Please pardon the broken pictures

I’m currently in the process of fixing my Google Picasa Albums, which is where a majority of my pictures come from.  I had to delete 3,500 pictures and re-upload them…it’s a lot of work.  In the meantime, my blog suffers because I have broken pictures.  Please disregard the broken pictures if you see any.

Gastric Bypass Surgery, an Effective Resolution to Obesity

Introduction
Obesity is a severe medical condition where a person’s BMI exceeds 40.  Being overweight or obese may cause a person to suffer from conditions such as high blood pressure, heart disease, and depression (Mayo Clinic Staff, 2015).  When a person has made many attempts to lose weight and failed, often a primary care physician will refer a patient to a surgeon for consultation for a weight loss surgery.  Gastric bypass surgery is just one of the surgeries for which a primary care physician may make a referral.  While there are risks involved, like malnutrition or injuries during surgery, there are a plethora of rewards including a 81% to 95% weight loss in laparoscopic and a 67% average weight loss in open gastric bypass surgeries (Pories, 2008; Allergan, 2008).  Gastric bypass surgery (or Roux-en-Y), whether laparoscopic or open, is one of the most effective weight loss surgeries.

Criteria
The goal for gastric bypass surgery is for a patient to reduce his/her weight to meet a normal BMI of 18.5 to 24.9 (CDC, 2012).  To qualify for gastric bypass surgery, a person must have a BMI of 40 or more (generally with 100 or more pounds to lose).  A patient with a BMI of less than 40 may still qualify for the surgery if there are other health conditions involved, like sleep apnea, type 2 diabetes, or heart disease (Rogers, 2015).  In addition, a patient should reach out to his/her insurance company to confirm the surgery will be covered or if it will need to be paid out of pocket.

Pre-operation
After a consultation with a surgeon, a patient will be required by his/her insurance or his/her surgeon’s office to complete certain tasks.  This may include a physical exam, blood and other tests.  These tests are to ensure a patient is healthy enough to undergo surgery.  Nutritional and post-op care classes are required to teach the patient how living after surgery will be different than now.  A psychologist may also be required because of the emotional changes that occur after the surgery (Rogers, 2015). 
Each facility and each surgeon will have their own requirements before completing the surgery.  In addition, insurance companies will have their own requirements, too.  For example, CHRIAS (Christiana Institute of Advanced Surgery) requires an educational seminar, where surgeons and other people who have had the weight loss surgery will speak about the surgery and outcomes, and a consultation with a surgeon to discuss which surgery would be best (Irgau, 2015).
After the consultation, CHRIAS requires lab work to be done within two weeks to ensure the patient is healthy enough to go through surgery.  Nutrition classes are required to teach the patient how to live after the surgery.  An endoscopy will also need to be done to confirm the patient does not have H. Pylori, which is a bacteria that causes ulcers in the stomach.  An estimated six months before the surgery, the patient will need to visit a pulmonology and cardiologist to have sleep studies and stress tests done respectively to confirm the patient will be able to undergo anesthesia without difficulties.  CHRIAS will also refer a patient to a nurse practitioner, a dietitian, and a psychologist (Irgau, 2015).
In addition, insurances may require several months of follow-up with a physician to ensure weight loss during the pre-operative phase, like BlueCross BlueShield, or two years of weight loss history, like Aetna or Core Source.  There is one final office visit with the surgeon, where the patients picks up a two week supply of OPTIFAST, a meal replacement to assist with fat and liver reduction that will make surgery easier.  The surgery will be scheduled three-to-four weeks after the final office visit (Irgau, 2015).

How is the Surgery Performed?
After being placed under general anesthesia, the surgeon will either make one large cut (open gastric bypass) or several small incisions (laparoscopic gastric bypass).  In laparoscopic gastric bypass, a tiny camera in inserted in the incision and connected to a video monitor so the surgeon can perform the surgery.  The next step is to reduce the size of the stomach to about one ounce by separating the upper section and lower section of the stomach with staples.  Finally, the surgeon will connect the small intestine to a small hole in the new stomach.  See Figure 1 for a visual of the new stomach after surgery.  The surgery generally takes between two and four hours.  After the surgery a patient will be placed in a recovery room, then his/her own hospital room.  They should expect to be asked to walk several times throughout the day to assist with gas in the stomach (Rogers, 2015). 

