The answer is no.

Prescription Medications and Drug Absorption

Patients who undergo a Lap – Band procedure will not have any of the small intestines bypassed, so they shouldn’t worry about medication absorption. Many will ask why we place them on supplemental vitamins and calcium if the upper portion of the small bowel is not bypassed like after the Roux-en-Y Gastric Bypass. The answer to that question is many patients don’t eat a balanced diet which is high in iron such as green leafy vegetables, or avoid some food groups such as milk products which are high in calcium. About one out of every three Weight Loss Surgery patients are found to have low iron, calcium or “B” vitamin on the pre-op labs we perform. In addition over 50% of women over age 50 who haven’t had weight loss surgery will develop osteoporosis in their lifetime, so taking supplements is a good idea.

Gastric Bypass patients do have around 20% of the small bowel bypassed along with the portion just beyond the stomach called the duodenum. This will decrease the absorption of iron, calcium and “B” vitamins, so they must take supplements to remain healthy. This bypassed intestine only represents around 20% of the bowel, so medications can be absorbed normally in the remaining 80% of the distal bowel. No medications, vitamins, or nutrients are absorbed in the stomach. It simply serves as a mixer to grind up the food particles into smaller pieces. This is why you must chew your food until it is almost liquid to make up for the bypassed stomach.

We are not aware of any medications that are absorbed better or worse after Gastric Bypass Surgery. We occasionally see a reduction in prescription thyroid medications, but we believe this is due to a change in the patient’s metabolism and weight loss, not a change in absorption. Requirements for other medications like for diabetes, high blood pressure or cholesterol may also decrease after Gastric Bypass due to weight loss and changes in the body’s metabolism, but it is not due to a change in absorption. Birth control pills are absorbed normally, but must be taken as prescribed. Fertility often increases with weight loss, so remember to be diligent with birth control methods the first 18 months. All methods of birth control including the pill have a known failure rate of at least 1%.

So remember, take your medication as prescribed and do not make adjustments or changes without clearance from either your Primary Care Provider or Dr. Champion. Please call our office if you have any questions.

J. K. Champion MD FACS, Clinical Professor of Surgery, Mercer University School of Medicine

Director of Bariatric Surgery, Emory-Dunwoody Medical Center in Atlanta Georgia USA

Obesity has reached epidemic proportions in the United States and Western Europe in the past decade, and has now begun to effect Asian populations as high calorie convenience “fast foods” and lack of exercise become more common in modern society. Morbid obesity now occurs in approximately 5% of western populations, and weight loss surgery is increasingly being utilized to treat the issue successfully because medical approaches have demonstrated a 95% long term failure rate. This presentation reviews the currently established surgical options for bariatric surgery with the history of their evolution, and future areas for development and research.

Current operations for weight loss are based on two mechanisms of action: either gastric restriction or intestinal malabsorption, or a combination of the two. Gastric restriction relies on a small proximal gastric pouch of less than 30 cc and stabilization of the outlet with a prosthetic band. Examples include the Vertical Banded Gastroplasty (VBG) and the Laparoscopic Adjustable Gastric Band (Lap-band) or Swedish Band. Gastric restrictive procedures are simpler to perform with less risk, but are associated with less weight loss and higher revisions rates compared to other bariatric procedures.

The Roux-en-Y gastric bypass combines gastric restriction with some intestinal malabsorption to increase weight loss, by excluding a length of proximal small bowel from the common digestive tract. Controversy exists over the appropriate length of the small bowel bypass and technical aspects of the procedure due to a lack of prospective controlled trials to objectively compare outcomes with changes in technique. Hybrid operations result in greater weight loss and more sustained weight loss, but are associated with greater risk, including micro-nutrient deficiencies and difficulty accessing the distal stomach.

Purely malabsorptive procedures like the Bilio-pancreatic Diversion (BPD) and Duodenal Switch (DS) utilize a long bypass of the small bowel to the terminal ileum to form a common channel for digestion of only 50-100 cm. While popular in Western Europe and certain limited centers in the US, they are considered experimental by most bariatric surgeons due to their high risk of chronic diarrhea and protein malnutrition.

Laparoscopic approaches to perform all the currently accepted bariatric operations have led to an exponential increase in patient and surgeon interest since 1995. The laparoscopic approach has reduced wound morbidity and recovery time from surgery.

Future areas for expansion and research include the novel introduction of Gastric Pacing and Vagal Nerve Stimulation for weight loss utilizing an implantable gastric stimulator. Endo-luminal procedures for gastric restriction which will be accomplished by a totally endoscopic approach are in the development stage and will probably be introduced with the next 12-24 months.

