient's Success Story -Improving Diabetes- Don Swonger
The following videos are of Don Swonger telling of the changes in his life since his laporoscopic Roux en-Y Gastric Bypass as of a year ago.
Part 1
Part 2
Monday, February 22, 2010
Am I at risk for developing vitamin and mineral deficiencies if I have Bariatric surgery?
An adjustable gastric band or a gastric sleeve operation are NOT likely to cause any vitamin or mineral deficiencies since the small intestine has not been reoriented in any way. It is still a good idea to take a multivitamin and calcium each day especially for women but it is not absolutely necessary if you chose to have either of these operations.
Also, it is very unlikely that a person that has a Roux en-Y gastric bypass will develop deficiencies IF they take a multivitamin each day and have yearly checkups with laboratory evaluation to check their vitamin and mineral levels. However it is very important that a gastric bypass patient is willing to take their vitamins and calcium every day.
The reason this is so important is that a Roux en-Y gastric bypass excludes the first part of the small intestine from the flow of nutrients and therefore the B vitamins need to be supplemented and levels checked periodically since htis is where the B vitamins are best absorbed. Otherwise vitamin B1 deficiency can cause numbness or memory loss and vitamin B12 and vitamin B6 could lead to anemia.
Also it is important that a calcium supplement be taken each day. This should be taken as calcium citrate (800mg / day) since calcium citrate is nearly 100% absorbed. Unfortunately calcium carbonate, the usual form of calcium supplement, is not absorbed well since a gastric bypass patient does not produce very much acid in the gastric pouch which is necessary to help make the calcium available to be absorbed. Of course, calcium is not absorbed well in the absence of adequate vitamin D. Although a gastric bypass is not likely to interfere with vitamin D absorption, persons of size often have vitamin D deficiency and they need vitamin D supplementation regardless if they have had surgery or not. This may be from not being out in the sun much or there may be other reasons we are not yet aware of. We check all of our patients for vitamin D deficiency when they first are seen even before their operation. If they have a low vitamin D level we will start them on Ergocalciferol, (the active form of vitamin D), at 50,000 units monthly or weekly depending on the severity of the deficiency. I believe a bone density study should be done every 2 years for postmenopausal women and women who have had a total hysterectomy and have had a gastric bypass operation. Osteoporosis can be avoided if a gastric bypass patient follows these directions.
Iron deficiency is unlikely except in menstruating women. If a woman has heavy periods it may be difficult for them to keep up with their iron needs. If they begin to be anemic we will check their iron stores by checking a Ferritin level and if this is found to be low we will start them on an iron supplement. This supplement should be Ferrous Fumarate or Ferrous Glucanate since the usual for of iron supplementation, Ferrous Sulfate, will not be absorbed well since like calcium carbonate it needs acid to make the iron available for absorption and since the new small gastric pouch makes very little acid, Ferrous Sulfate is likely to pass out in the stool without being absorbed. You any need to remind your family doctor about this since they are so used to writing for Ferrous Sulfate and may forget you need a different form of Iron. Occasionally iron supplementation is not enough so a patient may be referred to their gynecologist for further evaluation and hormone treatment or surgery such as an endometrial ablation or hysterectomy. Of course, a full work up for anemia may be in order in certain circumstances. Remember the years of obesity may place a patient at increased risk for colon polyps or colon cancer. Therefore, a colonoscopy may be in order. My patients are always pleased when I recommend that study!
Early in my bariatric surgery practice I checked for vitamin and obtained a blood count at 3 and 6 months after surgery. However, it seems that it take about a year to see any of these changes except in unusual circumstances. Therefore I usually wait for 1 year before I check these lab tests unless there is a good reason the check before.
I also check a vitamin A level yearly although like vitamin D a gastric bypass is unlikely to be the cause of vitamin A deficiency.
I should make a comment regarding another bariatric operation that has a much greater risk of vitamin and mineral deficiencies. that is the "duodenal switch" or bileopancreatic bypass. This operation leaves the patient with only about 2 feet of small intestine to be used to absorb nutrients. This often causes much more difficulty with maintaining appropriate vitamin levels including vitamins A, D, B1, B6, B12 and sometimes K. Although this operation is performed well and safely by several of my bariatric surgery colleagues, I personally feel this is a more radical operation than necessary for most patients and I have chosen not to perform these operations. If this is of interest to you I would suggest doing a Google search for "Duodenal Switch" and finding an experience bariatrics surgeon to do this operation for you. By the way, the surgeon that is moat associated with this operation is Dr. Douglas Hess from Bowling Green, Ohio. Dr. Hess trained at the Riverside Methodist Hospital where I am now the Director of Bariatric Surgery. Dr. Hess is now retired but he is a wonderful man and has helped many persons of size resolve their obesityand their obesity related medical problems.
The "take home" message is this: if you chose to have a gastric bypass operation, take a multivitamin and calcium citrate 800 mg each day and see your bariatric surgeon or a primary care provider that is comfortable following you for these matters YEARLY and you are very unlikely to have a significant vitamin or mineral deficiency. I hope this is helpful.
