(even men go crazy over hair loss!) Pic credit: here.

But who is man enough to tell a lady that her hair loss is not serious?

Though it is not possible to discuss the physiology of hair loss in any kind of detail in this platform, we should have a working knowledge of how and why this happens.

Hair follicles are the living part of hair, the latter being keratin strands without inherent blood and nerve supply. When hair follicles get less nutrition or blood supply, the hair falls off. The important things to understand here are that:

1. The hair follicle itself is capable of recovering fully and regenerating hairs, and

2. The hair loss that the patient notices is a reflection of the insult suffered by the hair follicle several weeks beforehand.

So, in practice, what happens is that a patient notices clumps of hair coming off in the bathroom or during sleep, three or more months after the gastric bypass. A panic appointment is made, and we take time to assuage the panic. Usually, women being women (please forgive the unintended sexism), the reassurance wears thin, as the hair loss continues. In the meantime, the visible scalp areas elicit comments in the patient’s family and circle (“OMG! What is wrong with you? My aunt had something like this, and they later said it was cancer!!” is one of the comments you may hear), and the panic washes up once too often (“But, doctor, you never told me about this!”).

True, as surgeons, while we dwell at length about leaks, thromboembolism, weight loss plateaus and other such major issues, we may not harp much on the hair loss thing. One of the reasons is that this is a reversible phenomenon. Once the weight loss is achieved and the patient’s nutritional intake comes to near normal, the hair loss stops and the regrowth is established.

Anecdotal reports of benefits exist for various supplements, including biotin, primrose oil and flaxseed oil and horsetail extract, among others. It is all up to you to experiment and find out which one would work magically for you!

One thing we do strongly advise is not to go for hair transplants and other major interventions like this. After all, there is such a thing called common sense: why over-think something that is self-correcting?

For a nice overview of nutritional and metabolic complications after bariatric surgery, read this article in Diabetes Care.

We have all heard of this saying, and all of us agree. A skilled laparoscopic surgeon plots to take out huge tumors and cysts through the keyhole method, while the dinosaur surgeon tends to think of employing his hands to remove organs (like the appendix) that may have been better left alone.

Let me tell you a small story about myself. Not too long ago, at a Bariatric Surgery conference three or some years back, I had a chat with a renowned endocrinologist who was known for his work in obesity and diabetes. At that time, I was 86 kgs heavy, and most of it was fat. A hard-working surgeon, I was in the peak of physical un-fitness and a heart attack waiting to happen. My resting heart rate was always around 100 and my blood glucose was similarly poised over the century mark. I asked this gentleman how I could improve my markers and lose my fat. I also didn’t want to become a diabetic, I said.

He told me what anyone in his position would have: take a metformin pill, and do some walking. If your sugar levels go up, we will add another drug, he said.

I thought long and hard over what he said. I embarked on a new journey in life: a life of health and fitness. I trained hard and started IF (Intermittent Fasting). After an year of blundering along, I found my groove and results came in: resting heart rate down to 6o, blood glucose and lipid levels normal, and body fat well down (BW now 75 kgs).

To come back to the point, the doctor I asked hit my problem with the drug hammer he was holding by default. I did the smart thing by trying something different. I now firmly believe that everyone should try healthy eating and exercise in order to improve health and reduce body fat. As bariatric surgeons, we should not use the surgery hammer to hit every obese patient. When there is clear burden of disease (diabetes, hypertension, sleep apnea, gallstone disease, etc.) and the level of obesity is such that it is statistically unlikely to come off with lifestyle regulation, we recommend bariatric surgery. Not otherwise.

In other words, as specialists dealing with obesity and related diseases, we should have a broad perspective. We are always in danger of using a narrow knife-wielder’s perspective and eyeing every patient as a potential victim. We must be very careful. At BMI, we never stop telling each other this.

In clinical practice, the psyche of the patient is very important. But a more important factor (and an often unrecognized one) is the psyche of the doctor.

If you have had bariatric surgery and are now having reflux, what now?

(Are you worried about your reflux? Pic source: here)

We need to see what procedure you had. If you had a Band, tough luck! Because, as we mentioned before, the Band does cause reflux and also esophageal dilatation. Now, many surgeons will quickly accuse me of bias here. To which I plead guilty. I have always maintained that the Band is not exactly my favorite operation. While I maintain that it causes reflux in a lot of patients, there are conflicting reports worldwide.

For example, in Dixon’s study, they have found fantastic results after the Lap Band in terms of reflux symptoms and otherwise, too. Ten years later, the Australians reported excellent results in this paper.

