Dr. Callery

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  1. CzJ, Most people are pretty anxious before surgery no matter how prepared they are. I can't give personal medical advice. In our practice we generally prescribe about 4 low dose (0.25 mg) Xanex tabs during the prep op visit. Patients can take one each night for a couple of nights before surgery and then take the other two when they hop in the car to be driven to the hospital. We find that the minor tranquilizer improves sleep, greatly reduces anxiety in the hospital, and according to medical reports may help reduce post op pain. We thoroughly discuss the surgery along with risks, complications, and alternatives with each patient prior to the hospitalization for informed consent. We find that people are still alert and thoughtful before surgery, but the medication takes the "edge" off with good effect. Talk with your surgeon about this during one of the work-up visits rather than at the pre op visit. That way you and your surgeon can discuss whether or not it is a good idea in your case. Surgeons vary in their attitude about pre op sedation. The pre op visit is a busy visit, and may not be the best time to bring up the idea if the surgeon does not routinely prescribe a sedative. In addition, there may be some rules in your hospital that may apply one way or the other. Your surgeon can explain these as well if needed. Dr. Callery
  2. When blood sugar drops, people get an adrenalin surge. This causes rapid heart rate, sweating, and anxiety. People do often wake up if they are hypoglycemic. But sometimes they do not. The sugar can fall far enough and fast enough that the brain goes into a stupor, coma, sometimes convulsions, and death without fully awakening the patient. The patient could partially awaken, but not have the mental capacity to recognize the situation. Rare, but scary.
  3. VSGJV, Erratic changes in heart rate are not normal. The may or may not be pathological, but are not normal. You did the right thing by seeking medical attention. If they continue ask your APN to refer you to an internist or cardiologist for further evaluation. Dr. Callery
  4. Dear Obsidian, 1. You should only go to surgery if and when you are ready. No one should push you into it. And you shouldn't push yourself. There certainly are risks to surgery as well as benefits, and there are heavy patients who clean up their diet, exercise regularly, and lead very satisfying lives. They have the latitude to eat and celebrate as they wish. They may shorten their life expectancy and incur accelerated health problems, but it's a trade off. They have more freedom and no short term or long term surgical risks or side effects. 2. Oral anti-appetite drugs help people lose 5 - 10 % of their body weight over the short run. They are costly (up to $200 per month). They do not have proven long term (5-year) efficacy. Perhaps they can be used to help sustain weight loss if a patient who has lost weight goes through an emotional rough patch. They may help a person jump start or augment weight loss. 3. There are 3 brands of gastric balloons available that help provide similar short term weight loss. They may help patients lose up to 20% of their weight. They are expensive ($8-10,000)and cary some risk and discomfort. When the balloons are removed, eventual weight regain seems almost inevitable. 4. 90-95% of patients who lose weight by calorie restriction regain it. However some do keep it off. Perhaps through real dedication you can be one who does. So, if you have really cleaned up your diet, your activity, your sleep, and your stress levels, you might try an oral agent as an adjunct to weight loss. Know that you can't take the drugs forever, and that at some point you're going to have to stop and keep a very close eye on the scale. Only when your are truly satisfied that you have made a maximum effort and believe that the long term benefits outweigh the risks of surgery should you move forward. Disclaimer: These points reflect fairly well informed personal opinion. Other physicians or surgeons will have a spectrum of thoughts on the matter. Dr. Callery
  5. Dear Elisa, Post op weight loss is a long term proposition. Much of the early weight loss is loss of excess water weight. The first 20 or 30 pounds usually goes quickly, and then weight loss slows down. Almost nobody loses weight in a smooth way. The weight goes down a little, then there's a pause. Then there is more weight loss, then another pause. If your weight is stable for a couple of weeks or more you're at a plateau, but day to day fluctuations in weight loss don't mean much. So take the long view. Over the long run, working out is helpful for overall health both physical and mental. However, weight loss comes from calorie restriction. If your weight stabilizes over several weeks, it means that you are balancing your calorie expenditure with calorie intake. To lose more weight, you have to consume fewer calories on a long term basis. Paradoxically bumping up the exercise does little to promote more weight loss directly. You burn calories when you work out, but use fewer calories during the rest of the day! Exercise builds muscle, improves mental health including self-esteem, promotes a focus on good diet, helps one to sleep better, keeps one off of the couch, turns the focus away from food, can build friendships, reduces lipid levels, promotes bone health, makes your heart stronger, reduces blood pressure a little, probably makes you think clearer, and more! But to repeat, eating fewer calories long term gets the weight down and later keeps it down. Join the "just don't eat it" club, and resign for the "clean plate club". Dr. Callery
  6. Dear Annegirl, Most of the time people gain a few pounds of fluid weight during the hospitalization. When you're under stress, your pituitary gland secretes a hormone called vasopressin, AKA, antidiuretic hormone. Vasopressin causes the kidneys to conserve salt and water. This is a defensive move by your body to conserve fluids. When the stress is resolved, the hormone is no longer secreted, and the kidneys let the excess water go. You urinate the excess fluids. You had complications, were under stress longer, and held on to more fluid. Most of the time the body takes care of this on its own. Once in a while a diuretic (water pill) is needed. The decision to use a diuretic is complicated, and you should consult with your surgeon rather than trying to treat your self. Post op headaches are not uncommon and can have many causes. Carrying the extra water weight may be a contributing factor. Your migraines may have kicked in, you might have had muscle related headaches from your position on the OR table and hospital bed, one of your medications may have affected you, and there are other causes that are less common. I ask my patients to let me know if they are having a headache so that I can work with them to sort it out and find a solution. Most people lose anywhere from 10 to 20 pounds during the first couple of weeks after surgery. This may include a few pounds of fat weight, but it is mostly water weight. People who have a lot of excess fluid on board before surgery usually lose more weight early on. People who have been sticking to a "liver shrinking diet" usually have less water weight, and consequently lose less during the first couple of weeks. As a rule, I tell patients not to worry much about how much weight they lose in the first 6 weeks. Some folks worry so much about it, and what really counts is your weight loss over many months and years. The weight that you lose in the early weeks doesn't predict your long term success. What really matters in the long run is a pattern of healthy eating, portion control, snack avoidance, and other lifestyle factors. Dr. Callery
  7. Dear Blameithonthegenes, A significant drop in blood sugar following meals or snacks is called reactive hypoglycemia. This phenomenon, also called late dumping, is seen in a substantial number of gastric bypass patients, and may also be seen occasionally after sleeve gastrectomy. At times blood sugars can drop dangerously low causing decreased mental status and even loss of consciousness. Fatal traffic accidents caused by decreased level of consciousness have been reported. Fatality from profound nighttime hypoglycemia is conceivable, but I have not seen it reported in the medical/legal literature. If a person is prone to reactive hypoglycemia, it would be wise to avoid eating anything for several hours before bedtime. Drinking water or other sugar free drinks is OK. It would also be wise to avoid large carbohydrate loads any time of the day. Eating smaller, low glycemic meals seems to be best. Real success with weight control comes with a true commitment to lifestyle change. I've included several up to date summaries of medical studies for further information. Dr. Callery ______________________________________________________________________ Surg Obes Relat Dis. 2016 Oct 17. pii: S1550-7289(16)30746-8. doi: 10.1016/j.soard.2016.10.007. [Epub ahead of print] Overall and cause-specific mortality after Roux-en-Y gastric bypass surgery: A nationwide cohort study. Gribsholt SB1, Thomsen RW2, Svensson E2, Richelsen B3. BACKGROUND: Few population-based studies provide data on mortality after bariatric