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Duodenal Switch Information Zone Search the Duodenal Switch Information Zone! Search Query Read and Post in the Duodenal Switch Support Forums! The entire contents of this page are used with permission, and are copyright ©2000 by Douglas S. Hess, MD, FACS, et al, all rights reserved. Text, graphics, and HTML code are protected by US and International Copyright Laws, and may not be copied, reprinted, published, translated, hosted, or otherwise distributed by any means without explicit permission. Correspondence should be directed to Douglas S. Hess, M.D., 640 South Wintergarden Road, Bowling Green, Ohio 43402, USA. Telephone: 419-352-1452; Fax: 419-352-1244 Introduction Why the BPD? Anatomy of the Digestive System How Digestion Works Surgical Procedure How This Operation Works Important Features of this Procedure Supplements Required after Surgery Special Note on Calcium Childbearing Risks and Complications Blood Loss Long-Term Complications Risk Factors Associated with Accelerated Bone Loss Diarrhea Bad Breath Flatulence Follow-up Late Weight Gain Food Types Food Ideas Some Final Thoughts INTRODUCTION No other medical condition has been more misrepresented, misunderstood, and maltreated as much as obesity. Current scientific information tells us that obesity is mainly a hereditary disease, passed down through the genes. The exact method of transmission is not known, and the expression of obesity varies with social, environmental, cultural, economic and psychological influences. The adverse effects of obesity on health and longevity are many, and include (but are not limited to), hypercholesterolemia, diabetes mellitus, an excess mortality from many cancers, hypertension, gallbladder disease, gastrointestinal disorders, menstrual irregularities, fertility problems, degenerative arthritis, coronary artery disease, and arterial sclerotic disease. Obesity is seldom the result of a glandular or hormonal problem, an eating disorder, a lack of willpower, or a psychological disorder. Morbid obesity is defined as being above 75 pounds over ideal weight, but to be considered for surgery one must weigh 100 pounds or more over their ideal weight, and/or have one or more of the co-morbidities (associated diseases) listed above. There are degrees of obesity, of course, and there are certain terms used to describe the severity of obesity such as “superobese” (>225% overweight) and “mildly obese” (20-50 pounds overweight). Despite the numerous attempts at weight loss, many people just cannot get the excess weight off and keep it off. Because the non-surgical methods of weight control used by the morbidly obese person have failed us miserably (with many initially losing weight and then gaining back the original weight plus some more) we have chosen the Biliopancreatic Diversion procedure as we feel it is the superior method for long-term weight loss. WHY THE BPD? The concept of controlling obesity through surgical methods has been practiced for nearly forty years. It evolved from surgical procedures that were performed on ulcer and cancer patients in which large portions of the stomach or small intestine were removed. Through medical observations, it was determined that these patients often lost weight. Some could not eat enough food and some could not absorb all that they were able to eat. Surgeons first bypassed large amounts of the small bowel to cause poor absorption of food and produce weight loss using a procedure called a small bowel bypass (a malabsorption procedure), which is no longer performed today because of the long-term complications. Several years later the restrictive procedures were developed in which the stomach was stapled closed so you could eat only a small amount. Generally, the size of the stomach is ½ to 1 ounce and has a small opening so that the food empties from the stomach slowly. This is called a gastric bypass roux-en-y (GBR) or a vertical banded gastroplasty (VBG). Today, in Bowling Green, we use a combination of both restrictive and malabsorptive methods, but neither at a severe level. In fact, each by itself does not promote adequate weight loss. The combination procedure, which we call a Gastric Bypass with a Long Lim Roux-en-y and a Duodenal Switch procedure, allows limited food intake and causes a reduction of fat absorption to take place, which will produce sustained weight loss. ANATOMY OF THE DIGESTIVE SYSTEM In order to understand this surgery you need to know about the anatomy of the digestive system. Here is an overview, starting from the top (mouth): Saliva: Contains the digestive enzyme amylase to start digestion of carbohydrates (starches and sugars). Esophagus: Carries food to the stomach. Stomach: This organ holds food and mixes it with saliva, acid and stomach digestive