FREQUENTLY ASKED QUESTIONS ABOUT LAPAROSCOPIC BARIATRIC SURGERY

OK, SO WHAT DOES THIS SURGERY INVOLVE?

IS GASTRIC BYPASS A NEW SURGERY?

WHAT DOES IT MEAN TO HAVE A SURGERY DONE LAPAROSCOPICALLY?

AFTER GASTRIC BYPASS HOW LONG WILL I BE RECOVERING?

WHAT CAN I EXPECT FOR WEIGHT LOSS AFTER GASTRIC BYPASS?

IF I DON'T LIKE IT, CAN A GASTRIC BYPASS BE REVERSED?

What happens to the majority of stomach that is stapled away?

WHAT ARE MY RISKS WITH THE BYPASS PROCEDURE?

CAN GASTRIC BYPASS SURGERY FAIL TO PROVIDE ME WITH SIGNIFICANT WEIGHT LOSS?

Why do patients do this?

What can you tell me about a surgery I have heard about that place a band around the stomach to help lose weight?

How CAN I ENROLL IN THE PROGRAM?
 

OK, SO WHAT DOES THIS SURGERY INVOLVE?

Laparoscopic Roux-en Y Gastric Bypass (Figure #1)

Laparoscopic Adjustable Silicone Banding (Figure# 2)

Surgical treatments to promote weight loss have been around for many years. Many of the procedures involve making your stomach extremely small, and then limiting the small stomach's ability to empty. Therefore you feel full with much less food. Even if you wanted to eat more, you can't. You would make yourself sick trying.

Other surgeries for obesity involved bypassing much of your small intestine. When you bypass the small intestine, the body's ability to absorb calories is decreased. The problem is that if you bypass too much intestine, you can become extremely malnourished and develop life-threatening illnesses like liver failure. Surgery to bypass this much small intestine is therefore not done anymore.

Gastric bypass surgery combines a little of both the above procedures, but should be considered to be primarily one that produces restriction. In this procedure, the stomach is made extremely small (1-2 ounces), and then that small stomach is reconnected or bypassed to a point lower down on your small intestine (see enclosed figure #1).
Another surgery that is offered by us is called the Lap-Band (see figure #2). In the Lap-Band procedure a small silicone band is placed around the top portion of the stomach to create a small stomach pouch and more restriction to food passing (more on this procedure later).

Important to remember is that with either surgery, you will have a new relationship with food. Due to the smaller stomach, you will no longer be able to sit down at a meal and have a large or even averaged sized portion. For gastric bypass, the food you eat will not be completely absorbed due to the bypass of part of the small intestine.
 

IS GASTRIC BYPASS A NEW SURGERY?

The gastric bypass procedure has been around for several decades. It appears safe compared with other weight reduction procedures of the past. In fact, many studies suggest it is superior to other procedures for initial and long-term weight loss. What makes the surgery such a talked about procedure today is the escalating problem of obesity in this country and the ability to perform the surgery laparoscopically.
 

WHAT DOES IT MEAN TO HAVE A SURGERY DONE LAPAROSCOPICALLY?

Laparoscopic surgery involves operating through tiny incisions. A camera is placed inside your abdomen through one small incision, and the surgery is then performed by introducing surgical instruments through other small incisions. There are many benefits in having small incisions. You should have less postoperative pain, you will recover more quickly, and you will have much less chance of wound complications (infection, hernia) than if you had a large incision. You must understand, however, that at any time during a laparoscopic procedure, there may be a need to make a larger incision to complete the gastric bypass. Conversion to an open procedure can be due to scar tissue from previous operations, bleeding, differences in your internal anatomy that make the bypass more difficult, or even equipment failure. The chance of needing a conversion is about 1-2%. Remember, it is more important to have a safe operation than one involving small incisions only.
 

AFTER GASTRIC BYPASS HOW LONG WILL I BE RECOVERING?

If you are able to have the procedure done laparoscopically, you may be able to go home as soon as 48 hours after surgery. You should have only mild to moderate pain that is well controlled by medicine. You will have an IV pain pump that you control for the first 24-36 hours before you are switched over to pain medicine taken by mouth. You will wake up with a drain coming out of your abdomen and only rarely one coming out your nose. You will be expected to rapidly advance your activity level (this is very important in decreasing the chances of some serious conditions including pneumonia and blood clots). Within a week or two you should be feeling less tired, and your mobility will be about the same as before surgery. Most patients will require about 4 weeks to return to work. You will be allowed to have some liquids on the first day after surgery and there will be a gradual increase in the amount of liquids over the first few days. You will not be on solid food for many weeks. You may experience a long period of time where solid or even soft food causes nausea, vomiting, and discomfort. Of course, if you need to have your operation performed through a large incision rather than the laparoscopic method, your overall recovery especially out of the hospital may be slowed by days to weeks.
 

