Vertical Banded Gastroplasty About Morbid Obesity Surgery for Morbid Obesity Who are Candidates for Obesity Surgery Pre-Operative Evaluation The Operation Hospitalization Discharge Instructions Recovery Period Post -Operative Follow Up The Long Term

About Morbid Obesity

The term "morbid obesity" originated from Life-table statistics compiled by the Metropolitan Life Insurance Company which showed obesity of considerable magnitude to be a significant risk to life. Morbid obesity leads to such conditions as high blood pressure, gallbladder disease, gynecologic cancer, and most importantly, premature death. Morbid obesity is defined as: weight greater than 100 pounds over "ideal body weight" as determined by standard life insurance tables; absence of obesity-related glandular problems (endocrine disorders); medical problems associated with severe obesity. Morbid obesity is surprisingly common in the United States, affecting more than 7 percent of women and nearly 5 percent of men. The long term failure rate of various dietary treatments in patients with morbid obesity approaches 100 percent. This page of the GSI Website answers common questions regarding surgery for morbid obesity.

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Surgery for Morbid Obesity

Due to the high incidence of failure of non-operative methods of weight control in the morbidly obese, surgery has become an acceptable method of treatment. Gastric operations for treatment of morbid obesity were introduced in 1967. Gastric reduction surgery restricts oral intake by closing off the upper part of the stomach using intestinal staples so ingestion of small quantities of food produces a "feeling of fullness."  In 1991 a National Institutes of Health consensus development panel endorsed gastric restrictive surgery as appropriate treatment for patients with medically severe obesity defined according to guidelines similar to those listed above.

Dr. William H. Toedebusch began his program of surgical treatment for morbid obesity at Reid Hospital  in 1982. Dr. Toedebusch is a member of the American Society of Bariatric Surgery. Today the most commonly performed gastric reduction operation is gastroplasty.  With gastroplasty, the upper stomach is stapled in a vertical direction with a pre-measured plastic band separating the upper and lower stomach. The band prevents the stomach from stretching at this point. The popularity of this procedure over other weight loss procedures, is because the incidence of early postoperative complications are significantly reduced. Long-term complications are also significantly reduced with this procedure as opposed to gastric bypass type procedures.

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Who are Candidates for Gastric Reduction Surgery

Individuals who weigh at least 100 pounds above ideal body weight as determined by standard life insurance tables or a body mass index (BMI) >40 kg/m2. Body mass index is a relatively complicated mathematical method of calculating the degree of obesity. Exceptions have been made in patients with coexisting medical problems who are almost 100 pounds over ideal body weight with a BMI> 35 kg2/m2. Individuals who have failed after serious attempts at weight reduction such as a physician-prescribed diet, behavior modification, counseling with dietitian, or enrollment in a group weight reduction program such as Weight Watchers, Nutri-Systems. or Overeaters Anonymous. Failure of unsupervised attempts at weight reduction on the part of prospective patients is not considered sufficient justification for the operation.

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Preoperative Evaluation

All prospective patients considering gastric reduction surgery with Dr. Toedebusch undergo screening interviews with the surgeon who must decide whether the patient  is a good candidate for the procedure. Glandular (endocrine) disorders must be ruled out as the major contributing factor to morbid obesity. Psychological stability must occasionally be determined by preoperative interviews.

There must be understanding of the risks associated with the operation and acknowledgement of the fact that the operation is not guaranteed to lead to a specified amount of weight loss. In rare cases, other medical problems may make the risk of a major abdominal operation under general anesthesia too great. Usually, obesity related medical problems are considered an indication to perform surgery for morbid obesity.

Reasons not to perform gastric reduction surgery include the presence of active peptic ulcer disease or advanced cardiac (heart), pulmonary (lung) or renal (kidney) disease.  Because gastric reduction surgery is still relatively new, there is potential for the development of other complications which have not yet been recognized. A barium upper GI contrast study and ultrasound of the gallbladder are performed following the screening interviews. The upper GI is performed to rule out unexpected (occult) peptic ulcer disease. The ultrasound is performed to determine if you have gallstones. If gallstones are found, the gallbladder is removed at the same time as the gastric reduction procedure.

