What suggestions do you have to reduce the risk of blood clots in bariatric surgery patients?

This is a very important question because persons of size are at greater risk for developing blood clots than persons of standard size no matter what operation they are choosing to have. This is true whether they have a knee replacement, hysterectomy or a bariatric operation.
I think persons of size are at increased risk for several reasons. 1). Increased pressure from the weight that is carried in the abdomen places pressure on the blood vessels returning blood from the lower part of the body back to the heart allowing pressure to develop in the veins of the legs and pelvis. This pressure can injure the valves in the deep veins of the legs and make the veins larger slowing the flow of blood and increasing the risk of clotting. This increased pressure is also the reason many persons of size have developed varicose veins since the pressure is transmitted to the more superficial veins of the legs which have thinner and weaker walls resulting in these veins increasing in diameter. The pressure is transmitted to the vessels of the skin causing leakage of red blood cells causing discoloration and irritation of the skin called venous stasis changes. 2). Many bariatric surgery patients have obstructive sleep apnea which causes the right side of the heart to work less efficiently further retarding the blood flow back to the heart making the pressure situation even worse in the blood vessels returning the blood to the heart. 4). Also, the large amount of fat mass causes the increased production of estrogens in both men and women. This is like being on birth control pills all the time and of course this high level of estrogen may increase the risk of developing blood clots. 4). Finally, a bariatric surgery patient is likely to have an increased level of inflammation which may also increase their risk of forming blood clots.

A person that develops a blood clot in the leg, called a deep vein thrombosis, can have significant symptoms like swelling and pain. However, the more serious risk is if the clot is dislodged from the leg or pelvis and travels up to the heart and out to the lungs. At this stage it is called a pulmonary embolus. This blockage can result in keeping the blood that is pumping out of the heart from getting to the lungs. If enough of the flow to the lungs is interrupted the person will not have enough oxygen and may not survive.
To prevent this problem we do several things for everyone that is having bariatric surgery at Fresh Start Bariatrics at Riverside. Many other bariatric surgeons also do the following: 1). Everyone receives blood thinners that start just before surgery and continues through their hospitalization and is continued for 6 days after they are discharged from the hospital. 2). They have sequential compression devices placed on their legs prior to surgery so the blood will be circulating out of their legs back to their heart even while they are on the operating table and while they are asleep. 3). All of our patients are walking in the halls of the hospital just 6 hours after they leave the operating room. 4). Finally, if a patient is at significantly higher risk than normal I request that they undergo placement of a temporary vena cava filter placed by a cardiologist or other specialist into the main blood vessel, called the vena cava, that returns blood to the heart a few days prior to their bariatric operation.
Although some bariatric surgeons are using vena cava filters for high risk patients the following scoring system is unique to the program I have had the privilege of developing at Fresh Start Bariatrics at Riverside. After reviewing the medical literature I have developed a scoring system that identifies patients that are at significant increased risk for blood clots and will need this temporary filter to protect them from a clot reaching their heart and lungs. The cardiologists I work with most frequently here in the Columbus, Ohio call it the “Myers’ Scoring System”. Take a look at the following:

“Myers’ Scoring System for Venous Thomboembolism Prophylaxis”
In the Bariatric Surgery Population

High Risk Score
History of blood clots (DVT/PE) 4
Venous stasis changes, 4
(cellulitis, ulceration, discoloration)
Genetic clotting disorder 4
Immobility, (wheelchair bound) 4
BMI, (Body Mass Index), over 60 4
Moderate increased risk
Obstructive Sleep Apnea 2
Lower increased risk
Male 1
BMI over 50 1
Recent smoker 1
Hormone replacement therapy 1
Total score ___________
Total Score that is equal to or greater than 4 results in a referral for a vena cava filter.

A vena cava filter is generally placed through the groin much like a heart cath is done. After the risk of developing a blood clot is reduced in 4 to 6 weeks the filter is removed. We have found this scoring system and the placement of a vena cava filter in high risk individuals to be very effective in protection patients form this potentially life threatening problem. I believe we have saved several lives with this intervention. This is just one of many ways we work to decrease the risk of bariatric surgery for patients that select our program for their bariatric surgery. I hope this understanding will be helpful to you regardless of where you chose to have your operation.

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Should I avoid Non-Steroidal Anti-Inflammitory medications after my bariatric operation?

The short answer is it depends on which operation you have chosen.

This class of drugs included Ibuprofen, Naprosyn, Motrin, Aleve, Meloxicam, Mobic, Celebrex and several other medicines. Asprin has some similar side effects of gastric irritation.

I do not know of any reason why patients that choose to have an adjustable gastric band or a gastric sleeve operation should not take these medicines. However I believe that a gastric bypass patient should avoid these medicines for life if at all possible.