The field of Bariatric Surgery is currently undergoing an evolution towards less invasive techniques with a variety of opportunities for research and development.

Dealing with Emotional Hunger

Atlanta Bariatric Support Group

J. K. Champion MD FACS and Susan Champion

Hunger and eating often have nothing to do with food in patients who have the metabolic disorder called “morbid obesity”. Recognition of the lack of association between “head hunger” and a physical need for nutrition is an important step in developing a successful approach to maximize weight loss after bariatric surgery.

Emotional Eating

“Head hunger” is a popular term discussed on Internet support groups describing a real entity, which is better classified as “emotional hunger”. Food is comforting and can serve the same purpose as a drug in dealing with our emotions. This action is usually sub-conscious, but becoming aware and recognizing the behavior gives patients the power to change old habits. This process of regaining control over your life is called “behavior modification”, and it is crucial to long-term success after weight loss surgery.

The disease of morbid obesity has slowed the body’s metabolism down to the point that most people need only 1000-1200 calories daily to maintain their weight after bariatric surgery. They don’t have the luxury of eating chocolate when sad, or nervously snacking on junk food when dealing with stress, anger, or boredom. Many patients with morbid obesity are not over-eaters, but are “foragers” or “grazers”, who eat not when they are hungry, but when they are stressed emotionally. This insidious weight gain is usually around 10 pounds per year, which over a decade adds up to being 100 pounds overweight again.

Current bariatric operations (Roux gastric bypass, VBG, or Lap-band) rely on a small gastric pouch to severely limit or restrict food intake to aide in weight reduction. This limitation on food intake can create a large “void” or “hole” in a person’s ability to emotionally handle the trials and tribulations of everyday living if food has been a method of coping with stress. The utilization of food to deal with stress has nothing to do with hunger, but the brain often interprets it as hunger, because it is the only way a person may know to deal with stress. The ability to deal with sadness, anger, frustration, or boredom is called “coping skills”, and it is a learned behavior, not something we are born with like brown eyes or blond hair.

There are three changes in your life, which need to occur after bariatric surgery in order to realize the full benefit of the operation and maintain weight loss long term.

One: CHANGE YOUR EATING PATTERN:

(3 meals per day and 1 snack on a set schedule 4-5 hours apart)

The principal pattern for eating before surgery is people eat whenever they are hungry or believe they are hungry. This may be 6, 8, or 10 times per day of small amounts of high calorie junk food (carbohydrates or fats). Eating is often not related to a physical need for food, but rather in response to a mental or emotional craving for the act of eating and the comforting effect it produces. In other words, we use it to make us feel better mentally. This is emotional hunger. Ask yourself; “Am I eating this because I’m hungry, or because I’m angry, sad, or bored?”

The gastric pouch must be filled with a small amount (8-12oz) of fibrous bulky food every 4-5 hours, and remain in the pouch for at least 30 minutes to relieve physical hunger and control appetite. This means eating on a set schedule, by the clock !! It does not mean eating whenever you think about or obsess about food. It does not mean skipping meals or making excuses. It does not mean drinking fluids with meals to wash the pouch out. It does mean following directions and changing a behavior, which endangers your health and shortens your life expectancy.

TWO: CHANGE YOUR ACTIVITY PATTERN:

(exercise 5 days per week for 30 minutes)

This is a major compliance issue for post op patients. Exercise improves your energy level, releases endorphins, which reduces stress and improves your mood, it builds muscle mass, which burns more calories and tightens loose skin, and it resets your body’s metabolic rate to a higher level to drive weight loss. This requires action on a patient’s part, to set aside time to exercise and to repeat it enough to make it a habit.

THREE: CHANGE THE WAY YOU DEAL WITH STRESS

(develop coping skills to deal with stress thru outside advice)

If we could change on our own, we would! All people have stress and frustration in their lives, as it is a part of daily living. In addition, change brings on stress, so post op there are many bridges to cross in regards to food, exercise, work, and personal relationships. Many people do a poor job dealing with stress and may turn to food, which is comforting and makes us feel good. Unfortunately for morbid obese patients, food has become self destructive, and cannot be used to deal with emotional hunger. Individual or group counseling can provide insight into ways to deal with stress in a healthy fashion. Outside advice is like a mirror held up in front of us so we can see our faults and ways to change. Suggestions to deal with stress constructively may include developing new hobbies or activities, or the development of new relationships. Attendance at support groups, asking questions, talking to others and sharing your own experiences helps not only yourself, but also others present in developing a new approach to life. Remember you don’t have to accept all outside advice, just be open to look and see if it fits your situation and can it help. Instead of trying to compare and see how you’re different, look for ways how you are like others and can use their experience to grow.

