Obesity is a very common condition affecting between 20 and 30% of the U.S. population. In fact it is the most common nutritional disorder in our nation. A person is considered obese when they are about 30% over their ideal body weight. The term “morbid obesity” is used to describe people who are about twice the weight they should be or 100 pounds overweight. A formula based upon height and weight is used to determine if someone is morbidly obese: Weight in Kg/(Height in meters)2 = Body Mass Index If this number, the Body Mass Index, or BMI, is 40 or greater, or 35- 39 with certain other health problems due to obesity, a person is considered morbidly obese and may be a candidate for surgery.
Rationale for Treatment
A number of health problems are directly related to obesity. They include atherosclerosis affecting the heart vessels and other vessels, congestive heart failure, hypertension, and severe back and knee arthritis due to the tremendous weight these joints have to bear. Adult onset diabetes is often brought on by obesity. In fact up to 50% of massively obese individuals have diabetes. Diabetes is a leading risk factor for heart disease and a leading cause of premature death. Because fat cells affect the metabolism of estrogen, many morbidly obese females have irregular periods or may even have trouble conceiving. Obesity is also thought to be a risk factor for the development of uterine cancer. In addition to the known health risks, morbidly obese people may suffer from other less obvious but no less troubling psychosocial problems including diminished career opportunities, social maligning, and difficulty in public places such as mass transit vehicles, and airliners.
As the average weight of a population increases, so does the incidence of these co-morbid conditions. Likewise, we see life expectancy decline. When the average weight of the population reaches about twice the average ideal body weight, these health risk factors begin to change exponentially. Simply put, the problems associated with obesity begin to mount rapidly when a person enters the realm of morbid obesity.
While weight loss may not correct all of these problems, it has been shown to improve many. In this era of preventative medicine, we realize that the best “treatment” for heart disease is to prevent its occurrence in the first place. Diabetes and hypertension control are improved with weight loss. In fact some individuals who require insulin when they are morbidly obese, no longer require it after losing weight. Arthritis sufferers generally have less pain after losing weight, and those individuals who do not yet have arthritis may be able to prevent it by losing weight.
But, while weight loss improves the outlook of many individuals, some actually have difficulty adapting to their “new bodies.” We have seen familial and marital discord develop likely as a result of families and friends thinking their loved one has changed, and indeed they have.
However, this is not “cosmetic” surgery. And while we define success as losing 50% or more of your excess body weight, not everyone achieves that. In other words, surgery is not successful for all patients.
Many patients claim, “I don’t eat too much,” and while the literature suggests obese people may indeed be more efficient with the calories they ingest, for the most part, you simply cannot be overweight without overeating. In general, obesity is best treated by taking in fewer calories than you burn. While this may sound simple, adhering to that dictum is difficult. The National Institutes of Health studies estimate the success of dieting for weight loss is relatively low. Less than 1/3 of dieters will avoid weight gain over a 3-year period. In fact, it may be lower than that for morbidly obese people. Diet pills seem to help some. However, regaining weight after stopping the diet pills often proves to be problematic.
Surgical treatment of obesity, called bariatric surgery, has evolved over the years. We currently perform both open and laparoscopic gastric bypass surgery and laparoscopic vertical sleeve gastrectomy. The following information will provide you with an overview of both. This is considered required reading for entry into our Bariatric Program.
Indications for Operation
People with a body mass index (BMI) of 40 or greater, who have tried and failed conservative
weight loss measures preferably including physician directed methods are considered for operation.
Rarely people with a lower BMI (35 – 40) but with severe co-morbid obesity related conditions such as
diabetes are considered.
Contraindications for Operation
Patients with severe heart conditions, angina pectoris, bleeding problems such as hemophilia, or unrealistic expectations of surgery (see below) are generally not surgical candidates. There may be other reasons to exclude patients from surgical consideration as well, and your surgeon can discuss these with you when he takes your medical history.
SURGICAL OPTION: GASTRIC BYPASS SURGERY
The specific gastric bypass approach utilized in our bariatric program is the Roux-en-Y gastric bypass. The stomach is partitioned by placing a line of staples along the upper aspect creating a very small gastric pouch. It is designed to hold 1 to 2 tablespoons only. The GI tract is rerouted such that food empties from the upper gastric pouch into a 100 cm intestinal conduit before mixing with the digestive enzymes which emanate from the pancreas. Gastric bypass, therefore, attacks the problem of obesity from two angles. The small stomach produces early satiety (feeling of fullness), and the gastrointestinal bypass decreases the efficiency of the GI tract. Thus the gastric bypass is both restrictive and malabsorptive.
The point of the operation is to drastically limit how much a patient can eat. It is life style changing. Many people experience frequent vomiting after the procedure which is generally secondary to overeating. Fatigue, especially during the period of active weight loss, is common. Vitamin and micronutrient deficiencies, such as iron, and calcium are common, and it is mandatory that you take a multivitamin with iron daily for the rest of your life, as well as a calcium supplement. Vitamin B12 absorption is particularly affected and requires supplementation in the form of an injection four times per year. Ultimately it can be replaced with a daily oral supplement if you prefer. You may experience hair loss which coincides with weight loss or sometimes protein deficiency. This is usually self-limited,
but is concerning for some patients. Some patients develop certain food aversions which are unique and unpredictable. Foods you once liked may no longer have the same appeal. Diarrhea or constipation sometimes ensue, and may be aided with a daily fiber supplement such as Metamucil, Citrucel, or Fibercon.