After the results of these tests are reviewed and the results of the interview have been analyzed, admission to the hospital for the operation is scheduled. A physical examination is also performed preoperatively.

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The Operation

Stapled gastroplasty can usually be performed in 1 1/2 to 2 hours while additional gallbladder surgery may add an additional hour. Family members and friends may wait in the surgical waiting room of the hospital during the operation and speak with the surgeon shortly after the operation is completed. Most patients spend an hour in the recovery room before returning to their room in the surgical intensive care unit. Patients with known cardiac or pulmonary problems usually spend one or two nights in the surgical intensive care unit so they can be more closely monitored.

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Hospitalization After the Operation

On the first day following surgery, the patient is given clear liquids such as juice or Jell-O. The second day following surgery the diet consists of soft food such as mashed potatoes and applesauce. On the third day following surgery most patients are discharged to home. Prior to discharge, all patients are counseled by the dietitian who reviews all the food groups in the diet and emphasizes the need to take small bites and chew the food carefully.

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Discharge Instructions

Do

	sip liquids
	chew solid foods carefully
	take multi-vitamin with iron supplement
	follow new menu of soft foods

	crush all pills and tablets for the first few weeks
	stop eating at first feeling of fullness--learn this signal well!

Don't

	eat fast
	swallow large pieces of food
	eat beyond the first feeling of fullness
	eat when you are not hungry
	try to eat too much at one time

If  vomiting occurs, patients should  stop drinking and eating until the feeling of nausea passes. After the nausea disappears, the patient should resume drinking liquids before attempting to eat solid foods. Persistent vomiting of solids and liquids should be reported to your surgeon.

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Recovery and Activity

Following discharge form the hospital, patients should not drive for one  week and should not attempt any strenuous activity, particularly heavy lifting, for approximately four weeks. Patients may walk as much as they wish, climb stairs as they need to, and take baths or showers. It is not uncommon to feel weak and tired immediately after discharge for the hospital. The body is still recovering from the stresses of a major operation and the feeling of weakness may be somewhat prolonged because weight loss is occurring during the recovery period. A regular exercise program will speed the recovery process.

Some patients with sedentary-type jobs have returned to work as soon as two weeks after the operation. Patients with physically demanding jobs should wait four weeks before returning to work.

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Post-Operative Follow Up

Postoperative follow-up after gastric reduction operations is extremely important for several reasons. The success of these operations is not determined at the time of discharge. Weight loss after stapled gastroplasty generally occurs over a  twelve to eighteen month period. Counseling by the nutritionist is important as the nutritionist will emphasize the importance of making appropriate food choices. These choices must be made properly in order to maintain a balanced diet and to avoid the high calorie liquids and soft foods (junk foods) which can defeat the purpose of the operation. All gastric reduction operations can be defeated by consuming too many calories.

The follow-up visits are also very important to track your weight and maintain a constant weight loss. The best weight loss generally occurs in patients who regularly keep their follow-up visits.

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The Long Term

Weight loss after gastric reduction operations is gradual and occurs at the greatest rate during the first several months after the operation. Over the long term, consistency rather than rapidity of weight loss is stressed. After a few months the rate of weight loss will gradually decrease. Not every patient will reach ideal body weight.

The main reasons for poor weight loss after gastric reduction surgery are bad food choices and frequent snacking. Patients are encouraged to see their own medical doctor at regular intervals after surgery, particularly for adjustments in their medication. With steady weight loss, patients often require lower doses of medication for diabetes and high blood pressure. Patients may not require any medications for these problems after achieving a substantial weight loss.

All gastric reduction operations are potentially reversible. Reversal requires an operation of the same magnitude and risk as the original operation. Reversal of gastric reduction operations is uncommon. In the long term, changes in the original configuration of the operation can occur. Disruption (pulling out) of the staples is now an uncommon problem and usually does not occur beyond six weeks from the time of surgery. Stretching of the upper part of the stomach may occur to some degree. but is rarely a reason for inadequate weight loss. The major reason for inadequate weight loss following surgery in between meal snacks of junk food. The patients who eat healthy foods on a regular schedule and avoid between meal snacks enjoy the greatest success in weight loss and long term weight control.

For further information on this topic, please visit the American Society for Bariatric Surgery web site at http://www.asbs.org.

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