Frequently Asked
Questions
FREQUENTLY
ASKED QUESTIONS CONCERNING
GASTRIC BYPASS AND ANSWERED BY DR. SAMUELS
Is
this surgery covered by insurance?
Many insurance
companies cover this procedure, however, each
insurance policy differs. Once it is established
that you qualify for the procedure, our staff
will work with your insurance carrier and submit
all required information to expedite their
approval process. This helps the patient in two
ways. First, it eliminates the inconvenience of
the patient having to deal with the insurance
companies themselves. Secondly, the patient
knows, in advance, what the insurance company
will cover.
To discuss insurance or payment information, feel
free to contact our office and speak with one of
our knowledgeable staff members. Or, watch for
our "Insurance/Payment Information"
online page, coming soon. Unfortunately, many
HMO's will not cover this procedure.
Will I
have to count calories?
No, the diet is
very simple. You eat animal protein with all
meals in addition to vegetables and fruit.
Can I
drink alcohol?
It is unadvisable
to consume alcoholic beverages during the weight
loss period, as alcohol digests to sugar. After
goal weight is attained, you may drink
moderately.
Will I
ever be able to eat sweets again?
It varies, some
people have no difficulties, while others have a
severe reaction to sweets. The reaction, however,
does tend to decrease with time.
Will I
have a scar? Will vitamin E help?
Yes, there will be
a scar. There is no scientific evidence that
using Vitamin E will aide in healing scars, but
some patients feel that it does help.
When
can I swim? Will I ever be able to get pregnant?
You may resume
swimming in 4-6 weeks. Yes, but it is not
advisable during the weight loss period.
What
exactly is the 'program' after Gastric Bypass?
The program begins
with the first call to our office. We know that
people who are suffering with morbid obesity have
gone through many "fad" programs, false
promises, and 'diet industry' quackery, so we
immediately want to dispel myths about morbid
obesity and teach factual information about the
realistic benefits and patient responsibilities
related to choosing surgery for obesity. Our team
has a high motivation for helping patients
succeed post surgically. We define success as 80%
of excess weight lost, with no major problems in
quality of life and improved medical and
psychological status.
So, the program
actually begins before the surgery. We encourage
our patients to become very involved in
understanding the program, their personal
commitment to have the Gastric Bypass, behavior
and dietary choices BEFORE they are admitted in
the hospital. This involves participating in an
extensive teaching session with Dr. Samuels,
review of an in-depth patient education folder,
as well as receiving a comprehensive
psychological evaluation. Our program dietician
also conducts a one-to-one nutrition teaching
interview. We strongly advise patients to attend
our patient support groups before surgery, and we
have a list of successful "veteran"
patients with whom prospective patients can
engage in private conversations. These
pre-surgery steps help surgical candidates in
many ways: the relationship between the patients
and the clinical team is already under way and
established on a sincere teamwork format, and the
patient is more and more familiar with the
surgery and the follow-up program. This later
point is very important because with more
understanding and trust, there is less fear for
new patients and they are able to 'get' the
necessary steps to improve their success
following surgery.
The actual
"Gastric Bypass Program", is generally
basic, good health care strategies. You must
follow a simple but consistent program of 10
rules;
1. Eat 3 meals per
day, no skipping of meals. Each meal should last
between 30-45 minutes.
2. In each meal
you must eat a low fat animal protein, what we
call a "High Biological Protein", for
example, chicken, fish, turkey, lean meat. You
may also have a fruit and a portion of
vegetables. You must take supplements daily as
ordered by Dr. Samuels. These include vitamins
and nutrient supplements. There are certain drugs
that you must avoid, including all Non-Steroidal
Anti-Inflammatory Drugs (e.g. Advil, Motrin,
etc), and aspirin.
3. You may not
drink with your meal. You must also allow a
30-minute window before and after your meal in
which you do not drink any beverages.
4. Otherwise, you
may drink to your preference, however, all
beverages must be 'Zero' calories; therefore, no
fruit juices, alcohol, or soups may be consumed.
It is advisable to avoid gulping beverages.
5. You must eat
slowly, and chew your food to a soft consistency.
6. Starches, (both
grains and vegetables) are limited to two
servings per week.
7. Given the above
guidelines, it follows that sugars and fats are
to be avoided. Despite the relative simplicity of
these rules, the program is usually quite
different than the typical American diet and
eating patterns, so our program also includes
behavioral rules.
8. In order to
have the maximum capacity to enjoy your food
comfortably after surgery, we advise patients to
be as calm as possible during and after meals.