The overall theme of change is activity. Success depends on action on the part of the post op patient. Relying on the bariatric operation to “do all the work” without changing eating habits, exercise levels, or ability to manage adversity, will result in failure long term. Emotional hunger will create a void, which will demand to be filled.

Will you fill the void with calories or action?

J K CHAMPION MD

POST-OP NUTRITIONAL SUPPLEMENTS AND MONITORING

Problems with nutrition or malnutrition can develop after surgery for morbid obesity. The absorption or intake of vitamins, minerals, and nutrients may be reduced enough to adversely effect your health. These problems can usually be corrected with supplements if detected early. This is why we emphasize periodic nutritional monitoring with blood tests for life, so deficiencies can be addressed. Occasionally (1/200) nutritional problems fail to respond to supplements and a reversal of weight loss surgery is indicated, although there is increased operative risk with subsequent surgery.

The purpose of this post is to emphasize the importance of taking vitamin and calcium supplements after surgery and having routinely yearly blood monitoring by our office to try and avoid complications. We are seeing a lot of patients not taking supplements and refusing to keep follow-up appointments, or be monitored by their local physician, despite everyone signing a contract to comply. Permanent irreversible damage to your health, or even death can result from failure to follow post-op instructions.

Lets review our recommendations for nutritional supplements and monitoring:

Vitamins:

Vitamins are organic chemicals needed in small amounts to assist in normal metabolism that cannot be manufactured in the body. They must come from outside. They assist our body to function normally and severe irreversible damage can occur from deficiencies

Examples

B vitamins;  thiamine B1, riboflavin B2, niacin B3, pyridoxine B6, cobalamin B12

These are needed for metabolism and effect cardiovascular and nervous system function. Deficiences can cause permanent nerve damage, which is irreversible, anemia, cardiovascular disease and heart failure, and birth defects in pregnant women.

Folic acid; needed to form genes and promote growth
Vitamin C; antioxidant

Vitamin A; important in vision and skin, also antioxidant

Vitamin D; needed for calcium absorption

Vitamin E; antioxidant and important for fertility and muscle function

Minerals:

Minerals are non-organic chemicals we need to function normally

Examples:

Iron; required to form red blood cells which transport oxygen in our body

Calcium; for bone formation and chemical messenger in heart and nerve tissue. Deficiencies cause osteoporosis

Phosphorus; important for cell activity as energy source

Magnesium; required to assist other proteins to work

These vitamins and minerals can be obtained in a good multivitamin with iron such as the Flintstones chewable we provided in the office. Other examples of good vitamins include one-a-day, Centrum, Theragram. All should include additional iron. Calcium supplements are required with 1000 mg per day. Examples are 3 Tums, os-cal , caltrate, and viactiv. These may include additional vitamin D to aide absorption.

The problems we usually encounter after weight loss surgery are with B vitamins, iron and calcium deficiencies. We monitor a complete blood count (CBC), comprehensive chemistry, iron and B12 level at 6 months, 12 months and then yearly to assess nutritional needs and make adjustments to maintain good health.

DO NOT FAIL TO TAKE YOUR SUPPLEMENTS AND BE MONITORED ON A YEARLY BASIS, OR PERMANENT IRREVERSIBLE DAMAGE COULD OCCUR!

Presented at SAGES 2004

J.K. Champion MD, Mike Williams MD

Emory-Dunwoody Medical Center, Atlanta Georgia USA

Background: The laparoscopic adjustable gastric banding system (Lap-band) underwent two multi-center clinical trials with controversial results in the United States before its approval in July 2002. We report our single center experience with the device over a 51 month period.

Materials: From 5/99-3/01, 17 patients participated in a FDA approved clinical “B” trial of the Lap-band (Inamed, Carpenteria, Ca) with IRB endorsement at a single institution. There were 2 males and 15 females, ages 23-55 (mean = 41), with a mean BMI of 44 (range 36-53), and mean weight of 120 kg (range 93-154). Bands were placed in a peri-gastric (15) or pars flacida (2) position utilizing a calibration balloon inflated to 20cc. Band adjustments were made in small frequent intervals in the office without fluoroscopy as advocated by O’Brien. Yearly barium swallows, labs and visits were requested.