Please feel free to make a comment or ask a question about this or any other issue by clicking on the yellow word "comments" at the end of this posting.
Also, it is very unlikely that a person that has a Roux en-Y gastric bypass will develop deficiencies IF they take a multivitamin each day and have yearly checkups with laboratory evaluation to check their vitamin and mineral levels. However it is very important that a gastric bypass patient is willing to take their vitamins and calcium every day.
The reason this is so important is that a Roux en-Y gastric bypass excludes the first part of the small intestine from the flow of nutrients and therefore the B vitamins need to be supplemented and levels checked periodically since htis is where the B vitamins are best absorbed. Otherwise vitamin B1 deficiency can cause numbness or memory loss and vitamin B12 and vitamin B6 could lead to anemia.
Also it is important that a calcium supplement be taken each day. This should be taken as calcium citrate (800mg / day) since calcium citrate is nearly 100% absorbed. Unfortunately calcium carbonate, the usual form of calcium supplement, is not absorbed well since a gastric bypass patient does not produce very much acid in the gastric pouch which is necessary to help make the calcium available to be absorbed. Of course, calcium is not absorbed well in the absence of adequate vitamin D. Although a gastric bypass is not likely to interfere with vitamin D absorption, persons of size often have vitamin D deficiency and they need vitamin D supplementation regardless if they have had surgery or not. This may be from not being out in the sun much or there may be other reasons we are not yet aware of. We check all of our patients for vitamin D deficiency when they first are seen even before their operation. If they have a low vitamin D level we will start them on Ergocalciferol, (the active form of vitamin D), at 50,000 units monthly or weekly depending on the severity of the deficiency. I believe a bone density study should be done every 2 years for postmenopausal women and women who have had a total hysterectomy and have had a gastric bypass operation. Osteoporosis can be avoided if a gastric bypass patient follows these directions.
Iron deficiency is unlikely except in menstruating women. If a woman has heavy periods it may be difficult for them to keep up with their iron needs. If they begin to be anemic we will check their iron stores by checking a Ferritin level and if this is found to be low we will start them on an iron supplement. This supplement should be Ferrous Fumarate or Ferrous Glucanate since the usual for of iron supplementation, Ferrous Sulfate, will not be absorbed well since like calcium carbonate it needs acid to make the iron available for absorption and since the new small gastric pouch makes very little acid, Ferrous Sulfate is likely to pass out in the stool without being absorbed. You any need to remind your family doctor about this since they are so used to writing for Ferrous Sulfate and may forget you need a different form of Iron. Occasionally iron supplementation is not enough so a patient may be referred to their gynecologist for further evaluation and hormone treatment or surgery such as an endometrial ablation or hysterectomy. Of course, a full work up for anemia may be in order in certain circumstances. Remember the years of obesity may place a patient at increased risk for colon polyps or colon cancer. Therefore, a colonoscopy may be in order. My patients are always pleased when I recommend that study!
Early in my bariatric surgery practice I checked for vitamin and obtained a blood count at 3 and 6 months after surgery. However, it seems that it take about a year to see any of these changes except in unusual circumstances. Therefore I usually wait for 1 year before I check these lab tests unless there is a good reason the check before.
I also check a vitamin A level yearly although like vitamin D a gastric bypass is unlikely to be the cause of vitamin A deficiency.
I should make a comment regarding another bariatric operation that has a much greater risk of vitamin and mineral deficiencies. that is the "duodenal switch" or bileopancreatic bypass. This operation leaves the patient with only about 2 feet of small intestine to be used to absorb nutrients. This often causes much more difficulty with maintaining appropriate vitamin levels including vitamins A, D, B1, B6, B12 and sometimes K. Although this operation is performed well and safely by several of my bariatric surgery colleagues, I personally feel this is a more radical operation than necessary for most patients and I have chosen not to perform these operations. If this is of interest to you I would suggest doing a Google search for "Duodenal Switch" and finding an experience bariatrics surgeon to do this operation for you. By the way, the surgeon that is moat associated with this operation is Dr. Douglas Hess from Bowling Green, Ohio. Dr. Hess trained at the Riverside Methodist Hospital where I am now the Director of Bariatric Surgery. Dr. Hess is now retired but he is a wonderful man and has helped many persons of size resolve their obesityand their obesity related medical problems.
The "take home" message is this: if you chose to have a gastric bypass operation, take a multivitamin and calcium citrate 800 mg each day and see your bariatric surgeon or a primary care provider that is comfortable following you for these matters YEARLY and you are very unlikely to have a significant vitamin or mineral deficiency. I hope this is helpful.
Please feel free to make a comment or ask a question about this or any other issue by clicking on the yellow word "comments" at the end of this posting.
Sunday, February 21, 2010
Why do some adjustable gastric bands "slip"?
Band "slippage" is a frustrating and often disappointing known consequence of selecting an Adjustable Gastric Band as the choice for bariatric surgery. At present I know of no definite way t assure that slippage will not occur after surgery. In fact, about 5% of patients who have an Adjustable Gastric Band placed will need to return for a laparoscopic operation to reposition the band because of "band slippage". usually this occurs several months or a few years after the band is placed and can happen regardless of which product is used, the Lap-Band or the Realize Band.