juices by peristaltic action (automatic muscular contractions). Pylorus: This is a muscle around the lower end of the stomach. It opens and closes rhythmically and regulates the emptying of the stomach. This helps to prevent the “dumping syndrome”. Small bowel: This is the portion of the bowel from the stomach to the colon (large bowel), which is about 15 to 30 feet long and where 95% of all the digestion and absorption of food takes place. It is divided into three parts; duodenum, jejunum, and ileum. All of these parts digest food and minerals. Duodenum: about 2 feet long, the 1st part of small bowel. The ducts from the liver and the pancreas secret bile and pancreatic digestive juices into the duodenum. Jejunum: middle portion of small bowel, about 6 to 8 feet long and has many cells for digestion. Ileum: lower portion of the small bowel. About 10 to 12 feet long. Also have many digestive cells in the lumen. Large bowel: Starts at the end of the small bowel, is larger and goes to the rectum. Its main function is to hold waste and absorb water to reduce the body’s water loss. Liver: Organ, which receives nutrients absorbed from the bowel, through the portal veins, and processes food products. The liver also excretes bile into the duodenum, which is a necessary enzyme in fat digestion. Pancreas: Organ, which secretes insulin and other hormones. Also secretes into the bowel many digestive enzymes including lipase, which mixes with the bile to digest fat. HOW DIGESTION WORKS Digestion starts in the mouth with saliva from the salivary glands where 40% of the body’s amylase (enzyme which breaks down starches into simpler sugars for digestion) is produced. The food travels to the stomach, where it is held, mixed with acid and pepsin, and is further prepared for complete digestion. As the pylorus opens and closes, it allows the stomach to empty in an orderly manner into the small bowel, where 95% of all digestion and absorption takes place. In the 1st part of duodenum, both the bile from the liver and the pancreatic digestive enzymes enter the small bowel. Complete digestion continues throughout the small bowel to the large bowel where water is absorbed and the waste material is moved on to the rectum. SURGICAL PROCEDURE The surgery that we perform in Bowling Green is both a restrictive and a malabsorptive procedure, but neither the restriction nor malabsorption is extreme. The restriction in this operation is accomplished by removing the greater curvature portion of the stomach (outer side), leaving the remaining portion of the stomach at about 3 to 5 ounces in size. In this process we do not take out the pylorus so it can still function normally. The size of this new stomach sill start out at about the size of a small juice glass and will probably double in size as time goes by. We do not put any bands or rings around the stomach to make it empty more slowly. We allow it to function on its own. The pylorus functions by opening and closing and allows the stomach to empty in the normal manner. Just beyond the pylorus at about 2 inches, on the duodenum, we transect the duodenum in preparation to later connect the alimentary limb. We measure the entire small bowel from where it goes into the large bowel at the cecum) all the way back up to where it attaches to the stomach. The total length of this small bowel will vary anywhere from 16 feet to 36 feet, as it varies from one individual to another. We then cut the bowel in half at a point about 40% of the total length of the small bowel. This distance is measured up from the cecum so that the lower part (the alimentary limb) that carries the food is equal to 40% of the total bowel length (typically, we would measure approximately 275 cm or somewhere around nine feet from the large bowel to transect the small bowel). That portion which is connected to the cecum (large bowel) is then taken upwards and is connected to the small portion of the duodenum, which is about 2 inches long, just beyond the pylorus. This portion of the small bowel then carries food from the stomach to the large bowel and digestion takes place all along this small bowel. The upper portion of the small bowel (bilio-limb) will now be taken downward and attached to the side of the previously described portion of small (alimentary limb) bowel at about 20 to 40 inches form the cecum. This is the portion of small bowel that carries the digestive juices, which come from the pancreas the bile which comes from the liver (bilio limb). The portion of small bowel after this attachment is called the common channel. Refer to the picture that describes the Biliopancreatic Diversion with a Duodenal Switch. Following surgery, when you eat food, it will go into the stomach (which is now small – about 4 or 5 ounces), and through to the pylorus. The pylorus will then