WHAT CAN I EXPECT FOR WEIGHT LOSS AFTER GASTRIC BYPASS?

Studies of bypass patients reveal that they can expect to lose between 60 to 70 % of their excess weight within12-18 months. Most will keep off significant weight even beyond 5 years (>50% excess). Some very motivated individuals may be able to maintain greater than 80% loss of their excess weight. To these individuals the surgery is only the start of a healthy new attitude that also combines:

1. Wise food choices to fill but not overfill (stretch) the new stomach pouch, and
2. A mild to moderate exercise program. Conversely, an unsuccessful person will likely make poor quality and quantity food choices as time passes.

The initial time period (up to 12 months) after the surgery is when weight loss is easiest. Therefore, during this time it is of utmost importance that you focus on developing and solidifying new, healthy eating and exercise habits and work hard to eradicate old overeating patterns. Remember you should not go into this surgery thinking that this drastic surgery will ever allow you to eat like you do now and still lose weight. If you keep pushing the stomach pouch to accept significant volumes of food, then over time you will stretch your stomach and regain your weight.

In addition to improving overall quality of life, many post operative patients will see improvement or even resolution of medical illness brought on by obesity (including sleep apnea, diabetes, high blood pressure, and arthritis). Most will enter into a category of weight (BMI<35) in which the risk of major illnesses or sudden death is not much higher than in the general population.

You will be closely followed in the postoperative weeks, months, and years. You must be committed to these follow up appointments with medical, surgical, behavioral, and nutritional staff. Not only is safe weight loss dependent on these follow-ups, but so is your also your ability to permanently keep the weight off. Bypass surgery can finally give you the capacity to avoid food and begin the weight loss process, but long- term success will be dependent on modifications in your behavior, nutrition, and physical activity.
 

IF I DON'T LIKE IT, CAN A GASTRIC BYPASS BE REVERSED?

The bypass procedure should be considered a permanent change. The bypass procedure involves cutting and reshaping your stomach and small intestine. Any reversal of it would be extremely difficult, but not impossible. Any reversal procedure would need to be done through a large incision and would pose significant medical risks.
 

What happens to the majority of stomach that is stapled awaY?

This portion will remain with you (see figure #1). It will continue to make gastric juice that will mix with bile and other digestive juices before emptying back into the intestine downstream. At that point it will meet with the food coming down from the small pouch. It would appear from long term studies that there is no increased risk of any problems in this cut away stomach. If some time in the future there were problems suspected in the old stomach, it may have to be investigated by an open or laparoscopic procedure (an endoscopy through the esophagus can no longer reach this portion of the stomach to view it).
 

WHAT ARE MY RISKS WITH THE BYPASS PROCEDURE?

Risks can be classified as intraoperative (during the operation), early postoperative (first week), and late postoperative (after leaving the hospital).

Intraoperative risks are similar to that for any surgery. They involve risks related to the anesthesia, bleeding that may require transfusions, and injury to surrounding abdominal structures that can occur with surgery. Most of these injuries are non-life threatening, but may delay your recovery significantly.

Early postoperative risks may include death, bleeding, wound or intra-abdominal infection, lung problems including pneumonia, heart problems including heart attack, and blood clots. One of the more serious and recognized problems with this surgery is called anastomotic leak. Any place that the bowel is cut and then fashioned back together is called an anastomosis. A leak of bowel contents is possible from any of these places. Leaks may be managed with bowel rest (nothing to eat) and antibiotics, or they may require another operation to fix the problem.  The incidence of death is <0.5%, with other major complications including leak around 2%.

Late postoperative risks can be from many sources. The wounds still carry a risk for infection or hernia. You may have significant problem with your ability to tolerate solid foods due to pain, nausea, or vomiting. You may develop reflux, ulcers, bowel obstructions, gallbladder stones, diarrhea or strictures (narrowings) of the anastomosis (areas where the stomach or small intestine are sutured or stapled together). Many problems can be corrected, but some may require a second operation. Many will experience nutritional disturbances in the postoperative period (malnutrition, vitamin deficiency, calcium deficiency, anemia). Most are controlled with supplements, diet change and close follow up.

Other complications/risks include:

1. Kidney stones

2. Abdominal cramping/gas

3. Dumping syndrome - inability to tolerate sugar and/or simple carbohydrates in anything but small quantities. The condition is seen in about 70-80% of patients in their first year after surgery. Patients may experience a range of symptoms including abdominal pain, bloating and cramps, diarrhea, weakness, dizziness, headache, and low blood sugar levels. Dumping tends to function as an aid to weight loss for many patients because of the foods they will need to avoid. Most (but not all) patients eventually resolve dumping symptoms by 2 years.