9. All patients
must participate in an exercise program, which is
increased gradually, given the individual
characteristics of patients. We encourage
patients to begin walking in the hospital. This
activity improves the recovery process by
improving such factors as respiratory status,
decreasing pain sensitivity after surgery, and
increasing mobility. In the weeks immediately
following surgery, we continue to support daily
walking, gradually building up the time and speed
of the walks. At this point we are beginning to
introduce walking for aerobic benefits (exercise
to increase Oxygen use, increase metabolic
efficiency to improve weight loss results). As
time passes, and patients are increasingly
stronger, we step up the exercise guidelines to
include 4 aerobic exercise sessions per week of a
30-minute duration. Walking, treadmill,
stationery bike, aerobics class are some of the
most popular activities. Finally, several months
after surgery, we advise patients to add in a
moderate weight-training program, perhaps two
sessions a week. This step helps patients
maintain good lean muscle mass - in other words;
body weight is lost from excess fat not muscle.
This fact is very important for maintaining
general health status.
10. Success -
losing massive body weight, improving related
medical problems, feeling and being well AND
maintaining your weight loss over many years
requires at least 80 % cooperation with these
guidelines and any special orders given to you by
Dr. Samuels. There is just no way around this
fact. Our final guideline is to advise patients
to attend every monthly team office visit until
you are discharged by Dr. Samuels. This rule is
incredibly important because it gives us all the
chance to help correct little adjustment problems
before they become crises, and it gives the
opportunity for patients to have monitoring and
help to really make the most of their surgery.
Even though the
program may sound impossible, the having the
surgery itself makes these major behavior and
dietary changes not only possible, but also very
"do-able". With the help of the team,
and successful prior patients, we build each step
of change carefully, one after the other, to help
you reduce anxiety, create a healthy outlook and
adjust to new, permanent way of living with a
slim and healthier self.
Will I be
able to maintain my goal weight for many years or
the rest of my life?
Yes! As long as
you keep the commitment to the 10 steps of the
program to at least 80 % consistency, and keep a
good relationship with your bariatric surgery
team. Remember morbid obesity is a chronic
disease process and you must maintain good
healthcare practices, following doctors
guidelines for the rest of your life.
I feel
pretty discouraged and hopeless about my weight.
I hardly ever go out, feel ugly have low self
esteem. If I lose all this weight, how will my
life change?
Of course, we
can't predict exactly how your life will change
after losing 100, 150 or 200+ pounds. That old
motto, "everyone is an individual" is
wise and true! We can ASSURE you that your life
WILL change and the changes are very likely to be
quite dramatic! Over the last 12 years that we
have monitored our patients, we find that some of
the major changes to be:
Improved physical
status, for example, blood pressure, blood sugar
and respiratory regulation), more energy, less
body aches and pains, improved sleeping.
Improved
psychological status, including decreased
depression, improved self esteem, improved social
skills, more confidence and realistic hope for
the future.
Changes in
relationship, including family, love
relationships, friends and co--workers. In
general these changes are positive and exciting.
They are also demanding. In order to cooperate
with our program, patients must really put their
own health care choices first. This is very often
a change for our patients, since many have felt
depressed and hopeless they have given their own
lives the lowest priority. Our patients have to
learn to make assertive, healthy decisions for
themselves, even when these decisions upset their
loved ones. For example, they may choose to go on
their exercise walk instead of sitting down and
eating pretzels, OR they may have to deal with
their spouse's jealousy or discomfort when they
become increasingly attractive and independent.
Body image:
Patients undergo incredible changes in how they
see and feel their bodies. Losing 100 or more
pounds creates drastic changes in body size,
appearance, and related areas such as dressing
choices, feelings of being attractive and sexy.
Accepting normal
body image is sometimes a major challenge for
obesity surgery patients! Even though wearing a
size 8 dress may be a lifetime goal, some
patients require some adjustment time to accept
this reality, sometimes still "feeling
fat", or worrying that they will gain weight
back. We find that as more time passes and
patients learn to become experts in managing the
program guidelines with their individual lives,
they experience more real success, and the new
healthy body image becomes more comfortable and
reliable.
FREQUENTLY
ASKED QUESTIONS CONCERNING
AGB AND GASTRIC BYPASS AND ANSWERED BY DR.
HELLERS
What
is Adjustable Gastric Banding (AGB)?
