In the last few years, I have been approached by a number of people who were not comfortable sharing this health decision with the public. A number of them are famous for one reason or another and wished to undergo weight loss surgery, but they did not wish to disclose this decision publicly. I have also performed weight loss surgery for a number of private citizens who felt that they would prefer to keep their health decisions and weight loss surgery decision private.

It is part of the physician’s code of ethics to honor patient privacy. As a physician and surgeon, I always strive to do the utmost to do so. Bariatric surgery is no different from any other health decision when it comes to privacy.

Or is it? Studies have shown that people wishing to lose weight are more successful when they have the support of friends and family, or others like them who are also striving to lose weight. In addition, many of the best weight loss surgical programs provide not only support groups but also group education events such as seminars and classes on weight loss surgery, weight loss techniques, dieting, exercise, etc.

So how do we respect the privacy wishes of an individual and also offer the very best weight loss solution?

I have spent a lot of time thinking about this question, and ultimately I have crafted what I think is the best solution for the patient who wishes to protect their privacy and not disclose their decision to have weight loss surgery.

What I have done in these cases is make special arrangements to minimize the exposure of the patient to any other patients or bystanders in the office or at the surgery center. We have gone so far as to create an alias under which people schedule their appointments and check in at the surgery center. We have also created a personalized version of the classes and study materials and utilized on-line teaching and training methods.

All of this has worked well, and for the person who wishes to keep their decision to have weight loss surgery private, we can both respect that decision, and provide the best surgical weight loss solution.

There are pros and cons to pursuing weight loss surgery in this private fashion. You may avoid unwanted judgments but miss out on some support from other people. And of course, there is no absolute guarantee to privacy!

In a future blog post, I plan to discuss more aspects of this question:

Should you keep your decision private or should you disclose it?

Revision weight loss surgery is sometimes necessary and sometimes very beneficial to re-start the weight loss process. Over time, some patients with gastric pouches after gastric bypass (RYGB) or sleeve gastrectomy (SG) will feel that they can eat substantially more, and feel they have lost a sense of restriction.

Sometimes the pouch is larger on an upper GI Xray, done with Xrays after taking oral contrast. Sometimes the pouch looks the same but it no longer produces the restricted outflow it once did. Other times, rarely, new complications may have arisen, such as a fistula, or connection to the larger portion of the stomach.

With hundreds of thousands of Americans and millions of people worldwide having undergone weight loss surgery in the past years, more patients are seeking revisions years later. In the past the only options were to perform a type of open revision procedure, or to simply press on with nonsurgical efforts.

Times have changed. A number of revision options are available and successful. Most commonly, a stretched pouch can be surgically revised with a laparoscopic surgical technique. The goal is to create another, small, pouch, and re-establish the sense of restriction and satiety. Other times a laparoscopic adjustable gastric band (LAGB) can be placed over the prior surgery to create better restriction. These both work in many cases, though certainly not in every case.

Additionally, sometimes a procedure can be converted to a different type of surgery, such as converting a LAGB to a RYGB or biliopancreatic diversion (BDP).

Most recently, the use of Stomaphyx, an endoscopic technique performed with a scope passed down the throat, can be used to revise and tighten a stretched pouch. It advantage is that it is the least invasive procedure. Its disadvantage is that long term data are not available.

In sum, many options exist for a patient who has had weight loss surgery and is now re-gaining weight. A medically-supervised weight loss program, sometimes with the aid of prescription weight loss drugs, is often helpful. Re-dedication to the weight loss goals, renewed commitment to long term successful behaviors of shopping, eating, and exercise, are essential. And if surgery is being considered, a visit with an experienced bariatric surgeon who has performed many types of revision procedures is often very helpful. There are many good options available, and the goal of improved health and healthy weight loss are too important not to explore every option.

One of the most exciting developments in the field of weight loss surgery is the emergence of new technologies that allow revising and shrinking stomach pouches without surgical incisions.