surgery. We hypothesized that hypoglycemia could be an underdiagnosed cause of death. OBJECTIVES: To examine perioperative, all-cause, and cause-specific long-term mortality in Roux-en-Y gastric bypass (RYGB) patients versus population comparisons. SETTING: Danish nationwide population-based cohort study. METHODS: We included all 9895 patients who underwent RYGB during 2006-2010, and a 1:25 age- and gender-matched comparison cohort (n = 247,366) (0.3% lost to follow up). We compared mortality rates and computed mortality rate ratios (MRR) for all-cause and cause-specific mortality using Cox regression analysis. For deceased RYGB patients (n = 91), we conducted a detailed medical record audit. RESULTS: The perioperative (30-days) mortality after RYGB was .04% (4/9895). After 4.2 years, RYGB-related mortality (deaths due to intestinal obstruction/intra-abdominal leakage) was .15% (16/9895). All-cause mortality was very similar in the 2 cohorts (median age, 40.2 years; 21.7% men): RYGB cohort, .89% (n = 91); comparison cohort, .92% (n = 2204); MRR = 1.03 (95% confidence interval [CI], .84-1.27). Mortality due to suicide (2.78; 95% CI, 1.44-5.33), accidents (2.29; 95% CI, 1.16-4.54), gastrointestinal diseases (2.01; 95% CI, 1.06-3.84), and infectious diseases (1.75; 95% CI, .98-3.17) was higher in the RYGB cohort versus comparison groups, but mortality from cancer was lower (0.43; 95% CI, .27-.70). Our medical record audit indicated that 8% of deaths after RYGB (n = 7) were possibly hypoglycemia related. CONCLUSION: Perioperative mortality after RYGB is low in Denmark, and subsequent all-cause mortality is similar to that of matched comparisons. After RYGB, patients have substantially increased mortality due to external causes such as suicide, accidents, and possibly hypoglycemia. ________________________________________________________________________________________ Surg Obes Relat Dis. 2017 Feb;13(2):345-351. doi: 10.1016/j.soard.2016.09.025. Epub 2016 Sep 28. Postprandial hyperinsulinemic hypoglycemia after Roux-en-Y gastric bypass: an update. Øhrstrøm CC1, Worm D2, Hansen DL3. Roux-en-Y gastric bypass (RYGB) is an efficient treatment for morbid obesity and reduces obesity-related co-morbidities. With the growing number of patients undergoing gastric bypass, complications now demand further attention. Postprandial hyperinsulinemic hypoglycemia (PHH) after Roux-en-Y gastric bypass is a complex condition, characterized by increased glucose variability including both hyperglycemic and hypoglycemic values. PHH seems to be more prevalent than previously suggested and is highly dependent on the choice of diagnostic tool, which has not yet been standardized. Questionnaires, an oral glucose tolerance test, a mixed meal tolerance test, and continuous glucose monitoring have been used, each with their own advantages. The condition is further complicated by a large group of asymptomatic cases. Patients with symptoms of PHH after gastric bypass are characterized by exaggerated insulin and glucagon-like peptide-1 responses compared to asymptomatic operated patients. The counter-regulatory mechanisms responsible for preventing hypoglycemia appear to be altered. The cause of these changes is not entirely understood, and it remains difficult to identify patients at risk of developing hypoglycemia. Known risk factors are female sex, longer time since surgery, and lack of prior diabetes. Management of the hypoglycemic episodes is difficult, and only dietary modifications consisting of frequent and less carbohydrate-rich meals seem to be efficient. Medical treatments and surgical procedures have been attempted in few studies and still warrant further examination. _________________________________________________________________________________ Surg Obes Relat Dis. 2015 May-Jun;11(3):564-9. doi: 10.1016/j.soard.2014.11.003. Epub 2014 Nov 13. Hypoglycemia after Roux-En-Y gastric bypass: detection rates of continuous glucose monitoring (CGM) versus mixed meal test BACKGROUND: Neuroglucopenic hypoglycemia might be an underestimated threat for roux-en-Y gastric bypass (RYGB) patients leading to fatigue, syncope, seizures or even accidental deaths. Different measurements can assess hypoglycemia such as a finger-stick glucometer, an Oral Glucose Tolerance Test, a Mixed Meal-Test (MMT) or, as introduced recently, continuous glucose monitoring (CGM). SETTING: University Hospital, Austria. METHODS: To assess the incidence of hypoglycemic episodes under real life conditions, 5-day CGM was performed in a series of 40 patients at a mean of 86 months after RYGB. The detection rates were compared to a mixed meal-test. RESULTS: Continuous glucose monitoring detected hypoglycemic episodes of <55 mg/dL or <3.05 mmol/L in 75% of the patients, while Mixed meal test indicated hypoglycemia in 29% of the patients. Continuous glucose monitoring also detected nocturnal hypoglycemic episodes in 15 (38%) of the patients. A mean of 3±1 hypoglycemic episodes per patient with a mean duration of 71±25 minutes were observed by CGM. CONCLUSIONS: Assessed under real life conditions by CGM, post-RYGB hypoglycemia was found more frequently than expected. CGM revealed hypoglycemic episodes in 75% of the patients while MMT had a lower detection rate. Thus, CGM may have a role for screening but also for the evaluation of dietary modifications, drug therapy or surgical intervention for hypoglycemia after RYGB. __________________________________________________________________ Obesity (Silver Spring). 2016 Jun;24(6):1342-8. doi: 10.1002/oby.21479. Risk of post-gastric bypass surgery hypoglycemia in nondiabetic individuals: A single center experience. Lee CJ1, Wood GC2, Lazo M3, Brown TT1, Clark JM3, Still C2, Benotti P2. OBJECTIVE: The epidemiology of post-gastric bypass surgery hypoglycemia (PGBH) is incompletely understood. This study aimed to evaluate the risk of PGBH among nondiabetic patients and associated factors. METHODS: A cohort study of nondiabetic patients who underwent Roux-en-Y gastric bypass (RYGB) was conducted. PGBH was defined by any postoperative record of glucose < 60 mg/dL, diagnosis of hypoglycemia, or any medication use for treatment of PGBH. Kaplan-Meier analysis was used to describe PGBH occurrence, log-rank tests, and Cox regression to examine associated factors. RESULTS: Of the 1,206 eligible patients, 86% were female with mean age of 43.7 years, mean preoperative BMI of 48.7 kg/m(2) , and a mean follow-up of 4.8 years. The cumulative incidence of hypoglycemia at 1 and 5 years post-RYGB was 2.7% and 13.3%, respectively. Incidence of PGBH was identified in 158 patients and was associated with lower preoperative BMI (P = 0.048), lower preoperative HbA1c (P = 0.012), and higher 6-month percent of excess body weight loss (%EWL) (P = 0.001). A lower preoperative HbA1c (HR = 1.73, P = 0.0034) and higher 6-month %EWL (HR = 1.96, P = 0.0074) remained independently correlated with increased risk for PGBH in multi-regression analysis. CONCLUSIONS: The 5-year incidence of PGBH among nondiabetic individuals was 13.3% and was associated with a lower preoperative HbA1c and greater weight loss at 6 months following surgery. ______________________________________________________________________ Ann Surg. 2016 Nov;264(5):878-885. Incidence and Predictive Factors of Postprandial Hyperinsulinemic Hypoglycemia After Roux-en-Y Gastric Bypass: A Five year Longitudinal Study. Raverdy V1, Baud G, Pigeyre M, Verkindt H, Torres F, Preda C, Thuillier D, Gélé P, Vantyghem MC, Caiazzo R, Pattou F. BACKGROUND: Postprandial hyperinsulinemic hypoglycemia (PHH) is often reported after Roux-en-Y gastric bypass (RYGB). In the absence of a prospective study, the clinical and biological determinants of PHH remain unclear. OBJECTIVE: To determine the incidence and predictive factors of PHH after RYGB. METHODS: Participants were 957 RYGB patients enrolled in an ongoing longitudinal cohort study. We analyzed the results of an oral glucose tolerance test (OGTT) routinely performed before surgery and 1 and/or 5 years after. PHH was defined as blood glucose < 50 mg/dL AND plasma insulin > 3 mU/L at 120 minutes post glucose challenge. Validated indices of insulin sensitivity (Matsuda index), beta-cell function (Insulinogenic index), and beta-cell mass (fasting C-peptide: glucose ratio) were calculated, from glucose, insulin, and c-peptide values measured during OGTT. RESULTS: OGTT results were available in all patients at baseline, in 85.6% at 12 months and 52.8% at 60 months. The incidence of PHH was 0.5% at baseline, 9.1% * and 7.9%* at 12 months and 60 months following RYGB (*: P < 0.001). In multivariate logistic regression analysis, PHH after RYGB was independently associated with lower age (P = 0.005), greater weight loss (P = 0.031), as well as higher beta-cell function (P = 0.002) and insulin sensitivity (P < 0.001), but not with beta-cell mass (P = 0.381). A preoperative elevated beta-cell function was an independent predictor of PHH after RYGB (receiver operating characteristics curve area under the curve 0.68, P = 0.04). CONCLUSIONS:: The incidence of PHH significantly increased after RYGB but remained stable between 1 and 5 years. The estimation of beta-cell function with an OGTT before surgery can identify patients at risk for developing PHH after RYGB.
