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HAIR LOSS AFTER GASTRIC BYPASS SURGERY

ramana — Tue, 29 Jun 2010 04:38:14 +0000

Hair loss is one of the commonest laments in female patients after gastric bypass surgery (whether for weight loss or surgical cure of Type II Diabetes Mellitus), and is at once one of the least heralded topics in the subject. This is but natural: after all, surgeons are more bothered by complications that are life-threatening and serious.

(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.

ACID REFLUX AND BARIATRIC SURGERY- PART THREE

ramana — Fri, 14 May 2010 14:11:57 +0000

In Part One, we outlined the nature of the beast. In Part Two, we dealt with ways of cooking it. Now, in this part, we will clean up the remains. Sorry to our Gujju (and other vegan) friends for this analogy!

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.

ACID REFLUX AND BARIATRIC SURGERY- PART TWO

ramana — Fri, 14 May 2010 12:23:56 +0000

In Part One, we outlined the nature of gastroesophageal reflux and how it occurs, as well as how we detect it clinically.

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.

Handling Social Commitments After Bariatric Surgery

ramana — Sun, 14 Feb 2010 04:36:47 +0000

So you have had a gastric bypass and are now on the way to normal life. You have a party you need to go to. Fine. Till you realise that you can’t eat most things there, and people are staring at you — someone who is saying ‘No’ to every dish being offered. It’s not that you are being picky. It’s just that you are not feeling like it (some foods turn you off) or you know some foods will make you sick. Like gulab jamuns and sodas.

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.

“HOW MUCH WEIGHT CAN I LOSE, DOC?”

ramana — Tue, 01 Sep 2009 12:43:16 +0000

This is one of the commonest questions we face as providers of obesity care. The question may be posed by a matronly lady in her fifties, an out-of-shape PYT, or by a morbidly obese patient looking at bariatric surgery.

(pic source: here.)

The answer to that question, therefore, has to be contextual. In the more common non-surgical weight loss candidate, the question is not easily answered. How much of weight someone could lose is dependent on so many variables that it is foolhardy and unwise to venture a straight answer. This is in direct contrast to the typical slimming center approach of treating the entire complex subject of weight loss as a potatoes-by- the-kilo thing. You want to lose ten kilos? No problems, pay x amount.

The answer I give in the above context is, “How much do you want to lose, and what are you willing to do for that?” The focus, therefore, comes squarely back to the patient. It is not I who will melt your fat. It is you who will do so. I will merely set you on the right path for it. You would need to walk the path. If you are looking for a painless option, find yourself a slimming center, have a nice day!

The bottom-line being that in fat loss, you have to work hard– there is no escaping that. You will have to find a way to avoid the cravings. You will have to get up from bed for your workout. You will have to take your fish oil capsules. You will have to push yourself for that last rep when your body is screaming for you to rest at the end of your workout. I can only help you if you stand up to be counted.

If you have the requisite motivation, as I say in this article, we will surely guide you to success. But you can take all the credit for that. We only facilitate weight loss, demystify it, and bring a scientific perspective to it.

When a bariatric candidate asks, “How much fat can I lose?”, the answer is, “It depends“. Again, a contextual answer. In procedures like the gastric bypass, around 70-75% of excess body weight loss is typical. After this, the results depend on how well the patient controls his lifestyle. In the lap band procedure, weight loss is around 50%, much less. But then the mortality risks of this procedure are also less. On the other hand, more complex procedures like the duodenal switch have a greater (85%) weight loss, but also a higher risk of mortality.

In perspective, the more successful procedures (in terms of fat loss) come with a higher risk, and the lowest risk procedures give you the lowest fat loss rates.

Nature demands that we get something only if we take risks!

If you are the guy or girl intent on losing around 10 to 20 kgs of fat, the answer to your quest is that of course you can be successful but are you willing to be successful? Do you have what it takes to work your way to success?

BARIATRIC SURGERY PATIENTS AND PREGNANCY- ACOG RECOMMENDATIONS

ramana — Sat, 15 Aug 2009 02:35:34 +0000

From Medscape Medical News:

Specific conclusions and clinical recommendations based on limited or inconsistent scientific evidence (level B) are as follows:

• Because pregnancy rates after bariatric surgery in adolescents are twice that in the general adolescent population, contraceptive counseling is especially important in these patients.

• Administration of hormonal contraception by nonoral routes should be considered in patients with a significant malabsorption component after bariatric surgery because these patients have an increased risk for oral contraception failure.

• Testing drug levels may be necessary for medications in which a therapeutic drug level is critical to ensure a therapeutic effect.

Specific conclusions and clinical recommendations based primarily on consensus and expert opinion (level C) are as follows:

• There should be a high index of suspicion for gastrointestinal tract surgical complications when pregnant women who have had bariatric procedures present with significant abdominal symptoms.

• Bariatric surgery should not be performed with the intention of treating infertility, although fertility may improve in association with rapid postoperative weight loss.

• Bariatric surgery in and of itself does not mandate cesarean delivery, although the rate of cesarean delivery in these patients may approach 62%.

• Despite the lack of consensus regarding the treatment of pregnant patients who have had an adjustable gastric banding procedure, it is suggested that these patients have early consultation with a bariatric surgeon.

