12 Signs & Signals To Know For Potential Issues After WLSJuly 13, 2020
Issues After WLS
If you’ve had WLS I would like to congratulate you on taking a huge step in getting your life back! If you are considering WLS then I would encourage you to get all the facts and proceed with a well-thought-out plan, you will not regret taking this step! It is important to know about the issues after WLS that can come up
In either case, this article about issues after WLS is written to give you an idea and is informational only. You MUST see an experienced physician to get the correct diagnosis and treatment plan. Many of these signs and symptoms may be a transient and normal adaptation of your body to the new anatomy created for weight loss.
Understanding the Issues After WLS
The importance and the issue of pain after WLS is frequently misunderstood. We have all experienced pain at some point in our lives. Anytime an insult is inflicted on the body we get an uncomfortable, suffering sensation that immediately grabs our attention. This is a protective mechanism that prevents ongoing harm to our bodies.
Imagine what would happen if you placed your hand on a hot stove and didn’t have pain sensation! Your entire hand will be burnt if you were not paying visual attention to it.
Pain serves as a warning system to alert us of something potentially dangerous and we need to focus our attention in that direction and to that site.
Post-operative pain is common after any surgery, the intensity of this pain is variable. It depends on the type of surgery you had, your pain threshold, chronic use of pain medications, and several other factors. Remember your skin and muscle were cut and in many instances sutured together after your procedure was completed, most of the pain is from the abdominal wall and not from the organs inside!
The pain needs to be assessed by your physician and he or she can tell you if it’s normal or abnormal. Having said that, most pain after surgery is completely normal and as time passes it gets better.
2. Nausea & Vomiting
Post-operative nausea and vomiting are some of the most common symptoms and issues after WLS. Remember the stomach is cut and sutured in most weight loss surgical procedures. When we add the stress of anesthesia to surgery, post-operative nausea risk is accentuated.
Your stomach will need some time to recover, on the other hand, your brain is trying to figure out what exactly happened to the stomach.
There are millions of nerve fibers connecting your gastrointestinal system to your brain and that feedback is very important for the healthy function of both organs. As both your stomach and brain understand how to deal with your new stomach your nausea symptoms will slowly resolve.
Nausea is the body’s attempt to lure you away from oral intake because it wants to rest. If that doesn’t work, it will get rid of the food you ingested back through your mouth, otherwise known as vomiting.
Again the stomach is attempting to recover and wants a little break from food. Vomiting blood or blood-tinged fluid immediately after surgery is very rare but may happen. Once again, the stomach was cut and sutured so a little blood inside of the stomach is completely normal.
Most bariatric centers of excellence implement specific pathways before and after WLS to decrease the potential of post-operative nausea and vomiting.
Since you have been on a low-calorie diet and, most surgeons have their patients on a liquid diet for several days prior to and after WLS, constipation becomes very prevalent. Furthermore, protein drinks may exacerbate constipation symptoms. In fact, almost ALL bariatric patients will have post-operative constipation.
If your constipation lasts more than 3-5 days, which means none or very hard bowel movements, you will need to take laxative.
I prefer a liquid form of laxatives and encourage patients to drink at least 64 ounces of fluid every day in the immediate post-operative period. As you progress through the different dietary stages constipation will improve.
After your WLS, especially once you get home, your immediate fight and flight hormones subside. These usually help you get through the initial two to three days after surgery and you’ll feel pretty energetic.
However, as their levels decrease you may feel tired and fatigue. Most surgeons will have you on a low calorie diet or clear liquid diet to deplete your liver from its sugar reserves in an attempt to shrink it, prior to your WLS. As your energy sources start running low, and your body’s need for large quantity of energy after surgery as it’s trying to heal, you will feel tired even if you attempt to perform simple physical activities.
As you advance your diet and replenish your energy reservoir you will feel more energetic. This usually takes anywhere between three to six weeks.
There are other causes of fatigue which are beyond the scope of this article.
5. GERD/Reflux and Heartburn
As one of the issues after WLS is the definite risk of developing GERD (Gastroesophageal Reflux Disease) after WLS.
Sleeve gastrectomy has the highest risk of GERD and heartburn after surgery, this is due to the way the stomach is cut.
The incidence of GERD after sleeve gastrectomy is about 30% (so 1 in 3 patients will develop heartburn symptoms after sleeve gastrectomy even if they didn’t have it before WLS).
The symptoms are usually well controlled with anti-acid medications. The risk of developing heartburn is significantly lower in gastric bypass.
6. Swallowing Difficulties
Swallowing difficulties/feeling food bolus is being stuck. The medical term for this is "dysphagia," immediately after WLS it’s fairly common to ‘feel’ food as it makes it way through the upper digestive tract.
When you swallow liquid or solids, they will slowly move from your mouth, esophagus, and into your new stomach. After the stomach is cut, it will be more narrow, swelling of the leftover stomach, the sleeved part, both of these factors along with some irritation at the suture line will slow the transit of food through this are. Many patients have a sensation of food either being stuck or very slowly transiting through the stomach which is located behind the lower part of your sternum.
If this occurs several weeks or months after your WLS it may be due to a narrowing and further investigations are needed to establish the diagnosis and come up with a treatment plan. Most of the time an endoscopy is needed and dilation of the narrowed (strictured) portion or connection, in the case of gastric bypass, may be done at the same time.