Results: Follow-up averaged 42 months (range 30-51). Bands were adjusted an average of 6.6 times (range 3-14) with a mean volume of 2.75cc (range 1-4cc). Early morbidity (12%) included 1 post-op bleed requiring transfusion and one band obstruction requiring revision. Late morbidity (24%) requiring surgical intervention includes 1 posterior slippage, 2 conversions to gastric bypass for esophageal dilatation (1) and esophageal failure (1), and 1 band removal for esophageal dilatation. One additional patient is pending band removal for severe reflux and dysphagia associated with a low amplitude motility disorder. Percent excess weight loss was 55% at 1 year, 52% at 2 years and 49% at 3 years. Late weight regain has occurred in 64% (9/14) patients with bands intact. Post-op compliance with radiologic monitoring was poor with 12% at 1 year, 37.5% at 2 years and 75% at 3 years failing to return for follow-up, despite patient’s contractual agreement to participate in the clinical trial.

Conclusion: Utilization of the Lap-band system was associated with a high incidence (18%) of esophageal dysfunction requiring re-operation, long term weight regain, and poor patient compliance in a single center experience. Poor patient compliance may be an etiology of poorer outcomes in the U.S. trial, and poses a significant long term potential health risk with an esophago-gastric prosthetic device.

Emergency Care of the Bariatric Surgery Patient

JK Champion MD FAC

Clinical Professor of Surgery, Mercer University School of Medicine

Director of Bariatric Surgery, Northside Hospital

Atlanta GA USA

(**Also see our PDF Chart Treatment of Bariatric Patients for Medical Professionals)

Complications and surgical emergencies are a fact of life bariatric surgeon is unavailable, necessitating the on-call general surgeon to manage a complex situation for which they may have limited prior experience. The average incidence of in-hospital complications after bariatric surgery as reported by Livingston [1] is approximately 10%, and The American Society for Bariatric Surgery Centers of Excellence Program reports a 90 day incidence of readmissions of 4.7% and re-operation rate of 2.6% in its initial review of the first 106 centers approved. These numbers probably reflect an ideal and underestimate the true incidence depending on the geographic area, availability of resources to manage the bariatric patient, and the demographics of the patient population. If the bariatric surgeon in your area operates on high risk patients; those with a BMI > 60, age over 50, have multiple co-morbidities (especially pulmonary, cardiac or hypertension), are male gender, or revision patients, there is increased morbidity and mortality risk with these factors [2,3].

Bariatric Emergency

Bariatric surgical patients differ from the average general surgery patient in that the complications may present with minimal physical signs and symptoms, they are difficult to evaluate due to the patients body habitus and inability to fit on many diagnostic exam tables, and the patient deteriorates rapidly and has very little reserve to weather a catastrophic illness. The best opportunity to improve outcomes is in the first 6-12 hours, and after 24 hours the morbidity and mortality escalate rapidly.

Bariatric Emergencies:

The surgeon on-call will usually be called on to deal with one of three life threatening surgical emergencies: bleeding, leaks, or obstructions [4-6]. The initial phone call typically won’t alert you to the underlying problem, other than the patient is “sick”. I propose to provide an overview, then take each of the three surgical emergencies and provide guidelines outlining what are you likely to be called for, how will the patient present, can you identify the problem short of a re-exploration, and emergent treatment and surgical management.

Surgeons will be told a patient has bleeding, unstable vital signs or sepsis, abdominal pain, or vomiting. These may be subtle and non-specific initially, but serve as “red flags” that a serious problem may be developing and deserve prompt evaluation and assessment.

Medical Professionals, Doctors, Surgeons

Bleeding is self evident. Unstable vital signs or sepsis are defined as fever > 101° F, hypotension, tachycardia > 120 for four hours, tachypnea, decreased urinary output or rise in BUN and creatinine. Abdominal pain and colic which lasts more than four hours, or vomiting that lasts more than four hours also constitute a call for prompt treatment.    Patients who present with the previously listed complaints deserve a prompt evaluation, and the evaluations must not delay treatment unduly. Options include: (1) a physical exam and vital signs which may require a serial exam over the next 6-12 hours, (2) labs to include a CBC and comprehensive chemistry profile, (3) X-ray evaluation to consider an abdominal series, CT of abdomen and pelvis with oral contrast, gastrograffin swallow or barium UGI with small bowel follow through, and ultrasound of the gallbladder, (Note: the patient may not fit on exam table) (4) EGD. All diagnostic studies are frequently negative, so a normal study rules out nothing.

Emergency treatment of a patient who shows signs and symptoms of being “sick”, without an identifiable and rapidly correctable etiology (6-12 hours) require surgical exploration. There exists a tendency for the on-call surgeon and at times the primary surgeon to rationalize the problem can’t be related to the primary operation, or they delay and hesitate for 24-48 hours until the patient is in extremis before considering exploratory surgery. Patients are much more likely to die from delays, missed diagnosis, and failure to treat than from a negative exploration.

