UHS Medical Times 1 Newsletter September 2018 علاج ال دانة وجراحة السمنة MINIMALLY INVASIVE Time For A FRESH START EVERYTHING YOU NEED TO KNOW ABOUT BARIATRIC SURGERY! While any surgical procedure carries some level of risk, bariatric surgery is a safe treatment option for patients struggling to maintain a healthy weight. WHAT IS BARIATRIC SURGERY? Bariatric or weight loss surgery is a catch-all term that includes any surgical procedure performed on the stomach or intestines with the goal of inducing significant weight loss. It is the only weight loss treatments with a proven track record of success and, for many people, it is the only viable option for achieving durable weight loss.
2 THE TYPES OF BARIATRIC SURGERY INCLUDE: Sleeve Gastrectomy Gastric Bypass Gastric Banding Duodenal Switch All of these procedures are typically performed using minimally-invasive (laparoscopic) techniques and work by altering the anatomy of the stomach and digestive tract, which helps limit food intake, makes patients feel full sooner, and limits digestion. By decreasing the storage capacity of the stomach, bariatric surgery prevents overeating and helps patients eat fewer calories, generating significant weight loss in a short period of time. HOW DOES BARIATRIC SURGERY WORK? Bariatric surgery, such as gastric bypass, gastric sleeve, and laparoscopic adjustable gastric banding, work by changing the anatomy of your gastrointestinal tract (stomach and digestive system) or by causing different physiological changes in your body that change your energy balance and fat metabolism. Regardless of which bariatric surgery procedure you and your surgeon decide is best for you, it is important to remember that bariatric surgery is a tool. Weight loss success also depends on many other important factors, such as nutrition, exercise, behavior modification, and more. By changing your gastrointestinal anatomy, certain bariatric procedures affect the production of intestinal hormones in a way that reduces hunger and appetite and increases feelings of fullness (satiety). The end result is reduction in the desire to eat and in the frequency of eating. Interestingly, these surgically-induced changes in hormones are opposite to those produced by dietary weight loss.
23 e-newsletter Newsletter September 2018 2016 WHO IS A CANDIDATE FOR BARIATRIC SURGERY? Qualifications for bariatric surgery in most areas include: 1. BMI 40, or more than 100 pounds overweight. 2. BMI 35 and at least one or more obesity-related co-morbidities such as type II diabetes (T2DM), hypertension, sleep apnea and other respiratory disorders, non-alcoholic fatty liver disease, osteoarthritis, lipid abnormalities, gastrointestinal disorders, or heart disease. 3. Inability to achieve a healthy weight loss sustained for a period of time with prior weight loss efforts. American Society for Metabolic and Bariatric Surgery (ASMBS) also recommend that surgery be performed by a board certified surgeon with specialized experience/training in bariatric and metabolic surgery, and at a center that has a multidisciplinary team of experts for follow-up care. This may include a nutritionist, an exercise physiologist or specialist, and a mental health professional.
4 BARIATRIC SURGERY PROCEDURES Bariatric surgical procedures cause weight loss by restricting the amount of food the stomach can hold, causing malabsorption of nutrients, or by a combination of both gastric restriction and malabsorption. Bariatric procedures also often cause hormonal changes. Most weight loss surgeries today are performed using minimally invasive techniques (laparoscopic surgery). The most common bariatric surgery procedures are gastric bypass, sleeve gastrectomy, adjustable gastric band, and biliopancreatic diversion with duodenal switch. Each surgery has its own advantages and disadvantages. Gastric Bypass Gastric bypass surgery aids in weight loss by changing how your stomach and small intestine handles the food you eat. After the surgery, your stomach will be smaller and you will feel full with significantly less food. Additionally, the food you eat will no longer go into some parts of your stomach and small intestine that absorb food, which means that you will not be getting all of the calories from the food that you are eating. So, eating less plus not absorbing all of the calories that you are eating will set you up for rapid weight loss.