Actually I believe "band slippage" is a poor name for this problem. Maybe a more accurate term would be "Forced Upward Migration of the Stomach". May be we should even label the problem "FUMOS" after this phrase!
Let me explain why I feel "slippage" is a poor term. When a person that has a gastric band in place eats more than the volume the gastric pouch above the band can accommodate, the extra volume remains in the esophagus. Of course the esophagus contracts forcing the food down into the gastric pouch increasing the pressure in the pouch. Often the patient will experience a severe squeezing pressure sensation in their chest. This force causes pressure on the sides of the pouch. If this occurs repeatedly this is likely to force the stomach wall just below the band to be pulled up or "migrate" up under the band. As the stomach migrates upward the size of the gastric pouch increases. This may occur even though the stomach below the band is stitched to the gastric pouch above the band in an attempt to keep this from happening. As one of our team members,Mike Palasek, RN, CRNFA, says "the determined user can overcome any amount of stitching" and the a gastric pouch will become too large. Also eventually so much stomach is drawn up into the band that the increased amount of stomach inside the band makes the band too tight so that fluid will need to be removed from the band to allow anything to pass through.
In the mean time patients will develop symptoms including vomiting and severe reflux especially at night which is a sign that the band is too tight for the amount of stomach that is within the band. Sometimes the food that comes up is food they swallowed several hours before since the enlarged gastric pouch can store allow more food and it really can not pass through the band.
If you have been doing well with no need for a band adjustment for several months and rather suddenly develop vomiting and reflux "slippage" or FUMOS could be the problem. Sometimes early in the evolution of this problem symptoms are present but the CAT scan will not show enough of a change to make the diagnosis. Your bariatric surgeon should consider removing some of the fluid. If this gives your esophagus a rest and you avoid eating more than the volume of your pouch maybe the "slippage" or FUMOS will not evolve into a problem requiring a second operation.
However, if the problem persists there is a solution. The band position can be revised laparoscopically and placed back in the correct position. I have found that the problem resolves and patients do quite well after the repositioning. To date the problem has not come back. I think this is partially because the patient is careful to not eat more than the volume of the pouch.
In this situation an ounce of prevention is truly worth a pound of cure. I suggest that my patients avoid relying on the band to keep them from eating more than the volume of the pouch. They should use the symptom of squeezing chest pressure in this setting as a signal that they are eating too much too fast. I ask my patients to use their eyes and brain to tell them how much they can eat BEFORE they notice this symptom happens to them. In this way they should be able to avoid putting so much pressure on their pouch that "slippage" or FUMOS occurs.
Now you know my best understanding of why this happens and what you can do to try to prevent this problem. I would be delighted to hear your thoughts or questions regarding this frustrating problem. Just click of the word"comments" in yellow at the end of this posting.
Actually I believe "band slippage" is a poor name for this problem. Maybe a more accurate term would be "Forced Upward Migration of the Stomach". May be we should even label the problem "FUMOS" after this phrase!
Let me explain why I feel "slippage" is a poor term. When a person that has a gastric band in place eats more than the volume the gastric pouch above the band can accommodate, the extra volume remains in the esophagus. Of course the esophagus contracts forcing the food down into the gastric pouch increasing the pressure in the pouch. Often the patient will experience a severe squeezing pressure sensation in their chest. This force causes pressure on the sides of the pouch. If this occurs repeatedly this is likely to force the stomach wall just below the band to be pulled up or "migrate" up under the band. As the stomach migrates upward the size of the gastric pouch increases. This may occur even though the stomach below the band is stitched to the gastric pouch above the band in an attempt to keep this from happening. As one of our team members,Mike Palasek, RN, CRNFA, says "the determined user can overcome any amount of stitching" and the a gastric pouch will become too large. Also eventually so much stomach is drawn up into the band that the increased amount of stomach inside the band makes the band too tight so that fluid will need to be removed from the band to allow anything to pass through.
In the mean time patients will develop symptoms including vomiting and severe reflux especially at night which is a sign that the band is too tight for the amount of stomach that is within the band. Sometimes the food that comes up is food they swallowed several hours before since the enlarged gastric pouch can store allow more food and it really can not pass through the band.
If you have been doing well with no need for a band adjustment for several months and rather suddenly develop vomiting and reflux "slippage" or FUMOS could be the problem. Sometimes early in the evolution of this problem symptoms are present but the CAT scan will not show enough of a change to make the diagnosis. Your bariatric surgeon should consider removing some of the fluid. If this gives your esophagus a rest and you avoid eating more than the volume of your pouch maybe the "slippage" or FUMOS will not evolve into a problem requiring a second operation.
However, if the problem persists there is a solution. The band position can be revised laparoscopically and placed back in the correct position. I have found that the problem resolves and patients do quite well after the repositioning. To date the problem has not come back. I think this is partially because the patient is careful to not eat more than the volume of the pouch.
