• MBSAQIP Bariatric Surgical Risk/Benefit Calculator
• Introduction
• Magnet
• Mortality
• Leaks
• Damage to Surrounding Organs
• Bleeding
• Risks of Blood Transfusion
• Heart Attack
• Pulmonary Embolism
• Kidney Failure
• Pneumonia
• Gallbladder Complications
• Bile Reflux
• Bowel Obstruction and Internal Hernia
• Abdominal Wall Hernia and Hiatal Hernia
• Acid Reflux
• Marginal Ulcer
• Stricture
• Wound Infection
• Electrical Burn
• CO₂ or Air Embolism
• Nerve Damage
• Nausea and Food Intolerance
• Changes in Bowel Habits
• Fatigue
• Vitamin Deficiency
• Mood Changes and Suicide
• Alcohol and Substance Abuse Disorder
• Impact on Social Relationships
• Hair Loss and Loose Skin
• Excessive Weight Loss and Weight Regain
• Lap Band Specific Complications

MBSAQIP Bariatric Surgical Risk/Benefit Calculator

The American College of Surgeons runs a national bariatric surgery quality/accreditation program called MBSAQIP which has a free online bariatric risk/benefit calculator. All patients are encouraged to enter their specific factors and discuss with our team.

Introduction

With surgery on the near horizon, its time to ensure you fully understand the risks associated with the metabolic surgeries.  The benefits of metabolic surgery are significant.  Your surgical team will not proceed unless its felt the benefits out weight the risks of surgery. Its important that you understand the the average risks for the average metabolic surgery patient.  Upon completion of our pre-operative work up you will have an opportunity to discuss specific factors related to your current medical condition with your surgical team, and what if any effect that will have upon your risk.  During your work up process the surgical team will have done their best to identify and optimize any medically correctable conditions and induce pre-operative weight loss in order to reduce your risk of complication from your metabolic  surgery.  This site will cover risks associate with all of the metabolic surgery procedures.  This material also covers risk related to revisions or corrective metabolic surgery.  Keep in mind that revisional or corrective metabolic surgery is higher risk than primary metabolic procedures being done for the first time.  The surgical literature suggest this increased risk can be up to three to five time the risk of the original primary operation which will be the focus of the statistics presented in this material.  

At the end of the preoperative visit you will be asked to sign a operative the consent form.  It is our expectation that you do not sign until you understand these risks, have asked any and all questions, and wish to proceed with this procedure. 

 Remember this is an elective procedure.  There are medical alternatives to surgery, and you should not proceed unless you are doing so deliberately based upon your own decision making and careful research.

No matter which specific metabolic  surgical procedure you have chosen your surgeon will attempt to preform this through a laparoscopic approach.  The goal is to accomplish this in the safest and most minimally invasive method as possible.  Most cases will be done through standard laparoscopic techniques where there are multiple small incisions.  If conditions are right we will consider using a reduced number of  small incisions.  In order to accomplish this we occasionally employ the use of specialized equipment which may include but not be limited to included: magnets for retraction,  robotics, and single incision platforms.  In rare cases an open incision could be required.  This typically involves a incision from the breast bone carried

 down to near or below the belly button.  When an open incision is required in patients struggling with weight there is an increased risk of hernia and infection in the wound.  

 At the time of your operation your surgeon will first assess the overall condition of your abdomen.  If deemed medically necessary we may need to to additional procedures to prevent further complications.  The most common include:

1. Hiatal hernia repair – The associated risks with a hiatal hernia repair include, but are not limited to injury to the esophagus, dysphasia (difficulty swallowing) and hernia recurrence.

2. Abdominal wall hernia repair 
3. Lysis of Adhesions – This means to break up scar tissue from previous surgery or previous inflammation. The associated risks include but are not limited to unrecognized injury to the bowel causing leakage

4. Removal of the gallbladder 
5. Placement of a drain: In certain circumstances, your surgeon may elect to leave a temporary plastic tube – a drain behind. The drain is to collect infection, blood or other secretions or may serve as an early warning for leakage. If there is no leakage it will typically removed prior to discharge from the hospital. 
6. In extremely rare cases a feeding tube could be required.  

Under very rare circumstances, the surgeon may determine that the procedure should be aborted all together. This is most often due to massive scarring from previous surgeries, or the intra-operative diagnosis of medical problems such as severe liver disease or tumors.  

In most of the metabolic operations we check for leaks at the end of the operation with an endoscopy, blue dye test, or fluorescent imaging test. 

The consent form your team use is standardized for the Health System and includes several generic  bullet points which will not be covered.  However it is our expectation that you carefully read these and ask any questions prior to signing the consent form.  

