Post-op Birth Control

October 23, 2017 3:29 am

Carolyn M. Post-op birth control is very important if you are female, heterosexual, between the ages of 13 and 50, and have all your female parts intact. It is very dangerous to get pregnant in the 18 months following your surgery. Not just because it can mess up your weight loss, and not just because it is hard to nourish an unborn baby when your intake is restricted and you are malabsorbing protein and vitamins, but because for at least the first few months, you will be in ketosis much of the time. Ketones can cause fetal brain damage. Don’t risk it. This is why post-op birth control is so important. You may not think you are fertile, and many obese women aren’t very fertile, but you can become fertile again very quickly as the weight comes off. Many but not all surgeons will advise you to use reliable birth control post-op. Birth control pills alone aren’t considered reliable post-op, because they may be partly malabsorbed, and because as you lose fat, your estrogen levels fluctuate anyway. And if you didn’t know it already, the more overweight you are, the less reliable the Pill is to begin with. If you are on the pill, you will also need to use a barrier method, such as condoms, the sponge, a diaphragm, or vaginal film or foam (listed in order of reliability). You could also use condoms plus the Sponge, or condoms with vaginal foam or film for post-op birth control. If your family is complete, male or female sterilization procedures may be your best long-term option. Temporary post-op birth control methods that you can use alone are the Depo-Provera shot, the Nuva Ring, or the Mirena or Paragard IUD. A little bit about these post-op birth control choices: 1. The shot is extremely effective birth control, similar to having your tubes tied but less permanent. You may have irregular bleeding for the first 3-6 months or so, after that most people have little to no bleeding. Other side effects–if you are prone to depression, it can make depression worse. If you are prone to acne, it can make acne worse. In 25-30% of women, it stimulates the appetite. This is why it can be associated with weight gain. In about 2% of women it can cause hair loss. Because many of us have had problems with depression and appetite pre-op, and problems with hair loss post-op, this might not be the best choice. It takes up to a year to become fertile again after going off the shot. 2. The NuvaRing is a thin flexible plastic ring that you insert into your vagina, leave in for three to four weeks, and then remove. You can leave it out for up to 7 days to have a period, or insert the next ring immediately to skip periods (if you use it to skip periods, you will have breakthrough bleeding from time to time. You can remove the Ring for 3-5 days and then reinsert it to stop breakthrough bleeding. But to avoid losing contraceptive effectiveness, always leave each new Ring in for at least three weeks and reinsert the next Ring within 7 days). With the NuvaRing, you have more local hormone effect, so it is very good at preventing pregnancy and controlling periods, but a lower blood level of hormones than with any other hormonal method, and thus fewer side effects. It is very comfortable to wear; you won’t even feel it when it is in place. Most women who try the NuvaRing end up loving it. You become fertile again right away after stopping the Ring. It’s not a preferred medication on most insurance plans, so you may pay higher co-pay (compare to the costs of using the Pill plus a barrier method). 3. The Paragard IUD is expensive to start out with, full cost is $450-750 to purchase and get it inserted. But it lasts 10 years, so it’s the cheapest method in the long run. It takes a procedure to put it in, which can be a little uncomfortable. After placement, you may have intermittent spotting and cramping for a couple of months. After that, your periods may continue to be a little heavier and crampier than your usual. It contains no hormones, so you will not have any hormone related side effects. You can usually use the Paragard IUD even if you haven’t had any children. Your fertility returns immediately after the IUD is removed. 4. The Mirena IUD contains a small amount of progesterone. It is also expensive to start with, but lasts 5 years. It can be used not only for birth control, but to decrease bleeding for women who have heavier or more frequent periods. By the time you have had it in for 2 years; you will have very scant periods, if any. For the first year or so, you may have frequent and/or prolonged episodes of very light bleeding. This can be annoying but isn’t dangerous as the actual amount of blood loss is low. Most of the progesterone effects are confined to the uterus, however, sensitive women may experience some of the side effects listed under Depo-Provera (depression, acne, hair loss, etc.) These effects, if experienced, tend to decrease with time. You can use the Mirena IUD only if you have already borne at least one child. It may take a few months after this IUD is removed for you to become fertile again. Please make an appointment with your OB/GYN provider or visit your local Planned Parenthood or County Health Dept. to discuss which of these post-op birth control methods may be right for you.

