The Honeymoon is Over!

You can't believe it's finally over! All of this time you have been waiting to have your surgery...and it's finally over. The nervous excitement leading up to surgery has come to a crescendo. "It isn't that bad" you say to yourself as you take an inventory of your new scars, learn how to sip liquids out of a tiny little medicine cup, and try to convince yourself that Whey protein is really more tasty than Soy protein (or the other way around).

You go home and try to settle into your new "life" of measuring liquids and sipping without gulping. You didn't realize how nasty that pill tasted when it was crushed, but you choke it down with some apple sauce anyway because your surgeon tells you it's important. Speaking of nasty, don't you think someone could come up with a pain medicine that tastes good! There's a huge market in grape, cherry, and orange-flavored medicine for children because we all know how hard it is to get them to swallow their medicine. So why do they think we adults will just suck it up, squint our eyes, and chug it down with a nice Crystal Lite® chaser? Because we do! Besides, if there isn't a good alternative, what can you do?

About a week into this you realize things are great. You have more energy than you could even imagine. You have already lost 10 pounds and you look great! The golf course looks really appealing. In fact, going back to work even sounds easy (in a "are you out of your mind" kind of way). Where did all of this energy come from? You are on top of the world and you can do just about anything.
Then week three starts. Dr. Jenkins warned you this would happen, but you didn't want to believe him. The honeymoon is over. He said you would feel worn out and want to nap all of the time. "I'm not a napper" you said to yourself, but you can't resist the urge to "rest" a little. After all, you did just have major surgery. The incisions may be small, but Dr. Jenkins said he had to "rearrange your anatomy". Besides, he won't let you drink more than four ounces every hour for the first few weeks. Imagine that. In the middle of the summer (winter/fall/spring, insert yours here), he expects me to drink no more than one ounce every 15 minutes. I can't eat more than a couple of bites at a time and I feel really full. I guess that's why I feel so tired all of the time. I remember something he said about my body using more energy than I was able to supply with my food intake. That kind of makes sense now.

But don't worry because week five is just around the corner. By now you are finally able to eat something more than baby food or pureed food. Those protein shakes sure are gooooood! (You can't remember which one tastes better now). Maybe you'll catch Dr. Jenkins off guard and he'll let you have some real food this week. Stage IV is starting to look like a buffet. It seems as if your energy is finally starting to improve. The thought of going back to work seems to be achievable at this point because that afternoon "rest" is not as crucial as it once seemed.

Dr. Jenkins says you need to start exercising now. Not the kind of exercise you used to do like walking around the house or working in the yard. No, this is the real thing; the kind of exercise that makes you sweat, breath hard, and feel like you want to take another "rest". In a strange way, you are beginning to like to exercise, because you have seen an extra 20-30 pounds leave you forever. Not only is it easier to exercise, but it's kind of fun. You actually see the results of your labors and you want it to continue. In fact, sometimes you feel kind of bad if you miss a workout. Did you ever think that would happen before you had surgery?

The honeymoon is over. But just like marriage, you are in for a wonderful journey. It will take a great deal of work to succeed. But the rewards will be incomprehensible. You are about to experience a whole new way of life so enjoy the ride.

~ Jeffrey R. Jenkins, MD, FACS

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How is my Weight Loss?

One of the most common questions I get is “how is my weight loss?” This is a natural question and one that is obviously on most patients’ mind following gastric bypass surgery. The answer is a little complex, but for the most part weight loss is fairly consistent from patient to patient. The following formula is a simple way of viewing weight management:

Energy in (food) – Energy out (exercise, metabolism) = Weight loss or Weight gain

In other words, the more you eat and the less you exercise the more weight you will gain. This, of course, also works the opposite way for weight loss. This is important in understanding weight loss following surgery.

As a general rule of thumb, weight loss in the first month is about one pound per day. There are several reasons for this. First, the body is using a tremendous amount of energy to repair the “surgical trauma”. Second, the patient is not able to take in much nutrition. Part of this is the result of the reduction in the size of the stomach, but part of this is the body’s natural reaction to surgery which causes a decrease in appetite. As a result, the amount of energy going into the body is less than that which is being used by the body. The result is rapid weight loss!

