Gastric Bypass and Pregnancy : Which One is More Difficult ?

There are some well known risks for the patient and the baby after obesity surgery, but it should be indicated that, prognancy at the obese women is quite risky whether obesity surgery procedures have not been applied. In developed countries, obesity is one of the most clearest nutrition problem that endanger the pregnancy. Prepregnancy obesity is a risk that increases the posibility of encountering with many negativities can be faced at the pregnancy. Prepregnancy high weights increase infanth death during pragnancy as the studies recently executed.

In a study executed by Wittgrove et al. (Pregnancy Following Gastric Bypass for Morbid Obesity, Wittgrove et. al., Obesity Surgery, 8, 1998, 461-464) complication rates at the pregnancy have been interpreted with a definit number of pregnants. It has been recorded that from the followed patients those have experienced pregnancy after the operation, have 95% less risk for diabetes depending on pregnancy, macrosomia and caesarean. In conclusion, the patients which have underwent food intake avoiding operation are indicated to must take simple precautions during the pregnancy. The group those experienced pregnancy post operation had been exposed to less complications than the patients at the group of morbid obese at their previous pregnancy.

In a study recently executed by Patel et al. (Patel JA et al. Pregnancy outcomes after laparoscopic Roux-en-Y gastric bypass. Surg Obes Relat Dis. 2008 Jan-Feb;4(1):39-45.) and evaluates the pregnancy outcomes after gastric bypass application it has been showed that; there are similar risks to non obese women. In this study the author has indicated that pregnancy after gastric bypass application is safe and the complications will be occured are less from the obes women have not underwent operation and morbid obese pregnant women.

In the same way Wax JR et al. (Obesisty Surgery 2008) and Dao T et al. (American Journal of Surgery 2006) in their study have stated that there is not increasing in clear malnutrition episodes and bad fetal outcomes at the pregnancy outcomes after gastric bypass operation. Obtained results are similar to pregnancy of normal weight women.

Suggestions to the Patients Those Consider Pregnancy After Gastric Bypass Operation

The thing should be known is that there is risk both for mother and baby after the obesity surgery. Most of these risks are malnutrition and can be prevented by simple vitamin and mineral support. Preterm birth should be considered at pregnancy and up to this care and nutrition evaluations should be made. It is quite important to make the nutrition evaluation at the beginning of pregnancy. Laboratory data should be used and set up from stratch if there is a lack. Ideally best approach is to consider the nutrition problems at the pregnancy planning. Vitamin and iron support is important at all of the pregnancies but this is more important at the patients after gastric bypass operation. Prenatal vitamins, should be given not instead of the patient’s prescribed vitamin support, but in addition to this. Prepregnancy care should be followed up with careful coordination of the obesity surgeon and the gynaecologist.

Assoc. Prof. Halil Coskun M.D. www.halilcoskun.com

Weight Loss Mechanism Following Gastric Bypass Surgery

It is a known fact that the patients fill more quickly and eat less after Gastric Bypass (GP) surgery due to decreasing of stomach volume. Two mechanism most mentioned as the cause of GP beeing successful are :

1. Malabsorbtion (decreasing of food absorption)

2. Dumping Syndrome

Malabsoption that clinically have importance and characterized with increased fat quantity at the feces, is not seen after the standart GB. Dumping syndrome (nausea, bulge, colic pain, diarrhea, dizziness, perspiration and flutter) is typically seen at some patients after high carbohydrate foods. Due to these effects this syndrome, creates a negative approach against the fattening foods like sugar at patients.

Impairing of the Ghrelin secretion that has developed after GB is indicated to be effective at the anorexia development. Ghrelin is an enteric peptide and it is the only known and participated to the circulatory appetizer. Endogenous levels increase before the meal and decrease after the meal. Ghlerin, is generally producted from the stomach and a small part from the duodenum. Both of these areas are bypassed after GB. Since the eaten food is main Ghrelin secretion trigger and this food is unable to contact the stomach and duodenum, this strengthens the accuracy about the hypothesis of this surgery impairs the Ghrelin secretion. In a study which Ghrelin levels have been investigated; 77% decreasing at the values of patients those have underwent GB 1.5 years ago compared with the thin patients and 72% less Ghrelin secretion compared with the obese control group have been seen.