  8. Dear Connie77, I can't give personal medical advice, because I don't know all the details of your situation. Here are some general points. Lap gastric bypass after Nissen fundoplication is feasible, but is one of the most technically advanced bariatric procedures. The Nissen wrap is taken down (unwrapped. If there is a recurrent hiatus hernia, it is repaired. Then the gastric bypass is performed. There is usually a lot of scar tissue, and it very tricky to unwrap the stomach safely. The biggest risk is damage to the esophagus causing a leak followed by a stomach staple line leak. The complication rates reported in the medical reports have been high. I have a lot of respect for the difficulties that can be encountered with this procedure. As a general rule, I don't think a sleeve is a good choice in this situation for a number of reasons. I haven't seen any reports of leaving the Nissen intact and doing a bypass under it. I've included a couple of abstracts from the surgical literature regarding GBP after Nissen fundoplication. Some surgeons are performing combination anterior fundoplication/sleeve procedures for patients with reflux. I included one summary below. I haven't seen any reports of doing a fundoplication/sleeve after takedown of a Nissen. I hope this information helps. Dr. Callery Acta Chir Belg. 2015 Jul-Aug;115(4):268-72. The Efficacy of Laparoscopic Roux-En-Y Gastric Bypass after Previous Anti-Reflux Surgery: A Single Surgeon Experience. Gys B1, Gys T, Lafullarde T. BACKGROUND: In this study we assessed feasibility, weight loss results and recurrence of Gastro-Oesophageal Reflux Disease (GORD) in patients undergoing laparoscopic Roux-en-Y Gastric Bypass (RYGB) after previous anti-reflux surgery. METHODS: Retrospective analysis of prospectively collected data was performed for patients undergoing laparoscopic RYGB after previous anti-refux surgery between 1/1/2000 and 1/1/2015. Weight loss was assessed using %Excess Weight Loss (%EWL) and every patient was compared with two matched control subjects. Telephone interviews were conducted to assure maximum follow-up data. Quality Of Life (QOL) was assessed using the Gastro-Intestinal Quality of Life Index (GIQLI), Gastro-intestinal Symptom Rating Scale (GSRS) and Bariatric Analysis and Reporting Outcome System (BAROS). RESULTS: A total of 18 patients (11 female, 7 male) were identified (17 Nissen and 1 former Belsey-Mark IV fundoplication). Mean time between surgical interventions was 9.4 years. Laparoscopic RYGB was feasible without intra-operative complications. One patient needed relaparoscopy for falsely suspected leakage and another suffered from postoperative pneumonia. Symptomatic GORD after RYGB was reported by 3 patients (16.7%). QOL was rated good with a GIQLI-score of 118 (range 97-140), GSRS score of 33 (range 15-59) and BAROS-score of 4,6 (range 1.2-6.8). EWL 3 years after surgery was comparable with matched control subjects (80.1% vs. 79.2% in controls, P=0.70). CONCLUSIONS: Laparoscopic conversion of anti-reflux surgery to RYGB with breakdown of the fundoplication is feasible and safe. Weight loss results are equal to control subjects and treatment of GORD is good. No significant decrease in QOL was reported. _____________________________________________________________________ Surg Endosc. 2012 Dec;26(12):3521-7. doi: 10.1007/s00464-012-2380-7. Epub 2012 Jun 13. Laparoscopic fundoplication takedown with conversion to Roux-en-Y gastric bypass leads to excellent reflux control and quality of life after fundoplication failure. Stefanidis D1, Navarro F, Augenstein VA, Gersin KS, Heniford BT. BACKGROUND: Recent data suggest that reoperative fundoplication is associated with poor long-term control of reflux. For long-term reflux control, laparoscopic Roux-en-Y gastric bypass (LRYGB) may be a better option. This study assessed outcomes and quality-of-life data after fundoplication takedown and conversion to LRYGB for patients with failed fundoplications. METHODS: After institutional review board approval, the medical records of 25 patients who underwent fundoplication takedown and LRYGB conversion between March 2007 and July 2011 were reviewed. The data recorded included patient demographics, body mass index (BMI), preoperative symptoms, operative duration and findings, hospital length of stay (LOS), estimated blood loss (EBL), length of the follow-up period, and postoperative outcomes. The gastrointestinal quality of life index (GIQLI) and the gastrointestinal symptoms rating scale (GSRS) were used at the most recent follow-up visit to assess symptom severity and quality of life. RESULTS: The patients in this study had undergone 40 total prior antireflux surgeries. They had a median age of 55 years (range 36-72 years), a BMI of 34.4 kg/m(2) (range 22-50 kg/m(2)), an operative duration of 345 min (range 180-600 min), an EBL of 181 ml (range 50-500 ml), and an LOS of 7 days (range 2-30 days). Five patients had concomitant incisional hernia repair. There was no mortality. Of the 10 patients (40%) who had had complications, 5 required reoperation. During a 14-month follow-up period (range 1-48 months), 96% of the patients were reflux-free with a GIQLI score of 114 (range 80-135) and a GSRS score of 25 (range 17-45). Excess weight loss was 60%, and comorbidity resolution was 70%. Most of the patients (96%) were satisfied with their outcome and would undergo the surgery again, and 62% reported that their personal relationships and sexual life had improved. CONCLUSIONS: Patients who undergo LRYGB after failed fundoplications have excellent symptomatic control of reflux, excellent quality of life, and high rates of satisfaction with their outcome. Nevertheless, because the procedure is challenging and associated with considerable morbidity, it should be performed by surgeons experienced in antireflux and bariatric surgery. ________________________________________________________________________________ Surg Obes Relat Dis. 2016 Oct 17. pii: S1550-7289(16)30747-X. doi: 10.1016/j.soard.2016.10.008. [Epub ahead of print] Safety and effectiveness of anterior fundoplication sleeve gastrectomy in patients with severe reflux. Moon RC1, Teixeira AF1, Jawad MA2. BACKGROUND: Laparoscopic sleeve gastrectomy has become a popular bariatric surgery in recent years. However, it has been linked to worsening or newly developed gastroesophageal reflux disease (GERD) in the postoperative period. OBJECTIVES: The purpose of this study is to determine the safety and effectiveness of anterior fundoplication sleeve gastrectomy in patients with reflux. SETTING: Academic hospital, United States. METHODS: We prospectively collected data on 31 sleeve gastrectomy patients who concurrently underwent anterior fundoplication between July 2014 and March 2016. Patients were selected when they reported severe reflux before the procedure. Each patient was interviewed using the GERD score questionnaire (scaled severity and frequency of heartburn, regurgitation, epigastric pain, epigastric fullness, dysphagia, and cough) before and 4 months after the procedure. RESULTS: Our patients comprised 27 females and 4 males with a mean age of 49.9±9.6 years (range, 29-63 yr). They had a mean preoperative body mass index of 42.8±5.6 kg/m2 (range, 33.3-58.4 kg/m2), and 67.7% (n = 21) of these patients underwent hiatal hernia repair as well. Preoperatively, patients had a mean heartburn score of 7.4±3.6 (range, 1-12), regurgitation score of 5.4±4.1 (range, 0-12), epigastric pain score of 2.1±3.2 (range, 0-12), epigastric fullness score of 2.7±3.9 (range, 0-12), dysphagia score of 1.3±2.2 (range, 0-9), and cough score of .9±1.8 (range, 0-6). Mean preoperative GERD score was 18.9±9.8 (range, 6-36) in these patients. Patients were interviewed with the same questionnaire approximately 4 months postoperative. Patients had a mean heartburn score of 1.5±3.2 (range, 0-12), regurgitation score of .9±1.7 (range, 0-8), epigastric pain score of .4±1.1 (range, 0-4), epigastric fullness score of 1.1±2.4 (range, 0-8), dysphagia score of .3±1.1 (range, 0-6), and cough score of 0. Mean postoperative GERD score dropped down to 4.1±5.8 (range, 0-28), and the difference was statistically significant (P<.01). One patient was readmitted 28 days later for a staple line leakage, and was treated conservatively. No patient required a reoperation due to the procedure within 30 days. CONCLUSION: Anterior fundoplication sleeve gastrectomy may be a safe and effective alternative in obese patients with severe reflux who want to undergo sleeve gastrectomy.
