What is the significance of the drainage tube?
With regards to the drain: The amount of drainage is not of much significance.  If the drainage begins to look like oral intake that is of concern and should be confirmed by drinking something blue or purple (food coloring or grape juice) and seeing if the color appears in the drainage.  If it does it should occasion a call to the physician. Drainage or wetness outside and around the drain tubing is usual and does not signifiy that anything is wrong, in particular it is not a sign of infection.  Redness extending more than two inches from the drain site should be seen by the surgeon.  The drain is protection against a wound infection at the drain site and against  the life threatening consequences of a leak. Leaks are very rare after two weeks.  Removal of the drain before two weeks after surgery entails some extra risk.  Patients who want the drain removed early should consider the risk.  About 2% of patients will develop a leak.  It is ok to shower and get incision sites or drain sites wet and soapy after surgery.  The area should be dried off afterwards and dressed if wetness at the site might stain clothing.  A temperature greater than 101 degrees is reason to call the doctor.  Lower temperatures are not usually of much significance.  Patients often complain that the drain site hurts and that relates to two considerations:  First, the drain is brought out the largest and therefore tenderest port site.  Second, the drain is sutured to the skin so that it will not be accidentally pulled out and if it is not taped so that pulling on the drain does not pull on the suture a good deal of discomfort can result from normal activity.

What if I'm having constipation?
Constipation after gastric bypass surgery is a common complaint.   It is caused by decreased food and water intake and, in some people, supplemental iron, or narcotic pain killers, tranquilizers, and antidepressants.  It is often aggravated by weak abdominal muscles or busy schedules wherein people defer having a bowel movement when the urge exists.  Our approach is to provide the following advice:

What if I'm having gas?
Excessive air swallowing is probably the commonest cause and may result from deliberately belching to relieve a sense of fullness or from swallowing frequently as sometimes occurs with anxiety and nervousness.  A deliberate change in behavior is usually effective.  Simethicone, marketed as Gas X, helps reduce large bubbles of gas to small ones and may relieve the cramping sensations.  Nullo which is a chlorophyll derivative also may be helpful.           

After gastric bypass, excessive dietary intake of fat increases intestinal transit time and delivers undigested food to the colon.  Food in the colon is broken down by resident bacteria and results in a very malodorous gas.  A restriction of dietary fat intake may be sufficient to eliminate the problem.  Bismuth subgallate marketed as Devrom (1-800 453 8898) is also helpful.  If the problem occurs soon after a distal gastric bypass, Pancrease—a pancreatic enzyme supplement—taken with meals may be useful.

Milk sugar called lactose is digested by an enzyme called lactase the production of which declines with age and following gastrointestinal surgery.  Lactase tablets, drops and milk products with pre-added lactase are available. Beans, cauliflower, onions, broccoli and other vegetables contain complex carbohydrates (oligosaccharides) which are broken down in the colon to form gas.  Beano contains a-galactosidase which helps to convert the oligosaccharides to simple sugars which can be absorbed and gas is thereby prevented.

An alteration in intestinal flora usually caused by antibiotics may produce gas.  Ultraflora—a bacterial preparation—may be given to repopulate in intestinal tract normally.  When the cause is fungal overgrowth, Diflucan (fluconazole) may be effective. Flagyl is sometimes tried to suppress anaerobic bacterial growth in bypassed portions of the intestine. 

Other causes are gallstones, diverticulosis, irritable bowel syndrome, and parasites, and, rarely, cancer of the ovary or bowel.

Is hair loss typical?
Hair loss is commonly assumed to be due to lack of adequate dietary protein but a clear cause and effect relationship is lacking.  Nevertheless, one should measure the prealbumin, and if it is low, increase protein intake.   Ephedrine is said to be effective in restricting protein weight loss and enhancing fat weight loss.  Hair loss due to dietary restriction is nearly always temporary.  Rogaine and Nexium shampoo have both been reported to be effective and should be tried if the loss is excessive. 

