Every year, thousands of Americans die from the complications of being severely overweight. More specifically, they develop diseases such as high blood pressure, diabetes, heart failure, degenerating joints, urinary incontinence, vein diseases and leg ulcers that do not heal. Billions of health care dollars are spent every year treating these diseases that improve or completely resolve after adequate weight loss.

In addition to the health problems, many morbidly obese patients are subjected to many social and relationship problems. Properly fitting clothes are difficult to find, with less selection, restaurant, theater and airplane seats are small and uncomfortable, health insurance is more difficult and more expensive to obtain, job opportunities may not be made available to you.

What is Morbid Obesity?
Plenty of people are overweight. How many people have you heard say that they could stand to loose ten or twenty pounds? Just because someone is overweight doesn’t mean he or she is “morbidly obese”. Morbid Obesity is defined as a Body Mass Index of greater than 40 if there are no other health problems and 35 if there are other health problems. Your Body Mass Index is calculated by dividing your height in meters by your weight in kilograms squared.

Why a “New Beginning”?
The Gastric Bypass will result in some very pleasant changes in your life. Imagine having more energy, more choices in clothes, more compliments on how you look! If you have been severely overweight for as far back as you can remember, this operation will give you “A New Beginning”.

Why Not Just Stop Eating?
There are many reasons why a person is obese. There may be many more reason that we haven’t discovered yet. Most of the time, it is simply overeating due to a learned behavior; for instance, eating makes you feel better or eases stress. Sometimes, it is due to a genetic reason, or a combination. As most morbidly obese individuals know, diets are ineffective at treating their weight problems. A National Institutes of Health has shown that 97% of morbidly obese people fail to have any permanent weight loss from dieting alone. In fact, The Centers for Disease Control has labeled obesity an epidemic! Permanent weight loss comes from permanent behavioral modification, and surgery helps do just that permanently modify your eating habits.

Digestion
The chemical process that makes up digestion starts in your mouth when you chew a bite of food. The saliva in your mouth is rich in enzymes that begin to break down the food into very small particles. Next, in the stomach, it is mixed with acid and mucous and is stored until it is broken down into even smaller particles. Once emptied into the small intestine, the food particles are mixed with bile and pancreatic juices necessary for absorption. The food mixture is milked down the small intestines, and as it passes, the particles are absorbed for use as a fuel for the body. When the amount of fuel (Calories) ingested exceeds the needs of the body, the excess fuel is stored as fat.

Fat And Dieting
You become fat when you ingest more food than is needed to maintain bodily functions, day after day, month after month, year after year. Likewise, when you take in less food than is needed for bodily functions, the body uses your fat stores for power, and thus loose weight. Until you force your body to live off of its fat stores, you will remain fat, and possibly get fatter. No pill, supplement, herb, or “spa treatment” will get rid of fat.

Types of Weight Loss Surgery
Several types of weight loss surgery have been tried over the years. Only two types are commonly done at this time.



Adjustable Lap-Band® Device
The Lap-Band® Device was FDA approved for use in the United States in June 2001. The device is relatively safe, but is subject to frequent needle injections for adjustments of the volume of fluid with in the band, infection, slippage, erosion, and mechanical failure. Excessive weight loss can be good, often exceeding 60% at one year after placement in well chosen individuals.

Roux-en-Y Gastric Bypass
The Gastric Bypass is the operation that we feel is most effective and the one that we perform most often. It is similar to the vertical banded Gastroplasty in the it involves placing a row of staples across the stomach to create a self contained pouch of about 15 – 30 cc in volume. This is done with a special surgical instrument that has two jaws. The stomach is positioned between the two jaws. As the jaws are closed, it squeezes the two walls of the stomach together. At that point, two parallel rows of staples “fired” through both walls of the stomach to connect them, thus closing off the larger portion of the stomach. We then cut between the rows of staples, separating the stomach into two separate, distinct parts. This allows each part to heal separately, and to prevent the possibility of the staples line coming apart in the future. A very small opening is made in the pouch and is connected to a section of small intestine, allowing a small amount of food to pass.

