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When a board certified surgeon fails to assist a patient with follow-up care and healing, who would you next contact in the MD hierarchy for help?

Please explain what and when the procedure was performed. Has the patient been seen since surgery by the physician? What was the reason provided for not seeing the patient?There is a patient abandonment issue. The person doing the surgery should do follow up for any complication related to the procedure he/she performed. Is it because of noncompliance, schedule conflict, non-payment etc?[Edit: Per additional history provided in the Comments section. The article below addresses medical management after bariatric surgery. The physician has tried to work up surgical complications. This is the section regarding nausea and vomiting. The authors mention antiemetic unless there are other issues. I hesitate to second guess what the surgeon’s train of thought is. I do think there should be response to the patient’s communications. I understand the frustration and the cost of repeat emergency room visits. Someone here has suggested contacting the chief of surgery. Post bariatric surgery recuperation can be problematic and I hope the symptoms resolve in time.Nausea and vomitingNausea and vomiting can often be helped by antiemetic or prokinetic drugs, however, some patients have chronic functional nausea and/or vomiting that does not fit the pattern of cyclic vomiting syndrome or other gastrointestinal disorders, hence particular attention should be directed to potential psychosocial factors post bariatric surgery. Therefore, low dose antidepressant medications and psychotherapy should be addressed. On demand CT scan and Gastroscopy could be the gold standard investigations in chronic situations[39,40].]World J Gastrointest Surg. 2014 Nov 27; 6(11): 220–228.Published online 2014 Nov 27. doi: 10.4240/wjgs.v6.i11.220PMCID: PMC4241489Medical management of patients after bariatric surgery: Principles and guidelinesAbd Elrazek Mohammad Ali Abd Elrazek, Abduh Elsayed Mohamed Elbanna, and Shymaa E BilasyAuthor information ► Article notes ► Copyright and License information ►This article has been cited by other articles in PMC.Go to:AbstractObesity is a major and growing health care concern. Large epidemiologic studies that evaluated the relationship between obesity and mortality, observed that a higher body-mass index (BMI) is associated with increased rate of death from several causes, among them cardiovascular disease; which is particularly true for those with morbid obesity. Being overweight was also associated with decreased survival in several studies. Unfortunately, obese subjects are often exposed to public disapproval because of their fatness which significantly affects their psychosocial behavior. All obese patients (BMI ≥ 30 kg/m) should receive counseling on diet, lifestyle, exercise and goals for weight management. Individuals with BMI ≥ 40 kg/m and those with BMI > 35 kg/m with obesity-related comorbidities; who failed diet, exercise, and drug therapy, should be considered for bariatric surgery. In current review article, we will shed light on important medical principles that each surgeon/gastroenterologist needs to know about bariatric surgical procedure, with special concern to the early post operative period. Additionally, we will explain the common complications that usually follow bariatric surgery and elucidate medical guidelines in their management. For the first 24 h after the bariatric surgery, the postoperative priorities include pain management, leakage, nausea and vomiting, intravenous fluid management, pulmonary hygiene, and ambulation. Patients maintain a low calorie liquid diet for the first few postoperative days that is gradually changed to soft solid food diet within two or three weeks following the bariatric surgery. Later, patients should be monitored for postoperative complications. Hypertension, diabetes, dumping syndrome, gastrointestinal and psychosomatic disorders are among the most important medical conditions discussed in this review.Keywords: Obesity, Bariatric surgery, Postoperative care, Body-mass index, El bannaCore tip: Obesity is a growing health concern worldwide that impacts the life of individuals both physically and psychologically. There are several well-established health hazards associated with obesity. Additionally, obese subjects are often exposed to public disapproval because of their fatness which significantly affects their psychosocial behavior. Bariatric surgery is one of the definite solutions for obesity. In this review, we will briefly discuss the general guidelines that should be considered before bariatric surgery. Also, we discuss the protocols of patients’ postoperative care and the management of medical disorders that must be considered after bariatric surgery.Go to:INTRODUCTIONObesity is a chronic disease that impairs health-related quality of life in adolescents and children. In 2010, overweight and obesity were estimated to cause 3.4 million deaths, 3.9% of years of life loss, and 3.8% of disability-adjusted life-years worldwide. Obesity is increasing in prevalence, currently, the proportion of adults with a body-mass index (BMI) of 25 kg/m or greater is 36.9% in men and 38.0% in women worldwide[1]. Attempts to explain the large increase in obesity in the past 30 years focused on several potential contributors including increase in caloric intake, changes in the composition of diet, decrease in the levels of physical activity and changes in the gut microbiome. More than 50% of the obese individuals in the world are located in ten countries (listed in order of number of obese individuals): United States, China, India, Russia, Brazil, Mexico, Egypt, Germany, Pakistan and Indonesia. Although age-standardized rates were lower in developing