(your favorite antacid may help. Pic: here)

After sleeve gastrectomy, reflux is temporary but may be distressing. If you have this problem, here is a list of what to do:

* Chew your food slowly or drink your liquids slowly.

*Avoid processed carbs

*Stay away from coffee, alcohol and tea

*Stop smoking, really stop it, will you?!

* Walk around after dinner

* Take an hour or two (or more) to sleep after dinner

* Keep the head end of the bed elevated

* Take PPIs as prescribed. PPIs are drugs that banish acid secretion.

* For short term burning sensation, drink  little cold water and have some preparation like Mucaine gel or Xylocaine viscous (local anesthetic).

* Contact the bariatric team for further advice.

After sleeve, reflux may be distressing and persistent in a small subset of patients. As this recent paper says, there may be an association between a wider proximal stomach tube and a narrower distal tube. This means that the upper part of the stomach tube is wider than the lower part. However, this is not related to the size of the bougie (the rod like thingie that is used as a sizer for the tube prior to stapling). Whether 3 cm or 6 cm of the lower part of the stomach (the antrum) is left behind has no relationship to the severity of reflux. Most of these patients also respond well to medical treatment.

Well, that should wrap up the subject pretty much for you! Please get in touch with us if you need more information.

So let us now assume that you are awaiting bariatric surgery and have reflux symptoms. So how does your reflux have an implication on your surgery? Will bariatric surgery (after all, we are operating on the stomach) make your reflux worse or better?

Let us take this procedure by procedure:

The Band: The band produces a mechanical obstruction right below the junction of the food pipe and the stomach. While this produces a barrier for the downward descent of food and accounts for the restriction in food intake after its placement, it does just the reverse for acid reflux. In other words, it tends to make reflux symptoms worse. Not to waste too many words on this, the Band is out if you have reflux.

The Gastric Bypass: This is the ultimate anti-reflux operation. It has a nearly 100 percent success in banishing reflux. After all, the pouch is separated from the stomach, where most of the acid is produced. What more, the small gut (jejunum) that is connected to the pouch acts to drain the acid away from the food pipe downwards. The special “Roux-en-Y” way in which we attach the jejunum to the pouch is the key to banishing reflux disease.

Sleeve Gastrectomy: Sleeve gastrectomy converts the stomach into a straight tube. In addition, it removes the part of the stomach from where muscle fibers go as a sling to loop around the LES (Lower Esophageal Sphincter). So it is possible that this operation weakens the sphincter and enhances reflux. In fact, clinically, most patients tend to have some degree of reflux after the sleeve, but this is self-limited and resolves soon. Once weight loss is begins, reflux also tends to reduce and go away.

In patients with a lax esophageal hiatus (the gap in the diaphragm through which the food pipe enters the abdomen) or with hiatus hernia, the sleeve can be done along with a repair of the hiatus (a procedure known as cruroplasty). This is also an accepted modality of treating reflux in the bariatric patient.

So the sleeve is a good bariatric procedure with a fairly good tolerance for the patient with some degree of pre-existing reflux symptoms.

The Duodenal Switch: This operation does not do much more than the sleeve for reflux. Indeed, the sleeve gastrectomy is the first part of the DS operation.

To sum up, if you are looking at bariatric surgery and you have symptoms and evidence of reflux esophagitis, then you should NOT consider the Band. If reflux is making your life miserable, then a bypass will be the best operation for you. If you don’t want the bypass for any reason, by all means consider the sleeve procedure.

In Part Three, we will examine the rest of the reflux story.

While a detailed discussion on the why’s and how’s of acid reflux are outside our syllabus in today’s class, it is important to just get an idea of the basic reasons why gastric acid gets up (against the tide) into the food pipe (esophagus).

The normal junction between the esophagus and the stomach is marked by a whorl of muscle fibers of the two organs that functionally works as a valve. This valve, called the LES (Lower Esophageal Sphincter) allows food to pass from the food pipe into the stomach, but not the other way. If it weren’t for this, we would keep burping up food into the mouth like infants. Now that wouldn’t impress our girl friends, would it?

(diagrammatic representation of the area of our interest. Pic source: www.chw.org)

In certain circumstances, the function of the LES is impaired, and the net result in the reverse entry of gastric acid into the food pipe (a place that is not adapted to acid pH). This happens if you eat too much, or oily/spicy/processed food, drink too much coffee or alcohol, or if you smoke. I am not even scratching the surface here.