In this situation an ounce of prevention is truly worth a pound of cure. I suggest that my patients avoid relying on the band to keep them from eating more than the volume of the pouch. They should use the symptom of squeezing chest pressure in this setting as a signal that they are eating too much too fast. I ask my patients to use their eyes and brain to tell them how much they can eat BEFORE they notice this symptom happens to them. In this way they should be able to avoid putting so much pressure on their pouch that "slippage" or FUMOS occurs.
Now you know my best understanding of why this happens and what you can do to try to prevent this problem. I would be delighted to hear your thoughts or questions regarding this frustrating problem. Just click of the word"comments" in yellow at the end of this posting.
Thursday, February 18, 2010
Dr. Myers, will I need to use my CPAP machine for obstructive sleep apnea after bariatric surgery?
The short answer is; most likely you will be able to discontinue your CPAP machine sometime after you lose a significant amount of weight from bariatric surgery. In fact over 80% of the time patients with a diagnosis of obstructive sleep apnea will resolve this obesity related medical problem after bariatric surgery.
Let me explain. As our weight increases we see our size become larger. What we do not see is the soft tissue of obesity increasing in our throat making our airway crowded. When we are sitting up and awake gravity brings our tongue down and the muscles of our neck and throat keep our airway open. However, when we lay down on our backs gravity works against us and our tongue falls back into the back of our throat further narrowing the airway that is compromised by the soft tissue of obesity. In addition, when we fall asleep our muscles relax and the airway may become nearly or completely closed. That is why many persons of size are loud snorers! As the air is moving in and out the soft tissue in the airway vibrates making the snoring sound. This may not wake the person snoring but it certainly can keep the one they are sleeping with from sleeping!
But obstructive sleep apnea is not just about sleep. It is mostly about what happens to your heart while you are sleeping. When you are sitting up and awake your red blood cells are likely to be about 98% saturated with oxygen. You need that oxygen for your body' tissues to stay healthy. Your heart especially needs the oxygen to keep beating as well as possible. When a person with obstructive sleep apnea falls asleep and and their airway becomes obstructed their oxygen level decreases since they are not moving air in and out as well as they should. their oxygen level may fall into the 80% range, down to the 70% range into into the 60's and even lower. Our hearts do not like and sometimes your heart will run off a string of irregular beats and the heart will no longer be pumping and the person will be found dead in bed in the morning. Even if your heart does not react in this manner, it will be trying to keep up with the needs by pumping faster and harder. However, since it is starving for oxygen it is often in relative heart failure during the night. That is why people that have obstructive sleep apnea often have to get up at night to urinate since there heart is strained and gives off a hormone that tells the kidneys that you are "drowning" from heart failure and you need to get rid of some of the body's fluid. In addition people of size that have obstructive sleep apnea often wake up in the morning with their ankles still swollen because of the heart failure during the night.
This all can be prevented by using a CPAP machine, (continuous positive airway pressure), that pushes air under gentle pressure into the airway keeping the soft tissue out of the way and keeping the airway open, This allows them to breath normallykeeping their oxygen where it should be.
Since it takes about 3 weeks for the heart to recover from its previous failure we require all of our patients that have obstructive sleep apnea to be using their CPAP machine for at least 3 weeks before their bariatric operation and expect them to continue using it after their operation until they lose enough weight that the machine is no longer needed. This generally takes from 3 to 6 months to lose the amount of weight necessary.
In the hospital our patients may be on pain medicine that could make their sleep apnea temporarily worse so they are continuously monitored for their oxygen level and this information is sent to the central nursing desk for additional monitoring.
At Fresh Start Bariatrics at Riverside we are constantly looking for ways to make bariatric surgery safer for our patients and this includes making sure they are doing everything possible to be as healthy as possible before and after their operation.
Of course there are other reasons people have obstructive sleep apnea and that is why about 15% to 20% of people need to be on CPAP despite loosing their weight. For example, I have a BMI of about 27 but I use CAPAP because I have a palate deformity that narrows my airway.
Fortunately, over 80% of our patients with obesity related obstructive sleep apnea will have resolution of this problem.
Does anyone have any further questions about this? Feel free to post a coment or ask a questiion
by clicking on the word "comment" at the end of this posting.
Let me explain. As our weight increases we see our size become larger. What we do not see is the soft tissue of obesity increasing in our throat making our airway crowded. When we are sitting up and awake gravity brings our tongue down and the muscles of our neck and throat keep our airway open. However, when we lay down on our backs gravity works against us and our tongue falls back into the back of our throat further narrowing the airway that is compromised by the soft tissue of obesity. In addition, when we fall asleep our muscles relax and the airway may become nearly or completely closed. That is why many persons of size are loud snorers! As the air is moving in and out the soft tissue in the airway vibrates making the snoring sound. This may not wake the person snoring but it certainly can keep the one they are sleeping with from sleeping!
