Comparison of Gastric Banding and Gastric Bypass Surgeries

	Gastric Banding	Gastric Bypass
Graphical Representation
Anatomy	A band made of adjustable silicon, has been inserted around the stomach as to form a small stomach pouch of approximately 15-20 ml.	The stomach is divided into two parts as to form a pouch of approximately 20-30 ml and this small stomach is connected to the intestine.
Weight Loss Mechanism	Food intake decreases due to restruction of the stomach volume and it can be well decreased by adjusting of the staple.	Food intake decreases due to restruction of the stomach volume and also digestion of the foods decreases because of the foods have taken directly pass down from small stomach to the intestine.
Weiht Loss Rates	50-60% of the excess weight is lost at 18-24 months period.	70-80% of the excess weight is lost at 18-24 months period.
Diet and Required Life Style Changes	High calorie diet (chocolate, icecream, desert etc) should be avoided. Regular exercises should be done in the forward periods.	High protein foods must be taken in the beginning, sugar foods should be avoided (dumping syndrome) and regular additional vitamins must be taken against to lack of vitamin and minerals. Regular exercises should be done in the forward periods.
Nutritional and Vitamin Requirements	Multivitamin, Calcium (rarely)	Multivitamin, Calcium, Vitamin B12, Iron
Surgery risks	Surgery risk rate of early and late period %0-8	Surgery risk rate of early and late period %0.2-10
Eating Adaptation	May be difficult, frequently nausea and vomittings may be experienced	There is usually more qualitied and easier eating adaptation.
Technical Difficulties	No	Yes (a difficult application, more training and surgery practises are required)
Prosthetics (Foreign) Material	Yes (there is silicon material but it’s adaptation is quite good, the reservoir sometimes may create problems)	No
Reversing of the surgery	Yes	Yes (but quite difficult)

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.

Nutrition Plan After the Gastric Bypass Operation

Soon after the surgery, you need time for the internal sutures to recover. Nutrition plan that you will apply after the surgery has a great importance in digestive system’s compliance with the new way your foods will follow. Therefore, you have to comply with suggested nutrition plan from first days after the surgery.

The time for everything to be okay and for digestive system to begin working regularly include a duration of 3-6 months. Some days you can take the foods easily without any problem whereas the next day same type of foods may make nausea. This is a normal case that may be encountered during the transition period. Long-term eating discomforts are extremely rare at this operation.

Between 0 – 2 weeks

You will be able to intake the liquid foods those can pass through digestive system without have been caught. This condition should be under your doctor’s control and should begin with his/her permission. We suggest you to feed with only liquid foods in particular during this one week. These liquid foods are : water, tea (prefer sweetener rather sugar), skimmed milk, low calorie fruit juices without intense consistency, grainless crushed vegetable soups, broth and foods in puree nature with low sugar, without rough grains.

Between 2 – 4 weeks

Now, you can begin to take more from the soft foods in puree case. You should eat slowly and as 4-5 mealsa day at this period. Yoghurt, paste foods with increased fluency (boiled potato plane mixing with broth and crushing in puree case and cheese), pudding with moderate fluency and in soup consistency, diluted purees of fruits like peach, pear and apricot. During a few day, after providing a well compliance with these type of purees, again as be crushed and kept the puree consistency, protein rich foods like meat, chicken, fish, bean, lentil and egg should be added to these purees and begin to intaken. All of the foods should be paid attention to be at low fat and sugar rates.

Hardness-softness degree of your foods should be at a baby can eat. Best way to provide this is to use a puree maker tool called “blender”. It is also possible with fork and spoon provided very good crashing. Boiled vegetables can be make puree by crashing them with blender. Protein sources like egg can be mixed with these vegetables and crashed with blender after bringing them into the case that could be crashed by blender. Fruits also can be eaten by being crashed with blender. Fluids like water or juices are used to provide necessary habit level at crushing of the vegetables or fruits. It is possible to use the souces those have low fat and sugar and appropriate fluency to increase the favour.