What is Iowa Bariatrics relationship with physicians I already see?
If your physicians have doubts about bariatric surgery we provide literature and attempt to educate them as to its merits. In any case we work with them to be sure that you are in the best shape you can be so that surgery may be safely done. Afterwards we send them a summary of your surgery and hospitalization with pertinent laboratory results and a letter describing your future needs as a gastric bypass patient.

How is laparoscopic gastric bypass different than open gastric bypass?
Laparoscopic gastric bypass is accomplished with 5 small incisions rather than one long incision. A camera is placed through one of the incisions and long instruments through the others. The operation is performed while watching a video screen. The actual operation on the stomach and intestine is the same with both approaches.

Is laparoscopic gastric bypass safe?
Many studies done by experienced laparoscopic bariatric surgeons have demonstrated laparoscopic gastric bypass to be safe. A study done by Dr. Oliak (see Description of Surgeries section) demonstrated the importance of surgeon experience. He found complication rates to be significantly higher during the “learning curve” for laparoscopic gastric bypass. Complication rates stabilize at a low rate after a surgeon completes approximately 75 laparoscopic gastric bypass operations.

How does laparoscopic gastric bypass compare to open gastric bypass?
Laparoscopic gastric bypass results in a shorter hospital stay, less pain, less scarring, and a quicker return to usual activities. Complications such as wound infections and wound hernias are nearly eliminated with the laparoscopic approach. The risk for serious complications (such as leak) is similar with both laparoscopic and open gastric bypass.

Why aren't all gastric bypasses done laparoscopically?
Laparoscopic gastric bypass is a difficult operation to learn to do safely. It also takes longer and is more expensive. The result is that most gastric bypasses in the United States are done open at this time. For most patients laparoscopic surgery is better (less pain, shorter hospitalstay, less scarring, quicker return to usual activities). As more surgeons learn to do laparoscopic gastric bypass safely and patients demand it, more laparoscopic gastric bypasses will be done.

Is laparoscopic surgery right for me?
Laparoscopic surgery is a good choice for most people. People who have had previous bariatric surgery or surgery on the stomach are probably better candidates for the open approach. People with BMI > 60 (more than 200-250 pounds overweight) may be better candidates for open surgery.

Can the surgery be reversed?
Yes, but it would take another operation. No one, in my experience, has asked to have the surgery reversed.

What are the main risks of surgery?
Put simply the main risks are death and complications. Mortality risk is 0.5% or 1/200. The commonest causes for death are pulmonary emboli and infections. The commonest complications are wound infections, strictures, and hernias.

Are there long term risks after surgery?
Any abdominal operation sets the stage for a possible bowel obstruction the lifetime frequency of which is approximately 8%. Vitamin and mineral deficiencies can occur if calcium, B12, and iron supplements are not taken as prescribed. Less commonly protein deficiency can occur.

How long is the hospital stay?
About 3 days after laparoscopy and about 4 days after open bypass.

Can I have a hysterectomy at the same time?
We do routine pelvic ultrasounds in patients who have not previously had a total hysterectomy. When the findings indicate the need a gynecologic surgeon may scrub in and do the appropriate surgery at the same time as the bypass.

Under what conditions is the gallbladder removed?
In patients who do not have gallstones at the time of surgery only 4% subsequently develop stones. We therefore only remove the gallbladder in patients who have stones diagnosed before or during surgery.

How can stomach surgery cause me not to crave ice cream or mayonnaise?
Food preferences change for many patients after surgery; others have to make do with discipline. The reasons for changes in food preferences are unknown.

I have irritable bowel syndrome. Will that go away after surgery?
Irritable bowel syndrome is neither improved nor worsened by surgery.

Will my sex life improve?
Not guaranteed, but it is a common experience.

What if my friends accuse me of taking the easy way out?
You and your friends should be aware that there is no easy way out. Surgery makes the discipline of exercise and dietary control effective when it would not otherwise be effective. Obviously, surgery also entails risk and the courage to take that risk.