But obstructive sleep apnea is not just about sleep. It is mostly about what happens to your heart while you are sleeping. When you are sitting up and awake your red blood cells are likely to be about 98% saturated with oxygen. You need that oxygen for your body' tissues to stay healthy. Your heart especially needs the oxygen to keep beating as well as possible. When a person with obstructive sleep apnea falls asleep and and their airway becomes obstructed their oxygen level decreases since they are not moving air in and out as well as they should. their oxygen level may fall into the 80% range, down to the 70% range into into the 60's and even lower. Our hearts do not like and sometimes your heart will run off a string of irregular beats and the heart will no longer be pumping and the person will be found dead in bed in the morning. Even if your heart does not react in this manner, it will be trying to keep up with the needs by pumping faster and harder. However, since it is starving for oxygen it is often in relative heart failure during the night. That is why people that have obstructive sleep apnea often have to get up at night to urinate since there heart is strained and gives off a hormone that tells the kidneys that you are "drowning" from heart failure and you need to get rid of some of the body's fluid. In addition people of size that have obstructive sleep apnea often wake up in the morning with their ankles still swollen because of the heart failure during the night.
This all can be prevented by using a CPAP machine, (continuous positive airway pressure), that pushes air under gentle pressure into the airway keeping the soft tissue out of the way and keeping the airway open, This allows them to breath normallykeeping their oxygen where it should be.
Since it takes about 3 weeks for the heart to recover from its previous failure we require all of our patients that have obstructive sleep apnea to be using their CPAP machine for at least 3 weeks before their bariatric operation and expect them to continue using it after their operation until they lose enough weight that the machine is no longer needed. This generally takes from 3 to 6 months to lose the amount of weight necessary.
In the hospital our patients may be on pain medicine that could make their sleep apnea temporarily worse so they are continuously monitored for their oxygen level and this information is sent to the central nursing desk for additional monitoring.
At Fresh Start Bariatrics at Riverside we are constantly looking for ways to make bariatric surgery safer for our patients and this includes making sure they are doing everything possible to be as healthy as possible before and after their operation.
Of course there are other reasons people have obstructive sleep apnea and that is why about 15% to 20% of people need to be on CPAP despite loosing their weight. For example, I have a BMI of about 27 but I use CAPAP because I have a palate deformity that narrows my airway.
Fortunately, over 80% of our patients with obesity related obstructive sleep apnea will have resolution of this problem.
Does anyone have any further questions about this? Feel free to post a coment or ask a questiion
by clicking on the word "comment" at the end of this posting.
Monday, February 15, 2010
How will bariatric surgery affect my pregnancy?
The fact is bariatric surgery is likely to make pregnancy safer for both mother and baby. Obesity increases your risks of developing medical problems such as pregnancy related diabetes and serious blood pressure problems. Obesity also increases the likelihood that you will have an abnormally large baby that may make delivery more difficult. There is now good evidence that you can decrease the risk that you will develop pregnancy related diabetes, called gestational diabetes, by about 50% after you lose much of your weight after bariatric surgery. Studies have also shown that you can reduce your risk of developing pregnancy related blood pressure problems by more than 50%. This is great news for both mom and baby!
Also birth defects, problems with the placenta and low birth scores, called Apgar scores, are NOT any more likely after bariatric surgery.
You are also likely to gain less excess weight when you are pregnant and therefor you are likely to get back to the dress size you were in prior to the pregnancy more quickly and easily!
I suggest you do not become pregnant during the first year after bariatric surgery since I would not want you to subject the baby to the weight loss you will experience. Be careful to use adequate birth control measures since it is likely it will be easier for you to become pregnant soon after bariatric surgery since your ovaries will no longer be suppressed from the high amount of hormones your obesity was putting into your blood stream. Of course some women are even referred to me specifically to have bariatric surgery so they are more likely to become fertile.
You should be careful to take care of yourself during your pregnancy by taking the vitamins that are prescribed every day and by gaining the appropriate amount of weight during the pregnancy. Your doctor is likely to check your vitamin levels during your pregnancy and will check your blood count and iron levels.
Finally, it is important that you understand that your pregnancy is likely to be healthier no matter which operation you choose. There is no evidence that any one operations is better than another.
Also birth defects, problems with the placenta and low birth scores, called Apgar scores, are NOT any more likely after bariatric surgery.
You are also likely to gain less excess weight when you are pregnant and therefor you are likely to get back to the dress size you were in prior to the pregnancy more quickly and easily!
I suggest you do not become pregnant during the first year after bariatric surgery since I would not want you to subject the baby to the weight loss you will experience. Be careful to use adequate birth control measures since it is likely it will be easier for you to become pregnant soon after bariatric surgery since your ovaries will no longer be suppressed from the high amount of hormones your obesity was putting into your blood stream. Of course some women are even referred to me specifically to have bariatric surgery so they are more likely to become fertile.
You should be careful to take care of yourself during your pregnancy by taking the vitamins that are prescribed every day and by gaining the appropriate amount of weight during the pregnancy. Your doctor is likely to check your vitamin levels during your pregnancy and will check your blood count and iron levels.
Finally, it is important that you understand that your pregnancy is likely to be healthier no matter which operation you choose. There is no evidence that any one operations is better than another.