than in developed countries overall, 62% of the world’s obese individuals live in developing countries. Recently, United States accounted for 13% of obese people worldwide, the prevalence of obesity was 31.7% and 33.9% among adult men and women, respectively. In Canada 21.9% of men and 20.5% of women are obese. Reported prevalence rates of obesity include: 27.5% of men and 29.8% of women in Australia, 24.5% of men and 25.4% of women in the United Kingdom, in Germany 21.9% of men and 22.5% of women, in Mexico 20.6% of men and 32.7% of women, in South Africa 13.5% of men and 42% of women, in Egypt 26.4% of men and 48.4% of women, in Saudi Arabia 30% of men and 44.4% of women and in Kuwait 43.4% of men and 58.6% of women Figure ​Figure11)[2].There are several well-established health hazards associated with obesity, e.g., nonalcoholic steatohepatitis (NASH), type 2 diabetes, heart disease, chronic kidney disease, gastroesophageal reflux disease, gastrointestinal motility disorders, sexual disorders, cerebrovascular stroke, certain cancers, osteoarthritis, depression and others[3-10]. The risk of development of such complications rises with the increase of adiposity, while weight loss can reduce the risk. Bariatric surgery could be the definitive clue in many situations[11-15]. Bariatric surgery is one of the fastest growing operative procedures performed worldwide, with an estimated > 340000 operations performed in 2011. While the absolute growth rate of bariatric surgery in Asia was 44.9% between 2005 and 2009, the numbers of procedures performed in the United States plateaued at approximately 200000 operations per year[16,17]. Starting in 2006, the Center for Medicare and Medicaid Services, United States, restricted the coverage of bariatric surgery to hospitals designated as “Centers of Excellence” by two major professional organizations[18]. Medical management and follow up of patients who have undergone bariatric surgery is a challenge due to post operative complications.GENERAL GUIDELINES FOR SURGEONS/GASTROENTEROLOGISTSA well skilled physician or a surgeon has to consider the followings:(1) as the prevalence of obesity increases so does the prevalence of the comorbidities associated with obesity. Losing weight means overcoming illness at the present, complications in future and alleviating the economic burden in the present and future;(2) Overweight; BMI between 25 and 30, technically refers to excessive body weight, whereas “obesity” BMI ≥ 30 kg/m refers excessive body fat, “Severe obesity”, BMI ≥ 35 kg/m, or “morbid obesity” refers to individuals with obesity-related comorbidities. Furthermore, severe obesity and morbid obesity groups who failed dietary and medical regimens are candidates for bariatric surgery;(3) Children obesity; refers to children with BMI > 95th percentile for their age and sex and “overweight” refers to children with BMI between the 85th and 95th percentile for their age and sex;(4) Patients undergoing a bariatric operation should have a nutritional assessment for deficiencies in macro and micronutrients, also with no contraindication for such a major operation;(5) Most of bariatric procedures are performed in women (> 80%) and approximately half of these (> 40% of all bariatric procedures) are performed in reproductive aged women, accordingly, pregnancy planning and contraception options should be discussed in details with women who will undergo bariatric procedures. Fertility improves soon after bariatric surgery, particularly in middle-aged women, who were anovulatory. Additionally, oral contraceptives may be less effective in women who have undergone malabsorptive bariatric procedure. Therefore, it is better to delay pregnancy for 6-12 mo following bariatric surgery. Risk of preeclampsia, gestational diabetes, and macrosomia significantly decrease post bariatric surgery, but the risk of intrauterine growth restriction/small infants for their gestational age may increase. Body contouring surgery is in high demand following bariatric surgery;(6) All bariatric operations are accompanied with restrictive and/or malabsorption maneuvers; less food intake and malabsorption concepts;(7) The most common types of bariatric surgeries performed worldwide are Sleeve gastrectomy (SG): This procedure involves the longitudinal excision of the stomach and thus shaping the remaining part of the stomach into a tube or a “sleeve” like structure. SG removes almost 85% of the stomach (Figure ​(Figure2);2); Roux-en-Y gastric bypass (RYGB): It reduces the size of the stomach to the size of a small pouch that is directly surgically attached to the lower part of the small intestine. In this procedure, most of the stomach and the duodenum are surgically stapled and therefore, bypassed (Figure ​(Figure3);3); The laparoscopic adjustable gastric band (AGB): This is one of the least invasive procedures, where the surgeon inserts an adjustable band around a portion of the stomach and therefore, patients feel fuller after eating smaller food portions (Figure ​(Figure4).4). Bariatric surgical procedures, particularly RYGB, plus medical therapy, are effective interventions for treating type 2 diabetes. Improvement in metabolic control is often evident within days to weeks following RYGB; and(8) Complications reported following bariatric surgery vary based upon the procedure performed. Cholilithiasis, renal stone formation and incisional hernia could be the delayed phase complications; on the other hand, bleeding, leaking, infection and pulmonary embolism could be the early phase complications following the bariatric procedure. The overall 30-d mortality for bariatric surgical procedures worldwide is less than 1%.Roux-in Y Gastrectomy, sleeve gastrectomy. and adjustable gastric band.POST OPERATIVE CARE AND FOLLOW UPEarly post operative period; (1-3) d post bariatric surgeryPatients undergoing