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General
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Life After Surgery
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Preparations for Surgery
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The Hospital Stay
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General
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The age limit for bariatric surgery is usually 18-65 years. Though surgery has been performed on patients in their teens, it is considered that patients below 18 years of age are not mature enough to make this type of decision. It is important that young weight loss surgery patient have a full understanding of the lifelong commitment to the altered eating and lifestyle changes necessary for success.
Conversely patients over 65 require very strong indications for surgery and must also meet the stringent Medical criteria. The risk of surgery in this age group is increased, and the benefits, in terms of reduced risk of mortality, are reduced. |
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There is good evidence from scientific research that if you have Type 2 diabetes (or other serious obesity-related health conditions) are at least 100 lbs over ideal body weight, and are able to comply with lifestyle changes (daily exercise and low-fat diet), then weight loss surgery may significantly prolong your life. A female smoker with a BMI of greater than 40 could lengthen her life expectancy by more than 15 years if she loses weight and quits smoking |
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Life After Surgery
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The basic rules are simple and easy to follow.
- Immediately after surgery, the doctor will provide you with special dietary guidelines. You will need to follow these guidelines closely. You will begin with a liquid diet the day after surgery, then move to pureed foods and later, sometimes weeks later, solid foods an be tolerated without risk to the surgical procedure performed. Allowing time for proper heating for your new stomach pouch is necessary and important.
- When able to eat solids, eat 2-3 meals per day, no more. Protein in the form of lean meals (chicken, turkey and fish) and other low fat sources should be eaten first. These should comprise at least half the volume of the meal eaten. Food should be cooked without fat and seasoned to taste. Avoid sauces, gravies, butter, margrine, mayonnaise and junk food.
- Never eat between meals. Do not drink flavored beverages, even diet soda, between meals.
- Drink 2-3 quarts or more of water each day. Water must be consumed slowly, 1-2 mouthfuls at a time, due to the restrictive effect of the operation.
Exercise aerobically every day for at least 20 minutes (one-mile brisk walk, bike riding, stair climbing etc.). Weight/resistance exercise can be added 3-4 days per week, as instructed by your doctor. |
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When you have a weight loss surgery procedure. You lose weight because the amount of food energy (calories) you are able to eat is much less than your body needs to operate. It has to make up the difference by burning reserves or unused tissues. Your body will tend to burn any unused muscle before it begins to burn the fat it has saved up. If you do not exercise daily, your body will consume your unused muscle, and you will loss muscle mass and strength. Daily aerobic exercise for 20 minutes will communicate to your body that you want to use your muscles and force to burn the fat instead.
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Many patients are hesitant about exercising after surgery, but exercise is an essential component of success after surgery. Exercise actually begins on the afternoon of surgery- the patient must be out of bed and walking. The goal is walk further on the next day, and progressively further every day after that, including the first few weeks at the home. Patient are often released from medical restriction and encouraged on begin exercising about two weeks after surgery, limited only by the level of wound discomfort. The type of exercise is dictated by the patient’s overall condition. Some patients who have severe who have server knee problems can’t walk well. But may be able to swim or bicycle. Many patients begin with low stress forms of exercise and are encouraged to progress to more vigorous activity when they are able.
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| It is strongly recommended that woman wait at least one year after the surgery before a pregnancy. Approximately one-year post- operative, your body will be fairly stable (from a weight and nutrition standpoint) and you should be able to carry a normally nourished fetus. You should consult your surgeon as you plan for pregnancy. |
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Contact your original surgeon- he or she is most familiar with your medical history and can make recommendation based on knowledge of your surgical procedure and body.
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The stomach is left in place with intact blood supply. In some cases it may shrink a bit and its lining (the mucosa) may atrophy, but for the most part it remains unchanged. The lower stomach still contributes to the function of the intestines even though it dose not receive or process food-it makes intrinsic factor, necessary to absorb vitamin B12 and contributes to hormone balance and motility of the intestines in ways that are not entirely know.