After the first month, weight loss predictably slows to a rate of one to two pounds per week. This is often frustrating to the patient because the rapid results of the first postoperative month are so gratifying. The reason weight loss slows is also related to the above “equation”. After about one month, the patient is able to eat more consistently and the body’s need for energy becomes less as the surgical trauma is healed. Therefore, the equation above becomes more balanced and the weight loss slows. It is at this point there is a natural tendency to wonder what is “wrong”. If you are prepared for this transition, it will be much easier to accept the slower rate of weight loss.

Once you reach this “steady state” of weight loss, it is important to establish good exercise and dietary habits. Even though you continue to lose weight at a continuous rate, it is possible to influence this in a positive or a negative way. For instance, if you do not exercise, the amount of energy expended by the body will be lower. To the contrary, if you eat too much, the equation will tilt back toward weight gain. As you can see, I can give you the “tool” for weight loss, but it is up to you to use it correctly. Weight loss will reach a maximum between one and two years after surgery. By using the tool that your surgeon has given you, weight loss can be maintained over the long run. If you have
been doing routine exercise and practicing good eating habits, the rewards will become obvious at this point.

~ Jeffrey R. Jenkins, MD, FACS

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Late Complications of
Gastric Bypass Surgery, Part I

There is a great deal of talk about the perioperative (the time right around surgery) complications associated with gastric bypass. It is not often that we discuss the long-term complications that can occur. By “long-term” I mean beyond the first few months after surgery. In this first of two parts I will discuss the anatomic problems.

Incisional hernias occur when the strong layer of the abdomen (the fascia) is weakened from surgery. The resulting weakness leads to a bulge that can be painful, unsightly, or both. Essentially, the contents inside the abdomen are trying to come out through the weakness in the abdominal wall. The risk of developing a hernia is dependant on many factors including: obesity, underlying poor nutritional status, use of steroids (for diseases such as rheumatoid arthritis or asthma/COPD), infection at the time of the original operation, and the location and size of the incision. For gastric bypass surgery the risk of developing a hernia is about 20% for patients who have open procedures, but only 5% for those having laparoscopic procedures. The main concern with an incisional hernia is that something inside the abdomen will become stuck (incarcerated) in the hole and will not reduce back inside. If this were to occur, there is potential for damage to the structure that is incarcerated. This may require removal of this structure at the time of the emergency hernia repair. Fortunately, most hernias do not become incarcerated and can be repaired electively prior to any significant complication developing.

Internal hernias are similar to incisional hernia in the sense that something (usually a piece of small intestine) gets incarcerated within a defect (or hole) inside the abdomen. The defect can be created by the anatomic rearrangement such as the one that occurs with gastric bypass surgery, or it can result from scar tissue. This is typically a surgical emergency and requires immediate attention. Patients will present with sudden onset of abdominal pain, vomiting, and sometimes abdominal bloating. Evaluation with abdominal X-rays and blood tests are typically negative in the first several hours. However, CAT scan of the abdomen will usually reveal the cause. Operative repair of the hernia includes reduction of the hernia (removing the intestine from the hole) and closure of the hernia defect. If the hernia is not identified and repaired quickly enough, the incarcerated loop of intestine may die from loss of blood flow and more complicated surgery will be required. Therefore, it is imperative that someone trained in Bariatric surgery evaluates you if you have abdominal pain after gastric bypass surgery. The risk of developing an internal hernia after gastric bypass is 5-10% and the most common time to develop one is greater than one year after surgery.

Anastamotic stricture is a narrowing of the connection (the anastamosis) between two pieces of intestine. In gastric bypass surgery, the most common area of stenosis is the connection between the gastric pouch and the roux limb (the small intestine). The narrowing of the anastamosis may develop slowly over many months or years, but usually occurs about 4-6 weeks after surgery. This is typically the time the patient is advanced from a pureed diet to one in which more solid foods can be eaten. It is at this time the patient discovers food seems to hang-up or stick in the pouch unless it is liquid in consistency. The narrowing represents excessive scarring at the anastamosis after surgery and may be related to poor healing or simply the result of the anastamosis being too small. There is a 10% risk of stricture occurring after gastric bypass surgery. Fortunately, almost all of these can be repaired as an out-patient by dilation at the time of upper endoscopy (looking into the pouch with a lighted scope). Typically 2-3 separate dilation procedures are required to completely resolve this problem.

