How do you think a gastric bypass helps to resolve Type II Diabetes?

Over 80% of Type II Diabetics show no evidence of diabetes after a gastric bypass operation. If a person has had diabetes for less than 5 years 95% of these people have no evidence of diabetes after this operation. Although we are still working out the reasons why this occurs, I believe Diabetes is improved or resolved in a three staged sequence.

1). Early after the operation carbohydrate intake is minimal so the glucose level remains low. In fact in our practice I have patients on a very low carbohydrate diet for 1 to 2 weeks before surgery and frequently they no longer need their diabetic medicines even before surgery as long as they continue to consume very few carbohydrates. The reduction in the amount of carbohydrates consumed is clearly an important component in this process that continues even after their operation since it takes several weeks or a few months for the amount of carbohydrate a person consumes increases and stabilizes at a new lower amount.

2). A second component that helps the diabetic is the hormone change that occurs after a gastric bypass. Probably the most important of these changes is the increase in a hormone like substance from the last part of the small intestine and the first part of the large intestine called GPL-1 (Glucagon Like Polypeptide-1) which increases the amount of insulin a gastric bypass patient sends into the blood stream from their pancreas. This begins immediately after the operation and is part of the reason that most diabetics do not need further diabetic medicines by the time they leave the hospital after their operation.

3). Finally, since obesity is the most important reason most of our patients develop diabetes, losing weight and keeping it off decreases the obesity and the patients lose their resistance to insulin. Therefore the amount of insulin they are able to make is enough to keep their glucose in the right range. Unlike the previous two components that decrease the blood sugar right after surgery this component takes time to show the beneficial effect of weight loss but by the time the patient is able to consume a more normal amount of starch and sugar he or she has lost enough weight to no longer need their diabetic medicines because of the loss of insulin resistance from the resolution of their obesity. This is why with some patients we need to slowly decrease the amount of diabetic medicine they are on over several weeks or even a few months.

It is important to understand that not everyone will have resolution from their diabetes. About 15 to 20 percent will still need to be on some diabetic medicines after a gastric bypass operation. The longer a person has type II diabetes the less likely it is that they will resolve their disease. However I have seen some patients resolve their diabetes after a gastric bypass operation even after 10 or 15 years of diabetes. Nevertheless even if the diabetes is not completely resolved it is much easier to manage and usually a person needs to be only on a pill they can take by mouth and they will not need to take insulin shots.

Recently I have been hearing from our patients that their endocrinologist is encouraging them to investigate bariatric surgery early after a new diagnosis of type II diabetes so it is more likely that they will resolve the disease instead of waiting for years until they have sustained injury to other organs. This is an amazing change in the attitudes of endocrinologists and I believe it represents a great opportunity for people with diabetes.

And to think I have the privilege of helping people in this way! How cool is that?

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Gastric Sleeve Operation, New Report and Dietary Issues

J Am Diet Assoc. 2010 Apr;110(4):600-607.
Nutrition Care for Patients Undergoing Laparoscopic Sleeve Gastrectomy for Weight Loss.
Snyder-Marlow G, Taylor D, Lenhard MJ.

Laparoscopic sleeve gastrectomy (LSG) is a bariatric surgery in which 60% to 80% of the stomach is removed longitudinally, resulting in a smaller stomach that takes the shape of a "sleeve." The mechanism for weight loss is gastric restriction and possible neurohormonal changes resulting from lower levels of ghrelin (an appetite-stimulating hormone), as a consequence of removing the gastric fundus. LSG may be more desirable than laparoscopic adjustable gastric banding because there is no foreign object inside the abdomen and no need for postsurgery appointments to adjust the band. LSG may be preferred over Roux-en-Y gastric bypass (RYGB) because LSG is a less complicated operation that does not result in dumping syndrome or malabsorption, yet weight loss is comparable to RYGB. While LSG is suggested to have advantages over the commonly performed laparoscopic adjustable gastric banding and RYGB, there are no long-term (>5 years) outcomes and few studies specific to nutrition care for LSG patients. This article will present a protocol for pre- and postsurgery nutrition care for LSG and the important role the registered dietitian plays in the multidisciplinary team. Postsurgery diet progression from liquids to solids during 6 to 8 weeks should focus on meeting protein and fluid needs. In addition, LSG patients are at risk for nutrient deficiencies due to decreased hydrochloric acid and intrinsic factor from removed parietal cells and reduced dietary intake due to decreased ghrelin levels. Therefore, LSG patients should take daily micronutrient supplements, including vitamin B-12 and potentially supplemental iron, to prevent deficiencies. Copyright © 2010 American Dietetic Association. Published by Elsevier Inc. All rights reserved.

Single Incision Laparoscopic Surgery, SILS, is another way to do laparoscopic surgery but may not add value.

Today I spent the day at Ohio State University at a conference about performing Single Incision Laparoscopic Surgery, also referred to as SILS.

Over the last three years I have been involved in the development of SILS technology as well as technology to perform surgery using natural orifices such as the mouth, vagina or rectum without making incisions in the skin at all. So using new devices to perform laparoscopic surgery through a single fairly small incision is not new to me. But it did start me thinking about how much value there is to this technique.