Saturday, February 13, 2010
Today I was thinking...
This morning I gave another Fresh Start seminar to prospective patients. I do this about 3-4 times a month and there are always interesting questions from the audience at the end. Today I met a delightful young woman who said, "I had a 'Gastric Stapling Procedure' back in the 1980s and I have gained my weight back. Am I was still a candidate for a Laparoscopic Gasstric Bypass?"
The procedure that is popularly known as "gastric stapling" is technically a vertical banded gastroplasty. This was an early attempt of Dr. Ed Mason in at the University of Iowa to help persons of size resolve their obesity and was used by many surgeons for a great many patients. The operation helped patients loose about 35% of their excess weight but the frequency of recurrence of obesity was very high. The operation created a small pouch of stomach below the junction of the esophagus and stomach with staples but left a small opening between the pouch and stomach open. A non-adjustable "band" was placed around this opening in an attempt to keep the opening from getting bigger. Unfortunately the band often failed to keep the restriction needed and would allow too much dilation over time. Also, since the pouch was in continuity with the rest of the stomach, any food that passed through the opening had no restriction and was absorbed normally. Of course, high calorie liquids would run right through the opening and would thwart the weight loss process and the patient could gain weight again. Also since the part of the stomach that produced the hormone, ghrelin, that makes us hungry for breakfast, lunch and dinner as not excluded from the flow of nutrients patients experienced no decrease in hunger. Also, since there was no opportunity to adjust the outlet of the pouch many patients did not feel restricted or their sense of restriction eventually went away and their obesity returned.
I told her, "Please do not 'beat up' on herself for gaining back her weight after the 'gastric stapling' because it was not a very successful operation and has been abandoned by nearly all bariatric surgeons since we have better techniques today." This was not a long term solution for most patients that had this procedure and as far as I am concerned I feel "failure" is nearly inevitable because it is the operation that failed the patients.
I further explained, "You can be converted to a Roux en-Y Gastric Bypass and usually I can do the operation laparoscopically even though your first operation was done open through a large incision." I have found this revision to be nearly as successful as the usual gastric bypass operation and have been very fortunate to have few complication after doing this revision but the risk of complications such as a staple line leak are reported as higher than if this was the first operation on the stomach.
She was excited about this possibility and is looking forward to starting the process. I feel she has every right to feel this revision could help her find a better long term solution for her obesity and I would be honored to be part of her transformation.
The procedure that is popularly known as "gastric stapling" is technically a vertical banded gastroplasty. This was an early attempt of Dr. Ed Mason in at the University of Iowa to help persons of size resolve their obesity and was used by many surgeons for a great many patients. The operation helped patients loose about 35% of their excess weight but the frequency of recurrence of obesity was very high. The operation created a small pouch of stomach below the junction of the esophagus and stomach with staples but left a small opening between the pouch and stomach open. A non-adjustable "band" was placed around this opening in an attempt to keep the opening from getting bigger. Unfortunately the band often failed to keep the restriction needed and would allow too much dilation over time. Also, since the pouch was in continuity with the rest of the stomach, any food that passed through the opening had no restriction and was absorbed normally. Of course, high calorie liquids would run right through the opening and would thwart the weight loss process and the patient could gain weight again. Also since the part of the stomach that produced the hormone, ghrelin, that makes us hungry for breakfast, lunch and dinner as not excluded from the flow of nutrients patients experienced no decrease in hunger. Also, since there was no opportunity to adjust the outlet of the pouch many patients did not feel restricted or their sense of restriction eventually went away and their obesity returned.
I told her, "Please do not 'beat up' on herself for gaining back her weight after the 'gastric stapling' because it was not a very successful operation and has been abandoned by nearly all bariatric surgeons since we have better techniques today." This was not a long term solution for most patients that had this procedure and as far as I am concerned I feel "failure" is nearly inevitable because it is the operation that failed the patients.
I further explained, "You can be converted to a Roux en-Y Gastric Bypass and usually I can do the operation laparoscopically even though your first operation was done open through a large incision." I have found this revision to be nearly as successful as the usual gastric bypass operation and have been very fortunate to have few complication after doing this revision but the risk of complications such as a staple line leak are reported as higher than if this was the first operation on the stomach.
She was excited about this possibility and is looking forward to starting the process. I feel she has every right to feel this revision could help her find a better long term solution for her obesity and I would be honored to be part of her transformation.
Thursday, February 11, 2010
Dr. Myers, how can I minimize my hair loss after bariatric surgery?
We normally lose about 200 hairs a day. After significant rapid weight loss, whether by surgical, dietary or medical intervention, a person is likely to experience more hair loss between the 4th month and 6th month. The hair loss is not likely to continue much past the 6ht month mark after surgery and the hair follicles will regenerate after that time.
At Fresh Start Bariatrics we suggest the following to minimize hair loss:
1). Make sure you get in the necessary dietary protein every day. That is 60 grams daily for women and 80 grams for men.