Food intake amount; foods of 100 gram or 5-6 tablespoons are the correct amount. You should eat approximately this quantity of food at this period. Check whether you can do this or not and try to provide this food intake without forcing. A copule like potato puree with fish puree can be eaten as main course. It enough for you to be serviced by a person and two type of the complamentary food at this stage.

You should stop to eat at the moment of fullness feeling. Your new stomach is above the previous one and the fullness feeling will be occur in a more different way than you have used to. The pouch that serves as new stomach is felt at the chest area since it is next to here. Some people describe this as a “tightness” or a “heaviness”. 1.5 liter of water should be drunk everyday. This amount of water should be taken between meals spreading throughout the day as parts of 100-200 ml. It’s not right to drink water with the meal.

Sample Menu to Apply During The Period

Breakfast

A small bowl of yoghurt or

fresh curd cheese or

3 tablespoons of gruel

Lunch

A cupful of warm soup or

Whipped egg

Dinner

Potato or fish puree

Chicken at white souce

Potato puree by cheese or

Mixed vegetable puree by potato puree

Between meals (once a day will preferred)

Boiled and softened apple by cream or pudding or banana puree or

Milky pudding ( rice pudding or semolina pudding) or

Yoghurt or fresh curd cheese

Liquid Foods

Water (mineral waters or bubbly, carbonated waters are not suitable), tea, skimmed milk or

Fruit juices or

Pates producted for diet

Between 4 – 6 weeks

Continue to take the food types you have taken at first four weeks, but this time they don’t have to be in puree case. A well done chewing will bring the foods as soft as to be eaten by a new begun to walking child. Soft and same amount of foods still should be taken at 4-5 meals a day at this period. You must be sure that the bites are small and well chewed.

After 6 weeks

Now your are ready to apply the long-term nutrition plan. Don’t forget that you are no longer eating only to decrase calorie intake or to loss weight, but you should also intend to take the building bloks those your body needs bu using your current new digestive system effectively. Previously, you were taking fat and sugar as weight makers by eating much with a large stomach but there were also significant building blocks like proteins and vitamins in this eaten much amount and you were taking them enougly and overly with the fat and sugar. But now, you have to prefer and choose. When you took foods with much fat and sugar, doesn’t remains any space for more necessary protein and vitamin as well as already they can not be absorbed due to duedonum doesn’t function. Although the nutrition preferences varies from person to person some gold nutrition rules should be followed after Gastric Bypass are as folllows :

Avoid sugary foods !!!

Sugary food intake at high amounts will cause the condition that has been expressed as depression, exhaustion or weakness. Excess nausea, discomfortable feeling at stomach, diarrhea, abdominal pain and weakening will acoompany to this. When too much sugar taken, large amount of insulin will be secreted but the new digestive way after the bypass has changed response mechanism of insulin against sugar. This can be interpreted as an impotant advantage of Gastric Bypass that creates an internal hate against sugar. In such a situation you should be relax laying until the sugar quantity decreases, take liquid to reduce the solution consistency of sugar and to make it leave as soon as possible and wait the insulin level to reduce. If liquid derivatives of any drug, in particular antibiotics have been prescribed, ask to your pharmacist which ones are sugar free and choose them.

Eat three meals a day !!!

You must eat three meals a day without eating anything between the meals. Don’t allow nutrition ways those will able to emerge in form of “junk foods” or “snacking” at any time during the day.

Eat healthy, solid foods !!!

Soft foods easily slip down at the digestive system and many of the soft food include high sugar and fat, so they cause you to experience the problems we mentioned above. Besides, these soft foods slow and stop weight loss because of the high calorie they have, if they taken insistently. Solid foods should be preferred without using much sauce. Garnish vegetables can be eaten (with a soupsoon of sauce or broth) by a small piece of chicken. In this way you can stay filled for longer time by eating less and qualified.