The transition from open operations using a single large incision was the only way operations were able to be done until the late 1980’s. Then surgeons began to do operations through several very small incisions by using a scope with an attached camera called a laparoscope with the image projected on a TV screen. Today most bariatric operations are performed using the laparoscopic approach. In fact in my practice I do nearly all the bariatric operations using a laparoscopic approach and do an open operation for bariatric surgery only a couple of times a year.
This revolution from large incisions to laparoscopic surgery brought with it a tremendous amount of added value to our patients. In bariatric surgery this technique results in less pain, less infections at the incisions, less risk of hernia in the incisions, better cosmetic results and earlier return to work to mention a few of the benefits. There is no argument today that laparoscopic bariatric surgery has resulted in better outcomes.

The question is whether a Single Incision Laparoscopic Surgery adds additional value beyond the present standard laparoscopic approach.

In the SILS approach a single incision, usually about one and a half inch in length, is made in the skin and in the muscle layer of the abdomen. One of several devices is inserted into this incision that allows all of the instruments needed in the operation to be passed through the device. After the operation is completed, the incision through the muscle layer of the abdomen is closed with stitches as is the skin layer.

Surgeons are constantly looking for ways to perform surgery that adds value for our patients. However, although this technique is a very legitimate way to do an operation we must ask ourselves whether this adds value to our patients or not. It does not result in less pain, less risk of infection, and may increase the risk on a hernia forming in the incision since a larger incision is made in the muscle layer of the abdomen.

About the only possible added benefit to the patient is a better cosmetic result and this may only occur if the operation is done through the belly button, (which surgeons call the umbilicus).

Let’s call “a spade a spade”. The biggest benefit may be for the surgeon to “market” his practice. There does not appear to be a significant value to the patient at this time. I think it is very legitimate to offer this option to patients in select situation and I will offer this option to my patients that I think might be interested. However, this should only be offered as long as it is not touted as adding a lot of value to the patient and any additional risks are explained.

It is a wonderful privilege to have our patients trust us to do the best on their behalf. Surgeons must make sure we are honest and transparent in how we present these options to our patients. Our Hippocratic Oath binds us to “first do no harm”. Marketing should not drive these decisions.

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I have now lost about 90 lbs since my bariatric operation and recently I noticed pain in my tailbone. Could this be related to my weight loss?

Yes! It is very likely to be a result of your weight loss. Before you lost your weight from bariatric surgery your “tail bone”, which doctors call your coccyx, is protected by the fatty tissue at your bottom. Now that you do not have this protection your coccyx is being irritated by the chair you are sitting on and is repeatedly traumatized day after day. This is like having arthritis of the “tailbone” and is called coccydynia.

This does not happen to everyone because it depends on a person’s anatomy. If the coccyx is high enough to be above the pelvic bones on either side, the “tailbone” is not bothered. However if it is lower than the pelvic bones on either side it is likely to touch the chair or whatever you are sitting on and become uncomfortable.

In my practice I have someone with this complaint about once every other month. Usually they have already tried changing chairs and cushions but continue to complain about the pain. In my opinion the best therapy for this problem is a steroid injection at the coccyx. I use Kenalog and local anesthesia and do the injection in the office. It only takes a few seconds. Patients feel better almost immediately because of the local anesthetic in the injection but the discomfort returns in an hour or so. This shows that the medicine was placed in the correct location. Usually the pain will slowly improve over the following few weeks and will eventially be gone completely. The steroid will continue to do its work for about three months. Often the discomfort will not return after this injection.
I hoe this is helpful.

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Am I able to take extended release medicines after my bariatric operation?

Patients that choose an adjustable gastric band or a gastric sleeve operation should still be able to absorb any medications prescribed since there has not been any changes in the small intestine. With the gastric sleeve procedure the stomach has been reduced in size and anything that is ingested may leave the stomach faster that prior to surgery but I doubt that this will be a significant problem with medicines. Therefore I do not recommend any changes in medications for people that choose to have either of these two operations.

However, patients that have a gastric bypass are choosing an operation that essentially allows the medications that are taken by mouth to pass directly into the small intestine. The time it takes to pass through the mouth through the small gastric pouch, through the available length of small intestine and into the large intestine, (also called the colon), is about 45 minutes. That will be fine for medications that are in a regular form since the small intestine is so efficient in absorbing these medications. However medicines taken in some forms will be effected by this change.

There are many ways the drug companies have made taking medicines easier for us. For instance, medications are sometimes “wrapped” into a pill that releases medications in two stages hours apart or in other preparations the medicine is released very slowly over several hours so a person only has to take the medicine once a day and instead of several times a day.

Unfortunately, to get all the medication that is in these extended release pills a patient needs a stomach that stores at least some of the medicine for a few hours slowly sending the medication out of the stomach a little at a time. The combination of an intact stomach and a small intestine that is of full length results in several hours between swallowing the pill until it would reach the large intestine. This allows extended release medications to work so they can slowly release the medicine over a long time.

A gastric bypass shortens the time so much that the person only has time to have the first part of the medicine released. Anything that would be released after 45 minutes is no longer available for absorption because the pill is likely to already be in the colon by that time.