Some Risks of Operation
Gastric bypass is a major operation, and as such is associated with significant risks. Complications can and do occur commonly. They may be minor or major, and may include bleeding, wound infection, or intra-abdominal abscess. Disruption of the surgical wound or disruption of the connection between the stomach and intestine or between the two limbs of intestine may occur. Bowel obstruction either early on or years later, development of an abdominal wall hernia, pneumonia, or heart attack are possible complications related to surgery.
Because of the proximity of the stomach to the spleen, it can be injured during the operation and necessitate splenectomy. Formation of clots in the legs (deep vein thrombosis) that can break free and clog the vessels going to the lungs (pulmonary thromboembolus) resulting in sudden death has been known to occur. Some complications may require re-operation, and women of child-bearing age should avoid pregnancy during the 12 to 24 months after surgery when weight loss is most rapid. These are only some of the possible problems. Others can occur. In fact, estimates put the risk of death related to surgery at about 1 in 100 patients. Laparoscopic gastric bypasses may need to be converted to open for various reasons.
As a part of the pre-operative evaluation process, a nutritional consultation may be required, as well as psychological and medical clearance from a doctor. Our Bariatric Coordinator will walk you through that process. We also have some educational information and presentations on our website at www.cahabavalleysurgical.com.
At your initial visit with our surgeon, you are expected to have reviewed the information in this packet. There may be some additional forms to complete at your consultation. A nurse will record your height and weight, and the surgeon will evaluate you. After obtaining a brief medical and weight history, a physical exam is performed. The rest of the visit will allow you to ask any questions and have a detailed conversation with your surgeon to help determine if you would be a good candidate for weight loss surgery. If you are deemed a candidate for surgery, and you desire to proceed with surgery. You will then meet with our surgery scheduler to discuss the process of insurance approval.
Patients who lose weight between their first visit with us, and the actual surgery date, generally have better post-operative results. Pre-operative dieting is encouraged. During this period, we may also be working with you to obtain any pre-operative labs or diagnostics, or any applicable related consultations (eg, sleep study, cardiac clearance, etc. As applicable, based on each individual’s health condition).
The Preoperative Period
The surgical and anesthesia staff will bring you from the pre-holding to the holding area where you may meet the anesthesiologist, have an IV started, and receive preoperative sedation to calm you. Subsequently you are taken to the operating room, helped to sleep with a combination of intravenous medicines and inhaled agents. A breathing tube will be placed into your trachea after you are asleep as well as a tube into your stomach via your nose or mouth. Most patients also have a Foley catheter placed into their bladder. For the open operation, the incision is usually in the mid-line from the tip of the breast bone to the umbilicus. The laparoscopic gastric bypass is done via 6-7 ½ to 1 inch incisions on the upper abdomen. Operative time is about 2 to 3 hours. After surgery, you are allowed to wake up somewhat in the operating room, the breathing tube is typically removed, and you are brought to the recovery area. The tube in the bladder may remain in place for several days, and occasionally a tube directly through the abdominal wall into the stomach to facilitate decompression is also left. After 45 minutes to an hour in the recovery room you are brought to your hospital room. Sometimes a patient may be admitted to the critical care unit for extenuating circumstances or other medical conditions, such as sleep apnea.
The surgical and anesthesia staff will bring you from the pre-holding to the holding area where you
may meet the anesthesiologist, have an IV started, and receive preoperative sedation to calm you.
Subsequently you are taken to the operating room, helped to sleep with a combination of intravenous
medicines and inhaled agents. A breathing tube will be placed into your trachea after you are asleep
as well as a tube into your stomach via your nose or mouth. Most patients also have a Foley catheter
placed into their bladder. For the open operation, the incision is usually in the mid-line from the tip of
the breast bone to the umbilicus. The laparoscopic gastric bypass is done via 6-7 ½ to 1 inch incisions
on the upper abdomen. Operative time is about 2 to 3 hours. After surgery, you are allowed to wake
up somewhat in the operating room, the breathing tube is typically removed, and you are brought to
the recovery area. The tube in the bladder may remain in place for several days, and occasionally a
tube directly through the abdominal wall into the stomach to facilitate decompression is also left. After
45 minutes to an hour in the recovery room you are brought to your hospital room. Sometimes a
patient may be admitted to the critical care unit for extenuating circumstances or other medical
conditions, such as sleep apnea.
