LEGAL

It is very important for you to fully understand that obesity surgery is a major surgery and is performed only to prevent the complications associated with morbid obesity. The final decision for proceeding with the surgery rests both with you, the patient, and with the surgeon, whose responsibility is to accept or reject patients for surgery based upon his or her interpretation of all the facts in any specific case.

Major surgery for morbid obesity, as with any other form of surgery, has its risks and complications. Obesity surgery is performed because the risks of major complications in the patient who remains morbidly obese are even greater than the risks associated with the surgery. This is an important fact that you should keep in mind as you read the following material about the possible complications of surgery.

Perhaps the best example for comparing the risk levels between the surgery and morbid obesity would be the risk for the ultimate possible complication – death. Current reports concerning the risk of mortality from the Roux-en-Y procedure, put the rate of death from complications of the procedure to 1 per 100; Past surgical experience has shown that on the average, 1 in every 100 or more patients undergoing the Roux-en-Y procedure, die from complications associated with the surgery. On the other hand, the risk of a patient dying from complications of morbid obesity is calculated to be around 3% or more per year. This means that the risk of dying from surgery is about the same as from being morbidly obese for about 4 months. Usually, however, the surgery only occurs once, but the risk of dying from morbid obesity continues for as long as the individual remains obese.

Patients should also be aware that, although the mortality risk for obesity surgery is higher than some other forms of surgery, the risk rate is high not so much because of the type of surgery, but because all forms of surgery have greater risk when the patient is morbidly obese. Furthermore, complications of morbid obesity often cause patients to undergo other forms of surgery (gallbladder removal, cesarean section, etc.) and the mortality rate for those forms of surgery are also higher for the morbidly obese patient.

Before listing the major forms of complications associated with the Roux-en-Y and Lap Band surgical procedures, there are some general principles with which you should be familiar. First, dieting is of course, the preferred way to lose weight. Nevertheless, patients need to be aware that many diets are potentially harmful and a physician should be consulted before any form of stringent diet is started. The need for surgery occurs when the patient is unable to maintain the desired weight loss over a long period of time. “Yo-Yo” dieting (losing, regaining weight or perhaps adding on even more weight) is even more harmful than not dieting. Unfortunately, it is not possible for the vast majority of morbidly obese people to maintain long-term complaint of their weight without surgical intervention.

Second, there are many forms of surgery that provide the means to help control morbid obesity. These surgeries have many possible complications in common, and each form of surgery has its own risks. Both the Roux-en-Y Gastric Bypass and the Lap Band surgery can be performed either openly or laparoscopically. A laparoscopic operation is performed with the aid of the laparoscope, a fiberoptic tube and light source connected to a video camera, which allows visualization of the abdominal organs on a TV monitor. Surgical instruments are inserted through small incisions in the abdominal wall. This is less invasive and reduces pain and the risk of complications. Recovery is usually more rapid, shortening the hospitalization. Laparoscopic operations have been used in general surgery for over a decade, and the technique is not experimental. Laparoscopic procedures for morbid obesity employ the same surgical principles as in Open Roux-en-Y Gastric Bypass. The laparoscopic technique must be precise and should vary from open operations only in the size of the abdominal incision. However, these laparoscopic techniques are not fee of complications and require special surgical expertise to reduce operative time and other risks. In some cases the laparoscopic technique may need to be terminated and converted to an open procedure. The laparoscopic technique for Roux-en-Y is relatively new, thus, there are no long-term statistics available to compare for the two techniques. Not all patients are candidates for this procedure.

Other forms of surgery performed for morbid obesity include: gastric banding (which is not a procedure recognized by the National Institute of Health), placing “balloons” in the stomach, wiring the jaws, severing the vagus nerve to the stomach, (none of which have been proven to have a long term effectiveness), Vertical Gastroplasties (Vertical Banded Gastroplasty, Silastic Ring Vertical Gastroplasty, Silastic Ring Vertical Gastric Bypass), Biliopancreatic Diversion with “Duodenal Switch”, etc.

Third, surgery is not a magic cure-all. Effective weight control after surgery depends upon the patient’s compliance and cooperation. Any form of obesity surgery can be “defeated” by what is called “eating through”. Patients must be committed to long-term follow-up care and they must have genuine desire to change their eating habits. Some of these changes include eating slowly, chewing your food well, eating small meals at regular intervals and eliminating high calorie liquids. Surgery helps to make eating habits changes easier to achieve.

Fourth, there is no guarantee that patients will benefit from the surgery. Surgery is highly effective for most patients, and it is hoped that the patient will lose at least one half of his or her excess weight within the first year after the operation. However, in rare cases there are some patients who do not achieve any weight loss control after surgery, and there are some patients who may actually continue to gain weight after surgery. In most of the cases where no weight loss is achieved, the cause is that the patient is non-compliant and unwilling to change their eating habits.

Fifth, there is no surgery without risks of complication, and there is no surgeon who will not have patients who experience some of these complications. Though no list of possible complications can ever be 100% complete, it is important that you understand as many of these complications as is practical. It is also important that only after being cognizant of these complications, you are willing to undergo the operation despite these risks, in order to try to alleviate the greater potential for complications associated with morbid obesity.