What is dumping?
Foods high in sugar and some fats will cause the intestine to release vasoactive chemicals which cause sweating, flushing, weakness, fatigue, and sometimes abdominal cramps and diarrhea—a phenomenon called "dumping."

Why is Trinsicon required? Why can't I just get iron or B12 over the counter?
Trinsicon is an iron, B12, folate and intrinsic factor combination which is simply a convenient way to get iron and B12 which certainly can be taken separately and are available over the counter. Calcium should not be taken at the same time as iron since they compete for absorption. Iron absorption is enhanced if taken with vitamin C (ascorbic acid).

What is the reason for protein shakes after surgery?
The shakes ensure adequate protein and calorie intake after surgery which is important for healing and other reasons. A liquid diet ensures that the pouch and opening will not be stretched early on when that is more easily accomplished. The shakes also interpose a significant change between the way you have eaten and the way we hope that you will eat in the future. Because the shakes are somewhat monotonous when you switch to a low fat more healthy diet it is ‘tasty' by comparison and therefore more likely to be preferred in the long run.

How long do I have to take the shakes?
Four weeks; and it is a good test of your willingness to make some dietary changes.

How long do I have to take vitamins?
For life, if you want to be safe. Indeed everyone ought to take a multivitamin as well to prevent the fairly common and widely varied deficiencies seen as people get older.

How much food can I eat after surgery?
The gastric pouch although initially very small has a hole in the bottom so that a reasonable amount of food can be eaten if taken slowly. As time passes the pouch enlarges and where initially only one or two bites could be taken without a sense of fullness, later a small adult meal can be consumed.As it becomes possible to eat more food it becomes also more important to have developed good habits with regards to food choices.

Are there specific foods or drugs that I should avoid after surgery?
Except for the tiny hormone replacement pills most tablets should be crushed after surgery. Foods high in sugar and some fats will cause the intestine to release vasoactive chemicals which cause sweating, flushing, weakness, fatigue and sometimes abdominal cramps and diarrhea—a phenomenon called "dumping."

Is it possible to rupture the staples after surgery?
Vomiting may sometimes cause a tear and a leak, but usually does not. After about three weeks it is nearly impossible to rupture the staples.

Why don't people just keep losing weight until they get sick or die?
Everyone who has gastric bypass surgery has a strong genetic capacity to use calories efficiently. So it is always possible to provide high calorie foods and induce weight gain. In practice what happens is that with time people are able to eat more at a time, they lose weight and require fewer calories just to move around and their metabolism becomes even more efficient that it was preoperatively.

How can I prevent stretching out my new stomach?
Don't eat after you feel full.

Does surgery affect how well I absorb my medications?
Generally speaking not, but with certain medications it may be wise to check blood levels after surgery.

Can I drink carbonated beverages after surgery?
They may make you feel gassy, but I know of no other problems. They idea that they may stretch the pouch seems to me illogical, since no real pressure buildup can occur when both ends are unobstructed.

How long before I can go to work? Exercise? Drive a car? Have sex?
We advocate walking and light weight lifting immediately after surgery. Although both can theoretically slightly increase the risk of a hernia, it is unlikely that effort that does not cause abdominal pain very much affects the likelihood of developing a hernia. Similarly, if you can hit the brake hard without discomfort and are not taking painkillers then it is ok to drive a car. The discomfort standard should be applied to sex as well: if it doesn't hurt, go for it.

Will I ever eat normally again?
It depends on what you mean by normal. Many overweight people eat more and make higher calorie food choices than the rest of the population. So it is possible that you were not eating 'normally' to begin with. After surgery although you can eat small amounts of anything, we hope that you will choose lowfat foods for the most part. Also you will in general consume fewer calories than someone your size who was not previously overweight. Your could eat frequent small amounts of high calorie foods and gain your weight back.

1. Increase the difficulty of unscheduled everyday activities. For example, try to walk farther—a pedometer is helpful in this regard—climb the stairs instead of taking the elevator; volunteer for small tasks that you might not otherwise choose.
2. Schedule workouts two or three or four times a week simply for the purpose of exercising. Although any activity is helpful, weightlifting is the most efficient for extra weight loss.

