These are some problems that patients may experience that do not fall into the medical category of "complications.” Nevertheless they arise as issues that some patients have to deal with, so we aim to provide proactive information.
One of the key features that helps a patient control calorie intake after Gastric Bypass is the fact that food leaves the tiny stomach pouch only into a section of the small intestine called the jejunum. This pathway for the food is the "Roux-en-Y" part of the full name for the procedure, and it matters because the jejunum is simply not made to handle concentrated calories, especially refined sugar. The effect of this is that if a person consumes sugar after a gastric bypass (such as ice cream, chocolate candy, or a soda) the presence of the sugar in this segment of intestine will create a reaction called dumping syndrome that affects the whole body.
An episode of dumping shows up as palpitations (heart racing), a sweaty and clammy feeling, cramping abdominal pain, diarrhea, and then a feeling of weakness during which the person simply must lay down for an hour or so until it passes. Dumping syndrome is not dangerous, but it feels awful. It is not exactly a side effect, in the sense that works in a beneficial way by steering patients away from that type of food.
Patients with an Adjustable Gastric Band should not have dumping syndrome. Patients who have a Sleeve Gastrectomy should not have dumping syndrome, but many patients do lose their desire or their "taste" for sweets.
The lower part of the stomach and the upper (proximal) part of the small intestine do not participate in the digestion of food after a Gastric Bypass because they are bypassed. These sections of intestine play an important part in the absorption of some minerals (Iron, Calcium, and to a lesser extent Magnesium) and vitamins (Vitamin B12 and to a lesser extent B6). In our practice, patients who have had a Gastric Bypass need to take Multivitamins with Iron twice each day, and supplemental Calcium three times each day (usually Calcium Citrate), every day for life. Up to 25% of patients also require supplemental B12, which is given as a shot once each month or as a pill taken twice each day. Rarely, patients cannot keep up their Iron stores by oral supplements and they need intravenous Iron therapy.
Although patients with an Adjustable Gastric Band should not experience any problem with mineral absorption, the practical reality is that they can also become profoundly deficient in some of the above nutrients. These deficiencies are probably due to low overall intake of nutrients. We recommend exactly the same supplements for our Band patients as for gastric bypass outlined above.
Lactose (milk sugar) is a particular type of sugar found in milk and dairy products. Absorption of lactose requires a particular enzyme that is mostly found in the bypassed segment of intestine. So, many of our patients who did well with milk before surgery find that after Gastric Bypass dairy products cause abdominal cramping and flatulence. This can be treated by Lactaid, which is an over-the-counter enzyme supplement. The bowel also tends to adapt over time and this is less of a problem in most patients six months after surgery.
Two or three weeks after Gastric Bypass or Adjustable Gastric Band, the patient’s body "figures out" that it is not going to be receiving its accustomed calories for a long time. In about half of our patients this results in what we call the hibernation syndrome, where one’s body falls back on its built-in evolutionary response to a low food supply. The person just wants to rest and be as still as possible until the food returns. Energy level drops through the floor, and the patient can become emotionally labile (tearful or irritable). There can also be a component of depression caused by the loss of the previous relationship with food. This syndrome can be unnerving for patients because it comes at a time when they are just beginning to get over the pain and other effects of surgery. They believe they should be feeling better but they just want to curl up and go to sleep. The good news is that this is not a dangerous or unusual thing, and will resolve in about two weeks when the body figures out how to use fat as its main energy source.
Most patients notice some increase in hair loss around three to five months following surgery. For some patients the amount of hair loss is dramatic. They describe clumps of hair in their brush, hair covering the floor of the shower, etc. This occurs as part of the body’s response to sudden calorie and protein deprivation just after surgery. The body puts some of its normal maintenance activities on hold until nutrition is coming in again, and the effects take a few months to show up. In fact, nothing actually happens to the hair follicles except that they go to sleep, and at the time the hair loss is noticed the follicles are probably busy regenerating hair. It is rare for patients to have thinner hair one year after surgery than what they began with. In fact, at 18 months after surgery most patients have fuller and healthier hair because the body’s hormone balance has been significantly improved.
Many bariatric surgeons advise their patients to maximize protein intake to prevent or treat hair loss. We agree that the food that the patient eats should focus on protein (don’t waste space on non-protein calories), but we advise against setting a specific protein goal because of the following:
Unfortunately, the skin that holds all of your fat tissue before the surgery tends not to shrink down as the fat goes away. Most patients are left with large floppy areas of skin, especially on the abdomen, upper arms, thighs and breasts. Exercise is very important for the patient’s overall success, but to be honest, it is not very effective in causing shrinkage of skin. Actual removal of the skin by plastic surgery is frequently desirable, although most insurance companies view this as cosmetic surgery in the vast majority of patients and so won’t pay for it. We recommend that our patients wait at least one year following the gastric bypass to undergo surgery for removal of excess skin. This delay is because the skin surgery works best for the long term if it is done when you are at a stable weight. It’s disappointing and counterproductive to undergo surgery and then develop more flabby skin as weight loss progresses. Also, the skin may shrink a bit and does not finish shrinking until about 18 months after surgery. We also feel more confident that patients are nutritionally up to surgery when their weight is stable.
Cycles of weight loss and weight gain predispose to formation of gallstones, so many patients who undergo bariatric surgery have already had their gallbladders removed. For patients who still have their gallbladder, we will check it during the operation and if we find stones we will plan to remove it. If a laparoscopic approach is planned we will check by ultrasound before the surgery. If the patient’s gallbladder is normal we will leave it alone; however, the rapid weight loss creates increased risk of forming gallstones during the time period after gastric bypass so we will ask you to take Actigall (a bile thinning medicine) for six months after surgery.
Consider how deeply intertwined food is with many American social functions ranging from weddings to funerals to just going out. People who undergo bariatric surgery do not function normally in these food-oriented situations, as they are not able to occupy themselves with food and must learn new ways to occupy themselves socially. Not only do patients face the stress of choosing and implementing new life patterns, they may also mourn the loss of the relationship they had with food. Some patients are addicted to food, and they may be at risk for trading one type of addition for another such as alcohol or gambling when the food addiction can’t be satisfied. Some morbidly obese patients have been subject to sexual abuse as children, and the fat serves them as a protective barrier from others. It is in everyone’s interest to get your particular psychological issues addressed before taking the leap into WLS.
Dramatic weight loss in a patient will affect all interpersonal relationships, but the marital relationship is one of the most significant. In fact, a very high percentage of WLS patients get divorced within the first two years after weight loss surgery. The patient generally becomes more outgoing and socially involved as weight loss progresses - in some cases this creates a crisis in confidence for the spouse, and in other cases the patient desires to leave the marriage. We do not have a solution to this problem, except to strongly encourage patients and their loved ones to consider the upcoming stress before surgery. The marriage appears likely to survive in most cases where the patient was of normal weight at the time of marriage; however, if the marriage is not a strong one, the couple should engage in marriage counseling before the weight loss surgery. Other interpersonal relationships can experience unexpected changes as well. More than one mother or child of a patient has expressed regret over the loss of “the person they knew.”
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