A gastric bypass patient may be paying more for a specially designed extended release medicine but only absorbing half of it. You are probably just wasting your money and not benefiting as much as you should from extended release medicines.
Therefore I recommend that my patients avoid extended release medicines and take the medicines in a non-extended release form.

For example, Toprol is an extended release form of Lopressor, (metoprolol). You may have taken Toprol XL 100 mg prior to your gastric bypass operation. If you continue to take Toprol XL 100 mg daily after your operation you are likely to only absorb the first half on the pill and since Lopressor is a 12 hour medicine you are likely not to have the appropriate amount of medicine for the second half of the day. Therefore I would suggest that you change from the extended release form to the regular form of metoprolol and have your doctor prescribe it as Lopressor 50 mg twice a day.

In fact, I would suggest that you always ask your doctor about each of your medicines and ask to have the non-extended release form. Primary care doctors and psychiatrists may or may not be aware of these issues and you as the patient must remember to inform them of your new changes and request that the medicines that are prescribed for you are in the correct form.

This goes for over the counter medicines as well.. Read the labels and make sure the medicines are not extended release or delayed release medications. Ask your pharmacist if you are not sure.

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Dr. Myers, how do patients that had a gastric bypass do several years after surgery? (Before and After Pictures)

Although it is clear patients lose alot of weight over the first year after having a gastric bypass, I was recently asked how patients do several years after surgery. I recently saw Twila at the time of a routine follow up visit and sh wanted to share her story with patients that are curious about the long term outcome after surgery. I follow our patients for life as long as they are willing to have our practice involved with there care. Each year we make sure they maintaining their weight at a reasonable level and to make sure their vitamin levels and other labs are normal. Twila is doing great and had encouraging lab results. This is what she wanted you to know:

"My name is Twila Senters and I had bariatric surgery Jan 16th 2005
I am doing great keeping my weight off, I started at 273lbs and I now weight 132lbs. I now have more energy, I dont come home and sit in my chair until bedtime now, I dont even have a chair now. I am always doing something, before surgery you could not get me out of the chair until bed time and the next day would be the same , work, home to chair and bed. and all of that has changed for the better. I never stay home if there is something to do, which there always is."

This result is not unusual for patients several years after surgery. In fact it is very unusual in our practice for patients not to do well long term. That is what this blog is really about. I am trying to share with everyone how they can obtain their very best result regardless of where they choose to have surgery. I believe the princilals we are sharing can help anyone be more sucessful. There is alot of noise and errors shared on the internet and although what I say others may disagree with, Our patients are doing extremely well and are very happy with their outcomes. This is not because I am a better surgeon. I believe it is the principals we teach our patients that meke the difference.
I just hope the effort I am making to share this will help more patients to do well.

Should I avoid Non-Steroidal Anti-Inflammitory medicines after my bariatric operation?

The short answer is it depends on which operation you have chosen.

This class of drugs included Ibuprofen, Naprosyn, Motrin, Aleve, Meloxicam, Mobic, Celebrex and several other medicines. Asprin has some similar side effects of gastric irritation.

I do not know of any reason why patients that choose to have an adjustable gastric band or a gastric sleeve operation should not take these medicines. However I believe that a gastric bypass patient should avoid these medicines for life if at all possible.

In general patients that have an adjustable gastric band or a gastric sleeve procedure may take these medicines. Of course there are risks of a gastric ulcer, bleeding or cardiovascular risks but that is the same as for people that do not have a bariatric operation.

For gastric bypass patients I suggest they avoid all of these medicines for life unless it is really medically necessary.

That is because these all can cause ulceration in the gastric pouch which may result in scarring and narrowing at the connection between the gastric pouch and the small intestine. This can result in vomiting and may require dilation of the narrowing by a special balloon during an endoscopy, (passing a scope into the through the mouth into the stomach).

Let me tell you a story to demonstrate what I mean. Several years ago I had someone who had a gastric bypass operation a few years before in Colorado. She returned to Ohio where her family lived and came into our emergency room with complaints of vomiting. She had also lost a lot of additional weight over recent weeks and she looked dehydrated as well. She had been taking a few Naprosyn tablets daily for pain in her knees. She told me no one had told her she should not take non-steroidal anti-inflammatory medicines. I admitted her to the hospital and looked into her gastric pouch with a scope the following day, I found that she had a very small opening that a pencil point could not even go through. I was able to pass a guide wire through and into the small intestine and then passed a dilating balloon across the narrowing. After inflating the balloon I was able to dilate this area. She did well for a few days but soon this narrowed again. I dilated the area again only to have it narrow again a few days later. Eventually I had to take her to the operating room to make a completely new connection between the gastric pouch and the small intestine.

Also this ulcer may cause very significant bleeding and even perforation with leakage of gastric contents into the abdomen requiring an emergency operation.
For all of these reasons I strongly suggest that these medicines be avoided after a gastric bypass operation.