In general patients that have an adjustable gastric band or a gastric sleeve procedure may take these medicines. Of course there are risks of a gastric ulcer, bleeding or cardiovascular risks but that is the same as for people that do not have a bariatric operation.

For gastric bypass patients I suggest they avoid all of these medicines for life unless it is really medically necessary.

That is because these all can cause ulceration in the gastric pouch which may result in scarring and narrowing at the connection between the gastric pouch and the small intestine. This can result in vomiting and may require dilation of the narrowing by a special balloon during an endoscopy, (passing a scope into the through the mouth into the stomach).

Let me tell you a story to demonstrate what I mean. Several years ago I had someone who had a gastric bypass operation a few years before in Colorado. She returned to Ohio where her family lived and came into our emergency room with complaints of vomiting. She had also lost a lot of additional weight over recent weeks and she looked dehydrated as well. She had been taking a few Naprosyn tablets daily for pain in her knees. She told me no one had told her she should not take non-steroidal anti-inflammatory medicines. I admitted her to the hospital and looked into her gastric pouch with a scope the following day, I found that she had a very small opening that a pencil point could not even go through. I was able to pass a guide wire through and into the small intestine and then passed a dilating balloon across the narrowing. After inflating the balloon I was able to dilate this area. She did well for a few days but soon this narrowed again. I dilated the area again only to have it narrow again a few days later. Eventually I had to take her to the operating room to make a completely new connection between the gastric pouch and the small intestine.

Also this ulcer may cause very significant bleeding and even perforation with leakage of gastric contents into the abdomen requiring an emergency operation.
For all of these reasons I strongly suggest that these medicines be avoided after a gastric bypass operation.

When I tell people this at the Fresh Start Seminar they frequently ask what other suggestions do I have to help them with their joint and back pain. First, I tell them that most people will not need these medications after they lose their weight from bariatric surgery. This of course will decrease the weight on their joints and relieve much of the pressure. Usually our patient lose about 60 lbs in the first three months after bariatric surgery so the feel much better shortly after their operation. Secondly that have access to pain medicine after surgery such as Percocet or Vicodin for a little while. Sometimes I will suggest Ultracet or extra strength Tylenol. Occasionally someone will need to be on a Fentanyl patch for a few weeks or see a sports medicine doctor or orthopedist for a steroid injection. Finally, if the pain is too limiting for them I will agree to place then of Celebrex at about 3 months after their operation but they are informed there is still a risk of these problems even with Celebrex.

I am sure that other bariatric surgeons may feel differently about these matters but this is how I have chosen to instruct our patients and I find that it keeps them from having problems after their operation in they follow these directions.
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Am I able to take extended release medicines after my bariatric operation?

Patients that choose an adjustable gastric band or a gastric sleeve operation should still be able to absorb any medications prescribed since there has not been any changes in the small intestine. With the gastric sleeve procedure the stomach has been reduced in size and anything that is ingested may leave the stomach faster that prior to surgery but I doubt that this will be a significant problem with medicines. Therefore I do not recommend any changes in medications for people that choose to have either of these two operations.

However, patients that have a gastric bypass are choosing an operation that essentially allows the medications that are taken by mouth to pass directly into the small intestine. The time it takes to pass through the mouth through the small gastric pouch, through the available length of small intestine and into the large intestine, (also called the colon), is about 45 minutes. That will be fine for medications that are in a regular form since the small intestine is so efficient in absorbing these medications. However medicines taken in some forms will be effected by this change.

There are many ways the drug companies have made taking medicines easier for us. For instance, medications are sometimes “wrapped” into a pill that releases medications in two stages hours apart or in other preparations the medicine is released very slowly over several hours so a person only has to take the medicine once a day and instead of several times a day.

Unfortunately, to get all the medication that is in these extended release pills a patient needs a stomach that stores at least some of the medicine for a few hours slowly sending the medication out of the stomach a little at a time. The combination of an intact stomach and a small intestine that is of full length results in several hours between swallowing the pill until it would reach the large intestine. This allows extended release medications to work so they can slowly release the medicine over a long time.

A gastric bypass shortens the time so much that the person only has time to have the first part of the medicine released. Anything that would be released after 45 minutes is no longer available for absorption because the pill is likely to already be in the colon by that time.

A gastric bypass patient may be paying more for a specially designed extended release medicine but only absorbing half of it. You are probably just wasting your money and not benefiting as much as you should from extended release medicines.
Therefore I recommend that my patients avoid extended release medicines and take the medicines in a non-extended release form.

For example, Toprol is an extended release form of Lopressor, (metoprolol). You may have taken Toprol XL 100 mg prior to your gastric bypass operation. If you continue to take Toprol XL 100 mg daily after your operation you are likely to only absorb the first half on the pill and since Lopressor is a 12 hour medicine you are likely not to have the appropriate amount of medicine for the second half of the day. Therefore I would suggest that you change from the extended release form to the regular form of metoprolol and have your doctor prescribe it as Lopressor 50 mg twice a day.