An FDA approved device, called Stomaphyx, is available through my surgical practice at Western Bariatric Institute and selected other centers nationally. It allows the experienced bariatric surgeon to approximate tissue, and reduce the size of a stretched stomach pouch. This is particularly appealing for people who have previously undergone Roux-en-Y gastric bypass and have experienced stretching of the stomach pouch.

I perform the procedure under anesthesia, by passing a flexible tube down the mouth and esophagus, and into the stomach pouch. There, the pouch tissues are brought together using advanced technology creates plications, like sutures, in the wall of the stomach pouch. The result is a much smaller stomach pouch and a renewed sensation of gastric restriction.

Nutritional and Vitamin deficiencies following bariatric surgery.

While we are all thinking of finding some healthy holiday meals, and enjoying some excellent holiday recipes, let’s not forget our important vitamins!

Modern weight loss surgery is a highly successful intervention by almost any measure. In numerous studies modern weight loss surgery is demonstrated to prolong life, improve quality of life, and reduce the incidence and impact of many health conditions including diabetes, hypertension, hyperlipidemia, obstructive sleep apnea, degenerative joint disease and many others. But weight loss surgery can lead to vitamin and nutritional deficiencies in some cases. These deficiencies can be serious, so it’s important for patients to prevent them by remembering to take the vitamin supplements your bariatric surgeon recommends!

Some overweight individuals have preoperative vitamin and nutritional deficiencies before they ever even attend a weight loss seminar. After bariatric surgery, the most common deficiencies occur in the operations which have a “malabsorptive” component, in which some of the intestine is bypassed, and some of the nutrients are not absorbed. In some intestinal bypasses performed prior to the 1970s, numerous nutritional deficiencies occurred that in some cases led to liver failure and hurt the reputation of weight loss surgery (despite the deficiencies, however, patients who had jejunoileal bypass markedly outlived their obese counterparts who did not undergo weight loss surgery).

Today, the frequency and severity of vitamin deficiencies is least after LapBand surgery (which usually requires only the Omni Bariatric Vitamin supplement), then increases with Gastric Bypass (which requires the vitamin supplements listed in the table below), followed by further increases with Biliopancreatic diversion or long limb gastric bypass (even more nutritional/vitamin supplements needed – email us for a list). In the vast majority of cases, vitamin deficiencies can be prevented by taking the vitamin supplements your bariatric surgeon recommends. iMeatbolic makes all of these supplements, made in FDA-inspected labs, available on their website at www.imetabolic.com.

VITAMIN SUPPLEMENTS NEEDED AFTER GASTRIC BYPASS

Iron

Iron deficiency anemia is among the most common nutritional abnormalities. Many female preoperative have iron deficiency, as high as 44% of patients in recent studies, including one in the Journal of Gastrointestinal Surgery. After Roux-en-Y gastric bypass surgery, as many as 75% of patients exhibit iron deficiency anemia if iron is not supplemented and the condition not treated.

Gastric bypass leads to iron deficiency anemia in large part because the bypassing of the acid-producing portion of the stomach prevents the reduction of iron to the absorbable ferrous iron. If you are experiencing symptoms such as fatigue or discomfort or enlargement of the tongue, these could be signs of significant iron deficiency anemia. Sometimes people with iron deficiency also feel cold even when the room temperature is normal. The problem is detected with a routine blood test, hemoglobin and serum iron studies (iron level, TIBC, ferritin, transferrin)

Iron deficiency is common enough that iron supplementation is recommended for every patient undergoing weight loss surgery. We generally use ferrous sulfate, 325 mg p.o. daily or this can be increased to twice a day. For more severe cases, intravenous iron infusion may be required.

Vitamin B12

B12 (cyanocobalamin) deficiency is common following bariatric surgery, especially Roux-en-Y gastric bypass surgery. The decreased exposure to stomach acid and the less overall secretion of stomach acid leads to less release and absorbtion of vitamin B12 from foods. Oftentimes, patients consume less B12 because foods such as beef and chicken are consumed less frequently.