25 e-newsletter Newsletter September 2018 2016 Advantages Produces significant long-term weight loss (60 to 80 percent excess weight loss) Restricts the amount of food that can be consumed May lead to conditions that increase energy expenditure Produces favorable changes in gut hormones that reduce appetite and enhance satiety Typical maintenance of >50% excess weight loss Disadvantages Is technically a more complex operation than the AGB or LSG and potentially could result in greater complication rates Can lead to long-term vitamin/mineral deficiencies particularly deficits in vitamin B12, iron, calcium, and folate Generally has a longer hospital stay than the AGB Requires adherence to dietary recommendations, life-long vitamin/mineral supplementation, and follow-up compliance
6 SLEEVE GASTRECTOMY The Laparoscopic Sleeve Gastrectomy often called the sleeve is performed by removing approximately 80 percent of the stomach. The remaining stomach is a tubular pouch that resembles a banana. Advantages Restricts the amount of food the stomach can hold Induces rapid and significant weight loss that comparative studies find similar to that of the Roux-en-Y gastric bypass. Weight loss of >50% for 3-5+ year data, and weight loss comparable to that of the bypass with maintenance of >50% Requires no foreign objects (AGB), and no bypass or re-routing of the food stream (RYGB) Involves a relatively short hospital stay of approximately 2 days Causes favorable changes in gut hormones that suppress hunger, reduce appetite and improve satiety Disadvantages Is a non-reversible procedure Has the potential for long-term vitamin deficiencies Has a higher early complication rate than the AGB
7 ADJUSTABLE GASTRIC BAND The Adjustable Gastric Band often called the band involves an inflatable band that is placed around the upper portion of the stomach, creating a small stomach pouch above the band, and the rest of the stomach below the band. Advantages Reduces the amount of food the stomach can hold Induces excess weight loss of approximately 40 50 percent Involves no cutting of the stomach or rerouting of the intestines Requires a shorter hospital stay, usually less than 24 hours, with some centers discharging the patient the same day as surgery Is reversible and adjustable Has the lowest rate of early postoperative complications and mortality among the approved bariatric procedures Has the lowest risk for vitamin/mineral deficiencies Disadvantages Slower and less early weight loss than other surgical procedures Greater percentage of patients failing to lose at least 50 percent of excess body weight compared to the other surgeries commonly performed Requires a foreign device to remain in the body Can result in possible band slippage or band erosion into the stomach in a small percentage of patients Can have mechanical problems with the band, tube or port in a small percentage of patients Can result in dilation of the esophagus if the patient overeats Requires strict adherence to the postoperative diet and to postoperative follow-up visits Highest rate of re-operation
8 BILIOPANCREATIC DIVERSION WITH DUODENAL SWITCH (BPD/DS) GASTRIC BYPASS The Biliopancreatic Diversion with Duodenal Switch abbreviated as BPD/DS is a procedure with two components. First, a smaller, tubular stomach pouch is created by removing a portion of the stomach, very similar to the sleeve gastrectomy. Next, a large portion of the small intestine is bypassed. Advantages Results in greater weight loss than RYGB, LSG, or AGB, i.e. 60 70% percent excess weight loss or greater, at 5 year follow up Allows patients to eventually eat near normal meals Reduces the absorption of fat by 70 percent or more Causes favorable changes in gut hormones to reduce appetite and improve satiety Is the most effective against diabetes compared to RYGB, LSG, and AGB Disadvantages Has higher complication rates and risk for mortality than the AGB, LSG, and RYGB Requires a longer hospital stay than the AGB or LSG Has a greater potential to cause protein deficiencies and long-term deficiencies in a number of vitamin and minerals, i.e. iron, calcium, zinc, fat-soluble vitamins such as vitamin D Compliance with follow-up visits and care and strict adherence to dietary and vitamin supplementation guidelines are critical to avoiding serious complications from protein and certain vitamin deficiencies
9 BENEFITS OF BARIATRIC SURGERY The risk of damage to your health can be reduced by losing weight through surgery compared to staying morbidly obese. Bariatric surgery can improve and effectively solve many health conditions related to being overweight, for example: 1. Type 2 diabetes 2. Hypercholesterolemia (high cholesterol) 3. Gastroesophageal Reflux Disease (GERD) 4. Hypertension 5. Heart disease 6. Depression 7. Osteoarthritis of joints 8. Joint pain 9. Sleep apnea and respiratory problems 10. Urinary stress incontinence 11. Asthma and lung conditions 12. Reproductive health Reduction in food intake which leads to a reduction in calorie intake and consequent weight loss Weight Loss surgery can not only help you look and feel better, it can also ensure that you lead a healthier life Weight loss will improve the physical and lifestyle conditions associated with being overweight Energy levels will increase enabling you to move around easier and improve your quality of life Successful weight loss surgery can improve your self-esteem and self-worth. It can give you a new found confidence, positive feelings and control over a life that has had issues with being overweight for a long time It s sad but true, being overweight can prejudice and influence the perception and attraction of others at work, at home and within relationships. Weight loss surgery can turn that around as your self-esteem and confidence improves so does others perception and reactions around you
10 LIFE AFTER BARIATRIC SURGERY Bariatric surgery is a major event in a patient s weight-loss journey, but the event is best seen as a new beginning. Post-surgery you ll also need to be committed to a specific and restricted diet, an exercise plan, to changing your behavior and making lifestyle changes. Diet Post-surgery dietary guidelines will vary depending on the type of weight loss procedure you choose to have. Immediately following weight loss surgery you will not be able to eat at all. Your recovery diet will slowly progress from clear liquids to full liquids, pureed food, soft foods, and then you will finally be able to start eating solid foods. You may be recommended to take vitamin and mineral supplements on a daily basis to prevent nutrient deficiencies. After weight loss surgery the difference in your body will make it physically easier to adjust your eating habits. Here are some guidelines for a healthy diet when you start eating solid food. Aim for three small meals a day. Eat the protein foods first as these are the most important. Choose healthy, low fat/sugar solid dry textured foods that will fill you up quicker and for longer All meals should be eaten slowly and food should be thoroughly chewed. Aim for about 15 chews per bite so that the food turns to mush and 25 minutes for each meal. Stop eating when you feel full or tightness in your chest, even if you haven't finished your meal. Don t eat and drink at the same time. This can flush food out of your stomach pouch and make you feel less full or it can overfill your pouch leading to vomiting and stretching. Limit snacking between meals. Avoid carbonated drinks and drink alcohol in moderation.