In
the adjustable gastric banding method a band is
applied around the stomach about 20 mm below the
gastro-esophageal junction. On the inner lining
of the band there is a longitudinal balloon (like
a bicycle tire). This balloon is through a small
tube attached to a subcutaneous port. The band is
left empty at time of surgery but is thereafter
gradually filled with fluid by injection through
the subcutaneous port. It is thus possible to
vary the opening in the stomach after surgery.
The
balloon band system can be regarded as putting a
straight-jacket on the stomach. The band induces
an early feeling of satiety and thereby decreases
food intake. Our method as well as other methods
for obesity surgery does not however change the
basic patient behavior pattern. If the band is
removed the weight will quickly increase to what
it was before surgery. This means that the
operation is not a definite solution to the
patient eating pattern or the problem of morbid
obesity. It however induces sustainable weight
loss and therefore it leads to a healthier life
with less risks for obesity related secondary
diseases.
How
is AGB Performed?
In the adjustable gastric
banding method a band is applied around the
stomach about 20 mm below the gastro-esophageal
junction. On the inner lining of the band there
is a longitudinal balloon (like a bicycle tire).
This balloon is through a small tube attached to
a subcutaneous port. The band is left empty at
time of surgery but is thereafter gradually
filled with fluid by injection through the
subcutaneous port. It is thus possible to vary
the opening in the stomach after surgery.
In most cases the band is
applied through open surgery, but we have
recently also started to develop laparoscopic
application of this band. The total experience in
Sweden is now about 1000 cases. About 100 of
these have been put in place using laparoscopy.
The first patient was operated in 1985 and the
method has since then developed gradually. Today
we can expect that approximately 75% of the
patients will loose 75% or more of their
overweight within 18 months after surgery. Recent
results indicate that weight loss is sustainable
since most patients have the same weight at four
years as at two years after surgery.
Are
there any short-term side
effects of the operation?
Vomiting
Most patients will
once or twice feel pain or vomit after intake of
food. This is in most cases caused by eating too
much and too quick. If eating is slow and calm,
patients will learn to listen to the signals from
the stomach. Eating should be abandoned if the
patient feels nauseated, have pain or vomits.
Regular vomiting is a sign of warning. This can
either be caused by wrong eating behavior or
be caused by the outflow of the gastric pouch
becoming too narrow. This means that the balloon
may need to be adjusted. Regular vomiting should
be discussed with the physician in charge and
corrected.
Constipation
Many patients feel
constipated after surgery. This is mainly caused
by the fact that the reduced food intake leads to
less feces and it is thus normal with fewer bowel
movements. If laxatives become necessary, it is
advisable to abstain from so called bulking
agents and instead use liquid laxatives, such as
lactulose.
Hair loss
Many patients are
suffering from increased hair loss during the
first six months after surgery. This is also
caused by the relative starvation. This however
never leads to baldness and normal hair growth
will eventually return.
What
complications may occur?
Adjustable gastric banding
is well tolerated by most patients. Complication
rates are low but this does not mean that
complications are non-existent. The following is
list of the complications that have been seen
following this operation;
Infection
There has been a few cases
of deep infection in the abdomen leading to
removal of the band. There has also been some
infections of the port system leading to removal
of the port. These events must be regarded as
failures of the operation. Sterility during
injection is obviously of great importance in
order to minimize or avoid this complication.
Band Problems
Three bands broke early in
our series. Since then the band has been
reinforced with additional Dacron mesh and this
complication has since then not occurred. In five
other cases the balloon has broken and these
patients immediately started to gain weight. The
balloon has also lately been reinforced in order
to withstand increased pressure. All these cases
had to be reoperated. Although we have now
improved the implant it must be pointed out that
a definite guarantee against technical problems
like these can never be given.
Band Migration
There are two types of
bands that we use. There is a Swedish band (sold
by Obtech AG) and a French band (sold
by Lowate AB). Migration occurs when the band and
balloon migrates through the stomach wall into
the stomach lumen. These cases are outright
failures and these patients have quickly regained
their preoperative weight. This has so far
occurred in about 3% of the cases when the
Swedish band has been used. With the French band
there are no migrations at this point in time.
The French band has however been used much
shorter time and since migration usually does not
occur until 18-24 months after surgery it is too
early to say which band will be the better in
this respect. Patients who have their bands
filled quickly and with high total volumes have
an increased risk of migration. Filling must be
slow and gradual. Total volumes over 9 ml should
be avoided with the Swedish band and 5 ml with
the French band. If these guidelines are observed
the frequency of this type of complication will
decrease.