  9. Dear Brenda, Several things can happen as time goes by. Your pouch can stretch a little. The gastrojejunostomy (the connection of pouch to the small intestine) can widen. You can change your dietary habits to accommodate more food. You can eat richer food with more calories per serving. There may be changes in your internal metabolic signaling that alter your weight set point and make you hungrier. All of these changes can result in greater calorie intake and result in weight regain. One way to estimate your "pouch size" is to obtain an 8 or 12 oz container of large curd cottage cheese and see how many ounces you can eat in 5 minutes. Another way is to undergo an upper GI series with food. You bring a sandwich to the x-ray lab. The radiologist does an initial barium swallow. Then the technician puts some barium paste on the sandwich. You eat the sandwich. You and the radiologist see how big the pouch is and how wide the stomach-small bowel connection is when the food enters the stomach. It's a great educational experience if you can watch it on a monitor. Once you see what's going on you will be able to change your behavior to optimize your eating. Doing revision surgery to make the pouch smaller or decrease the size of the gastrojejunostomy is controversial. It may help for a while, but all too often the effects are minimal and short lived. Many people adjust their eating style and don't lose or keep off much additional weight. There may be isolated cases where pouch or anastomosis reduction procedures have beneficial long term results, but there's not much in the surgical literature to support these procedures. I've attached an article which you can download that summarizes causes and treatments of weight regain after gastric bypass. Obes Surg. 1996 Feb;6(1):38-43. Measurement of Functional Pouch Volume following the Gastric Bypass Procedure. Flanagan L1. Abstract BACKGROUND: The cottage cheese test was developed in an attempt to find a simple way to measure functional pouch volume and to better understand the fate of the tiny proximal pouch following the gastric bypass procedure. METHODS: Our patients were asked to eat cottage cheese in a structured fashion before their return visits from 3 months to 2 years postoperatively. RESULTS: We found there was a step-wise progression of increase in functional pouch volume with statistical significance between each time interval. Also, we compared the patients' excess weight loss at 1, 2, and 3 years postoperatively to their pouch size at 1 year postoperatively. Although there is a wide range (2.5-9.0 oz) of pouch sizes at 1 year, there is no significant difference in excess weight loss between the smaller and larger pouches. CONCLUSIONS: The pouches enlarge by the orderly process of hyperplasia. Within the 2.5-9 oz volume variation, the pouch volume alone is not a predictor of weight loss. Rather, how the patient uses the pouch/tool, in addition to the other behavior modifications, determines the degree of weight loss. This data strongly suggests that the surgeon's understanding of and teaching of the optimal use of the pouch/tool may be more important than previously thought. Maleckas 2016 Weight regain after gastric bypass.pdf
  10. Dear Bigfuzzy, Contact your surgeon's office and ask the office to send you a list of the blood tests that he or she recommends. I can't comment on your particular medical situation or give you personal recommendations. The routine blood work that we generally recommend for patients every 6 months is as follows: -CBC, Chemistry panel -Iron, TIBC -Vitamins A, B1, B12, D -Whole molecule parathyroid hormone -Bone density studies on selected patients Many PCPs will also get a lipid panel and HgA1C when appropriate. It's very important to remember that each patient is different. So we tailor our recommendations accordingly. The attached guidelines are provided by our surgical society, the American Society for Metabolic and Bariatric Surgery, the Obesity Society, and the American Association of Clinical Endocrinologists. Feel free to download the file, print it, and share it with our doctor. Follow up recommendations start on p. 177, R42. I hope you and your doctor find this material useful. Dr. Callery AACE_TOS_ASMBS_Clinical_Practice_Guidlines_3.2013.pdf
  11. Dear Tg, As a general rule, it's good to see your PCP first. Your surgeon is there if there is a surgical emergency or if there is a problem that your PCP and specialists such as a gastroenterologist can't sort out or treat. Your PCP or GI consultant can always call you surgeon if she or he has questions. Dr. Callery
  12. Dear JoeG, Inadequate weight loss 10 months after sleeve gastrectomy is extremely frustrating. The sleeve may be too large to be effective, you may be eating more than you realize, or both. An upper GI series with food is an effective way to evaluate sleeve size. If it really is too large, then going back and recutting the sleeve is a reasonable option. Any type of revision surgery is riskier than initial surgery because of scar tissue. The staple line leak rate is increased several fold over primary surgery. I did a search of the medical literature on PubMed, and couldn't find any medical articles describing the success or complication rates of resleeving. Another option would be to convert the sleeve to a gastric bypass. This might be easier technically and perhaps safer depending on the shape of the upper part of the sleeve and the amount of scar tissue present. It could be a fall back option if your surgeon finds too much scar tissue at the time of the resleeve procedure. Also it might be better if you have significant diabetes. Again, there is little data in the medical literature to inform these decisions. So in summary, resleeving can be a good option. You may achieve much better long term success. You just want to be absolutely sure that your dietary choices aren't the real issue. Patients who are snacking, comfort feeding, and eating a high carb diets frequently continue to do so after revision. For success: good surgery and good choices. Dr. Callery
  13. Dear North Star, As you know a bougie is a flexible tube that is place in the stomach by the anesthesiologist. The surgeon uses the bougie to guide the stomach transection (cut/stapling). Bougie sizes are expressed in French (Fr.) units. Divide the Fr. by 3 to get mm. So 42 Fr. is the same as 13 mm. If the sleeve is too tight, people can't eat thicker foods. If the stomach is too large, there is less restriction. There may also be an increased risk of staple line leak if the stomach is too narrow. Here's were it gets tricky. Many surgeons use the bougie as a guide, but don't cut exactly on the bougie. To do so would leave the stomach too narrow near the top of the stomach and near the bend in the stomach (angula incisura). So surgeons often cut wide of the bouie as needed. There is no absolute agreement on bougie size, and there is little objective research that can be used to inform a surgeon's choice. To make matters even trickier, there is a lot of variation from stomach to stomach. Some are thicker or thinner and some are more or less elastic. These differences can make getting an exact diameter of the sleeve difficult. In addition the stomach isn't flat. It bends toward the back near the top. So getting a nice clean staple line going around a bend while not getting too close to the esophagus is a challenge. Bougie size choices range from 36 to 50. The "consensus" among surgeons who have done large numbers of cases is that about 40 Fr. best. However, as we all know consensus is a good starting point. There is no substitute for carefully done research. "The great tragedy of science - the slaying of beautiful hypothesis by and ugly fact." - Thomas Huxley. Bariatric surgeries including the sleeve are "tools" to help with weight loss. The