5 Tips For Success after Bariatric Surgery

All bariatric surgery patients can benefit from these tips but especially those who have a gastric band. 

This week I had several adjustable gastric band patients who complained of occasionally vomiting after eating their meals but seemed to have no idea why this was occurring.

 Remember, for those of you who have had a gastric band, you have asked your bariatric surgeon to place a band around the upper part of your stomach to create a gastric pouch and adjust this band so the outlet is only about the size of the end of your ring finger. This is what gives you the resistance to eating too fast and too much at any one time.

 Consistently applying these principles will help.

 1). Liquid calories are not your friend
 Your pouch and narrowed outlet from the band is like a funnel. The purpose is to hold solid food in your pouch for a time, allowing the solid food to slowly leave the pouch and therefore suppress your appetite by releasing a small amount of the food over the next couple of hours. I call this “auto-snacking”; giving you the effect of snacking to suppress your appetite with out eating. Them after a few hours the pouch is empty and the person becomes hungry in about 3 hours when it is time for another meal.

 I often hear, “but liquids go down so easily!” but that is exactly the point; too easily! Your band is not made to hold back liquid food. All liquids will run straight through the narrow outlet. So take your calories as solid food not liquids.

 Avoid milk, (even skim since it has too many sugar calories), ice cream, cream soup, soda and fruit juices. Get your protein in solid food and only use protein shakes if you cannot get enough protein in your solid foods.

 Instead drink water, tea with sweetener, and Crystal lite or other non caloric beverages. This is an easy way to reduce your overall calorie intake and help you lose weight.

By the way, be careful of too much fruit since many fruits like watermelon are really sugar water in disguise.

 2). Minimize crunchy foods
 Crunchy foods like chips, crackers, pretzels and cookies, after saliva is added, go to mush and will go into the pouch and pass through the narrowed outlet too quickly. These types of foods can be your downfall. I am not saying you should never eat them but when you see them train your brain to flash “DANGER”. It is a question of portion size. One of my patients did a video on this blog sharing how she deals with this problem. She swore off ever eating out of a bag or box again. Now when she brings home the groceries she breaks down the crunchy foods into small zip lock bags for portion sizes. She no longer takes the large bag to the TV for her snack but goes to the pantry to get a zip lock portion size for her snack.

 3). Apply the “rule of 30s” consistently

 Chew 30 times before swallowing

 Wait 30 seconds before your next bite

 Wait 30 minutes before drinking

 4). Avoid foods that are likely to be difficult; steak, chicken and bread
 Steak will not pass through the narrowed outlet of your pouch if the particle sizes are larger than the tip of your ring finger. The stringy fibers you see when breaking open a grilled chicken breast can be chewed all day long but will probably ball into a “twine ball” in your pouch causing blockage of the outlet of the pouch. Doughy bread will become a “dough ball” in your pouch and block the small outlet of your pouch.

 This is a frequent cause of vomiting after a band is placed.

 If one of my patients tells me they can eat these things without difficulty it tells me their band probably needs adjustment. Usually they are gaining wait as well.

 5). Establish a “No Fly Zone”
 I want to my patients to establish good boundaries for what comes on their property and tell their friends and family, “Certain foods just don’t fly here.” We all have what I would call trigger foods; that is foods that comfort us and when these are around we have difficulty staying away from them. For me it is cookies, so guess what? My wife only buys one type of cookies to bring home from the grocery; Fig Newtons. That is because I really don’t like Fig Newtons much and they will stay around along time. If she brought chocolate chip cooking they would be gone in a flash because I have difficulty staying away from most other cookies. Without fully realizing it my wife has established a “No Fly Zone” at our home. Cookies just don’t fly at our house.

 Maybe your food trigger is pizza or soda or ice cream. Whatever it is you should establish a no fly zone at your house. You don’t bring these things into your house and family or friends and not welcome to bring these things as well. Let them know they are welcome to go out for these things but these foods just don’t fly at your house.

 Applying these principles consistently is the key to understanding what is going on with your body after having an adjustable gastric band or any other bariatric operation as well. If you are doing these things you are more likely to understand what is going on if you are having difficulty.