Anti-Diabetic Effects of Gastric Bypass

Comorbidity related with obesity which has most dramatically showed recovery by GB is Type 2 Diabetes Mellitus (DM). 82-98 % diseases of patients with diabetes have been indicated to showed completely recovery. In a lasting approximately 5 years prospective study of the obese patients with impaired glucose tolerance, obesity surgeries have been shown to decreased the progress rate of diabetes more than 30 times. Thus, it has been seen that GB is largely effective on reversing the diabetes which has conventionally accepted as a progressive and deadly disease.

At the patients those have significantly lost weight after GB operation increasing of Adiponectin levels and muscle insulin receptor concentration and in addition decreasing of lipids and fatty acyl-coenzyme A molecules (cause to insulin resistance) have been shown. After weight loss induced by GB, insulin sensitivity measured with minimal modelling has been increased about 4-5 times. Decreasing of diabetes can be commented to weight loss which it’s impact on insulin sensitivity increasing is well known, thus glucose toxicity and lipotoxicity are decreased and cell function is improved.

After GB has adjusted the insulin secretion effect, positive changes occure at intestine hormones. Ghrelin is a hormone which has decreasing probability after the surgery, altough Ghlerin stimulation creates create induced hyperglycemia at humans, it supresses the insulin levels. Glucagon Like Peptide-1 (GLP-1) hormone and Glucose-Dependent Insulinotropic Polypeptide (GIP) are classical incretins which have stimulated the insulin secretion againts the enteral foods. After GB, the foods have gone down to stomach, more easily reach to the last intestine by skipping a part of upper bowel. Greater postprandial bolus of the foods after GB, raises the GLP-1 levels. Peptide YY (PYY) has been shown to decrease eating and body weight at humans. Since this is also a last intestine hormone, it’s levels increases after GB, particularly after the meal has been eaten and this is considered to help to the weight loss.

In brief; the mechanisms those can explain the weight loss and improved glucose tolerance after GB are :

1. Stomach volume decreasing that causes to early fillness, small meal porsions and negative conditioning

2. Impairing of the Ghrelin secretion due to mechanisms those can not be exactly defined and bypassing of the upper bowel that creates light malabsorption

3. Increasing of the PYY and GLP-1 and acceleration of the foods to reach to the lower bowel

4. Dumping syndrome formation due to intake of concentrated carbohydrates can contribute to the weight loss at some people.

Assoc. Prof. Halil Coskun M.D. www.halilcoskun.com

Vitamin and Mineral Using After Gastric Bypass Surgery

Vitamin and mineral deficiency is a situation that frequently encountered but easily can taken precautions at the patients those have underwent Gastric Bypass surgery.

Iron, Folic acid, Vitamin B 12, Calcium and Zinc deficiencies are encountered more frequently. The list of necessary vitamins and minerals and their daily doses have been given following. You can find all of these drugs from the local pharmacies or vitamin support products selling stores.

If you have trouble to find, then we definitely suggest you to contact with your doctor.

COMPULSORY	DOSAGE/DAY
Multi-Vitamin and Mineral	1-2*
Vitamin B12	500 mcg**
Iron	27-28 mg
Vitamin C	500 mg
Calcium Citrate by Vitamin D	1200-1500 mg
OPTIONAL
Zinc	10-20 mg
Laxatives (Stool Softeners)	Constipation depending on iron intake

* Multi-vitamins and minerals should be taken as 1-2 tablets a day with meals.

** 500 microgram tablets or monthly applicable 1000 microgram injectable (injection) forms are available for Vitamin B12 intake.

More than one equivalents of drugs mentioned above belongs to the various companies are available. Your doctor will prescribe you a suitable one among them.

Assoc. Prof. Halil Coskun M.D.