Port Problems
There has been
port problems in about 4% of the cases. There has
been two types of problems. The first is
dislocation of the port. It may move around, turn
up-side-down and can in this position not be
injected. It is thus necessary to adjust it. This
is a simple operation in local anesthesia but
nevertheless a nuisance to the patient. The
second problem is perforation of the connecting
tube close to the port. Some patients have extra
fat over the chest and it is therefore sometimes
difficult to hit the ”bulls eye” with
the needle and the tube may be accidentally
perforated. This leads to loss of fluid, widening
of the opening and subsequent weight gain. This
is also corrected in local anesthesia. The port
is brought to the surface, a bit of the tube
including the hole is cut off, and the remaining
tube is reattached to the port and finally the
port returned into position. The design of the
system has because of this problem been changed.
The distal 2 cm of the tube is now covered with a
protective sleeve in order to avoid this problem.
What
is the long-term success rate?
There
are various reported success rates for different
types of procedures and there is never a
guaranteed 100% success rate.
What
is Gastric By-Pass?
This
procedure creates a short-cut for
"trafficking" of food through the small
bowels. This reduces the overall food
absorption. This leads to weight loss in
most patients.
Several
different techniques have been developed.
One
method currently used is to place staples around
the upper part of the stomach. The
"pouch" formed by the staple line is
cut off from the rest of the stomach and
connected with the approximate 100-120 inch
end-portion of the small bowel.
Weight
loss with this procedure is caused by early
satisfaction by temporary retention of food in
the stomach pouch and by reduced absorption as
the food bypasses most of the small bowels.
When
is a person considered obese?
Recommended BMIs
are in the range of 20 to 26. The
"overweight" range is 26 to 27.3 for
women, 26 to 27.8 for men, though some
authorities peg the upper limit of overweight at
a BMI of 30.
Most authorities
say that "obesity" begins at BMIs above
27.3 for women and 27.87 for men. All authorities
agree that anyone with a BMI over 30 is obese.
According to these conventions, the woman who is
5' 0" and weighs 155 has a BMI of 30.14, and
is obese.
Someone who is 5'
4" and weighs 155 has a BMI of 26.6, and is
overweight, but not obese. Someone who is 5'
11" and weighs 155 is in the healthy BMI
range.
Morbid obesity
means being overweight to the point of being
prone to disease. You are considered morbidly
obese if you are more than double your ideal body
weight or more than 100 pounds overweight.
I had
2 stapling surgeries done. Both surgeries have
not been successful because my stomach is too
muscular and the staples leak. I was also
scheduled to have the bypass but they denied me
because of my previous history. Now I want to
know if I can have AGB done or if my previous
surgeries will affect this?
It is indeed
possible. But you should probably have a by-pass
later when you have lost weight and are down to
more normal weight. A previous VBG including
stapling does not in principle prevent a patient
from having a later adjustable band. I have done
a number of those. However - the results have not
been as good as I wanted them to be. Patients
tend to loose 50-60 pounds but not the 100 or so,
which I see in most primary patients. I am not
sure about why this is so - but it is
nevertheless my experience. I am still doing
adjustable bands on top of a VBG but fewer and
fewer. I think a by-pass is the best secondary
operation to a failed VBG. It is not very
difficult to do and it seems to work well. The
weight ends up within the normal interval in
almost every case.
I
would like to know if after I have AGB surgery,
how long would I have to wait to have children
and then how can I increase the intake of my
foods to nourish my child?
There is no
problem with pregnancy and birth after obesity
surgery. It is good to wait about 6 months so
that you get over the first phase of rapid weight
loss after surgery. There are no special dietary
requirements after surgery. The rule is that the
baby always takes what he/she needs. So, you can
feel confident that there are no problems with
pregnancy should you decide to have surgery.
What
is the difference between a Roux-en-Y and a
Gastric by-pass?
A Roux-en-Y is a
gastric by-pass! A gastric by-pass means that you
cut the stomach high up so that you separate the
stomach in two parts - a small upper part and a
large lower part. The upper part is then
connected to the small bowel a bit downstream on
the small bowel. The larger lower part of the
stomach is just left lying idle. It is out of the
food circulation and will never again be filled
with food. So you end up with a small stomach and
a shorter bowel. This means that you will feel
full more quickly (because of the small stomach)
and that you will absorb less of the food
actually eaten (because of the shorter bowel).'
Now - the small upper part of the stomach can be
connected to the small bowel in a number of
different ways: antecolic GE, retrocolic GE, with
or without enteroanastomosis (EA), Fobi pouch -
and Roux-en-Y. So the name Roux-enY is not a
separate operation - it is just a technical
description for the model for connecting the
small stomach to the bowel. All of these
(including Roux-en-Y) are gastric by-pass
operations.