Diabetes Dramatically Improved-Pat Dittilo Shares in an Email

I received this Email from Pat Dittilo last week and she has agreed to share this with all of my readers. She said would like to encourage as many as possible. Here is what she shared:

Dr. Myers,

Hope you are doing well in your new position. I wanted to give you an update on my status since you and I have talked several times about the surgery and diabetes. I had a robot assisted gastric bypass by you in October of 2010, about 18 months ago. I was your 13th or 14th robotic case. I had type 2 diabetes diagnosed about 5 years before my operation and was on oral medicine as well as 10 micrograms of Byetta that I had to inject three times a day in addition to injecting 105 units of long acting insulin twice a day.

You may remember that my diabetes was out of control – my A1C was 11.7 and while I haven’t had it tested recently, my last A1C was 7.1 six months ago, (i will be having it checked again soon). I wanted to let you know that my sugar level yesterday and today were 94 and 89 and I am not taking any diabetic medication. I am so pleased and happy about my decision to have the surgery and even more pleased that you were here to do that for me. I have maintained my weight at 138 for over a year and I feel awesome. In addition to not taking any medication for my diabetes, I also no longer take medication for my blood pressure like I was before and my sleep apnea is completely gone. I’m 55 (almost 56) and I feel like a kid again. I have more confidence than I’ve ever had in my life.

It’s funny that so many people are more aware of the results of the surgery for those who have diabetes and the media attention it’s getting. Almost weekly I see something in the news about how people with diabetes are no longer dependant on insulin or completely cured. I can’t tell you how wonderful it is to wake up every day and not think about having to take those shots. I can eat without worrying about injecting the Byetta 30-60 minutes before I eat and how it made me sick to my stomach sometimes.

Thank you again for everything you did for me – I never thought I would feel so good again. Living my life without drugs and machines is a blessing, not to mention going from a size 18-20 to an 8-10!

God Bless you and your family. You are truly an Angel in many people’s lives.

Pat Dattilo

Diabetes is Treated Better with Surgery plus Medical Management than Medical Management Alone

Many of you may have read or heard about an important study published in the New England Medical Journal on March 26, 2012. Dr. Phil Schaur and his colleagues at the Cleveland Clinic completed a trial that has very profound implications for patients with Type 2 diabetes.

They compared 50 poorly controlled diabetic patients who had intensive medical management of their diabetes to 50 patients treated with a laparoscopic gastric bypass plus medical therapy and another 50 patients who were treated with a laparoscopic gastric sleeve plus medical therapy.

There was no mortality and complications were low.

The primary finding was that at the end of 1 year the patients who had surgery plus medical therapy achieved much better control of their diabetes. In fact, nearly 4 times as many patients in the surgery plus medical therapy group achieved excellent diabetic control than the group receiving only intensive medical therapy.

Between the two surgical options, the laparoscopic gastric bypass patients did somewhat better than the laparoscopic gastric sleeve patients.

Another important finding was that those receiving only intensive medical therapy increased the number of medicines they had to take over the year while those who had surgery plus medical therapy decreased the number of diabetic medicines and often were on no diabetic medicines at all.

Although it will be helpful to continue to follow these patients for several more years to evaluate the long term effects of better control, it is very clear that patients with type 2 diabetes do better if they have bariatric surgery than those who do not choose to have surgery.

Several months ago I mentioned that the medical establishment was too slow in accepting the remarkable improvement in diabetes after bariatric surgery. Could there be a sea change coming with this and other studies?

Why Robotic Bariatric Surgery?

Using a robot to perform a Roux en-Y gastric bypass brings significant value to patients.

I had performed at least 800 gastric bypass operations laparocopically without q robot before I began to perform this operation with the help of a surgical robot. The robot does not perform the operation but helps me perform the operation with more precision and with allowing me to see better.

I compared the last 100 gastric bypass operations I performed without a robot to the first 100 gastric bypass operations I performed with a robot. I found the following:

1). It took more time to perform the robotic operations. On one hand this is not surprising since I had performed so many laparoscopically and had the opportunity to decrease the time it takes me to perform the operation in that way. On the other hand it will take time for me to continue to to improve on the time.