a bariatric operation are admitted to the post-anesthesia care unit (PACU) immediately at the conclusion of the operation. Usually, on postoperative day (POD) one, we begin oral therapy in tablet or crushed-tablet and liquid form if there is a naso-gastric tube after the gastrografin leak test. A basic metabolic profile (e.g., complete blood count, electrolytes, renal function, liver function, prothrombin time and partial thromboplastin time) should be obtained every 12 h for the successive two PODs, then every 24 h for another 3 d. Oxygen is administered by nasal cannula and weaned thereafter. The likelihood that, early specific complication, will arise for a given patient is determined by the nature of the procedure, the anesthetic techniques used, and the patient’s preoperative diseases. Respiratory problems are common complication in the early postoperative period following bariatric surgery. Patients with significant comorbidities, particularly neuromuscular, pulmonary, or cardiac problems are at a higher risk for respiratory compromise, but any patient can develop hypoxemia following bariatric surgery. For prophylaxis against Deep Venous Thrombosis (DVT) following bariatric surgeries, ultrasound evaluation is recommended for all patients, D-dimer test should be applied for suspected patients with DVT, especially after long operative time, repeat ultrasound or venography may be required for those with suspected calf vein DVT and a negative initial ultrasound investigation[19,20].Late post operative monitoringAfter the PACU period, most patients are transferred to the inpatient surgical postoperative unit. For the next 24-72 h, the postoperative priorities include ruling out an anastomotic leak following laparoscopic RYGB or laparoscopic SG. If no leak is observed, patients are allowed to start a clear liquid diet and soft drinks. The postoperative care team cares for the following: control of pain, care of the wound, continuous monitoring of blood pressure, intravenous fluid management, pulmonary hygiene, and ambulation. Post-bariatric nausea and vomiting is directly correlated with the length of the surgery; it also increases in females, non-smokers, and those patients with prior history of vomiting or motion sickness. Prophylaxis with pharmacologic treatment before the development of post operative nausea and vomiting significantly reduces its incidence after surgery[21-23].After hospital dischargeDiet: Usually patients are discharged 4-6 d after surgery. Most patients are typically discharged from the hospital on a full liquid diet, patients should be taught to keep monitoring their hydration and urine output. Approximately two-three weeks after surgery, the diet is gradually changed to soft, solid foods. The average caloric intake ranges from (400) to (800) kcal/d for the first month, and thus the daily glycemic load is greatly reduced. We encourage patients to consume a diet consisting of salads, fruits, vegetables and soft protein daily.To control the epigastric pain and vomiting, patients should be taught to eat slowly, to stop eating as soon as they reach satiety and not to consume food and beverages at the same time. For most patients suffering chronic vomiting, prokinetic therapy and proton-pump inhibitors (PPIs) should be considered. Patients, who underwent SG, LAGB or RYGB, benefit from a well-planned dietary advancement. Patients should understand that the surgery has changed their body but not the environment, they have to choose healthy foods, do not skip meals and to visit the dietitian regularly in the first 12 mo after surgery. However, if food intolerance develops, patients may choose a more vegetarian-based diet. Nevertheless, fresh fruits and vegetables are usually tolerated without a problem. The daily protein intake should be between 1.0 to 1.5 g/kg ideal body weight per day[24]. The biliopancreatic diversion/duodenal switch (BPD/DS) is a malabsorptive procedure for both macro- and micronutrients. Hence, we encourage higher protein intake of 1.5 g to 2.0 g of protein/kg ideal body weight per day, making the average protein requirement per day approximately 90 g/d[25,26]. Alcohol is better prevented in the first 6-12 mo after surgery[27].Monitoring: Patients should generally have their weight and blood pressure measured weekly until the rapid weight loss phase diminishes, usually within 4-6 mo, then again at 8, 10 and 12 mo, and annually thereafter. Patients with diabetes are encouraged to check their blood glucose daily. Glycemic control typically improves rapidly following bariatric surgery. Patients maintained on antihypertensive or diabetic medications at discharge should be monitored closely for hypotension and hypoglycemia, respectively, and medications should be adjusted accordingly. We recommend that the following laboratory tests be performed at three, six, nine months and annually thereafter: (1) Complete Blood Count; (2) Electrolytes; (3) Glucose and Glucose Tolerance test; (4) Complete iron studies; (5) Vitamin B12; (6) Aminotransferases, alkaline phosphatase, bilirubin, GGT; (7) Total protein and Albumin; (8) Complete lipid profile; (9) 25-hydroxyvitamin D, parathyroid hormone; (10)Thiamine; (11) Folate; (12) Zinc; and (13) Copper.Complications following the surgical treatment of severe obesity vary based upon the procedure performed. Secondary hyperparathyroidism, Hypocalcemia, Gastric remnant distension, Stomal stenosis/Obstruction, Marginal ulcerations, Cholilithiasis, Ventral incisional hernia, Internal hernia, Hiatus Hernia, Short bowel syndrome, Renal failure, Gastric prolapse, infection, Esophagitis, Reflux, Vomiting, Hepatic abnormalities and dumping syndrome are common late-phase complications after bariatric surgery. However, the clinician should aware of complications specific for every bariatric procedure[28,29]. Before therapy, the