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In the Roux-an-Y gastric bypass, the stomach pouch is created at one ounce or less in size (15-20cc). In the first few months it is rather stiff due to natural surgical inflammation. About 6-12 months after surgery, the stomach pouch can expand and will become more expandable a swelling subsides. Many patients end up with a meal capacity 3-7 ounces.
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The staple use on the stomach and the intestines are very tiny in comparison to the staples you will have in your skin or staples you use in the office. Each staple is a tiny piece of stainless steel or titanium so small it is hard or to see other than as a tiny bright spot. Because the metals used (titanium or stainless steel) are insert in the body, most people are not allergic to staples and they usually do not cause any problems in the long run. The staple materials are also non-magnetic, which means that MRI will not affect them. The staples will not set off airport metal detectors.
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It’s normal not to have an appetite for the first month or two after weight loss surgery. if you are able to consume liquids reasonably well, there is a level of confidence that your appetite will increase with time.
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Most pills or capsules are small enough for the new stomach pouch. Initially, your doctor may suggest that medications be taken in liquid from or crushed.
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Most patients have no difficulty in swallowing these pills
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Patients can return to normal sexual intimacy when wound healing and discomfort permit.
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Patient may begin to wonder about this early surgery when they are losing 20-40 pounds per month or may be when they’ve lost more than 100 pounds and they’re still losing weight. Two things happen to allow weight t stabilize. First a patient’s ongoing metabolic needs (calories burned) decrease as the body sheds excess pounds. Second, there is natural progressive increase in calorie and nutrient intake over the months following weight loss surgery. The stomach pouch and attached small intestine learn to work together better, and there is some expansion in pouch size over a period of months. The bottom line is that. In the absence of a surgical complication, patients are very unlikely to lose weight to the point of malnutrition.
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Many people have enough to meet the surgical criteria for weigh loss surgery have stretched their skin beyond the point from which it can “snap back”. Some patients will choose to have plastic surgery to remove loose or excess skin after they have lost their excess weight. Doctor generally will not recommend surgery for skin removal until at least one year post-operatively, at which time your weight loss has begun to stabilize.
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Exercise is good in so many other ways that a regular exercise program is recommended.Unfortunately, most patients may still be left with large flaps of loose skin.
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| Your doctor will determine whether medication for blood pressure, diabetes, etc, can be stopped when the condition for which they are taken improve or resolve after weight loss surgery. For medicines that need to be continued. The vast majority can be swallowed, absorbed and work the same as before weight loss surgery. |
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Infrequently: if needed, it is usually given after surgery to promote healing.
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Undesired blood clotting in veins, especially of the calf and pelvis. It is not completely preventable. But preventive measures will be taken, including.
1 Early ambulation
2 Special stockings
3 Blood thinners
4 Pulsatile boots
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Many patients experience some hair loss or thinning after surgery. This usually occurs in the fourth and the eighth month after surgery. Consistent intake of protein at mealtime is the most important prevention method. Also recommended are daily volumes of fluid intak.
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Most patients experience natural hair regrowth after the initial period of loss.
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It is the interruption of the normal sleep pattern associated with repeated delays in breathing. Sleep apnea often shows rapid improvement after surgery. In most patients, there is a complete resolution of systems by six months following surgery.
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Preparations for surgery
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Certain basic tests are done prior to surgery:
- A Complete Blood Count (CBC).
- A complete profile in terms of liver functions, kidney functions and lipid profile.
- Thyroid Function Test, iron levels. B12 levels.
- All patients except for the very young are also sent for a chest x-ray and an electrocardiogram. Due to the high incidence of obstructive sleep apnea, most patients will require a polysomnography study.
- Patients also need to undergo an abdominal ultrasound.
Other test, such as pulmonary function testing. Echocardiogram, Gl evaluation, cardiology evaluation, or psychiatric evaluation, will be requested when indicated.
