Bariatrics of Texas - About Us

Making the decision to seek bariatric surgery is a step that must be carefully and thoughtfully considered. Many patients who have been through bariatric surgery say they would do it again, that bariatric surgery has been a life-saving step for them. On the other hand, there are inherent risks as well as physical and lifestyle changes, so the decision to have bariatric surgery requires a thorough understanding of everything involved. We require that prospective patients scrutinize educational materials we provide them to understand our treatment options. We also require that they visit with patients who have been through the surgery, so they can know what to expect, both good and bad. The National Institutes of Health (NIH) suggests a few important questions to ask yourself in deciding whether weight-loss surgery is right for you.

"Are you:

1.	unlikely to lose weight or keep weight off long-term with nonsurgical measures?
2.	well informed about the surgical procedure and the effects of treatment?
3.	determined to lose weight and improve your health?
4.	aware of how your life may change after the operation (adjustment to the side effects of the operation, including the need to chew food well and inability to eat large meals)?
5.	aware of the potential for serious complications, dietary restrictions, and occasional failures?
6.	committed to lifelong medical follow-up and vitamin/mineral supplementation?

Remember: There are no guarantees for any method, including surgery, to produce and maintain weight loss. Success is possible only with maximum cooperation and commitment to behavioral change and medical follow-up-and this cooperation and commitment must be carried out for the rest of your life."

NIH Publication No. 04-4006, December 2004

We offer patients the most sophisticated options in bariatric surgery treatment:

Laparoscopic Adjustable Gastric Band (Lap Band)

Roux-en-Y Gastric Bypass


	Lifestyle changes

It is also very important that patients exercise daily for the rest of their lives, as long as they physically can. Some patients may also need to develop new coping skills if food consumption has been a way of dealing with stress in the past. So many daily cultural activities are centered around eating that it is important to prepare for the anticipated modifications that will be necessary. Patients should realize they will be limited not only in how much they can eat, but in the types of foods they can eat. All of our patients must receive dietary/nutritional education as well as psychological evaluation before receiving clearance for surgery. All patients must attend the support group prior to surgery and are strongly urged to continue after surgery. As well, all patients are required to quit smoking prior to surgery.

Risks of Lap Band

	Vomiting - This is one of the most common problems. It occurs when the patient eats too much or the narrow passage into the larger part of the stomach becomes blocked, for example, by fibrous vegetables or doughy bread.
	Band Slippage - Slippage or prolapse of the stomach through the band can occur. Symptoms include heartburn, vomiting, difficulty swallowing, coughing spells particularly at night, wheezing and the ability to tolerate fluids only. This may require surgical correction.
	Erosions - Erosion of the Lap Band into the stomach is uncommon, but can occur. The diagnosis is confirmed by endoscopy and correction made surgically.
	Problems with the port or tubing - Breaks in the tubing or problems with the port can occur and may need to be corrected surgically.
	Respiratory problems - This is always a risk following general anesthesia. Prevention consists of frequent deep breathing following surgery.
	Bleeding - Despite using all precautionary measures, there is a small chance of bleeding during or after any major surgery, resulting in possible transfusion or re-operation.
	Postoperative Infection - This may involve the internal organs or be limited to the abdominal wall. Antibiotics are given perioperatively to all patients. Postoperative infection is uncommon, but when it occurs, it is treated aggressively.
	Blood clotting - This can occur in the leg veins during any major surgery, and increases in frequency with the degree of obesity. To reduce the likelihood of clots, low-dose heparin injections are given, inflatable boots or stockings are used, and patients walk soon after surgery.
	Cigarette Smoking - Patients are required to quit smoking prior to surgery. Smoking can cause many serious complications following surgery, including pneumonia, poor wound healing, and pulmonary embolism (clot blocks blood supply to the lungs).
	Pregnancy - Can occur more easily following surgery in previously infertile females. In anticipation of pregnancy, getting proper nutrition and vitamins (especially folate) at all times is essential even before pregnancy occurs and certainly during pregnancy. Patients should notify their surgeon as well as obstetrician as soon as possible when they do become pregnant.
	Death - There is an inherent risk of death with any and all surgical procedures. The NIH reports that in less than 1% of all Lap Band cases, complications can result in death.

This procedure does entail a greater degree of structured follow-up than Gastric Bypass. National reports show a 10% re-operation rate due to long-term problems that may develop with the band. In general, Gastric Bypass shows better results in maintenance of long-term weight loss. It is not unusual for some patients who have higher BMIs and have had Lap Band to decide at a later time to have Gastric Bypass. The important thing is for each patient to make a knowledgeable decision about which procedure is right for him or her.