I have done many, many gastric by-pass operations
including Roux-en-Y. I did three the week before
Christmas. I did one yesterday, one this morning
and I will do one tomorrow! My standard way for
connecting the stomach to the bowel is in fact a
Roux-en-Y anastomosis. So - you are welcome. You
can expect to be in hospital for 4-5 days. Then
you have to stay in hotel here in Stockholm for
another 4-5 days before you are fit to go home.
You can of course also choose a gastric banding
operation, which is a bit less invasive. But - if
you have set your mind on a by-pass we can do
that.
I am
very concerned about possible complications with
AGB.
The risk for
initial postoperative complications is very, very
low. Of course it exists - but so does being hit
by a car while crossing the street.
The most important thing is not really the
surgery itself. This is very straightforward and
simple. The factor determining final outcome is
the post-op. follow-up and patient compliance.
The patient has to work with the band, listen to
it and behave accordingly. Patients who fight the
band are not doing as well as those who are
compliant.
What
is the true success rate without any
complications?
About 85-90%.
There are three reasons for failure. First,
patient-related reasons: Some patients go over to
liquid high-calorie diet (cream, ice-cream,
chocolate etc.). Second, band failure (leakage,
breaking etc.). Third, placement failure or
dislocation of the band (slippage, pouch
dilatation, wrong initial placement = surgeon
error).
How
many have had an extended stay due to
complications at surgery?
One patient has
stayed 4 days during the last 5 years. Everyone
else 1-3 days. No patient in intensive care.
What
is the total number of deaths you have had in
your practice?
No deaths after
either laparoscopic or open surgery. With the
Swedish band (more than 10.000 carried out in
Europe) there has as far as I know not been a
single death.
Do you
have problems with dehiscence of the wound after
surgery and what is the rate of infection you
have noted with this procedure? I am concerned
about the healing process after the surgery.
Wound dehiscence
is not possible after laparoscopic surgery. The
holes are just not big enough. After open surgery
about 0,5%. Wound infection almost does not exist
after laparoscopic surgery. After open surgery
0,5% or maybe even less. I have not had any
infections during the last 5 years.
Is
there any scaring after surgery?
There is minimal
scaring after laparoscopic surgery. However - if
you loose 100 pound you will need a tummy-tuck.
That produces a long scar along the entire
abdominal midline. After a tummy-tuck the scars
will thus look the same whether you have had
laparoscopic or open surgery.
How
many days in the hospital, and how much down from
work is necessary?
One night in
hospital for laparoscopic and two nights for open
surgery. The patient normally spends up to a
total of 3 days in the hospital, and can
generally be back at work within 10 days.
I can no longer walk due to foot
injury from weight. I weigh 748 lb. I am now also
on oxygen due to asthma and difficulty in
breathing. Can AGB be performed while I’m
awake? Help.
I am sorry to tell you that
the procedure cannot be carried out while you are
awake. You are also too big to be transported.
You must seek medical advice close to home. You
should probably be admitted to hospital or at
least a nursing home and have strict dietary
restrictions for a couple of months. You should
also have diuretics because I am sure that part
of your weight problem is edema. After that you
will probably be 600-650 pounds. Then you should
have a band, which is simple and safe. That will
bring you down to 300 or 350. You should then
have a second operation and do a distal by-pass.
This could work but it would have to be done
close to home.
Can
the port used in AGB produce allergies or
infections?
There
are several different types of ports; basically
they are either plastic or metal. Allergy to
either of these two materials probably does not
exist. I have never heard of it. If you have
problems with the port it is therefore always due
to infection. This may be anything from a very
virulent to a very slow infection. If you once
get bacteria in there it is very difficult to get
rid of them. I have done well over 1000 bands and
has never seen allergy. I have port complications
in about 1% of patients over a 5-year observation
period. The only thing to do is to take out the
port, tie the tube so that it does not leak and
then 2-3 months later (when everything has
healed) put in a new port in a different
location.
Statement: In 1994 I had a
gastric banding done (a non-adjustable one). The
surgery worked for a while, but has since failed.
I have gained all weight back plus more. I have
gained all weight back plus more (600lb). I
am willing to do anything to get my weight under
control.
There has been a lot of
water under the bridges since you had your
operation. The technique is now different and
today you would have a much better outcome. You
are however in a weight category that is
difficult to manage with just one method or one
operation. You should probably today have first a
band and when you are down to about 300 a
by-pass. The band is a restrictive method and the
by-pass a malabsorptive method. If you are 600+
you need to combine the two.