In cases where the pressure within the abdomen is very high (as in advanced pregnancy or severe obesity) the excess pressure on the stomach overcomes the resistance of the lower esophageal sphincter and causes reflux. The food pipe gets inflamed as a result of the acid attack (reflux esophagitis).

In many instances there is a condition called hiatus hernia that causes severe reflux. This condition occurs when the junction between the food pipe and the stomach slides up into the chest cavity, as a result of which the positive intra-abdominal pressure pushes up the acid from the stomach into the esophagus, which is located in a negative (low) pressure zone inside the chest cavity.

With this background, we need to understand that most obese patients, specially those being considered for bariatric surgery, are chronic sufferers of reflux. However, it is important to understand that many upper abdominal or digestive symptoms (like pain after eating, vomiting, “gas”, for example) are due to associated gallstone disease.

Obviously, each of this is deserving of treatment on its own merit.

When we see patients, we evaluate the patient’s symptoms and consider reflux as a clinical diagnosis. The diagnosis is documented by other studies like upper GI endoscopy, barium study and esophageal manometry.

An ultrasound is always done to exclude gallstone diseases and to see the state of the liver. Fatty liver is almost always a given in the bariatric patient before surgery.

Now that we know what reflux is, how it occurs in the obese patient and how we detect it, we need to know what to do about it.

That will be Part Two.

Each time, I sigh. It means another ten minute lecture is due on my part. I have to teach an important lesson to the patient (not to mention the family) all over again.

So my lecture goes somewhat like this:

Why are you here? Because eating the way you do has led to a level of obesity that is dangerous to your health and even your very existence. You have suffered endlessly because of your obesity. You have lived through your own self-recrimination, the admonishment of your family, the chiding and teasing of your friends, and countless other miseries unique to the severely obese individual.

Eating the kind of foods the way you have been eating has caused you so many life-threatening diseases like diabetes, sleep apnea and hypertension. Eating sugars and junk has brought you to surgery as a last resort.

So why are you not looking further ahead to being leaner and healthier? Why are you looking back to eating the same kind of way that has made you what you are today? Look at this thing in perspective. You have a whole new life ahead. Plan on how you can make the most of this with your new-found health and look. Liberate yourself from guilt and misery. Focus! The goal is health and leanness, not food. Focus! Look, you are several trouser sizes down! Look, you look great in that new slim-fit T-shirt! Look, people are wide-eyed at your transformation. Look, your husband thinks you are beautiful again!

Don’t miss these achievements. None of this is possible if you think surgery is your destination. It is not. Surgery is your vehicle. It will take you where you would never have dreamed of reaching. But you will do so only if you keep sight of your goals. That is what is called FOCUS.

At work, your colleagues are eating samosas and cutlets along with sweet tea or coffee from the vending machine. You politely say, “No” to all these, because you know these are not good for you, and you don’t want to eat this junk, anyways. “What’s wrong with you?” your colleagues ask. You mumble about being on a special diet. But this situation is going to come up every now and then. Life will keep throwing up newer situations every day to challenge your status quo, your resolve and your health. Temptations are everywhere. How should you,  the patient, handle this?

Here are some suggstions:

1. Do not be shy of admitting or revealing to people that you have undergone a gastric bypass (or any bariatric procedure). You don’t need to advertise the fact, but do tell those people with whom you are regularly interacting and breaking bread. The truth shall set you free!

2. Once people realise you cannot eat like they do, they will not impose their foods on you. This will make social life far easier and healthier.

3. Avoid people or situations that are not compatible with your freedom of choice. This does not mean I want you to be a social recluse. I am merely asking that you avoid those people who do not have the sense not to force their food choices on the unwilling or unable.

4. Carry a couple of ‘lifesavers‘ — foods that you could just pop out of your bag and eat when you don’t find anything you can eat. Realise that society is still far away from being responsible and user friendly to special populations. Yes, with a small stomach and many medical problems, you are part of a special population.

5. Prepare for a party. This means calling up the host in advance, and specifying your needs (for example, you could ask for a small portion of a salad, a tomato/chicken soup, a small serving of a kebab or grill (paneer/fish/meat). If you cannot ask the host, tell your family member or person accompanying you to find your kind of foods for you, even talking to the host if needed.

6. If all the above are not working, don’t eat anything. This kind of sucks, but not as much as getting sick after eating junk.

Note that the above is more valid for the bypass patient, but also very relevant to the patient of the lap band, and less so for the patient of the sleeve gastrectomy.