Relationship Challenges before and after Weight-loss Surgery

 Relationship Challenges before and after Weight-loss Surgery

by Walter Medlin, MD, FACS

The weight-loss surgery journey is one of the most profound changes in our lives. Following nutrition, an exercise and follow-up program may be hard work, but the most challenging daily adjustment is, “the way people treat me differently.”

She burst into tears. Why? I had just walked into the hospital room, saying “your nurse tells me you are doing great from surgery yesterday!”

“No – I’m happy!” She manages to sob. “It’s just…a bit…overwhelming.” This patient figured out early, some of us figure out later, that the weight-loss surgery journey is one of the most profound changes in our lives.

Relationships change in many ways, as you change after surgery. Even though life may have been hard in many ways before surgery, leaving familiar old ways behind can be stressful. This stress can be a threat as well as an opportunity. This article will take a look at a few types of relationships that patients have shared that have been impacted by weight-loss surgery.

Self
Why save the most important for last? If your self-care is lacking, nothing can replace it. So many still follow a self-neglectful or self-berating pattern. Take the time to practice internal messages that console, talking back and taking a stand against your internal critic. Life is tough enough; shame, blame and harshness do not add anything to just taking responsibility, which can be empowering if done in a caring, loving way. Just because we talk about “self” doesn't mean we have to do it alone. Support groups, therapy or a good program team can help.

Spouse/Significant Other
This is the person with the most at stake for change in your life. They love you, but they are also “losing” some version of you. Some spouses have gotten away with taking advantage of power if you have had to rely on them and may fear you will retaliate with increased freedom and power after obesity no longer limits your financial and relationship prospects. Even if they haven’t taken you for granted, they can be afraid. If they are affected by excess weight, it may feel like a rejection.

Spouses can react in many different ways but they usually adjust if you do. Support groups sometimes invite spouses (most are happy for the perspective) and some programs have separate events for spouses. Many programs now even have a consent process before surgery, which can take some pressure off you to get them to understand the basics.

The fact is, somewhere around half of all marriages in the U.S. end in divorce, and weight-loss surgery patients are not immune. Support groups often say, “strong relationships grow under stress, weak relationships grow apart or fail.” Counseling can usually help when there is friction or dysfunctional communication.

Parents
If your mom is alive, she is probably the toughest to convince. Her “baby” is always going to be the center of her world. This can cloud her ability to do a non-emotional assessment of the risks versus the benefits, even with current overwhelming evidence for most patients.

The second issue can be the reflection on her. Often, moms can have hurt feelings if they perceive that they created the problem (even if you never said such a thing). Don’t give up on parents, because they can really be your “rock” afterwards, even if they never accept the idea fully beforehand.

Dads are so varied, it is difficult to predict. Sometimes they express fear by withdrawing, and that can seem like disapproval. They are often the slowest to share, but can be your most vocal supporter once they see how you are able to use your weight-loss surgery tool functionally.

Children and Siblings
So many different family systems are around today, it is probably hardest to predict how your kids and siblings will react. My mom frosted her hair when I was about 10-years-old, and I didn't want to talk to her for two days! Why was I upset? I have no idea and probably didn’t then, either. Some get totally focused on the risk of losing you to surgery – be careful to respect their intelligence. If you try to pretend that there is no risk, they won’t respect you, so get them the real information (take them to an info session or support group) and they will come around.

The other issue with kids or grand-kids in the home is the grocery shopping and pantry. It may not be fair to ask them to deprive themselves for you, but it is also not fair to you to have to always be tempted. Compromise happens from both sides, and in a loving, functional way. You can likely find some treats for them that don’t appeal as much to you, and they can follow some basic household rules to keep you from temptations.

Work Friends
Watch out for “Frenemies!” There are many types. A very few are truly bigots and should be avoided, but most are simply uninformed, and you can change that by informing them. Some are affected by obesity and feel threatened or jealous. They also admire you, but may not say it. They will greatly respect you if you show reasonable expectations and talk to them about the “tool,” rather than the “cure.”

Old Friends
I know of alcoholics who fell out with all their “drinking buddies” when they went to Alcoholics Anonymous. Luckily, we can still enjoy food with our heavy friends. Sometimes they are surprised to see that you actually eat real food and enjoy it more than before. I have some very caring relatives, however, who honestly feel my health looks worse because I now have more wrinkles and don’t have as much of a “glow.” We do have to acknowledge that many people have mainly been exposed to people getting thin with serious diseases – and that can impact the emotional response early on.

Strangers/New Friends
How do you introduce the issue with people you meet casually? I was on the phone with a physician assistant talking about my practice and he said, “Yeah, we get a lot of fatties here!” It took all my restraint, but I was able to keep my cool. “Well, I had a sleeve gastrectomy myself, and I can tell you it is very effective and safe.” That is certainly not the model start for a great relationship. I will keep working on this guy. Mostly, I have been pleasantly surprised at the acceptance of new acquaintances.

