• bleeding.
• infection in the incision or deep inside.
• potential problems with the heart and/or lungs.
• obstruction (blockage) of the intestine caused by adhesions.
• hernia through the incision, rejection of suture materials.
• the risks associated with general anesthesia.

These risks are rare, and only slightly higher in most morbidly obese patients than in normal weight patients.

During Surgery

1. Although a surgery may start out as minimally invasive (laparoscopic), in rare cases the surgeon may need to make an open incision to complete the operation.

2. Unexpected findings, such as unusual rotations of the intestines, or enlarged liver, may force the surgeon to modify the operation, or stop surgery without doing the bypass.

3. Injury to spleen is a very uncommon complication, which may require removal of the spleen if bleeding cannot be controlled.

4. Injury to other organs such as the esophagus, intestine, liver, or bladder are extremely rare, but may occur and need further surgery to correct.

Early Risks

1. Leakage of fluid from the stomach or intestine through the staples or sutures may result in abdominal infection. This potentially serious but rare complication sometimes requiring a second operation for drainage of infection.

2. Mortality (death) is a very rare complication (approximately ONE OUT OF 200 patients). Although serious infections and heart problems may lead to this complication, the most common cause is from a blood clot forming in the legs and traveling to the lungs (Pulmonary embolus). We use blood thinning medication, and compression stockings to reduce the risk of blood clots, but the most effective prevention is by walking. Patients are encouraged to walk in the hallways as soon as possible after surgery, and to continue to walk once they go home.

3. Bleeding from the intestines where it is connected to the stomach or to itself occurs in less than two out of 100, and may result in further surgery.

4. Lung complications such as pneumonia may occur from not taking deep breaths. It is more common in patients who are smokers, and those that are not active after surgery.

Late Risks

1. The formation of ulcers in the stomach or small intestine. This is an uncommon complication, which occurs in approximately three out of 100 patients after gastric bypass surgery. Ulcers are more common in smokers and patients taking medications for arthritis.

2. Dumping. Patients may development loose stools and/or abdominal cramps shortly after eating certain types of foods. These symptoms can be avoided by not eating the offending foods. Common "offenders" include rich deserts and milk. Diarrhea is uncommon after gastric restrictive surgery and can be successfully treated with medication. Dumping is occasionally associated with brief periods of light-headedness, sweating or heart palpitations due to low blood sugar. These symptoms can usually be reduced by eating or drinking a small amount of food as soon as the symptoms start.

3. Obstruction of the opening of the stoma. This rare complication occurs in less than one out of 100 gastric bypass patients and can occur when a piece of food becomes lodged in the stoma. When this happens, the piece of food is removed through a tube (endoscope) passed from the mouth into the stomach.

4. Vitamin and/or iron deficiency. This may occur in a mild form in as many as 40 percent of patients after gastric bypass. Iron and some vitamins, most notably Vitamin B-12, are primarily absorbed in the stomach and upper part of the small intestine which is bypassed. Both the vitamin and iron deficiencies are easily treated by either oral supplementation or injections. Women who are regularly menstruating will need additional iron supplements. A generic multivitamin is recommended daily for life after any gastric bypass procedure. Vitamin levels should be checked at 6 months after surgery, and then yearly after that.Low calcium and protein levels and deficiencies in fat-soluble vitamins (A,D,E) are known to occur after distal gastric bypass. Gas, flatulence and diarrhea may be more prominent after distal gastric bypass.

5. Inaccessibility of the lower stomach and upper intestine to diagnostic tests such as upper GI (barium) x-rays and upper GI endoscopy. When the stomach is closed off in a gastric bypass, there is no way for contract material or an endoscope to reach the bypassed stomach (the part of the stomach below the staples). This would make diagnosis of a problem such as an ulcer of the lower bypassed stomach more difficult. The incidence of problems occurring in the bypassed part of the upper GI tract is extremely low.

6. Staple disruption can occur at any time after these operations but is uncommon (less than 1 in 100). If staples pull out, the feeling of fullness will probably disappear. A second operation may be required (restapling) if weight loss is not maintained.

7. Mild hair loss or thinning may be a temporary problem for some patients within the first six months after the operation. There is no specific remedy other than good nutrition and multivitamin supplements. The hair usually becomes thick again at six to twelve months after surgery.

ADMISSION TO THE HOSPITAL

• Most patients are admitted on the same day as the operation after undergoing pre-admission testing as outpatients.
• Patients with major heart or lung problems may be admitted a day prior to the operation for more intensive preoperative evaluation and preparation. Such patients may be examined before the operation by appropriate medical specialists who may assist in their management after the operation.

THE OPERATION

• Gastric bypass is generally performed in 2 to 3 hours, but may take up to 5 hours.
• Family members and friends may wait in the surgical waiting room of the hospital during the operation and speak with the surgeon shortly after the operation is completed.
• Most patients spend several hours in the recovery room before returning to their room on the surgical floor.
• Patients with known cardiac or pulmonary problems usually spend one or two nights in the surgical intensive care unit so they can be more easily monitored.

HOSPITALIZATION AFTER THE OPERATION

• For one or two days after all gastric operations, patients are given nothing my mouth (NPO) and remain on intravenous fluids. This is to minimize the possibility of leaks and also to allow normal gastrointestinal function to return following surgery.
• Patients who can be removed from the respirator (breathing machine) on the day of the operation are assisted (helped) out of bed later in the evening.
• On the first day after the operation, patients are offered cracked ice by mouth. On the second day, an "upper GI" study is done in radiology to check on the healing process. This is done by having the patient drink a small amount of contrast liquid and taking several x-rays. If the healing process is going well, a clear liquid diet is started. This is followed by a modified full liquid diet on the third postoperative day. All patients are discharged home on a modified full liquid diet which has a 1,000 calorie maximum daily restriction. Prior to discharge, all patients are counseled by the dietitian who reviews all of the food groups in the diet and emphasizes the need to take small bites and eat small meals.
  