I had gastric bypass surgery
approximately three years ago. I initially
lost weight quickly going from 294 to 210 within
the first six to eight months. Now three years
later, my weight ranges between 229 and 334 and I
can't get it to go down. I find that I am
hungry all the time and I can eat almost as much
as I did before the surgery.
I am sorry to hear about
your story. Indeed, most patients who undergo a
by-pass will have a good outcome. Most of them
end up with a BMI between 25 and 30 with more
patients closer to 25 rather than to 30. Your
present BMI is a bit over 38 which means that you
(in medical terms) can be seen as a treatment
failure. Now, there are a number of possibilities
to explains this. There may be a technical
failure (something has gone wrong inside of you)
or there may be no technical failure (you are
basically still eating much too much). You should
be evaluated first to check if something has gone
wrong. This can be done by x-ray. If everything
is technically OK, the only explanation is that
you are eating too much. If this is the answer,
the next issue is if this should be treated
medically (by some kind of diet with or without
pills) or surgically (move the small bowel
by-pass loop further downstream or add a gastric
restriction to your previous procedure).
This was just a summary of how I see your
problem.
I had obesity surgery 20 yrs.
ago. I started gaining weight after a car
accident. I was hit in the stomach by the
steering wheel, and it felt like something came
undone. Is this possible? Could it have come
undone?
First, I am sure that you
had a VBG (vertical banded gastroplasty) done to
you because that was by far the most popular
operation back in 81. Second, I am sure that it
was undone when you were hit by the steering
wheel. So basically you are now without obesity
surgery. Your previous operations are as I see it
not contraindications to doing revisional
surgery. I think you should have a gastric
by-pass. With a bit of luck (you have not had
much of that!) it would bring you down to a BMI
of about 26-28.
My brother has
diverticulitis. Does this affect his chances of
having obesity surgery?
Diverticulitis is a problem
of its own. It is not a contraindication for
having obesity surgery. He should however have a
by-pass and not a band. A band is an implanted
foreign body and thus a bit sensitive from an
infection point of view. In by-pass there is no
implant. In fact, after a by-pass the
diverticulitis is probably going to improve. Also
- if there is a need for surgery for
diverticulitis this is easier after a by-pass and
a successful weight loss.
I am confused regarding my
eligibility for obesity surgery. I am a
compulsive over-eater and have gained 80 lbs in
the past 5 years. Dieting and exercise have not
been successful. I am on my way to becoming
morbidly obese. Does it make sense that I have to
develop serious health problems and/or gain 50
more lbs. to become a candidate? My BMI is 33.
The overall indication is
that the weight should be so high that it
statistically can be proven that the patient has
a significantly increased risk of dying compared
to a normal weight individual. There is a lot of
statistics on this and it seems as if the body
can compensate for an increase until you reach
BMI 38. Thereafter the risk increases very
rapidly. So - most health authorities in the
world (including the FDA in the USA) are not
recommending obesity surgery if you are less than
BMI 38. There are some exceptions. If you have
additional risk factors (that may be related to
obesity) such as hypertension, diabetes etc. the
authorities recommend surgery down to BMI 35. I
have operated a patient myself who had a BMI of
33 but she had all of the above as well as some
other serious complications. On the other
hand, over BMI 38 the risk increases very
rapidly. I usually tell my patients the
following: A 40-year old women with a BMI of 40
has the same risk of dying before age 50 as a
40-year old woman with a newly detected breast
cancer. So - obesity is dangerous once you have
crossed the line - but not so much before that.
Two months after surgery, I
experienced some pain. I spoke with a doctor and
it turns out it was my gall bladder! So I guess
nothing to worry about. Sure was painful though.
Now for sure I won't eat things I'm not suppose
too! Is this common?
At a recent conference, a
recent French study showed that about 20% of
patients having undergone obesity surgery develop
gallstones within the next 24 months. The French
had looked at this problem in detail and their
conclusion was that quick weight loss changes the
balance between the various salts in the bile.
The result is that the bile becomes
supersaturated with cholesterol (obese patient
have a lot of that!) and the cholesterol
crystallizes and forms stones in the gallbladder.
Many of us have seen this in patients but we have
not had the numbers clear and there has never
been such a good and detailed study about it
before. An obvious discussion was of course if we
should automatically take out the gall bladder in
all patients undergoing obesity surgery. There
was no distinct answer to this question. It is
obviously of benefit in 20% of the patients - but
in 80% you take something out without a real
reason. So - this is a difficult ethical issue.
