10
Andover Road
Portland, Maine 04102
207-761-6642
www.cascobaysurgery.com
Bariatric
Surgery Handbook
Gastric
Bypass
Overview
Our program is recognized nationally as a Bariatric Surgery Center of Excellence. We offer laparoscopic Roux-en-Y gastric bypass, laparoscopic adjustable gastric band (LAP-BAND) and revisions of failed bariatric operations. We believe that an operation is just one part of the successful treatment for morbid obesity in those people who choose surgery. We use a comprehensive team approach to help our patients also make the behavioral changes necessary for long-term success.
Location
MMC Bariatric Surgery Center
12 Andover Road
Portland, Maine 04102
(207)-761-5612
Toll-Free: (866)-268-9274
Fax: (207)-253-6073
Your Surgeon
Our surgeons dedicate a substantial amount of their surgical practices to bariatric surgery. They are experienced advanced laparoscopic surgeons. They will share parts of your evaluation and preparation for surgery as well as for your follow-up care, but only one will do your operation. In general, the surgeon who evaluates you during your first appointment will be the surgeon who does your operation, unless you agree to a switch before surgery. You may request a specific surgeon but please do so before getting a date for your first appointment. If we have to reschedule your appointment it could delay your evaluation.
Morbid Obesity
According to insurance data 20% of the American population is obese. Morbid obesity, however, is when a person is greater than about 100 pounds over their ideal weight. In this weight range, obesity becomes a serious medical condition, one that substantially shortens a person’s life expectancy. Morbid obesity causes or contributes to many other health conditions and illnesses (such as diabetes, high blood pressure, high cholesterol, heart disease, gastroesophageal reflux (GERD), urinary incontinence, arthritis, gallbladder disease, female infertility). For some of these conditions, the only hope of improvement or control is through sustained weight loss. Unfortunately, even well organized and monitored diet programs fail to maintain weight loss by 2-3 years for over 95% of those people who use them. Surgery has been shown in many published studies to be the only successful method of achieving lasting weight loss for most people with morbid obesity.
Program Objective
Each patient we evaluate wants to lose weight and keep it off. That is
our goal, too. Although we share each successful patient’s joy and improved
self-esteem, our primary interest is in prolonging life and preventing or
helping control the illnesses caused by morbid obesity. This is not cosmetic
surgery.
Our
program uses bariatric (weight control) surgery to enable weight loss and
long-term weight control. We take a team approach before, during, and after
surgery. No operation alone is a cure for obesity. But
the operation gives most patients better control of their food intake for the
rest of their lives. We expect our patients to stay in touch with us and
involved in the program for the rest of their lives, too. This helps us help
them by periodically (yearly after the second year) checking their weight,
eating patterns, exercise, blood tests, and anything else that can affect their
results. Not all patients will achieve the results they desire, but by selecting
our patients well and following their progress long-term, we can help most
patients reach and maintain healthy, realistic, and satisfying weight loss.
Qualifications
for Surgery
Body-Mass
Index (BMI) 40 or greater. This represents being roughly 100 pounds
overweight and defines morbid obesity.
or
BMI of 35 or greater and serious secondary illnesses (such as poorly controlled
adult-onset diabetes).
[Calculate your BMI automatically.]
Failed attempts at non-surgical weight loss methods
Attendance of at least one monthly Bariatric Support Group meeting before
surgery
Commitment to life-long dietary changes and follow-up
No smoking for 3 months before first appointment. [See separate Policy on Tobacco Use]
Willingness to use birth control for
18 months after surgery (women only)
Compliance with the program’s instructions,
appointments, assignments
About the Operation (Laparoscopic Roux-en-Y Gastric Bypass)
The gastric (stomach) bypass involves separating a tiny portion of the
upper stomach from the main chamber of the stomach. We don’t remove anything.
A portion of the small intestine is connected (anastomosis) to the new gastric
pouch to allow swallowed food to go around (bypass) the rest of the stomach and
part of the intestine. The operation works by giving patients a feeling of
fullness after eating very little food and by preventing absorption of some of
the ingested meal. People eat less and absorb less of what they do eat, so they
lose weight. The operation forces substantial permanent changes in what and how
patients eat. Many can never again tolerate sugar in their diets. Processed
sugars often cause Dumping Syndrome. This is an unpleasant condition that
can occur shortly after eating sweets or any meal containing processed sugars,
even if it doesn’t taste sweet. Dumping Syndrome can include any of the
following: cramping and explosive diarrhea, overwhelming flu-like fatigue,
nausea, lightheadedness, sweating, and heart palpitations. These symptoms can
last for several hours after the meal. This is another reason the operation
maintains weight loss long-term.