Program Team and Surgeon
Once you are through surgical recovery and the bandages are off, your relationship with the team changes. Our greatest concern is that the patient will become uncomfortable, exposing vulnerability to us, talking candidly about their real issues, or worse yet, be afraid of being judged. We work for you! Don’t forget that most of us went into healthcare to solve problems – you will not disappoint anyone by being honest.

Conclusion
In those post-lottery TV shows (big house, nice car, early retirement), none of those things matter if you don’t have peace with yourself, and even then, it’s pretty lonely without good relationships. High tech medicine doesn't have anything to do with this important part of a healthy, rewarding life, so we don’t talk about it much. We share different aspects of our life with each of these groups, and each of these groups has something special to offer us, as well. Many times in support groups I have heard, “well, I would never tell anyone else this, because they wouldn't understand, but…” Cherish those connections; they are the essential fabric of our journey.

Boundary issues can sneak into any relationship. There is a time and place for all types of sharing. Learn to recognize and seize the opportunity, but be respectful of the “body language” of others. Leadership books talk about putting the “right amount of heat” into a relationship. If you are too cool, distant and analytical, nothing much happens, but if the heat of aggression causes things to “boil over” you just end up with a mess.

Patience is probably the most useful tool we have. Stay gentle, stay engaged and stay in touch with all your supporters. Time changes everything, and most difficulties will adjust if you give them time. As they say in support group, “after a while, it’s the same life in different sized clothes.” Your good relationships will still be there, stronger for the challenge!

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Weight Loss Surgery and Life Expectancy

Gastric Bypass Surgery Adds Years of Life

Weight Loss Surgery and Life Expectancy

For those who are obese, gastric bypass can reduce the risk of death by 40% over a 7-year period, according to a study in the New England Journal of Medicine.

Gastric Bypass Benefits: The Research

The study examined the medical records of almost 10,000 gastric bypass patients, from   1984 to 2002, and compared them to data based on age, sex, and BMI--this is a way to from almost 10,000 severely obese persons who had applied for driver’s licenses.

Researchers matched individuals in each group ensure that these other factors don't play into the results. They then looked up each individual in the National Death Index to learn about any deaths that occurred over a 7-year period.

The Findings

People who underwent gastric bypass surgery had a 40% reduction in the rate of deathcompared to their obese counterparts. More specifically, they had a 56% reduction in death from coronary artery disease, a 92% reduction in death from diabetes, and a 60% reduction in death from cancer.

Oddly, the group that had gastric bypass surgery had a 58% increased risk of death by injuries, suicide and other non-disease causes.

Benefits of Gastric Bypass Surgery

A second study enrolled more than 4,000 obese participations. About half of those people underwent bariatric surgery (the most common type of which is gastric bypass surgery), and the other half were given non-surgical treatment. The participants were followed for an average of 10.9 years.

This study found that the non-surgery subjects had less than a 2% change in body weight over the follow-up period. The bariatric surgery group, on the other hand, reported large changes in body weight: 

• Gastric Bypass patients lost an average of 32%
• Vertical-banded gastroplasty patients lost an average of 25%
• Banding patients lost an average of 20%

After 10 years, these patients were able to keep the weight off. Ten years post-surgery: 

• Gastric bypass patients were 25% of their pre-surgery weight.
• Vertical-banded gastroplasty patients were 16% of their pre-surgery weight.
• Banding patients were 14% of their pre-surgery weight.

Studies have shown that a weight loss of 12% can reduce diabetes risk. The people in the surgery group were 24% less likely to die over a ten-year period.

The Bottom Line

These findings emphasis the health benefits of losing weight. Obesity is linked to dramatic increases in the risk of heart disease, diabetes and cancer. Losing weight can dramatically reduce those risks, as seen in this study.

Gastric bypass surgery is an option for people who have not been able to lose weight through lifestyle modifications. Once weight is reduced, controlling blood sugar, high blood pressure and other health conditions becomes much easier.

Another outcome of these studies may be the lowering of the BMI threshold for gastric bypass surgery. Until these studies came out, there was no solid evidence that gastric bypass surgery increased life expectancy. Now that that evidence exists, we may see gastric bypass surgery recommendations being made for more and more people.

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Exercise after Weight Loss Surgery

When it comes to exercise after weight loss surgery, the first rule of thumb is: start slow. You didn't gain all the excess weight overnight, and you won’t lose it overnight, either. Fortunately, with bariatric surgery, you will lose more weight more quickly than you could with fad diets or sheer willpower. And, by adding exercise to the mix, not only will the pounds melt off faster, but you’ll improve your heart health and increase your overall energy.

Of course, if you have struggled with your weight most of your life, the whole concept of physical fitness may be a major turn-off. But, if you want to achieve and maintain a healthy weight, moderate exercise must become a way of life. In addition to speeding your metabolism by creating healthy muscle tone, exercise helps improve your circulation and blood sugar levels.

Some people embrace exercise joyfully, while others are hesitant to put their bodies in motion. Whether or not exercise is exciting, fulfilling or fun, it is necessary to stay healthy—no exceptions. Weight loss surgery is just a tool, and you can use that tool most skillfully when making exercise a part of your daily routine.