How soon after surgery can I bathe or shower?
Infections virtually always come from bacteria present in the wound at the time of closure. Wounds seal to the outside within hours after surgery so it is safe to bathe or shower the next day. similarly, iv and drain sites can be cleansed and redressed with minimal likelihood of infection.

What will the support group do for me?
It provides people with similar experiences to use as a sounding board for common problems. Like Church attendance serves to remind you to behave morally, support groups serve as a reminder to maintain a healthy lifestyle. Support groups can also educate you in what constitutes a healthy lifestyle.

What if my overweight friends reject me?
This is a difficult area. If you change your activity and dietary behaviors so as to be more healthy you may at the same time change what you had in common with your friends. Moreover, what you do may be threatening to them. In some cases it may be easier to find new friends. The support groups can help you make the change.

How about my scar? Can I make it go away or become smaller?
Except for using steroid injections to stop keloiding I have heard of no tested way to diminish scarring, but lots of remedies are tried and perhaps some work. In any case it seems harmless to try.

Will I need plastic surgery after I lose weight to remove loose skin?
Whether plastic surgery is desirable depends on how old you are (skin is less elastic with age) how much weight you lose (the more the more skin) and individual differences in elasticity. Loose skin bothers some more than others, but there is nothing shameful about wanting to look your best and we will try to help anyway that we can.

Does exercise help prevent loose skin?
Exercise is wonderful for many things but unfortunately does very little for loose skin.

What causes some people to regain their weight?
Most often it is forgetting that weight control is a lifelong project. But obviously the genetic pressure to gain is greater in some than others and although we cannot currently recognize it the surgery may be better for certain types of obesity than it is for others.

ADVICE ON ACCELERATING EARLY WEIGHT LOSS, MAINTAINING AFTER WEIGHT LOSS AND REVERSING LATER REGAIN 

Current understanding is that the tendency to gain weight is largely genetic with a whole lot of modifiers or triggers like upbringing, stress, advertising, etc.  Not surprisingly, short of genetic re-engineering, to effectively lose weight and maintain, it takes surgery and a lot of personal effort.     In my opinion, the main component responsible for roughly 50%-60% of weight loss is the surgery.  Weight loss in the first 10 to 12 months after surgery is much easier than later on and can be accelerated with dietary discipline and exercise.  In general you lose weight in the first ten to twelve months and not much thereafter, so it is worth making an effort to maximize the early weight loss and not test the surgery with dietary lapses as many poorly committed patients do.

Another 20%-30% of weight loss is due to a combination of dietary discipline, exercise, and behavior modification: 

Dietary discipline means making a consistent effort to maintain a very low fat diet.  Ideally it means three to five protein and produce meals a day and no ‘grazing in between'.  Trying to be a vegetarian, eat no salt, and avoid sugars, noble as it sounds, distracts from avoiding fats and processed carbohydrates and is likely to be counterproductive. Replace high cal snacks like cheese, nuts, crackers, seeds, with proteins like shakes (Carnation non-fat breakfast, Trader Joe's soy protein, HMR, etc), hard boiled eggs, jerky esp turkey, non-fat milk, non-fat yogurt, non-fat cottage cheese.  Other snacks like baby carrots, lettuce with salt, fruits etc are low calorie and crisp substitutes but not as satisfying as proteins.  Chocolate cravings can be managed somewhat with bananas or other fruit dipped in chocolate syrup—it makes a little chocolate ago a long way.

Exercise, exercise, exercise is the mantra of long-term success and short term weight loss acceleration.  It should be one of life's rituals like showering or combing one's hair.   If you have never exercised, pick any activity schedule it and try to increase the intensity and duration.  Any exercise that you can do week in and week out is desirable but the best exercises are muscle building.  Muscle has a higher resting energy expenditure than many other tissues and an increase in muscle mass, most effectively produced through weight lifting, can elevate resting energy expenditure for days rather than hours as is true with other forms of exercise.