Sometimes people who are deficient in B12 may also experience tingling or numbness in their hands and feet, or unsteady walking. Sometimes people experience an enlarged tongue, weakness or depression. Because B12 deficiency would occur commonly after gastric bypass surgery, it is a standard recommended supplement postoperatively. This is given either as an intramuscular injection monthly with 1000 to 3000 mcg per injection. Intramuscular injections are available locally at iMetabolic, at 971 W. Moana at Lakeside. More recently, good absorption of B12 occurs with sublingual preparation and nasal sprays. Our standard practice is for every patient to take sublingual B12 daily for a lifetime. Sublingual B12, and all of the vitamins we recommend, are available at our website and soon at the WBI Arlington office itself, after the renovations are done!

Thiamine

Thiamine is otherwise known as vitamin B1. Thiamine is found in foods such as beef and pork and to a lesser extent in some legumes, dried beans, peas and in certain grains. Mild thiamine deficiency is fairly common among seriously overweight individuals prior to surgery and can worsen after surgery or any prolonged illness with vomiting. The symptoms of thiamine deficiency can be vague and include fatigue, poor memory, appetite suppression, abdominal discomfort, difficulties with balance or unsteady walking, even confusion or neurologic changes. It is supplemented in the bariatric multivitamins an can be further supplemented if necessary in rare cases.

Vitamin B6 (pyridoxine)

Vitamin B6 is present in meats, beans, whole grains and certain nuts. Many people are deficient in B6 if it is tested rigorously. The incidence is probably increased after gastric bypass and bariatric surgery. It appears to be well absorbed and effective if given in a standard multivitamin dose. There are symptoms such as those of thiamine and B12.

Folic acid

Folic acid is important for red blood cell production. It is present in green leafy vegetables, as well as beans. Folate is another B complex vitamin that is absorbed less after gastric bypass surgery or any procedures that decreases the stomach acids’ contact with the meal. Confusion, weakness, anemia, enlarged tongue and neuropathy are all symptoms of thiamine(?) deficiency. It is treated with thiamine replacement and is generally bioavailable in the multivitamin. It can also be given as an intravenous supplementation.

Calcium and vitamin D

Mineral calcium and vitamin D are interrelated as they work together in maintaining the serum calcium levels. Vitamin D is found in milk, eggs, fish and liver. Calcium is present in dairy products. Calcium deficiency may result after gastric bypass and Vitamin D deficiency may result from any type of intestinal bypass procedure that leads to decreased absorption of fat-soluble vitamins. Fat-soluble vitamins (A, D, E and K) tend to be reduced most in biliopancreatic diversion, duodenal switch, and jejunoileal bypass. The fat-soluble vitamins can also become deficient in patients taking Alli or Xenical, the fat-blocking weight loss drug. The active form of vitamin D requires sun exposure to the skin.

Deficiencies of calcium and vitamin D lead to increased breakdown of bone deposits to liberate calcium for the bloodstream. Symptoms of vitamin D and calcium deficiency are muscle aches, fatigue, joint pain. Progression to osteoporosis increases risk of bone fracture.

Calcium and vitamin D should both be supplemented with1200 mg of calcium and 8 mcg of vitamin D or more. Some bone loss appears to occur with significant weight reduction independent of calcium and vitamin D deficiency.

Vitamin A

Vitamin A is a fat-soluble vitamin present in an array of foods including dairy products, pumpkins, cantaloupe and liver. Deficiencies of vitamin A can lead to night blindness and ocular symptoms. Deficiencies of vitamin A generally occur as a result of the deficiencies that involve the fat-soluble vitamins. This generally results from an intestinal bypass procedure such as jejunoileal bypass (no longer performed) or biliopancreatic diversion/duodenal switch procedures. In these procedures, fat absorption is markedly impaired. There is the potential for vitamin A deficiency with use of Xenical or Alli weight loss medications.

Treatment can be given with oral or intramuscular vitamin A. Specific oral vitamin A routine supplementation is not generally felt to be necessary after Lap Band or gastric bypass, but is necessary after duodenal switch or biliopancreatic diversion.

Vitamin K

Vitamin K is a fat-soluble vitamin present in green leafy vegetables. Deficiencies can lead to impairment of the blood clotting system and therefore lead to bruising and bleeding of the gums. Vitamin K deficiency is possible after procedures that result in significant fat malabsorption such as biliopancreatic diversion or duodenal switch and jejunoileal bypass. It appears to be less common and reported and is not routinely supplemented or tested.