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An accurate assessment of your health is need before surgery. The best way to avoid complication is to never have them in the first place. If you are diabetic, special steps must be taken to control your blood sugar. Our objective is to maximize your of success.
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Patients who have significant gastrointestinal for abnormal symptoms such as upper abdominal pain, heartburn, belching sour fluid, etc., may have underlying problems such as a hernia,gastroesophageal reflux or peptic ulcer.
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The steep study detects a tendency for abnormal stooping of breathing, usually Associated with a high, mortality rate and is present in nearly 70% of obese. Patients. It is important to have a clear picture of what to except and how to handle it.
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Bariatric surgery will require significant changes in your lifestyle and will also change your life. A psychiatric evaluation will help prepare you for these changes by developing coping skill and encouraging behavior modification. Additionally, our psychiatrists will evaluate your understanding and knowledge of the risk and complication associated with weight loss surgery and your ability to follow basic recovery plan.
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Medical problems, such as serious heart or lung problems. Can increase the risk of any surgery. On the other hand; if they are problems that related to the patient weight, they also Increase the need for surgery. Severe medical problems may not dissuade the doctors from recommending gastric bypass surgery if it is appropriate, but those conditions will make a patient’s risk higher than average.
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- Make a list of all the diets you have tried (a diet history) and bring it to your doctor.
- Bring any pertinent medical data to your appointment with the surgeon-this would include report of special tests (echocardiogram, sleep study, etc.) or hospital discharges summary if you have been in the hospital.
- Bring a list of your medication with dose and schedule.
- Stop smoking surgical patient who use tobacco products are at a higher surgical risk.
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The Hospital Stay
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Because a DVT originates on the operating table, therapy begins before a patient goes to the operating room. Generally, patient are treated with sequential leg compression stocking and given a blood thinner prior to surgery. Both of these therapies continue throughout your hospitalization. The third major preventive measure involves getting the moving and out of bed as soon as possible after the operation to restore normal blood flow in the legs.
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Diet
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We recommend a period of four weeks or more without solid food after surgery. A liquid diet, followed by pureed foods, will be recommended for at least four weeks until adequate heading has occurred. We will provide you with specific dietary guidelines for the best post-surgical outcome.
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Skim milk, curd (using skim milk ),Eggs, low-fat cottage cheese, tofu, fish, other seafood, chicken (white meat ). Dals and sprouts are a very important source of proteins for vegetarian.
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When you are losing weight, there are many waste products to eliminate, mostly in the urine. Some of these substances tend to form crystals, which can cause kidney stones. A high water intake protects you and helps your body to rid itself of waste products efficiently, promotion better weight loss. Water also fills your stomach and helps to prolong and intensify your sense of satisfaction with food. If you feel desire to eat between meals, it may be because you did not drink enough water in the hour before.
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Eating sugars or other foods containing many small particles when you have are stomach can cause dumping syndrome in patient who have had a gastric bypass where the stomach pylorus is removed. Your body handles these small particles by diluting them with water, which reduces blood volume and cause a shock-like state. Sugar may also induce insulin shock due to the altered physiology of your intestinal tract. The result is very unpleasant feeling: you break out in a cold clammy sweat, turn pate, feel “butterflies” in your stomach. And have a pounding pulse. Cramps and diarrhea may follow. This syndrome can be avoided by not eating the foods that cause it, especially on an empty stomach. A small amount of sweets, such as fruit, can something be well tolerated at the end a meal .
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Snacking, nibbling or grazing on foods, usually high-calorie and high fat foods, can ass hundreds of calories a day to your intake, defeating effect of your operation. Snaking will slow your weight loss and can lead to regain weight.
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You can. But you will need to be very careful, and we recommend that you avoid it for the first several month. Red meats contain a high level of meat fibers (gristle) which hold the piece of meat together, preventing you from separating it into small parts when you chew. The gristle can plug the outlet of your stomach pouch and prevent anything from passing through, a condition that is very uncomfortable.