How the Gastric Bypass Works
This operation has been shown to produce greater and more sustained weight loss than other operations. It does this in four ways. First, the amount of food that you can eat is restricted by the size of the pouch. Secondly, the small opening into the small intestine slows the flow of food out of the pouch. Third, up to 100 centimeters of small intestine is rendered “non-absorptive” due to the lack of bile, pancreatic juices, and food not being present at the same place to allow absorption of calories. And fourth, and solid sugar containing food such as cake, candy, ice creams, and some colas, will produce a temporary, unpleasant “illness” called Dumping Syndrome. The Dumping Syndrome is caused by a concentration of sugars in the small intestines and produces nausea, tremors, chills, sweating, palpitations, and diarrhea. It will last from one to four hours. Sugars are high in calories, and will lead to weight gain. The dumping syndrome will discourage you from making these poor food choices.
After surgery you will only be able to eat about one ounce of food at a time. You can eat more, but you will usually bring it back up and wish you hadn’t. Even though your body has enough fat stores to keep you going for six months or more, you would eventually starve to death at this rate. However, over the course of a year, the small pouch will stretch a great deal, and you will find yourself able to eat more at any one time. However, do not be mislead by thinking that the operation will restrict your eating for about a year and then allow you to eat as much as you want. YOU WILL NEVER AGAIN BE ABLE TO EAT AS MUCH AS YOU CAN NOW. That means no more second helpings, no more large holiday dinners, no more “all
you can eat” specials. You will need to take vitamin and mineral supplement forever.


The Problems
After this operation, you will be like an infant learning to eat. Just like a baby “spits up”, you can expect to regurgitate or vomit from time to time. You and your body are going to have to learn how much you can eat, what you can eat, and how often you can eat. The reason you may vomit after this operation is simple. You have eaten more than the pouch can hold. The food will sit in the lower esophagus and this will cause pain until the food is pushed out. Don’t worry; you will have time to make it to the bathroom.
Another reason vomiting is common in the first month or so is obvious, you’ve had a major operation on your stomach! Your stomach has been stretched, stapled, sewed, and cut. This causes a great deal of inflammation just as a sprained ankle causes a lot of swelling. You must treat your stomach gently at first, and avoid foods that might upset it.
A common concern from patients has been the perception that they can eat a certain amount on one day, but only half that amount the next. For example, let’s say that you ate five bites of hamburger on Friday night, but on Saturday night, you threw up after on two or three bites. What happened? Well, the food from Friday night and Saturday morning was still in your stomach. The opening out of the pouch is very small and designed that way on purpose. This is to prevent your pouch from emptying an ingested meal right away leaving you hungry soon after you ate. Different foods are going to empty from your pouch at different rates and the same foods affect different people differently. This is unpredictable and
part of your learning process.

Most people, though, are pretty much over the vomiting after about six to eight weeks. Nonetheless, even years after the operation, if you eat too much, you’ll probably vomit
.
RISK OF GASTRIC BYPASS SURGERY
When we discuss the risk associated with the gastric bypass surgery, be it performed via an open incision or by a laparoscopic approach we have to look at these risks in the context of the experience and maturity of not only the surgical program itself, but also that of the performing surgeon.

When we look back at the published medical literature concerning gastric bypass surgery, we see that the past President of the American Society for Bariatric Surgery, Dr. Alan Wittgrove who performed Carnie Wilson’s gastric bypass, declared that complications from gastric bypass surgery specifically laparoscopic gastric bypass surgery would be more frequent and more severe during a surgeon’s initial learning phase. Other literature determined that this initial learning curve for a surgeon learning to do laparoscopic gastric bypass surgery could be as many as 100-150 cases. In fact, Dr. Philip Schaurer has stated that a laparoscopic gastric bypass is approximately three times harder than a laparoscopic removal of a gallbladder.
A recent University of Washington study determined that a patient undergoing laparoscopic gastric bypass surgery was 4.7 times more likely to die if that patient was one of the surgeon’s first nineteen cases. In fact it has been determined that the risks and the mortality or death rate from laparoscopic gastric bypass surgery is higher than originally determined.

This increased risk is especially magnified with inexperience. Not only is the program inexperienced in the procedure itself, they are also inexperienced in recognizing the sometimes subtle early signs of a complication leading to a delay in treatment. Moreover, they are inexperienced in treating the complication when it does arise. This leads to a magnification of risk during a surgeon’s initial learning curve.

There is an inverse relationship between risk and surgeon experience. But, risk is never zero!