Magnet

Intra-operatively your surgeon may elect to use a magnetic retraction device on the liver or gastro-intestinal tract which may allow for less surgical incisions.  Magnetics can interrupt the normal function of pacemakers or stimulators.  As a result they should not be use together.  Our team will have you sign a screening measure used to determine eligibility for consideration of magnetic retraction usage intra-operatively. 

Mortality

In general the literature show increased long term survival after metabolic surgery. The mortality rate or chance of dying from the common metabolic procedures nationwide is between 0.3% to 2%. 

Comparison of Mortality Rate for Common Surgical Procedures

Procedure	% Mortality 30 Days	% Mortality 90 Days	% Mortality 1 year
Gallbladder Surgery	0.2	0.3	0.8
Hysterectomy	0.1	0.2	1.0
Bariatric Surgery	0.1	0.1	0.4
Colon Resection	2.8	4.5	9.4
CABG	5.9	7.8	10.2
Knee Scope	0.1	0.2	0.8
Prostatectomy	0	0	0.4
Gastric (Stomach) Resection	4.5	7.7	17.4

Leaks

A leak can occur anywhere there is a surgical connection between two portions of the gastro-intestinal tract that require sutures or staples.  It also occurs if there is an unrecognized injury during surgery. The most common locations for leaks associated with each procedure is highlighted by the red highlights below. The incidence ranges from 0.5% to 3%.  If a leak occurs gastric or intestinal contents leak out into the abdominal cavity causing inflammation and may require re-operation, prolonged hospital stay, multiple organ failure and death. 

Most leaks are identified and corrected intra-operatively by running an endoscope down through the mouth and inflating the gastro-intestinal tract with air or carbon dioxide to see if the connections or staple lines are air tight.  Leaks are recognized by gas bubbles escaping.  We typically submerge the accessible high risk zones under saline to make the air leak easier to identify and correct.  

Post operatively leaks are discovered most typically in the first day or so after surgery.  If discovered most will require a re-operation.  Some leaks don’t begin until 5-10 days out from surgery.  Most common symptoms include: elevated heart rate especially over 120 beats per minutes, uncontrolled abdominal pain, fever.  If any of these symptoms develop we expect you to come to the emergency department for evaluation.  

 In extremely rare circumstances leaks can occur several months after surgery.  While it can occur with any of the procedures these delayed leaks appear more common with sleeve gastrectomy.  

Damage to Surrounding Organs

The stomach lies under the liver.  When over weight, the liver can be very large making surgery difficult or impossible.  In our nutrition classes you will be taught how to shrink your liver for surgery.  The importance of this cannot be overstated.  If the liver is too large your surgery could require an open incision or be stopped altogether.  

 In addition to the liver the pancreas, spleen, small intestine, and colon are intra-abdominal organs that lie near the stomach and could be damaged at the time of your operation possibly necessitating repair, complete, or partial removal.  

Bleeding

Bleeding may occur unexpectedly in the operating room. Bleeding may also occur post-operatively in the days after the operation. This bleeding may be through the intestinal tract at the anastomosis and result in the passage of blood in the stool. Bleeding may also be unseen inside the abdomen and be diagnosed through other means. Incidence of bleeding in the surgical literature occurs between 1 and 4 percent of the time. A transfusion may be necessary in some circumstances. Transfusion is required in about half the cases where bleeding occurs. Re-operation to stop bleeding may be necessary.

If you or any member of your family have a known  bleeding disorder or history of excessive bleeding with surgery make sure our team is aware and we have a well communicated plan.  

List of Medications That Affect Blood Clotting:

• Antiplatelet Medication: Anagrelide (Agrylin®), aspirin (any brand, all doses), cilostazol (Pletal®), clopidogrel (Plavix®), dipyradamole (Persantine®), dipyridamole/aspirin (Aggrenox®), enteric-coated aspirin (Ecotrin®), ticlopidine (Ticlid®)
• Anticoagulant Medication: Anisindione (Miradon®), Arixtra, enoxaparin (Lovenox®) injection, Fragmin, heparin injection, Pradaxa, pentosan polysulfate (Elmiron®), warfarin (Coumadin®), Xerelto
• Nonsteroidal Anti-Inflammatory Drugs: Celebrex, diclofenac (Voltaren®, Cataflam®), diflunisal (Dolobid®), etodolac (Lodine®), fenoprofen (Nalfon®), flurbiprogen (Ansaid®), ibuprofen (Motrin®, Advil®, Nuprin®, Rufen®), indomethacin (Indocin®), ketoprofen (Orudis®, Actron®), ketorlac (Toradol®), meclofenamate (Meclomen®), meloxican (Mobic®), nabumeton (Relafen®), naproxen (Naprosyn®, Naprelan®, Aleve®), oxaprozin (Daypro®), piroxicam (Feldene®), salsalate (Salflex®, Disalcid®), sulindac (Clinoril®), sulfinpyrazone tolmetin (Tolectin®), trilisate (salicylate combination)
• Herbs/Vitamins: Ajoene birch bark, cayenne, Chinese black tree fungus, cumin, evening primrose oil, feverfew, garlic, ginger, ginkgo biloba, ginseng, grape seed extract, milk thistle, Omega 3 fatty acids, onion extract, St. John’s wort, tumeric, vitamins C and E