Bleeding:

Bleeding presents as bright red blood per mouth or rectum, bloody drainage, melena, tachycardia, or hypotension. Early bleeding (first 48 hours) from the GI tract is due to the staple lines. If it’s from a drain site it may originate from the external staple lines, mesentery, omentum, spleen or trocar sites. Oral blood usually originates from the proximal pouch while rectal bleeding comes from the distal stomach or small bowel.

Bright red bleeding usually requires surgical intervention by EGD or exploratory surgery, especially within the first six hours post-op. Melena is more likely to be managed with replacement therapy and discontinuation of anticoagulants. Indicators for a return to the OR include a decrease in HCT of 10, decreasing hematocrit despite transfusion, tachycardia of > 120 for four hours despite a fluid bolus, hypotension despite blood replacement, or greater than 100cc/hr blood out a drain.

At the time of surgery the bleeding invariably stops on induction of anesthesia, so the bleeding site won’t be identifiable. If there is intra-luminal bleeding, perform an EGD first under general anesthesia, and if a definitive bleeding site is identified in the pouch, then treat with injection of epinephrine and cauterize. If no bleeding site is seen, then over sew all the staple lines, decompress the GI tract of clots even if it takes a G-tube, place a drain and get out. If there is intra-abdominal bleeding, evacuate all the clots, perform a meticulous inspection and obtain hemostasis of every bleeding site to include a suture of clip on every site with a clot, consider fibrin glue on the staple lines, and place a drain.

Leaks:

Unstable vital signs or signs of sepsis are leaks until proven otherwise. You need to first rule out hypovolemia, atelectasis, bleeding, PE, or closed loop small bowel obstruction all with the first 6 hours. Start with a physical exam, CBC, renal profile, CXR, gastrograffin swallow or oral methylene blue test, and consider CT (abdomen with oral contrast and chest with IV contrast) all with the first 6 hours. Keep in mind the physical exam, lab tests and radiologic exams are usually negative. A persistent and progressive tachycardia of >120 for over 4 hours is an indication for emergent surgical exploration.

Surgical exploration requires inspection of the entire abdomen with an intra-op leak test of the pouch and gastro-jejunostomy. Don’t forget to inspect the distal stomach and entero-enterostomy anteriorly and posteriorly. Look for iatrogenic injuries of the distal bowel or organs, and rule out a closed loop bowel obstruction by running the entire bowel.

If a leak is identified remember repairs usually will break down, and revisions are ill advised in the face of infection unless there is no recourse. If the leak is less than 24 hours old attempt a suture repair or omental patch and drain, drain, drain. Have one drain posteriorly in a dependent position for when the patient is supine or on a ventilator. Place a G-tube for decompression and nutritional support. Irrigate profusely, provide broad antibiotic coverage for gram negative and anaerobic bacteria, coverage for candida, establish DVT prophylaxis, and begin nutritional support. Remember the principles of damage control laparotomy and leave the abdomen open if there is gross contamination, or if the inspiratory pressure increases over 10mm on closing the abdomen. Consider reopening the abdomen later if bladder pressure increases above 25 mm Hg, or the patient develops respiratory or renal insufficiency [7]. Many patients survive a leak and repair to succumb to the abdominal compartment syndrome post-op.

Abdominal Pain and Vomiting Over Four Hours:

Abdominal pain is a common post-op complaint, as is occasional vomiting from dietary indiscretions, but persistent pain over 4 hours duration or associated with vomiting requires prompt evaluation in the ER. Closed loop bowel obstructions and internal hernias are unique to gastric bypass patients and can be lethal if dead bowel develops. Progressive vomiting of solids but not liquids which is not associated with abdominal pain usually means a stoma stenosis which can be managed with an EGD. Be aware many bariatric patients have had other abdominal procedures (especially TAH and C-sections) so consider adhesive or distal obstructions. Beware of the “red herring” of gallstones on US in a patient with abdominal colic. Don’t overlook a closed loop obstruction, pelvic pathology or even appendicitis as the real culprit. A patient with a history of recurrent colic or prolonged colic requires an exploratory lap regardless of x-ray findings, which are often negative in this population. There is no place for a NG tube or conservative management in a bariatric patient. Evaluation consists of a CT with oral contrast or barium UGI with small bowel series. Beware of gastrograffin aspiration if a patient goes to surgery after a study, and always give the vomiting patient 100 mg of thiamine IV to prevent Wernicke’s encephalopathy and avoid dextrose in the IV until the thiamine is infused. Bariatric surgery patients who present with vomiting and confusion, ataxia or nystagmus / blurred vision have a neurologic emergency of Wernicke’s encephalopathy and must have IV thiamine and avoid dextrose or the neurologic deficient will be converted to a permanent irreversible state.