Much of the increased risk that we have seen in laparoscopic gastric bypass surgery over the past several years has stemmed from the explosion of popularity in this operation brought about primarily by the endorsement of celebrities such as Carnie Wilson, Randy Jackson, Al Roker, and others. This explosion popularity accompanied by the acceptance of bariatric surgery by the general population AND decreasing reimbursements to general surgeons for non-bariatric surgery led to a rapid growth in new gastric bypass programs. This explosive growth of gastric bypass surgery and bariatric surgery programs resulted in a majority of bariatric surgery programs in this country being in their initial learning phase. This led to an sudden marked increase in the complication and mortality rate. This increase resulted in the dramatic withdrawal of insurance coverage for gastric bypass surgery, especially in the state of Florida.

Several years ago, the insurance companies and specifically Blue Cross Blue Shield was approached with a request that bariatric surgery be credentialed and reimbursed separately from their general surgery contracts. These requests were abruptly rebuffed by the medical directors of the insurance company and as a result many learning surgeons used their contracts with Blue Cross Blue Shield and other insurance carriers to fund their learning curve. This resulted in the unexpected increase in complications and extended hospitalizations and therefore, rising cost associated with this surgery. In fact, in March of 2004, CNN.com quoted Barry Schwartz, Vice President at Florida’s Blue Cross as saying that “The risks drove the decision not to cover the surgery, but to a lesser extent cost was a factor.” Mr. Schwartz was later quoted as saying “Many physicians considered the procedure a cash cow,….The number of unqualified doctors performing the surgery has spiked dramatically.”
Therefore it is important to understand that while the risks and complications from any major surgery, but especially when performed in a particularly high-risk individual can never be zero, but can be brought as close to zero as possible with an experienced surgeon and surgical team.

That being said, the risks of a gastric bypass procedure are as follows:
BLEEDING: Bleeding is a risk with any operation, especially one in which several incisions are made. We are working up underneath the liver and next to the spleen. We are cutting the intestine in several places and splicing it back together and several others. We are doing this in an environment of a blood thinner injection that is given before surgery for reasons we will discuss shortly. The typical amount of blood lost from this operation is so little so as to be difficult to measure. No one leaves the operating room actively bleeding. The risk of needing a blood transfusion at our facility is less than 1%. A drain is placed in the area of the pouch and is helpful in determining whether any postoperative bleeding is occurring. It is important to know that we routinely draw blood counts every six hours after a gastric bypass within the first 24 hours to determine whether any postoperative bleeding is occurring prior to there being any changes in the patient’s vital signs. Risk: 0.4%
The risk of contracting HIV or hepatitis C in the South Florida blood bank population is approximately 1 in 500,000 units of blood.

INFECTION
Infection rates with abdominal surgery are always higher when one opens the intestine as we do with a gastric bypass procedure. For this reason, we ask you to clean out the intestines prior to surgery in order to decrease the bacteria counts and to give us as much room to operate as possible. In addition, we do administer intravenous antibiotics beginning before the operation and continuing during the hospitalization. We also leave that drain in the area of the pouch to wick out any potentially contaminated fluids before they can become an abscess. Risk 0.7%

STAPLE LINE LEAK
A staple line leak is a complication that generates bad press surrounding a gastric bypass procedure. The staples we use are manufactured from titanium steel wire and are laid down in triple row, staggered overlapped layers. Staples do not fail, but occasionally the patient’s tissue fails because of poor visceral protein stores and poor collagen formation. We reinforced some of these staples with non absorbable suture material. In the case of the pouch and its connection to the small intestine, we will either use a biological glue or vascularized fat around the anastomosis to serve as an additional layer of protection from leaks. We then test these staple lines by clamping off the small intestine draining the pouch and placing the area under a clear salt water bath. An additional camera is placed down the patient’s mouth to the inside of the pouch while they are still asleep in the operating room. This allows us to inspect the inside of the pouch for bleeding and to pressurize the pouch with air. We then observe the outside of the pouch on a secondary television camera and determine if there are any air bubbles. No one leaves the operating room unless the anastomosis and staple lines are intact. The following morning the patient is taken to the radiology suite and asked to swallow a few swallows of x ray dye. This is to make sure that the connections have remained watertight overnight and there no blockages exist. If a patient were to leak within the first 24-48 hours after surgery, there likely would be symptomatic with a rapid heart rate and an inappropriate sense of anxiety. If these findings were determined after surgery, additional x-ray studies would be performed and if it was determined that the leak was existent or likely, a return to surgery to close that leak would be necessary. On rare occasions, some people leak after discharge from the hospital. Generally, these individuals would call our office and tell us that they had eaten some green jello and now there is some green discharge from the drain in their site. In this case, we repeat x ray studies and slowly
withdraw the drain over a period of weeks allowing the leak to heal behind the drain as it is withdrawn. Risk: 0.35%