7. Late Abdominal Pain
For late abdominal pain, four weeks or later, it might be related to your WLS or it may be completely unrelated. Your surgeon will ask you questions to determine the potential causes of your abdominal pain and then decide if further investigations are needed.
Abdominal pain which starts insidiously and increases in intensity progressively without relief is concerning for acute conditions such as gastrointestinal ulcers, appendicitis, internal hernia (if the patient had gastric bypass or duodenal switch surgery) and in many instances, they may require surgical intervention. While these causes are rare it’s important to be aware of them and, your surgeon will certainly do that.
On the other hand, as you lose weight your chances of developing gallstones increase and you may develop acute cholecystitis which is an infection of the gallbladder and it’s usually treated with antibiotics and possibly surgery to remove it so it will not cause future problems.
Constipation due to inadequate water and fiber intake or gastroenteritis may also cause cramping abdominal pain and they are treated with intravenous or oral re-hydration.
As you can see the causes of abdominal pain can vary tremendously, the diagnosis can be tricky, it’s important to see an experienced physician to evaluate your pain and make sure the cause of the pain does not need surgical intervention.
There are two hormones that are associated with hunger, Ghrelin and Leptin.
Ghrelin is a hormone responsible for hunger, we believe it’s made and regulated by the stomach, the hormone is released when the stomach is empty. That’s a signal of low on calories. Its counterpart is Leptin which is the satiety hormone, this hormone is made in fat cells of the body.
Initially, after surgery, Ghrelin is decreased therefore our hunger sensation is decreased too. As time passes the body adapts therefore, the sensation of fullness will slowly decrease and feeling of hunger returns. This is a normal metabolic adaptation.
When this occurs it’s very important to discuss it with your bariatric surgeon, the intensity of the hunger sensation is variable from person to person. Some patients may get an insatiable hunger feeling and this may lead to significant weight gain. Dietary changes along with medication may help in curbing this sensation as your metabolic profile changes.
9. Weight Regain
A small amount of weight regain is completely normal after WLS, it usually occurs anywhere between nine months to one year, and lasts for a few weeks.
However, if the weight regain is very rapid or uncontrollable you should see your bariatric surgeon sooner than your routine scheduled appointment to halt or slow down weight gain.
The causes for weight regain are multiple but, generally speaking, it’s because of the metabolic adaptation which occurs during this post-operative period. Dietary changes and, on some occasions, medications will help in slowing the weight regain as your body’s hormones return to normal. It’s very important to work closely with your dietician during this phase to implement adequate dietary changes which will help you both in the short and long-term.
10. Vitamin and Nutritional Deficiencies
Regardless of the WLS procedure you had, taking your daily required dose of multivitamins, calcium/Vitamin D, Iron, Vitamin B-12, and other micronutrients is absolutely essential and must not be skipped or overlooked.
The dose may vary depending on your procedure, following these simple steps will prevent severe and potentially non-reversible neurological deficits.
The sensation of lower extremity weakness, pins and needles, lightheadedness, memory difficulties, fatigue, headaches, neurological clumsiness may be symptoms of nutrition deficiencies. If you suffer from these or family and friends notice them you have to seek medical attention.
In addition to vitamin and nutritional deficiencies, make sure to understand the impacts that medication absorption plays for each of the WLS procedures.
11. Excessive Weight Loss
Excessive weight loss is a common concern for many patients, which is exaggerated significantly. Patients usually tell me ‘I don’t want to lose too much weight!’
Excessive weight loss is very rare after WLS, it tends to happen in situations where post-operative complications occur.
For example, if there is a narrowing after either sleeve gastrectomy or gastric bypass, this will lead to an inability to get adequate nutritional and caloric intake. In certain circumstances, this may occur fairly rapidly.
Depending on the cause of the problem, surgical intervention in the form of temporary feeding tube or nutrient through the vein- known as total parenteral nutrition- may be needed to slow the weight loss and replenish the micro and macro-nutritional requirements.
12. Loose Skin
If your skin has been stretched for a long period of time, in other words, you have been suffering from obesity for many years and, have been successful in losing a significant amount of your excess weight, loose skin will most likely occur.
Your skin will generally recoil a little but in most cases, it would have lost a significant part of its elastic property. This means that abdominoplasty and body contouring will be needed to remove the rest of the excess skin.
This is as important as the WLS itself because the excess skin may cause ulcerations and recurrent infections at creases. You should wait until your weight loss has plateaued for at least three months before considering removal abdominoplasty and/or body contouring.
Most insurances may not cover abdominoplasty so, you may have to work with them to see if they are going to cover it.
What To Do With These Issues After WLS
These are some of the potential signs and signals which you may experience during your weight loss journey. Should you experience any of these signs and signals make sure to call your bariatric surgeon to discuss them with him/her and come up with a plan of action. Additionally, it is important to know the potential issues to watch for if you're a long-term post-op.
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ABOUT THE AUTHORDr. Husain Abbas of Memorial Advanced Surgery, is a Board Certified surgeon trained in Minimally Invasive Surgery. After his surgical residency at St. Mary's, a Yale University affiliated hospital, Dr. Abbas completed a fellowship in Minimally Invasive Gastroesophageal & Bariatric Surgery at the University of Florida, Gainesville. Dr. Abbas' expertise extends to a wide array of gastroesophageal disorders, anti-reflux surgery, complex hernia repairs, endocrine, oncology and bariatric procedures.
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