Reported rate Time to presentation
Early (within 1 week)
Late (several months later)
Crampy abdominal pain, nausea, vomiting
High index of suspicion
Internal hernia, torsion of Roux limb at transverse mesocolon, adhesions, jejunal-jejunal intussusception Laproscopic or open exploration often required
Reassurance and empathy is essential to help the patient overcome food intolerances. By six months, most patients are able to tolerate most foods, and tend to eat three small meals per day. If problems continue, referral to an experienced dietitian can be helpful. Patients with a preoperative history of eating disorders (binge eating, reactive overeating, etc.) tend to manifest difficulty in adjusting to the change in eating habits more commonly. Referral to an experienced psychologist can help unmask some of the underlying emotional issues associated with food.
Weight loss is rapid in the first six months, averaging 10-15 lbs per month. Average weight loss at the six-month follow-up visit is 60-80 lbs. Thereafter, the rate of weight loss tends to slow down to 5-7 lbs per month, reaching a peak at 12 months postoperatively, averaging 100-120 lbs. Despite its superiority to other methods of weight loss for the morbidly obese, surgery still carries the risk of failed weight loss or weight regain. When there is weight regain, it typically begins 18-24 months postsurgery.22-24 Delin and Watts report that although most patients do well initially, some ultimately fail to sustain their improvement.23 Continuous snacking and consuming large quantities of soft or liquid foods has been described. Some researchers attribute the weight gain to physiological factors, but others claim that inadequate coping strategies are usually at the source of patients' inability to maintain weight loss.25 Unfortunately, a small percentage of patients become grazers after bariatric surgery and have a poor weight loss.
Rapid weight loss results in many psychological changes as the body shape changes. Several studies have shown increases in self-esteem, self-confidence, asser-tiveness, and expressiveness.26,27 Improvements in the patients' self-esteem and psychological state result in greater assertiveness and improvement in social interaction, sexual activity, and work performance.
On the other hand, a significant number of patients discover they have underdeveloped coping mechanisms in their new persona as a thin person. These patients often require psychological therapy to deal with issues of past sexual abuse, body-image changes, and relationships with intimate partners.
The most striking changes in medical symptoms after bariatric surgery are those that are most difficult to quantify. Fatigue improves with an increase in energy level. Exercise habits improve with an increase in activity of daily living, as well as recreational activity. In a majority of patients, back pain disappears.
Osteoarthritis improves to a lesser degree, and is dependent on the degree of underlying bone and cartilage damage. The advantage of bariatric surgery is that the preoperative risk for an orthopedic procedure decreases, making subsequent surgery risks similar to those of lean controls. Sleep apnea tends to improve significantly, and refitting of the mask is often needed by six months postoperatively. At 12 months postop, repeat overnight somnography is suggested to document the need for continued CPAP.
While weight loss improves the social lives of patients, they often have difficulty adjusting to dramatic changes in social circles. Patients previously involved in relationships with other obese persons may find that changes in their lifestyle (i.e., more activity, greater social contacts, and changes in eating behavior) become incompatible with that of presurgical relationships. Given that the capacity of the stomach is significantly reduced following restrictive surgery, social and business functions that revolve around food become awkward. Family members, friends, coworkers, and acquaintances may also react with envy or feel threatened following the patient's rapid weight loss. The patient may feel resentment at his sudden social acceptance following weight loss. Being related to positively by people who once treated you badly because of your weight may not be a joyful experience.23 These issues are often dealt with in long-term support groups.
When weight loss has stabilized, usually at the 12-month follow-up visit, the majority of patients request information about plastic surgery. Unfortunately, most insurance companies regard plastic surgery following bariatric surgery as cosmetic surgery and will not cover it. There are cases where the abdominal pannus is infected or excoriated, and documentation will be required by the insurance company for coverage. An experienced plastic surgeon will be helpful for those who wish to pursue plastic surgery.
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