open and close and allow the food to come out of the stomach at the lower end where a short portion of duodenum is attached to the small bowel. This alimentary limb had been previously measured and carries food all the way down to the large bowel. The portion of bowel that is not carrying food (bilio-limb) carries bile and digestive juices from the liver and pancreas down towards this last part of the alimentary limb. Full digestion will take place in the last few feet of the small bowel (the common channel) where the digestive juice and bile mix with food. The advantages of this surgery are: You have a small stomach without any band restricting it or any foreign body in the stomach. You still have the pylorus and this is completely reversible except for the portion of stomach that we removed. None of the bowel is removed. Part of your bile salts and fluids from the pancreas are re-absorbed so you do not lose them from the body and you are able to eat a relatively normal type of meal. This is a very effective operation for weight loss, and patients tend to keep their weight off for a long period of time. HOW THIS OPERATION WORKS This operation works by two ways, restriction and malabsorption, but neither method at the severe degree. In fact, either method by itself would not cause weight loss. It is the combination of the two methods, which works. The restrictive portion is a stomach of three to five ounces formed by removing part of the stomach with no band or narrowing at the lower end – only your own pyloric muscle opening and closing. The selective fat malabsorption is achieved by using only the lower eight to ten feet of the small bowel (ileum). In addition, only the last two or three feet of this bowel has full pancreatic digestive juices and bile (see illustration). The bypassed portion of the small bowel (bilio-limb) carries the pancreatic digestive juices and bile from the liver, it absorbs water and bile salts from these fluids, and no bowel is removed. So if you can’t eat as much, and you can’t digest all the fat you eat, you can’t stay fat! IMPORTANT FEATURES OF THIS PROCEDURE The stomach is 3 to 5 oz. in size, like small juice glass, and will slowly enlarge so you can eat a small normal meal. Not a large meal. The pylorus is not removed or bypassed so it can continue to function in controlling the emptying of the stomach (therefore no dumping syndrome), and allows for small bowel reversal to normal if it should ever be needed. The alimentary limb (the new portion of small bowel from the stomach to the large bowel) digests part of the food and carries the rest to the common channel where it mixes with bile and pancreatic digestive enzymes for a more complete digestion. The bilio limb (the portion of small bowel which is bypassed and carries bile and pancreatic digestive juices) reabsorbs many of the bile salts and water, as you did normally before the surgery, so you do not lose these important salts. Normally, the liver and pancreas secrete about one to two quarts of fluid per day, and it is reabsorbed in the bowel. The common channel (the last portion of the alimentary limb after the bilio limb is attached) area is the only place you have full digestion of FATS. Therefore, you have a selective malabsorption of fats, which lowers your cholesterol, triglycerides, and your weight. Only part of the fat you eat is digested. Since you can’t digest all of your fat food, you can’t digest all of your fat-soluble vitamins – A D, E, and K so you must take vitamins daily for the rest of your life. NO MARGINAL ULCERS: These re ulcers that form in the location where the small bowel is sutured to the stomach in gastric bypasses. We have never had a marginal ulcer with this operation due to the duodenal switch and removal of part of the stomach (which makes most of the acid). NO DUMPING SYNDROME: This is a complication caused by liquids and foods high in sugar, which may occur after gastric bypass or a gastrectomy, where the food “dumps” into the small bowel without control of the pylorus. SUPPLEMENTS REQUIRED AFTER SURGERY VITAMINS: A and D are very important fat soluble vitamins, you will need to take a water maniscaple vitamin, called Allergy A and D [list note: many people take ADEK vitamins found at http://www.scandipharm.com/] , generally three per day to maintain a proper level of these vitamins. D is very important in calcium absorption and bone formation. A is important for your eyes and skin among many other things. These are absolute must! Vitamins E and K are important, but do not seem to be a problem. However, if you need to be on blood thinners, you must watch your vitamin K level, and your doctor needs to know that you will be very sensitive to anticoagulants. No, other vitamins A and D are not acceptable! MULTIVITAMINS: We want you to take one