Home Obesity Gastric Roux-En-Y Bypass

Information for those contemplating surgery for Obesity

If you are a smoker, you must stop for at least one month prior to your operation, as
the complication rate in smokers is nearly 100%"

It seems like such a drastic step to contemplate surgery, and it takes a lot of courage to do so. It may be one of the more difficult decisions you have ever faced. We realize this, and respect your apprehension….it is a big step, and one we do not undertake lightly. In fact you will find we do not sell the operation, and out advice is:

“If you’re not sure, don’t do it!”

Life style changes are essential, as it is inevitable that although genetics and evolution play a
huge part of the problem, you will have to correct and change some aspects of your life if the
gastric band is to work.

Laparoscopic Gastric Banding

It is essential you understand how the gastric banding procedure works, so you will understand
why the lifestyle changes are necessary.

The stomach portion above the band is only the size of a large marble. Like the rest of the stomach, it can distend, and thus most people will feel fullness with a small meal. A message is sent to the brain that you have eaten a big meal, and thus reducing your appetite. The gastric band slows the emptying of this pouch, prolonging this effect. However, 20% of morbidly obese patients are incapable of feeling this sensation, so it is important not to keep eating until you feel full. We will show you the maximum amount you can eat at one sitting (about a bread plate size). The band does suppress appetite, so

“If you are not hungry, don’t eat”

However, those who can't eat something are not eating correctly. Portions swallowed have to be chewed to smithereens, or a glob of dough or fibrous tissue plugs the pouch.

Easier said than done. Eating more than this volume can lead to over stretching of the pouch, and thus loss of elasticity i.e. poor emptying. Worse still, you will place stress on the stitches holding the band in place, and they may cut out and the band will slip down the stomach.

This is extremely dangerous and potentially life threatening, and always requires urgent surgery. Slippage can cause obstruction, or torsion of the stomach about the band.

As you lose weight, your appetite starts to return, and the rate of weight loss slows. It is time to have an inflation of the band, which will immediately suppress your appetite again. Note that inflations do not affect the size of the pouch, and therefore the amount that one can eat. Again it is stressed that inflation has no effect on what you eat, nor on how you exercise. Those factors still require you to comply with the requirements.

The problem is that every single patient who has the operation is bound and determined to make the lifestyle changes, and yet about 30% of females, and 11% of males, are unable to do so.

It seems so simple, so why can’t they?

There is some evidence suggesting that the abnormal genes involved with morbid obesity are closely linked to the genes that determine what type of person we are, even our personality! We are suspicious that sometimes these personality or behavioral traits may subliminally sabotage even the best of intentions, and thus prevent some patients from making all of these changes. We realize how complex these problems are, so we invite patients to come and see us if they are struggling to make the changes. Our job is not to criticize, but to help identify why the patient is struggling, and to come up with some strategies to help them.

The changes required are:

1. Low fat diet and watch the calories

The problem is “hidden” fat, which is in nearly all processed foods. You must read the label and ignore statements such as “96% fat free”. This should be banned, as it is deliberately misleading. Have a look at the 2 minute noodle packets and check out the actual fat content between different brands. Some have the equivalent fat content of 4 meat pies!

2. Never mix fluids with food

This will allow the food to empty out of the pouch more quickly, thus the messages of food in a full stomach is lessened.

3. Eat slowly, a minimum of 20 minutes for a meal

It takes that long before the appetite centres know you have eaten. (An aspirin taken for a headache needs to be absorbed from the stomach into the blood stream, and then do its thing in the “headache centre”, thus it takes about 20 minutes before you start to feel the headache settling.)

4. You must take part in an exercise programme

Joint problems will obviously limit what you can or can’t do. If you are unable to do any form of exercise that will raise your heart rate significantly, then surgery (or any form of treatment) is unlikely to have good results.

We will advise simple goals for you to attain with exercise. Walking is inadequate exercise for good fat burning. You should set yourself a goal, such as walk a ½ marathon, or hike the Milford track, or something challenging and achievable. Exercise should be regarded as a training programme, not just the occasional stroll for ½ hr. You need to get your heart rate about 65% - 85% of your maximum heart rate. You can calculate your maximum heart rate by subtracting your age from 226 (females) or 220 (males).

5. Monthly visits after surgery are essential

Your fat content will be measured at every visit, so you know if you are on track. Nearly all patients inadvertently make mistakes, and are unaware of it. You will also need a dietary analysis at times, particularly when you have reached your “happy size”, as you will be limited in what you eat for the rest of your life. We will not chase people who miss appointments….it is up to them, not the band. If you live too far away for monthly follow-ups, then gastric banding is not the best procedure for you, and you might consider other forms of weight loss surgery.

So what can we realistically hope for?
The results are variable, but if you make the changes, then you should loose weight.

Our aim is two-fold:

1. Get your BMI below 35

2. Down to a size that you are comfortable with.

You are unlikely to get down to an “ideal” weight, and will probably still be overweight but “cuddly”. We aim for physical and mental well being, not just weight loss. What’s the point of loosing a lot of weight and still be unhappy.