The last word has obviously not been said yet.
I am
writing in regards to my youngest son who is 11
years old and weighs 47lb. Help me, please. I am
desperate. I have visited with a local
bariatric specialist. He will not perform
an AGB or anything else on a youngster. I just
know if he was given a jump start on weight loss
through the AGB or other recommended procedure
that he would be dedicated to reaching his
healthy weight and maintaining it. Why would
anyone want him to continue in such miserable and
dangerous physical state?
One of the issues often
discussed at obesity conferences is obesity
surgery on children. The experience is not great
but there is some information. There is total
consensus that procedures that are malabsorptive
in nature (i.e. by-pass) should not be carried
out in children irrespective of the child's
weight. The reason is that malabsorption would
probably affect the growth and development of the
child. There was also consensus that gastric
restrictive procedure (i.e. gastric banding) can
be carried out but rarely and only after thorough
evaluation of the child. There are two new papers
about the psychology of children undergoing
obesity surgery. These papers both reported
severe mental depression in several children
undergoing surgery. Many obese children seem to
have underlying psychological disturbancies and
use food as a way to control anxiety. The food is
that child's Prozac. So when you do obesity
surgery you deprive that child of his/her Prozac
and they go into deep depression. There was even
reports of a couple of young kids that had tried
to commit suicide after obesity surgery - luckily
they were not "successful" in their
attempt. Another "recommendation" was
that it is probably wise to postpone surgery (if
possible) until the child is 15 or 16 because
then most of the development phase is over. So -
we must approach this with great caution. I will
based on what I heard in Greece talk to doctor
Marcus again and get his views. If we are going
to do this there are also a couple of conditions.
First – you must have a doctor who is
willing to do the technical follow-up (filling of
the gastric band etc.). Second - you must have a
good contact with a child psychologist or
psychiatrist who is willing to closely monitor
your child after surgery.
I had a gastric bypass surgery in
1977. I went from 285lb to 180lb and felt great.
Now I am back at 242. I am wondering if it is
possible to have gastric banding now?
I am a bit surprised to
hear that you had a by-pass and the preop weight
has now returned. This usually never happens with
by-pass. My suspicion is that you had a
gastroplasty (VBG) and that you now have a
so-called staple line disruption. Your weight
curve is typical for this. If you had a VBG
before you should not have a band, you should
have a by-pass. If you really had a by-pass it is
possible to put a band on top of that and induce
new weight loss. My recommendation is that you
start by getting hold of a copy of your operative
report. A decision can be taken after reviewing
it.
I have been turned down as a
candidate for Lap Band because the doctors are
concerned about two issues: 1) I take
immunosuppressant (prednisone and cyclosporine --
either of which I could go off of for a time, but
neither of which I can give up permanently) and
2) the Lap Band is made of silicone and is
therefore contraindicated in autoimmune patients.
As I understand it, the Swedish band is also made
of silicone. Presumably it would have the same
problem. What about the French band? What is the
material? Are there any of these bands that
you would recommend for a lupus patient?
There
are now 5 or 6 different bands. The Lap Band is
the only one approved in the US. The others have
not applied yet. All are made of silicone. So I
guess you will have the same problem with all
brands. Gastric by-pass is of course an option
but since you are on steroids the operative risk
is something you have to count with. Healing is
more difficult when you are on steroids.
I am planning on having at least
one more child in 1-2 years. I understand from
the literature that there shouldn't be any
problems. Have you had many patients
conceive normally and deliver without
incident? Have there been any complications
that you are aware of?
Having a child is no
problem. It is in fact often easier to conceive
after obesity surgery than before. One of the
complications of severe obesity is irregular
ovulation and irregular periods. Some women even
loose their periods all together when they become
real obese. So - absolutely no problem with
having a child.
Generally, how long is
the incision with open surgery?
The incision with open
surgery will be in the midline from the rib cage
to the belly button. The incision is as I see it
not a big deal because you will probably need a
tummy tuck sometime later. At that time you will
get a lot of new scars. These will however look a
bit "nicer" and the old scars will be
taken away.
How does the body know when to
stop losing weight? (I don't want to
look anorexic)
Food is the same thing as
gas in your furnace. If you have a bigger house
you need more gas to heat it. If you have a small
house you need less. So - every human being
sooner or later reaches a steady state in terms
of weight. You will continue to loose weight
until your intake is equal to what your body is
consuming. The smaller you get the less you
consume, and eventually you stop loosing weight.