Eat slowly and stop the eating as soon as youl feel full

Most of the obese people are those used to eat hurrying and without chewing. Eat your meal slowly. Tightness of the stomach wall tells to the brain that you are full, so you must stop eating immediately in this stuation. Otherwise you will encounter with feeling pain and risk of vomiting. You should take care to this matter. Take the foods in small bites case (meat or chicken that cut into pieces as a global rubber at behind of pencils or as a largish taw) and stop eating when you feel the fullness.

Continue to intake plenty of liquid !!!

You were taking a large amount of liquid with the foods you have eaten but now, these amounts will not be enough since you can eat only small amounts of foods. You must increase this liquid intake particularly except the meal times. You must intake liquid one hour after the meals or until remains half hour to the next meal. If you intake liquid just before the meal this time, this time you will not be able to eat. High calorie liquid foods and alcohol have not any function except to increase your daily calorie intake. These should be avoided. Women need calcium. This need can be met with skimmed milk or other dairy products. Fruit juices, paste foods, and foods those called “milk-shake” and made of milk, fruit and high sugar should be avoided. If you try at first few weeks, you will be explore that gaseous and bubbled foods discomfort and cause to nausea. The best way is tocompletely avoid them rather trying.

Healthy Diet

There are five main group of foods and a healthy diet is performed by taking appropriate amounts from the each group. These foods and the amounts should be taken are :

Protein Foods

Foods like meat, fish and bean. They should taken 2-3 times a day as 60-90 gram. You should chew well the foods like meat or chicken before swallow them.

Milk and Diary Foods

You should choose low fat cheeses from this group. You can take 1-2 times a day of 30-60 gr. Skimmed milk and low fat yoghurt should be preferred. These portions of the diary products will provide you to obtain enough calcium from the diet.

Fruits and Vegetables

Try to take 4-5 portions a day. A little water glass of unsweetened tomatoes can be considered as one portion. Salads are always tend to be easily digested. Green vegetables are also easily digested generally.

Carbohydrates

Bread, potato and grains are the mainly carbohysrate sources. They should be taken 2 portions a day. It is quite difficult to digest some foods of this group for many people have underwent Gastric Bypass. Change the soft bread made of white flour and crispy bread with whole wheat bread or wholemeal bread those can be easier digested. It will be agreeable to eat a small portion (2-3 slices) of 60-90 gr at each meal.

Fats and Sugary Foods

Use small amount of olive oil for cooking process and change the puddings with low fat yoghurt. Avoid foods like chocolate, desert and icecream those will cause you to vomit and weakness of your body.

Multivitamin Intake after Gastric Bypass Surgery

Additional vitamin intake after Gastric Bypass surgery is very important. Because it is no longer possible to intake enough vitamins from your foods. Vitanin and mineral deficiency is a complication that has been encountered after Gastric Bypass surgery but can be overcome and eliminated. Unfortunately dedinition of the vitamin level at the body is too difficult. Therefore you may experience vitamin deficiency before show it’s signs or symptoms. If you can not buy or swallow or you vomit the vitamin tablets, you must ask your doctor to provide you to take the vitamins in other format in terms of not suffer vitamin deficiency after Gastric Bypass operation.

The best vitamin and mineral source is the “HEALTHY DIET”. For example the diary products those you will eat three portion a day during your diet, will meet your calcium need (1 portion = 1/3 pt milk, match box sized cheese or 1 bowl of yoghurt)

Our Suggestion for Tablet Intake

One multivitamin tablet each day that included the followed described vitamins and minerals at defined amounts :

· Vitamin B 1 (Thiamine) : over 1.4 milligram

· Vitamin B 12 : over 1 microgram

· Folacin (Folic Acid) : over 200 microgram

· If you are prone to anaemia or weak to this or your routin blood tests show you are anaemic, we suggest you to take Iron Sulphate tablet of 200 milligram additionally

· Calcium : If you can not take the dairy products mentioned above at definite amounts for any reason we suggest you to take a calcium tablet of 800 – 1000 mg a day. These tablets are generally taken by chewing.

Assoc. Prof. Halil Coskun M.D.