Sunday, September 30, 2007

Alcohol after Gastric Bypass

A glass of wine or two. A beer. A little mixed drink. Would that be OK after a gastric bypass? Well, early after the surgery, while the stomach is healing, you really want to avoid the irritant effect of alcohol. You want your pouch to heal well. So, the answer, as far as we know, is "no". But, what about drinking, let's say 6 months, a year, or more after the surgery? A very interesting study confirmed the previous opinion, that is, alcohol levels go higher after gastric bypass than people who had no such surgery. In a study published in the September issue of the journal "Surgery for Obesity and Related Diseases" (SOARD), researchers from Stanford School of Medicine, Stanford, California, concluded that the gastric bypass patients had a greater peak alcohol level and a longer time for the alcohol level to come back down to zero than the individuals who did not have gastric bypass. A particularly interesting finding was that the gastric bypass patients did not feel that alcohol influenced them any more than the no-surgery group. Could that explain why there are reports of post-gastric bypass patients who were cited for driving under the influence (DUI) after a small social alcoholic drink? Maybe. But also remember that there are other complications related to alcohol intake. Liver disease from alcohol is well-known. To develop alcoholic liver disease on top of the known obesity-related liver disease can be particularly dangerous. Alcohol is not good for peptic ulcers, either. Alcohol calories are empty calories, which is not what gastric bypass patients want to ingest. Also alcohol drinking has been linked to vitamin B1 deficiency. Severe vitamin B1 deficiency can lead to serious nerve damage, that is, Wernicke’s encephalopathy. So far, we do not have a perfectly scientific answer to the question: Is it OK to drink, in moderation, if you are not driving, several months or years after gastric bypass? We just do not have the final answer, and prefer to err on the cautious side. Better be safe than sorry.

Klockhoff H, Naslund I, Jones AW. Faster absorption of ethanol and higher peak concentration in women after gastric bypass surgery.Br J Clin Pharmacol. 2002 Dec;54(6):587-91.

Hagedorn JC, Encarnacion B, Brat GA, Morton JM. Does gastric bypass alter alcohol metabolism? SOARD. 2007 Sept;3(5):543-8. (Note: This is the study quoted above)

Sunday, September 23, 2007

Gallbladder, stones, sludge, and Gastric Bypass

Formation of gallstones or sludge in the gallbladder is known to increase with obesity and with rapid weight loss. According to one report, at 6 months, gallstones had developed in 36% and gallbladder sludge in additional 13% of patients

But another question is: What percentage of patients will actually develop symptoms or problems from gallstones or sludge after bariatric surgery? Well, reports quote anywhere from 3% to 30%.

There are different ways of dealing with the gallbladder, in relation to gastric bypass, and all of them are acceptable. A new trend in recent reports concluded no need to screen for gallbladder disease, based on the low incidence of patients who will actually have symptoms from gallstones after gastric bypass. Some reports will even not consider it necessary to remove a gallbladder with stones during a gastric bypass, because the majority of those with no symptoms before, will not develop symptoms after gastric bypass.

Many surgeons, however, still routinely order an ultrasound of the gallbladder before a gastric bypass. If abnormal, the gallbladder may be removed the same time of a gastric bypass. Surgical removal of the gallbladder is called "Cholecystectomy". Also, if a patient has symptoms of typical biliary pain, even if the ultrasound appears normal, a cholecystectomy may be considered.

Other surgeons routinely recommend the removal of the gallbladder at the time of a gastric bypass surgery, particularly with the open technique. If it is chosen that the gallbladder not be removed at the time of a gastric bypass, most will wait until symptomatic gallbladder disease develops, at which time the gallbladder would be removed (cholecystectomy). Some surgeons will ask patients to take a medication, Ursodiol (Brand Name: Actigall) to help lowering the chance of developing gallstones. One report documented a decrease in the incidence of development of gallstones from 32%, with no treatment to 2%. As you realize, there is no one unified approach.

The symptoms of gallstones or sludge after gastric bypass are not different from the general. In the most typical form, right upper quadrant pain in the abdomen, radiating to the back. However, there are so many variations of this typical picture.

Doing a cholecystectomy after a patient loses weight may be technically easier than during maximum obesity, and will almost always be covered by insurance companies when performed for symptoms. But, notice that treating gallstones, if they migrate to the common bile duct, is much more challenging after gastric bypass. The reason is that, after gastric bypass, patients can no longer have an endoscopic retrograde cholangiopancreatography (ERCP) performed in the usual manner. ERCP is a procedure performed using an endoscope, and allows the extraction of those migrating stones from the common duct, without a need to do surgical cutting into the abdomen. The procedure becomes much more difficult or impossible because the stomach has been completely divided, so the endoscope can no more be guided in the usual way from the stomach to the duodenum. Alternatives do exist, but none of them is that easy, nor the necessary set-up and expertise may be available. Therefore, after gastric bypass, a bigger operation, that is an open common bile duct exploration may be needed. Although the incidence of this particular challenging situation is low, it is still a significant occurrence for the individual unfortunate patient. This possibility needs also to be factored when deciding, weighing the benefits vs. the risks of removing the gallbladder along with a gastric bypass.

Wednesday, September 5, 2007

Life Expectancy - again

A very good article reporting and commenting on the 2 studies from the August 23 issue of the New England Journal of Medicine (NEJM), appeared in the Independant Weekly of Lafayette, Louisiana. It is titled "Life Expectancy - New studies show bariatric surgery patients are living longer." By following this Link, you can access the article. This "Bariatrics Lounge" blog reported on the NEJM article on August 22, so our readers were among the first to be informed. You can go back to that blog entry by clicking this Link.

Monday, September 3, 2007

Just to be thinner?

I read a statement like "It's sad what some put themselves (or their kids) through, in order to be thin." Of course, referring to going through bariatric surgeries like Lap Band, gastric bypass, etc. This statement shows a major misconception as to what bariatric surgery is all about. The name "weight loss surgery" is correct in that bariatric surgery is designed to lead to weight loss. That is true. But the above statement implies that the entire reason for the weight loss is for a "thin" image. Here comes the misunderstanding. Although many patients like being thinner, which is a bonus result of the surgery, the real reason to have the surgery is for health purposes. Morbid obesity leads to three categories of major problems: (1) Life expectancy may be shortened (2) Co-morbidities may get worse, and certainly would not be cured (please, see note below) (3) Quality of life may deteriorate. Those are the real reasons why someone should consider bariatric surgery. Patients do not come and say, "I need weight loss surgery because I want to be thinner." They say things like "I want to get my [type 2] diabetes cured", "I want to be able to play with the kids", "I have many in my family who died from heart disease, and I am still young and would like to prevent that", "my orthopedic surgeon wanted me to lose weight before he replaces my bad knees", "I have sleep apnea, and my doctor said if I lose weight, I may be able to come off the CPAP machine." You've got the picture. So, my counterstatement to the first line here would be "It's sad what some put themselves (or their kids) through, by not controlling their weight and allowing an unhealthy life style to continue." And, as an aside, yes, weight loss will also lead to being thinner. Remember, bariatric surgery is not for everyone who has a problem with weight or obesity. In well-selected patients, the risk of bariatric surgery is, statistically, less than the risk of morbid obesity itself. It is an option if non-surgical weight loss fails to achieve a sustained healthy weight.

Note: "Co-morbidities" is the term given to describe medical problems that are either caused by, or made worse by, obesity.