During
the period of maximum weight loss some patients will form stones in
their gallbladders. For that reason, if a patient already has gallstones before
surgery (determined by an ultrasound of the gallbladder), the surgeon will
remove the gallbladder at the time of surgery.
Our surgeons are experienced laparoscopic surgeons. They do these operations laparoscopically through five tiny abdominal puncture wounds and make incisions during surgery only rarely, when they must. This speeds recovery, avoids some of the problems associated with the incision required by the usual open abdominal approach, and provides a better cosmetic result. However, whether done laparoscopically or open the operation is done the same way on the inside and should achieve the same long-term results.
Changes in Eating After the Operation
Surgery forces major eating and lifestyle changes. A patient’s ability
to eat “normal” amounts of food is gone forever. For many people with
life-long obesity, for the first time in their lives they feel what it’s like
to be full and not interested in eating more. In fact, we usually have to
encourage people to eat and drink more during the first month
after surgery. Bypass patients don’t just eat less; they absorb less of what
they eat. As a result most patients require daily vitamins for the rest of their
lives. Eating and meals have strong family and social significance for many
people, so the dietary restrictions required of a gastric bypass can affect more
people than just the patient. The first few months can be physically and
emotionally draining for some patients, but most patients quickly begin to feel
better and more energetic. Health problems caused by obesity usually improve or
even disappear.
During the first month, the diet consists of blended foods and smooth
liquids the texture of applesauce. This allows the new gastric pouch to
strengthen and heal. Because the pouch is so small, patients initially need to
eat and drink often in order to get enough liquid and nutrition. We sometimes
ask patients to take protein supplements. We don’t want our patients using
straws or drinking carbonated beverages during the first month because these can
cause the pouch to overstretch with air. It
is important to closely follow the dietary guidelines provided in the Nutrition
Handbook.
After the first month, patients slowly advance to eating soft, then
regular foods. Some people will not be able to eat red meats, non-toasted bread,
fruits with peels on them, or some raw vegetables after this operation. Many
patients won’t ever be able to tolerate sweets again because they get Dumping
Syndrome. A typical restaurant meal after full recovery will be the size of a
child’s portion. Patients will need to stay in touch with their family
physicians and a dietician in order to check periodically for vitamin and
mineral deficiencies, weight regain, and inadequate nutrition. We encourage all
our patients to have their life-long follow-up with us at the Bariatric Surgery
Center.
Anticipated Results
The
average patient will lose 60-80% of his or her excess body weight (amount
over their ideal body weight) over the first 18-24 months. Most of that weight
loss is over the first six months. It can drop as fast as 5-10 pounds per week.
Someone 200 pounds overweight should lose 120-160 pounds. Over the next decade
the average patient will regain 10-15% of that lost weight. Those who exercise
regularly can expect better results than those who do not. Those who adhere to
the gastric bypass diet will do better long-term. Those who stay involved with
the Bariatric Surgery Center and its Support Group will probably also do better
than those who do not.
The gastric
pouch created at surgery should be seen as a tool the surgeon provides to
help curb appetite on a long-term basis. Success still depends on the patient,
though. Pouches can be stretched over time by repeated over-eating. Fatty and
fried foods (such as corn and potato chips), alcohol, and snacking
(“grazing”) throughout the day can greatly increase calorie intake and cause
weight regain despite the pouch. This is why we believe in a life-long program
through which we periodically reassess each patient’s weight and food intake
(among other important measurements) and help each achieve and maintain his or
her goals.