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50 to 65 grams a day are generally sufficient. Check with our dietitian to determine the right amount for your type of surgery.
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No. your salt intake will be unchanged unless otherwise instructed by your primary physician.
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Most patients are able to enjoy spices after the initial 6 months following surgery.
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You will find that even small amounts of alcohol will affect you quickly. it is suggested that you drink no alcohol for the first year. Thereafter, with your physician’s approval, you may have a glass of wine or a small cocktail.
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You will need to take a daily multivitamin for the rest your life, as well as, a B12 complex. Some patients may require iron and calcium supplement as well.
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Women are more susceptible to iron and deficiency if they are still menstruating, therefore. Women are likely to be placed on iron and calcium supplements in addition to there multivitamin. B12 injections are sometimes suggested if your B12 levels run low. B12 may also be taken orally or sublingually (under the tongue) by many patients.
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We require patients to consult with a nutritionist before surgery. Counseling after surgery is also available and recommended.
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We provide patients with materials that clearly outline their expectations regarding diet and compliance to guidelines for the best outcome based on your surgical procedure. After surgery, health and weight loss are highly dependent on patient compliance with these guidelines. You must your part by restricting high-calorie foods, by avoiding sugar,snacks and fats and by strictly following the guidelines set by the surgeon.
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Before proceeding any further it is essential to get your basics right. So we start with answering some essential question first like what is obesity, what are its causes, what are the complications arising out of it and the like.
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Clinically, obesity is described as the excessive accumulation of that exceeds the body’s skeletal and physical standards. The national institute of health (NIH) states that excessive weight becomes a health hazard when it is 20 percent or more above ideal body weight. Obesity becomes a serious health risk when it becomes morbid. in such cases the patient is susceptible to serious diseases like chronic hearts diseases or even infertility. Called co- morbidities, these conditions or diseases may results in either significant physical disability or even death. Morbid obesity is described as having a body mass index of 35 or higher. According to the national institutes of health consensus report, morbid obesity is a serious disease and must be treated as such. It is a chronic disease. Meaning that morbid obesity symptoms build slowly over an extended period of time.
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| Research shows that the recent rise in obesity is due to changed lifestyles, energy-dense diets and low levels of physical activity. However various factors may contribute to obesity which includes environmental factors, heredity, psychological & cultural influences and many others. Various possible causes of obesity, as suggested by renowned doctors, are given below. |
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Research shows that heredity influences fatness and the distribution of fat tissue. Heavy newborns grow into heavy adolescents only when either parent is overweight or obese. Weight regulation in the human body depends upon various hormonal and neural factors which are genetically determined. Any abnormality in these factors could result in substantial weight gain. Size and number of fat cells, distribution of body fat, and RMR also determined genetically. In 66% to 88% of the cases, obesity is found to be inherited. Studies have proved that above 250 genes, markers and chromosomes are linked obesity. Genetic conditions like the prader-will syndrome may also lead to obesity and linked diseases.However, there is no complete consensus on the fact that an abnormality in genes may lead to obesity. A recent study shows that while genes may increase vulnerability to obesity, the presence of other factors, like the environment, is necessary for obesity toactually occur.
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Before we study the metabolic factors that lead to obesity we need to have a basic understanding of metabolism in the human body. In short, basal metabolism rate (BMR) is the energy (measured in calories) used by the body at rest to maintain normal bodily functions. This continuous activity contributes to 60-70% of the amount of calories we “burn” in a day. Increased activity increases the BMR and the amount of calories burnt. Most obese people lead an inactive life. Thus their energy expenditure is minimal. Low levels of spontaneous physical activity leads to vulnerability towards obesity. Modern lifestyle has also done their share to contribute towards obesity. Endless hours of working. Sitting at the computer and leisure activities like watching television have reduced energy expenditure on physical activity. This combined with eating more calories than needed. Have led to the growing problem of obesity. |
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Certain drugs may contribute to weight gain, such as corticosteroids, sulfonylureas for diabetes, steroidal contraceptives and anticonvulsants such as valproate used in epileptic therapy. Antipsychotics, antidepressants, mood stabilizers like lithium are medicines that have weight gain as a side effect. |
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Several research models show that obesity is linked to various behavioral and emotional processes that may originate due to genetic or environmental reasons. Though these factors play a minor role in the development of obesity, they are important in relation to responses to treatment. For example, many patients reduce depressive symptoms by eating. These people may gain weight with one episode of depression and increase it with the next. Further, concepts of dietary restraints, body image dissatisfaction and binge eating disorders have been intimately linked to the increase in obesity today.