Risks
While there are a plethora of benefits to the gastric bypass surgery, there are also risks involved.  During the surgery a patient is placed under anesthesia.  While under anesthesia, a patient may have an allergic reaction and breathing problems.  This usually occurs if the patient has never been under anesthesia and doesn’t know how his/her body will react before the surgery.  During the surgery, there is also a chance of bleeding, clots, and infection because of the blood loss and injuries to organs during surgery.
After the surgery risks can include stomach problems, like heartburn, ulcers, and gastritis.  Post-operation risks can also include malnutrition due to not eating enough or getting the proper vitamins and vomiting from overeating or scar tissue build-up blocking bowels (Rogers, 2015).  Age, procedure type, and patient risk all play a part in the complications that could also occur during surgery like hemorrhaging, arrhythmias, pulmonary emboli, and anastomotic leaks (leaking from the stapled area of the stomach due to not healing properly) (Pories, 2008).  It is extremely important to report pulmonary emboli and arrhythmias to the surgeon right away because they are the suspected risks associated with mortality rates in bypass patients (Pories, 2008).  While the risk of death due to surgery is low (about 0.50%), it is important to note that it does occur, but there are precautions to take to prevent health risks after surgery (Allergan, 2008).

Post-operation
The quality of life post-op dramatically increases in obese people.  Type 2 diabetes sees a rapid remission.  In addition, a patient suffering from pseudotumor cerebri, hypertension, asthma, and reflux will see an immediate, positive change in his/her condition, often no longer needing medications.  Diseases like chronic obstructive pulmonary disease, cardiac diseases, atherosclerosis, Pickwickian syndrome, and many cancers also see a total remission.  Infertility declines and arthritis in the joints decreases (Rogers, 2015).
Many positive outcomes come from having the gastric bypass surgery; however, there is maintenance that needs to be followed in order to ensure continued success.  Portion sizes will be incredibly smaller, and will need to stay small for the rest of the patient’s life.  Not only do the portions need to be small, but the food needs to be healthy.  Exercise should also because frequent in the patient (Rogers, 2015).  Also, to prevent malnutrition, a patient will need to take a multivitamin, plus iron, calcium, and vitamin B12 for the remainder of his/her life (Schauer et al, 2000).  A patient will also be required to consume between 70 and 100 grams of protein daily (PMRI, 2012).
After surgery it is recommended that women avoid pregnancy for 18 to 24 months after the surgery.  This is recommended as rapid weight loss can negatively affect the unborn child.  Also, alcohol should be avoided after surgery as there is an increased chance of liver disease post-op (Irgau, 2015).  It’s also recommended to wear a medical ID bracelet after surgery with the surgery date, type of surgery, and listing no NSAIDs (anti-inflammatory drugs), and no blind NG-tubes (a tube that carries medicine and food through the nose and to the stomach) (Irgau, 2015). 
Depending on where the surgery is performed, a surgeon may have different follow-up requirements.  CHRIS requires a follow-up with the surgeon six weeks after surgery, then three months, six months, nine months, twelve months, eighteen months, then each year after that (Irgau, 2015).  At one year post-op, a patient can expect to have lost 67% of his/her excess weight and, at five years after surgery, a patient can expect to have lost 58% of his/her excess weight (Allergan, 2008).

Research
Like many other medical techniques, research is continuously being done on gastric bypass and other weight loss surgeries.  Research was done at Cleveland Clinic’s Bariatric & Metabolic Institute regarding single incision laparoscopic surgery (SILS).  Fourteen patients underwent laparoscopic gastric bypass surgery.  After four months, the average weight loss was 45.4 pounds.  Before a full analysis can be determined, additional research with larger groups will need to be done, however it’s safe to say that this surgery lessens pain post-op, leaves the patient with less scars, and gives a high satisfaction in those who underwent surgery (Zepeda Mejia, 2015).
Ersoz et al (2015) writes about the effect gastric bypass, especially laparoscopic, has on type 2 diabetes.  A 38-year-old woman with type 2 diabetes mellitus has uncontrollable blood glucose levels.  Medical treatment has previously been attempted, but did not work.  After having the laparoscopic gastric bypass surgery the woman’s symptoms improved within 10 months (Ersoz et al, 2015).
Research was also done in Spain on the effect gastric bypass surgery has on adolescence.  A BMI reduction from 58.5 (average) to 22.4 (average) was shown after five years.  In a 5-year follow-up, it shows that gastric bypass surgery is an effective way to reduce obesity in children and young adults (Carbajo et al, 2015).
In addition to research that has already been performed, future research is always being conducted.  It was speculated that gastric bypass surgery had an effect on the brain and how patients perceive food after the surgery.  In a study conducted on rats, it was shown that brain activity is affected by the surgery in areas of the brain related to reward and taste-related behaviors.  Additional research will need to be completed in a human study (Thanos et al, 2015).
The University of California San Francisco’s Division of General Surgery also completes several trails.  Currently, the university is running two studies, one regarding the sensitivity to insulin after gastric bypass surgery, where there is a desire to understand the effects the surgery has on insulin sensitivity and hormone secretion in the stomach.  They’re also completing a study on what is factored into poor weight loss after the surgery.  Ten-to-fifteen percent of patients suffer from poor weight loss after surgery and while there are speculations like diabetes and a larger new stomach size that affect it, further research needs to be completed (UCSF, 2015).