Small Steps to Success
Walking is one of the easiest ways to start an exercise routine. Your doctor or nurse will probably want you to get up and walk around within hours after your weight loss surgery to reduce the chance of clots and speed your recovery.

Talk with your surgeon about when you can begin a walking regimen once you’re at home. As soon as you get the green light, it’s time to get moving. The walks don’t need to be long when you’re first starting out, and there’s no need yet to “pump” your arms or speed walk. Just a short stroll is enough at first–even doing short laps around the house can help you get in the swing of things. Then, make your walk a little longer each day—either in distance or duration.

How Far, How Long?
At first, the distance and the amount of time you spend walking may not seem like “exercise” to those who haven’t been obese. While you’re beaming with pride for having made it once around the block, others are baffled at the short stretch. Don’t worry about what anyone except your doctor says. You can even ask your doctor to set your first fitness goal, since he or she knows your body best. An early milestone may simply be walking to the mailbox, walking a quarter of a mile, walking for five minutes or walking for 15 minutes.

Some patients will find that if they plan to walk for a certain length of time, they “cheat” and go at a slower than usual pace—but if they elect to walk a particular distance, then they keep a good pace. Others respond quite differently—they’ll take an hour to walk a distance they could have covered in 30 minutes—but if they set a goal to walk a for “x” number of minutes they are able to keep meeting their goals. Whichever system you use, just make sure you keep adding a little more to your fitness routine each day.

To Thine Own Self Be True
Although some post-op patients revel in creating new contours by lifting weights or running marathons, and they are exhilarated by their new freedom of movement, not everyone is enamored of exercise after weight loss surgery. You can boost your motivation and improve your chances of sticking with a fitness program by finding something that’s fun for you.

Don’t like the gym? Take a walk in the park. Knees hurt? Try a recumbent bike. Love winter weather? Skiing, snowboarding and ice skating are all great for your heart!

There are almost as many kinds of exercise as there are personalities. From yoga and Tai Chi to swimming, cycling, rock climbing, swing dancing, hula hooping, tennis, basketball, badminton or bowling, you’re sure to stumble across some form of physical activity that gets you inspired.

Finding a buddy with whom you can break a sweat will also help you stay on track. You can encourage each other on your continued success, and hold each other accountable on days you’d rather not work out. Remember, cheating only cheats you out of fitness and health.

Final ThoughtsJust like your new lifestyle involves eating smaller portions and sticking with low fat foods, you need to make physical activity a part of your daily routine for weight loss surgery success. And remember, weight loss surgery isn't about getting skinny, it’s about getting healthy. Ultimately your goal is not just to look better, but also to live longer.

So, when it comes to exercise after weight loss surgery, be mindful of one simple rule: Get moving! 

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Is Sex Better After Weight Loss Surgery?

Overweight or obese men who lose weight following gastric bypass surgery may have more satisfying sex lives than their counterparts who do not have bariatric surgery. The findings appear online in the April issue of the Journal of Clinical Endocrinology & Metabolism.

Overweight men may experience sexual problems that include erectile dysfunction and shortness of breath during intercourse. The new study shows that dramatic weight loss achieved with weight loss surgery fosters an increase in levels of the male sex hormone testosterone, which may yield a better sex life.

On average, the men in the study weighed approximately 333 pounds at the start and had a body mass index (BMI) of 46. (A BMI of 30 or more is considered obese.) Over the following two years, the men who had weight loss surgery lost 40 to 100 pounds.

Researchers measured the men's reproductive hormone levels at the beginning and end of the study. Study participants also completed questionnaires on quality of life, including sex life, during the two time periods.

Weight loss and declining BMIs in men who had the surgery were directly linked with increases in all measures of testosterone levels, declines in levels of the female sex hormone estradiol and improvements in self-reported sexual quality of life.

Whether these findings can be extrapolated to include women who have gastric bypass surgery is not yet known, but the researchers point out that a woman's sex drive is not as strongly linked to hormone levels.

"This is a really important study," says Christine Ren Fielding, MD, an associate professor of surgery and the founder and director of the New York University Program for Surgical Weight Loss in New York City. "We have always had the feeling that the physiological, psycho-emotional and physical changes that occur after bariatric surgery can have positive effects on a person's sex life, but now we know."

Overweight people likely minimize just how important sex is to their quality of life. "Then they realize how improved their sex lives are after weight loss. They feel terrific and look back and ask, 'how did I ever live that way?'" says Dr. Fielding, also a member of Consumer Guide to Bariatric Surgery's advisory board.

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Revision for Weight Loss Surgery

Revision weight loss surgery

Revision Weight Loss Surgery is a surgical procedure that is performed on patients who have already undergone a form of bariatric surgery, and have either had complications from such surgery or have not successfully achieved significant weight loss results from the initial surgery. Procedures are usually performed laparoscopically, though open surgery may be required if prior bariatric surgery has resulted in extensive scarring.

With the increase in the number of weight loss surgeries performed every year, there are growing numbers of individuals who have experienced an unsatisfactory result from their bariatric procedures. There are several weight loss surgery options, some of which may limit later options for revision weight loss surgery.