Surgical management consists of exploratory laparotomy. The surgeon must be familiar with the anatomy of the bariatric procedure the patient previously underwent. Inspect the entire abdomen and run the entire small bowel and you may need to begin distally. Inspect and close all mesenteric defects, and perform an intra-op EGD to rule out a stoma stenosis.

(**Also see our PDF Chart Treatment of Bariatric Patients for Medical Professionals)

References:

1. Livingston EH. Procedure incidence and in-hospital complication rates of bariatric surgery in the United States. Am J Surg 188: 105-110, 2004.
2. Helling TS, Willoughby TL, Maxfield DM, et al. Determinants of the need for intensive care and prolonged mechanical ventilation in patients undergoing bariatric surgery. Obes Surg 14: 1036-1041, 2004.
3. Fernandez AZ, DeMaria EJ, Tichansky DS, et al. Multivariate analysis of risk factors for death following gastric bypass for treatment of morbid obesity. Ann Surg 239: 698-703, 2004.
4. Nguyen NT, Longoria M, Chalifoux S, et al. Gastrointestinal hemorrhage after laparoscopic gastric bypass. Obes Surg 14: 1308-1312. 2004.
5. Gonzalez R, Nelson LG, Gallagher SF, et al. Anastomotic leaks after laparoscopic gastric bypass. Obes Surg 14: 1299-1307, 2004.
6. Champion JK, Williams M. Small bowel obstruction and internal hernias after laparoscopic roux-en-y gastric bypass. Obes Surg 13: 596-600, 2003.
7. Orlando R, Eddy VA, Jacobs LM, et al. The abdominal compartment syndrome. Arch Surg 139: 415-422, 2004.

JK Champion MD FACS

Videoscopic Institute of Atlanta

Atlanta GA

Patients often ask; “Which surgery is best for me?” How do you decide whether to have a Lap-band or a Gastric Bypass?

Time Magazine Obesity 2004

Many patients considering an  Adjustable Lap Band (Adj. Lap Band or LapBand) favor it based on it is simpler and has lower risk compared to the Gastric Bypass. The Lap-band doesn’t involve stapling or cutting the stomach or intestine, so the risk of infection or leakage is reduced. The operation time and hospital stay is generally shorter. That’s the good news. The bad news is weight loss is less, improvement in health issues is less, and the risk of having another procedure or surgery related to the Band is higher compared to the Gastric Bypass.

What are factors to consider and are there patients we don’t like to see have a Lap-band?

1. Lap-bands have better results in patients whose BMI is less than 50. Ideally around 35-40 BMI and 100 pounds or less overweight. The average weight loss with a Lap-band is around 50% of the excess weight and only half the patients will maintain the weight loss over time. The weight loss with a Gastric Bypass is around 75% of excess weight and 90% remain successful over time.
2. Sweet eaters shouldn’t consider a Lap-band since it doesn’t restrict sweet intake the way a Gastric Bypass does. About 50% of Lap-band patients will regain a significant amount of weight due to snacking and sweets over time.
3. Diabetics and patients with high cholesterol do better with a Gastric Bypass. Around 90% of Gastric Bypass patients will leave the hospital after 48 hours off medication and insulin for diabetes, and 80% will lower their cholesterol without medications. The Gastric Bypass alters the way the intestine recognizes sugar and reduces the absorption of cholesterol and fat. Improvements can occur after a Lap-band, but depend on substantial weight loss and dietary compliance.
4. The Lap-band is dependent on absolute compliance with the diet and regular exercise to maximize weight loss. Patients who are “poor” rule followers don’t do well.
5. The Lap-band is a good choice for older or very high risk patients, who even a modest weight loss, will benefit. The risk of dying from a Lap-band procedure is about 1/1000 and for the Gastric Bypass around 3/1000.

In summary, we like the Laparoscopic banded Gastroplasty in patients with a BMI less than 50 who aren’t diabetic or have high cholesterol, and whose diet is typically big meals of meat and veggies. Sweet eaters, snackers and grazers can easily defeat the operation.

Plateaus are normal!!! And unavoidable!! After weight loss surgery or anytime you are dieting

-      Bariatric surgery is an aide to dieting it is a tool.

-      If you do not follow the guidelines for eating and exercise you will have a less successful outcome or you can out right fail with your weight loss.

There is a 10% failure post op in long-term weight loss.  It is almost always due to patient noncompliance.