Serious Risks Immediately After Surgery
 |
Anastomotic leak [1%] – Immediately after surgery the stomach and intestine are connected to each other only by tiny staples and stitches. They rapidly heal permanently together, but initially there is a chance that food and saliva will leak into the abdominal cavity, potentially causing a serious infection. This problem usually requires immediate re-operation and is one reason why we stress strict adherence to the first month blended diet to allow the new pouch to strengthen. |
|
Pulmonary
embolism – This occurs when blood clots form in the large veins of the
legs and pelvis, break lose, and travel to the heart and lungs. We
administer a gentle blood thinner while in the hospital, but the best way to
prevent this is to get up and walk. Blood that’s kept moving through
activity usually won’t clot. |
|
Death
[0.5% (1 in 200 operations)]. This occurs due to a complication of the
operation, usually a leak or pulmonary embolism. Those patients who have
serious complications from their obesity (such as severe heart or pulmonary
disease or poorly controlled diabetes) are less able to recover from
complications and less likely to survive if a serious one occurs. |
| Bleeding
– Patients
occasionally receive a blood transfusion after surgery. This is usually for post-operative bleeding that stops on its own, but
re-operation is occasionally necessary to stop more serious bleeding. We
respect the wishes of patients who refuse blood transfusion, but as a
result, they will be more likely to require an
emergency re-operation that could be avoided by giving a transfusion. |
|
Atelectasis/pneumonia
– It can be uncomfortable to take deep breaths and cough immediately after
surgery. When patients fail to do so, portions of their lungs tend to
collapse (atelectasis). This
can cause fevers and fast heart rates mimicking more serious complications
and can lead to pneumonia, itself a potentially serious problem. The best
way to avoid this is to deep breath, cough, and get out of bed for walks in
the hallway and after going home. |
| Nausea - Some patients feel nauseated for weeks or even a few months after surgery. The sight, smell, taste, thought of food can be repulsive. Medication can't always correct it. Regardless of nausea, you must take in enough fluid and nutrition to stay healthy. Fortunately, the nausea resolves on its own. |
|
Vomiting
– This is expected during the first few months. It is often difficult to
explain or to prevent. It can happen when over-eating or when eating the
same foods that have gone down just fine for the past week and will go down
fine again the next day. This is often frustrating because it can be so
unpredictable. |
| Anastomotic stricture – In the first 1-2 months about 15% of our patients develop a narrowing where the intestine connects to the gastric pouch. This causes vomiting that will gradually get worse over a few days or week. It can usually be simply remedied by stretching it under sedation with a short outpatient endoscopy. |
|
Re-operation – Our surgeons do not hesitate to re-operate on patients who are not progressing well the first few days after surgery. If they cannot find an acceptable explanation for a rapid heart rate or if a patient is not looking or feeling as well as they think they should, they will put the laparoscope back in at a second operation to make sure there has not been a leak or other problem. Complications that are detected early, before a patient gets critically ill, can more often be managed easily without major setback. |
Long-Term Risks After Surgery
|
Calcium
deficiency – Calcium might not be absorbed as well. Patients should take
TUMS or some other source of calcium after surgery. |
|
Vitamin B12 deficiency – This can be prevented with a daily B12 pill or monthly injection. |
| Other
vitamin deficiencies –
These can cause serious and permanent nerve damage. It is essential to take a daily
multivitamin. |
|
Iron deficiency – This problem is more common in menstruating women. They should take a daily iron supplement. |
| Gallstones - Some patients form gallstones during the period of rapid weight loss. Most of the time gallstones don't cause problems, but in some people they can cause recurring upper abdominal pain, often under the ribs on the right side, sometimes going through to the back. When this happens, we remove your gallbladder laparoscopically, often on an outpatient basis. |
| Internal
Hernia - This occurs when the intestine slips underneath or spins around
the jejunal (Roux) limb of small intestine. It can happen after
substantial weight loss loosens things up on the inside (1-2 years after
surgery). It usually causes
crampy or severe mid-abdominal pain that comes without warning, can last for
hours, then disappear. It can be extremely serious and usual tests often don't find it. Laparoscopic surgery is sometimes necessary to diagnose it.
Please contact the Bariatric Surgery Center if these symptoms occur. |
|
Hanging
skin – Many patients retain some extra, loose skin on their abdomens
(sometimes also arms and thighs) after
they lose weight. Often the only way to get rid of this extra skin is to
remove it surgically. The bariatric program has support from some local
plastic surgeons, but this operation (panniculectomy) is considered by many insurance companies to be cosmetic surgery and, therefore, often won’t be
covered. |
|
Dissatisfaction
with the operation – Not everybody achieves his or her desired
weight-loss results. Others
lose weight but don't like the dietary restrictions. Although the operation can be
reversed, it is a big operation. Our surgeons will not reverse a gastric
bypass unless it is absolutely necessary for health reasons. This is the
commitment we need from our patients and one reason why we are selective in
our patient evaluation. |
The Evaluation
Process
Many patients find the program’s evaluation process slow and drawn-out. This is not unique to our program. Waiting lists are long at almost all centers offering a comprehensive team approach to bariatric surgery. Most of the wait is simply because our surgeons can do only so many operations in any given week. Part of the slow pace is because we want it that way to allow time for us to get to know each patient and to allow each patient to become entirely familiar with our team, our program, the operation, and the necessary life-long dietary changes after surgery. We realize this rigorous approach is difficult for those traveling from outside the Portland area, but we don’t know a safe way to cut corners.
First contact – Our nurses review each referral to make sure the BMI is appropriate to qualify for surgery or even an appointment. We mail out information packets for the patient and forms to be filled out and returned to us (or completed online) so we can gather information from primary care providers and any other physicians involved. We also begin work on insurance approval. Patients should also start the tedious insurance approval process. Some insurance companies require documented efforts at supervised dieting and exercise for 6 months within the 1-2 years before weight-loss surgery. Be sure you know your policy.
First
Bariatric Surgery Center appointment
– A patient meets for about an hour each with our dietitian, therapist, and
one of our surgeons. These separate evaluations are important and necessary. A personal or local
therapist or dietitian can’t substitute at this point in the evaluation.