multivitamin per day, any type you can buy over the counter. This will cover most of the other vitamins and trace minerals. CALCIUM: since you have the 1st 60% of your small bowel bypassed, you will not absorb enough calcium. You must take calcium supplements, about 1500 to 2000 mg. per day. Tums will work well in the first few weeks, are easy to take, help settle your stomach, and reduce gastric irritation. Later, when you are able to take pills more easily, we will start you on “Citracal” which is a form of calcium citrate, or “Cal Apatite”, which is a form of microcrystalline hydroxyaptite. Microcrystalline hydroxyapatite is the most readily absorbed form of calcium, followed by calcium citrate, and finally calcium carbonate. Calcium carbonate is the most common form of calcium supplement, but it requires acid to dissolve it in the stomach, and is best taken with meals when there should be more acid in the stomach. Since you have a small stomach (and less acid) and/or you are taking medicine to reduce stomach acid, it may not be the best form of calcium for you. Any type of liquid minerals or vitamins will be absorbed better than tables will. If you can drink skim milk, it is a good source of calcium (300 mg. per cup) and is absorbed well. POTASSIUM: We have all patients take potassium supplements in the beginning, later some people will not need extra potassium. IRON: About 10% of the patients will need to take iron medication at some time. The reason for this is that the small bowel bypassed is important in absorbing iron from your food, so you could possibly become anemic. With part of your stomach removed this also increases the possibility of low iron anemia. SPECIAL NOTE ON CALCIUM Calcium is the most important mineral for you to take after this surgery. Most of the body’s calcium is stored in bones, which are very important in your strength, function, and body stability. Calcium plays a vital role in many basic physiological processes, including blood coagulation, the sending of messages along nerves, maintenance of muscle tone, preservation of cell membrane integrity and permeability, and certain glandular functions. Less than one percent is available in extracellular fluid (body fluid outside cells) for these important functions, the rest of the calcium is found in bone. If your serum (blood) calcium is low, your body will take the calcium that it needs from your bones and over a long time will make the bones soft and easier to break. Thus, it is important to take the proper calcium supplementation. If you do not take your calcium regularly you could develop osteoporosis, especially if you are a post-menopausal woman. Microcrystalline hydroxyapatite (Cal apatite) is 20% more absorbable than calcium carbonate (tums) and even more absorbable than calcium citrate (Citracel). CHILDBEARING Women of childbearing age who are having weight reduction surgery should use some type of birth control during the period of rapid weight loss (18 to 24 months). They should understand maternal malnutrition may impair normal fetal development. All patients who are losing weight at a rapid rate are in some way suffering some form of malnutrition. Pregnancy should be put off until your weight becomes stable for some time. Women who become pregnant after bariatric surgery should have specific attention with the surgical care team along with their obstetrician. We have had several patients become pregnant after bariatric surgery without any difficulty, but they do need to be watched more closely and they also need to make sure they are taking all the necessary vitamins, minerals and proteins. Folic acid, one of the B vitamins, has been found to be important in preventing neural tube defects (NTD). Folic acid can reduce the risk of NTDs, such as anencephaly and spina bifida (open spine) by as much as 50 to 70 percent if women take enough of it before conception and in the early months of pregnancy. The March of Dimes is promoting a campaign to educate women about folic acid. The goal is to reduce NTDs by 30 percent by the year 2001. The way to ensure enough folic acid is to take a multivitamin containing 400 micrograms of folic acid (the standard in more multivitamins) every day. Many patients who are morbidly obese also have a fertility problem, but after losing weight they will frequently be able to become pregnant. So you need to be careful until your weight is stable. RISKS AND COMPLICATIONS There are some risks, especially in the patient who is more than twice their ideal size. However, most people do quite well. Short-term risks would be the ones considered in the hospital or the first month after surgery. It is possible to have any of the problems which patients are at risk for with any surgery such as infection, blood clots, bleeding, pneumonia etc. The ones we