clinician should understand that the impact of various bariatric surgeries on drug absorption and metabolism are scarce. On the other hand, RYGB and other malabsorptive procedures that significantly exclude the proximal part of the small intestine, decrease the surface area where most drug absorption occurs and may result in a reduction in systemic bioavailability[30-32].Go to:COMMON MEDICAL CONDITIONS FOLLOWING BARIATRIC SURGERYHypertensionHypertension is not always related to obesity, and dietary interventions do not assure the normalization of blood pressure. However weight loss, whether by an intensive lifestyle medical modification program or by a bariatric operation, improves obesity-linked hypertension. Patients should be monitored weekly until the blood pressure has stabilized, and patients may need to resume antihypertensive medications, but often at adjusted doses[33].DiabetesPatients with diabetes should have frequent monitoring of blood glucose in the early postoperative period and should be managed with sliding scale insulin. Many diabetic patients have a decreased need for insulin and oral hypoglycemic agents after bariatric surgery. Oral sulfonylureas and meglitinides should be discontinued postoperatively as these medications can lead to hypoglycemia after bariatric surgery. Metformin is the safest oral drug in the postoperative period, since it is not associated with dramatic fluctuations in blood glucose. RYGB is associated with durable remission of type 2 diabetes in many, but not all, severely obese diabetic adults. However those who underwent LAGB generally exhibit a slower improvement in glucose metabolism and diabetes as they lose weight in a gradual fashion[34,35].RefluxMedications for gastroesophageal reflux disease (GERD) may be discontinued after RYGB and Laparoscopic AGB, however, SG has been associated with an increased incidence of GERD in some procedures. Recurrent GERD symptoms after RYGB, particularly when accompanied by weight regain, should raise the possibility of a gastrogastric fistula between the gastric pouch and remnant, and should be investigated by an upper GI contrast study or CT scan and referred to the bariatric surgeon. Upper endoscopy is the best investigation to exclude other esophagogastroduodenal disorders. GERD may be associated with esophageal complications including esophagitis, peptic stricture, Barrett’s metaplasia, esophageal cancer and other pulmonary complications. Failure of the PPI treatment to resolve GERD-related symptoms has become one of the most common complications of GERD after bariatric surgery. Most patients who fail PPI treatment have Non Erosive Reflux Disease and without pathological reflux on pH testing. In patients with persistent heartburn despite of medical therapy, it is reasonable to recommend avoidance of specific lifestyle activities that have been identified by patients or physicians to trigger GERD-related symptoms[36-38].Nausea and vomitingNausea and vomiting can often be helped by antiemetic or prokinetic drugs, however, some patients have chronic functional nausea and/or vomiting that does not fit the pattern of cyclic vomiting syndrome or other gastrointestinal disorders, hence particular attention should be directed to potential psychosocial factors post bariatric surgery. Therefore, low dose antidepressant medications and psychotherapy should be addressed. On demand CT scan and Gastroscopy could be the gold standard investigations in chronic situations[39,40].Marginal ulcerationDue to increased risk of ulcer formation from nonsteroidal anti-inflammatory drugs (NSAIDs), these medications should be discontinued postoperatively, especially after RYGB. NSAID use is associated with an increased risk of bleeding. If analgesic or anti-inflammatory treatment is needed, the use of acetaminophen is preferred in a dose of 1-2 g/daily[41-45]. Other factors associated with increased risk of ulcer formation are smoking, alcohol, spicy food, gastrogastric fistulas, ischemia at the site of surgical anastomosis, poor tissue perfusion due to tension, presence of foreign material, such as staples and/or Helicobacter pylori infection. Diagnosis is established by upper endoscopy. According to our strategy, all patients should undergo diagnostic upper endoscopy to exclude congenital or GI diseases prior to bariatric procedures. Medical management is usually successful and surgical intervention is rarely needed[46-48].Go to:DUMPING SYNDROMEDumping syndrome or rapid gastric emptying is a group of symptoms that most likely occur following bariatric bypass. It occurs when the undigested contents of the stomach move too rapidly into the small intestine. Many patients who underwent bariatric bypass experienced postprandial hypoglycemia. However, the dumping syndrome usually occurs early (within one hour) after eating and is not associated with hypoglycemia. It is presumed to be caused by contraction of the plasma volume due to fluid shifts into the gastrointestinal tract. Dumping syndrome may result in tachycardia, abdominal pain, diaphoresis, nausea, vomiting, diarrhea, and sometimes, hypoglycemia. The late dumping syndrome is a result of the hyperglycemia and the subsequent insulin response leading to hypoglycemia that occurs around 2-3 h after a meal. Dumping syndrome is a common problem that occurs in patients who have undergone RYGB and when high levels of simple carbohydrates are ingested. Accordingly, patients who have experienced postgastric bypass bariatric surgery should avoid foods that are high in simple sugar content and replace them with a diet consisting of high fiber and protein rich food. Eating vegetables and salad is encouraged; beverages and alcohol consumption are better avoided[49].Go to:PSYCHOSOMATIC DISORDERS/DEPRESSIONMany patients usually experience enhanced self esteem and improved situational