When I tell people this at the Fresh Start Seminar they frequently ask what other suggestions do I have to help them with their joint and back pain. First, I tell them that most people will not need these medications after they lose their weight from bariatric surgery. This of course will decrease the weight on their joints and relieve much of the pressure. Usually our patient lose about 60 lbs in the first three months after bariatric surgery so the feel much better shortly after their operation. Secondly that have access to pain medicine after surgery such as Percocet or Vicodin for a little while. Sometimes I will suggest Ultracet or extra strength Tylenol. Occasionally someone will need to be on a Fentanyl patch for a few weeks or see a sports medicine doctor or orthopedist for a steroid injection. Finally, if the pain is too limiting for them I will agree to place then of Celebrex at about 3 months after their operation but they are informed there is still a risk of these problems even with Celebrex.

I am sure that other bariatric surgeons may feel differently about these matters but this is how I have chosen to instruct our patients and I find that it keeps them from having problems after their operation in they follow these directions.
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I asked the Fresh Start Bariatrics dieticians, Joann Schaumb and Alyssa Bixler, what they recommend for patients preparing for bariatric surgery.

"This is a very key topic! These comments are an initial response. We will share more later.

I think it is helpful to have people practice before surgery, eating the types of foods they will need to eat after surgery. I like to work together with clients to find foods that they like well enough to eat regularly instead of the high fat, high sugar choices they may have enjoyed in the past. This takes some trial and error, particularly in restaurants. It is important though, because people eat what they like. To achieve long term weight loss, they need to like lower calorie foods. It may seem hard, but we are usually able to help people find these foods.

When you focus on what to eat instead of what not to eat, it puts you in a more positive frame of mind and healthy eating becomes easier. We like to help people build confidence in their ability to enjoy healthy foods.

One of the most challenging goal on our pre-op list of goals is eating small, frequent meals. People are very busy and don't always think about eating much during the day. The typical American pattern is to eat very little or nothing through the early part of the day and consume most of the calories late in the day. This pattern leads to weight gain. Stomach capacity is limited after surgery, so we strive for high quality, nutritious foods. Every bite contributes to good health.

It is helpful to plan specific times for snacks and meals and design reminders, like setting a cell phone to beep when it is time for a snack.

It is very important to drink calorie free beverages. We recommend some weight loss prior to surgery and this is a very effective way to achieve that. Liquid calories are generally not satisfying. When you drink calories, you still eat the same amount of food, so total calorie intake is higher and leads to weight gain.

Replace liquid calories with calorie free drinks such as Crystal Light, Powereade Zero, Decaf coffee or tea, diet juices, diet flavored water or water with lemon."

I think their recommedations are terific and this is a great start to help people what changes would be helpful to make before surgery!

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New!! Fresh Start Bariatrics Video Blog!

Come visit Fresh Start Bariatric new video blog at:

www.freshstartbariatricvideoblog.blogspot.com

Here is what you can find on the video blog:

- Rounds. Dr. Myers doing his rounds to interviewing patients in the office and hospital
- Meet the Team. Meet the entire Fresh Start Bariatrics team that you will work with if you go through the Fresh Start Bariatrics Program at Riverside Methodist Hospital. Also includes Bloopers of the Team members!
- Before and After Pictures (Coming soon!)
- Much more information about procedures, patients experiences, and more!

Dr. Myers, am I likely to need to have access skin removed after bariatric surgery?

This is an important question that I have asked of me often at the seminars I give several times each month. Most patients from our practice do not feel they need plastic surgery. However, as a person increases their weight their skin does not just stretch, they actually grow more skin in response to the pressure the increasing weight has on the skin. That means after weight loss there is the same amount of skin but less beneath the skin to fill out the space. Therefore most patients have some excess skin after losing their weight from bariatric surgery. For many patients this is not bothersome and they will not feel the need to have this skin removed surgically.
However, the more weight you have to loose, the more likely you will have enough excess skin that you might like to have removed. Also, aging and a history of smoking seems to correlate with the need for plastic surgery. Finally, if you carry allot of your weight around your abdomen you may want to have the extra skin removed since the fatty tissue will be gone leaving an “apron” of skin.
People have different reasons for having plastic surgery. Some patients have skin irritation or ulceration of the skin. These are medical reasons to have the excess skin removed and usually this will be covered by your health insurance plans. I suggest that you document these problems by taking photos since your plastic surgeon can use this information to request your health insurance company cover your plastic surgery operation.
Sometimes plastic surgery is primarily to look better. This is often called cosmetic surgery and the expense may not be covered by health insurance. Regardless this should be an individual decision. I suggest that my patients wait until they have lost most of the weight they expect to lose before they consult with a plastic surgeon. Usually this is at least one year following bariatric surgery.
But keep in mind that most people have bariatric surgery for their health. I have never had a patient say they wish they had not had bariatric surgery because they have excess skin.
Our program refers patients to 3 or 4 plastic surgeons. I saw Dr. John Wakelin in the operation room at Riverside Methodist Hospital today and asked him to give us his thoughts from the a prospective of a plastic surgeon. This is his response to my request:

“It's very common for people to have Plastic Surgery after losing weight. Skin normally has elasticity, which allows it to shrink back to its normal size and shape after it has been stretched small amounts. This is most noticeable in young people when you pull on their skin and watch it go back to normal. However, when skin is stretched beyond a certain point for a prolonged period, like when someone is overweight, it can lose its elasticity and not spring back to its normal shape.