*The above list includes common medications but is not a complete list.  Make sure you have a preoperative plan for these medications with our team to prevent bleeding.  (list obtained from American College of Surgeons patient education materials)   

Risk of a Blood Transfusion

• Uncommon Reactions- 1-5% Chance include:
  • Itching 
  • Rash
  • Fever
  • Headache
•  Rare – which occur less than 1% of the time include:
  • Respiratory distress (shortness of breath) or lung injury
  • Exposure to bacteria and parasites that could result in an infection 
  • Possible effects on the immune system, which may decrease the body’s ability to fight infection
  • Exposure viruses such as hepatitis B 
  • Shock
•  Extremely rare cases one in a million or less reactions include:
  • Exposure to hepatitis C and HIV the virus that causes AIDS
  • Death

Heart Attack

In general metabolic surgery has been shown to reduce risk of heart attacks.  However there is a small chance of heart attack in the peri-operative period.  Risk factors for heart attack are shown.  During our work up process, our team and you, will have worked to reduce risk by optimizing these known risk factors.  Please alert our team if you feel any of these factors have not been adequately optimized at this time.

Risk Factors

• Age (Men >45, Women >55)
• Tobacco Use
• High Blood Pressure
• High Cholesterol
• Diabetes
• Family History
• Lack of Physical Activity
• Obesity
• Autoimmune Disorders

Pulmonary Embolism

Risk Factors

• Leg ulcers or venous stasis disease
• BMI>60
• Central abdominal obesity or apple distribution of obesity
• Severe sleep apnea
• History of blood clots
• Clotting disorders (hyper-coagulable state)
• Birth Control
• Paraplegia or immobility

A Pulmonary embolism is a blood clot that most commonly forms in the legs, and break off traveling into the lungs.  In rare cases these can cause death. People suffering from obesity who have abdominal surgery are at a increased risk for these blood clots.  

Given this risk, preventative measures will  be initiated to decrease the risk of blood clots formation, these preventative measures include: the use of heparin (a medication that thins the blood), special foot and leg stockings, walking soon after surgery, and altering some medication use at home before and after surgery.  Completely eliminating the risks of DVT (clots) altogether is not medically possibly. 

 The risks associated with the medications used to prevent blood clots can include excessive bleeding. Rarely, patients develop allergies to heparin, sometimes causing very severe reactions.

 Any symptoms of leg swelling, chest pain or sudden shortness of breath should be immediately reported to the team or presentation to the emergency department

 After any surgery people are at a increased risk for blood clots up to 90 days after surgery.  The greatest risk is in the first 30 days.  Post metabolic surgery blood clots occur around 1% of the time.  Our team looks at your individual risk factors and determines a prevention strategy.  Every patient is instructed to take short walks each and every waking hour during the the at risk period which is up to 90 days after surgery.  At the pre-op appointment some select higher risk patients will be given a prescription for blood thinners to be used at home after surgery.  Its our expectation that you get this prescription filled prior to surgery. If you have difficulty getting the prescription filled we expect to be notified before you have your procedure.  There will be some patients based upon risk factors that arise during your hospitalization who will be given a prescription for blood thinners to take at home.  If you are unable to get the prescription filled its our expectation that you alert the team immediately.

Kidney Failure

Transient kidney failure occurs rarely. Irreversible kidney failure has been reported in rare cases. 

 In rare cases from simply laying on the operating room table damage can occur to the buttocks muscles causing them to break down in a process called rhabdomyolysis.  The broken down muscle can cause kidney failure and other electrolyte abnormalities.  Its more common in patients with a BMI>50 who have a lengthy procedure typically greater than 4 hours.  If this becomes a concern intra-operatively your surgeon could make a decision to only perform part of your metabolic  operation and bring you back for completion at another date.  

Pneumonia

During metabolic surgery patients are placed under general anesthesia which requires a breathing tube to be placed in the trachea or windpipe through the mouth after asleep.  During the procedure the anesthesia team will control your bodies intake of oxygen through mechanical ventilation.  A common complication of ventilation is collapse of small air spaces in the lungs knowns as atelectasis. If not treated in the post op period a pneumonia or infection in the

lung can develop. The lungs can be expanded after surgery by walking and use of a incentive spirometer  which will be provided in the hospital.  After metabolic  surgery the incidence of pneumonia is about 0.6%. Uncommonly this could be so severe that you could need help breathing with a breathing machine or ventilator.