depression following weight loss. Depression often requires continued treatment, specially that, many patients with severe obesity often use food for emotional reasons. Therefore, when those patients experience a small gastric pouch postoperatively they may grieve the loss of food. Many studies documented the relationship between eating disorder and anxiety disorder, depression or schizophrenia[50,51]. Displaced emotions can result in somatization with symptoms of depression and psychosomatic disorders. It is important that clinicians recognize the psychological aspect of food loss after bariatric surgery, and reassure patients that the symptoms are related to the small gastric pouch size. Antidepressants often help to decrease the anxiety related to grieving associated with food loss, although the use of antidepressants needs to be approached with an empathetic style. Behavioral and emotive therapies are reported to be very helpful[52,53].Go to:OUTCOMEBariatric surgery remains the only effective sustained weight loss option for morbidly obese patients. The American Society for Metabolic and Bariatric Surgery estimated that in 2008 alone, about 220000 patients in the United States underwent a weight loss operation. The optimal choice for type of bariatric procedure, i.e., RYGB, SG, AGB or the selected surgical approach, i.e., open versus laparoscopic depends upon each individualized goals, i.e., weight loss, glycemic control, surgical skills, center experience, patient preferences, personalized risk assessment and other medical facilities. Laparoscopic sleeve gastrectomy is the most common bariatric procedure. However weight re-gain after long-term follow-up was reported[54-58]. Prospective studies and reviews report a general tendency for patients with metabolic disorders to improve or normalize after bariatric surgery. However weight loss is highly variable following each procedure. Recent studies have evaluated the potential impact of obesity on outcomes in organ-transplant recipients, for example bariatric surgery may be an important bridge to transplantation for morbidly obese patients with severe heart failure[59-63].Go to:RECENT ADVANCES IN BARIATRIC SURGERYA modified intestinal bypass bariatric procedure (Elbanna operation), reported a novel surgical technique designed to maintain good digestion, better satiety, and selective absorption with less medical and surgical complications (Figure ​(Figure5).5). This procedure preserves the proximal duodenum and the terminal ileum and thus preserving the anatomical biliary drainage and enterohepatic circulation[64,65].Figure 5Novel ElBanna surgical procedure.Recently, a novel bariatric technique dedicated; Modified Elbanna technique in childhood bariatric, showed promising success in pediatric surgeries (non published data).Go to:CONCLUSIONThe rising prevalence of overweight and obesity in several countries has been described as a global pandemic. Obesity can be considered like the driving force towards the pre-mature deaths. It increases the like hood for the development of diabetes, hypertension and NASH. The American Heart Association identified obesity as an independent risk factor for the development of coronary heart disease. In order to minimize post-surgical cardiovascular risk, surgical weight loss may become a more frequently utilized option to address obesity. Currently, bariatric surgery passes through a plateau phase, hence medical management and follow up of patients who have undergone bariatric surgery is a challenge.Go to:FUTURE RECOMMENDATIONSChildren obesity has become one of the most important public health problems in many industrial countries. In the United States alone, 5% of children have severe obesity. It is imperative that health care providers should identify overweight and obese children so as to start early counseling and therapy. To establish a therapeutic relationship and enhance effectiveness, the communication and interventions should be supported by the entire family, society, school, public media and primary health care. Bariatric surgery could be considered in complicated cases that failed all other options.Go to:FootnotesP- Reviewer: Amiya E, Firstenberg MS, Narciso-Schiavon JL S- Editor: Tian YL L- Editor: A E- Editor: Lu YJGo to:References1. Schauer PR, Kashyap SR, Wolski K, Brethauer SA, Kirwan JP, Pothier CE, Thomas S, Abood B, Nissen SE, Bhatt DL. Bariatric surgery versus intensive medical therapy in obese patients with diabetes. N Engl J Med. 2012;366:1567–1576. [PMC free article] [PubMed]2. Ng M, Fleming T, Robinson M, Thomson B, Graetz N, Margono C, Mullany EC, Biryukov S, Abbafati C, Abera SF, et al. Global, regional, and national prevalence of overweight and obesity in children and adults during 1980-2013: a systematic analysis for the Global Burden of Disease Study 2013. Lancet. 2014;384:766–781. [PMC free article] [PubMed]3. Hogan MC, Foreman KJ, Naghavi M, Ahn SY, Wang M, Makela SM, Lopez AD, Lozano R, Murray CJ. Maternal mortality for 181 countries, 1980-2008: a systematic analysis of progress towards Millennium Development Goal 5. Lancet. 2010;375:1609–1623. [PubMed]4. Rajaratnam JK, Marcus JR, Flaxman AD, Wang H, Levin-Rector A, Dwyer L, Costa M, Lopez AD, Murray CJ. 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Prevalence of alcohol use disorders before and after bariatric surgery. JAMA. 2012;307:2516–2525. [PMC free article] [PubMed]45. Sasse KC, Ganser J, Kozar M, Watson RW, McGinley L, Lim D, Weede M, Smith CJ, Bovee V. Seven cases of gastric perforation in Roux-en-Y gastric bypass patients: what lessons can we learn? Obes Surg. 2008;18:530–534. [PubMed]46. Capella JF, Capella RF. Gastro-gastric fistulas and marginal ulcers in gastric bypass procedures for weight reduction. Obes Surg. 1999;9:22–27; discussion 28. [PubMed]47. Abd Elrazek AE, Mahfouz HM, Metwally AM, El-Shamy AM. Mortality prediction of nonalcoholic patients presenting with upper gastrointestinal bleeding using data mining. Eur J Gastroenterol Hepatol. 