2). Take at least 3 mg (3000 mcg) of Biotin each day and start it long before your operation. In fact I recommend you start it as soon as you start thinking you want to have bariatric surgery. This was recommended to our patients by a dermatologist that is a friend of mine. Biotin is an over the counter vitamin that strengthens your nails and hair. You may know people that take biotin just to make their hair thicker.
3). Finally, if your hair loss is bothersome to you consider a naloxone scalp treatment at your hair dressers or a local spa. This is supposed to rejuvenate the scalp. I know the spa at the Macy's department store at Easton here in Columbus, Ohio has this available and does a great job for our patients.
If you are doing these things you are doing the best you can for your hair. Probably all weight loss surgery patients experience some hair loss but most of our patients do not seemed to be bothered by it if they have stayed on this plan. Hope this helps.
At Fresh Start Bariatrics we suggest the following to minimize hair loss:
1). Make sure you get in the necessary dietary protein every day. That is 60 grams daily for women and 80 grams for men.
2). Take at least 3 mg (3000 mcg) of Biotin each day and start it long before your operation. In fact I recommend you start it as soon as you start thinking you want to have bariatric surgery. This was recommended to our patients by a dermatologist that is a friend of mine. Biotin is an over the counter vitamin that strengthens your nails and hair. You may know people that take biotin just to make their hair thicker.
3). Finally, if your hair loss is bothersome to you consider a naloxone scalp treatment at your hair dressers or a local spa. This is supposed to rejuvenate the scalp. I know the spa at the Macy's department store at Easton here in Columbus, Ohio has this available and does a great job for our patients.
If you are doing these things you are doing the best you can for your hair. Probably all weight loss surgery patients experience some hair loss but most of our patients do not seemed to be bothered by it if they have stayed on this plan. Hope this helps.
Today I was thinking...
Among the 30 plus patients I saw in the office today was a wonderful couple who are supporting each other in their journey for better health through weight loss surgery. I operated on both the husband and wife last September (2009) just 2 weeks apart and are about 5 months out from surgery. They have already lost between 60 and 90 lbs each since surgery and much more since they began the Fresh Start Bariatrics program. They are both doing very well and are delighted with their progress. I am so impressed at how they encourage each other and look out for each other. They are both great examples and are taking advantage of all the program has to offer. It is so important to have a good support person as you go through this jouney. Their faith is important to them and is evident in how they treat each other and others here in the office. I told them I am excited to see where they are in their transformation next September one year after surgery!
Wednesday, February 10, 2010
Today I was thinking...
Being a bariatric surgeon is a very special privilege. The patients are so very grateful for the work I do for them. Last night I went to the hospital in the evening to see one of my patients. Her brother was there with her and I recognized him as one of my patients! I had performed laparoscopic gastric bypass on him 2 years ago and he has lost 160 pounds. He is very happy with his result and looks great. You would never know he had been heavy in the past. He was so thankful and it made me very pleased to be doing what I do. My patients are not just "patients" they often become very special friends and often feel like family. Their effort to become healthier inspire me to keep helping persons of size. A bariatric surgeon is not just a surgeon that does weight loss surgery. We are different than many surgeons since we are involved in our patients lives for many years and help with a lot of their medical care, probably much more than most surgeons. Sometimes it seems we are both surgeon and family doctor for a while. We get very close to our patients. There is nothing I would rather be doing at this time of my life. I am now 57 years old and I think this is the most fun I have had in my career. I just love it. It feels like I was made to be a bariatric surgeon. I will say it again. Being a bariatric surgeon is a very special privilege.
What implication might bariatric surgery have on my bowel function?
This is a question that is often asked of me. Constipation is most likely to occur in the case of the three most common bariatric operations; Rou en-Y gastric bypass, adjustable gastric band and gastric sleeve operations. This is most likely to happen early after surgery for 2 reasons. First, taking pain meds that contain narcotics such as Percocet or codeine causes the bowel to slow down and stool to become hard and dry. Secondly, soon after surgery you are consuming very little fiber. Treatment is relatively simple.
1). Stop all narcotics if possible
2). Take Miralax for immediate relief
3). Take Benefiber, which can be added to all of your fluids since it is dissoluble. Your goal is to take 25 grams of fiber each day. This may seem to be a truck load of Benefiber but eventually some of your fiber will come from other sources of food.
4). You may want to add over-the-counter Colase 100 mg twice daily.
If you follow this plan you should not have further problems with constipation.
Some other operations such as BPD with or without duodenal swith, long limb gastric bypass and the antiquated JI bypass are much more malabsoptive and will cause chronic diarhea.
1). Stop all narcotics if possible
2). Take Miralax for immediate relief
3). Take Benefiber, which can be added to all of your fluids since it is dissoluble. Your goal is to take 25 grams of fiber each day. This may seem to be a truck load of Benefiber but eventually some of your fiber will come from other sources of food.
4). You may want to add over-the-counter Colase 100 mg twice daily.
If you follow this plan you should not have further problems with constipation.
Some other operations such as BPD with or without duodenal swith, long limb gastric bypass and the antiquated JI bypass are much more malabsoptive and will cause chronic diarhea.