In fact, I would suggest that you always ask your doctor about each of your medicines and ask to have the non-extended release form. Primary care doctors and psychiatrists may or may not be aware of these issues and you as the patient must remember to inform them of your new changes and request that the medicines that are prescribed for you are in the correct form.

This goes for over the counter medicines as well.. Read the labels and make sure the medicines are not extended release or delayed release medications. Ask your pharmacist if you are not sure.

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What suggestions do you have for keeping your weight off after a Roux en-Y Gastric Bypass or Gastric Sleeve surgery?

This is a very important question that nearly every bariatric surgery patient asks. Let me fist explain to you that weight loss from a gastric bypass or a gastric sleeve occurs over about 1 year following surgery.
The operation will help you maintain your weight but will not help you loose weight after about a year. (A patient with an adjustable gastric band is on a different schedule and will be discussed in a separate posting on this blog). So it is very important that you put your best effort into doing "all the right things" in that first year and continue them thereafter. Therefore it is important that you are truly ready for surgery and get help for problems, (such as binge eating or unresolved emotional trauma, or stress eating), that may keep you from being successful even before you have surgery and you should lose as much weight as possible before surgery so you arrive at a weight near ideal weight at the end of the year after your operation.
So what are "all the right things" to do in the first year after surgery and thereafter?
1). Do not drink your calories. I find that this is one of the most frequent errors people make. Although for the first 8 weeks or so you are likely to need to take liquids since most other things will not go through the connection between the gastric pouch and intestine, once you are able to eat solid food I would strongly suggest you avoid calorie containing liquids. This includes avoiding milk, (even skim milk since it still has sugar calories ). cream soups. ice cream, fruit drinks and all soda products. Drink liquids like crystal lite, tea with sweetener instead of sugar and water. I once had a patient that was upset that she was not losing as much weight as she was expecting. She said her main fluid intake was only coffee and she would drink several coffees a day. She even brought in a "coffee" with her into the exam room and it was a large cafe latte with regular milk! Of course the amount of milk she was consuming was blunting her weight loss! You should start your meals with solid food especially your protein and drink only between your meals.
2). Avoid eating too much carbohydrate such as mashed potatoes, junk food or other carbohydrates.
3). Establish a "NO FLY ZONE" for foods that are too tempting for you and are foods that trigger overeating. Just tell your family and anyone also that come onto your property that your home is a "NO FLY ZONE" for pizza, cookies or what ever you have difficulty with and these items won't fly here. Also make strategies for eating out or going to social gatherings such as which foods you will and will not eat or how you might tell the server you are 'eating light and please bring a container to the table with the food" so you can take some of the food off the plate before you start eating. These are great suggestions from "Exodus From Obesity" by Paula Peck and you can probably get her book on Amazon.com.
4). Be aware of your portion size and listen to your body. Use your eyes and brain to determine how much you should consume at any one time. Do not expect to have your operation tell you you have eaten too much. If you do you probable have already exceeded what you should have eaten. Most patients will be able to eat about 1 cup, (pressed down), of food at any one time. Eating more than this with keep you from being successful.
5). Get in an exercise program using an exercise therapist or personal trainer and work out 3 to 5 times a week. In our program this is an integrated portion of the overall program and our offices are even in the McConnell Heart Health Center which is a medically oriented fitness center. Only tell you this to reinforce how important I think this component of your recovery really is. You will be losing muscle mass while you loose fat mass after your bariatric surgery. A great exercise therapy program will help you to build muscle, lose more weight and look better as you fill out some of the space with muscle that used to be filled with fat mass. You also may me less likely to need plastic surgery!
I find that if patients in my practice are following these directives they will lose on the average about 20 lbs. per month for the first 3 months and then a little less each month. Therefor they have lost about 60 lbs. in the first month and about 80 % of their excess weight at 1 year. The most frequent BMI I record for our patients at 1 year is a BMI of 28. I let them know this is their goal at the end of a year and that way they can "shoot" for that goal. The great thing is almost everyone in our practice reaches that level of weight loss and it is very infrequent to have one of them regain significant weight back. I don't tell you this to brag, although I am very proud of the work our patients and the staff put in, but to give you some bench marks to try to make happen in your own life.
Please feel free to leave other suggestions you have found helpful by clicking on "comments" at the end of this posting and may you experience all the success you deserve as you travel this jouney to better health.