A prolonged stay on a ventilator in the intensive care unit may occur if a patient has severe sleep apnea or after certain significant complications. A temporary tracheostomy may be necessary. 

Gallbladder

The gallbladder is a storage sac for a substance called bile which is made by the liver and helps digest fats.  The gallbladder is attached to both the liver and the intestine by way of some ducts or tubes which carry the bile to intestine to mix with food allowing for fat digestion.  Anyone can form a stone in their gallbladder but this happens at a higher rate after weight loss of any cause.  These stones can partially or completely block the ducts or tubes between the liver and the intestine causing pain and infection.  The treatment for gallbladder problems is surgical removal.  After metabolic  surgery the rate of gallbladder removal in the literature varies widely between 3-28% of people need their gallbladder removed at some point after metabolic  surgery.  The mean incidence is around 5%.  Because the gallbladder is a relatively small structure connected to delicate ducts between the liver and intestine we worry about damaging these at the time of gallbladder removal.  Removing the gallbladder at the time of metabolic  surgery can be very difficult due to the large size of the liver which can pose technical challenges.  As a result we inspect everyones gallbladder but only plan two remove at the time of metabolic  surgery if you have been having symptoms related to your gallbladder, intra-operatively it appears safe to remove, and shows signs of previous inflammation.  

If we do elect to remove your gallbladder at the time of metabolic surgery or later on down the line a risk is damaging the ducts between the liver and intestine is called a bile duct injury.  If this occurs its often missed and may require a re-operation or a special test known as a ERCP to diagnose and manage this injury.  To preform a ERCP a endoscope is brought down through the mouth to the region where the ducts enter the intestine to examine this region. After a gastric bypass or duodenal switch due to the anatomic changes this may require more surgery to access the GI tract in the regions shown by the red circles to allow access to the bile duct with the ERCP test.

The gallbladder is a storage sac for a substance called bile which is made by the liver and helps digest fats.  The gallbladder is attached to both the liver and the intestine by way of some ducts or tubes which carry the bile to intestine to mix with food allowing for fat digestion.  Anyone can form a stone in their gallbladder but this happens at a higher rate after weight loss of any cause.  These stones can partially or completely block the ducts or tubes between the liver and the intestine causing pain and infection.  The treatment for gallbladder problems is surgical removal.  After metabolic  surgery the rate of gallbladder removal in the literature varies widely between 3-28% of people need their gallbladder removed at some point after metabolic  surgery.  The mean incidence is around 5%.  Because the gallbladder is a relatively small structure connected to delicate ducts between the liver and intestine we worry about damaging these at the time of gallbladder removal.  Removing the gallbladder at the time of metabolic  surgery can be very difficult due to the large size of the liver which can pose technical challenges.  As a result we inspect everyones gallbladder but only plan two remove at the time of metabolic  surgery if you have been having symptoms related to your gallbladder, intra-operatively it appears safe to remove, and shows signs of previous inflammation.  

If we do elect to remove your gallbladder at the time of metabolic surgery or later on down the line a risk is damaging the ducts between the liver and intestine is called a bile duct injury.  If this occurs its often missed and may require a re-operation or a special test known as a ERCP to diagnose and manage this injury.

To preform a ERCP a endoscope is brought down through the mouth to the region where the ducts enter the intestine to examine this region. After a gastric bypass or duodenal switch due to the anatomic changes this may require more surgery to access the GI tract in the regions shown by the red circles to allow access to the bile duct with the ERCP test.

Bile Reflux

As described in the gallbladder section, the liver produces bile which flows down into the small intestine to help absorb ingested fat. When your anatomy has been altered, it can result in an abnormal situation where bile flows upward to the stomach and esophagus, causing inflammation and pain. If bile reflux is left uncorrected over many years could increase the risk for cancers. This cancer risk is primarily theoretical, and no cases of cancer associated with bile reflux have been reported. Each procedure will have a different chance for bile reflux, as shown in the table below.

Minimal Risk	Low Risk	Moderate Risk
Duodenal Switch	Loop Duodenal Switch (SAIDI-S)	Loop Gastric Bypass (OAGB)
Adjustable Gastric Band	Sleeve Gastrectomy
Gastric Pacer	Gastric Bypass
	Endo or Surgical Plication

Bowel Obstruction and Internal Hernia

With any abdominal surgery you can form scar tissue which could block or obstruct the bowel.  These occur about 2.5% of the time after laparoscopic procedures.  With the gastric bypass and duodenal switch there are additional spots to develop a blockage or internal hernia.  These occur at the sites where gastrointestinal tract was divided and re-connected.  At the connection sites we close at the time of surgery the potential site of herniation.  However what we are closing are layers of fatty tissue which with weight loss can open up at a higher rate than after non weight loss procedures where bowel divided and is re-connected.  Incidence after metabolic surgery has ranged in the literature from about 2-10% of patients.  Often internal hernias or even suspension of an internal hernia will require re-operation to avoid damage to bowel stuck in the suspected hernia space.  