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Various studies conducted attribute an increase in caloric intake as the major causes of the current obesity epidemic. Changes in lifestyles, food systems, and increased portion sizes have been cited as causes for increased caloric intake. Larger portion sizes have led to a 30% increase in overeating. Eating out frequently also leads to increased calorie intakes as one meal served in restaurant and fast food outlets exceeds a person’s caloric needs for the entire day.
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Research shows that excessive body weight is linked to overall health and susceptibility to chronic ailments. It has been proven that a BMI beyond 20kg/m2, increases the risk of cardiovascular death, heart attack and diabetes, even after adjusting for age, smoking, social class, alcohol consumption and physical activity. Studies show that non smoking overweight men and women lose. 3.1 And 3.3 years of life respectively compared to normal weight non smokers. These studies have also established that weight fluctuations increase the risk of death. Coronary heart disease is the major cause of weight related death followed by diabetes mellitus, digestive disease and cancer. Evidence suggests that women can reduce mortality rate by 25% in diabetic. Cardiovascular and cancer conditions by achieving a weight loss of 9kgs. However if an obese person has already developed an associated co-morbidity, then planned weight loss of any amount has been reported to reduced mortality by 20%. It has also been establishedthe risk of mortality is greater in younger patients suffering from obesity as compared to older ones.
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Obesity is associated with chronic diseases such as heart disease, Type2 diabetes, hypertension, stroke, gallbladder disease, sleep apnea, certain cancers and osteoarthritis. These chronic ailments tend to worsen with increasing degree of obesity. Nonalcoholic fatty liver disease which may progress to end-stage liver disease is now also being recognized as a consequence of obesity. Obesity also may leads to poor wound healing and poor antibody response to hepatitis B vaccine.
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Benefits to the obese of a 10% weight-loss |
Mortality |
20-25% fall in total mortality
30-40% fall in diabetes-related deaths.
40-50% fall in obesity-related cancer deaths. |
Blood pressure |
Fall of 10mm Hg systolic pressure
Fall of 20mm Hg diastolic pressure. |
Angina |
Reduces symptoms by 90%
33% increase in exercise tolerance |
Lipids |
Fall by 10% in total cholesterol
Fall by 155%in LDL-cholesterol
Fall by 30% in triglycerides
Increased by 8% in HDL –cholesterol |
Diabetes |
Reduced risk of developing diabetes by > 50%
Fall of 30-50% in fasting glucose
Fall by 15% in HbA 1c |
Rheology |
Decreases blood viscosity by 20-27%
Decreases red cell aggregation by 20% |
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There are basically to types of obesity. Android and apple-shape obesity where the excess fat is primarily subcutaneous abdominal /truncal fat or gynoid or pear-shape obesity where excess fat is gluteofemoral fat. This fat is distribution is determined genetically and varies among men and women. Android obesity is more common among males whereas females are more susceptible to gynoid obesity. While incase of gynoid obesity is more difficult to shed weight, the android obesity is linked to chronic ailments such as glucose intolerance. Insulin resistance, hyperlipidemia and hypertension. Aging is also an important factoring the development of central obesity. This type of obesity is also closely associated with the development of metabolic syndrome (a complex of unified conditions like glucose intolerance, high blood pressure and alteration in serum lipids).