Procedures

·         An adjustable gastric band is an inflatable silicone prosthetic device that is placed around the top portion of the stomach. This procedure can be performed as a revision procedure for many patients who have had a previous stomach stapling, gastroplasty procedure, or roux-en-Y gastric bypass surgery but have regained weight. The procedure is normally performed laparoscopically, though in a small minority of instances prior surgery may have resulted in extensive scarring, requiring open surgery.

·         Roux-en-Y gastric bypass is a commonly chosen revision technique, particularly in patients who have not been successful in meeting their weight loss goals after stomach stapling, gastroplasty, vertical gastric banding, or laparoscopic-adjustable gastric banding. Often the prior procedure still lends itself to a revision to become a roux-en-Y gastric bypass. It may be performed laparoscopically, and the average recovery time is approximately two weeks.

·         Sleeve gastrectomy removes a large portion of the stomach, with the remaining portion reshaped to become tube-like or sleeve-shaped. This creates an increased sense of satiety and decreased hunger in patients, often leading to weight loss and improved health. The procedure is generally less invasive than many other weight loss surgeries and has a lower potential for complications than may be associated with gastric bypass surgery.

·         StomaphyX revision is a completely endoscopic revision technique used to tighten a stretched gastric pouch using internal sutures or fasteners. It may be used in patients who have had prior roux-en-Y gastric bypass surgery and have a stretched stomach pouch.

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Weight-Loss Surgery can halt diabetes symptoms — almost immediately

Weight-loss surgery is a drastic step.

In Linda Nelson's case, a surgeon removed 80 percent of her stomach, took out her gallbladder and disconnected, rearranged and reconnected her intestines.

TYPES OF BARIATRIC SURGERY
Roux-en-Y gastric bypass: This is the most common method of gastric bypass. It works by decreasing the amount of food a person can eat at one sitting and reducing absorption of nutrients. The surgeon cuts across the top of the stomach, sealing it off from the rest of the stomach. The resulting pouch is about the size of a walnut and can hold only about an ounce of food — down from the normal 3 pints. Then, the surgeon cuts the small intestine and sews part of it directly onto the pouch. Food then goes into this small pouch of stomach and then directly into the small intestine sewn to it.

Biliopancreatic diversion with duodenal switch, or, simply, duodenal switch: About 80 percent of the stomach is removed. The valve that releases food to the small intestine remains, along with a limited portion of the small intestine (duodenum) that normally connects to the stomach. The surgery bypasses the majority of the intestine by connecting the end portion of the intestine to the duodenum near the stomach. This surgery limits how much a person can eat and reduces the absorption of nutrients. While it's very effective, it has more risks, including malnutrition and vitamin deficiencies. It's generally used for people who have a body mass index greater than 50.

Laparoscopic adjustable gastric banding: The surgeon positions an inflatable band around the uppermost part of the stomach. When the band is inflated, it compresses the stomach, acting like a tightening belt. This separates the stomach into two parts, with a very small upper pouch that communicates with the rest of the stomach through a channel created by the band. The small upper pouch limits the amount of food a person can eat. The band can be adjusted so that it restricts more or less food. Because of its relative simplicity, the operation is one of more common weight-loss surgeries. However, it may lead to less weight loss than may other procedures, and a person may need to have the band adjusted periodically.

Vertical banded gastroplasty: This procedure, also called stomach stapling, divides the stomach into two parts, restricting how much food a person can eat. The upper pouch is small and empties into the lower pouch — the rest of the stomach. Partly because it generally doesn't lead to adequate long-term weight loss, this weight-loss surgery isn't as popular as other types.

Sleeve gastrectomy: A sleeve gastrectomy, also called a vertical sleeve gastrectomy, is a newer type of weight-loss surgery. The sleeve gastrectomy actually is the first part of the surgical process for a biliopancreatic diversion with duodenal switch. However, the sleeve gastrectomy portion of surgery may be all that's needed to lose sufficient weight — in some cases the second part isn't needed. With sleeve gastrectomy, the structure of the stomach is changed to be shaped like a tube, which restricts the amount of calories a person's body absorbs.

Source: Mayo Clinic
The procedure already has worked wonders for her: She has lost 31 pounds since just before the Jan. 9 surgery. Five days after the surgery, she left Omaha's Methodist Hospital free of diabetes symptoms.

No more painful insulin shots. No more blood-sugar spikes that left her feeling shaky and jittery. No more diabetes medications.

Linda, who lives near Harlan, Iowa, is among a growing number of very overweight people undergoing the operations to not only lose weight but also rid themselves of the symptoms of Type 2 diabetes.

Not all who have the surgery become symptom-free, and for some that effect fades after a few years.

But for those whose diabetes symptoms go away, the effect usually is immediate — before any significant weight loss.

Researchers aren't sure why that is, but they're working to identify the process in an attempt to create drugs that could help with the treatment of diabetes.

Dr. John Anderson, the president of medicine and science for the American Diabetes Association, said the surgery is appropriate for severely obese people, particularly those who have shown an inability to lose weight. The evidence that it's right for moderately obese people, he said, is less compelling.