2014;26:187–191. [PubMed]48. Abd Elrazek AE, Yoko N, Hiroki M, Afify M, Asar M, Ismael B, Salah M. Endoscopic management of Dieulafoy’s lesion using Isoamyl-2-cyanoacrylate. World J Gastrointest Endosc. 2013;5:417–419.[PMC free article] [PubMed]49. Ukleja A. 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Mechanick JI, Youdim A, Jones DB, Timothy Garvey W, Hurley DL, Molly McMahon M, Heinberg LJ, Kushner R, Adams TD, Shikora S, et al. Clinical practice guidelines for the perioperative nutritional, metabolic, and nonsurgical support of the bariatric surgery patient--2013 update: cosponsored by American Association of Clinical Endocrinologists, the Obesity Society, and American Society for Metabolic & amp; Bariatric Surgery. Surg Obes Relat Dis. 2013;9:159–191. [PubMed]59. Adams PL. Long-term patient survival: strategies to improve overall health. Am J Kidney Dis. 2006;47:S65–S85. [PubMed]60. Gore JL, Pham PT, Danovitch GM, Wilkinson AH, Rosenthal JT, Lipshutz GS, Singer JS. Obesity and outcome following renal transplantation. Am J Transplant. 2006;6:357–363. [PubMed]61. Meier-Kriesche HU, Arndorfer JA, Kaplan B. The impact of body mass index on renal transplant outcomes: a significant independent risk factor for graft failure and patient death. Transplantation. 2002;73:70–74. 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Why did you decide to have gastric bypass surgery?

I actually decided not to have bypass surgery. The reasons for this were numerous, but the main one was a much higher risk of complications from that versus vertical sleeve gastrectomy.Additionally, I wanted to be able to eat a wider variety of foods and after bypass many patients cannot tolerate a lot of foods. I still have things I cannot eat (beef - steak or ground beef or hamburgers are all off limits) and I can’t drink plain water anymore (it feels horrid in my stomach and now also tastes kind of like soap). Since that’s all I used to drink I am fairly bummed about that. I now have to drink Crystal Light (and there’s only one flavor I really like).Bypass patients typically see a larger weight loss, but the long term health consequences are very real and also very concerning (or were to me, at least). The risk of vitamin deficiency is much higher with bypass.I wanted to be able to utilize the principles of Intuitive Eating, along with Health At Every Size, that I spent over a decade working on, and bypass would’ve made that much more challenging. Since I have a very strong history with not one, but two, eating disorders (non-purging bulimia and binge eating disorder) I wanted to have a surgery done that would require less restriction in the long term (short term it’s still restrictive, up until you’re about 6 weeks post-op).It is important to know that all of the various bariatric surgeries come with risks, require major change in how you eat/live, run the risks of complications and can even cause death (as can any surgery). Lap Band is actually the one with the worst risks from complications (which doesn’t surprise me, given it involves a medical device and they are poorly regulated, to say the least). The newer procedure of gastric balloon, which is aimed at people who have very little weight they even “need” to lose (typically 50 pounds or less) in the first place, has already been linked to a number of deaths since it came out.Additionally, if you have your gallbladder the odds are very high you will eventually have to get it removed, as rapid weight loss triggers gallstone development (some bariatric surgeons have started to remove it when they perform the initial surgery, in fact, because of how common this issue is). You may get gout (inflammation caused by high uric acid) because of the rapid weight loss (I did).Finally, the psychological side effects cannot be ignored. Many people develop other forms of maladaptive coping mechanisms to deal with their emotions, since food is no longer a viable source for them. This leads to a much higher rate of alcohol and drug addictions in post-op patients.Whatever you decide, the most important thing to know is that while surgery has a higher success rate than traditional dieting in terms of weight loss and sustainability, it’s still not going to make everyone thin. In fact, many people will stop losing weight before they’re ever in a range that’s close to a “normal” weight if you go by BMI charts (which I don’t support since they’re used in ways they were never meant to be).My surgeon’s initial “best case” for me was 240 pounds and I literally laughed at him. I said, I am 41 and have been over 300 pounds since I was 15. That’s not happening.Interestingly, on the day of my surgery he came in with a best case of 300 lbs. Which is still unlikely to ever happen, honestly. I am currently at about 397 and I suspect I won’t lose anymore weight, or that any additional weight loss will be minimal.I am okay with that because I did not do this to be thin or look any certain way. I also didn’t do it for my health, because I knew there was a HUGE risk it could make me LESS healthy.I did it because I was hoping against hope I might regain some mobility lost due to multiple health issues and surgeries in the past eight years. I did it after I had an accident that resulted in my probably tearing my right bicep. They couldn’t do the tests to figure it out because, despite all the obesity epidemic hoopla, the medical profession still doesn’t truly accommodate fat bodies. I had the terrifying thought of, what if I get cancer?I’d basically be screwed. Imaging wouldn’t be available for me at my body size, and my grandmother had been dealing with three different types of cancer, so I was thinking of it a lot.Now, to make it crystal