Hair Loss

October 23, 2017 3:28 am

Hair loss can happen as a result of surgery. Telogen Effluvium occurs when sudden or severe stress, like surgery, causes an increase in the shedding of the hair. Hair follicles prematurely stop growing and enter into a resting phase. The hair stays in the resting phase for about 3 months after which time a large amount of hair will be shed. Surgery can cause this loss because after the stress of surgery your body compensates by diverting nutrients toward more vital organs. Also, when there is rapid weight loss, losing hair is not uncommon. In most cases the hair loss is temporary and the hair soon recovers.  

Hair Loss Prevention Program

Tips for Hair Loss:

• Temporary hair loss is a very real side effect of surgery and it can be a disheartening problem. Hair loss happens due to the way hair follicles grow in cycles and because it takes several months for a hair follicle to grow. The shock of surgery, lower calorie & protein intake, and anesthesia cause the hair follicle to stop growing. Because this may happen any where in the growth cycle you often don’t see the hair loss right after surgery but a few months after surgery.
• Protein intake is extremely important for healing, hair growth and to prevent muscle wasting. After surgery you need 80 gm or more of protein every day. Again while you are going through the weight loss period your body does not care if it loses fat mass or muscle mass. The best way to enhance hair growth, fat mass loss and prevent muscle loss is to get 80 gm or more of protein daily and to exercise daily.
• Multivitamins with minerals every day are also an important supplement because if you are defiant in vitamins and minerals then your body takes the essential vitamins for the general running of your body and doesn’t give the unessential things like hair and nails what they need to grow.
• Nioxin shampoo has been traditionally used by cancer and chemo patients but some GRDS patients have had good luck with it also.
• Biotin tablets or powder are great for healthy hair, skin, and nails. 600-1000 mcg daily and can be found at most health food, vitamin or beauty supply store. Also assist the body in turning fat mass into usable energy.
• Folicure tablets and shampoo can also help. They can be found at Sally’s Beauty Supply.
• Zinc 50mg tablets every other day for no more than a month. Zinc blood levels can get too high after this period of time. Zinc can interfere with iron absorption at higher levels. Zinc helps with protein synthesis and collagen formation (both ingredients for hair growth). Inactivity can lower the body’s levels of zinc another reason why exercise is important.

  By Carolyn M. Please note that following this program will not mean you won’t lose ANY hair. It just minimizes your hair losses. I did lose hair myself, although I was the only one who noticed. And you have to do all three parts, and you have to do them as described. The zinc and selenium won’t do much good if you aren’t getting in enough fluid and protein. I know it’s a struggle to get in this much fluid and protein at first, but persevere. You can get the fluid in if you sip, sip, sip all day long. You can get the protein in if you use protein shakes and supplements as necessary. And it is untrue that you can only absorb a limited amount of protein at one time. You absorb 50% of what you take in, period, whether you take in 30 grams or 90 grams at a time. So here’s the program: 1. Make sure you get at least 60 grams of protein every day beginning as soon as you get out of the hospital. Use shakes until you can get enough food. Build up to 80-100 grams when you can. Rationale: Protein is essential for hair growth and hair that doesn’t grow falls out. 2. Force the fluids. At least 64 oz a day the first week or two then bump it up to 80-100 oz per day. Rationale: Fluids flush out the ketones your body makes when burning fats. Ketones are toxic to rapidly dividing cells like the hair follicles. 3. Beginning the first week after surgery, add 100mg of Zinc and 200 mcg of Selenium to your supplements. Crush these tablets for the first 3 months to guarantee absorption. Rationale: These mineral support the telogenic (resting) phase of hair growth. Biotin supplements may also help, some swear by them. Nothing you put ON your hair from the outside will do anything to prevent loss, although it may plump up the individual strands and make your hair seem thicker. Topical emulsions don’t usually penetrate the scalp to the level of the hair follicles–Minoxidil is an exception to this general rule. For more information on Telogen Effluvium: https://www.aocd.org/skin/dermatologic_diseases/telogen_effluvium.html  For more information on Hair Loss: Central Valley Bariatrics PDF on Hair Loss

Open vs Laparoscopic Surgery

October 23, 2017 2:57 am

The differences between open vs. laparoscopic surgery are explained. Duodenal Switch can be performed open (traditional) or laparoscopic. Open surgery requires a 6 to 8 inch incision to open the abdomen for the operation and laparoscopic surgery uses multiple small incisions, and then a camera is used to view the abdomen while small instruments are used to perform the surgery through the incision points. The laparoscopic approach may also require a small 3 inch incision below the belly bottom for the hand port. This is so the small bowel can be measured for its entire length. Although open surgeries are still very common, many surgeons now perform the laparoscopic procedure. Some surgeons choose to perform their surgeries traditionally based on preference, and the anticipated technical issues that may be encountered, such as the revision cases from a gastric bypass to the duodenal switch operation. Keep in mind there are times when on the operating table, due to unexpected findings, complications or difficulties, a laparoscopic procedure may become an open surgery. Regardless of which way the abdominal cavity is entered weight loss and improvements in quality of life are equivalent between the approaches in terms of long term outcomes. [33-34] The laparoscopic approach is not suitable for all patients. Patients, who are extremely obese, have had previous abdominal surgery or have complicating medical conditions, may be required to have their surgery performed open.   Laparoscopic Advantages [23-28]