The surgery comes with risks and high costs, and not all insurance policies cover the procedure. In some cases, diabetes symptoms don't go away after surgery. When they do, some patients must resume taking diabetes medications after five years or so.

Over the years, Linda had tried diets, weight-loss programs and exercise, but the weight wouldn't stay off.

“It just was very frustrating to know that you're spending all that money and nothing's happening,” she said.

Linda, who is 65, is 5 feet tall. A couple of days before her surgery, she weighed 280 pounds. She has had Type 2 diabetes for four years. A little over a year ago, she developed a severe blood infection and was hospitalized for eight days. Her family physician wasn't sure that the diabetes was to blame, she said, but it certainly didn't help.

The doctor recommended that she consider weight-loss surgery.

Diabetes, both Types 1 and 2, is on the rise in the U.S.: From 1980 through 2010, the CDC says, the number of Americans with diagnosed diabetes more than tripled. The total number of people with diabetes, both diagnosed and undiagnosed, is more than 8 percent of the U.S. population.

People with diabetes can experience nerve, kidney, eye and blood-vessel damage. They face an increased risk of heart attacks and stroke.

The weight-loss surgeries allow many people with Type 2 diabetes, especially those not as severely affected, to go off all diabetes medications.

Medical experts don't know why people can stop taking their diabetes medicine so quickly after the surgeries, but they say hormones play a role.

In the operation Linda decided to have, a complicated one called a duodenal switch, the surgeon takes a patient's football-sized stomach down to bratwurst-size and reconnects the upper intestine so food from the stomach and digestive enzymes move through separate channels. They don't mix like they did before the surgery until they meet toward the end of the small intestine.

The intestinal reconfiguration also means that people don't absorb important nutrients, so they must take dietary supplements for the rest of their lives.

Linda's surgeon, Dr. Gary Anthone, said the duodenal switch works in a variety of ways: You eat less because your stomach is smaller; you absorb less because your intestine is shorter; you absorb less fat because bile and food don't have as much time to mix together; and you're presenting food to the lower part of your intestine more quickly. Moving the food lower in the intestine, it is thought, triggers the hormone that makes your pancreas secrete more insulin, and that tells your cells to respond to insulin better.

Steven Munger, a professor and researcher at the University of Maryland School of Medicine, said one theory is that the removal of tissue through these surgeries also removes some factor that promotes diabetes, or insulin resistance. Another, he said, echoing Anthone's explanation, is that in some weight-loss surgeries, part of the intestine is bypassed so that food goes from the stomach into a lower part of the intestine than it normally would, thus producing more “anti-diabetic” hormones.


Two other possibilities, Munger said: It's neither of those or it's some combination of the two.

Determining exactly what's happening, he said, could lead to the identification of a diabetes drug that would mimic the changes that occur in a person's physiology after the operation. “That would seem to be a nice way to go — to not have to go through this, which is a very significant surgery.”

From 2009 through 2011, 45,000 Medicare patients had weight-loss surgery. The American Society for Metabolic & Bariatric Surgery, a national group of weight-loss surgeons, estimates that 160,000 people in the U.S. had the operations in 2010. That's down from estimates for previous years of 200,000 surgeries annually, said Dr. Jaime Ponce, the society's president. Ponce attributed the drop, in part, to patients' out-of-pocket costs and insurance restrictions on coverage.

Although the totals are down, he and other surgeons said more people are turning to the surgeries to address diabetes.

Anderson, of the diabetes association, noted that while the surgeries are a good alternative for the right patients, they're still surgeries.

“The complication rates in the hands of experienced people is very low,” he said, “but it's not zero.”

Complications can include infections, leaks, internal hernias, ulcers, gallstones and blood clots. Since Linda had her surgery, she has vomited a few times when she tried to eat too large a portion, and has battled heartburn. Anthone, her surgeon, prescribed heartburn medication at her three-week check.

Anthone said he has performed 2,500 duodenal switch operations since 1992. It used to be, he said, that leaks — from the altered stomachs or the reconnected intestines — would occur in 5 to 10 percent of the cases. Today, he said, that rate is down to .5 percent to 1 percent of cases. “Locally, I would say we're even better than that,” he said.

How well the procedures combat Type 2 diabetes over the long term depends on how advanced someone's diabetes was when they had the surgery, according to a Seattle researcher.

Dr. David Arterburn, an associate investigator at the Group Health Research Institute in Seattle, said his recently published research found that people who have had diabetes for a long time, who already are on insulin or have poor control of their diabetes are much less likely to see their diabetes symptoms go away after gastric bypass surgery than are people with less-severe diabetes. Those with more-severe symptoms, he said, also were more likely to redevelop diabetes within five years.

“It didn't really matter what your weight change was,” he said.

Arterburn and other researchers looked at more than 4,400 people with diabetes who had a Roux-en-Y gastric bypass. More than 68 percent saw a complete remission of their diabetes symptoms. But of those, more than a third saw their symptoms return within five years.

Still, Arterburn said, people with diabetes who are severely obese should talk to their physicians about weight-loss surgery. Even if their diabetes symptoms don't go away, he said, the disease may be better controlled and they will move around better. And if they experience even just a short period of remission from their symptoms, he said, they will benefit.