2). Most patients in the robotic group left the hospital the day after the operation while most of the patients that had a gastric bypass operation without the use of the robot left the hospital after 2 days.

3). The patients in the robotic group had less bleeding. in fact only one patient in the robotic group received even 1 unit of blood whereas 5 patients in the non-robotic group received blood and they each received an average of more that 2 units of blood. I believe this is because I can see better, perform the operation with more precision and with the help of the robot I am able to perform some of the connections with sutures instead of staples.

4). There was no increase in complications with using the robot even though these were my first 100 operations.

Although it took a lot of patience and effort to learn to perform a gastric bypass with the surgical robot, I believe it was more than worth it.

Today most gastric bypass operations are performed laparoscopically without a robot. There is nothing wrong with having an operation in this manner and in fact this would be the choice for most surgeons. However, the robotic approach is being used by more surgeons and in my practice I have shown that I have even less complications when I use the robot.

If you have questions please let know and I will be happy to do my best to answer them.

Coughing at Night

This week I saw two patients in the office who complained of reflux and coughing when they laid down at night. Both had had an adjustable gastric band placed a few years ago and had not had a recent adjustment to there band.

Their symptoms are related to the band being too tight causing back up of saliva in their esophagus. When they lay down the pooling of saliva can overcome the ability of the muscle at the upper end of the esophagus to keep the saliva out of the throat.

When the contents of the esophagus come up into the throat it they can come in contact with the vocal cords and cause coughing. Occasionally this will aspiration of these contents into the lungs and cause pneumonia.

This problem is usually rectified by taking some fluid out of the band.
In both cases this immediately relieved the symptoms in both of these individuals and they were able to drink water comfortably.

Although this solved the immediate problem, band slippage could be the reason this has only recently developed.

If the problem recur rs with or without placing more fluid into the band the patient should be investigated with a special X-ray such as an upper GI or a CT scan to determine whether slippage has occurred.

If the band has been forced to slip down further on the stomach the band may have to be repositioned with another laparoscopic operation. Hopefully this will not be the case for either of these individuals and they will be able to avoid another operation. I will be seeing each of them in the office again in a few weeks for follow up.

Managing Nausea and Vomiting after Bariatric Surgery

Two nights ago I met one of our patients in the emergency room because she was unable to control the sensation of nausea and had been vomiting at home. I had just discharged her from the hospital that very morning after an uneventful time in the hospital following a laparoscopic gastric bypass two days before. Most patients do not complain of these symptoms after bariatric surgery but occasionally nausea is significant problem.

Here are three steps to avoiding nausea and vomiting after bariatric surgery:

1). Maximizing prevention by medications given prior to surgery. My routine for my patients includes Zofran 4 mg given intravenously by the nurse just before surgery. I also order Decadron 10 mg through IV just before surgery as long as the patient is not diabetic. (This steroid medication will cause a high sugar level in diabetic patient.) Finally, if the patient has had nausea with previous operations or has a history of motion sickness I will prescribe a scopolamine patch to be placed behind the ear starting the night before surgery. This helps to prevent motion sickness but can be very helpful to prevent nausea after an operation as well. This patch can stay on for three days delivering a small amount of medicine slowly during this time. The reason it should go on the night before is to assure an appropriate amount has been absorbed by the time surgery starts.

2). After surgery my preferred medication is Zofran if the patient feels nauseated. This can be given through the IV while in the hospital or by mouth in pill form if the patient is at home. The scopolamine patch can be added for more severe symptoms. I prefer to avoid medications such as Phenergan or Compazine since they can cause very bothersome side effects.

3). Finally the speed of taking fluids may need to change. If you feel nauseated I suggest you slow down even more taking only teaspoons of fluid at a time and waiting at least 30 seconds between swallows since it takes about that long for the swallow to reach your revised stomach. Sometimes it is helpful to take the fluids at room temperature as well.

If the nausea and vomiting persists call your surgeon so you don't become dehydrated.

If nausea and vomiting develops weeks, months or years after bariatric surgery consult your doctor or surgeon as this may be a symptom of a narrowing or ulcer.

With good preoperatve preparation nausea and vomiting can usually be avoided.. However, if it does occur I hope this posting is helpful to you..