Ulceration of the anastamosis can cause pain and, in rare situations, reconnection of the pouch and the gastric remnant (the stomach that is bypassed). If the connection between the pouch and the small intestine does not heal correctly, an ulcer may develop. This can be a painful problem and/or cause difficulty swallowing giving the sensation that food gets stuck in the pouch. Most of the time an ulcer will heal with medication. If the ulcer persists despite adequate medical treatment, it may indicate there is a connection between the pouch and the remnant stomach (a fistula). The acid from the remnant stomach causes the ulceration because there is no mucous to protect the pouch. When the acid leaks into the pouch, it digests the lining of the pouch or the small intestine and results in an ulcer. The only way to resolve the ulceration in this situation is to revise the bypass by removing the ulcer and closing the connection between the pouch and the remnant stomach. Revision of a gastric bypass is a major operation and the risk of complications is even higher than for the initial surgery. Therefore, this surgery should only be undertaken by Bariatric surgeons trained to do revisions. Ulcers occur in about 5-10% of patients and it is rare to need surgery to correct this problem.

As you can see, there are some long-term problems that can develop after gastric bypass surgery. Fortunately, the incidence is low and most patients do well after correction of the problem. In next month’s column I will discuss the nutritional complications that may develop after surgery.

~ Jeffrey R. Jenkins, MD, FACS

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Late Complications of Gastric Bypass Surgery, Part II

In last months column I discussed the anatomic complications that can occur after gastric bypass surgery. In part II this month I will discuss the nutritional complications that can occur. The most common nutritional problems that can occur are: Vitamin B12, iron, calcium, and thiamin (vitamin B1) deficiencies.

Vitamin B12 is an essential vitamin that is important in maturation of red blood cells (RBC’s). It also has important actions in nerve function and DNA synthesis. The most common source of B12 is meat, eggs, liver, and milk products.

Ingested vitamin B12 is normally bound to intrinsic factor which is made in the stomach and then it travels into the intestine where it is absorbed preferentially in the end of the small intestine (the terminal ileum). Inadequate B12 results most commonly in anemia (decrease RBC’s). However, neurologic changes such as weakness, unsteadiness, delirium, and confusion can also occur. After roux-en-y gastric bypass (RYGB) food does not pass through the part of the stomach that makes intrinsic factor. As a result, absorption of this vitamin is not as efficient as it would be with normal anatomy. Fortunately, symptoms of B12 deficiency usually take months to years to develop. Our body has enough B12 stored to last about 6 months before we become deficient. If you become deficient in B12 you may be able to reverse the deficiency with oral vitamin B12, but some patients will require monthly shots of B12 to treat this successfully.
Iron deficiency also results in anemia. The body needs plenty of iron to make RBC’s as this is a major component. The primary sources of iron in our diet include: beef, kidney, liver, beans, clams, and peaches. Iron is primarily absorbed in the first portion of the small intestine (the duodenum). Because the food does not pass through the duodenum after a RYGB there can be inadequate absorption from the rest of the intestine. Iron-deficient anemia
develops slowly over several months and is easily reversed with oral supplementation in most patients. “Preventative” iron supplementation should be done cautiously because several medical problems can develop from excessive iron intake (cirrhosis, diabetes, skin pigmentation).