Dr. Kalyana Nandipati, a surgeon and assistant professor at Creighton University School of Medicine, said some researchers have suggested that because of the surgeries' impact on diabetes symptoms, the operations should be performed on people who aren't morbidly obese. He also said the procedures could prevent diabetes from ever developing, citing a study, reported on last fall, that followed 3,400 obese men and women over 15 years. The Swedish researchers found that weight-loss surgery reduced the study participants' risk for developing Type 2 diabetes by 78 percent.

Linda Nelson was all smiles at a follow-up appointment almost three weeks after her bariatric surgery. After years of failed weight-loss efforts, she is optimistic this time: “I think it's a very doable thing,” she said. CHRIS MACHIAN/THE WORLD-HERALD

The surgeries “are not just to make people skinny but make them healthy,” Nandipati said.

Dr. Jennifer Larsen, a diabetes researcher and vice chancellor of research at the University of Nebraska Medical Center, argues that people with diabetes don't have to do something as drastic as undergoing surgery to lose some weight and gain better control over their disease.

“It is important for people to recognize there is an immediate cost and potential risk of surgery that usual care for diabetes doesn't have,” she said.

Ponce, from the national bariatric surgeons group, said certain types of weight-loss surgeries for severely obese patients who have other health problems are covered by some private insurers, as well as Medicare; Tricare, which is the insurance program for active and retired military and their dependents; and 47 state Medicaid programs. United Healthcare and Blue Cross Blue Shield of Nebraska say their standard policies don't cover such operations.

Linda's husband, Adrian, is glad that her insurance policy covers the procedure. When he opened the bill last week and saw that the charge for her surgery alone was more than $28,000, he grabbed his heart as if he were having a heart attack.

Dr. Cori McBride, a Nebraska Medical Center surgeon, said some insurers have told her that they don't want to pay for weight-loss surgeries because it takes several years to recoup the cost. Ponce said he had been told the same thing. The insurers, he said, say they won't see the benefit of what they spend because the average person changes insurance companies every two or three years.

Blue Cross Blue Shield of Nebraska provided a written statement acknowledging the procedures' costs. “We have excluded surgical treatment for morbid obesity as a standard contract term,” the statement reads, “to stay comparable with competitors and avoid passing on the costs to our customers.”

McBride noted that people who choose to have the operations must change their behaviors afterward. “They still have to watch things that they eat, eat healthy foods, modify their portions, eat when they're hungry, stop when they're full and not graze on garbage all day long.

“Unless they are committed to making the changes,” she said, “we shouldn't do the surgery.”

Anthone told Linda that she most likely will lose 60 to 80 percent of her excess body weight — between 96 and 129 pounds — within 18 months. Linda, who returned to work on Monday, said she's optimistic that will happen. “I do have the moral support, with Adrian, and I have my friends,” she said. “I think it's a very doable thing.”

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Mental Health Care needed before, after Bariatric Surgery

I REALLY LIKED THIS ARTICLE...a piece of advise I give anyone thinking about WLS, consider seeking out someone to talk to before and after you make the decision. WLS has a funny way of making most people (including myself), feel that when we wake up we are somehow a different person. The reality is that, we only look different in the mirror. Surgery makes us feel different because we learn how to love ourselves again and if this is still a difficult thing for you, make an appointment with a Therapist to try to change some of the feelings that possibly was the reason we allowed our bodies to get so out of control.   HUGS, Sherri


Mental health care needed before, after bariatric surgery


Bariatric surgery is the most effective weight-loss option for people who are severely obese. However, the surgery involves substantial risks and requires a lifelong commitment to behavioral change. People eligible for the surgery often have a history of mental health problems or eating disorders. Therefore, patients must be prepared mentally as well as physically before surgery, reports the January 2008 issue of the Harvard Mental Health Letter.

The psychological aspects of bariatric surgery are less well understood than the physical risks and benefits. Although the surgery is generally associated with improved mental health and quality of life, post-surgical psychological and behavioral changes are less predictable than physical changes.

The Harvard Mental Health Letter notes that mood disorders such as depression and anxiety affect many people who are eligible for bariatric surgery. The weight loss following surgery generally improves mood, at least initially. In studies, depression and anxiety scores were reduced significantly one year after surgery, but tended to be higher two and four years later. And some research has found higher-than-expected rates of suicide among surgery patients.

Eating disorders, such as binge eating, also affect many people considering bariatric surgery. And a highly controversial theory—as yet unproven—is that bariatric surgery may cause some people to lose weight but then “transfer” their food addiction to some other harmful addiction. Surgery may change the rate at which alcohol is absorbed, which may increase the risk of dependence in people who are vulnerable to becoming addicted. All of these factors underscore the need for mental health treatment before and after surgery, says the Harvard Mental Health Letter.

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Bariatric Surgeries Explained

Bariatric surgery includes a variety of procedures performed on people who are obese. Weight loss is achieved by reducing the size of the stomach with a gastric band or through removal of a portion of the stomach (sleeve gastrectomy or biliopancreatic diversion with duodenal switch) or by resecting and re-routing the small intestines to a small stomach pouch (gastric bypass surgery).

