Jan - Feb 2012

The Surgery is the Easy Part

By Scott A. Shikora, MD FACS

 

Many patients incorrectly think that when their eyes open up after bariatric surgery, the hard part is behind them. Unfortunately, they are very much wrong. In fact, the work has just begun. Despite which of the current bariatric procedure was performed, safe, successful, and enduring weight loss requires knowledge, compliance, and effort.
 
Here is a simulated conversion between a patient (Ms. Smith) who recently underwent a laparoscopic gastric bypass and her surgeon (Dr Jones).
 
Dr. Jones: Ms. Smith, everything is looking great. Your wounds are healing, you are tolerating liquids well, have no pain, and feel good. I believe that you are right on course. In addition, it is only 2 weeks since your surgery and you already lost 15 lbs.
 
Ms. Smith: Thank you Dr. Jones. I do feel great. Wow, I already lost 15 lbs in 2 weeks. That means that I should lose 30 lbs per month so I will lose 180 lbs in 6 month’s time.
 
Dr. Jones: Hold it right there. That is not entirely true. There is almost always a large weight loss early after surgery. This is due to the metabolic stress of the surgery and also the excretion of excess body fluid. It is not indicative of future weight loss that will be determined by dietary compliance, physical activity, and even your genetics.
 
Ms. Smith: Diet? What diet? I thought the whole point of this surgery was that it would make me eat less. Isn’t that true Doctor?
 
Dr. Jones: Ms. Smith, I am a bit surprised. Didn’t you listen to the dietitian? Yes, you are correct. After gastric bypass surgery, you can only comfortably eat small amounts of food. However, if you are not following a low calorie, low fat, sugar free diet, you are likely to either not lose all of the weight you are able to lose, or you may gain back some of the lost weight. Also, if you are not being careful with your portion size, you can slowly stretch out your small pouch and be at risk for regaining your lost weight.
 
Ms. Smith: Fine. I’ll try to eat small low calorie meals. Anything else I need to know.
 
Dr. Jones: Yes. You must make sure your meals are high in protein. Eating such small portions of food mandates that you eat high protein foods to insure that you do not develop a protein deficiency. Our program has several good suggestions for high protein foods. Also, don’t forget about taking your vitamins.
 
Ms. Smith: Vitamins? I didn’t know that I needed to take vitamins! Why is that; I never had to take vitamins before?
 
Dr. Jones: Now, now Ms. Smith. We discussed this at our support group meeting and it is listed in multiple places in our program literature. When you eat such small portions of food you are not likely to take in sufficient vitamins from the food alone. To make matters worse, after gastric bypass, some vitamins such as B12, folate, iron, and the mineral calcium are less well absorbed. It is essentially a double whammy. To take less in and don’t absorb all that you do take in. Taking supplemental vitamins and calcium is critical to prevent you from developing sufficient deficiencies.
 
Ms. Smith: Boy Doc. I really didn’t know all this. I just assumed that after surgery I would be on “autopilot” and the weight would just melt off of me. I’ll have to work hard to succeed.
 
Dr. Jones: That’s correct. The surgery was the easy part. Now the hard work begins. But I assure you; it will be worth all of your efforts.
 
This simulation represents the conversion many clinicians have had with their patients after surgery. Prior to surgery, patients need to be clearly instructed about the dietary changes necessary for success. It is then the responsibility of the patients to follow the recommendations. These instructions may need to be reinforced repeatedly to overcome any knowledge deficit a patient may have secondary to a number of factors including misunderstanding, language difficulties, a limited capacity to understand, or lack of attention. If a patient finds the compliance to changes difficult, the surgical program is there for further guidance. Support groups are another way for patients to feel empowered to adhere to the recommendations. Remember, if you are a patient, struggling with weight regain and/or the return of old habits, make an appointment with your surgical program and go to support group meetings.