Risk specifically related to gastric reduction operation can be divided into early and late complications. The most serious complication is death. As stated earlier, death occurs in about 1 patient out of 100 with Gastric Bypass surgery and is very rare with Lap Band surgery. This is usually due to heart attack or sudden irregularity in the heart rhythm, or blood clots to the lungs (pulmonary embolus). Other technical early complications include leakage through the staples or sutures (which hold the stomach and intestines together), perforation of the esophagus, or injury to the spleen. Leakage is a serious complication and often requires additional operations to drain the infection and repair the site of the leakage. In spite of your surgeon exercising the utmost care, injury to the internal organs can occur. Injury to the spleen is uncommon, but should it occur, it may require removal of the spleen if the bleeding cannot be controlled.

Later risks include wound infections, including Lap Band port site infections that could require additional surgery. Also, the formation of ulcers in the stomach or small intestine can occur after weight loss surgery. This is rare, occurring in less than 2 patients out of 100, and can usually be successfully treated with medications. Obstruction (blockage) of the opening or stoma can occur when a piece of food becomes lodged in the outlet. This is a rare occurrence and generally can be remedied by removing the food using an endoscope passed from the mouth to the stomach. Conversely, there may be pouch or esophageal dilation (stretching) or, rarely, staple disruption with the Gastric Bypass Surgery, or band slippage with Lap Band Surgery. With this complication the feeling of fullness disappears and the operation loses its effectiveness. Another possible complication with Lap Band surgery is erosion of the band into the stomach, resulting in infection, and possibly requiring surgery.

Another late complication is vitamin and or iron deficiency. This complication is fairly common and occurs in 34 – 40 percent of patients after Roux-en-Y Gastric Bypass surgery. With Gastric Bypass surgery, eating sweets can cause “dumping syndrome” to occur. If patients are not careful to follow good dietary regimens or to take vitamins and mineral as ordered by the physician, nutritional problems can occur. Lack of these substances may also be manifested as muscle weakness, paralysis, confusion, rashes, anemia, hair loss, bone and joint problems, poor healing of wounds, tongue soreness, night blindness, numbness, etc.

Vitamin and iron deficiency are among the reasons that close, life-long follow-up is very important, especially with Gastric Bypass surgery. Deficiencies of vitamins and minerals can generally be restored with oral supplements or injections, it is very important that the patients be committed to life-long nutritional care with vitamins and minerals.

Like any weight loss method, these procedures appear to be associated with an increased incidence of gallstone formation. Therefore, there is an increase in complication secondary to gallbladder disease. Failure to lose weight or maintain lost weight, is another long-term complication. In some patients the reason for this failure can be identified and corrected, but in a small number of patients, there is no apparent explanation.

Persisting vomiting, nausea, abdominal swelling, or heartburn may occur after surgery. If severe enough, naso-gastric tubes or intravenous feeding may be needed to maintain adequate nutrition until the problem is solved. Vomiting can most often be controlled through proper dietary measures. Diarrhea, while very uncommon with the Roux-e-Y procedure, can occur. Certain types of food may be more difficult for the patient to digest after surgery. With Gastric Bypass surgery, patients’ taste in food may change after surgery, they may dislike items they liked prior to surgery, or may develop “cravings” for other foods.

The effects of surgically induced weight reduction on pregnancy are not known. There is information to suggest that deficient nutrition in pregnancy carries with it a great risk of fetal damage or loss. Therefore, it is strongly recommended tat secure birth control methods are utilized after surgery, especially during the period of rapid weight loss (up to 18 months after surgery). Pregnancy following that period of rapid weight loss, when weight has stabilized, has occurred with excellent results, but with special attention from the clinical care team to achieve these results.

When weight is lost quickly, the skin of the arms, legs, neck, abdomen, face, and elsewhere may wrinkle, droop or sag, possibly causing rashes, infections or odors. Sometimes, patients desire cosmetic surgery to correct the problem. In general, it is the patients’ duty to inform the surgeon whenever any problem arises, so that proper medical care can be administered.

Because these methods of treatment are relatively new, the potential exists for complications to develop, which have not yet been recognized. In order to identify and treat any complications close, lifetime follow-up is essential.

If a complication arises that is extremely severe, re-operating may be necessary. Although this is uncommon, no one should have the surgery that is not prepared to accept the need for re-operating if it becomes necessary. Also, it may be necessary to admit patients to an intensive care unit for observation or to treat complications that can occur.

You will have to agree to follow the directions spelled out in the information given to you prior to surgery including beginning to exercise more regularly and vigorously (as your physical condition allows); to take the recommended medications and vitamin supplements as detailed on the pre-operative and post-operative instructions you receive; to be faithful in keeping your follow up appointments in the office so that your progress can be monitored more accurately; to get appropriate laboratory work as needed; and to try to attend the support group sessions on a regular basis since it has been shown that patients generally do better if they attend these meetings.