Conclusion
Obesity is a severe disease that should not be overlooked.  After consulting with a primary care physician, a referral to a surgeon may be written to discuss gastric bypass surgery, a technique best in reducing excess weight.  After completing required pre-operative criteria assigned by the surgeon, either a laparoscopic or open surgery will be performed.  While risks are possible after surgery, the remission of diseases caused by obesity outweighs the negatives possible during surgery.  Research continues on weight loss surgeries to continually better surgeons and surgery outcomes.  A patient can expect up to 67% of his/her excess body weight to be lost after surgery, making gastric bypass surgery the most effective weight loss tool (Allergan, 2008).

References
Allergan, Inc. (2008). The lap-band system – a comparison of feature and outcomes with roux-en-y gastric bypass and laparoscopic sleeve gastrectomy. Lap-Band System.
Carbajo, M. Á., Vázquez-Pelcastre, R., Aparicio-Ponce, R., de León, E. L., Jiménez, J. M., Ortiz-Solorzano, J., & José, C. M. (2015). 12-year old adolescent with super morbid obesity, treated with laparoscopic one anastomosis gastric bypass (LOAGB/BAGUA): A case report after 5-year follow-up. Nutricion Hospitalaria, 31(5), 2327-2332. doi:10.3305/nh.2015.31.5.8884
CDC. (2012). Defining adult overweight and obesity. Division of Nutrition, Physical Activity, and Obesity. Retrieved from http://www.cdc.gov/obesity/adult/defining.html
Mayo Clinic Staff. (2015). Obesity. Mayo Clinic. Retrieved from http://www.mayoclinic.org/diseases-conditions/obesity/basics/definition/con-20014834?p=1
Ersoz, F., Duzkoylu, Y., Deniz, M. M., & Boz, M. (2015). Laparoscopic Roux-en-Y gastric bypass with ileal transposition – an alternative surgical treatment for type 2 diabetes mellitus and gastroesophageal reflux. Videosurgery & Other Miniinvasive Techniques / Wideochirurgia I Inne Techniki Malo Inwazyjne, 10(3), 481-485. doi:10.5114/wiitm.2015.54224
Irgau, I., Wynn, G., & Peters, M. B. (2015). Weight loss surgery guide. Christiana Institute of Advanced Surgery. Wilmington, DE: Christiana Care.
PMRI. (2012). Gastric bypass life skills. Christiana Care Health System Bariatric Surgery Program, p. 2-72.
Pories, W. J. (2008). Bariatric Surgery: Risks and Rewards. The Journal of Clinical Endocrinology and Metabolism, 93(11 Suppl 1), S89–S96. http://doi.org/10.1210/jc.2008-1641
Rogers, A. (2015). Gastric bypass surgery. MedlinePlus. Retrieved from https://www.nlm.nih.gov/medlineplus/ency/article/007199.htm
Schauer, P. R., Ikramuddin, S., Gourash, W., Ramanathan, R., & Luketich, J. (2000). Outcomes After Laparoscopic Roux-en-Y Gastric Bypass for Morbid Obesity. Annals of Surgery, 232(4), 515–529.
Thanos, P. K., Michaelides, M., Subrize, M., Miller, M. L., Bellezza, R., Cooney, R. N., & … Hajnal, A. (2015). Roux-en-Y Gastric Bypass Alters Brain Activity in Regions that Underlie Reward and Taste Perception. Plos ONE, 10(6), 1-19. doi:10.1371/journal.pone.0125570
University of California San Francisco. (2015). Bariatric surgery research. Division of General Surgery Bariatric & Metabolic Surgery. Retrieved from http://bariatric.surgery.ucsf.edu/research.aspx
Zepeda Mejia, I. A., & Rogula, T. (2015). Laparoscopic single-incision gastric bypass: initial experience, technique and short-term outcomes. Annals Of Surgical Innovation & Research, 91-6. doi:10.1186/s13022-015-0016-z

One Month Post-op

The last month has been insane, to say the least.  For a full week, everything I ate for dinner I threw up.  There’s been days where I’ve hated the surgery and days where I’ve loved it.  Today is just neutral.  I’ve been able to eat normally…drink normally.  I’ve lost 35 pounds (since April, when I started the whole process).