sleeve works partially by restriction, partially by changes in internal hormone signalling, and to a great extent by patient behavior. As you know behavior is a matter of choice. But choice is a tricky issue. Our choices are a matter of immediate will power, but are influenced by environment, social factors, and genetics. The sleeve is definitely more restrictive early on, and like the bypass, becomes looser as time passes. Hormonal effects of surgery may be more profound early one and less so later. Finally, people are often more highly motivated at first, and lose resolve with time. So as you can see there are a lot of trade-offs. Larger diameter sleeves may be safer, but may not give quite as much resistance to eating. Sleeve diameter is probably not related to hormonal effect. Sleeve diameter doesn't affect a patient's social setting, genetics, or activity level. Before surgery each patient should have a discussion with her/his surgeon about technical aspects of the surgery and expectations for weight loss and relief of medical problems. From a practical standpoint, after surgery, each person should make the best of the situation. If you are not losing weight as quickly as you expect,discuss it with your surgeon. Are your expectations realistic given your preop weight and medical condition? How many calories are you taking in each day. It's easy to over eat after any operation by nibbling or snacking. What is the quality of the food that you are eating? Are you getting in as much physical activity as possible? Are you getting a good night's sleep? Who are your hanging out with, and what are their eating habits? Are you taking medications that tend to make you hungrier? Can you do anything to reduce your stress level? In summary, bougie size matters, but it's only one of many things that matter. Patients can see a real improvement in their health and weight regardless of which size bougie the surgeon uses. Choose healthy, be active, and have a Happy New Year, Dr. Callery Surg Endosc. 2015 Jul 21. [Epub ahead of print]Laparoscopic sleeve gastrectomy with 27 versus 39 Fr bougie calibration: a randomized controlled trial.Cal P1, Deluca L, Jakob T, Fernández E.BACKGROUND: Laparoscopic sleeve gastrectomy (LSG) has become a widely used primary bariatric surgery. As this is a restrictive procedure, calibrating bougie size is assumed to impact on both morbidity and weight loss. However, no prospective studies have confirmed this hypothesis. The objective of this trial was to compare LSG outcomes using different calibrating bougie diameters. MATERIALS AND METHODS:A randomized controlled trial: 126 patients undergoing LSG were randomized to either a 27-Fr (group A) or a 39-Fr (group calibrating bougie. Inclusion criteria were BMI 40-50 kg/m2, aged 20-70 and absence of prior gastric surgery. All surgeries were performed by the same surgeon. Sample size was calculated to detect a six-point difference in percentage of excess weight loss (%EWL) at 1 year after surgery, considering an α error = 0.05 and a β error = 0.2. The volume of resected stomach, morbidity and weight loss at 6 months and at 1 year after surgery were analyzed. RESULTS:Groups (group A n = 62, group B n = 64) were similar in BMI (44.3 vs. 43.5), aged (41.9 vs. 42.2) and female percentage (87.1 vs. 84.3 %). A 1-year follow-up was achieved in 90.1 and 87.1 %, respectively. Two major complications occurred, one leak in each group (1.6 %). The volume of resected stomach was similar (426 vs. 402 ml, P = 0.71), as well as 6 months %EWL (66.3 vs. 66.6 %; P = 0.91) and 1 year %EWL (75.6 vs. 71.3 %, P = 0.21). A 1-year %EWL higher than 50 was achieved in 96.5 % of patients in group A versus 85.2 % in group B (P = 0.11). CONCLUSIONS:The use of different bougie diameters had no impact on the volume of resected stomach, morbidity or short-term weight loss after LSG, although a trend was seen toward better weight loss with the smaller bougie. A longer-lasting follow-up will be necessary to further assess differences. ______________________________________________________________________________________________________________________________________________ Obes Surg. 2014 Jul;24(7):1090-3. doi: 10.1007/s11695-014-1199-9.Laparoscopic sleeve gastrectomy using 42-French versus 32-French bougie: the first-year outcome.Spivak H1, Rubin M, Sadot E, Pollak E, Feygin A, Goitein D.BACKGROUND:The optimal size of bougie in laparoscopic sleeve gastrectomy (LSG) remains controversial. The aim of this study was to evaluate the first-year outcome of LSG using two different sizes of bougies. METHODS:This study used a single institute retrospective case-control study of two groups of patients. Group A (N = 66) underwent LSG using 42-Fr and group B (N = 54) using 32-Fr bougies. A medication score was applied to assess the change in comorbid conditions. RESULTS:Groups A and B's age (39.5 ± 12 vs. 43.6 ± 12.3 years), weight (119 ± 17 vs. 120 ± 20), and BMI (42.8 ± 3.8 vs. 43.6 ± 6.9 kg/m(2)), respectively, were comparable (p = NS). Comorbid conditions were type 2 diabetes (T2DM) in 19 (29%) vs. 23 (43%) patients, hypertension in 22 (33%) vs. 18 (33%) patients, and gastroesophageal reflux (GERD) in 28 (42%) vs. 10 (19%) patients, respectively. At 1 year, group A vs. B BMI was (29.4 ± 5 vs. 30 ± 5 kg/m(2)) and excess weight loss was 67 vs. 65%, respectively (p = NS). Postoperatively, T2DM (79 vs. 83%), hypertension (82 vs. 61%), and GERD (82 vs. 60%) (p = NS), respectively, in groups A vs. B did not require previous medications anymore. Complications were comparable. CONCLUSIONS:Our data suggest that using a 42-Fr or 32-Fr bougie does not influence LSG first-year weight loss or resolution of comorbid conditions. Long-term data is needed to conclude this issue. _________________________________________________________________________________________________________________________ Int J Surg. 2014;12(5):504-8. doi: 10.1016/j.ijsu.2014.02.008. Epub 2014 Feb 18.Long term predictors of success after laparoscopic sleeve gastrectomy.Abd Ellatif ME1, Abdallah E2, Askar W2, Thabet W2, Aboushady M3, Abbas AE2, El Hadidi A2, Elezaby AF4, Salama AF4, Dawoud IE2, Moatamed A2, Wahby M5.BACKGROUND:To evaluate early, mid and long term efficacy of laparoscopic sleeve gastrectomy as a definitive management of morbid obesity and to study factors that may predict its success. MATERIALS AND METHODS:A retrospective study was conducted by reviewing the database of patients who underwent LSG as a definitive bariatric procedure, from April 2005 to March 2013. Univariate and multivariate analysis were performed. RESULTS:1395 patients were included in this study. Mean age was 33 years and women:men ratio was 74:26. The mean preoperative BMI was 46 kg/m(2). Operative time was 113 ± 29 min. Reinforcement of staple line was done only in 447 (32%) cases. 11 (0.79%) cases developed postoperative leak, with total number of complications 72 (5.1%) and 0% mortality. Percentage of excess weight loss (%EWL) was 42%, 53%, 61%, 73%, 67%, 61%, 59% and 57% at 6 months, 1-7 years. Remission of diabetes (DM), hypertension (HTN) and hyperlipidaemia (HLP) occurred 69%, 54% and 43% respectively. 