STENOSIS
Anastomotic stenosis is the most common complication after a gastric bypass procedure performed occurring in approximately 4.8% of the patients at our institution. If this occurs, it will become gradually symptomatic between three and six weeks after surgery, hallmarked by a decreasing tolerance for different foods and liquids rather than an improved tolerance for different foods and liquids. If this occurs, an appointment with our endoscopist is arranged and an outpatient upper endoscopy is performed with dilatation. If dilatation is performed, a repeat endoscopy is performed in 10-14 days
after the initial endoscopy for repeat examination and repeat dilatation. Risk:14%

SMALL BOWEL OBSTRUCTION
Small bowel obstruction, either from scar tissue or internal hernia can occur after any operation. In this case, we are routing the intestine in places that nature never intended for them to be. We do anchor the bowel down in places where we wish it to stay and close any gaps we create with non-
absorbable suture material. Risk: 2.0%

NUTRITIONAL DEFICIENCIES
Nutritional deficiencies, particularly with thiamine and other B vitamins, as well as, vitamin D, calcium, iron, and B12 can occur if multivitamins and other supplements are not taken as directed. In addition, essential fatty acids are many times required. We will give our patients a nutritional surveillance handbook after their one month visit. We draw routine blood tests periodically to determine whether the different levels of vitamins are appropriate. In addition, we perform a bone densitometry at 6 and 12 months after surgery. Thiamine deficiencies can result in permanent nerve damage particularly of the feet and hands. It can lead to heart damage, brain damage, generalized paralyses, and death. Likewise, vitamin B12 deficiencies can lead to dangerous anemias and nerve damage. Iron deficiency can lead to dangerous anemias as well. Inadequate calcium and Vitamin D intake in a patient population that is prone to calcium metabolism abnormalities can lead to dangerous osteoporosis. Other nutritional deficiencies
including essential fatty acids are common and can occur if appropriate supplementation is not taken regularly. Risk: Patient Dependent including

DEEP VEIN THROMBOSIS AND PULMONARY EMBOLUS
Deep vein thrombosis and pulmonary embolus is a complication to which morbidly obese individuals are particularly prone. Deep vein thrombosis is a condition that causes the blood to stagnate inside the veins, primarily the veins of the pelvis and lower extremities, and form clots. Those clots could potentially break loose and go to the lungs, called pulmonary embolism, and can cause chest pain, abnormal heart rhythms, or fatality in severe circumstances. It is for this reason that we give blood thinners starting before surgery and continuing after surgery. In addition, we use inflatable stockings on the patient’s legs and we have a very young aggressive physical therapy staff that does not take “come back later, I do not feel like it
now” as an appropriate answer to their request for you to get out of bed and walk with them. Risk: 0.16% now” as an appropriate answer to their
request for you to get out of bed and walk with them. Risk: 0.16%

ATELECTASIS
Atelectasis is a condition whereby the small microscopic air sacs in the lungs where gas exchange takes place collapse after general anesthetic. It is for this reason that we teach the patients to use an incentive spirometer before surgery to recruit all potential air sacs so that they know where they need to get back to after surgery. They are also encouraged to take deep breaths and cough, so that the bronchitis and pneumonia does not develop.

ASPIRATION AND ARDS
Aspiration resulting in acute respiratory distress syndrome with lung failure and possibly death is extremely rare, but is caused by the aspiration of gastric or intestinal contents into the lungs. This can be a severe complication, which results in long-term ventilator requirements. It is generally seen only in those cases of emergency bowel obstruction requiring general anesthesia.

LUNG ABSCESS
Lung abscess is a result of perhaps long-standing microaspiration of bacteria into the lungs until an abscess is developed. This is exceedingly rare and
generally only seen where narcotics are extensively used after surgery. Risk: 0.14%

PLEURAL EFFUSION
Pleural effusion is quite common after any upper abdominal surgery. It is a fluid collection in the chest cavity between the lung and the chest wall. Coughing and deep breaths can minimize the formation of pleural effusion. Large pleural effusions may result in shortness of breath and chest pain and
it may be required that these fluid collections be removed with a needle aspiration.

MYOCARDIAL INFARCTION
Heart attacks are possible, however, most reputable programs will screen at risk patients for heart problems and request cardiac clearance. In our particular program, no patient has had a heart attack in the peri-operative period.