Vitamin E

Vitamin E is found in green leafy vegetables, nuts, seeds and vegetable oils. Vitamin E deficiency appears rare and is associated with neurologic symptoms. It is not routinely tested or supplemented.

Protein deficiency and muscle wasting

Protein is increasingly recognized as import for maintaining muscles and for helping with weight loss. Bariatric centers generally recommend a person consume between 60 and 100 grams of protein daily.

Protein deficiency is often detected by serum protein measures including total protein, albumin and prealbumin. Protein deficiency can occur in patients who have complications following bariatric surgery or if they experience excessive food intolerance and diminished protein intake. Usually this problem is resolved once the person has begun eating more foods.

For patients with routine postoperative courses, emphasis on protein supplementation with meal replacements, shakes, bars and carefully selected foods are important to emphasize. A wide variety of protein-based shakes and snacks and other delicacies are now produced by high quality labs and manufacturers. We have made many of these available online at our website and at iMetabolic. Let us know online which ones you like or what others you would like to see carried!

It is also important to emphasize muscular activity to stimulate synthesis of muscle mass and preservation of lean body mass during rapid and profound weight loss.

Zinc

Zinc is a mineral found in meat, fish, eggs, grains and nuts. Zinc deficiency may be present in 5 to 10% of patients prior to surgery and zinc deficiencies result from procedures involving malabsorption, including gastric bypass surgery. Zinc deficiency is associated with hair loss, skin rashes and impaired wound healing. It is recommended to routinely supplement postoperatively with zinc in the form of a multivitamin that contains zinc. For specific identified deficiencies, increased dose of zinc sulfate may be warranted and may arrest hair loss following gastric bypass surgery.

Selenium

Selenium is a mineral that is an antioxidant like vitamin E. Selenium deficiency has been reported in a small percentage, perhaps 5%, of obese patients prior to bariatric surgery. After bariatric surgery, selenium deficiency increases although it is not clear what symptoms may arise as a result of impaired antioxidant function. Selenium supplementation is recommended as part of a multivitamin.

Conclusion

So enjoy the holidays, work hard to avoid the carbohydrates in all the holiday treats. Remember your weight loss and health goals. At Holiday events, try to enjoy the people more, and the food less! It sometimes takes hard work to achieve your potential, but you can do it.

And don’t forget your vitamins!

Diabetes is among the fastest growing health problems on the planet today. Within the next two decades, over 300 million people worldwide will have Type 2 diabetes. Numerous avenues of investigation have opened for researchers seeking to find a cure. In recent decades, weight loss surgery, or bariatric surgery, has proven highly successful in eradicating Type 2 diabetes among patients whose diabetes stems from being severely overweight.

It is now well demonstrated that approximately 90% of Type 2 diabetics experience resolution of their diabetes after Roux-en-Y gastric bypass surgery, the most commonly performed weight loss procedure in the U.S. A somewhat lower, but still remarkable 65% of patients undergoing LapBand surgery resolve their diabetes.

Both of these procedures are now widely performed in the United States with a minimally invasive, or laparoscopic procedure requiring a minimal hospital stay. Over 200,000 of these procedures are expected to be performed in the U.S. in 2007. Medicare and commercial health insurers increasingly recognize bariatric surgery as an effective treatment of diabetes that saves the plans money in the long run. Four major studies have demonstrated marked increased life expectancy after weiaght loss surgery. In most cases, there is no more need to fund the ongoing treatments of diabetes and its complications after weight loss surgery. So, it is clear that for obese individuals with Type 2 diabetes, there is a strong likelihood that their diabetes can be cured with surgery. But what about surgery for diabetic patients who are not severely overweight?