We know, from experience, how much bowel should
be out of loop so that your intake is on an
appropriate level.
Will you remove any adhesions
that I may have from previous surgeries?
Thank you for taking the time to respond.
You should preferably do as
little as you can with adhesions already present.
Every time you open the abdomen you get
adhesions. For each time they get thicker and
thicker. The more you cut them or touch them the
thicker they get. So - if you attempt to
"clean out" adhesions the result will
be that you get more adhesions. You should leave
them as much as you can and be as gentle as
possible to the tissues. The more gentle you are
the fewer adhesions you get.
A friend told me that the reflux
and heartburn I have now will be 10x worse after
the surgery even if I eat the protein as
suggested and the extremely small portions as my
life style changes?
The heartburn you have
right now is caused by reflux of gastric juice up
to the esophagus. The acid in the gastric juice
is not produced in the whole area of the gastric
mucosa. It is produced in something called
parietal cells. The upper limit of presence of
these cells is about 2 inches from the
gastro-esophageal junction. The band is placed
above these cells. This means that the band
actually prevents acid from running up in the
esophagus. The second factor of importance is the
hiatus (the opening in the diaphragm through
which the esophagus goes up into the thoracic
cavity). In most individuals the hiatus is tight
and no gastric juice is allowed to pass up into
the esophagus. In many obese individuals the
hiatus muscle becomes slack - so reflux is
actually a complication to obesity. When we
perform gastric banding we usually tighten the
hiatus muscle with a couple of sutures. The
result of both these factors is that obese
patient who have esophageal relux in most cases
experience an instant relief of those symptoms
after surgery. The hiatus is tightened and the
band prevent the acid from running up. Reflux
disease can occur later as a result of
dislocation of the band. If the band moves down
it comes below the upper limit of the parietal
cells and acid is produced above the band
resulting in reflux. This nowadays not so common
and we always try to prevent dislocation of the
band by suturing it in place.
If I got pregnant in the
future would the baby receive enough nutrients
from me?
Oh yes - no problem. You
will in fact have easier to become pregnant and
your child will be healthier because you will
have lower blood sugar.
Will my hair fall
out?
You will have increased
hair loss but it will come back once the weight
has stabilized.
Will I have excess flab
all over my body and need cosmetic surgery later?
You will probably need to
have a tummy tuck later.
How soon after the surgery will I
be able to start exercising? Will I be able to
return back to work in 2 weeks?
As early as possible with
gradually increasing intensity. After 4 weeks
everything should be normal. Probably not 2
weeks, 3 weeks is more realistic.
Is the solution used for the
filling the same for the LAP-band and the Swedish
band? Saline solution or a contrast medium?
There is no difference
between filling a band with saline or a radiology
contrast medium. The result is the same. The
difference is just that if you decide to do an
x-ray for some reason the band can be seen. So it
is just for convenience. You do not really need
fluoroscopy to do the filling, but some doctors
feel more comfortable using fluoroscopy when
doing the filling.
I have heard that, after
AGB surgery, I can only drink water a
little at a time. Does it mean that the intake of
liquid water or others is forever restricted to a
little at a time or do we at some point regain
the ability to drink a glass of liquid in a usual
and normal way?
No, it is just during the first 3-4 weeks after
surgery. Later you can take more at a time,
although you will have problems if you take a
full glass in one big "gulp"! It
will "return to sender", in particular
if it is cold. Moderation is always the key word
after obesity surgery.
I have Sjögren's
Syndrome. Is this a problem for obesity surgery?
Generally no. In some cases patients may be on
high doses of steroids and then the medication is
a problem. I decide in the individual case based
on the level of medication that the patients are
on.
Someone said that once
you have reached your desired weight after AGB
and you don't need to loose more weight, the port
and the connecting tube to the band can be
removed, leaving the band inside. Is this true?
Yes and no. You can take the port out but then
you have to seal the tube with all fluid inside -
and then you can't adjust the band. To do that
you have to put in the port again. We never do
that.
FREQUENTLY
ASKED QUESTIONS CONCERNING
AGB AND ANSWERED BY DR. FRERING
I am a
compulsive and emotional eater - do people that
eat for these reasons have as much success as the
ones who just happen to have large appetites (and
aren't compulsive)? I fear that this band
will not work for me because one of my worst
compulsive tendencies is to eat ice cream, which
doesn't seem like it would be restricted by the
band.
The results might be inferior, but there is no
rule. I have patients with the same problem who
have had excellent results.
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