clear, it is incredibly fucked up that I had to resort to amputating 80% of my stomach in the hopes that, should I get injured or ill in the future, I’d be able to access medical equipment required to diagnose and/or treat me. This should not have to be a choice people need to make. Sadly, it is… the medical profession is far too comfortable just telling fat patients, lose weight and this will get better, even when that’s clearly untrue (like when I had strep throat and got a lecture about how I needed to lose weight).A bariatric surgeon is one doctor who will tell you point blank what most other doctors are still in denial about - that dieting to lose weight not only does not work for the vast majority of people, but that it also frequently leads to weight gain in the long term. However, they won’t necessarily be totally up front about what to expect from your surgery, either. They’re still selling a product (they will frequently refer to your new “stomach” as a “tool,” in fact). They are very much in it for profit. My surgeon has done over 6,000 surgeries of this nature. That’s crazy and certainly is making him bank. But it also means he’s very experienced.Research a surgeon thoroughly if you decide to pursue any form of bariatric surgery. Check their online ratings/reviews and trust your gut. If you are not comfortable with the surgeon, do you want that person to cut into your body while you are unconscious from anesthesia? Probably not. I can’t say I like my surgeon… as a person. But I felt comfortable with him performing a potentially risky surgery on me.At the end of the day, it’s an intensely personal choice. I am very much NOT a poster child or cheerleader for bariatric surgery. In general, in fact, I am against the entire industry. I believe these surgeries are far too often pushed on patients who are really fine and could be healthy at the size they are currently, if only they focused on health and not on weight loss. Many patients who have one of these surgeries are not only unprepared for the dramatic lifestyle changes it will bring but also for the psychological impact of rapid weight loss and a major shift in your day to day dynamic/routine.Patients are often given the idea that surgery will “cure” things like diabetes or high blood pressure. The truth is more complicated. It may put these conditions into a type of “remission,” but it is rarely long term even IF a patient maintains their weight loss. The reason for that is simple… high BP and diabetes, along with cardiovascular diseases have a HUGE genetic component. So many patients seem to be diabetes free initially but go on to redevelop it eventually.I also think that these surgeons prey on a vulnerable, oppressed population that has been convinced they need to be thin to fit into societal standards or to be happy, or even to be healthy and the latter happens when a patient is currently metabolically healthy far too often. If you don’t have any major health issues currently, why put yourself at risk of developing some by going through a dangerous surgery?That’s bullshit. I have an amazing life. It’s not perfect, by any means, but at whatever sizes I’ve been, I have lived my life to its fullest. I have a great marriage (almost 15 years) to a man I’ve been with for almost 20 years. He’s loved me at my lowest (adult) weight (325 for about 5 minutes) and at my highest weight (probably around 525 but that’s a guess).He has supported me whether I was dieting, not dieting or using the tools I learned in therapy with an eating disorder therapist (Intuitive Eating and Health At Every Size). When I made the brutally difficult decision to have bariatric surgery, he supported me in that, too. And he told me I could change my mind up until I was knocked out from the anesthesia and he’d still support me. A lot of fat people are told they’ll never find love (that included me) but it’s BS. I know so many fellow fat people in happy relationships. I know some in unhappy ones, too. So, in other words, we’re just like thin people that way.We travel. We have an adorable dog, our third one we rescued and adopted together. I have a life I am so grateful for, so much better than I ever could’ve imagined I’d be worthy of or would have when I was in my teens and even early 20s.Life is good.My surgery went without a hitch. Considering my past surgeries all had complications of some sort, I have to give my surgeon credit for that. However, the surgeon was no longer interested in me the second I was done. The last time I saw him was for 2 minutes in the hallway when I was walking (you have to get up to walk for blood clot prevention afterwards). All follow ups have been with one of the nurse practitioners, and honestly they’ve been fairly useless to me. I had an issue once when I thought I was having a complication post-op (I was about five months out at the time). It called the office at the urging of my husband, who was very concerned. It was during their lunch hour, however, so I spoke to the answering service and the doctor was supposed to call me back in 20 minutes. Not only did he never call, but when I called back after the lunch hour to speak to a nurse, it still took them over an hour to call me back.It turned out what I had was not (at least directly) related to the surgery (surgery of any sort can weaken an immune system, and particularly one where the result is you’re eating less nutrients than is normal). I had shingles, and was developing a fever from it. Still, it took them so long to get back to me at all. And this is a GOOD surgeon’s practice.Bottom line: If you are going to get any type of “weight loss surgery” you want to do a LOT of research. It’s something to take extremely seriously. If you don’t already have a psychologist/psychiatrist (I have both) to help you through the aftermath, you really should find one beforehand.