Tuesday, February 9, 2010
Today I was thinking about...
Today was a good day for our patients. This morning I arrived late because of the snow, but we were able to do a laproscopic Gastric Sleeve operation on one of our patients and a laproscopic Gastric Bypass on another. After seeing my other patients at the hospital and meeting with the Statistician about some research, I was able to brave the snow once again and get to the Fresh Start Office to see the Post-Op patients that were operated on last week. They are all doing very well and it is so exciting to be a part of their journey. One patient is a diabetic who used to be on over 100 units of insulin a day. And now one week after his operation he is on no insulin and his blood sugar no longer requires any insulin or other diabetic medication. As he continues to lose the weight, it would be wonderful is he no longer needed diabetic medication. How cool is that?!The office is over now and I must brave this storm to get home to my precious wife. Hope to post again tomorrow after more operations.
"Am I a candidate for bariatric gastric bypass or other weight loss surgery options?"
People with BMI values over 40 are potential candidates for bariatric surgery. People with obesity-related medical problems such as diabetes, high blood pressure and obstructive sleep apnea may also meet the criteria for bariatric surgery, if they have a BMI between 35 and 40.
"What dietary instructions or suggestions do you have for lap band patients to assist with their success?"
I have found that it is extremely important for lap band patients once they are adjusted properly, to eat primarily solid food and drink non-caloric beverages. Any liquid beverages that have calories in them actually thwart the work of the band. For instance, milk, ice cream, yogurt and fruit juices are high caloric beverages. In addition, soups, especially cream soups are very high in calories. Therefore, all of these calorie containing liquids should be avoided. I suggest my patients to drink water, tea with sweetener, and crystal light, for other liquids. And should always eat solid food, with an emphasis on protein to begin each meal. Liquid should be taken between each meal. One area that is often not considered is the milk that is in a latte. This also is a high caloric liquid and should be avoided.
The good news is that there are a lot of good foods Lap Band patients can eat it is just that high calorie drinks will work against the procedure.
The good news is that there are a lot of good foods Lap Band patients can eat it is just that high calorie drinks will work against the procedure.
Monday, February 8, 2010
Why are some patients choosing to have a Gastric Sleeve Procedure?
The Gastric Sleeve Procedure is an operation that has been around for about seven years and we have found it to be a very successful operation. At Fresh Start Bariatrics we have proformed over 100 Gastric Sleeve Procedures. Often patients would pefer not to be concerned with vitamin and mineral difficiencies after a Gastric Bypass Operation. Since the small intestine is not effected by a Gastric Sleeve operation, there is less concern regarding absorption of vitamins and minerals. Also, many patients choose to have a Gastric Sleeve operation because they would like to avoid any potential complications from the placement of an adjustable Gastric Band. In our practice, now approximately 20% of patients choose to have a gastric sleeve procedure. We have found that their weight loss is very similar to the results of the Gastric Bypass operation.
"Which Operation do I choose to resolve my Type 2 Diabetes?"
This question comes up often when a new patient is interested in the Fresh Start Bariatric Program. At least 25% of our patients have Type 2 Diabetes. If your goal is to resolve Type 2 Diabetes, the most effective tools is a Roux en-Y gastric bypass. In fact 95% of patients that have had Type 2 Diabetes for less then 5 years, will have no evidence of Type 2 Diabetes following this operation. A gastric sleeve procedure is somewhat less effective and an adjustable gastric band operation is even less effective in resolving Type 2 Diabetes. Overall, 84% of patients who have Type 2 Diabetes have remission of their diabetes.
Welcome!
I have developed this blog to help people to get their very best result from Bariatric Surgery. I have performed over 700 successful bariatric operations and would like to share with you many of the lessons I have learned from my patients and my experience doing bariatric surgery.
Whether you choose to have a Gastric Bypass operation, a gastric-sleeve procedure, or an adjustable gastric band, there are unique things you need to know to help you get your best result. Each operation can help patients resolve their medical problems, but some operations are better for particular issues.
If you have had a bariatric surgery, are interested in having the surgery, or you are a supportive family member or friend, this blog can help you in your quest for success.
Through out this blog you are welcome to ask questions and I will do my best to give you as much information as possible. Sometimes I will begin with a question that I have heard from one of my patients.
I am excited to be of assistance to as many people as possible. It has been a real privilege for me to be involved in the journey for patients to loose weight and become healthier by way of Bariatric Surgery.
Whether you choose to have a Gastric Bypass operation, a gastric-sleeve procedure, or an adjustable gastric band, there are unique things you need to know to help you get your best result. Each operation can help patients resolve their medical problems, but some operations are better for particular issues.
If you have had a bariatric surgery, are interested in having the surgery, or you are a supportive family member or friend, this blog can help you in your quest for success.
Through out this blog you are welcome to ask questions and I will do my best to give you as much information as possible. Sometimes I will begin with a question that I have heard from one of my patients.
I am excited to be of assistance to as many people as possible. It has been a real privilege for me to be involved in the journey for patients to loose weight and become healthier by way of Bariatric Surgery.
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