are concerned about are related primarily to something we call a “leak”. A leak simply means a perforation of the stomach like a perforated ulcer or a leak from any place where the bowel is sutured together. When this happens, you become very sick. A leak must be re-operated and could extend your hospitalization or require you to return to the hospital for several weeks. Fortunately, this is not common. The chances of you having a gastric leak is less than 1%. After we resect the outer side of the stomach with the stapler we turn that cut edge in and re-sew it with a serosal to serosal stitch which turns in the side that was transected and gives us a second row all the way down the stomach. This has reduced our leaks and we feel this has helped a great deal. Anywhere tissue is sewn together, it can fall apart or leak which could require a second operation. Once you get beyond a month after surgery all of these things rarely occur. Some people will have difficulty taking fluids in the very beginning because there is a lot of swelling around this stomach and different portions of the small bowel hook-ups. Patients occasionally have to be admitted to the hospital for a day or two to have some IV’s until they get re-hydrated again. For the first two or three weeks we will have you taking mostly fluids or fluid-like foods. BLOOD LOSS Generally before surgery we will try to take one pint of your blood two weeks prior to surgery and save that because that is usually enough blood for this operation. On occasion we will need to use more blood. We do have good blood in our blood bank and it has never give us any problems. Abscesses are very uncommon and unless you have a leak or something of that nature you will probably not see any infected areas. LONG-TERM COMPLICATIONS Long-term complications would be related primarily to your malabsorption portion of the surgery. Since you are not able to digest all of your fat, you also will not be able to digest all of your fat-soluble vitamins, particularly Vitamin A, and Vitamin D. Also since you are only using about 40% of your small bowel you will need to take extra calcium in order to have enough calcium absorbed in your body. We want you to eat good protein; meat, fish, and so forth so you will have plenty of body protein. We will check you periodically in the office and we will check your blood counts every so often to make sure that your protein and calcium are satisfactory and that you are taking enough vitamins. This is something that you need to have done at a minimum of every 6 to 9 months, if things are going well and more frequently if you are not feeling up to par. Menopausal women (natural or surgical) should take, in addition to the vitamins A, D, and calcium supplements, estrogen, in order to reduce the risk of osteoporosis. The table below lists some risk factors associated with accelerated bone loss. RISK FACTORS ASSOCIATED WITH ACCELERATED BONE LOSS: Family history of osteoporosis, chronic stress, poor digestion Lack of or inadequate exercise, sedentary occupation or lifestyle Heavy use of tobacco or alcohol Early removal of ovaries (oophorectomy), menopause Small boned and slender, as opposed to large boned and overweight Poor diet (low calcium foods, high phosphorus foods) Chronic use of certain drugs (steroids, diuretics, antacids containing aluminum.) Chronic disease conditions (liver disease, hyperthyroidism, cushings syndrome) Malabsorptive surgery (if not taking vitamins and minerals) DIARRHEA There are many causes of diarrhea and it becomes a problem only occasionally for the patient who has had the who has had the biliopancreatic bypass with duodenal switch. Some patients may even become constipated. You can expect larger stools more frequently because of the undigested food, but not necessarily watery diarrhea. Normally you will have two to four stools per day, generally in the morning. This will vary from patient to patient. Occasionally you may have difficulty with excessive diarrhea and you will need medication. For this, medically, we generally treat this with Lomotil (prescription) or Immodium (over the counter) as needed. Pepto-Bismol also may help and may be used. You may need an antibiotic like Flagyl to reduce your diarrhea. Or, if you go to just liquids for a while this problem may clear up relatively quickly. Many times taking Metamucil, one to three teaspoons per day will give bulk to your stool and reduce your loose stools. If you’re having too much trouble and can’t seem to get ahead of the problem, you may need to be admitted to the hospital for a day or so for IV fluids. Also note that occasionally, particularly after you have had antibiotics for some reason or been in hospital on antibiotics, some of your normal bacteria are also destroyed. Until these “good” bacteria are replaced, you