Gastric Bypass Long-term Complications

I am a 64 y/o female, 20 years post roux-en-y gastric bypass. I have GERD, a “small” hiatal hernia, Barrett’s esophagus, nighttime bile regurgitation, and bilious vomiting after any decent sized meal. I continue to get worse each year. My GI doctor does not believe it is possible for a gastric bypass patient to have GERD. He believes I simply misunderstand the meaning of GERD. I am so frustrated and miserable. Where should I go from here? Continue reading “Gastric Bypass Long-term Complications” →

I was asked to review a study titled “Laparoscopic Treatment of Gastroparesis: A Single Center” submitted for publication in SOARD (Surgery for Obesity and Related Diseases). It is a single center, retrospective study. The charts of 93 patients with either idiopathic or diabetic gastroparesis were reviewed over a period extending from 2003 till 2014. Most patients were treated with gastric electric stimulator implantation. 15 patients underwent Roux-en-Y gastric bypass surgery.

The authors showed that gastric bypass surgery unlike gastric electric stimulation is not associated with statistically significant improvement in vomiting and pain. They also showed that 40% of operated patients continued to use an antiemetic and or pro-kinetic medication after either gastric bypass or gastric electric stimulation. 18% of patients required reoperation. Most of those patients underwent gastric electric stimulator removal. The authors conclude that surgery is feasible and effective for gastroparesis treatment. Although both procedures have some degree of efficacy, Gastric Electric Stimulation seems to provide improvement of more gastroparesis symptoms.

Gastroparesis incidence is rising and we still don’t have a good understanding of its pathophysiology. Most importantly, there is no established effective treatment guidelines for gastroparesis. Many gastroparesis patients are left untreated or poorly treated with symptoms that significantly diminish their quality of life and overall health.

Randomized, prospective controlled studies have clearly shown that gastric electric stimulation showed no symptom improvement in gastroparesis patients. RYGB is not well studied for gastroparesis treatment. In my personal experience, I have seen no improvement of gastroparesis symptoms following RYGB especially in severe and medically refractory cases.

I disagree with the author’s conclusion stating that gastric bypass and electric stimulation are effective surgical solutions for gastroparesis. According to this study, gastric bypass did not alleviate vomiting and pain and gastric electric stimulation, GES, showed symptom improvement in around 60% of patients. GES and gastric bypass procedures have therefore limited efficacy in gastroparesis management.

I think it is very important for general and bariatric surgeons to understand that gastric bypass surgery is not a good option for medically refractory gastroparesis cases. I have developed a procedure for treatment of gastroparesis, few years ago, based on published reports showing improved gastric emptying following gastric sleeve surgery. A longitudinal gastrectomy or modified sleeve gastrectomy that preserves the gastric antrum (stomach pump) and leaves some gastric fundus (especially for the malnourished patients) has been amazingly effective for gastroparesis treatment in my private practice. I have used this approach in around 10 patients with great results. These patients had complete resolution of all gastroparesis related symptoms including nausea, vomiting and abdominal pain. Any outcome short of complete symptom resolution should not be labeled as “effective”.

Resecting the greater curvature while preserving the gastric antrum has a real potential for being a breakthrough treatment for this poorly understood disorder. Prospective randomized studies evaluating the modified sleeve gastrectomy for gastroparesis treatment are needed to help us improve our care of this medical condition.

Jimmy is a 50-year-old male who has been struggling with excess weight for the past 25 years of his life. 15 years ago, he underwent a purely restrictive procedure called Molina band in Houston, TX. Through an open approach, the weight loss surgeon at the time, placed a Gore-Tex band around the upper stomach creating a small gastric pouch with a narrow opening. The mechanical restriction allowed Jimmy to lose some of his excess weight. However, within few years and as it is expected with purely restrictive procedures he gained back around 100 pounds. Furthermore, he developed significant narrowing of the gastric pouch opening leading to gradual worsening of acid reflux, food regurgitation, inability to tolerate solid diet and daily vomiting. Over the past 10 years, Jimmy has been living on a puree diet including ice cream.

When Jimmy presented to my office, it was obvious that he had gastric pouch outlet obstruction. He underwent an upper endoscopy that confirmed the diagnosis and was immediately scheduled for revision surgery. The procedure we agreed upon was conversion of Molina band to Roux-en-Y gastric bypass. Jimmy underwent the surgery with no complications and had an uneventful recovery in a very short period. His heartburn and food regurgitation have resolved. His diet choices include now fruits, vegetables and lean proteins. He felt more energetic and was started to exercise daily. Jimmy likes weight lifting and one year after surgery he lost 110 pounds while building an impressive body physique.

Jimmy is the perfect example of a star bariatric patient. He used the gastric bypass procedure as a tool to overcome excess weight, sleep apnea, acid reflux and hypertension. He followed Houston Weight Loss Surgery Center recommendations and adopted a healthy lifestyle that allowed him to achieve the goals he has always wanted: live a healthy, happy and disease free life. If you or someone you know is interested in losing their excess weight and gain back their health give us a call. Our team of weight loss experts are happy to assist you.

Recently I have seen a good number of patients who had successful gastric bypass surgery several years ago and now are gaining weight back. Erin, for example, has lost 90 pounds after her bypass surgery and has managed to maintain the weight loss. For nine years, Erin has enjoyed her new life; free of medications for hypertension and diabetes, she traveled all over the world, hiked the Appalachian trail, enjoy her daily swimming and many other activities she was not able to do before her weight loss surgery.

Suddenly, Erin started gaining weight (20 pounds over the past 8 months). She still has excellent restriction and appetite control. Erin, however, admits to “munching on peanut butter and cheese crackers throughout the day”. She reports that she has recently developed this new habit and started buying boxes of cheese crackers to stock her pantry!

I have always been intrigued by this behavior. Why do bariatric patients revert to old habits? Habits they have overcome longtime ago and as a result they have enjoyed years of healthy happy living.

The answer is STRESS. The majority of patients that I have encountered in my practice, who regain weight many years after gastric bypass surgery report new onset anxiety and stress.

Chronic stress is one of the main reasons for weight gain in the 21st century. Whether you had bariatric surgery or not, chronic stress increases body cortisol level, which in turn leads to increased insulin resistance. High insulin resistance prevents the movement of sugar from the blood stream into muscles to be metabolized. Instead, excess sugar moves into fat stores favoring weight gain.

Furthermore, in addition to disrupting the metabolic machinery that burns excess calories and fat, chronic stress prevents an individual from exercising. Most people these days respond to stress by stewing in frustration and anger. Instead of moving, eating becomes the activity of choice to relieve stress. They stock their homes with an endless array of junk food items (crackers, pretzels, chips, ice cream, candy bars…) for munching on day and night. Grazing on junk food is the worst thing you can do to your gastric bypass. In addition to the hundreds of calories added per day, the efficacy of gastric bypass in dealing with processed food is very limited. Our intestines are not made to handle junk food. The end result of junk food consumption is invariably weight gain, diabetes, depression, hypertension, and sleep apnea…

In my next blog, I will go over techniques and solutions for coping with stress. Until then, try to relax, exercise and eat healthy.