11 Exercise Exercise is essential for bariatric patients to achieve long term success in their goals to lose weight and maintain their desired weight whilst living a healthy lifestyle. After your weight loss surgery you will be encouraged to be on your feet and walking about as soon as possible. Low impact exercise such as swimming, cycling and walking are ideal for bariatric patients. It s important that you choose exercise that you enjoy, and do it regularly. As you lose weight you may choose some toning exercise, combining weight resistance exercise with light weights, to help tighten excess skin. Cosmetic Issues Losing a great deal of weight following weight loss surgery changes the shape and contour of your body. You may be left with excess skin around your abdomen, thighs, buttocks, breasts, upper arms, face and neck. You might consider cosmetic surgery to improve your body s appearance and also for medical reasons. Health Problems As you lose weight quickly over the first 3 to 6 months, you may feel tired or cold at times. You may also have body aches, dry skin and hair loss or thinning. These problems should go away as your body gets used to the weight loss and your weight becomes stable. It s important that you keep to the diet recommendations made by your bariatric surgeon to ensure you re getting enough protein and are not suffering from any nutritional deficiencies as a result of your new diet. Emotional Adjustments Having weight-loss surgery causes a ripple effect and many areas of your life will change. You will often experience changes in your emotional state such as anxiety, depression and insomnia. Sensory Changes Sensory changes such as changes in appetite, taste and smell often occur for weight loss surgery patients. These are not all negative, and can lead to more weight loss among patients.
12 BARIATRIC SURGERY - FAQS How long after metabolic and bariatric surgery will I have to be out from work? After surgery, most patients return to work in one or two weeks. You will have low energy for a while after surgery and may need to have some half days, or work every other day for your first week back. Your surgeon will give you clear instructions. When can I start exercising again after surgery? Right away! You will take gentle, short walks even while you are in the hospital. The key is to start slow. Listen to your body and your surgeon. If you lift weights or do sports, stay low impact for the first month. Build slowly over several weeks. If you swim, your wounds need to be healed over before you get back in the water. Can I have laparoscopic surgery if I have had other abdominal surgery procedures in the past, or have a hernia, or have a stoma? The general answer to this is yes. Make sure to tell your surgeon and anesthesiologist about all prior operations, especially those on your abdomen and pelvis. Many of us forget childhood operations. It is best to avoid surprises! Does type 2 diabetes make surgery riskier? It can. Be sure to follow any instructions from your surgeon about managing your diabetes around the time of surgery. Almost everyone with Type 2 Diabetes sees big improvement or even complete remission after surgery. Can I have laparoscopic surgery if I have heart disease? Yes, but you may need medical clearance from your cardiologist. Bariatric surgery leads to improvement in most problems related to heart disease including: High Blood Pressure Cholesterol Lipid Problems Heart Enlargement (Dilated Heart, or Abnormal Thickening) Vascular (Artery and Vein) and Coronary (Heart Artery) Disease
13 When can I get pregnant after metabolic and bariatric surgery? Will the baby be healthy? Most women are much more fertile after surgery, even with moderate pre-op weight loss. Most groups recommend waiting 12-18 months after surgery before getting pregnant. Kids born after mom s surgery are LESS at risk of being affected by obesity later, due to activation of certain genes during fetal growth. Will I lose my hair after bariatric surgery? Some hair loss is common between 3 and 6 months following surgery. Even if you take all recommended supplements, hair loss will be noticed until the follicles come back. Hair loss is almost always temporary. Adequate intake of protein, vitamins and minerals will help to ensure hair re-growth, and avoid longer term thinning. Will I have to take vitamins and minerals after surgery? You will need to take a multivitamin for life. You may need higher doses of certain vitamins or minerals, especially Iron, Calcium, and Vitamin D. Will I have to go on a diet before I have surgery? Yes. Most bariatric surgeons put their patients on a special pre-operative diet, usually 2 or 3 weeks just before surgery. The reason for the pre-operative diet is to shrink the liver and reduce fat in the abdomen. This helps during the procedure and makes it safer. Will I have to diet or exercise after the procedure? No and Yes. Healthier food choices are important to best results, but most patients still enjoy tasty food, and even treats. Regular, modest activity is far more useful in the long term.