may continue to have diarrhea no matter which medications you take. One of the simple and easy ways to stop diarrhea in this condition is to take something like “lactovacillus acidophilus” and bifidobacteria”, if you can get both of these, or Ultra Flora which is a combination that is sold by Gilman Enterprises in California. This may solve your problem completely. This all works well on patients that are having a lot of gas problems and other crampy complaints. Mrs. Gilman in California recommends that you go to a pharmacist or nutritional health food store which keeps strong, refrigerated “lactobacillus acidophilus” and to make sure it is dairy free, and has a “DF” on it. Take ½ to a whole teaspoon three times per day and within a couple days your diarrhea should subside and you should be doing well. Diet can also be a culprit in causing GI distress. Sorbitol is a white, sweet, odorless, crystalline alcohol found in berries and fruits. It is used as a sugar substitute and in white flour. It is not absorbed well by the GI tract and most of it gets into the large bowel and the bacteria there digest it and form gas and loose stools. You may do better not eating white bread, pasta, etc. Use whole wheat bread, pasta and rolls since there is generally no sorbitol in those items. BAD BREATH Some patients who have the sweet smell of acetone on their breath have had good results by taking 10 mg of Reglan (prescription) at bedtime or 5 mg (1/2 tab) of Reglan during the day, two to three times per day, as needed. FLATULENCE For most people gas is a problem because it causes (sometimes painful) bloating and (often mortifying) odors. Everyone has gas. The average person generates 1 to 3 pints a day, but some people produce a lot more than others. One person reported passing gas 34 times per day. The average for most 30-year olds is only 14 times. Most gas is odorless. Although proportions vary from person to person, gas is largely composed of hydrogen, nitrogen, and carbon dioxide, with a touch of oxygen. About a third of the adult population produces copious quantities of methane, while the rest emits little or none. In the late 60’s it (methane) was a concern that it could cause explosions during long-term space flights. Less than one percent of gas smells. But boy, does it ever! Research has shown that several sulfur-containing compounds are responsible for most fecal odors. Unfortunately, the human nose can detect hydrogen sulfide in concentrations as low as one-half part per billion. Certain foods are gassier than others. Beans, brussel sprouts, raisins, apple juice, and prune juice are a few. But a gas producing food for one person may not be for the next. Extremely flatugenoc foods (more than 40 passages per day) vary from one person to another. Carbohydrates are largely to blame for large volumes due to sugars, starches, and fiber that reach the colon (large intestine) without being digested or absorbed. Once in the colon, the colonies of harmless bacteria eat them and give off by-products of hydrogen, carbon dioxide, and in some people, methane. These are the “good bugs” (bacteria) that are wiped out with antibiotics and may need to be replaced by taking Ultradophilus, Ultrabifidus, and lactobacillus acidophilus. The most common sources of gas are: Lactose which is a sugar that occurs naturally in milk products. Many people don’t have the enzyme (lactase) to digest lactose. Soluble fiber, like the pectin in fruits and the beta-glucans in oat bran. Researchers have shown that gas producing bacteria feed off small amounts of starch that escape digestion by enzymes in the small intestine. So far, wheat, oats, potatoes, corn, and virtually every starchy food except rice have been implicated. The fourth and most infamous source of gas is the family of raffinose sugars found in (large amounts) in beans, and in smaller amounts in many vegetables and grains. No one has the enzyme Alphagalactosidase to break them down. When they hit the large intestine, our bacteria have a feast! FOLLOW-UP It is very important that you follow-up with your physician, with the doctor who did your surgery, or someone who understands your type of surgery. You need to have regular blood counts to make sure that your malabsorption portion is not causing you a great deal of difficulty. It is also very important that the doctor is able to keep good follow-up with his patients so he knows how you are doing. If we don’t keep track of how you are doing, what your weight is, etc, then there is no way we will know if what we are doing is the right thing. There is an advantage both to you and to us to having a good follow-up. If you should move or change your telephone, anything of that nature, please call and let us know your new address and phone number, and make sure that you are seeing