Calcium is an essential co-factor and is required for most functions in our body. Bones and teeth require it for strength. Blood coagulation is dependant on calcium. And the ability of our muscles to contract or our heart to beat would not be possible without calcium. Fortunately for us, calcium is abundant in our diets. It is found in dairy products, meat, fish, eggs, cereal products, fruits, and vegetables. Unfortunately for the gastric bypass patient, it is not absorbed as easily as before bypass surgery. The primary source of absorption is in the duodenum. Just as with iron absorption, the anatomy after RYGB does not provide adequate exposure to this portion of the GI tract. However, the remainder of the small intestine is fairly efficient at calcium absorption so it is usually an easy problem to prevent. The main thing to keep in mind is the type of calcium you need. As a result of the RYGB there is no longer acid in the
gastric pouch. Calcium carbonate (TUMS®, Oscal®) requires acid to break it into particles that can be easily absorbed by the body. Calcium citrate (Bariatric Advantage®), on the other hand, is readily absorbed without the assistance of
gastric acid. Therefore, make certain you are taking calcium citrate after your surgery.

Thiamin (vitamin B1) deficiency is generally not a problem unless you are vomiting for a prolonged period. Symptoms of B1 deficiency are typically of the neurologic variety and include numbness or tingling of the lips and tips of the fingers. It can be serious and mimic a central nervous system disorder in alcoholics call Wernicke-Korsakoff syndrome which causes confusion, memory loss, and instability while walking. It can also mimic a stroke leading to weakness or numbness on one side of the body. If this is not treated early enough it can be permanent and completely debilitating. Fortunately, this is rare and usually responds to oral administration of Thiamine. All of these deficiencies can be serious if ignored. Fortunately, they can also be easily prevented and/or treated with the appropriate vitamin supplements. This is one of the many reasons it is important to continue to see your Bariatric surgeon for the rest of your life.

~ Jeffrey R. Jenkins, MD, FACS

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Nothing and Everything

I am often asked, “What happens to the rest of my stomach after I have surgery?” The answer is “nothing”. In general, the part of the stomach that is bypassed (the remnant) remains intact after a Roux-en-Y bypass (RYGB).

The intact, or native, stomach has many functions. The most obvious one is to act as a storage bin for the meal you just ate. The food is then mechanically agitated (like a bread maker) in order to break it up into smaller, more easily absorbed particles. This process is aided by the secretion of acid in the stomach. Once these particles are small enough, they can pass into the small intestine where they are absorbed and processed into useable fuel for the rest of the body.

The pylorus is a muscle at the outlet of the stomach that regulates passage of food into the small intestine. The opening to the small intestine is about 1-2cm (1/3-2/3 of an inch) and this limits the size of food passing into the duodenum (first portion of the small intestine). The reason for this is to prevent large pieces of food from getting to the small intestine without first being broken down by the stomach. If something larger were to make it past the pylorus, there would be a problem with absorption by the lining of the small intestine and this food would pass relatively unused through the GI tract.

The stomach also secretes several important molecules that help in digestion and absorption of food. One of these is intrinsic factor (IF). Intrinsic factor is needed to absorb Vitamin B12 adequately. Foods high in Vitamin B12 are broken down in the stomach and IF binds to the B12 which is then absorbed at the end of the small intestine.

You may be asking, “What does this have to do with me?” The answer is “everything”. Think about it, if you don’t have a stomach after a RYGB, how is the small intestine going to be able to do its job? Since the new gastric pouch only holds about 1-2 Tbsp of food (it holds several ounces later) there isn’t much room to churn and break down the food. In addition, the majority of the acid-producing cells and the cells that produce IF are located near the pylorus in the remnant stomach. As a result, there isn’t any acid to help break down the food and the B12 isn’t able to bind with IF until much farther downstream in the small intestine. Speaking of the pylorus, your new pouch doesn’t have one. Therefore, food passes into the small intestine (the Roux limb) from the pouch with the help of gravity only.

The bottom line is, you are the stomach for your RYGB! If you don’t adequately chew your food, or if you choose the wrong type of food, it will get stuck in the pouch. Since there isn’t any acid to help break down the food in your pouch, it will stay there until you throw up or gravity (and time) allows it to pass. In addition, once the food gets into the Roux limb, it may not be absorbed very well if it is too complex to be broken down by the mechanical action of chewing (example: beef jerky, protein bars). Speaking of wrong food choices, if you eat foods high in fat or sugar, you may experience the dumping syndrome because the small intestine isn’t equipped to deal with these foods without the assistance of the stomach.