56 (4%) patients underwent revision surgery, for insufficient weight loss (n = 37) and severe reflux symptoms (n = 19). Mean follow up was 76 ± 19 (range: 6-103) months. Smaller bougie size and leaving smaller antrum were associated with significant %EWL. Bougie ≤36F remained significant in multivariate analysis. CONCLUSION:This study supports safety, effectiveness and durability of LSG as a sole definitive bariatric procedure. Smaller bougie size and shorter distance from pylorus were associated with significant %EWL. Copyright © 2014 Surgical Associates Ltd. Published by Elsevier Ltd. All rights reserved. __________________________________________________________________________________________________________________ Obes Surg. 2013 Oct;23(10):1685-91. doi: 10.1007/s11695-013-1047-3.The effects of bougie caliber on leaks and excess weight loss following laparoscopic sleeve gastrectomy. Is there an ideal bougie size?Yuval JB1, Mintz Y, Cohen MJ, Rivkind AI, Elazary R.Laparoscopic sleeve gastrectomy (LSG) has become a common surgical procedure, yet there is no consensus on what bougie size is best for LSG. We reviewed the literature and assessed the relationship between the size of bougie used and the incidence of leak as well as weight loss parameters. We wanted to determine if there is an ideal bougie size for LSG. A search of the medical literature was undertaken. We limited the search to articles published in the last 5 years written in English and investigating humans. We analyzed 32 publications comprising 4,999 patients. We determined the frequency of staple line leaks as well as weight loss parameters in relation to bougie size. This study was exempt from our institutional review board. The use of bougies of 40 French (F) and larger was associated with a leak rate of 0.92% as opposed to 2.67% for smaller bougies (p < 0.05). Weight loss in percent of extra weight loss (%EWL) was 69.2% when a bougie of 40 F and larger was used, as opposed to 60.7% of EWL when smaller bougies were used (p = 0.29). LSG is becoming an important and common procedure. Larger sizing bougies are associated with a significant decrease in incidence of leak with no change in weight loss. Further studies are needed before an unequivocal decision on the optimal bougie size is made. A recommendation to use the smallest bougie possible should be avoided because the risks may outweigh the benefits. __________________________________________________________________________________________________________________ Surg Endosc. 2012 Jun;26(6):1509-15. doi: 10.1007/s00464-011-2085-3. Epub 2011 Dec 17.Sleeve gastrectomy and the risk of leak: a systematic analysis of 4,888 patients.Aurora AR1, Khaitan L, Saber AA.INTRODUCTION:Sleeve gastrectomy has become a popular stand-alone bariatric procedure with comparable weight loss and resolution of comorbidities to that of laparoscopic gastric bypass. The simplicity of the procedure and the decreased long-term risk profile make this surgery more appealing. Nonetheless, the ever present risk of a staple-line leak is still of great concern and needs further investigation. METHODS:An electronic literature search of MEDLINE database plus manual reference checks of articles published on laparoscopic sleeve gastrectomy for morbid obesity and its complications was completed. Keywords used in the search were "sleeve gastrectomy" OR "gastric sleeve" AND "leak." We analyzed 29 publications, including 4,888 patients. We analyzed the frequency of leak after sleeve gastrectomy and its associated risks of causation. RESULTS:The risk of leak after sleeve gastrectomy in all comers was 2.4%. This risk was 2.9% in the super-obese [body mass index (BMI) > 50 kg/m(2)] and 2.2% for BMI < 50 kg/m(2). Staple height and use of buttressing material did not affect leak rate. The use of a size 40-Fr or greater bougie was associated with a leak rate of 0.6% compared with those who used smaller sizes whose leak rate was 2.8%. Leaks were found at the proximal third of the stomach in 89% of cases. Most leaks were diagnosed after discharge. Endoscopic management is a viable option for leaks and was documented in 11% of cases as successful. CONCLUSIONS:Sleeve gastrectomy has become an important surgical option for the treatment of the ever growing morbidly obese population. The risk of leak is low at 2.4%. Attention to detail specifically at the esophagogastric junction cannot be stressed enough. Careful patient selection (BMI < 50 kg/m(2)) and adopting the use of a 40-Fr or larger bougie may decrease the risk of leak. Vigilant follow-up during the first 30 days is critical to avoid catastrophe, because most leaks will happen after patient discharge. ___________________________________________________________________________________________________________________ Surg Obes Relat Dis. 2008 Jul-Aug;4(4):528-33. doi: 10.1016/j.soard.2008.03.245. Laparoscopic sleeve gastrectomy: does bougie size affect mean %EWL? Short-term outcomes. Parikh M1, Gagner M, Heacock L, Strain G, Dakin G, Pomp A.BACKGROUND:Laparoscopic sleeve gastrectomy (LSG) has been increasingly offered to high-risk bariatric patients as the first-stage procedure before gastric bypass or biliopancreatic diversion or as the primary weight loss procedure. The bougie size has varied by surgeon during LSG. The aim of this study was to determine whether short-term weight loss correlates with the bougie size used during creation of the sleeve. METHODS:We retrospectively reviewed the data from all patients who had undergone LSG at our institution between 2003 and 2006. Revision LSG for failed bariatric procedures was excluded. The data analyzed included preoperative age, body mass index (BMI), bougie size, and percentage of excess weight loss (%EWL). RESULTS:A total of 135 patients underwent LSG during the 4-year period. Most of these patients (79%) underwent LSG as part of a 2-stage operation (either gastric bypass or duodenal switch within a mean of 11 months). The mean preoperative age and BMI was 43.5 years and 60.1 kg/m(2), respectively. The mean BMI and %EWL at 6 months was 47.1 kg/m(2) and 37.9%, respectively. The mean BMI and %EWL at 12 months was 44.3 kg/m(2) and 47.3%, respectively. When stratifying the %EWL by bougie size (40F versus 60F), we did not find a significant difference at 6 months (38.8% versus 40.6%, P = NS) or 12 months (51.9% versus 45.4%, P = NS). CONCLUSION:LSG results in significant weight loss in the short term. When stratifying outcomes by bougie size, our results suggested that a bougie size of 40F compared with 60F does not result in significantly greater weight loss in the short term. However, longer follow-up of the primary LSG group is required to determine whether a difference becomes evident over time.
  14. Dear Cocoa, Good to hear from you and to know that you are doing well after all of these years. It's always a good idea to carry a wallet card that states your medical conditions, medications, medication allergies, and previous surgeries. I'd place it with your insurance card so that in the event of a real emergency, the hospital folks will be sure to see it. NG tubes are riskiest for GBP patients. The tube can potentially perforate the stub of small bowel near the gastrojejunostomy. Misplacement or perforation can be avoided if the NG tube is placed under x-ray guidance (flouroscopy). Sleeve and lap band patients are much less vulnerable, but there is still increased risk in certain circumstances. If the cause of the vomiting is a lap band slip, the tissue that has slipped up through the stomach can become thinned out and weakened under certain circumstances. The tube could go right through it. Likewise, if a sleeve were twisted or "corkscrewed", the tube could be pushed through the wall of the stomach. So if you have to go to the ER because of repetitive vomiting, discuss your stomach surgery with the ER doctor. I would be sure to speak with the physician about this, not just the nurse or assistant. Let him or her know about your concern about stomach perforation. Suggest that either he or she pass the tube or have the radiologist do it under flouroscopy. Hope this is non-issue! Happy New Year, Dr. Callery
  15. Yes. A gastric feeding tube can be inserted into the lower (excluded) portion of the stomach. The tube is usually inserted using laparoscopic technique on an out patient or overnight stay basis. The tube can be used for feeding or it can be used to decompress the stomach. The tube may be used for feeding within a day in most cases.