Two major factors in Plateau’s

1. No exercise  (Exercise will increase metabolism and build muscle mass which burns more calories)
2. Snacking or failure to eat 3 meals plus a snack per day at regular intervals (eat every 4 hours)

Plateaus occur as calories decrease and your metabolism drops in response.

This is your body adjusting to change.

Plateau’s can occur at anytime after weight loss begins and can last 3 days to 3 weeks.

TO GET OUT OF PLATEAU’S

EXERCISE (MIN. 20 MINUTES 5 DAYS A WEEK)

EAT ON REGULAR SCHEDULE (EAT REAL FOOD)

DO NOT WEIGH YOUR SELF BUT ONCE A WEEK

OFTEN YOU WILL SEE A DROP IN INCHES RATHER THAN A DROP OF POUNDS ON THE SCALE.

BODY’S REMODEL DURING WEIGHT LOSS TO: 75% FAT AND 25 % MUSCLE

YOU HAVE 18 MONTHS TO LOSE AND CHANGE HABITS DON’T WASTE IT!!!!!!!!

SUCCESS HABITS OF LONG TERM GASTRIC BYPASS PATIENTS

OBESITY SURGERY, 9, 80-82, 1999

A survey of post-op gastric bypass patients by a bariatric surgery group in Salt Lake City revealed 6 common habits shared by the people who maintain long-term successful weight loss (defined as at least 74% of excess weight).

The 6 common habits for success are as follows:

1.EATING; eating 3 well balanced meals and 1 snack per day consisting of 3 servings of protein, & vegetables & 2 servings of bread or starch, & 1 serving of fruit.

2. DRINKING; on average drank 40 –64 oz of water per day and no carbonated beverages! 74% did not drink alcohol and 55% did not drink fruit juice.

3. VITAMINS AND SUPPLEMENTS; (see also Bariatric Patients Weight Loss Supplements)  Bariatric Patients took daily multiple vitamin, calcium, and iron if needed.

4. SLEEPING; slept 7 hours per night and reported energy level as high on average.

5. EXERCISE; (See Dr. Champion’s Exercise Group) average of 4 x a week for 40 minutes. *A key factor in ability to maintain their weight loss!

6. PERSONAL RESPONSIBILITY; took personal responsibility for staying in control. Weighed-in weekly and allowed themselves only a few pounds leeway. Attitude that their weight was up to them and the surgery was only a tool to help them maintain a healthy weight.

(See about joining Dr. Champion’s Bariatric Weight Loss Support Groups)

NON-SUCCESSFUL GROUP: The unsuccessful group regained an average of 50 lbs (both averaged losing 100 lbs initially) and all demonstrated an absence of at least one of the 6 common habits. THE MOST COMMON WERE LACK OF EXERCISE, GRAZING AND SNACKING, AND DRINKING REGULAR NON-DIET CARBONATED DRINKS! THE FIRST POSTOP YEAR IS A CRITICAL TIME THAT MUST BE DEDICATED TO CANGING OLD BEHAVIOR AND FORMING NEW LIFELONG HABITS.

Atlanta Bariatric Support Group

JK Champion MD

We are frequently asked questions about medication use after weight loss surgery. Patients want to know:

1)      Why they shouldn’t take aspirin or anti-inflammatory medications

2)      Are there other medications Bariatric Patients should avoid?

3)      Whether medications they are routinely on will be absorbed normally or will the dose need to be changed.

Aspirin and Anti-Inflammatory Medications (NSAIDS and steroids):

This class of medications includes aspirin products, non-steroidal anti-inflammatory meds (NSAIDS), COX-2 inhibitors, and steroids. All these medications can irritate the stomach or impair healing and lead to an ulcer in the stomach, which is quite serious after any weight loss operation.

They should only be taken if there is a good medical indication and the patient also takes a proton pump inhibitor medication at the same time. In no circumstance should they be taken for at least 6 weeks after surgery!!!!!!

After gastric bypass patients can develop a “marginal ulcer” which occurs where the stomach is re-attached to the small intestine. This can lead to pain, bleeding, excessive scar tissue build-up and the inability to eat solids, or eat a hole all the way through the bowel wall and perforate, causing peritonitis. Marginal ulcers occur in around 1% of gastric bypass patients, and half of these are due to anti-inflammatory drug use or smoking. Half the patients with ulcers will need an operation to manage a complication of the ulcer, so it’s quite serious and the risk needs to be minimized with your cooperation.

After Lap-band or VBG these medications can cause an ulcer in the pouch or distal stomach, or can cause the band to erode into the stomach wall. Again this may result in hemorrhage, pain, scarring, or a perforation with the need for subsequent surgery.