The excess skin caused by weight loss often sags and hangs, creating an undesirable contour and/or other problems. This is most common on the abdomen. Other common areas of skin excess are the upper arms, thighs, the buttocks and back, and neck. In addition, both men and women frequently have large amounts of excess skin on the breasts after weight loss. Each of these areas can be troublesome for many people. Beyond the cosmetic effects of this excess skin, some people have difficulty with rashes and sometimes even skin infections. Most people also have difficulty managing their excess skin with clothing, since the excess skin might not fit into clothes desirably.

Thankfully there are operations that are designed to remove this excess skin and restore contour to various parts of the body affected by excess skin after weight loss. These operations can remove skin and reshape the abdomen (abdominoplasty), the thighs (thigh-plasty or thigh lift), the buttocks (posterior body lift), arms (brachioplasty), and breasts (mastopexy or breast lift). Some patients also find that a facelift and/or neck lift procedure can restore shape and youth to sagging skin on the face and neck.”

If you would like further information you could contact Dr. Wakelin directly.
John K. Wakelin, M.D., F.A.C.S., Columbus Aesthetic and Plastic Surgery, Inc., 614-246-6900

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Why do you feel patients that are above a BMI of 55 should lose weight to get to that level prior to surgery?.

First, there is good evidence that risks of bariatric surgery increase as the BMI increases. Having the patient reduce their weight to a BMI of 55 is one way to decrease many of those risks. My plan is that my patients have an uncomplicated recovery after surgery. I do not want to have patients in the ICU on ventilators and have other problems. This is by far the most important reason to reach a BMI of 55 prior to surgery.
Secondly, the result will be much better. I have spoken to many people that had bariatric surgery when they had a BMI over 55 at the time of their operation. They often express disappointment in their overall outcome. They had lost 150 to 200 lbs but they still weighed 300 to 400 lbs and still had many of the medical problems they had hoped to have resolved. They assumed that once they had bariatric surgery they would lose their excess weight and reach a weight close to their ideal weight. Unfortunately, the fact is that even if they chose a Roux en Y gastric bypass for their operation, a gastric bypass operation usually results in about 150 to 200 lbs weight loss at the maximum. Therefore the operation is not designed to deliver the 300 to 400 lbs of weight loss they needed.
I have helped many people lose weight to reach a BMI of 55 or less prior to surgery. In our program we will use whatever approach will work for the patient. Sometimes this is dietary changes alone with frequent follow up appointments with the dietitians and me. At other times we use medications such as Meridia or Adipex-P. Often we also use a Very Low Carbohydrate Diet that will help a patient lose about 60 to 70 lbs over 12 weeks.
The bottom line is this. If someone really wants to get better they will be willing to do what it takes to work with us to decrease their risks and reach a preoperative weight that will help them obtain their best result from surgery.
There are many other very good bariatric surgery programs that have other approaches that may be equally valid. Many programs will operate on patients regardless of size and deal with the problems if they happen. However this is our preferred approach and it has worked very well for many patients.
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Dr. Myers, can you tell me why I sometimes wake up at night sweating and feeling my heart race?

I spoke with a woman in my office today who had a laparoscopic Roux en-Y gastric bypass by me over a year ago. She has lost nearly all of her weight and was very pleased with her outcome. However, she was bothered by episodes that occurred occasionally during the night that were concerning to her. Her symptoms included waking up from sleep wet with sweat, heart racing, feeling light headed, nauseated and mentally foggy.
It is important to explain that she is on no diabetic medication.
These symptoms may sound familiar to some gastric bypass patients since it sounds very much like symptoms they experience after eating too much carbohydrate which is called “dumping syndrome”.
Dumping syndrome is the result of absorbing a lot of sugar from a large amount of carbohydrate that is taken in the diet. With the sugar rise in the blood stream the insulin goes up as well. After the sugar is gone the insulin is still too high and the sugar goes too low which is called hypoglycemia. Low blood sugar causes the same symptoms this woman described.
However this patient stated that she had not eaten since 7 PM the evening before. And therefore could not be related to eating too many carbs.
A gastric bypass operation not only bypasses the stomach but also bypasses some of the small intestine including the first part of the small intestine called the duodenum. In addition the time it takes for food to arrive at the last portion of the small intestine is shortened because of the bypass of the stomach and the shortening of the small intestine. The result of these changes after a gastric bypass is that a patient puts out more insulin after ingesting carbohydrates than they did before the operation. This is because certain hormone like substance are released into the bloood stream from the intestine that causes the pancrease to release more insulin. This is especially important for diabetic patients since it helps them to get off insulin shots and diabetic pills.
This woman also is experiencing symptoms from a low blood sugar. Her difficulty is that she is waiting too long after a meal to have something more to eat. And since she produces more insulin to a carbohydrate meal she is using up her sugar and eventually the blood sugar is so low it caused symptoms. This problem may happen during the day as well if a person that had a gastric bypass waits too long before having another meal or snack. Usually the time between meals should be less than 4 hours while they are awake.
I believe the best treatment for this problem is a series of dietary changes. I suggested that she begin by decreasing the overall carbohydrate intake to smooth out the highs and lows. Second, she should eat later in the evening before going to bed and the meal or snack should have protein as well as carbohydrate to lengthen the absorption. Crackers and peanut butter or cheese would be a good choice. Finally I encouraged her to eat or snack more frequently about every 2 to 3 hours during the waking hours to decrease the likelihood of these symptoms occurring during the day.
It has been my experience that patients respond to these dietary changes very well with resolution of their symptoms. To this date I have not found additional therapy necessary for any of my patients.
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News Release