  16. Dear KN, There has been quite a bit written about the effect of gastric bypass on pregnancy. Sleeve is much newer, and medical reports are just starting to come in. As a general rule, pregnancy after weight loss surgery is safe both for mom and baby. Maternal complications decrease as the mother loses weight. There has been a higher risk of need for cesarean section in some studies of women who've had gastric bypass. There are very few fetal complications reported. There are some reports that suggest that there may be an increased incidence in babies who have a low birthweight. There are also reports of vitamin deficiencies. Most surgeons recommend that patients weight a year or 18 months before pregnancy, but some research suggests that this may not be necessary. Get good prenatal care from a reputable obstetrician. Ask her or him if you need to visit a "high risk" clinic. Your OB will make that decision based on his or her comfort level and experience with managing pregnancies after weight loss surgery. Managing the pregnancy during the acute weight loss phase, the first year, is trickier than later when mom's weight is stable. Be sure to take adequate protein and prenatal vitamins. Folate is especially important to avoid neural tube defects. Your vitamin levels should be checked before and during the pregnancy. Best of luck with very wonderful part of life. Dr. Callery Adv Nutr. 2015 Jul 15;6(4):420-9. doi: 10.3945/an.114.008086. Print 2015 Jul.Maternal micronutrient deficiencies and related adverse neonatal outcomes after bariatric surgery: a systematic review.Jans G1, Matthys C2, Bogaerts A3, Lannoo M4, Verhaeghe J5, Van der Schueren B2, Devlieger R6.Pregnant and postpartum women with a history of bariatric surgery are at risk of micronutrient deficiencies as a result of the combination of physiologic changes related to pregnancy and iatrogenic postoperative alterations in the absorption and metabolism of crucial nutrients. This systematic review investigates micronutrient deficiencies and related adverse clinical outcomes in pregnant and postpartum women after bariatric surgery. A systematic approach involving critical appraisal was conducted independently by 2 researchers to examine deficiencies of phylloquinone, folate, iron, calcium, zinc, magnesium, iodide, copper, and vitamins A, D, and B-12 in pregnant and postpartum women after bariatric surgery, together with subsequent outcomes in the neonates. The search identified 29 relevant cases and 8 cohort studies. The quality of reporting among the case reports was weak according to the criteria based on the CARE (CAse REporting) guidelines as was that for the cohort studies based on the criteria from the Cohort Study Quality Assessment list of the Dutch Cochrane Center. The most common adverse neonatal outcomes related to maternal micronutrient deficiencies include visual complications (vitamin A), intracranial hemorrhage (phylloquinone), neurological and developmental impairment (vitamin B-12), and neural tube defects (folate). On the basis of the systematically collected information, we conclude that the evidence on micronutrient deficiencies in pregnant and postpartum women after bariatric surgery and subsequent adverse neonatal outcomes remains weak and inconclusive. _______________________________________________________________________________________________________________________________ Obes Surg. 2013 Jun;23(6):756-9. doi: 10.1007/s11695-012-0858-y.Pregnancy outcomes after laparoscopic sleeve gastrectomy in morbidly obese Korean patients.Han SM1, Kim WW, Moon R, Rosenthal RJ.Laparoscopic sleeve gastrectomy (LSG) is an effective procedure for treating morbid obesity, and the majority of female patients who received LSG were at childbearing age. Female patients, who successfully lost weight following LSG and became pregnant, need to be evaluated carefully. Information was gathered, through prospectively maintained database and phone interview, on women who underwent LSG from May 2003 to July 2011. A total of 136 women underwent LSG in this period. There were 13 (9.6 %) pregnancies in 12 patients after LSG. The age before surgery was 28.3 ± 4.0. The mean weight and body mass index (BMI) before LSG were 95.3 ± 9.4 kg and 35.1 ± 3.5 kg/m(2), respectively. The average time from LSG to the first live birth was 32.0 ± 19.1 months. Mean BMI decreased significantly after LSG, from 35.1 ± 3.5 to 24.9 ± 2.3 kg/m(2) at conception. The mean percentage of excess body mass index loss was 85.8 ± 16.7 % at conception and 42.7 ± 25.1 % at delivery. Gained weight during pregnancy was 15.1 ± 5.2 kg. The mean gestational age and birth weight were 39.0 ± 1.6 weeks and 3,229.0 ± 505.9 g. In two cases (15.4 %), cesarean section was performed. No cases of pregnancy-induced hypertension and diabetes developed. Major congenital anomalies and neonatal deaths were not recorded. Larger study with longer follow-up is needed to evaluate the effect of LSG in pregnancies. However, these findings show that LSG seems to be a safe option for morbidly obese women in their reproductive period._______________________________________________________________________________________________________________________________ Int J Gynaecol Obstet. 2015 Aug;130(2):127-31. doi: 10.1016/j.ijgo.2015.03.022. Epub 2015 Apr 24.Pregnancy outcomes after laparoscopic sleeve gastrectomy among obese patients.Ducarme G1, Chesnoy V2, Lemarié P3, Koumaré S4, Krawczykowski D4.OBJECTIVE:To analyze pregnancy outcomes after laparoscopic sleeve gastrectomy (LSG) according to body mass index (BMI) at conception and the interval between LSG and pregnancy.METHODS:In a retrospective study, data were obtained for all women who became pregnant after LSG at a center in France between December 2001 and December 2011. Frequencies of perinatal events according to BMI at conception and the interval between LSG and pregnancy were compared.RESULTS:A total of 63 pregnancies occurring in 54 patients were included, among which 52 (83%) occurred after the first postoperative year and 26 (41%) in women who remained obese. Compared with women who were no longer obese at conception, women who were still obese delivered neonates of significantly lower gestational age at birth (P=0.02) and birth weight (P=0.001). Odds of preterm delivery were also increased (odds ratio 4.37, 95% confidence interval 1.17-16.27; P=0.03). Maternal and neonatal outcomes according to the interval between LSG and pregnancy did not differ significantly.CONCLUSION:Women who remain obese following LSG are at increased risk of adverse outcomes, including low gestational age at birth, low birth weight, and preterm delivery, and should be regarded as a risk group._______________________________________________________________________________________________________________________________ Surg Obes Relat Dis. 2014 Nov-Dec;10(6):1166-73. doi: 10.1016/j.soard.2014.02.011. Epub 2014 Feb 24.Pregnancy outcomes and nutritional indices after 3 types of bariatric surgery performed at a single institution.Mead NC1, Sakkatos P2, Sakellaropoulos GC3, Adonakis GL4, Alexandrides TK5, Kalfarentzos F6.BACKGROUND: Nutritional status during pregnancy and the effects of nutritional deficiencies on pregnancy outcomes after bariatric surgery is an important issue that warrants further study. The objective of this study was to investigate pregnancy outcomes and nutritional indices after restrictive and malabsorptive procedures.METHODS: We investigated pregnancy outcomes of 113 women who gave birth to 150 children after biliopancreatic diversion (BPD), Roux-en-Y gastric bypass (RYGB), and sleeve gastrectomy (SG) between June 1994 and December 2011. Biochemical indices and pregnancy outcomes were compared among the different types of surgery and to overall 20-year hospital data, as well as to 56 presurgery pregnancies in 36 women of the same group.RESULTS: Anemia was observed in 24.2% and 15.6% of pregnancies after BPD and RYGB, respectively. Vitamin B12 levels decreased postoperatively in all groups, with no further decrease during pregnancy; however, low levels were observed not only after BPD (11.7%) and RYGB (15.6%), but also after SG (13.3%). Folic acid levels increased. Serum albumin levels decreased in all groups during pregnancy, but hypoproteinemia was seen only after BPD. Neonates after BPD had significantly lower average birth weight without a higher frequency of low birth weight defined as<2500 g. A comparison of neonatal data between babies born before surgery and siblings born after surgery (AS) showed that AS newborns had lower average birth weight with no significant differences in body length or head circumference and no cases of macrosomia.CONCLUSION: Our study showed reasonably good pregnancy outcomes in this sample population after all types of bariatric surgery provided nutritional supplement guidelines are followed. Closer monitoring is required in pregnancies after malabsorptive procedures especially regarding protein nutrition._