Abdominal Wall Hernia

An abdominal wall hernia is a opening in the tough layers of the abdominal wall where intra-abdominal contents such as bowel can protrude out and get stuck causing a obstruction or poor blood supply known as ischemia to that portion of bowel.  This could result in emergency hernia surgery.  Abdominal wall hernias can develop after metabolic surgery at the site of our incisions.  After lapararoscopic metabolic surgery these type hernia’s occur infrequently about 0.2% of the time.  However many patient will have pre-existing abdominal wall hernia’s that have been their since birth or a previous surgery.  To properly fix a abdominal wall hernia at the time of metabolic surgery poses several potential issues.  Abdominal wall hernia’s are best fixed with lowest  recurrence in patients of normal weight by way of a permanent mesh that strengthens the abdominal wall.  These permanent pieces of mesh are prone to infection and when the gastrointestinal tract is being divided and re-connected increases chance of their getting infected requiring surgical removal. As a result we often evaluate the likelihood of a blockage based upon size, pre-operative symptoms, and whether the opening is plugged by intra-abdominal fat at the time of your metabolic surgery.  If the conditions are right we try to delay repair until significant weight loss has occurred and the gastrointestinal tract is not being divided to risk reduce recurrence and mesh infection risk.  

Acid Reflux

Acid reflux  or gastro-esophageal reflux is a very common condition in those struggling with their weight.  Gastric Bypass is considered by most to be a treatment for acid reflux.  However in rare instances individuals will still  struggle with acid reflux after gastric bypass.

 At the current time there is a lot of on going research into what happen with acid reflux after sleeve gastrectomy.  In general from the literature it appears acid reflux may worsen after sleeve.  In patients who do not have acid reflux before sleeve gastrectomy about 10 percent of patients develop new onset acid reflux.  Appears most cases of acid reflux can be treated with medications. In some cases another procedure or conversion to gastric bypass may be required to control the acid reflux after sleeve gastrectomy.

There is recent data suggesting patients after sleeve gastrectomy are at increased risk for developing Barrett’s esophagus after surgery.  Barretts’s esophagus often results from acid reflux causing replacement of the normal tissue lining the esophagus to be replaced by tissue similar that which lines the intestine.  

Barrett’s esophagus is associated with an increased risk of developing esophageal cancer. Although the risk is small, it’s important to have regular checkups for precancerous cells (dysplasia). If precancerous cells are discovered, they can be treated to prevent esophageal cancer.

While the bariatric surgical community has not published any recommendations for screening to detect Barretts esophagus after sleeve gastrectomy, it is likely that patients need regular screening to detect the presence of Barrett’s esophagus.  Currently, the most sensitive screening tool is an upper endoscopy also known as EGD.  

Marginal Ulcer

Patients who smoke, take non-steroidal anti-inflammatory (NSAID) medications, or oral steroid medications are at increased risk for marginal ulcers after gastric bypass.

Marginal ulcer is a type of gastro-intestinal tract ulcer which occurs just past the connection between the stomach and attached intestine.  They occur about 4% of the time after gastric bypass and rarely after duodenal switch.  They cause pain, food intolerance, and malnutrition.  Occasionally they perforate and require revisional surgery.  The incidence of marginal ulcers goes up significantly in gastric bypass patients who smoke, take non steroidal anti-inflammatory or NSAID medications, or oral steroid medications.  Gastric bypass patients specifically are asked to avoid NSAID medications for life after surgery.  Gastric bypass patients will also be placed on a ulcer prophylaxis medication for a period of time after surgery. When a patient develops a ulcer most can be cured by eliminating risk factors and medications.  However some will require revisional or reversal surgery. In rare cases marginal ulcers can perforate into the excluded stomach causing whats called a gastro-gastro fistula or GG fistula. GG fistulas can lead to weight gain and may require revisional surgery or reversal. 

Stricture

A stricture is a narrowing that can occur at any connection point made during surgery or along a sleeve gastrectomy.  This narrowing can impair the or stop the normal flow of food or gastro-intestinal contents through  this region.  These can occur as early as three to four weeks out from surgery and may require and endoscopy where a balloon device is used to dilate the narrowing.  Chronic strictures can require surgical revision.

Wound Infection

Patients struggling with their weight are at a higher risk for infections in their wound compared to those of normal weight.  Most metabolic procedures are done laparoscopically and the chance of developing a wound infection is about 4%. When a open incision is required wound infections occur about 16% of the time. 