So take the excellent advice you are given preoperatively and be a good stomach for your RYGB. And remember what happens to your stomach after RYGB..... “nothing and everything.”

~ Jeffrey R. Jenkins, MD, FACS

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Iron Deficiency

Iron is a trace element that is readily available in most Western diets. It is found in two primary forms; heme and non-heme. The heme form is thought to be the “best” form. It is the form the human body can most easily absorb and utilize. You find this form in animal sources such as red meat, dark poultry, shrimp, and tuna. The heme form of iron is released from food when it is digested by enzymes in the stomach and small intestine.

The other form of iron, non-heme, is found mostly in plants. This form of iron is harder to absorb because it takes more processing to release the iron from the plant source. Certain other foods can inhibit the absorption of this type of iron. They include tannins in tea, oxalates in green vegetables, chocolate, berries, compounds in grains, soy protein, and egg yolks. Absorption can be enhanced by simultaneous ingestion of heme iron (your mother always told you to eat your vegetables with your meat). Other substances such as Vitamin C, citric acid, and lactic acid improve absorption, as well.

Once iron is freed from the food that is ingested, it has to be absorbed. The difference between digestion and absorption is that digestion is the process of breaking down the food into smaller, simpler units the body can use. Absorption occurs when the small units are taken into the cells of the gastrointestinal (GI) tract and utilized for the energy or other properties they contain. The majority of digestion occurs in the upper GI tract, beginning with the saliva in your mouth and continuing well into the small intestine. Absorption occurs to a minor degree in the mouth and stomach, but the majority of the absorption occurs in the small intestine.

Iron is primarily absorbed in the duodenum. This is the first portion of the small intestine as it exits the stomach. The anatomy after a Roux-en-Y gastric bypass completely bypasses the stomach and the duodenum. Therefore, the iron never even goes through the part of the GI tract that is responsible for iron digestion and absorption. Obviously, some of the iron is absorbed in other parts of the small intestine; otherwise everyone would become iron deficient and anemic.

Duodenum “Roux” limb (after bypass)

The average dose for elemental iron replacement is about 15-20 mg once or twice daily. You may find iron in the store supplied in the 325mg concentration. The elemental concentration can be found on the back label of the bottle and usually reflects the fact that the iron is bound in a form that needs to be broken down prior to releasing the elemental form. So don’t get confused if you are advised to take 325 mg twice daily, the elemental iron will only be 15-20 mg in that compound.

One thing to keep in mind when supplementing with iron; many foods and vitamins affect the absorption of iron. Vitamin A appears to support iron absorption. Copper is required for iron metabolism and is usually found in multivitamins. Zinc and calcium can impair the absorption of iron. Therefore, it is a good idea to take your iron at different times than your calcium. Iron is supplied in many forms in stores.

As you can see, it is very important to continue with your follow-up on a routine basis so your iron level (among others) can be checked. Not every patient will require iron replacement, but if you are deficient in iron you may become anemic and this will affect your energy levels, as well.

~ Jeffrey R. Jenkins, MD, FACS

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The Easy Way?

So often I see patients in consultation for weight loss surgery (gastric bypass) and they are concerned about what their friends and family are going to say when they find out the patient has had surgery to lose weight. Many people are concerned they are “taking the easy way out” (of obesity). They are concerned about what everyone else is thinking and how they will respond when the patient returns to work or school. I fully understand where this is coming from because the obese patient has often endured a lifetime of discrimination, “fat jokes”, personal humiliation, and various other means of self degradation.

This strikes me as sad, and a little funny, because I haven’t ever seen anyone accused of “taking the easy way out” of other surgical diseases. You won’t see many people standing around the water cooler at work and discussing how John Doe is being weak and having surgery to repair his hernia. People don’t think twice about someone having surgery to remove a breast lump that might be cancer, do they?