I finally went back to work.  That’s been the hardest part.  I get nauseated easily.  There is food everywhere.  Twice since I’ve been back they’ve offered free food days, including a huge barbecue for the department and I couldn’t eat anything.  That’s probably the hardest part.  I’m still on pureed foods for another two weeks.  I’m getting tired of cottage cheese and yogurt and jello and popsicles and all the same consistency foods.

Our pool still hasn’t been set up yet.  Now we need to find a truck to get sand to our house.  Then, we need to level the sand.  Then, we need to put the pool up.  Then, we need to make sure the pool is level.  And if that we’re enough, then we put 1-2 inches in the pool, smooth out the interior and make sure it’s level, too.  Sigh.  It’s going to be a while.  I was cleared for pool swimming last Monday.

Yesterday, Hubby and I took Beckett to Fishing Creek, where Tulia and I spent a lot of our childhood.  Beckett loved it!  He was staring out the window the whole time and every time we drove over the water he got so excited.

Two Week Follow-up

I visited with the surgeon today.  Everything is going great!  I’m down 29.1 pounds.  My incisions are healing nicely.  I mentioned to Dr. Peters that every time I took the Lovinox shot I would get heart palpitations.  I’ve also been getting them when I get up and move around a lot (like when we go grocery shopping).  He approved me to stop the Lovinox shot, but said I need to make sure I walk a lot and drink a lot.  He also cleared me to start my pureed diet!  I’m so excited I can eat other foods.

I’m no longer taking the Verapamil, so right now I’m taking:

  • Acetazolamine (500 mg/2 times daily) — for my pseudotumor cerebri
  • Alprazolam (0.5 mg/as needed) — for my anxiety
  • Carvedilol (25 mg/2 times daily) — for my heart conditions
  • Omeprazole (40 mg/1 time daily) — for GERD, will be on for 6 months
  • Ursodiol (500mg/1 time daily) — for gallstones, will be on for 6 months

I’m also taking some vitamins:

  • Calcium (citrate) — 1200 mg
  • Multi-vitamin — 1200 mg
  • B12 — 500 mg
  • Iron — 325 mg
  • Vitamin D — 4,000 iu

I go back in to see Dr. Peters in a month!  I hope things are going just as well then.

Two Weeks Post-op

Life has been pretty crazy since the surgery.  Making sure I take my medicines (gall bladder, heart, blood pressure, blood thinner, stomach, migraine), making sure I take my vitamins (vitamin d, b12, calcium, iron, multi-vitamin), making sure I get enough protein (80mg a day), making sure I get enough water (64oz a day).  It is all over whelming, especially with my emotions running high.

Depression is kicking my ass.  My therapist is very adamant that I see a psychologist to get some sort of anti-depressant.  I haven’t looked anymore into the psychologists she recommended.  She wants me to talk to my primary at my visit with him next week to get a referral from him since her’s have all but failed.

I took the bandages off my incisions the day before yesterday.  Three of five of them are almost completely healed.  They look really good.  They’re only covered with band-aids now.

I’ve been weighing myself daily; it’s been 0.5-1.5 pounds a day loss, but today there was no weight loss.  I told myself if I gained or didn’t lose I’d start weighing myself once a week.  So, I’ll be weighing myself every Sunday going forward.  I’m down 26 pounds (since I started my journey in April) and about 19 since the surgery.

7 Days Post-op

Sigh.

I know this is suppose to be a good thing.  I know this is suppose to make my life healthier, but right now I’m so far stuck in a freaking depressive state I can’t see the light.  I wish I never had the surgery.

Yesterday I had my first experience with dumping.  Yay!  Only six days out…that makes the probability of dumping in the future all the more possible.  Especially since I hadn’t eaten anything I hadn’t eaten before.  All I’m getting is like 1/2 a pudding cup and a package of grits and maybe a popsicle or some fruit juice.  Everything else is my medications.  I’m literally taking 6 medications and 3-4 vitamins.  And I have to take them 7 times a day between the 9-10 of them.  Taking them makes me gag…I purposefully skipped a couple of them yesterday evening.