After surgery a small amount of clear, pink, or thin yellow drainage from the incision is common and does not mean there is any infection. 

 Signs of infection include: increased peri-incisional pain, redness around the incision, fever, and drainage of puss. 

If these signs occur we will need to look at the wound either by way of an in person visit or you can send us pictures through My Chart to determine a treatment strategy.  

Occasionally an infected incision will open up and drain either spontaneously or by way of our surgical team.  Open incisions often require frequent packing with gauze or use of a sponge attached to a suction device known as a wound vac in order to speed healing which in this scenario can take several weeks  

Electrical Burn

During surgery, electrical energy known as cautery is used to stop bleeding and cut tissue. Unintentional burn injuries can occur either on the skin or internally causing damage that could require more surgery to treat e#ectively. 

CO₂ or Air Embolism

During laparoscopic surgery, the abdominal cavity is “lled with gas to provide room to be able to see the organs properly. Rarely during surgery, this gas pumped into the abdomen can “ll small veins and travel back to the heart and lungs. This is known as gas embolism which can impede the normal $ow of blood and oxygen to the body. In rare cases, a gas embolism can lead to low blood pressure, low oxygen levels, and death. 

Nerve Damage

Lying on the operating table for the 1-4 hour period of time it may take to preform your surgery can exacerbate nerve issues.  The most common being back pain.  During the night we lay for extended periods of time but we unconsciously shift our weight periodically throughout the night to avoid nerve pain.  While on the operating table you are completely motionless.  We tilt the table to near standing position during surgery to use gravity to hold organs out of the operative field. Laying in this position can exacerbate these nerve issues.  It will be very important in the operating room that you help use pad and position you appropriately prior to going to sleep in order to prevent nerve damage. 

Nausea & Food Intolerance

Most patients after general anesthesia and abdominal surgery develop some nausea that is short lived.  Rarely patients will have nausea that can last several weeks to months. 

Following metabolic surgery especially the gastric bypass, patients may experience an intolerance to certain food types, usually fatty greasy foods, dairy products, and/or sweets, which may cause unpleasant symptoms similar to seasickness such as sweating, nausea, diarrhea and shaking. These symptoms may last from a few minutes to an hour. This is called “dumping.” Food intolerances vary from person to person. Some patients never experience any of these symptoms, or may become less sensitive over time. Rarely, a patient may have severe food intolerances that last for many months.  Rarely patients develop dangerously low blood sugars known as reactive hypoglycemia after metabolic surgery which usually responds to a combination of dietary change and medications, but in rare cases could require a feeding tube or reversal of the metabolic procedure.  

Changes in Bowel Habits

Changes in bowel habits are common. Changes may include constipation, diarrhea and excessive flatus. It varies between individuals but on average patients tend towards constipation after the gastric bypass and sleeve, while looser bowel moments are the norm after duodenal switch. 

Fatigue

After any general anesthesia, fatigue is very common. Fatigue may last days, or in some circumstances, much longer

Vitamin Deficiency

Taking vitamins is Mandatory for the rest of your life after all of the bariatric procedures

Symptoms of Vitamin deficiency

• Weakness 
• Skin Changes
• Diarrhea
• Craving non food items
• Palpitations (noticeable heart beat)
• Difficulty with concentration
• Tingling in the hands or feet
• Loss of control of body movement
• Memory Loss
• Confusion
• Disorientation
• Hair Loss
• Low blood levels
• Fatigue
• Brittle Bones

All of the metabolic surgeries are prone to vitamin deficiencies.  As a result taking vitamins as prescribed by our  nutrition team is mandatory for the rest our your life.  Regular blood tests to check your vitamin levels is mandatory and part of our normal followup regimen.   We will do our best to prompt you to take your vitamins and check your vitamin levels, but ultimately the responsibility is yours. Serious permanent complications can occur if neglected. 

A partial list of possible symptoms of deficiency are shown.  If these signs develop it warrants vitamin levels to ensure deficiency is not the cause.  Some of these symptoms can be permanent if left untreated.  

Of note metabolic surgery can result in decreased bone density over time.  Over all studies have not shown increased fracture rate but further study is warranted.  Current data doesn’t recommend  dual-energy X-ray absorptiometry or DXA scan beyond the current recommendations of the National Osteoporosis Foundation.   Your primary care doctor and our team will help you follow these recommendations.  

If you become deficient in any of these vitamin levels extra treatments or vitamins may be required to bring your levels back to baseline.

If a prolonged period of vomiting occurs it can lead to deficiency in thiamine.   It can result in the symptoms shown.  If left untreated these can become permanent a condition known as Wernicke -Korsakoff Syndrome.  