For the most part, people are very understanding and concerned when a friend or colleague has to have surgery. They are fully aware of the pain and suffering people go through to remedy a condition they perceive to have been no fault of the patient. When it comes to gastric bypass surgery, I suspect most people feel the same way. Sure, there are uninformed people out there who feel obese patients are “lazy” and “just need to exercise more and eat less” (I suspect these people don’t have to worry about dieting!). These are the ones who feel obesity was caused by some self-defeating action on the patient’s part. Of course, there are some people out there who are not candidates for surgery because of behavior like this, but most patients who turn to gastric bypass surgery truly have tried and failed to lose weight by all other means.

I may be wrong, but the basic human nature is one of compassion and caring. I have faith in our fellow human beings that deep down inside (most) people consider gastric bypass to be another surgical procedure that is associated with the same struggles one would go through for any other disease. So the next time you or someone else thinks gastric bypass surgery is“taking the easy way out” remember, obesity is a disease, and surgery is one of the treatments we have available to treat this disease. Don’t be afraid to let everyone know you are going to have an accepted and proven treatment for a deadly disease.

~ Jeffrey R. Jenkins, MD, FACS

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Starvation Mode

According to Webster’s collegiate dictionary, a calorie “is the amount of heat required...to raise the temperature of one gram of water one degree centigrade”. In other words, it is a measure of the amount of energy required to accomplish a task such as heating water (or losing weight).

Calories are the secret to weight loss. That’s right, it all comes down to this little word we hear so much about every day. I have said it many times before, and I feel it is worth repeating over and over: The secret to weight loss is burning more calories through exercise than you take in as food. Gastric bypass surgery provides the patient with a tool to manage the amount of calories taken into the body (food). It is your responsibility to regulate the amount of energy expended (used up) through exercise.

It is common for the average patient to eat between 800-1200 calories per day once they reach a steady state after surgery (usually 3-6 months postop). If you expend more energy than this through exercise, you will have a net energy loss for that particular day. It may only be a few calories, but over time this will result in net weight loss.

When exercise becomes routine, patients often discover they need to increase their food intake to compensate. This concept is not obvious to many people who simply feel that eating less will result in the desired weight loss.

From the discussion above one might think that if you just eat very little and then exercise a lot you will lose weight, right? Well, not exactly. Remember that secret I spoke about in the first paragraph? It isn’t really as simple as it appears because your body is preprogrammed to prevent you from starving. If you stop eating, your body will try to conserve energy to prevent starvation. It does this by switching over to a different pathway of energy utilization that is not as efficient as the normal way. As a result, the amount of energy you get out of each calorie burned by your body isn’t as much as it was before you were starving yourself. In other words, if you are not providing your body with enough fuel (starvation) it takes more calories to heat up that same gram of water one degree centigrade than it does when there is plenty of food available.

In practical terms, this results in you working much harder at exercise and not achieving any (weight loss) results because your metabolism is working against you. Luckily for us there is an easy solution to this problem. Eat more. I know, I just told you to eat more! Actually, you don’t need to overindulge, you just need to increase the amount of calories you are eating in order to compensate for the extra energy you are burning while exercising.

Providing the extra fuel prevents the body from switching to the starvation mode and you actually utilize calories more efficiently. For most people, this amounts to about 10-20% more calories than you were eating prior to exercising.

This can be done in several ways, but the most effective way for the post-surgical patient is to eat a high protein snack (with some carbohydrates) just prior to exercising and to eat another (recovery) snack at the completion of your workout. You will find you have more energy to get through your workout and you will also feel better after you exercise.

As you can see, if you are eating right and exercising regularly, you will actually need to eat more to achieve your weight loss goals. Obviously, this does not mean overeat, it just means you may need to increase the amount of food you are currently eating in order to “reset” your metabolism and prevent it from going into starvation mode.

~ Jeffrey R. Jenkins, MD, FACS

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The Formula for Success

Do you want to know the secret to weight loss? It’s actually pretty simple. No special pills. No fad diets. You don’t even have to starve yourself to death! For years, people have been making a killing off of other people trying to find the magic bullet, the holy grail of dieting. All the while it has been right there for the taking, and it’s free! Are you ready? You’ll never guess what it is. I will tell you on one condition; you promise to keep it a secret. Ok, here it is; a balanced diet and exercise will help you lose weight as long as you take in less (calories by eating) than you put out (calories by exercising).