Lifestyle changes

The goal of successful bariatric surgery is to provide a tool to achieve improved health and quality of life. Even though a new, small stomach restricts the amount of food that can be eaten, as well as types and consistencies of foods, the overall success of surgery depends on the patient's lifelong commitment to a healthy lifestyle. This includes eating a high protein diet, taking proper vitamin and mineral supplements, drinking enough fluids, and avoiding high sugar foods, alcohol, caffeine, and carbonated beverages. It is also very important that patients exercise daily for the rest of their lives, as long as they physically can. Some patients may also need to develop new coping skills if food consumption has been a way of dealing with stress in the past. So many daily cultural activities are centered around eating that it is important to prepare for the anticipated modifications that will be necessary. Patients should realize they will be limited not only in how much they can eat, but in the types of foods they can eat. All of our patients must receive dietary/nutritional education as well as psychological evaluation before receiving clearance for surgery. All patients must attend the support group prior to surgery and are strongly urged to continue after surgery. As well, all patients are required to quit smoking prior to surgery.

Reaction of Family and Friends

The reaction of family and friends to the idea of bariatric surgery can often be negative. There is no question that there is a significant societal stigma associated with the history of bariatric surgery, since some of the earlier surgical procedures did not provide good patient outcomes. Today many well-meaning people have a narrow understanding of what is involved with personal weight control, unfortunately. They may often make judgmental statements to the effect that if the overweight person would only eat less and exercise more, the morbidly obese person's problems would all be easily solved. They are not aware of many of the underlying complex issues, genetic and metabolic, that are an integral part of morbid obesity. It is incorrect to believe that bariatric surgery is in any way an easy way out. Rather, the decision to have bariatric surgery requires considerable psychological preparation, courage, and commitment. Bariatric surgery is a radical measure that should be considered only after exhausting all other non-surgical treatment options, confirming medical indication, and ruling out contraindications.

Risks of Gastric Bypass

It is extremely important that prospective patients and their families have a good understanding of all the risks and side effects associated with bariatric surgery. Bariatric patients are considered to be a high-risk surgical population. National reports show a relatively low morbidity (5-8%) and mortality rate (1%) for the open Roux-en-Y Gastric Bypass treatment compared with other surgeries. Risks include the following:

	Respiratory problems - These are the most common, but they are prevented by early walking and frequent deep breathing following surgery.
	Anastomotic leak - When the intestine leaks at the site of connection to the stomach or to the other part of intestine. This may result in infection and require re-operation or placement of drains by the radiologist in x-ray. This occurs in less than 0.01% of our patients (vs. national rates averaging 2-7%).
	Bleeding - Despite using all precautionary measures, there is a small chance of bleeding during or after any major surgery, resulting in possible transfusion, re-operation, or removal of the spleen. Dr. Warnock's bleeding complication rate is far above average, less than 2%.
	Blood clotting - This can occur in the leg veins during any major surgery, and increases in frequency with the degree of obesity. To reduce the likelihood of clots, low-dose heparin injections are given, inflatable boots or stockings are used, and patients walk soon after surgery. Dr. Warnock's clotting complication rate is less than 1%.
	Postoperative Infection - This may involve the internal organs or be limited to the abdominal wall. Antibiotics are given perioperatively to all patients. Postoperative infection is uncommon, but when it occurs, it is treated aggressively. Skin infections are usually self-limited and are easily treated by opening up the incision and allowing the wound to heal from the bottom up.
	Hernia - Because of the great pressure placed on the abdominal incision by an obese belly, sections of the wound may pull apart and result in hernia formation. An abdominal binder helps to support the abdominal muscles and incision as well as minimize pain when coughing. However, hernia does occur in 20% of patients over 300 pounds. It is easily repaired with another minor operation.
	Bowel obstruction - Adhesion (scar tissue formation) in the abdomen can occur after any abdominal operation. This scarring can lead to blockage of the intestine and result in pain, nausea, or vomiting. In 1% of patients, another operation is needed to break up the adhesions.
	Ulcers - These can occur at the small intestine or stomach following gastric bypass (2-4% of patients, similar to incidence in general population). Stomach ulcers are often caused by smoking, overeating, aspirin, non-steroidal anti-inflammatory drugs, or cortisone use. Medications can usually treat ulcers.
	Dumping Syndrome - This can occur when patients eat sugars or carbohydrates following gastric bypass. This involves nausea, flushing, cramping, and diarrhea due to the body's reaction to sugary or rich foods. Patients rapidly learn how to avoid the triggering foods.
	Constipation or Diarrhea - Since food intake is greatly decreased compared to prior to surgery, bowel movements will generally be decreased. Drinking adequate fluid (48-64 oz. per day) and eating high-fiber foods (fruits, vegetable, whole grains) can help prevent hard stools. On the other and, diarrhea can be caused by eating food that is too rich or greasy following surgery. By following post-operative dietary recommendations, patients can usually learn how to avoid these problems.
	Anemia - Due to the anatomical changes of the stomach and intestine, absorption of iron and vitamin B12 is altered by gastric bypass, and anemia may result. To prevent this, it is absolutely essential that patients take supplemental iron and vitamin B12 and have life-long medical follow-up at least annually. Regular, commercial daily multivitamins or children's chewable supplements are not effective in meeting all of the special nutritional requirements. We recommend vitamin and mineral supplements formulated specifically to meet the dietary needs of gastric bypass patients. Menstruating females should take 30 mg iron daily, postmenopausal females and males should take 15 mg daily. Patients should never donate blood, as this depletes iron stores. Patients should also take at least 200 mcg of Vitamin B12 daily after gastric bypass. Many patients also require periodic injections of vitamin B12 to supplement the oral intake.
	Calcium Deficiency - Calcium absorption is more limited after gastric bypass surgery due to changes in the intestinal tract. This can result in bone loss or osteoporosis with resultant fractures. To avoid these problems, we recommend taking at least 600mg calcium citrate or 1000mg elemental calcium per day along with Vitamin D and magnesium to increase absorption following gastric bypass.
	Hair Changes - Some patients will experience some thinning of the hair during the first six months after surgery. This is due to lack of protein in the diet. Protein is key to healthy hair and nails as well as to proper brain function and energy level. Hair thinning will usually reverse itself after 6 months of adequate protein intake, i.e. through protein supplements. After surgery, women need 40-50 g protein daily, and men need 60-80 g protein daily.
	Cigarette Smoking - Patients are required to quit smoking prior to surgery. Smoking can cause many serious complications following surgery, including pneumonia, poor wound healing, and pulmonary embolism (clot blocks blood supply to the lungs).
	Pregnancy - Can occur more easily following surgery in previously infertile females. It is important that gastric bypass patients avoid getting pregnant during the first year following surgery. In anticipation of pregnancy, taking needed supplements for protein, folate, calcium, zinc, iron, and vitamin B12 at all times is essential even before pregnancy occurs and certainly during pregnancy. Patients should notify their obstetrician as soon as possible when they do become pregnant.
	Death - There is an inherent risk of death with any and all surgical procedures. The national bariatric surgery mortality statistics show an average incidence between 0.5-2.0%. Bariatrics of Texas is glad to report a mortality of less than 0.1%.



	Adjustable Gastric Banding (Lap Band)

"Advantages:

Adjustable gastric banding is easier to perform and is generally safer than gastric bypass. Banding is usually done via laparoscopy, is more easily reversed if necessary, and results in few nutritional deficiencies.

Disadvantages:

Patients who undergo lap band generally lose less weight than patients who have gastric bypass, and are less likely to maintain weight loss over the long term. Patients generally lose about half of their excess body weight in the first year after lap band. By 10 years, as few as 20 percent of patients have kept the weight off, although long-term results with lap band are still being studied. Some patients regain weight by eating high-calorie soft foods that easily pass through the opening to the stomach. Others are unable to change their eating habits and do not lose much weight to begin with. Successful results depend on the patient's willingness to adopt a long-term plan of healthy eating and regular physical activity."

Gastric Bypass

"Advantages:

Most patients lose weight quickly and continue to lose for 18 to 24 months after the procedure. With the Roux-en-Y gastric bypass, many patients maintain a weight loss of 60 to 70 percent of their excess weight for 10 years or more. Because it results in greater weight loss, gastric bypass may also be more effective in improving the health problems associated with severe obesity, such as hypertension, sleep apnea, type 2 diabetes, and osteoarthritis.

Disadvantages:

Gastric bypass is more radical and invasive than lap band. Since gastric bypass causes food to bypass the duodenum and jejunum (where most iron and calcium is absorbed), nutritional deficiencies are more likely to occur. Menstruating women may develop anemia because not enough vitamin B12 and iron are absorbed. Decreased absorption of calcium may also bring on osteoporosis and related bone diseases. Patients must take nutritional supplements that usually prevent these deficiencies. Patients having gastric bypass may also experience 'dumping syndrome', an unpleasant reaction that can occur after a meal high in simple carbohydrates or sugars where stomach contents move too quickly through the small intestine, causing symptoms such as nausea, bloating, abdominal pain, weakness, sweating, faintness, and sometimes diarrhea after eating."

NIH Publication No. 04-4006
December 2004