Aspirin, even baby aspirin, should be avoided unless the patient has documented coronary artery disease which requires an angioplasty, stent, or surgery. Prophylactic use after a gastric bypass, in an attempt to reduce risk in patient with know risk factors or a strong family history of heart disease, causes more problems then it helps, and is unproven to benefit women under age 60.

NSAIDS include a wide range of name brand products and generics, so if in doubt ask.

Examples include Advil, Motrin, ibuprofen, Aleve, naprosyn, daypro, anaprox, voltaren, dolobid, feldene, mobic, Relafen, toradol, Indocin, and clinoril. This list is not all inclusive, so ask questions of the pharmacist or our office if in doubt. Most family physicians, orthopedists and internists don’t understand the need to avoid these meds after bariatric surgery and may mistakenly assure you it’s OK.

COX-2 inhibitors are also frequently prescribed for pain and have included celebrex, vioxx, and bextra. Some of these have been removed from the market due to increasing the risk of heart disease, but they may be re-introduced in the future. It was mistakenly believed these meds caused less stomach irritation and had less risk of bleeding from the stomach, but this has not been found to be the case, and is just as likely as aspirin or NSAIDS to cause stomach irritation.

Steroids delay healing in the stomach and impair the lining of the stomachs’ ability to repair itself and form a protective layer between the muscle wall and acid. This can again lead to an ulcer, bleeding or perforation. Examples of steroids are prednisone, medrol dose pack, decadron, depo-medrol, and solu-cortef.

Steroids should be avoided the first 6 weeks after surgery, and then if required must be accompanied by a proton pump inhibitor (PPI) for at least 30 days after the medication is stopped. Steroid injections into a joint or the back don’t affect the stomach so don’t require PPI’s.

Examples of PPI’s are:

Prilosec, Prevacid, Nexium, Protonix and Aciphex.

Medications which are classified as antacids but are NOT PPI’s and are not acceptable protection are: Pepcid, Zantac, and Tagamet

Other Medications to Avoid:

A commonly prescribed medication for women today is for the treatment of osteoporosis and it can result in ulceration of the esophagus or stomach if it doesn’t empty out of the pouch quickly, so I have advised my patients not to use them unless all other methods of treatment have failed. Examples are Fosamax and Actonel, but new meds are being introduced now. The safety of these meds after gastric bypass and other bariatric surgery is unknown. If needed, discuss with your physician using the once weekly dose schedule, and make sure you remain upright for an hour after the medication and report any heartburn, indigestion or abdominal pain promptly and stop the medication. These medications should not be prescribed for osteopenia, or to prevent osteoporosis due to a strong family history.

I recommend eliminating herbal supplements after bariatric surgery. These are not regulated by any agency and are of unknown strength and purity. Many have effects which are poorly understood and can cause un-wanted side effects.

Concentrate on a good brand name multi-vitamin and eat fruit and vegetables and you’ll be fine.

Patients should exhibit caution when on immune suppressant drugs, such as chemotherapy, or the newer immune suppressant drugs for arthritis and psoriasis. If in doubt stay on a PPI to reduce your risk.

Nicotine in the common form of smoking is one of the worst things patients can do after weight loss surgery, due to the high risk of ulceration of the stomach.

Illicit drug use in the form of cocaine also is known to result in ulceration and perforation of even normal stomachs.

Medication Dosage after Weight Loss Surgery:

Lap-band and VBG don’t alter the intestinal tract and don’t require any consideration except to not take 2 pills at once or they may get caught in the outlet.

The universal rule is: don’t take 2 pills at the same time. Take a medication, then drink some fluids and wait 5-10 minutes to take the next medication unless they are chewable.

Medications after gastric bypass are absorbed normally unless you have frequent diarrhea. No medication is absorbed in the stomach, so bypassing the stomach doesn’t affect it. Vitamin B, iron and calcium are not absorbed as well because we bypass the first foot of the small bowel called the duodenum. We supplement those nutrients and monitor them with lab tests on a routine basis. Other medications don’t require an adjustment due to poor absorption.

Medications may need to be reduced after surgery as medical conditions improve. Many diabetics leave the hospital off medication. Hypertension meds usually require 3-4 months to see a reduction as you lose weight, but only half the patients will come off the meds as not all hypertension is due to weight. High cholesterol meds are stopped post-op as 80% will not need them, but again we monitor them for the first year and if cholesterol or triglycerides remain elevated we may need to re-start the medication. Thyroid hormone requirements usually remain the same after surgery.