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Obesity and dieting are strongly related to an individual’s psyche. Studies shows that many obese people suffer from low self esteem which frequently manifests itself as anxiety and depression. A study done on severely obese subjects showed poor mental well-being. Most of them were also found to be suffering from anxiety and depression. A further study done on siblings. One being severely obese and other normal weight showed that functional and emotional wellbeing was significantly lower in severely obese siblings.
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The risk of obstetric complication is higher in obese women. Significantly obese women with an IBW of >135%have a 6.6-fold higher risk for the development of gestational diabetes, 1.9-fold risk for pregnancy induced hypertension, 1.4-fold risk for urinary track infections as well as other complications like preeclampsia, thrombophlebitis, post-partum haemorrhage and wound or episiotomy infections. Factors such as fetal size, especially macrosomia. An increase in material pelvic soft tissue narrowing the birth canal, late deceleration of the fetal heart rate. Intrapartum meconium staining, prolonged labor, malpresentations and cord incidents raise the risk of caesarean delivery. This higher prevalence of a caesarean delivery occurs with or without antenatal complications. Fetal weight appears to be a direct function of maternal size, with more than 50% of obese women having babies who weight greater than 3600g. An increased risk of neutral tube defects, especially spina bifida has also been reported in women with BMI greater than 29. Further, the protective effects of dietary folic acid as seen in leaner women are not seen in women weighing over 70kg. Studies have also shown that prenatal deaths were 3 times more common in obese women than their counterparts.
Obesity and incidence of maternal complications during pregnancy as summarized as follows-
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Obesity and incidence of maternal complication during pregnancy |
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Normal |
Overweight |
Obese |
Massively
Obese |
Number of Subjects |
54 |
48 |
34 |
30 |
Hypertension (%) |
9.3 |
33.3a |
54.6a |
79.3a |
Toxemia (%) |
3.7 |
17.8 |
30.3a |
42.9a |
Gestational diabetes
(%) |
1.9 |
12.3 |
39.4a |
44.8a |
Insulin (% patients) |
0 |
2.1 |
12.1a |
20.7a |
Insulin (%diabetics) |
0 |
16.8 |
30.7a |
46.2a |
Urinary infection (%) |
16.7 |
8.7 |
29.0 |
37.5 |
Preterm labor (%) |
14.8 |
13.0 |
22.6 |
28.0 |
Caesarean section (%) |
9.3 |
16.7 |
15.1 |
42.9a |
Hospitalization
Outpatients (%)
Inpatients (%) |
7.4
9.3 |
33.3a
33.3a |
45.5a
36.4a |
61.5a
66.6a |
Overall cost |
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Normal =BMI of 18-24.9;Overweight =BMI of 25-29.9; Obese=BMI of 30-34.9;
Massively obese=BMI>35.a = significantly different from normal weight group,
b=cost assessed as equivalent outpatient hospitalization. |
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The word ‘bari’ is the plural of ‘baros’ means weight/ burden/load or heaviness. From this stems “Baris” referring to the obese or fat/ heavy/ overweight people.
Surgeons first began to recognize the potential for surgical weight loss while performing operations that required the removal of large segments of patient’s stomach and intestine.
Bariatric surgery has continually evolved since its initial sporadic and tentative introduction in the 1950’s. The first bariatric procedure to be preceded (JIB) by animal studies and subsequently recognized by the surgical society was that of jejuno –ileal bypass (JIB) by Kremen and associates in 1954. Jejuno-ileal bypass involved joining the upper small intestine as an end-to-end or end-to-side anastomosis, thus bypassing a large segment of the small bowel. Which is thus taken out of the nutrient absorptive circuit? This procedure was associated with an array of early and late complications. These primitive procedures have been continually refined, in order to improve results and minimize risks.
Today’s bariatric surgeons have access to a substantial body of clinical data to help them determine which surgeries should be used and why. Today, society for bariatric surgery describes two basic approaches
- Restrictive procedure that decrease food intake.
- Malabsorptive procedures that alter digestion, thus causing incomplete absorption of food
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