Surprising!?! I bet you thought I was going to say surgery was the answer. After all, this is a column in a gastric bypass support group newsletter, isn’t it? Of course it is. And most of you are thinking “but that doesn’t work for me, that’s why I (had, want, am having) surgery”. For most of you, this line of thinking is mostly correct. The majority of morbidly obese patients get to a point where they are unable to exercise due to their size or they just can’t get below a certain plateau weight no matter how hard they exercise and no matter how little they eat. I say mostly correct because exercise and a balanced diet is still the key to your weight loss success. You will not have a good result if you eat poorly after surgery, no matter how much you exercise.

You can, however, be successful after gastric bypass surgery if you eat right and don’t do a bit of exercise. Shocked again?! “He said I don’t have to exercise”. What I mean by this is you will lose weight if you follow the prescribed diet and you don’t do any form of exercise. The amount of weight loss is another matter. As you probably already know, the average weight loss after a Roux-en-Y gastric bypass is between 50% and 70% of the preoperative excess body weight (EBW-the difference between your ideal body weight and your current weight) between 12 and 24 months after surgery. If we look at all patients undergoing gastric bypass surgery, the average of everyone will fall in this range. This means that some patients will lose 80-90% and some will lose only
40-50% of their EBW.

My personal experience is that those patients who exercise consistently and eat right are the ones that reach the higher weight loss goals. I am encouraged when I see a patient for the first time and they already have good exercise habits. They tell me they have been exercising 3-4 times per week and they are frustrated by the lack of results. Many times these people have bad eating habits and this is what has led them to their current state of excess weight. I know they will be successful after surgery because they already have the good habit of exercising regularly. I can teach someone how to eat right and how to use the “tool” I create surgically. Unfortunately, it is much harder to teach someone how to exercise routinely.

So you see, it is a matter of perspective what you may think is successful and whether the weight loss you achieve is adequate by diet alone or if you feel that adding exercise will help you reach that goal you had before surgery. One thing for sure is; the formula for success is eating right and exercising regularly.

~ Jeffrey R. Jenkins, MD, FACS

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Sleep Apnea and Gastric Bypass Surgery

Sleep apnea is a condition characterized by periodic cessation of breathing during sleep. Some patients complain that “my spouse says I quit breathing while I am asleep and he/she has to shake me to get me to breath”. Often there is a history of very loud snoring and patients are frequently forced to sleep alone because their partner cannot get any rest while in the same room. Other symptoms include excessive daytime sleepiness, chronic fatigue, and morning headaches. Personality disturbances such as paranoia, hostility, and agitation may develop.

There are two types of sleep apnea: central sleep apnea and obstructive sleep apnea. In central sleep apnea, there is a problem in the brain that fails to trigger normal respiratory movements.

This results in the absence of air movement and movement of the muscles involved in breathing. In obstructive sleep apnea (OSA), the problem is caused by airway obstruction as a result of excess tissue in the upper airway (from obesity, for example). When the patient falls asleep, the upper airway muscles relax and the tongue falls to the back of the mouth. This results in narrowing of the upper airway and collapse of the pharyngeal wall (back of the mouth) and the patient stops breathing. In this instance, airflow ceases, but the muscles of respiration continue to work until the patient gasps or wakes up enough to overcome the obstruction. Since this occurs up to ten times per hour, on average, you can imagine how difficult it would be to get restful sleep.

As a result of the failure to breath, the oxygen level in the blood (oxygen saturation) drops and results in less oxygen available to the body. When there is not enough oxygen available, the body compensates by either increasing the respiratory rate (rate of breathing) or the heart rate.

Obviously, the patient cannot increase the rate of breathing, so the heart takes on the extra work. As a result, patients with sleep apnea tend to put more stress on their heart even while they are sleeping. This results in an increased risk of heart disease in patients with sleep apnea. This is the reason these patients require a cardiac evaluation prior to being considered for surgery.