someone who is able to take care of you properly. For these reasons we have a meeting on the second Monday of every month, in which a doctor attends to answer questions, to bring you up to date with anything that is new, and to have your weight recorded, and it is your opportunity to also see us, get slips for your blood work, and keep in contact with other patients. LATE WEIGHT GAIN A few patients will need to worry about late weight gain. We have, however, never had a patient gain back all of their original weight. The following may be reasons for late weight gain. Body Compensation: The human body will try to adjust to overcome the results of our surgery. For example, the stomach will stretch allowing you to eat more. The bowel will become more effective, enlarging somewhat and absorbing more. This is one of the reasons why you will stop losing weight and level off to a satisfactory body size. Another factor stopping weight loss is the fact that you are not carrying around 100 pounds of excess weight. Most people will remain at a satisfactory weight and size. Grazing: We should not eat all day long. Try to stick to three or four meals per day. In the beginning, you may need to eat several times per day to get in enough food and fluid. But, if you snack all day you can eat a large number of calories especially if they are loaded with sugar and simple carbohydrates. Remember there is sugar in many of the liquids we drink and you can take in many calories this way. Volume: We should try to keep our volume of food under control. Don’t stuff yourself. Stop as soon as you feel comfortable. For this reason we try to make your stomachs small, about three to five ounces at surgery, and we expect this to enlarge so you can eat a reasonably sized meal. It is important that you eat well or you will become malnourished. FOOD TYPES Protein: This is your most important food type. It is needed for many body functions. Protein is the building material for all of your body, and since you are only using one half of your small bowel you need to eat as much protein as possible to keep your proteins at a normal level. You must eat protein to live and you will not get fat eating proteins. Fat: As you know you are bypassed for most of your fat absorption. But, you will absorb enough to meet the fatty acids we need to live. There is fat in most of the proteins we eat, so you get all the fat you need. Fat is generally not a factor in weight gain, but I would not purposely go out of your way to eat more fat. Carbohydrates: These are the foods that cause the most problems with late weight gain. You are not bypassed for carbohydrates, especially the simple sugars: candy, regular soda pop, cookies, pie, etc. (foods loaded with sugar). The complex carbohydrates can also be a problem with weight gain, because you can absorb them well. There are a lot of calories in juices and sweetened drinks of all kinds. Bread, potatoes, pasta and fruits are high in carbohydrates. You may have desserts, etc. but in small amounts. There are no essential carbohydrates needed for life. So, if you are having an amount of late weight gain cut out the carbohydrates. Eat proteins and non-sugar vegetables and you will be able to lose that weight gain. FOOD IDEAS FOR HEALTHY EATING FOR THE GASTRIC PATIENTS (by Dr. L. Hess) Pork tenderloin marinated in Mesquite flavor or Hickory flavor, grilled on the grill, served with reddish-green leafy lettuce with spinach and olive oil dressing made with real olive oil using Wishbone Italian or Newman’s Own Italian dressing. Steaks on the grill marinated as above with the same olive oil dressing. Delicious protein milk shake; Take ice cubes and fill blender ¾ full, add five to seven strawberries, about 12 blueberries, ½ peach or some combination of the above. Add water and let set so ice cubes melt to small size. Pour off the water. Everything chilled now and ice cubes small enough to blend. Blend using blender until icy-fruity pureed Add ½ brick of Tofu (firm) and blend again. Delicious high protein, nutritious, vegetarian milk shake using no milk and using Tofu (soy bean curd). Open a can of tuna or can of chicken and eat this as it comes from the can, with mayonnaise or olive oil dressing for breakfast. Quick salad: leafy nutritious lettuce, one tiny can of tuna on top or chicken on top, olive oil dressing as in No. 1 above. Leafy salad using avocado on top or other combination such as broccoli, cauliflower, sunflower seeds, almonds or flax seeds. Try different combinations. Boiled eggs also good on top. Deviled eggs; use real mayonnaise, not fat free. Remember your surgery bypasses FAT. FAT IS YOUR FRIEND! Go ahead and eat it! Remember it is better to snack on nuts, olives, meats, cheese rather than crackers. This is because your surgery does not bypass the