8 Rules for Longterm Success After Bariatric Surgery

1). NO FLY ZONE
Identify your food triggers. Those foods that are very difficult for you stay away from. If you are like me it is the cookies. For others it may be pizza or soda. These foods should not be brought you’re your home or onto your property. Your property should be a NO FLY ZONE for these foods; “they just don’t fly here “ Find suggestions like these in the great book, Exodus from Obesity.

2). PLAN BEFORE YOU ATTEND
Before attending a wedding or another special event where you know food will be a major part of the event make sure you plan ahead. Plan what you will eat and drink and what you will stay away from.

3). SOLIDS FIRST
Start with solids, especially protein, before you move on to other foods. This will make sure you get the most important foods in first and there will be less room for high calorie carbohydrates.

4). AVOID CALORIE CONTAINING LIQUIDS
Cream soups, ice cream, milk, soda and other high calorie liquids should be avoided. Regardless of which operation you choose, liquids will move through the pouch, band or sleeve without resistance and all those calories will be absorbed very quickly. These high caloric liquids can blunt your weight loss and keep you from reaching your goals.

5). RULE OF 30’S
Chew 30 times before swallowing, wait 30 seconds between bites and wait 30 minutes after completing a meal befor taking most of your liquids.
6). SMALL PLATES DEVIDED IN 4 QUADRANTS
Choose a small plate for your meals and visualize the plate being divided into 4 quadrants. One quadrant for protein, (fish, meat or beans), One for starch, (bread, rice, potatoes, corn or carrots) and then the other two quadrants should be for green vegatables.

7). STAY ACTIVE
Make arrangements for 30 to 60 minutes of vigorous exercise 3 to four days per week.

8). WEIGH YOURSELF AT LEAST EACH WEEK
Those who weigh themselves frequently are more likely to keep their weight off long term.

I asked the Fresh Start Bariatrics dieticians, Joann Schaumb and Alyssa Bixler, what they recommend for patients preparing for bariatric surgery.

"This is a very key topic! These comments are an initial response. We will share more later.

I think it is helpful to have people practice before surgery, eating the types of foods they will need to eat after surgery. I like to work together with clients to find foods that they like well enough to eat regularly instead of the high fat, high sugar choices they may have enjoyed in the past. This takes some trial and error, particularly in restaurants. It is important though, because people eat what they like. To achieve long term weight loss, they need to like lower calorie foods. It may seem hard, but we are usually able to help people find these foods.

When you focus on what to eat instead of what not to eat, it puts you in a more positive frame of mind and healthy eating becomes easier. We like to help people build confidence in their ability to enjoy healthy foods.

One of the most challenging goal on our pre-op list of goals is eating small, frequent meals. People are very busy and don't always think about eating much during the day. The typical American pattern is to eat very little or nothing through the early part of the day and consume most of the calories late in the day. This pattern leads to weight gain. Stomach capacity is limited after surgery, so we strive for high quality, nutritious foods. Every bite contributes to good health.

It is helpful to plan specific times for snacks and meals and design reminders, like setting a cell phone to beep when it is time for a snack.

It is very important to drink calorie free beverages. We recommend some weight loss prior to surgery and this is a very effective way to achieve that. Liquid calories are generally not satisfying. When you drink calories, you still eat the same amount of food, so total calorie intake is higher and leads to weight gain.

Replace liquid calories with calorie free drinks such as Crystal Light, Powereade Zero, Decaf coffee or tea, diet juices, diet flavored water or water with lemon."

I think their recommedations are terific and this is a great start to help people what changes would be helpful to make before surgery!

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To keep weight off long term after surgery, try Dr. Myers "Rule of 30's"

Would you like a suggestion to help you maintain your weight after bariatric surgery? Most bariatric surgery patients certainly would.

In addition to the suggestion to eat solid food and avoid drinking high calorie liquids such as milk, fruit juices, cream soups and ice cream add the following to your meal routine:

APPLY DR. MYERS’ RULE of 30’s TO YOUR EATING HABITS!

1). Chew all non-liquid food 30 times before swallowing. This will slow your eating down to the correct speed and you are likely to eat less calories with each meal.

2). Swallow your food once every 30 seconds. It takes about 30 seconds for food that is swallowed to travel all of the way down your esophagus to reach your stomach. Eating more frequently than every 30 seconds means you are not waiting long enough to allow the signals from your stomach to reach your brain and you are stacking food in your esophagus. It’s the food equivalent to traveling too close to the car in front of you in bumper to bumper traffic. It does not give you enough reaction time to stop in time before you crash! Give yourself a “safe clear distance” and avoid the problem that comes with eating too close together.

3). Wait 30 minutes after a meal before you drink your non-calorie containing liquids. This will give the solid food more time to leave your gastric pouch or sleeve and you are likely to have more room for the protein you need.

If you need some encouragement and a new technique try applying the RULE OF 30’S. I want everyone that has bariatric surgery to be successful and this technique may help you stay on track.