Behavior modification in practical terms means struggling with your habits and inner demons.  It is going to support groups to remind yourself that obesity is a chronic illness that requires lifelong attention.  It is sessions with a counselor of your choice to discover and deal with the reasons you eat.  It is part of your prayers and it is helping others to find a means to lose weight. 

Psychologic counseling:  An occasional patient will be losing weight quite satisfactorily and then without explanation begin to sabotage the process.  An underlying anxiety with regards to the danger—often sexual—of being thin may be the cause and can be helped with counseling. Other causes of an emotional nature are not uncommon and counseling is often helpful.

Fine tuners: Five to ten percent of weight loss can be ascribed to a number of "fine tuners" some of which can become habits while others can be used when regain threatens:

Pills.  Chromium may be particularly helpful to diabetics but is also of some small benefit to others.  Two hundred micrograms three or four times a week appears safe and may aid in weight loss.  DHEA in people over fifty has beneficial immune stimulation properties and may help slightly in weight loss and body fat distribution. Anorectic medications like phentermine have a role if you aren't where you want to be and some appear to be safe for long term administration.  Ephedrine although victimized with a lot of bad press is inexpensive, relatively safe, and a very effective way to increase metabolic rate and decrease appetite over the long haul. Feeling like you had too much coffee is an early side effect that disappears after about 8 weeks. The metabolic effect increases slowly for at least one year.        

Eating behaviors. If you must snack choose a protein.  Hardboiled eggs, jello as a drink, deli turkey or beef jerky provide longer periods of freedom from hunger and lower your metabolic rate less than do other foods.  High paid models drink lots of water to turn off hunger and the same technique is available to the rest of us.  Coffee, and tea may be better choices even than water as they contain caffein and theophylline which speed the metabolism and increase the rate at which calories are burned and therefore promote weight loss.  Unprocessed bran mixes well with juices, salads, cereals, meat loaf casseroles, pastas etc. and it prevents constipation, diverticulosis, and colon cancer as well as lowering cholesterol and decreasing appetite.

Casual exercise, the stairs instead of the elevator, kind of exercise is always available and an excellent habit to acquire.  If you are desk bound all day long, do five minutes of isometrics two or three times a day against the desk even just flex and hold; it's exercise and it is every bit as effective as exercise that moves you if done for the same amount of time.  A pedometer can be very useful as a means to recording and increasing the total number of miles you walk every day.  

Self-analysis. If you are tending to regain, start a diary and record your intake.  Analyze what you eat: some innocent looking foods are actually quite high in fat and therefore calories.  Examples include many crackers, nearly all cheese, nuts, and grain bars.  Look at where you store what you eat.  Do you keep it in your desk or somewhere quite handy or is some effort necessary to make it available?  If stress is making you eat, identify the stressor and find ways to eliminate or reduce the stress.  Nothing invigorates like a few decisions even if some of them are wrong and have to be changed later.

When is it safe to get pregnant?
Ideally, pregnancy should be delayed until weight loss is maximal, usually around 12 to 18 months after surgery. Weight loss makes women more fertile and decreases the likelihood of complications related to pregnancy.

How much weight should I gain?
Enough to account for the baby, the placenta, and some amniotic fluid—about 35 lbs. Ask your obstetrician.

How long after surgery before it is desirable to think about cosmetic surgery?
Results are best after weight loss has maximized—12 to 18 months after surgery.

Will I lose hair after surgery? If I do will it come back?
Hair loss is common and has never been conclusively related to any particular deficiency although many suspect that protein intake is important. If you do not have an ongoing tendency to baldness, it will all come back.

I don't have a support group where I live. What is the best way to stay in contact?
It is very important to try to followup with us at least once and better twice a year. At those times support groups can also be attended. We don't cure the tendency to gain excess weight; we manage it with discipline, support groups, accountability and sometimes adjunctive medications like ephedrine.