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.

Gastric Bypass Surgery Complications

Early Period Complications

Bleeding : Post operation may be bleeding from mesentric or omental vessels or from anostomosis stapler line into peritoneal cavity. The incidence is 0 – 4 %. The bleedings occuring by anostomosis line can be endoscopically identified and treated.

Anastomosis Leakage : This is the most to be considered among the complications. It can emerge at a very early period such as can be seen 5th day after the surgery. The incidence differs between the rang of 0 – 4.4 %. Tachycardia (over 120 minutes), tachypnea, high fever and oxygen saturation reducing those have developed at the patient post operation may be the signs of anostomosis leakage. In such a case it is necessary to assess the patient quickly and take abdominal CT and US if necessary and to define the location and the level of anostomosis leakage. Drainage, antibiotics treatment and surgical treatment when necessary must be applied.

Wound Infection : Wound infection is seen less at laparoscopic operations than open surgeries. Wound infection is less from 5% at the laparoscopic operations whereas this rate differs between 6-10 % at the open surgeries. These are easily recover with antibiotics treatment.

Thromboembolism : The more you have BMI value, the more you have risk of venous thromboembolism. Low molecule weight heparin assays those will begin at the operation day will be decrease this risk. Thrombosis development risk at the deep veins after Gastric Bypass operation is 0 – 1.3 % whereas pulmonary embolism risk is 0 – 1.1 %.

Anastomosis Stricture : Anostomosis stricture is seen at the range of 2-16% postoperation. The reason is depending more on experience of the surgeon performed the operation and the technics used for the anostomosis (hand-swen, lineer stapler or circular stapler). Marginal ulcers those have developed as a result of ischemia depending on the stress at the anostomosis line play important role at the stricture forming. The stricture reveals itself as nausea and vomiting at 3 months after the surgery. More than 85% of the anostomosis strictures can be treated by endoscopic dilatation.

Late Period Complications

Marginal Ulcer : This ulcer which has developed post operation is mostly occurs at GJ (gastrojejunostomy) line and generally at the jejunum part. The ischemia depending on the stress at anostomosis line and foreign materials (circular stapler metals and nonabsorbable suture materials) those have been used at this area have important role at forming of the marginal ulcer. On the other hand, nonsteroids anti-inflammatory (NSAID) drug using, smoking addiction and intense acid reflux at anostomosis area depending on gastrogastric fistula development are efective on the marginal ulcer development. Anemia as a result of abdominal paint, nausea-vomiting and sometimes bleeding is seen at these patients. Marginal ulser development is between 0.7 – 5.1 %. Drugs to prevent acid-forming, NSAIDs and giving up smoking are suggested for treatment. Rarely surgical intervention may be required at resistant ulcer.

Bowel Obstruction : The most important reasons of bowel obstruction are postoperative adhesions and internal herniation. The most important reason of advanced adhesion at the bowels may be based on too much manipulation with them during the operation. This type of adhesions is seen more at the open surgery applications. And the important reason of bowel obstruction depending on internal herniation is to not close the mesentric defects at enough level. Incidence of internal herniation is about 3%.

Gallbladder Stones : Incidence of gallbladder stones incerase with weight loss after Gastric Bypass. Gallbladder stones are indicated to develop at the range of 38-52% in the first year after the operation. However at 15% part of the patients those developed gallbladder stone colecistectomy by surgical treatment is required in the first 3 years. Colecistectomy is suggested at the same time with gastric bypass application if there are symptomatic gallbladder stones identified before the operation. On the other side colesistectomy at the surgery moment for asymotomatic gallbladder stones or for gallbladder without stone is not a much accepted concept. Some surgeons suggest prophylactic colesistectomy. But the most important disadvantage of this application is to may lead to unneccessary complications (hemorrhage, biliary tract woundings, prolonged surgery time) with a different surgical application during the operation.

Vitamin (Nutritional) Deficiency : Deficiency of iron, Vitamin B12 and some other nutritional elements is frequently experienced after Gastric Bypass surgery because the large part of the stomach, duodenum and the proximal part of the jejunum have been by-passed. Single dose vitamin tablet a day shoul be taken for this. Incidence of iron deficiency post operation differs in a range of 13-52 % in 2 – 5 years period. At the persons with iron deficiency, this need is met by iron tablet intake. In 37% of the patients Vitamin B12 deficiency may be encountered although multivitamin intake and in such a case the necessary treatment is provided by B12 suplementation. Calcium deficiency is seen at 10% of the patients whereas vitamin deficiency at 51%. Except these, secondary hyperparathyroidism may also develop and particularly after early surgical treatment increase bone turnover and decreased bone density may be defined in the first 3-9 moths period.