This is a rare condition easily preventable by giving thiamine.  As a result if you experience prolonged vomiting and present to any medical facility you should be asking about thiamine deficiency to alert any medical providers not familiar with metabolic surgery that this is a concern.  You will know you are receiving thiamine because it turns normal IV fluids a yellow color.   

Mood Changes and Suicide

Bariatric surgery results in significant positive effects on mood and quality of life in the initial years following surgery Less clear are the longer-term effects of bariatric surgery on mood and anxiety disorders. After the bulk of the weight is lost, the novelty of weight loss begins to fade and patients are now faced with life after dramatic weight loss leading to possible recurrence of depressive symptoms.

If you have a previous diagnosis of depression or anxiety and you have previously been prescribed medications, then you should continue to take your medication in the immediate time up to and after your operation. Do not make your own decision to stop these or any other medications. If you feel extremely anxious or depressed after your operation then please speak with your clinical psychologist

 While the absolute suicide rate among bariatric patients is still quite low, it remains higher than in the general population.

Alcohol and Substance Abuse Disorder

Metabolic  Surgery candidates have a greater lifetime risk of alcohol and substance use disorders, and the physiologic changes with surgery lead to greater sensitivity to alcohol.

In Signing our Consent Form You Agree to These Conditions

• I have been completely thorough and honest in my disclosure of my alcohol and substance use. 
• I understand that I will be permanently more susceptible to the effects of alcohol after surgery. 
• I understand that I should avoid alcohol for the first 12 months after surgery and that I should drink in extreme moderation afterward. 
• I understand that I am at higher risk for developing problematic use after surgery and that abstinence from alcohol is the best way to reduce this risk and other medical and psychological complications. 
• I agree that if my surgeon or another member of the surgery team (nurse, nutritionist, psychologist, etc.), have concerns about my alcohol and/or substance use, I will seek consultation and/or treatment as recommended. 
• I have had the opportunity to ask questions regarding alcohol and substance use. 

Impact on Social Relationships

Weight loss after metabolic surgery creates numerous positive changes for your health and longevity.  Even though families and friends are aware of the physical consequences of metabolic surgery, they are surprised and challenged by how the unexpected changes affect the interpersonal dynamics.

The treated family member gains energy and is eager to get more involved in sharing responsibilities in family life, as well as spending more time outside the family, to develop a social network. This leads to a need to negotiate new agreements regarding roles, routines and interactions which can be challenging.  

Bariatric surgery is  associated with increased incidence of divorce/separation compared with controls for those in a relationship and increased incidence of marriage or new relationship in those who were unmarried or single

 Changes in relationship status were more common in those with larger weight loss.

Pregnancy

Pregnancy should be deferred for 12 to 18 months after metabolic surgery because of concern for fetal and maternal health. Fertility in women may be substantially increased very early after surgery due to my weight loss. Appropriate patients are  responsible for using adequate  birth control methods in this time period. We typically recommend two forms of birth control.  Studies appear to show a decreased rate of complications of pregnancy in those patients who have had metabolic surgery. There may be rare instances where complications of pregnancy may be increased secondary to having metabolic surgery. 

Ideally prior to attempting pregnancy after surgery you would get a full set up vitamin levels and ensure any abnormality are corrected.

Hair Loss and Loose Skin

Temporary Hair loss  – Hair loss occurs in many people after a weight loss operation. Hair generally grows back. There are no proven supplements to alter hair loss. 

Loose Skin – More than half of post-metabolic surgery patients report that excess skin is a negative consequence of surgery

Excessive Weight Loss and Weight Regain

Excessive weight loss is uncommon and usually results from complications that require close management by the surgeon. 

As shown previously in our new patient class, our bodies have a highly regulated set point or set range for body fat because it’s a major fuel source our body relies upon for energy.   We loosely measure body fat through weight. We have some control of where we lie within that range based upon our behaviors.  

In this example blue represents an end of the range where behaviors that cause weight loss push our weight and red represents an end of the range where behaviors that promote weight gain put our weight. If through extreme behaviors like starvation we push ourselves out of that range the body will fight to push us back into our set range.  

This range varies from person to person based upon genetics.  Patient A has a very wide range and with behaviors that promote weight loss can likely keep their weight at a reasonable body mass index. 

Patient B has a much tighter range where behavior both those that cause weight loss or those that cause weight gain don’t have a significant influence on their body mass index.   

 Due to chronic exposure to factors in our modern environment the regulation of our set point range for weight gets disrupted and pushed upward.  

Our body tries to defend or keep our weight at this elevated set point range even if we try to lower our weight with diet and exercise.  Surgery is our most effective method at lowering this set point.  

 Each procedure has a typical range of weight loss after surgery corresponding to the lowered set point.  