Because scheduling the whole team is complex, it sometimes requires two visits
to complete the "first appointment." The
team discusses each patient individually and makes an initial determination
about the appropriateness of surgery and need for any further testing or
consultation. Each patient will be instructed to complete sample menus and to
prepare meals from the menu for the first month after surgery. The wait for the
first appointment will probably be the longest delay in the process.
Information Session - This is held at 8:00 a.m. on the day of your first appointment with the surgeon. One of our nurses and a surgeon will discuss the program and the operations. It's an opportunity to ask questions that might help you decide which operation sounds best for you (Gastric Bypass or Lap-Band) or to change your mind if you've already picked an operation. The surgeon who gives this presentation and evaluates you during your first appointment will also be the surgeon who does your operation, unless you agree to a switch before surgery (which could also create some delay).
Second
appointment
– Usually 4-6 weeks after the first. Each patient meets with the dietitian to
review the sample menus and to review the food items prepared from the menu. Our
therapist will discuss any issues or concerns that may have arisen about the
upcoming surgery. The surgeon will discuss the details of the operation again.
It is mandatory for each patient undergoing gastric bypass surgery to have a support person to
help him through the physical and emotional difficulties that can be encountered
during the first few months after surgery. This support person can be a spouse,
relative, friend, minister, or anybody else willing to be there in mind and body
when needed. After this visit, a date for surgery will often be assigned. That
wait can be another 1-3 months, depending on your insurance.
Support Group attendance – Attendance of at least one monthly Open Support Group meeting is required before surgery can be scheduled.
Pre-admission
interview
- Required evaluation by the anesthesia staff before any operation.
We’ll also obtain some blood tests, including nicotine levels for some
patients.
Surgery – Always performed at Maine Medical Center, usually Monday-Wednesday. Most patients will arrive 1-2 hours before surgery and stay in the hospital overnight, sometimes longer.
Three-month visit - Usually the last visit with the surgeon and therapist.
Long-term follow-up - Our nurses and dietitians continue to assess overall progress and obtain necessary blood tests at 6, 12, 18, and 24 months. Visits are once a year after that, as long as you're doing okay. It is important to bring a three-day food intake record to these appointments for review by the dietitian. To maintain our designation as a Center of Excellence, we must maintain 5-year follow-up on %75 of our post-op patients. Please help us do this by staying in touch with us every year.
Support Group
Support Group meetings are a way for new patients to meet old ones. They provide an opportunity for people to discuss obesity, how it has affected their lives, and how surgery has affected (or might affect) their lives. The Open Support Group (any bariatric operation) and Lap-Band Support Group (Lap-Band only) meet under the supervision of Bariatric Surgery team members but is really time for our patients and potential patients to use as they want. Attendance is limited to those people who have already had surgery or are considering it, their families, and support people. See our Support Group Schedule for times and locations.
Exclusion Criteria
We will delay scheduling surgery or
even cancel a scheduled operation for any patient who doesn’t meet our minimum
standards or who fails to follow through with instructions. Although we are
compassionate to our patients’ problems, we sometimes must exclude people when
we feel the operation is not right for them. Because we screen our referrals so
closely, this doesn't actually happen very often. Examples of possible obstacles
to surgery:
|
BMI too low. |
|
Failure
to stop smoking 3 months before surgery (blood tests for nicotine will be
checked prior to surgery). |
|
Failure to lose weight when instructed to (not usually required). |
| Failure to follow through with assigned therapy sessions between appointments. |
|
Failure
to recruit and bring along a support person. |
| Failure to bring your spouse to an appointment, if requested by the team. |
|
Failure
to attend a support group meeting before surgery. |
|
Failure
to comply with sample menus and diet assignments or understand
post-operative diet. |
|
Failure
to keep a scheduled pre-operative appointments without advance notification.
We are concerned that this situation might identify the patient who won’t
follow through with post-operative visits and instructions. |
|
Lack of commitment to the life-long dietary
and lifestyle changes required for long-term success. |
| A patient loses weight during the evaluation and decides to continue diet & exercise instead of surgery. |
| A patient loses interest. |
Summary
Morbid obesity is a serious health condition that contributes to or
causes many other medical problems and significantly shortens life expectancy.
Diet approaches to weight loss in this population usually fail. The
only well researched and tested method of long-term weight control for the
morbidly obese is surgery. Our goal is to offer successful surgery to as many
appropriate candidates as we safely can. Remember, no method, including
surgery, is certain to produce and maintain weight loss. Success is achieved
only with each patient’s full cooperation and commitment to dietary and
lifestyle changes and medical follow-up.
These pages were created and are maintained by Casco Bay
Surgery, PA
Last updated 5/7/07