Fortunately, we have a treatment for sleep apnea. The best treatment for an obese person with OSA is to lose weight. Loss of as little as 20-30 pounds can result in significant improvement and even resolution of the problem. For some, it may require greater weight loss. In patients who are not obese, or for those who have not been able to lose weight, there is a treatment called continuous positive airway pressure (CPAP). This is a breathing machine the fits over the patient’s nose while they sleep. It provides a continuous pressure in the upper airway to keep the excess tissue from collapsing while they sleep. This allows the patient to get restful sleep and decreases the stress put on the heart.

Obviously, knowing whether a patient has sleep apnea is an important piece of information. This not only allows us to begin treatment and improve symptoms of chronic sleep deprivation, it also identifies patients who are at increased risk of cardiac complications and also those who may be at risk for postoperative anesthetic complications. So if you think you may have sleep apnea, please let your doctor know as soon as possible so you can get the treatment you need.

~ Jeffrey R. Jenkins, MD, FACS

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Nesidioblastosis

Thanks to you (my patients) I am constantly learning. I guess that is why they call it “practicing medicine” because we don’t ever master every bit of information there is to know about our specialty. As a result of one of my patient’s recent battle with symptoms of hypoglycemia (low blood sugar), I have had the opportunity to brush up on nesidioblastosis, a subject I haven’t studied since my days as a resident on the Pediatric Surgery service. What is nesidioblastosis? It is a disorder in which there are too many insulin-producing cells (islet cells) of the pancreas. When this happens, the amount of insulin being made is too high and the blood glucose level falls to a dangerously low level. This can lead to life-threatening hypoglycemia. Traditionally this disorder has been seen mainly in newborn babies. The treatment consists of near-total pancreatectomy (removing most of the pancreas) in order to remove enough islet cells to bring the insulin level back to normal. Unfortunately, there are many other functions of the pancreas, and removing too much pancreas can lead to diabetes, as well as disorders of nutrient absorption.

So what does this have to do with gastric bypass? The symptoms of nesidioblastosis can be similar to “dumping”: light-headedness, fatigue, nausea, and even loss of consciousness. In addition, there is new evidence that nesidiobla stosis can develop in patients who have had gastric bypass surgery. But don’t panic; those episodes of dumping you occasionally experience after eating something high in sugar isn’t likely to mean you need your pancreas removed. In fact, it is very unlikely you will ever develop nesidioblastosis.

So why am I bringing this up at all? Because you may have read something about this disorder and may be wondering what is was all about. It also gives me an opportunity to speak about dumping and how to treat it appropriately. The first step is to avoid eating foods high in carbohydrates and/or high in fat (yes, excess fat can also cause dumping). Foods that contain more than 10 grams of carbohydrates per serving are more likely to cause dumping than those with lower amounts. If you stick with high protein foods, fresh fruits and vegetables, and avoid sugar-added fruit juice you will likely avoid dumping symptoms. You may, however, experience dumping if you eat too fast or if you eat too much at one sitting. So watch your portion size.

What do I do if I have dumping symptoms? If you have done as suggested in the paragraph above, you will likely avoid these problems. If you still have symptoms despite the above advice, you should contact your surgeon. There are a handful of patients who experience hypoglycemia after meals even if they watch what they eat very carefully. In these patients, eating something high in protein at the onset of symptoms is the best way to make them go away. If you eat something high in glucose (candy, orange juice, etc.) you may actually make it worse as the insulin level will increase and cause the glucose level to decline again about one hour later. This leads to a yo-yo effect; the patient feels bad then eats something to counter the symptoms and feels better for a short period, then feels bad from high glucose levels (dumping) and once again feels bad when the glucose level falls again later (because the insulin level has increased again). Eating protein helps to slowly increase the glucose level without causing an excess amount of insulin to be secreted and actually leads to a smoother recovery from symptoms of hypoglycemia.

~ Jeffrey R. Jenkins, MD, FACS

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Nesidioblastosis

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~ Jeffrey R. Jenkins, MD, FACS

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