Each individual is effected differently meaning how low their new set point goes

and for how long the set point remains lowered due to their own particular genetics. If we focus on several patients who all have the same procedure,  they will all lose weight over time.  They will also all have a different range in which their behaviors will help achieve more or less weight loss.    

For the first year or two after surgery patients are in what we term the honeymoon phase where this range seems to be shifting causing weight loss despite whether the patient is engaging in behaviors that promote weight gain or loss.  

At times this false lead patients to believe behaviors don’t matter.  After the set range has lowered the impact of behaviors upon your set range become evident once again.  On going chronic exposure to our modern environment will push some peoples set point back up again over time causing significant weight again.  

 Chance of significant weight regain over 10 years is shown for each major procedure if the data is available.  

 Likewise medical problems resolve at different rates for each individual.  It is possible for some of the medical problems which get better or resolve to come back over time time after surgery.

For most optimal weight loss and resolution of medical problems will be achieved through life long multi-modal measures to keep the bodies set point as low as possible.  These include all or a combination of weight loss promoting behaviors, set point lowering medications, avoiding medications that raise the set point, and when necessary more bariatric surgery.  

Lap Band Specific Complications

Acute Obstruction: Rare patients will not be able to tolerate any liquids or solids immediately after the gastric band is placed. Acute obstruction usually occurs in the first day after surgery and may require a re-operation to loosen the obstruction. There are several possible reasons for obstruction including band slippage, stomach swelling and poor positioning of the band.

Infection: Uncommonly, infections caused by the laparoscopic Adjustable Gastric Band can occur.  Infections caused by prosthetic devices are very difficult to treat with antibiotics alone. Infections of the laparoscopic Adjustable Gastric Band often require removal of the entire system. 

Slippage: The laparoscopic Adjustable Gastric Band can slip out of position. If this occurs patients may not be able to tolerate any food or even liquids. There may be mild to severe abdominal pain. Urgent repair is often necessary. There are very rare reports of patients who have died from a slipped gastric band that caused the stomach to lose its blood supply.

 Tubing Problems: During the adjustments performed in the office, it is possible to puncture the tubing accidentally. This would require a minor operation to correct. The tubing of the band can crack on rare occasions. If this occurs, all the fluid leaks out and the patient will experience a complete lack of restriction. This would require a minor re-operation to fix. 

 Adjustment Problems: I have discussed with my surgeon the gastric band adjustment process. My surgeon or another qualified individual will perform my adjustments. I understand that adjustments are either performed in the office or under X-Ray guidance, depending on what my surgeon believes is best for me. I understand that there is no fool-proof method to efficiently adjust my band. I understand that some patients may only need a few adjustments, while others may need numerous adjustments. I understand that my band may be accidentally adjusted too tightly. If this occurs, I will need to contact my surgeon’s office immediately. I understand that my surgeon will only perform an adjustment if it is in my best interest. Over- adjustment (over-tightening)   of the band may cause irreversible problems such as pouch dilation, esophageal dilation, gastro-esophageal reflux, pneumonia and perhaps band slippage. I understand that if I am traveling, I may have difficulty finding a qualified physician who can manage my band. I understand that if I move out of the area, I may encounter difficulty in finding a qualified surgeon to adjust and manage my band. Complications of the adjustment process may include bruising, discomfort, infection or damage to the port or tubing.

 Pouch Dilation and/or Esophageal Dilation: Dilation of the stomach pouch and/or the esophagus may occur after placement of the gastric band. This complication typically is due to over-adjustment (over-tightening) of the band. Symptoms may include poor weight loss and heartburn. Treatment of this complication may require band deflation, operative repositioning of the band, or band removal. 

 Port Problems: The port can flip out of position. If this occurs, it may be difficult to adjust the gastric band. The only manner to correct a port flip is to perform a procedure in the operating room. In people who lose a significant amount of weight, the port may be seen as an unsightly bump.

 Erosion: The gastric band may erode a hole into the stomach. If this occurs, a life-threatening infection may ensue. Band removal is the only treatment. This operation may be difficult with possible complications. Erosion is an uncommon complication. Erosions may occur years after the placement of the band. 

 Band Removal: Removal of the gastric band may be needed if the patient experiences complications. Typically, weight regain occurs quickly after band removal. Removal of the band may have complications associated with the removal procedure. 

Accessibility:  In recent years the popularity of the lap band has dramatically declined likely due wide variability in patient outcomes.  As a result very few lap band are being preformed across the world.  As a result it is becoming increasingly difficult to find bariatric surgeons willing or able to manage your band.  If you move out of our area you may not be able to locate a bariatric center to mange your band.  It also seems likely due to decreased sales that the manufactures of the band will stop selling the product in the near future.