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.

References:
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)

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.

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.

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.

Plastic Surgery after Massive Weight Loss

This posting is in response to a request to comment on cosmetic surgery for excess skin in the abdomen and other places, after weight loss surgery.

Body contouring, body lift, body shaping or body reshaping are alternative terms used to describe a group of plastic surgery procedures performed after massive weight loss, to manage hanging excess skin. Patients have to have reached a stable plateau weight before any such plastic surgery procedures. The person should have lost at least 100 pounds or achieved the target or maximum weight loss, had a stable weight for a good length of time after the weight loss surgery, and be in good health and not planning on becoming pregnant. Good candidates for a body lift should also have no medical problems that prevent them from going under general anesthesia for major surgery, and should not smoke. Smoking decreases blood flow to the tissues and, therefore, may slow healing.

Plastic surgery procedures after weight loss surgery include the following:

1. Panniculectomy: This is excising the "pannus", which is the excess hanging skin that is present below the belly-button.

2. Abdominoplasty (Tummy Tuck): Includes dissection and preservation of the umbilicus itself, and a more extensive skin mobilization and more aggressive skin removal than panniculectomy. A complete abdominoplasty also includes tightening of the abdominal wall muscles. Abdominoplasty and incisional hernia repair can be combined into a single procedure.

3. Arm lift or brachioplasty.

4. Breast lift or mastopexy.

5. Lower body lift is a combination of an abdominoplasty, plus a thigh and buttock lift. It requires a large incision around the belt line to lift the lower body.

6. Liposuction uses small, narrow tubes to remove fat and is often used in combination with other lifting procedures to help achieve better contouring in various parts of the body.

Combining multiple "lifts" entails longer operative time, and more potential blood loss, but is very appealing to many patients, from the stand-point of time off work and out-of-pocket costs. Combined procedures are avoided if there is active smoking history or medical problems that make a longer operation a particularly risky undertaking.

Insurance coverage varies from carrier to carrier, and a carrier may have different plans with different provisions. Almost all insurance carriers specify that coverage of aesthetic (cosmetic) surgery is excluded. Definition of medical necessity, that is essential for coverage, is variable.

Possible complications after body-contouring surgery include seroma (collection of thin serous or serosnaguineous fluid), hematoma (collection of blood), wound separation (usually minor), swelling and scarring. All patients will have scars, and basically the surgery trades excess skin for scars. For a small number of patients, scars can be excessively thick or inflamed. Before going for body contouring surgery, any nutritional deficiencies (as protein malnutrition, anemia, loss of muscle mass, and osteopenia/osteoporsis) need to be addressed and corrected.

Body contouring is considered major surgery. The outcome of body shaping is generally extremely satisfying to patients. It may take several months to see the final results of the procedure.

Obesity Rates - still on the rise :(

I thought the obesity epidemic is plateauing. Well, News Flash! Obesity and overweight rates continue to rise. A new report by Trust for America's Health (TFAH) showed that in 31 states, obesity rates got worse in the past year. State of Washington is actually one of them. Moreover, all states fail to meet the national goal of reducing adult obesity levels to 15 percent by the year 2010. The adult obesity rate of the State of Washington is 22.4 percent, ranking it the 31st heaviest in the nation, according to TFAH's report titled "F as in Fat". Mississippi is top of the list. Colorado continues to be the leanest.

The report noticed that 16 states and Washington, D.C. have passed taxes on junk food or sodas, including Arkansas, California, D.C., Illinois, Indiana, Kentucky, Maine, Minnesota, Missouri, New Jersey, New York, North Dakota, Rhode Island, Tennessee, Texas, Virginia, Washington, and West Virginia.

The full report with complete state rankings in all categories is available on TFAH's Web site at http://www.healthyamericans.org/. The report was supported by a grant from the Robert Wood Johnson Foundation.

Vitamin D supplements and Obesity

Did you know that there is a high incidence of vitamin D deficiency with obesity? The reason is probably that vitamin D is fat-soluble, so it deposits in the fat stores, and becomes less available to the body. There is a possibility that lack of adequate sun exposure, which is common in Seattle area and in the Northern regions, could contribute to a baseline vitamin D deficiency. This means that a typical patient most likely has a deficit of vitamin D before bariatric (weight loss) surgery. A study from the University of Maine, that was recently published in the journal "Surgery for Obesity and Related Diseases" (1) , showed the results of evaluating how adequate the correction of vitamin D deficiency is, one year after gastric bypass surgery. Before surgery, 34% of patients had suboptimal levels, and 54% had deficient levels, of 25-hydroxyvitamin D in their blood. By one year after Roux-en-Y gastric bypass surgery, the vitamin D deficiency improved remarkably with the intake of vitamin D supplements. Remember, nutritional supplements after weight loss surgery are not optional, they are a must. The researcher recommended higher doses of vitamin D than the average.



Vitamin D is essential for bone health. Calcium absorption requires vitamin D. Lack of calcium leads to osteopenia and osteoporosis. So, when you take your supplements, particularly after bariatric surgery, make sure that they include calcium and vitamin D. Actually, it may be better to start before having the surgery. Notice, though, that there are medical conditions in which taking extra calcium may be contraindicated. Therefore, make sure that your physician is OK with it. Also, after gastric bypass, the general recommendation is to take the calcium supplements in the form of calcium citrate, not carbonate. There is some controversy in that issue, but taking calcium citrate will keep you on the safer side, with regards to calcium absorption.



So, make sure that you take your nutritional supplements regularly, and stay healthy.



Reference:



(1) Nelson ML, Bolduc LM, Toder ME, Clough DM, Sullivan SS. Correction of preoperative vitamin D deficiency after Roux-en-Y gastric bypass surgery. Surg Obes Relat Dis. 2007 Jul-Aug;3(4):434-7. [PMID: 17400028]