The Postoperative Period
Special pneumatic compression stockings may be on your legs until you are able to walk and you may receive an injection of blood thinner beneath the skin twice daily to lessen the risk of developing blood clots in your leg veins. Those undergoing open gastric bypass may not eat or drink anything the day of surgery. On the first day after surgery, you will have a swallowing test called an upper GI to look for leaks. If this is OK, you are allowed sips of clear liquids up to two ounces every two hours, but no carbonated beverages. Because of their effervescence these tend to distend the stomach too much. If you tolerate limited liquids, progression to unlimited liquids follows the next day. Laparoscopic gastric bypass patients usually undergo a special x-ray the day after surgery looking for leaks, and are usually discharged on this day also. The initial diet is liquid with graded progression to a regular diet over 1-4 weeks. Portion size is critical, and will be discussed in detail during your consultation.
Not all contraindications, warnings or adverse events are included in this brief description of the
gastric bypass procedure.
SURGICAL OPTION: SLEEVE GASTRECTOMY
How a Sleeve Gastrectomy Works
A sleeve gastrectomy, or vertical sleeve gastrectomy, is a restrictive surgical weight loss procedure that limits the amount of food you can eat and helps you feel full sooner. During this procedure, a thin vertical sleeve of stomach is created using a stapling device, and the rest of the stomach is removed. The sleeve is about the size of a banana. It allows for normal digestion and absorption. Food consumed passes through the digestive tract in the usual order, allowing it to be fully absorbed in the body.
The majority of weight loss sleeve gastrectomies performed today use a laparoscopic technique, which is considered minimally invasive. Laparoscopic surgery usually results in a shorter hospital stay, faster recovery, smaller scars, and less pain than open surgical procedures. The length of time of the surgery varies. One study found that the average operative time was 1.5 to 3.5 Hours. The typical and the average hospital stay was one overnight stay; however, in some cases patients may be able to go home the same day, following a sleeve gastrectomy. Patients usually return to normal activities in 2 weeks and are fully recovered in 3 weeks.
Weight Loss Surgery Benefits
Sleeve gastrectomy can lead to significant weight loss and improved health. Some advantages to this surgery include:
• It is performed laparoscopically (minimally invasive)
• May be an option for carefully selected patients, including high-risk or super-super-obese patients1
• Mean excess weight loss at 1 year of 59%
• No implanted medical device
Sleeve gastrectomy patients have been shown to experience significant weight loss and improvements in their health. Patients have been shown to lose an average of 55%13 of their excess weight.
Improvements in health, quality of life, and, of course, significant weight loss are important bariatric surgery benefits. The information below provides greater detail about these benefits and will help you understand how sleeve gastrectomy can help you achieve and maintain a healthier weight.
Clinical studies of laparoscopic bariatric surgery patients found that they felt better, spent more time doing recreational and physical activities, benefited from enhanced productivity and economic opportunities, and had more self-confidence than they did prior to surgery.9
As you can see, a sleeve gastrectomy procedure may have many benefits. However, it isn’t for everyone. Only you and your surgeon can decide if bariatric surgery is an appropriate treatment option for you. Please see the education resources and links the end of this section for additional information.
Sleeve Gastrectomy Surgery Potential Risks and Complications
As with any surgical procedure, potential risks and complications can occur with sleeve gastrectomy. We’re committed to providing you with the information you need to make a well-informed decision about your surgery. Although these problems rarely occur, we want you to know the facts.
Potential bariatric surgery complications following the sleeve gastrectomy:
• Abdominal hernia
• Chest pain
• Collapsed lung
• Constipation or diarrhea
• Enlarged heart
• Gallstones, inflammation of the gallbladder, or surgery to remove the gallbladder
• Gastrointestinal inflammation or swelling
• Stoma obstruction
• Stretching of the stomach
• Surgical procedure repeated
• Vomiting and nausea
• Staple-line disruption, weight gain, failure to lose satisfactory weight
• Intolerance to refined sugars (dumping), with nausea, sweating, weakness
• Staple-line disruption, weight gain, failure to lose satisfactory weight
Sleeve gastrectomy surgery should not be considered until you and your doctor have evaluated all other options of non-surgical means of weight loss.
The proper approach to sleeve gastrectomy surgery requires careful consideration and discussion of the following with your doctor:
• Weight loss surgery is not cosmetic surgery. The procedures do not involve the removal of fatty tissue by cutting or suction.
• A decision to elect surgical treatment requires an assessment of the benefits and risks to the patient and the meticulous performance of the appropriate surgical procedure.
• The success of weight loss surgery is dependent on long-term lifestyle changes in diet and exercise.
What can you expect following sleeve gastrectomy surgery?
• Recovery will take time and patience
• Post-operative diet modifications
• You may experience discomfort and pain as your body heals.
• Length of time to return to normal activities can vary from patient to patient.
• The capacity of the stomach has changed.
• Your healthcare team will advise you when to return to work, resume prior activities and schedule your follow-up appointments.
Not all contraindications, warnings or adverse events are included in this brief description.
If you and your primary care physician feel you may be an appropriate candidate for bariatric surgery, please complete our Bariatric Packet and mail your request for a consult and surgery to:
Shelby Baptist Bariatric Coordinator
644 2nd ST NE, Suite 206
Alabaster, AL 35007
Please note that we do require original signatures, and all pages must be complete in order for us to process your paperwork.
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