70% of our female patients, and 85% of out male patients, are able to obtain these results.

What does the surgery involve?

Laparoscopic adjustable gastric banding is done under a general anaesthetic. Most patients stay one night in hospital, some 2 nights. Hunger is suppressed immediately, and that night, patients are not hungry, but interestingly, they are not interested in food! They are up out of bed the same day as surgery, and can shower that night or the following morning. There are no sutures that need to be removed, and no dressing changes.

They stay on a liquid diet for 2 weeks after the surgery, then gradually increase the consistency moving through thicker soups, to pureed, to mushy food, and finally to normal food.

Many patients are intolerant of certain food types, red meat and bread are common problems.

We recommend that patients take 2 weeks off sedentary work, mainly because there is an enormous learning curve that patients undergo, and work stress is often a negative influence on compliance.

Monthly follow-ups are essential. We have shown that those who don’t, have a less than satisfactory result.

As weight loss occurs, appetite gradually starts returning, and it is time for the first inflation. Again, hunger is immediately suppressed. Patients commonly hope that an inflation will make them loose weight. Unfortunately it won’t……..it just helps patients control their intake. It won’t make them exercise, not does it influence the type of food that goes into the stomach.

Laparoscopic gastric bypass

This also restricts volume of food, but in this operation, the small pouch is separated form the remaining stomach. A length of small bowel is bought up to this pouch, and the food passes down this and enters the digestive tract lower down, thus bypassing a segment of the upper intestine. (Roux-en-y Gastric bypass). Not surprisingly, malabsorbtion can become a problem so long term follow up is also essential.

Calorie rich foods will commonly induce an awful feeling of nausea and faint feeling. So it is in fact useful in ensuring correct foods are eaten.

Nausea is common for a while after bypass. This also helps in reducing food intake.

Otherwise, the information pertaining to gastric banding also applies to gastric bypass.

Surgical complications:

There are also anaesthetic complications, and it is regarded as high risk anaesthetic……mainly respiratory problems, particularly in those who smoke. The only respiratory complication we have had was in a smoker.

Complications can occur despite the best attempts to avoid them, as with any type of surgery.
This is extremely difficult surgery, and should not be undertaken lightly. Not all complications are discussed, and in fact it is possible that unknown complications may start occurring in the future.

Laparoscopic gastric banding

Intraoperative complications are uncommon. The main concern is inadvertently making a hole in
the back of the stomach, as the tunnel is created to pass the band around the stomach. If not recognized, and it would be difficult to recognize, the leak could be devastating.

The biggest concern is the band slipping. This can occur for no definable reason. It happens when
the suture holding the band in place, gradually cut through the stomach tissue. It can also occur if patients repeatedly overeat and overstretch the pouch above the band. This complication always requires further surgery, and it can be lethal.

Gallstones may become symptomatic. This can also occur in non- Lap-Band ® patients who have significant weight loss. It requires removal of the gallbladder (also done laparoscopically).

The connection between the catheter and the reservoir has a metal spigot. Wear and tear can
cause leakage and the band to deflate, with immediate return of hunger, and ability to eat
anything. It is disappointing, but easily rectified with a day stay procedure under a light
anaesthetic. The tubing is reconnected, and the band reinflated, and they go home the same day. However, modifications to the design have made this complication rare now.

There have been reports of the band eroding through the stomach into the lumen.

The re-operative rate has dropped from 11% to approximately 5%.

Blood clots (DVT) are a risk, and appropriate precautions are taken with every patient. One reason why we get you out of bed the day of your surgery.

Infections are now unusual but can occur, and particularly in those with chest problems.

It boils down to the simple equation…what is the risk of surgery compared to the risk or surgery.

Laparoscopic gastric bypass

There are different complications to this operation. The big concern is leaking. The intestinal tract
and stomach are divided, rearranged, and rejoined. A combination of staple guns and suturing are used for this. There is always the potential for one of these to leak, more commonly from the stomach end. The signs can be subtle and difficult to pick up, and unfortunately, most patients are too big to fit into a CT scanner. This complication is potentially lethal.

Bleeding from these joins can also be a problem.

As it is a more complex operation, there is a significant chance that the laparoscopic approach is abandoned midway through the operation and the open approach used. This is done when the procedure becomes technically too difficult, and then the spleen is at increased risk of damage (and possible removal).

There is also a lifetime possibility of developing bowel obstruction in the future.

The mortality from this operation is about 2 – 5%.

What do you do next:

1. Get more information, and peruse the internet for information about other surgical procedures. Particularly vertical banded gastroplasty and gastric bypass.

2. Make an appointment by phoning the office. You will be thoroughly assessed by a surgeon, bariatrician, clinical psychologist, and nutritionist. You may be better off with medical treatment, and you will be advised accordingly.

© New Zealand Obesity Surgery Centre- Auckland, New Zealand.