Supporting the Morbidly Obese Patient During and After Bariatric Surgery
Ninety-five percent of morbid obesity operations are or include gastric restrictive procedures. Those procedures include gastric bypass, vertical banded gastroplasty, the duodenal switch procedure, and the lap-band procedure.�²
Gastric Bypass
Surgeons have performed these operations for more than twenty-five years. A gastric bypass requires the stomach to be stapled, thus dividing it into a small and large section and connecting the smaller pouch to a portion of the small intestine (a limb). The length of the limb determines whether there is any malabsorbtion. This is the most common operation in the United States and is used frequently for those who have a greater than 50 kg/m�² BMI.
Vertical Banded Gastroplasty
In this procedure, the surgeon partitions the stomach in a similar manner to the gastric bypass. Then he inserts a band of plastic mesh into the opening between the sections and permanently limits the size of the pouch where food will be digested. The surgeon does not hook the intestine to the stomach as it is done in the gastric bypass. Studies indicate that this procedure may not allow for as significant a decrease in weight as that occurring after the gastric bypass. The studies also state that it is less successful for those who continue to eat sweets.
Duodenal Switch Procedure
This operation may be performed all at once or in two smaller surgeries. The first part of the procedure requires the removal of three-quarters of the stomach, leaving a stomach tube. Some patients opt only for the first part of the procedure. The second part of the procedure requires the disconnection of the duodenum, or first part of the intestine and the connection of another part of the small bowel, the jejunum. This bypasses a large portion of the bowel where most absorbtion occurs. The patient must modify his diet after surgery more than in the other procedures.
Lap-band Procedure
Newer than the other three procedures, the lap-band procedure is less invasive and not as complex. A band is inserted in the stomach that inflates over a period of weeks, thereby decreasing the size of the stomach. The operation is considered safe and reversible, but requires close clinical follow-up.
After surgery, the patient will encounter the hardest struggles. As a result, clinical pre-operative and post-operative support is critical. Most surgical teams include a nurse coordinator. He or she is responsible for overseeing and assisting with all preoperative teaching, making sure the patient fully understands what he will encounter in terms of radical changes in diet, complications, and the need for plastic surgery twelve to eighteen months following surgery. Ã?³ Once the patient proceeds to postoperative care, the nurse coordinator must once again “man the ship of support” to ensure the patient is successful in his long-term recuperation and adjustment.
A dietician is also essential in supporting the patient, for he will now be eating six small meals a day that are only a fraction of what he used to eat at a meal. Additionally, he is not allowed to consume food and beverages at the same time. High fats and sugars are to avoided at all costs, since they will cause a condition known as dumping syndrome in which the food passes too quickly from the stomach to small intestine, causing stomach cramping, diarrhea, nausea, dizziness, weakness, and rapid heart rate. Lactose intolerance may occur because the body may not produce enough of the enzyme lactase, the enzyme required to digest milk sugar or lactose. Additionally, certain food intolerances may occur, especially with regard to high fiber foods, such as red meat, bread, pasta, rice, and the membranes of citrus fruits. �²
There are five stages in diet a bariatric surgery patient must pass through over a period of weeks following surgery:
Stage 1-Clear Liquid Diet, sugar free or with no added sugar-This includes clear fruit juices, sugar-free powdered drink mixes, coffee, tea, or flat soda, preferably caffeine free, sugar-free gelatin and Popsicles, broth, and water.
Stage 2 – Full Liquid Diet, no added sugar/sugar free, low fat/nonfat-This includes the introduction of skim milk, low fat strained creamed soup, sugar-free low fat pudding, sugar-free, non-fat custard-style yogurt, sugar-free instant breakfast, thinned hot cereals, and protein drinks.
Stage 3 – Pureed Diet, sugar-free/no sugar added, low fat/nonfat-The patient may now proceed to regular custard-style yogurt, cottage cheese, pureed or baby meat, vegetables, and fruit, applesauce, strained creamed soup, mashed potatoes, and pureed tuna or egg salad. In this stage, the key is, “If you can chew it, don’t do it.”
Stage 4 – Soft Diet, no added sugar/sugar-free, low fat/nonfat-Now it’s time for hardier fare, such as baked white fish with no bones, imitation crab meat, well-cooked vegetables without seeds or skins, eggs (no fried ones), regular tuna and egg salad, and low fat or nonfat cheese.
Stage 5 – Regular Diet-It’s best for the patient to try one new food a day and build up. When eating, eat protein foods first. He must eat slowly and chew well and only drink fluids at least thirty minutes before he eats or a half hour to hour afterwards.
Complications facing the patient include: dumping syndrome, already discussed in this article; nausea and vomiting caused by eating too much at one time, drinking fluids with food, or from ulcers and strictures; hair loss, sometimes months after surgery, and constipation. The clinical team must encourage the patient to drink plenty of fluids, exercise regularly, try baby prunes for constipation, and take vitamins. Vitamins are essential, because malabsorbtion may occur. The patient may suffer from a vitamin or mineral deficiency.
Finally, twelve to eighteen months after surgery, the patient will most likely opt for plastic surgery. Since the skin has been stretched over time when the patient was at his heaviest, it has lost its elasticity. As a result, with the rapid weight loss, there will be excess skin. Lawrence Reed, a plastic surgeon from New York, does a three-part repair for the bariatric surgery patient:4
1) the lower body lift to improve tummy, thighs, buttocks, and back; 2) after a few months, the breast lift and inner thigh reconstruction; and 3) several months later, a repair of face, neck and arms.
Just because a patient loses weight and gets reshaped, doesn’t mean his life is also reshaped. A sound mental status is required, and he must be examined preoperatively to make sure he can cope with his life in the present and going forward. Many patients seek peers who have experienced bariatric surgery. There are support groups associated with most bariatric surgery centers and teams. They are important, because they represent a safety net that the clinical team cannot provide. No one knows what it fully feels like than those who took the giant steps required to find health and long-term satisfaction.