NEWS RELEASE, March 8, 2010
Columbus, Ohio


-Surgeon launches blog-
Dr. Stephan Myers, Director of Bariatric Surgery at Riverside Methodist Hospital in Columbus Ohio and founder of Fresh Start Bariatrics at Riverside recently began posting detailed information for all bariatric surgery patients, regardless of where they have their operation, on his blog at www.BariatricSurgeryBlog.blogspot.com. The decision to start the blog came after hearing from many patients who were not operated on at Fresh Start Bariatrics program complain that they wished they had received much more detailed information prior to their bariatric operation. Dr. Myers explains, “Persons of size want as much information as possible before deciding which bariatric operation fits best for them. They also need very detailed information to obtain their best result after surgery and to remain healthy from that time forward.” www. BariatricSurgeryBlog.blogspot.com answers such specific questions of importance to bariatric surgery patients as:
“Which weight loss operation is most likely to improve or resolve my type II diabetes?”,
“Will alcohol consumption effect me differently after my bariatric operation?” and
“Which vitamin and mineral levels should be checked after bariatric surgery and how often?”
Dr. Myers says, "This is a new day in medicine where patients are expecting much more detailed information from their doctors just as they are looking for this level of information for other things from the internet. Unfortunately much of the information on the internet is from other patients when they really need to hear from medical specialists directly. Surgeons used to share this information to one patient at a time. The BariatricSurgeryBlog is my method of sharing everything I can about bariatric surgery with as many patients regardless of where they choose to have their operation.” Hopefully, this is the beginning of a trend for more medical specialists will take the time to share their knowledge and experience more freely using blogs and other electronic media.

For more information please contact:

Dr. Steve Myers, M.D.
drstevemyers@gmail.com
freshstartbariatrics.com
mobile: 614.557.8125

I was recently asked to share about my work in Africa on this blog by Katie Hire who went with us to Africa this year...so here it is.

I love traveling to Africa to provide surgical care for those that are unlikely to have access to surgery. I usually do this the first 2 weeks of each year. You need to understand this is not a chore for me and I do not do it out of a sense of obligation. I do it because I love it. The people I serve there are so grateful and it is very rewarding to help someone that would otherwise not be able to be cared for. Also like Eric Little, the Olympic champion and later missionary to China, said in the movie “Chariots of Fire” when asked what motivates him to run, “Because God made me fast… and when I run I feel His pleasure”. For me the experience of doing short term missions is similar. I have been given so much and I feel God’s pleasure when I can give back in this way. And it is not just what happens to those I serve at the Hospital for Women and Children in Koutiala, Mali, West Africa. It is about what happens to me. It “recharges my batteries” and helps me put life into perspective. In a strange way I feel I can do what I do for people here in Columbus, Ohio because I am able to get to Africa and serve there.
Of course, the people I care for there do not need bariatric surgery. In fact I visited feeding camps run by Doctors without Borders filled with malnourished children when I was in Koutiala this year. My role is to do operations such as skin grafts for burn victims, release burn scar contractures, repair cleft lips and remove congenital neck masses and help in any way possible.
The hospital was developed over the last 7 years at the request of the people living in Mali that were seeing their pregnant mothers dying in childbirth and children dying of diseases that should be easily treatable. I was privileged to be on the steering committee for the hospital’s development and the hospital has been open for about 4 years. They have delivered over 5,000 babies and they are doing a great work. There is a fulltime American OB/GYN specialist and pediatrician as well as several advanced practice nurses. Otherwise the staff is from Mali. Together they are all doing a marvelous job.
Although I have been all over the world doing short term mission throughout my career including Honduras, Dominican Republic, Haiti, and Ecuador in our hemisphere, Tibet in China, and have been to Burkina Faso, Gabon, Ghana, and Sudan in Africa, I now have narrowed my focus to go yearly to this hospital in Mali. I usually take a small team of people with me, some of which are medical people, and I take my wife and often one or two or my adult children. It is a great privilege to do these missions and it is an honor to work alongside the wonderful people there. For more information about the Hospital for Women and Children in Koutiala, Mali just click on the link labeled African Hospital on the left side of this blog.

What suggestions do you have to reduce the risk of blood clots in bariatric surgery patients?