• Less postoperative pain
• Shorter hospital stay-even though this may not be significant (0.75 day shorter stay!)
• Faster postoperative recovery with comparable efficacy and less need for narcotics.
• Fewer wound complications (wound infections, dehiscence, incisional hernias)

  Laparoscopic Complications [29-32]

• Higher rates of postoperative bowel obstruction.

  The patient can discuss the pros and cons of each type of procedure with a number of surgeons before making a final decision.

Duodenal Switch Risks and Complications

October 23, 2017 2:56 am

The potential risks and complications associated with Duodenal Switch operation are listed below. Keep in mind all surgical procedures involve a degree of risk, however, this must be balanced against the significant risks associated with severe obesity without surgical intervention. The risks should also be considered when measured against the benefits of a particular intervention or treatment. A low risk intervention or procedure (walking for 15 minutes a day) has minimal risk, but also has an extremely poor outcome when measured in the form of a weight loss and resolution of the comorbidities. The risks and possible complications can be divided into three distinct time frames. The risks associated with some of the complications may include the intra-operative, and the postoperative time frames.   A-Intra-Operative

• Bleeding, sometimes requiring a blood transfusion.
• Possible injury to hollow or solid organs (Liver, Spleen, Esophagus, Large and small Bowel).
• Also, some cardiovascular complications can occur, such as a heart attack, and Pulmonary Embolism.

  B-Immediate Post-Operative

• Bleeding, sometimes requiring a blood Transfusion
• Deep-Vein Thrombosis (blood clot)
• Pulmonary Emboli (blood clot traveling to the lungs)
• Infection
• Abscess formation
• Bowel Obstruction
• Perforation involving small bowel, Duodenum, Stomach (leak)
• Pancreatitis
• Pneumonia
• Heart attack

  C-Long Term

• Hernia (incisional, and internal)
• Bowel Obstruction
• Excessive Weight Loss and malnutrition
• Mineral, trace element and vitamin deficiencies (anemia, Vitamin A, D deficiencies)
• Osteopenia/Osteoporosis
• Kidney Stones
• Malodorous bowel motions and flatus (stinky bowel movements and gas)
• Diarrhea (almost always associated with patient indiscretion with diet)