Mortality : In a meta-analysis executed by Buchwald et al. 136 studies have been evaluated. Mortality rate in first 30 days has been defined as 0.5% as a result of investigating a group of 22.094s patients those have underwent obesity surgery. In an other study has been executed by Podnos et al. Mortality rate at the patients those have underwent Gastric Bypass surgery has been found as 0% - 0.9%. In a review at JAMA journal, in a study has been realized by Zingmond et al. after evaluation of 60.077 patients those have underwent Gastric Bypass surgery, mortalite rate has been defined as 0.33% in first 30 days and 0.91% in first year.

Assoc. Prof. Halil Coskun M.D.

Gastric Bypass Surgery

This procedure is the most used method in the world for obesity treatment. First, stomach volume is reduced, therefore the food quantity have taken by the patient is decreased. Secondly, food absorption is decreased due to shortening of the covered way in intestine.

This operation should be more preferred particularly at the patients with sweet eating (nutrition with high calorie diet) habit. Because this group of patients are nourished with small quantities but high calorie foods. Achieving enough weight loss may be problem at the surgical operations those only have restricted the food intake. Beside the stomach volume has been decreased, gastric banding operation also provides discharge of the foods without being useful for the body by affecting the absortion of the foods have been eaten.
The patients loss 70-80% of their excess weights within average 1-2 years after the operation. This result is a close to excellent outcome. On the other side, easier adaptation period for new nutrition habit has been experienced after operation.

The most important problem for this operation is that some vitamin deficiencies may occur in the upcoming days due to malabsorption of the taken foods (like vit12, folic acid, iron deficiency). But it is not encountered with a problem for this condition by the vitamins suppliments from out. Experienced surgeons inform their patients on this issue and take the necessary precautions.
Gastric bypass is the most implemented procedur in the world, particularly in the USA. Because, the weight loss and the achieved success with this procedure is higher than the other methods. But reverse of this surgery is quite difficult. It is necessary to the patients will choice this surgery to know that this is a permenant operation.

In conclusion, Gastric Bypass Surgery is an operation that has very successful outcomes for long period. Also it should be more preferred at the patients those have been fed with high calorie foods compared to other methods.

Assoc. Prof. Halil Coskun M.D.

Evaluation of the Pregnancy and Birth Outcomes after Gastric Banding Surgery

Prevalence of the obesity that has been increased at recent years present the gynaecologists with obese pregnant women’s problems. At the women’s pregnancy period, obesity causes to increasing of some risks both for the mother and the baby will new born. The most important birth problems for the mother are premature birth risk, increased problems at the moment of birth, hypertension induced by pregnancy and preeclampsia, pregnancy diabetes and excess weight gaining during the pregnancy. On the other side intrauterin growth retardation, macrosomia and fetal growth anomalies are more frequently encountered for the baby.

Here, I will try to examine the outcomes of gastric banding (staple) surgery which we have encountered as a frequently used method at obesity treatment, on pregnant obese women.

Bar-Zohar et al. (Pregnancy after laparoscopic adjustable gastric banding: perinatal outcome is favorable also for women with relatively high gastational weight gain. Surg Endosc. 2006;20:1580-3) have evaluated 74 women those have become pregnant after gastric banding surgery and defined mean gained weight as 10.6±2.1 kg in their study. All births have realized after the 39_th week and mean birth weight has been identified as 3.09±0.5 kg. Major congenital anomaly at women, post-natal hypoglycemia at babies, baby death during or after the birth have not seen. In the light of these findings the authors those have performed this study, have been stated that; pregnancy and birth after gastric banding surgery are considerable confidential both for the mother and the baby.

John D. Dixon et al. (Birth outcomes in obese women after laparoscopic adjustable gastric banding. Obstet Gynecol 2005;106:965-72) have indicated that pregnancy and birth outcomes of the women those have underwent gastric banding surgery are in compliance with values of the women those have become pregant with normal weight and as a result they have pointed out the reliability of this method on pregnant obese women. Adjustability of the staple is an important feature, because this provides the ability for adaptation of the surgery procedure as per pregnancy requirements. A multidisciplinary approach included collective collaboration of obesity surgeon and gynaecologist has been suggested after such applications.

Vejux N et al. (Pregnancy after gastric banding: maternal tolerance, obstetrical and neonatal outcomes. Gynecol Obstet Fertil 2007;35:1143-7) have made evaluation by studying on 7 papers concerning this issue. With regard to obtained data they have ben stated that gastric banding surgery is quite tolerated during the pregnancy and it could be suggested to the obese women in the age of birth child.

The studies mentioned above have showed the pregnancy problems depends on obesity may result in quite high danger. The weight loss after gastric banding which has been commonly used at recent years decrease these risks. The women those have underwent gastric banding operation and then become pregnant can complete their pregnancy process in a successful way without removed their staples and in company with the regular controls.

Assoc. Prof. Halil Coskun M.D.