This is a very important question because persons of size are at greater risk for developing blood clots than persons of standard size no matter what operation they are choosing to have. This is true whether they have a knee replacement, hysterectomy or a bariatric operation.
I think persons of size are at increased risk for several reasons. 1). Increased pressure from the weight that is carried in the abdomen places pressure on the blood vessels returning blood from the lower part of the body back to the heart allowing pressure to develop in the veins of the legs and pelvis. This pressure can injure the valves in the deep veins of the legs and make the veins larger slowing the flow of blood and increasing the risk of clotting. This increased pressure is also the reason many persons of size have developed varicose veins since the pressure is transmitted to the more superficial veins of the legs which have thinner and weaker walls resulting in these veins increasing in diameter. The pressure is transmitted to the vessels of the skin causing leakage of red blood cells causing discoloration and irritation of the skin called venous stasis changes. 2). Many bariatric surgery patients have obstructive sleep apnea which causes the right side of the heart to work less efficiently further retarding the blood flow back to the heart making the pressure situation even worse in the blood vessels returning the blood to the heart. 4). Also, the large amount of fat mass causes the increased production of estrogens in both men and women. This is like being on birth control pills all the time and of course this high level of estrogen may increase the risk of developing blood clots. 4). Finally, a bariatric surgery patient is likely to have an increased level of inflammation which may also increase their risk of forming blood clots.

A person that develops a blood clot in the leg, called a deep vein thrombosis, can have significant symptoms like swelling and pain. However, the more serious risk is if the clot is dislodged from the leg or pelvis and travels up to the heart and out to the lungs. At this stage it is called a pulmonary embolus. This blockage can result in keeping the blood that is pumping out of the heart from getting to the lungs. If enough of the flow to the lungs is interrupted the person will not have enough oxygen and may not survive.
To prevent this problem we do several things for everyone that is having bariatric surgery at Fresh Start Bariatrics at Riverside. Many other bariatric surgeons also do the following: 1). Everyone receives blood thinners that start just before surgery and continues through their hospitalization and is continued for 6 days after they are discharged from the hospital. 2). They have sequential compression devices placed on their legs prior to surgery so the blood will be circulating out of their legs back to their heart even while they are on the operating table and while they are asleep. 3). All of our patients are walking in the halls of the hospital just 6 hours after they leave the operating room. 4). Finally, if a patient is at significantly higher risk than normal I request that they undergo placement of a temporary vena cava filter placed by a cardiologist or other specialist into the main blood vessel, called the vena cava, that returns blood to the heart a few days prior to their bariatric operation.
Although some bariatric surgeons are using vena cava filters for high risk patients the following scoring system is unique to the program I have had the privilege of developing at Fresh Start Bariatrics at Riverside. After reviewing the medical literature I have developed a scoring system that identifies patients that are at significant increased risk for blood clots and will need this temporary filter to protect them from a clot reaching their heart and lungs. The cardiologists I work with most frequently here in the Columbus, Ohio call it the “Myers’ Scoring System”. Take a look at the following:

“Myers’ Scoring System for Venous Thomboembolism Prophylaxis”
In the Bariatric Surgery Population

High Risk Score
History of blood clots (DVT/PE) 4
Venous stasis changes, 4
(cellulitis, ulceration, discoloration)
Genetic clotting disorder 4
Immobility, (wheelchair bound) 4
BMI, (Body Mass Index), over 60 4
Moderate increased risk
Obstructive Sleep Apnea 2
Lower increased risk
Male 1
BMI over 50 1
Recent smoker 1
Hormone replacement therapy 1
Total score ___________
Total Score that is equal to or greater than 4 results in a referral for a vena cava filter.

A vena cava filter is generally placed through the groin much like a heart cath is done. After the risk of developing a blood clot is reduced in 4 to 6 weeks the filter is removed. We have found this scoring system and the placement of a vena cava filter in high risk individuals to be very effective in protection patients form this potentially life threatening problem. I believe we have saved several lives with this intervention. This is just one of many ways we work to decrease the risk of bariatric surgery for patients that select our program for their bariatric surgery. I hope this understanding will be helpful to you regardless of where you chose to have your operation.

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How should a patient that has an adjustable gastric band eat to obtain their best result?

This is the advice I give to all of my adjustable gastric band patients at the time of the office visit about 5 weeks after their operation when I give them the first "fill" or adjustment:Adjustable Gastric Band Instructions:

You are embarking on the next phase of your Journey to significant weight loss and better health.
As you have changed your dietary habits you have:
• Learned healthy nutritional principles and demonstrated them with food
records that were requested by the dietitian.
• Stayed on a liquid diet before and after surgery to allow the band to
heal and transitioned through the phase of soft foods to regular food.
• From this point on protein and vitamin intake will no longer be your major concern.