Recent studies have demonstrated that the surgical techniques applied in weight loss surgery may, in fact, result in resolution of diabetes in non-obese individuals also. A number of centers have begun reporting that even non-obese diabetic patients experience rapid resolution of diabetes after gastric bypass surgery. In many cases, patients are discharged from the hospital in a euglycemic state (normal blood sugar level) and never resume their diabetic medications! This very early and rapid resolution of glucose control is not explained simply by calorie intake or pounds lost. The phenomenon has lead many investigators to think that the surgical technique may fundamentally change the body’s regulation of blood sugar.

Most of the early and dramatic success resolving diabetes has occurred with gastric bypass surgery. A recent study, published in Surgery of Obesity Related Disease, vol 3, 2007, by Cohen et.al., described these researchers’ experience with a surgical procedure called duodenal-jejunal bypass, a fairly simple procedure that causes food intake to bypass the first part of the intestine. Their early findings are that these diabetic patients also resolved their Type 2 diabetes, independent of weight loss.

So, are we entering a new era in which Type 2 diabetes can be cured in a large percentage of cases with a minimally-invasive surgical procedure? Time will tell, but the early studies are leading many to believe that what has been called “bariatric” surgery, or “weight loss” surgery, may prove the most effective treatment yet in the battle against Type 2 diabetes. It may further the call to change thte name of the surgery to “Metabolic surgery”, as it serves to correct metabolic abnormalities and not just obesity.

Synopsis:
For something new to truly revolutionize weight loss, the breakthrough treatments would have to be both safe and effective. They would have to produce short-term gains but long-term sustainable results. They would have to be minimally invasive and require a minimum of inconvenience and recovery time to become widely accepted. Is it possible that such a new treatment has arrived? According to the American Society of Bariatric Surgery, which reports a rocketing growth of procedures performed annually, it appears the revolution has arrived.

Modern outpatient weight loss surgery consists of a highly effective yet minimally invasive surgical procedure that takes about an hour. In the vast majority of cases, the patient can return home on the same day and expects to recover to full activity within a week. Because of these factors, unprecedented numbers of people are taking advantage of weight loss surgery. In 2008, over 200,000 Americans will undergo weight loss surgery. An increasing number of these will be minimally invasive outpatient procedures.

There are two primary outpatient weight loss surgical procedures. The most commonly performed outpatient procedure is the laparoscopic adjustable gastric band or the Lap-Band. In this procedure, a soft silicone-based polymeric band or belt is placed around the upper stomach with laparoscopic or minimally invasive technique using five small ½ inch incisions. A 1-inch access port is then placed beneath the skin and subcutaneous tissues of the abdominal wall. In most cases, the procedure can be performed in 30 to 45 minutes. Recovery is rapid. 85% of people can be discharged from the outpatient surgery center within four to six hours. Most people return to work within a week. The second procedure that is emerging as an outpatient option is laparoscopic Roux-en-Y gastric bypass procedure. In the gastric bypass, the same minimally invasive technique with five small ½ inch incisions is utilized, but the stomach itself is partitioned and a small 1-ounce stomach pouch is created. The small stomach pouch is then connected directly to the intestine. The results in both procedures is a sense of early satiety, push smaller portion consumption and weight loss. Long-term studies of patients after both of these procedures demonstrate a high percentage of patients keep the weight off long-term. More importantly, studies demonstrate that individuals undergoing weight loss surgery experience dramatic health improvement and gains in longevity when compared to similarly overweight individuals who choose not to undergo weight loss surgery.

Yet, there are pros and cons of outpatient weight loss surgery. Both Lap Band surgery and laparoscopic adjustable gastric banding surgery have risks, both short term at the time of the surgical procedure and anesthesia, and long term. Dr. Sasse discusses all of these potential adverse events as well as steps that can be taken to avoid them.

It is more important than ever to choose carefully the surgeon and program that provides bariatric surgery. Dr. Kent C. Sasse discussed how to go about finding an excellent bariatric surgeon and bariatric surgical program, and he outlines what questions to ask in order to be well informed about the surgeon and the procedures.

Dr. Kent C. Sasse describes the important steps one should take in preparing for outpatient weight loss surgery. He describes preoperative education and preoperative weight loss preparation programs. He then describes the essential tools for success after surgery.

Watch Dr. Sasse’s Interview