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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Monday, March 15, 2010
Wednesday, March 10, 2010
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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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.
Want to make a comment or ask your question? Click on the word ”commentS” at the end of this posting.
Want to have new postings I make to this blog sent free and automatically to your email? It takes less than 30 seconds. 1). Enter your email address where requested on the left side of this blog.2) Click on “subscribe” and follow directions to prevent spam.3). Click on “Complete Subscription Request”. It’s just that easy! Your email will not be shared or used for any other contact.
Tuesday, March 9, 2010
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.
Want to make a comment or ask your question? Click on the word ”comments” at the end of this posting.
Want to have new postings I make to this blog sent free and automatically to your email? It takes less than 30 seconds. 1). Enter your email address where requested on the left side of this blog.2)Click on “subscribe” and follow directions to prevent spam.3). Click on “Complete Subscription Request”. It’s just that easy! Your email will not be shared or used for any other contact.
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.
Want to make a comment or ask your question? Click on the word ”comments” at the end of this posting.
Want to have new postings I make to this blog sent free and automatically to your email? It takes less than 30 seconds. 1). Enter your email address where requested on the left side of this blog.2)Click on “subscribe” and follow directions to prevent spam.3). Click on “Complete Subscription Request”. It’s just that easy! Your email will not be shared or used for any other contact.
Monday, March 8, 2010
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
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
Sunday, March 7, 2010
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.
Thursday, March 4, 2010
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.
Want to have new postings I make to this blog sent free and automatically to your email? It takes less than 30 seconds. 1). Enter your email address where requested on the left side of this blog.2)Click on “subscribe” and follow directions to prevent spam.3). click on “Complete Subscription Request”. It’s just that easy!
Want to make a comment or ask your question? Click on the word ”commentS” at the end of this posting.
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.
Want to have new postings I make to this blog sent free and automatically to your email? It takes less than 30 seconds. 1). Enter your email address where requested on the left side of this blog.2)Click on “subscribe” and follow directions to prevent spam.3). click on “Complete Subscription Request”. It’s just that easy!
Want to make a comment or ask your question? Click on the word ”commentS” at the end of this posting.
Monday, March 1, 2010
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.
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