DISCHARGE INSTRUCTIONS

If vomiting occurs, stop drinking and eating until the feeling of nausea passes. After the nausea disappears, resume drinking liquids for the next 12-24 hours. After 12-24 hours solid foods may be tried again.

Repetitive vomiting is potentially dangerous and any patient experiencing this should immediately contact the operating surgeon or go to the hospital emergency room.

DISCHARGE INSTRUCTIONS-ACTIVITY

Following discharge from the hospital

• Do not drive for one to two weeks
• Do not attempt any strenuous activity, particularly heavy lifting, for approximately three weeks.
• Walk as much as you can to prevent blood clots.
• Climb stairs as you need to, and you may take baths or showers.
• Some patients with sedentary-type jobs have returned to work as soon as two weeks after the operation.
• Patients with physically demanding jobs should wait four to six weeks before returning to work.

It is not uncommon to feel weak and tired for a few days after discharge from the hospital. The body is still recovering from the stresses of a major operation and the feeling of weakness may be somewhat prolonged because weight loss is occurring during the recovery period.

Postoperative follow-up after gastric restrictive operations is extremely important for several reasons.

1. The success of these operations is not determined at the time of discharge. Weight loss after gastric bypass occurs for as long as 18 months after the operation, after which weight is usually maintained.
2. Patients who exercise are generally more successful in reaching a lower weight and maintaining the weight loss.
3. Counseling by the nutritionist, who is experienced in counseling patients after gastric restrictive operations, is important in making the transition from liquids to soft solid foods. The nutritionist will emphasize the importance of making appropriate food choices in order to maintain a balanced diet and to avoid the high calorie liquids and soft foods which can defeat the purpose of the operation. All gastric restrictive operations can be defeated by consuming too many calories.
4. The follow-up visits are also very important in recognizing vitamin and iron deficiencies in the early stages so that appropriate treatment can be given. Gastric bypass patients who miss their regularly scheduled follow-up visits along with the necessary postoperative blood tests can eventually develop severe vitamin and mineral deficiencies. Severe deficiencies may require shots or blood transfusions.
5. The best weight loss generally occurs in patients who regularly keep their follow-up visits.

SCHEDULE OF POST OPERATIVE VISITS

1. First visit: one to two weeks after discharge.
2. Second visit: two to three weeks after the operation. Solid diet is given.
3. Visits at approximately three-month intervals for the first year after the operation.
4. After the first year, follow-up visits are scheduled at six to twelve-month intervals for an indefinite period of time
   

LONG-TERM OUTLOOK

Weight loss after gastric restrictive operations is gradual and occurs at the greatest rate during the first several months after the operation. Over the long term, consistency rather than rapidity of weight loss is stressed. After a few months the rate of weight loss will gradually decrease. This is because the weight which is lost is fat (adipose tissue) rather than lean body mass (muscle). Hence, the more fatty tissue that is lost, the less remaining fat there is to be lost. Few patients will reach ideal body weight. Patients whose weight stabilizes within 50 percent of their ideal body weight are considered successful. The heaviest patients must lose more weight to be successful.

The main reasons for poor weight loss after gastric restrictive surgery are bad food choices and frequent snacking. Patients may "lose track" of their eating pattern and redevelop some of the bad eating habits which caused their obesity in the first place. In almost every case, these bad habits can be corrected by minor changes or substitutions in the diet. This is why regular follow-up visits are so important after this type of surgery.

Obesity-related medical problems may improve with a modest degree of weight loss after gastric surgery. Blood pressure is routinely monitored at each follow-up visit, as is blood sugar (glucose) in diabetics and blood fats (cholesterol and triglycerides) in patients with hyperlipidemia. Patients are encouraged to see their own medical doctor at regular intervals after the operation, particularly for adjustments in their medications. With steady weight loss, patients often require lower doses of medication for diabetes and high blood pressure. Patients may not require any medications for these problems after achieving a substantial amount of weight loss.

Obesity-related medical problems that significantly improve or resolve after weight loss:

• Diabetes 95%
• Hypertension 92%
• Heart problems 95%
• Arthritis 82%
• Sleep Apnea 75%
• Urine incontinence 87%
• GERD 98%
• High Cholesterol 97%

All gastric restrictive operations are potentially reversible. Reversal requires an operation of the same magnitude and risk as the original operation. Reversal of gastric operations is uncommon. In the long term, changes in the original configuration of the operation can occur. Disruption (pulling out) of the staples is now an uncommon problem. Staple disruption may occur beyond six weeks from the time of surgery.

Stretching of the upper part of the stomach may occur to some degree, but this is rarely a reason for in adequate weight loss.

GASTRIC BYPASS SUPPORT GROUP

A support group of patients who have had gastric stapling operations at Easton Hospital holds regular meetings, on a bimonthly basis. The primary goal of this group is to serve as a means for exchanging information among patients who have had this type of surgery and also to provide information for individuals who are considering gastric restrictive surgery as a possible solution for a serious weight problem. Many prospective patients have been reassured by speaking with someone who has previously undergone the surgery. Several members of the support group have volunteered to discuss their experiences by telephone with interested patients. More information about the support group can be obtained from either the operating surgeon or the nutritionist. Click here to visit our calendar of events.