• For patients who have had bariatric surgery that may be associated with malabsorption and/or dumping syndrome, alternative testing for gestational diabetes should be considered.

• After conception, consultation with a nutritionist may facilitate adherence to dietary regimens and allow the patient to cope with the physiologic changes of pregnancy.

• For women who have had bariatric surgery, a wide-spectrum assessment for micronutrient deficiencies should be considered at the beginning of pregnancy.

As a proposed performance measure, the guidelines authors suggest documentation of counseling regarding weight gain and nutrition in pregnancy.

Additional points made by the authors of the practice bulletin include the following:

• Specific complications of obesity in pregnancy include doubling to quadrupling of the risk for stillbirth.

• Waiting 12 to 24 months after bariatric surgery before conceiving may be helpful to avoid exposing the fetus to an environment of rapid maternal weight loss and to allow the patient to achieve full weight loss goals.

• If pregnancy occurs earlier than 12 to 24 months after bariatric surgery, closer surveillance of maternal weight and nutritional status, including ultrasound for serial monitoring of fetal growth, may be beneficial and should be considered.

• After bariatric surgery, there is a reduced risk for hypertension, pregestational diabetes, gestational diabetes, and preeclampsia, as well as of large-for-gestational-age infants and macrosomia.

• After bariatric surgery, the risk for premature rupture of membranes is increased, but the risk for preterm delivery, congenital anomalies, and perinatal death is not increased.

“As the rate of obesity increases, it is becoming more common for providers of women’s health care to encounter patients who are either contemplating or have had operative procedures for weight loss, also known as bariatric surgery,” the guidelines authors write. “The counseling and management of patients who become pregnant after bariatric surgery can be complex. Although pregnancy outcomes generally have been favorable after bariatric surgery, nutritional and surgical complications can occur and some of these complications can result in adverse perinatal outcomes.”

Obstet Gynecol. 2009;113:1405-1413.

RISK FACTORS FOR POOR OUTCOME IN BARIATRIC SURGERY

ramana — Tue, 11 Aug 2009 03:23:48 +0000

From Medscape’s reportage of the study published in the New England Journal of Medicine on July 30th, 2009:

July 29, 2009 — Several risk factors may help identify factors linked to poor outcomes for bariatric surgery, according to the results of a prospective, multicenter, observational study reported in the July 30 issue of the New England Journal of Medicine.

From 2005 through 2007, the investigators evaluated 30-day outcomes in consecutive patients undergoing bariatric surgical procedures at 10 clinical US sites. For 4776 patients undergoing first-time bariatric surgery, the composite endpoint of 30-day major adverse outcomes included death; venous thromboembolism; percutaneous, endoscopic, or operative reintervention; and failure to be discharged from the hospital.

Mean age of the study sample was 44.5 years, 21.1% were men, 10.9% were nonwhite, and more than half had at least 2 comorbid conditions. Median body-mass index (BMI), defined as weight in kilograms divided by the square of the height in meters, was 46.5 kg/m².

The bariatric procedure performed was Roux-en-Y gastric bypass in 3412 patients (performed laparoscopically in 87.2% of these patients) and laparoscopic adjustable gastric banding in 1198 patients. The analysis excluded 166 patients who underwent other procedures. Among patients treated with Roux-en-Y gastric bypass or laparoscopic adjustable gastric banding, 30-day mortality rate was 0.3%, and 1 or more major adverse outcomes occurred in 4.3% of patients.

In an accompanying editorial, Malcolm K. Robinson, MD, from Harvard Medical School in Boston, Massachusetts, is hopeful that learning more about how bariatric surgery works may help develop even less invasive procedures.

“It is a sobering fact that some obese young adults may lose up to 20 years of life expectancy if they do not reduce their weight,” Dr. Robinson writes. “One must treat obesity aggressively, though thoughtfully, and with an eye toward developing effective prevention and better therapies that ideally would eliminate the need for surgery altogether. But until we get to that point, the weight of the evidence indicates that bariatric surgery is safe, effective, and affordable.”

The practice of bariatric surgery has increased more than 10-fold in the United States between 1994 and 2005, and an editorial by Robinson, which accompanies the current study, describes current indications for bariatric surgery. According to the National Institutes of Health, bariatric surgery may be considered for patients with a BMI of 40 kg/m² or more. Alternatively, surgery may also be considered among patients with a BMI of 35 kg/m² or more if they have another serious coexisting medical condition.

Some patients who meet these indications may be reticent to undergo surgery because of a concern regarding potential adverse events. The current study examines the rate of adverse events in the first 30 days after laparoscopic adjustable gastric banding and Roux-en-Y gastric bypass.

Study Highlights

Clinical Implications

According to the National Institutes of Health, bariatric surgery may be considered for patients with a BMI of 40 kg/m² or more. Alternatively, surgery may also be considered among patients with a BMI of 35 kg/m² or more if they have another serious coexisting medical condition.

Variables associated with a higher risk for complications in the first 30 days among patients receiving bariatric surgery in the current study included Roux-en-Y gastric bypass surgery vs laparoscopic adjustable gastric banding, a previous history of deep venous thrombosis or pulmonary embolus, obstructive sleep apnea, and an inability to walk 200 feet.