carbohydrates. Potatoes, rice, crackers, sweets, chips, breads all have lots of carbs and need to be taken in very small quantities. Instead of croutons try one tablespoon wheat germ on top of salads. SOME FINAL THOUGHTS I want to again impress upon you the importance of not smoking. Everyone knows that, in general, smoking causes heart disease, cancer, and emphysema (among other life-threatening diseases) and will lead to a much shortened life. The patients who have had a gastric bypass with a long limb roux-en-y and a duodenal switch procedure are in a category all of their own. If you are a smoker it will increase your likelihood of having osteoporosis, reduce your absorption of calcium, cause you to have more gastric irritations and thereby require more antacids or medications to reduce the acid which also reduces your ability to absorb iron. All of these things are detrimental to the patient who has had bariatric surgery. Many patients ask me about alcohol and my answer is this: You may have an occasional drink. You should consider yourself a “Two Beer Bobby”. One drink will get to you in a hurry! You should plan on drinking a very minimal amount and only occasionally. You should never be in a position where most of your calories are coming from alcohol. This is very detrimental to your body. With a lack of vitamins it can lead to liver problems much sooner and you can expect to become intoxicated much more easily. If you insist on drinking lots of alcohol this surgery should be reversed. Exercise is important to all of you. Start out with small amounts; maybe simply walking, riding a bicycle or some sort of regular exercise, as it is important to the build-up of your body and to maintain muscle strength. You can get exercise in your daily life just by doing things like walking up one or two flights of stairs instead of taking the elevator, parking at the back of the parking lot instead as near to the door as you can, and walking whenever possible. Little things such as these help increase your activity, help maintain good muscle strength and good health and, of course, help keep your weight down. Patient requirements: Many insurance companies require certain items which you will need to have done prior to your bariatric surgery. For example, Gallagher Basset Ins. Co. has a company called Cost Care review your chart and before they can o.k. that they have to have 1. A letter from a psychologist or psychiatrist. 2. You have to be seen by an internist before they will o.k. your surgery. 3. When you are seen in the office we will order lab and x-rays at that time. Without these items they will not o.k. your surgery. We do not know what each company requires, most of these things are not necessary but they always wait till about one week before your surgery and then they call and state they cannot o.k. until we get all this information. Once this happens we cannot find anyone to get these requirements done in so little time. Either you have to get these all done ahead of time or you will have to call yourself directly to your company and ask them if they use Cost Care of any company that you must get all this information to and what is required. Many insurance companies will require the patient to give a list of diets of all kinds, what kinds, how long and if there is any under a doctor’s care, etc. You can use any and all dates and medical records you have, over counter diets, calorie counting, etc. You can use any dates you recall or what recorded weights you have at doctor’s office, your own recollections – if you were at 200,300,400 pounds six or seven years ago and whatever you need but that is your responsibility to get this information together. We schedule most of our surgery a month to six weeks ahead of time so we will have time for all of these things. It is difficult and this portion will be your responsibility. The entire contents of this page are used with permission, and are copyright ©2000 by Douglas S. Hess, MD, FACS, et al, all rights reserved. Text, graphics, and HTML code are protected by US and International Copyright Laws, and may not be copied, reprinted, published, translated, hosted, or otherwise distributed by any means without explicit permission. Correspondence should be directed to Douglas S. Hess, M.D., 640 South Wintergarden Road, Bowling Green, Ohio 43402, USA. Telephone: 419-352-1452; Fax: 419-352-1244 [Home] [Procedure] [Surgeons] [Patients] [FAQ] [Chat] [More Info] Email the site administrator with questions, corrections, or suggestions. Copyright © 1999-2002 by The Duodenal Switch Information Zone, all rights reserved. Text, graphics, and HTML code are protected by US and International Copyright Laws, and may not be copied, reprinted, published, translated, hosted, or otherwise distributed by any means without explicit permission.