Long-term studies show the procedures cause significant long-term loss of weight, recovery from diabetes, improvement in cardiovascular risk factors, and a reduction in mortality of 23% from 40%. However, a study in Veterans Affairs (VA) patients has found no survival benefit associated with bariatric surgery among older, severely obese people when compared with usual care, at least out to seven years.

The American Society for Metabolic and Bariatric Surgery  (ASMBS) is the largest society of healthcare professionals dedicated to the safe and effective provision of bariatric surgery. The vision of the Society is to improve public health and well being by lessening the burden of the disease of obesity and related diseases throughout the world. Founded in 1983, the purpose of the society is to advance the art and science of metabolic and bariatric surgery by continually improving the quality and safety of care and treatment of people with obesity and related diseases by:

The U.S. National Institutes of Health recommends bariatric surgery for obese people with a body mass index (BMI) of at least 40, and for people with BMI 35 and serious coexisting medical conditions such as diabetes. However, research is emerging that suggests bariatric surgery could be appropriate for those with a BMI of 35 to 40 with no comorbidities or a BMI of 30 to 35 with significant comorbidities.

 From Wikipedia

Contents

1 Indications

• 2 Classification of surgical procedures
  • 2.1 Predominantly malabsorptive procedures
    • 2.1.1 Biliopancreatic diversion
    • 2.1.2 Jejunoileal bypass
    • 2.1.3 Endoluminal sleeve
  • 2.2 Predominantly restrictive procedures
    • 2.2.1 Vertical banded gastroplasty
    • 2.2.2 Adjustable gastric band
    • 2.2.3 Sleeve gastrectomy
    • 2.2.4 Intragastric balloon (gastric balloon)
    • 2.2.5 Gastric Plication
  • 2.3 Mixed procedures
    • 2.3.1 Gastric bypass surgery
    • 2.3.2 Sleeve gastrectomy with duodenal switch
    • 2.3.3 Implantable gastric stimulation
• 3 Eating after bariatric surgery
  • 3.1 Fluid recommendations
• 4 Effectiveness of surgery
  • 4.1 Weight loss
  • 4.2 Reduced mortality and morbidity
• 5 Adverse effects
• 6 See also
• 7 References

Classification of surgical procedures

Procedures can be grouped in three main categories: Standard of care in the United States and most of the industrialized world in 2009 is for laparoscopic as opposed to open procedures. Future trends are attempting to achieve similar or better results via endoscopic procedures.

Predominantly malabsorptive procedures

In predominantly malabsorptive procedures, although they also reduce stomach size, the effectiveness of these procedures are derived mainly from creating a physiological condition of malabsorption.

Diagram of a biliopancreatic diversion.

Biliopancreatic Diversion

This complex operation is termed biliopancreatic diversion (BPD) or the Scopinaro procedure. The original form of this procedure is now rarely performed because of problems with malnourishment. It has been replaced with a modification known as duodenal switch (BPD/DS). Part of the stomach is resected, creating a smaller stomach (however the patient can eat a free diet as there is no restrictive component). The distal part of the small intestine is then connected to the pouch, bypassing the duodenum and jejunum.

In around 2% of patients there is severe malabsorption and nutritional deficiency that requires restoration of the normal absorption. The malabsorptive effect of BPD is so potent that those who undergo the procedure must take vitamin and dietary minerals above and beyond that of the normal population. Without these supplements, there is risk of serious deficiency diseases such as anemia and osteoporosis.  Because gallstones are a common complication of the rapid weight loss following any type of bariatric surgery, some surgeons remove the gallbladder as a preventive measure during BPD. Others prefer to prescribe medications to reduce the risk of post-operative gallstones. Far fewer surgeons perform BPD compared to other weight loss surgeries, in part because of the need for long-term nutritional follow-up and monitoring of BPD patients.

Jejunoileal bypass

This procedure is no longer performed.

Endoluminal sleeve

A study on humans was done in Chile using the same technique, however the results were not conclusive and the device had issues with migration and slipping. A study recently done in the Netherlands found a decrease of 5.5 BMI points in 3 months with an endoluminal sleeve.

Predominantly restrictive procedures

Procedures that are solely restrictive, act to reduce oral intake by limiting gastric volume, produces early satiety, and leave the alimentary canal in continuity, minimizing the risks of metabolic complications.

Diagram of a vertical banded gastroplasty.

Vertical Banded Gastroplasty

In the vertical banded gastroplasty, also called the Mason procedure or stomach stapling, a part of the stomach is permanently stapled to create a smaller pre-stomach pouch, which serves as the new stomach.

Diagram of an adjustable gastric banding.

Adjustable gastric band

The restriction of the stomach also can be created using a silicone band, which can be adjusted by addition or removal of saline through a port placed just under the skin. This operation can be performed laparoscopically, and is commonly referred to as a "lap band". Weight loss is predominantly due to the restriction of nutrient intake that is created by the small gastric pouch and the narrow outlet. It is considered one of the safest procedures performed today with a mortality rate of 0.05%. 