Now with your first band adjustment your focus changes to how you should eat:

You should eat small volumes of solid food for your meals and snacks. This will allow the food to fill the pouch and pass through the restriction created by the band slowly over the next few hours thus suppressing your appetite. I refer to this phenomenon as “auto-snacking” that is not feeling hungry because some food is slowly being released despite you not eating more food by mouth for a few hours. Liquid foods such as milk, soda, ice cream, soup, milk shakes and fruit juice only serve to sabotage your progress and will blunt your weight loss since they will flow through the narrow outlet created by your band without being slowed by the restriction and you will be hungry soon after eating these liquids.
Wait 30 minutes after eating a solid meal before drinking non caloric liquids such as water or Crystal Light. Drinking prior to this time is likely to only build up in your esophagus and cause you discomfort.
Listen to the signals your body gives you. You should pay attention to how much food you can eat prior to feeling too full. Pressure in your chest is telling you that you just ate more than can be contained in your pouch and food and drink are backing up in your esophagus. You have just eaten too much or too fast or both. If you are experiencing this symptom repeatedly you may put too much force on your pouch and cause “band slippage”. This is likely to occur if you exceed about ½ to one cup of solid food at a time. Learn to eat only this amount. One more bite or drink and you are likely to exceed the amount you can eat comfortably.
Potential Problems:
1). Not keeping your scheduled visits. It is very clear that patients seen in the office each month for the first year do better than those that do not. This is understandable since the band is encircled around fatty tissue as well as around the upper stomach. As you lose weight you are likely to lose some of the fatty tissue within the band as well. This can allow you to eat more food since the opening allowing food out of your pouch becomes larger. In turn this will decrease or arrest your weight loss.
In fact, if this continues you will begin gaining weight again. Therefore, it is crucial that you keep your monthly appointment. In our practice the average weight loss at one year for those who see us in the office each month is 63% of their excess weight. After your fist year the frequency of your office visits will decrease depending on the amount of weight you have lost and your weight loss goals.
2). Don’t drink your calories. Liquids run out of your pouch very quickly, the calories will be absorbed and you will feel hungry soon after taking high caloric liquids for your meals. This is a common mistake and will thwart you weight loss goals. Between meals always select non-calorie containing liquids such as water or Crystal Light. Do not waist your calories on liquids. Skim milk should be used sparingly since it still contains a lot of sugar as lactose despite having the fat removed. Choose high quality protein containing solid foods instead of liquids for your meals and snacks.
3). Eating the wrong consistency and types of food. When the band is adjusted properly, the size of the outlet to the pouch is only about ¼ inch in diameter. Therefore foods such as chicken, steak and doughy breads are not your friends. These are likely to obstruct the outlet of your pouch and cause you pain that will not be relieved until you throw up the food causing the blockage or wait until the particle of food finally passes through.
• Chicken has long stringy fibers and will make a ball much like twine after it is swallowed. Cooking it a long time and /or slicing it thin against the “grain” into very small pieces is likely to help.
• A bite of steak is likely to be larger than the outlet of the pouch unless it is cut extremely small. Of course ground beef is not likely to be a problem since the particles are small. Cooking beef a long time may also help.
• Crackers and toast are likely to form small particles and pass through the outlet of the pouch just fine. However, doughy breads may ball up into a ball in the pouch and “plug up” the outlet.
• Swallowing liquids will only make the problem worse since you would only add to the material that is backing up in the esophagus making it more painful as the esophagus squeezes in an attempt to push the food bolus through the outlet.
• Not chewing enough or eating too fast can cause similar difficulty

Your band is adjusted properly when you are:
• Satisfied with small solid meals
• Not hungry for about 3 hours following a small solid meal
• Not experiencing heartburn or reflux at night
• Losing between 1 and 2 lbs. per week

Your band may be too tight when you:
• Feel you can only take liquids
• Experience heartburn or reflux at night even if you have not eaten for 3 hours prior to bedtime
• Experience frequent vomiting

Your band may be too loose when you:
• Can eat foods such as chicken, steak and /or sandwich breads
• Feel hungry between meals despite small solid meals
• Lose less than 1 Lbs. per week for a few weeks in a row

Exercise:
Exercise is likely to enhance your weight loss and improve your health. However, as you begin an exercise program you are likely to begin increasing your muscle mass and your weight may plateau for a couple of weeks. Do not be alarmed. If you are still experiencing loss of inches despite a plateau in your weight you are likely continuing to lose fat mass and gain muscle mass and your weight lose will soon resume.

Final thoughts for success:
Your band is a tool to use properly. Tools are of no help and can even be dangerous if not used properly. Do not ask too much from your band. Your band is there to remind you how much solid food you should eat at any one time and to help you to manage your hunger. Your band is a tool not a crutch. You should not rely on the band to be so tight that you cannot make wrong choices. You should use your band to remind you to make correct food choices. Your band can help you to control of you eating habits. The band is there to help but do not rely on the band to make you feel “Full”. Use your eyes and brain to tell you how much is the appropriate amount of solid food you should eat at any one time.
If you are experiencing pain that you think is related to your band or having other difficulty that may be related to your band it is best to contact your bariatric surgeon directly or go to the emergency Room of the hospital where you had the band placed. It may not be in your best interest to rely of your primary care physician or another emergency room in case of an emergency. Of course in case of emergency, if you are out of town and cannot reach your bariatric surgeon or visit the emergency room of the hospital where you had the band placed, proceed to an emergency room in that area, preferably to a facility where bariatric surgery is routinely performed.
Finally, if you are vomiting frequently do not assume you have “the flu”. Vomiting in a patient with a band is almost always the result of the band and you need to contact your bariatric surgeon for help.
If you follow these instructions you are likely to be very successful in losing considerable weight, become more active and healthier.

I wish you the very best as you continue on your journey toward better health.