  Malnutrition Malnutrition is an uncommon and preventable risk after Duodenal Switch. [2] DS patients must be committed to taking vitamin and mineral supplements, consuming a high protein diet and having their blood tested each year. Deficiencies in vitamin D, vitamin A, calcium and protein can result in osteoporosis and anemia. Blood-work must be monitored and the adjustment of supplements as necessary.   Gas and Diarrhea In the history section for Duodenal Switch it was mentioned that this procedure was often confused with other surgeries. That confusion accounts for some of the exaggerated information about the frequency and volume of loose stools after the Duodenal Switch procedure. Excessive and foul smelling gas is primary related to a patient’s dietary intake. Carbohydrates, artificial sweeteners, fiber, high fat intake and carbonated drinks may all cause or exacerbate excessive flatulence. Many will also experience diarrhea if they eat excessive amounts of fats. It is important to distinguish between excessive flatulence, loose bowel movement and inability to control bodily functions such as urination and defecation, also known as incontinence. Incontinence is almost always and unrelated surgical problem with different root causes that needs to be evaluated and addressed. Normal patients were having incontinence should pay extreme close attention to the intake to identify possible causes. Patients have reported issues related to increase flatulence and loose bowel movements are post-op compared to pre-op. These are controlled with proper changes in the diet, and the ingestion of yogurt and probiotics to help control these issues. [2] When necessary some patients are prescribed the antibiotic metronidazole (Flagyl). [2] The antibiotic however should only be taken when the patient is making the proper dietary changes. One should not have a bagel with cream cheese and a diet coke, and then follow it up with Flagyl, wondering why their gas and diarrhea is not getting better! 81.3% of Duodenal Switch patients experience normal gastric emptying according to Martínez et al. [36] Anthone [9] reported the average number of bowel movements per day for 43 pre-op patients was 1.9, 421 patients six months post-op was 2.7, 316 patients twelve months post-op was 2.6 and 113 patients > thirty six months post-op was 2.8. In a study by Wasserberg et al. [19] they found that although Duodenal Switch is often associated with more bowel episodes than gastric bypass, the difference is not statistically significant. Bowel habits are similar in patients who achieve 50% estimated body weight loss with Duodenal Switch surgery or gastric bypass. In the study by Marceau et al. “15 year study Duodenal Switch: Long-Term Results” [2] they note “The negative side-effects with DS were not benign. The unpleasant odor of stool and gas and the frequent abdominal bloating were the price to pay for these patients and it was a major preoccupation for many of them. However, 95% of patients declared themselves satisfied despite this handicap and no one has required reversal of the procedure for this reason.” (1428) In the same way that RNY patients accept “dumping”, DS patients accept stronger odor of gas and stool.   Statistics on Possible Risks and Complications Generally, the perioperative mortality rate (admission, anesthesia, surgery and recovery) is between 0.5% and 1.5%. [2], [9], [14] This will vary by surgeon and can be affected by the number of high-risk cases they take. Ask a surgeon about his/her complication and mortality rate. These numbers may be higher by a surgeon who is taking on complicated revision cases compared to a surgeon who is only operating on young, healthy patients with low BMI and no comorbidities.   Marceau et al [2] reported that over 15 years of follow-up… Revision for protein malabsorption or diarrhea was required in 9 cases (0.7%). Of those nine, six had their alimentary and common channel lengthened and in 3 the diversion was reversed. Kidney stone occurrence increased from 6.3% prevalence before surgery to 14.8% during 15 years of follow-up. This is not different than the reported 16% during 11 years of follow-up after long Roux-en-Y gastric bypass. [16], [18] Bowel obstruction in 6% of patients’ occurred, which required a laparotomy for intestinal obstruction during the 15 years of observation. An incisional hernia was repaired in 13% of patients and was within expected outcomes after major abdominal surgery. Hess et al. [1] reported the following major complications after DS in the first 1,300 patients (42% of patients with a BMI > 50)…

• Gastric leaks 0.7%
• Mortality 0.57%
• Reversal 0.61%
• Revisions 3.7% (22 were for excess weight loss and protein deficiency and 2 were for frequent diarrhea). In these cases the common channel and alimentary limb were lengthened. Seven revisions were for inadequate weight loss and the common channel was shortened.

Duodenal Switch Vs. SADI, SIPS, Loop DS

October 23, 2017 2:49 am

The well-known standard Duodenal Switch (DS) operation is a clearly defined operation. It is assigned a specific CPT code (43845), which defines precisely that anatomy. SADI, SIPS and Single anastomosis Loop DS are not equivalents of the standard DS operation. In fact, from a physiologic perspective, the dissimilarities are more notable than the similarities when it comes to the theoretical weight loss mechanisms that are involved. The most critical information, however, is that the scientific data for SADI, SIPS and Single anastomosis Loop DS are very limited and thus far, short-term only. At the time of the publication of this summary, there is a research study that is looking into the efficacy, safety and the short- and mid-term outcome of the procedures. This is while some surgeons are offering these procedures as a substitute (or an alternative) of the standard DS, and claiming that it is an equivalent to the standard DS. This position has simply not been proven, nor is it likely to be true.  

	Duodenal Switch	SADI-SIPS, Loop DS
Proven Long term outcome	Yes, with over 20 years outcome- (reference)	No Long Term outcome. An Experimental procedure being studied (reference)
Technical ease	Hard	Easy
Laparoscopic	Yes	Yes
Bile Reflux	Not anatomically possible	Possible complication
Long term weight loss	Best outcome (reference)	No long-term data. The expectation would be that the weight loss will be much less than that of the Duodenal Switch with the potential of significant regain.
Potential nutritional deficiencies	Possible – (reference %) corrected with supplementation	Inadequate data
Individually tailored	Yes if the common and alimentary bowel lengths done as percentage of the total length (Hess Method)	Every patient gets the same operation
Diet for best outcome	Broad healthy non restrictive	No long term data
Variable a surgeon can adjust for the best outcome	1-stomach size 2-Common Channel 3-Alimaentary channel	1-stomach size 2-Common and Alimentary limb (are the same)
Selective Fat Malabsorption	Yes- negligible fat absorption in the Alimentary limb	No-The Alimentary the common channel are the same – no selective fat malabsorption
Selective nutrient absorption	Yes- The Alimentary and common channels are separate.	No-The Alimentary ad Common Channels are the same. Much higher increase in caloric absorption.