STROKES
Cerebrovascular accidents or strokes are a risk with any operation particularly with people at risk for cerebrovascular disease. In our program, no patient has had a stroke around the time of surgery.

RHABDOMYOLYSIS
Rhabdomyolysis is a rare complication of gastric bypass surgery generally occurring in very heavy males or in morbidly obese people undergoing very long operating room times. Rhabdomyolysis is a crush injury of skeletal muscle, in this case of the buttocks muscle. This is a complication of weight rather than of the operation itself. It can lead to renal failure and to very large bed sore-type erosions on the lower back and buttocks. Our operating room times are generally one hour to one hour and fifteen minutes. We do screen our patients the following morning for any signs of renal failure or skeletal muscle death. Risk: 0.14%

DEATH
Death from gastric bypass surgery is a real complication. This is a major surgery performed in very high-risk individuals. Risk: 0.29%

The risks of this operation are not to be taken lightly and should be taken in the context of the experience of the surgeon. The likelihood of these complications happening as stated above reflects our experience and are in no way intended to reflect a nationwide average or intended to reflect complications at programs staffed by less experienced surgeons. Remember, risk is never zero and this is a fact that must be understood by every person contemplating gastric bypass surgery.

The Gastrostomy Tube
When you wake up from anesthesia, you may have a rubber tube coming out of the left side of your abdomen. This tube is in place to drain the acid from the larger, bypassed section of your stomach. Sometimes, because of swelling in the intestines, the lower part of the stomach doesn’t drain well. This part of the stomach, in combination with the liver and pancreas, produce 2 to 3 liters of fluid per day. If this fluid has nowhere to go, the staple line could eventually tear and a large leak would occur. This could have disastrous consequences as this material is a major peritoneal irritant, and people can and do die from this complication. To prevent this complication, we sometimes drain the lower portion of the stomach to the outside, so that in case there is sufficient swelling to prevent this fluid draining by the normal route, it will not break down the staple line and leak. We will plug the tube before you go home, and remove it in the office two to three weeks later.

SIDE EFFECTS - NOT COMPLICATIONS

ALOPECIA
The temporary loss of hair (not all, only a thinning) is common after drastic weight loss. Don’t worry, it will grow back!

DUMPING SYNDROME
As described above, the dumping syndrome is caused by the presence of concentrated sugars in the small intestine. Because the sugars can be emptied into the small intestine out of the pouch without significant dilution, dumping syndrome is common after this operation. It is characterized by flushing, dizziness, nausea, sweating, and diarrhea. It will pass in a few hours, but will be unpleasant enough to discourage you from making any
future unwise food choices.

Preparation for Surgery
Prior to the day of surgery, you will have blood drawn for pre-operative tests as well as an electrocardiogram (ECG or EKG), and a chest x-ray. You will go to the hospital several days before surgery to do the necessary paperwork and to meet the anesthesiologist.
On the day before surgery, you are not to eat anything solid, but can take clear liquids. You should take NOTHING by mouth after midnight on the day before surgery. You will take a shower with antimicrobial soap on the evening before surgery, paying special attention to the navel or umbilicus. You will be asked to take a laxative such as Fleets PhosphoSoda to further cleanse the bowels on the afternoon before surgery. Bring no jewelry or
other valuables with you to the hospital on the day of surgery.

In The Hospital
You will stay in the Bariatric Unit on the Surgical Floor. The nurses can watch your fluid status, heart and lungs very carefully. On the next day, you will get a special x-ray at which time you will be asked to swallow a special dye. This is to insure that there are no leaks at the pouch. If this x-ray is normal, you will be started on clear liquids.
IT IS IMPERATIVE THAT YOU HAVE A GOOD ATTITUDE AND GET OUT OF THE BED AND DEEP BREATH!

After Discharge
After discharge, you will remain on water, broth, and gelatin for two weeks. You will attend a lecture to discuss your return to "normal" food. There are four important rules that make this program a success:
1. Drink your water. Work up to at least 64oz per day. You may add Crystal Lite or squeezed lemon juicce for flavor if desired.
2. Exercise. Move your body at least 30 minutes per day. After you have fully recovered, we strongly encourage a supervised exercise and weight training program. Studies have shown that, in addition to aerobic exercise, weight-training speeds weight loss!
3. Protein First. Once you resume "solid" food, and forever thereafter, eat the protein portion of your meal first. Eat only when you are hungry.
4. NO SNACKING! NO SOFT DRINKS! NO MILK!
Please write your questions down and bring them to the office with you.