Today I woke up with nose bleeds thanks to the blood thinner I’m on…and have to stay on for the next freaking month.  And I’m not 7 days out for that, I’m only 4 days out for that because they gave me 3 while in the hospital.  Food doesn’t even taste the same.  I tried yogurt today and it tasted gross.  Everything sweet tastes SUPER sweet and everything salty tastes SUPER salty.  It’s not like I can go back and change my mind now…wish I could though.

5 Days Post-op

Waiting room selfie…last selfie one before surgery

Today marks day 5 since I had my surgery. I’ve basically been sleeping all day and been kind of sore. The pain medicine they put me on makes me sleepy and itchy. So, not only is my stomach itchy from healing, but I’m extra itchy from the pain meds. They have me on Oxycodone because I get all weird on Tylenol with Codine.

I was in the hospital for 3 days and 2 nights.  The first day I was there the nurses were really attentive and made sure I was feeling okay and if I needed anything they were right there…even when I had to pee every hour and a half.  The second day and third day were just…ugh.  I would have been better if I’d gone home.  I went an hour without any pain medicine at all because a nurse wouldn’t answer my call.

Flowers from my Mommy and Daddy and my siblings

Michael ended up taking care of me and assisting me to the rest room and on my walks because we could’t get a nurse.  By the time the third day came around, I wanted to go home so bad.  I asked to be discharged at 8:00AM and we didn’t get out of there until 12:00PM.

My mom came to visit me in the hospital.  Also, Scottie and my Uncle Sean.  Mommy gave me flowers, and also gave flowers from my siblings and Scottie.

The worse part of being in the hospital was the IV.  I ended up having four IV locations.  I have lovely bruises all over from getting stabbed with the IV, the anti-nausea medication, and getting blood work done.  They stabbed both of my hands, then the inside and outside of my left forearm.

My four IV locations

Since I came home, I’ve slept and slept and slept.  After we left the hospital, we went to Redner’s Warehouse Markets to get some essentials we forget…

  • Bandage tape
  • Gauze
  • Pads (because of course Aunt Flo came to visit right after my surgery)

Today, I went grocery shopping, but didn’t take my pain medicine before I went and I felt it by the time I got home.  I managed to get my walking in through, and I got some more stuff for the liquid stage:

  • 1% Milk
  • Soy Milk
  • Yoplait Greek 100s
  • Yoplait Yogurts
  • Grits
  • Cream of Wheat
  • Watermelon
  • Bananas
  • Re-fried beans
  • Pill cutter

The great thing is, I had coupons for everything except the Cream of Wheat, grits, and produce.

My mini garden with cucumber, squash, zucchini, and tomatoes

Also, the day before my surgery I made a trip to Walmart for a couple of things we didn’t have:

  • Trowel — for my new garden
  • Hand Sanitizer
  • Hangers — to hang up all my donated clothes, so they’re not sitting on my office floor
  • Ice cube trays — to freeze soups in serving sizes
  • Square cake pans — to put jello in
  • 1 Gallon pitcher — to make some of my Crystal Light

I’m hoping after all these trips I’ll have everything I need going forward…although I do have a prescription ready to pick-up at Rite-aid.

OPTIFAST Pre-op Liquid Diet Week 2

My surgery is tomorrow.  Less than 24 hours away.  I’m severely considering canceling it.  I won’t because I want this more than anything.  I’m on the verge of losing my job because of it.  My health is in question because of it.  My mental state is in question because of it.

This last week has been better, but only because I cheated.  I ate food I wasn’t suppose to.  Three times.  I had panic attacks thinking the doctor wouldn’t perform the surgery, but the reassurance of the people in my support group made it okay.  I’m fucking starving.  I’m so hungry I want to hit something.  I want to kill something.  It’s my 2 year wedding anniversary today and I don’t even want to look at my husband because I’m just ravenous.

OPTIFAST does not taste good.  It tastes like rotten milk.  Then you drink you shake and in 5 minutes you’re rushing to the bathroom to prevent an accident in your pants, which by the way has happened twice.  Embarrassing…

I just want to curl up in a corner and sleep until the surgery time.  And I still have 3 shakes and a soup today…I don’t know if I’m gonna be able to keep them down because I feel like if I eat any more of these I’m going to hurl.  Just the thought makes me gag.

I’m hiding out in my office while my husband and my best friend enjoy their pizza.  I can smell it and it’s make it so much worse.

This is the reason I’m not seeing the therapist this week too, because I’m pretty sure she’d have me committed.

More tomorrow after my surgery when I’m groggy instead of bitchy.