Side Effects after WLS

[Guest guest]

Side Effects after WLS

These are some problems that patients may experience that do not

fall into the medical category of " complications. " Nevertheless

they arise as issue that some patients have to deal with, so we aim

to provide proactive information.

Dumping Syndrome

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.

Mineral absorption

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 (you guessed it) 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 intolerance

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 6 months after

surgery.

Hibernation syndrome

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 2 weeks when

the body figures out how to use fat as its main energy source.

Hair loss

Most patients notice some increase in hair loss around 3-5 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:

The most effective way to increase protein intake is to eat more

frequently (in fact, many dieticians erroneously advise bariatric

patients to eat 8-10 small meals per day).

Frequent eating is the only way to " defeat " the calorie restriction

of a surgically intact gastric bypass - it is possible to " graze "

your way to a calorie intake that will keep you from losing weight.

The capacity of the pouch and small intestine are so small that

patients lose weight no matter how frequently they eat for the first

couple of months, but the capacity naturally increases over a period

of months so that if bad habits (eating frequently) are established,

then long term weight loss will not proceed as far as it could.

We advise patients to eat no more than 3 meals per day (not more)

and to concentrate on healthy food - adequate protein intake will

come naturally if they comply with these simple rules. We also

strongly believe that patients should begin to learn to take eating

cues from the little stomach pouch. Therefore, if our patients are

not hungry they are advised not to eat, even if they don't eat for a

day or two (hydration does remain important).

Excess skin

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 (we don't share this opinion). Translation: " cosmetic " =

insurance 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.

Gallstones

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 - 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.

Depression and psychological distress

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 - 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/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.

If any of this issues rings a bell with you, it is definitely in

everyone's interest to get your particular issues addressed before

taking the leap into WLS.

Marital and Relationship distress

Every interpersonal relationship in which the patient participates

will change substantially as the dramatic weight loss occurs. This

change will affect all relationships, but the marital relationship

is one of the most significant - 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 the patient

desires to leave the marriage and in other cases this creates a

crisis in confidence for the spouse. 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. 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.

On a more favorable note, the marriage appears likely to survive in

most cases where the patient was of normal weight at the time of

marriage.