Sleeve gastrectomy

Sleeve gastrectomy, or gastric sleeve, is a surgical weight-loss procedure in which the stomach is reduced to about 15% of its original size, by surgical removal of a large portion of the stomach, following the major curve. The open edges are then attached together (typically with surgical staples, sutures, or both) to leave the stomach shaped more like a tube, or a sleeve, with a banana shape. The procedure permanently reduces the size of the stomach. The procedure is performed laparoscopically and is not reversible.

This combined approach has tremendously decreased the risk of weight loss surgery for specific groups of patients, even when the risk of the two surgeries is added. Most patients can expect to lose 30 to 50% of their excess body weight over a 6–12 month period with the sleeve gastrectomy alone. The timing of the second procedure will vary according to the degree of weight loss, typically 6 – 18 months.

·         Stomach volume is reduced, but it tends to function normally so most food items can be consumed in small amounts.

·         Removes the portion of the stomach that produces the hormones that stimulates hunger (Ghrelin), although the durability of this removal has yet to be confirmed.

·         Dumping syndrome is less likely due to the preservation of the pylorus (although dumping can occur anytime stomach surgery takes place).

·         Minimizes the chance of an ulcer occurring.

·         By avoiding the intestinal bypass, the chance of intestinal obstruction (blockage), anemia, osteoporosis, protein deficiency and vitamin deficiency are significantly reduced.

·         Very effective as a first stage procedure for high BMI patients (BMI >55 kg/m²).

·         Limited results appear promising as a single stage procedure for low BMI patients (BMI 35–45 kg/m²).

·         Appealing option for people with existing anemia, Crohn's disease, irritable bowel syndrome, and numerous other conditions that make them too high risk for intestinal bypass procedures.

Intragastric Balloon (gastric balloon)

Intragastric balloon involves placing a deflated balloon into the stomach, and then filling it to decrease the amount of gastric space. The balloon can be left in the stomach for a maximum of 6 months and results in an average weight loss of 5–9 BMI over half a year. While not yet approved by the FDA the intragastric balloon is approved in Australia, Canada, and Mexico, India and several European and South American countries. The intragastric balloon may be used prior to another bariatric surgery in order to assist the patient to reach a weight which is suitable for surgery, further it can also be used on several occasions if necessary.

Gastric Plication

Basically, the procedure can best be understood as a version of the more popular gastric sleeve or gastrectomy surgery where a sleeve is created by suturing rather than removing stomach tissue thus preserving its natural nutrient absorption capabilities. Gastric Plication significantly reduces the volume of the patient's stomach, so smaller amounts of food provide a feeling of satiety. The procedure is producing some significant results that were published in a recent study in Bariatric Times and are based on post-operative outcomes for 66 patients (44 female) who had the gastric sleeve plication procedure between January 2007 and March 2010. Mean patient age was 34, with a mean BMI of 35. Follow-up visits for the assessment of safety and weight loss were scheduled at regular intervals in the postoperative period. No major complications were reported among the 66 patients. Weight loss outcomes are comparable to gastric bypass.

The study describes gastric sleeve plication (also referred to as gastric imbrication or laparoscopic greater curvature plication) as a restrictive technique that eliminates the complications associated with adjustable gastric banding and vertical sleeve gastrectomy—it does this by creating restriction without the use of implants and without gastric resection (cutting) and staples.

Mixed procedures

Mixed procedures apply both techniques simultaneously.

Roux-en-Y gastric bypass.

Gastric bypass surgery

A common form of gastric bypass surgery is the Roux-en-Y gastric bypass. Here, a small stomach pouch is created with a stapler device, and connected to the distal small intestine. The upper part of the small intestine is then reattached in a Y-shaped configuration. The gastric bypass had been the most commonly performed operation for weight loss in the United States, and approximately 140,000 gastric bypass procedures were performed in 2005. Its market share has decreased since then and by 2011, the frequency of gastric bypass was thought to be less than 50% of the weight loss surgery market. A factor in the success of any bariatric surgery is strict post-surgical adherence to a healthier pattern of eating.

Diagram of a sleeve gastrectomy with duodenal switch.

Sleeve Gastrectomy with Duodenal Switch

A variation of the biliopancreatic diversion includes a duodenal switch. The part of the stomach along its greater curve is resected. The stomach is "tubulized" with a residual volume of about 150 ml. This volume reduction provides the food intake restriction component of this operation. This type of gastric resection is anatomically and functionally irreversible. The stomach is then disconnected from the duodenum and connected to the distal part of the small intestine. The duodenum and the upper part of the small intestine are reattached to the rest at about 75–100 cm from the colon.

Implantable gastric stimulation

This procedure where a device similar to a heart pacemaker is implanted by a surgeon, with the electrical leads stimulating the external surface of the stomach, is being studied in the USA. Electrical stimulation is thought to modify the activity of the enteric  nervous system of the stomach, which is interpreted by the brain to give a sense of satiety, or fullness. Early evidence suggests that it is less effective than other forms of bariatric surgery.

                

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