What is different between fasting and having bariatric surgery? Both severely restrict food consumption, but with fasting, you wouldn’t get sick, if you DID eat too much/or ate the wrong kind of food. Why is fasting almost universally condemned?

You made a false equivalence out of these two things: bariatric surgery and fasting. It sucks having to start an answer by pointing out a false equivalence. Bariatric surgery is not done for the same reason as fasting. Fasting is not a safe choice for everybody who opts for bariatric surgery.Bariatric surgery is a last resort extreme weight reduction option for those with a BMI of around 35, and often comorbid with type two diabetes and possibly hypertension, and for women, often with PCOS. Often, women who get bariatric surgery have been waiting to get pregnant. Surgery causes a spike in fertility, but a patient must be on birth control for two years following surgery, so that they may heal and readjust.The people who opt for this surgery are often on several medications and have tried everything under the sun to lose weight, have a history of fasting and yo-yo dieting, and actually re-gained more weight then they lost at any point.Before a person can have bariatric surgery, they must go through a series of counseling courses to make sure they are ready for the change. Only a couple of forms of bariatric surgery are reversible. Gastric bypass and gastric sleeve, for example, are permanent structural changes. In gastric bypass, part of your small intestine is moved up and attached where your top of your stomach would be. In gastric sleeve, your stomach is surgically turned into a sleeve by slicing most of it off. A bariatric surgeon will work with the patient to decide which particular surgery is the right one for them. It’s a life altering decision.After bariatric surgery, a person is usually on a liquid diet for a couple of weeks. After that, eating purées, high in proteins to facilitate healing, only easily digestible foods. Also, no carbonated drinks or alcohol. A person who goes through this will often be on vitamin supplements for the rest of their life. They are simply unable to eat enough to get the right amount of nutrients from their food. There are also fat malabsorption issues that arise out of bariatric surgery which means fat soluble vitamins are also forever a problem. Nutrient absorption problems will forever change a patient’s skin, hair, bones, and teeth.As you mentioned, a person who overeats or eats the wrong things after bariatric surgery can get sick really quick. It’s called dumping syndrome, and it happens because the stomach can only hold so little after surgery. Any extra, and undigested food trying to pass will cause a host of really unpleasant GI symptoms, and fast.Unlike fasting, bariatric surgery is done to facilitate a life-saving amount of weight loss. A person can fast for any reason they want to or for no reason at all. Fasting varies in form, but ultimately, it’s about periods of not eating. Fasting is not a weight loss solution for everyone. Diabetics have been found to experience hypoglycemia. Fasting is tough, too, for snackers. Fasting is not some kind of cure-all like some believe it is. While fasting is proven to improve biomarkers in some patients, studies have included really small sample sizes so far. These findings are not a definite.The most important thing about weight loss is this: a lifestyle habit a person can maintain and sustain. In many of the studies performed, people who did fasting every other day dropped out pretty quick. Fasting might work well for people who can do it and sustain it, but most people can’t, and that’s just the truth of it. Fasting is a solution that doesn’t last as a lifestyle change for most people. So, for this reason, health professionals will try to work with a client to get them on a lifestyle change they can maintain, and for the majority of health professionals, fasting is met with an eye roll and nothing more.The most important thing for a client seeking long-term weight loss is the ability to maintain the lifestyle change. Anybody can do fasting unless it is contraindicated by another condition. Not just anybody can stick to fasting. A healthy, balanced diet is always going to be better than a restricted diet, whether from surgery or voluntary fasting. Fasting takes both restraint and planning. It’s not a miracle idea. Nine times out of ten, a person who fasts abandons it quicker than a New Year’s resolution on week three.A2A, thanks Judith.

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