4. Neuropathy - from poor absorption of certain vitamins

5. Osteoporosis - from poor absorption of calcium 6. Miscarriage or birth defects – females of child bearing age need to avoid pregnancy during the period of acute weight loss (at least 18 months). After that period, it will be safe for you and your fetus to sustain a normal pregnancy.

7. Liver function abnormalities

8. Redundant skin folds from weight loss - a very common condition that may need to be dealt with by another operation (plastic surgery). This surgery may be classified as cosmetic and not necessarily covered by insurance.

CAN GASTRIC BYPASS SURGERY FAIL TO PROVIDE ME WITH SIGNIFICANT WEIGHT LOSS?

Unlikely, but over the long term you could gain back weight. Undoubtedly, this surgery will give you dramatic weight loss results through the power to reject large volumes of food, and these results should last a lifetime. But this surgery's ultimate success, to a large part, is dependent on you.
Some patients in time can learn to "out eat" the bypass. These patients may cause significant stretch of the tiny stomach pouch to allow them to eat much more than is reasonable (these patients are always trying to eat to much at one setting). Some patients may not be able to shed the overeating of high sugar or carbohydrate foods. This is particularly seen in patients who don’t have or eventually lose the "dumping syndrome". These eating patterns will obviously cause weight regain as sugar items are quite easily passed and absorbed by the intestine and converted to fat by the body.

Why do patients do thiS?

Frequently they do not put adequate effort into making the required behavioral changes and do not stay involved in the recommended follow-up treatment. Patients who no longer pay attention to their eating habits are at a great risk for regaining their weight. Patients who fail to maintain their weight loss may also have psychological issues that make them dependent on food and/or weight, such as the use of food for comfort or to deal with personal problems. In addition, significant stress can occasionally develop when a person who has been overweight for many years suddenly becomes thinner. For instance, some people may not find themselves as happy as they thought they would be, may feel uncomfortable receiving attention from the opposite sex, or may feel anxious about no longer being able to use their weight as an excuse for not doing or achieving certain things. Partners of individuals who lose large amounts of weight may feel threatened by their significant other's increased attractiveness, and can attempt to sabotage their weight loss. For all of the above reasons, close follow-up is crucial for your success. It can identify not only nutritional and medical problems, but also the behavioral and psychological issues that could lead to your failure to keep weight off.

What can you tell me about a surgery I have heard about that place a band around the stomach to help lose weighT?

Figure A

The procedure is called adjustable gastric banding and it is frequently done laparoscopically (you may see it described on the internet as the LAP-BAND). To learn about the procedure in detail click here.

In brief, it involves placing an inflatable silicone band around the upper stomach (see figure A). When progressively inflated over a span of many months, it effectively creates a small stomach pouch with a very narrow emptying site (like a tight belt). The inflation of the band takes place by placing a small needle into a port under the skin in your upper abdomen. It has been used for many years internationally with fair to good results and most recently, excellent long term results were reported from Australia. It has been available in the United States since June 2001. The good news is that the operation does not involve cutting your stomach or rearranging your anatomy, therefore there is decreased operative and post-operative risk associated with the LAP-BAND compared with bypass. It is also a shorter operation that can be more easily reversed, and does not carry concerns about malabsorption of certain vitamins or other nutritional problems. There also is a much shorter recovery period compared with bypass.

For many people, the LAP-BAND will be a good choice and can be done very safely. It is, in general, not recommended for people who are big sweet eaters as the liquid calories (ice cream, shakes, chocolate, etc.) will easily pass through the narrow outlet created by the band and sabotage weight loss (and there is no “dumping syndrome” created with a LAP-BAND to help avoid sugar calories). The band is also less recommended in our program for people who have much more weight to loose (BMI>55) or are tremendously disabled because of their weight.

The down side for some is that the overall weight loss is much slower and potentially not as good as the gastric bypass. There are also many more visits in the first 6-8 months (5 to 7 visits) in order to adjust the band properly for weight loss. It is, however, it is a viable option offered here, at Comonwealth Surgical for the right person.
 

Inquiries about the Program can be made by calling 781-279-1123

If you are interested in becoming a candidate for this procedure, you must begin by attending our orientation support group meeting. If you remain interested, you may then proceed on. Most insurance plans will require a referral through your primary care doctor. You can find out whether you need a referral by calling your insurance carrier or primary care doctor. Be aware that you must be evaluated by all the members of our group which include a behavioral psychologist, a medical internist (your present medical doctor), a nutritionist, and then finally a surgeon.

This whole process may take many months.