Long term complications of gastric bypass surgery
Because the anatomy of the stomach and intestines is altered, absorption of certain vitamins (iron, calcium,vitamin B12, folate) are impaired. Patients need to take multivitamins daily. Even with multivitamins, a few patients may develop deficiencies of B12 or iron and may need extra supplementation (sometimes shots). Blood tests should be performed at least yearly. Most patients will need to continue a lifelong regimen of:
- calcium with vitamin D • sublingual vitamin B12
- Iron (for menstruating women)
Hernias are openings in the deep (fascial) layer of the incision and can present at any time. They may
occur in 5 to 10% of patients after open operations. Hernias are usually fixed after 12 to 18 months (the time of maximum weight loss) and the repair can be combined with cosmetic procedures (i.e. “tummy tuck”). Although the cost of hernia surgery will be covered by insurance, additional cosmetic procedures will not. Hernias can also occur at laparoscopic incisions, but are smaller and less frequently bothersome. Nevertheless, new pain at an old laparoscopic incision should raise the suspicion of a small hernia.
Obstruction and internal hernia
The operation creates new connections between the intestines, and several windows (or pockets) between the segments of intestine must be created and re-closed. In addition, adhesions and scars may form within the abdomen over time. These adhesions and pockets may often block portions of bowel (obstruction) or intermittently trap them and choke them off (internal hernia). These complications occur in 1 to 2 % of patients.
Patients with obstruction may present with inability to pass gas and persistent vomiting. Sometimes this can be treated in the hospital with watchful waiting, while other times it may require another operation.
The diagnosis of an internal hernia can be difficult to make, but should be suspected any time a patient has recurrent intermittent or crampy pain.
Although, the roux-en-y gastric bypass helps acid reflux, the small pouch of stomach is very sensitive to agents that irritate the lining of the stomach. 3 to 4% of patients may develop a gastric ulcer requiring treatment. Ulcer causing agents include NSAIDs (motrin, advil, etc.), cigarrette smoking, and alcohol.
Most ulcers present with pain, and are diagnosed by endoscopy. Almost all ulcers can be treated effectively with anti-ulcer medications, but may take 6 to 12 weeks to heal completely.Occassionally ulcers can present with life threatening perforation (hole in the pouch) or bleeding, requiring urgent endoscopy or reoperation. Very rarely, ulcers than do not respond to medical treatment may require surgical removal.
Medicines and agents that can cause ulcers:
- NSAIDs: advil, motrin, ibuprofen, naprosyn, relafen (nabumetone), celebrex, vioxx
- Oral steroids (oral prednisone)
- Immunosuppressive medications for organ transplant patients and autoimmune diseases.
- Cigarrettes, cigars, chewing tobacco
Pain medications such as tylenol, codeine, vicoden, percocet are completely safe for treatment of pain, and DO NOT cause ulcers.
Progressive scarring at the junction of the stomach and small bowel may lead to an inability to keep food down in 2 to 5% of patients. Some patients may have difficulty even keeping liquids down. After the diagnosis is confirmed by an X-ray swallow study, the stricture may be widened with endoscopy. The need for another surgery is very rare.
Most strictures occur within the first few months of surgery.
With rapid weight loss, some patients (less than 10%) may develop gallstones in the gallbladder, resulting in episodes of pain. This usually presents as pain on the right side of the abdomen, under the ribcage. The treatment is an operation to remove the entire gallbladder with the stones (laparoscopic cholecystectomy)
When a large dose of sugar is released rapidly into the small intestine, the patient may experience sudden nausea, cramps, diarrhea, perspiration, weakness, and lightheadedness. The symptoms will resolve over 30 minutes to 2 hours, and help prevent patients from eating high calorie high sugar foods that lead to weight gain. Not everyone will experience dumping syndrome, but it is still very important for all patients to avoid high sugar foods.
There are many minor side effects that some patients experience, usually during the first year. These
include hair loss, bad breath, flatulance, feeling cold, hormonal changes, and mood swings. Almost all of these symptoms seem to occur in the first year during rapid weight loss, and improve afterwards.
Cosmetic effects of weight loss:
Quite often, as the fat is absorbed from the belly, buttocks, thighs, upper arms, and neck, the patient may be left with unattractive folds of skin. This excess skin can be removed surgically. Most plastic surgeons recommend waiting until 18 months after your bypass surgery. It is difficult to predict who will have excess skin.
It is important to remember that such operations are considered cosmetic, and will usually not be covered by Kaiser or other health insurances.