______________________________________________________________________________________________________________________________ Obes Surg. 2015 Mar;25(3):436-42. doi: 10.1007/s11695-014-1387-7.Maternal and perinatal outcomes after bariatric surgery: a Spanish multicenter study.González I1, Rubio MA, Cordido F, Bretón I, Morales MJ, Vilarrasa N, Monereo S, Lecube A, Caixàs A, Vinagre I, Goday A, García-Luna PP.BACKGROUND: Bariatric surgery (BS) has become more frequent among women of child-bearing age. Data regarding the underlying maternal and perinatal risks are scarce. The objective of this nationwide study is to evaluate maternal and perinatal outcomes after BS.METHODS: We performed a retrospective observational study of 168 pregnancies in 112 women who underwent BS in 10 tertiary hospitals in Spain over a 15-year period. Maternal and perinatal outcomes, including gestational diabetes mellitus (GDM), pregnancy-associated hypertensive disorders (PAHD), pre-term birth cesarean deliveries, small and large for gestational age births (SGA, LGA), still births, and neonatal deaths, were evaluated. Results were further compared according to the type of BS performed: restrictive techniques (vertical-banded gastroplasty, sleeve gastrectomy, and gastric banding), Roux-en-Y gastric bypass (RYGB), and biliopancreatic diversion (BPD).RESULTS: GDM occurred in five (3 %) pregnancies and there were no cases of PAHD. Women whose pregnancies occurred before 1 year after BS had a higher pre-gestational body mass index (BMI) than those who got pregnant 1 year after BS (34.6 ± 7.7 vs 30.4 ± 5.3 kg/m(2), p = 0.007). In pregnancies occurring during the first year after BS, a higher rate of stillbirths was observed compared to pregnancies occurring after this period of time (35.5 vs 16.8 %, p = 0.03). Women who underwent BPD delivered a higher rate of SGA babies than women with RYGB or restrictive procedures (34.8, 12.7, and 8.3 %, respectively).CONCLUSIONS: Pregnancy should be scheduled at least 1 year after BS. Malabsorptive procedures are associated to a higher rate of SGA births._______________________________________________________________________________________________________________________________ Obes Surg. 2013 Aug;23(8):1281-5. doi: 10.1007/s11695-013-0903-5.Timing of pregnancy after gastric bypass-a national register-based cohort study.Kjær MM1, Nilas L.Author informationCurrent recommendations suggest postponing pregnancy by at least 1 year after gastric bypass. During the first postoperative year, women are in a catabolic phase with a rapid weight loss which may increase the risk of adverse pregnancy and neonatal outcomes. This study tested the hypothesis that the risk of adverse pregnancy and neonatal outcomes is increased in women who conceive during the first year after gastric bypass surgery.METHODS: This is a national register-based cohort study covering all Danish deliveries during 2004-2010 in women with prior Roux-en-Y gastric bypass surgery. Only the first postoperative birth was included. The risk of adverse pregnancy and neonatal outcomes was compared between women who conceived within the first postoperative year and women who conceived later. Data were extracted from the Danish National Patient Registry and The Danish Medical Birth Register.RESULTS: Of 286 women who had a singleton delivery after Roux-en-Y gastric bypass surgery, 158 women conceived within the first year and 128 later. There was no statistically significant difference (p > 0.05) between the two groups regarding neonatal birth weight, gestational age, risk of preeclampsia, gestational diabetes mellitus, labor induction, cesarean section, postpartum hemorrhage (>500 ml), preterm birth (before 37 weeks), small for gestational age, large for gestational age, or Apgar score (5 min ) below 7, or in the need of neonatal intensive care.CONCLUSIONS: This study showed no evidence to support a recommendation to delay pregnancy until after the first postoperative year. At present, the optimal time for pregnancy after gastric bypass is unknown.
  17. Dear HJ, It's not unusual for patients to have a bite too much early on after sleeve or bypass surgery. If the sleeve or pouch streches there will be some pain. The pain usually resolves fairly quickly, but may last a day. Consider staying on clear liquids for a day or two. Monitor yourself for persistent vomiting, rising heart rate, elevated temperature, or any new pain in the shoulders, chest, or abdomen. If you notice new symptoms, call your surgeon. Your surgeon will advise you on how quickly to advance your diet. Surgeons have different general preferences. And surgeons will give specific advice to patients based on the patient's surgery and medical condition. We tend to keep our patients on clear liquids for 2 or 3 days, nutritious liquids for a couple of weeks, and then puree/very soft foods until six weeks. After six weeks our patients introduce solid foods like fresh vegetables and soft cooked meats. So you may be advancing to fresh vegetables before your sleeve is ready. My biggest concern as a surgeon is for patients one or two weeks post op who move from liquids to solids too quickly. The staple line still is in the healing process and may not tolerate food impaction and vomiting. A word to the wise. Many patients want to experiment with thicker foods during the first couple of weeks after surgery. Call it old habits, a need to experiment, the thrill of getting away with it, or what ever. Just don't! Think of this analogy. You are on a hike in the winter. You're in a hurry to meet some friends at a trail junction. You come across a dozen lake. Now, you can either take the train around the lake, or take the "short cut" across the lake. What are the chances that you will break through the ice and either have a nasty chill or freeze and drown? Go around the lake, don't be a fool. Same thing with your new sleeve or GBP pouch. It may take a while and be boring, but stick with the liquids until your surgeon says it's ok to move to thicker foods. Do not take the chance of eating solids, vomiting, and possibly rupturing your staple line. A staple line leak means a trip to the OR or radiology suite and weeks or months of recovery. You could develop blood clots. Your could die. So, enjoy the hike. Take your time. Be safe. Happy New Year!
  18. Dear MOK, Ferritin is an iron storage molecule. Interpretation of serum ferritin is fairly complicated. Ferritin is elevated with iron excess, but also goes up under a variety of other conditions. Some of these conditions include acute inflammation, liver disease, and significant malnutrition. I'd discuss your ferritin level with your PCP since so many factors need to be taken into account. The following is quoted from Mariana Koperdanova, British Medical Journal, 2015;351:h3692 "Elevated ferritin levels are usually due to causes such as acute or chronic inflammation, chronic alcohol consumption, liver disease, renal failure, metabolic syndrome, or malignancy rather than iron overload Exclude these causes clinically or with initial tests such as full blood count, liver and renal function, and inflammatory markers (C reactive protein or erythrocyte sedimentation rate) A normal serum transferrin saturation (ideally fasting) usually excludes iron overload (where it is raised) and suggests a reactive cause for raised ferritin Unexplained serum ferritin values >1000 μg/L warrant referral for further investigation Consider HFE mutation screen for hereditary haemochromatosis in individuals with elevated ferritin and a raised transferrin saturation >45%" Here's the summary of a medical journal article that you might find interesting: Nutr Hosp. 2014 Oct 16;31(2):666-71. doi: 10.3305/nh.2015.31.2.7629.Ferritin in hypertensive and diabetic women before and after bariatric surgery.Marin FA1, Rasera Junior I2, Leite CV3, Oliveira MR4. In addition to its important role as marker of iron stores, serum ferritin is a marker of systemic inflammation, and obesity has been associated with chronic inflammation. OBJECTIVE: To verify, six months after surgery, the effect of bariatric surgery on the serum ferritin of women who were hypertensive, diabetic, or comorbidity free before surgery. SAMPLE AND METHODS: This retrospective study included 200 women aged 20 to 45 years, with a body mass index (BMI) equal to or greater than 35 kg/m2, submitted to Roux-en-Y gastric bypass (RYGB). Seventy of these women were hypertensive, forty had type 2 diabetes (T2D), and ninety were comorbidity free (CF). They were assessed before and six months after surgery. Anthropometric, laboratory (serum ferritin and hemoglobin), and comorbidity- related data were collected from their medical records. RESULTS: Before surgery, women with comorbidities were older, the hypertensives had higher BMI, and the diabetics had higher serum ferritin levels than the CF women. The study comorbidities had resolved in 68% of the hypertensive women and 86% of the diabetic women six months after RYGB. Also at this time, the serum ferritin of hypertensive women decreased from 110.1±86.3 to 88.7±80.5 ng/dL and of diabetic women, from 164.8±133.4 to 101.2±97.7 ng/dL (p0.05). CONCLUSION: High ferritin in premenopausal obese women was associated with the main obesity-related comorbidities, and these comorbidities determined the reduction of serum ferritin after bariatric surgery.
  19. Dear Jerrod24, A gallbladder ultrasound sounds like a good idea. Patients who have undergone gastric bypass have a 30% chance of developing gallstones. The risk of developing gallstones can be reduced to about 2% if a patient takes ursodiol (Actigall) 300mg twice daily for 6 months after surgery. Gallstones can cause upper abdominal pain, upper back pain, right shoulder pain, nausea, and vomiting. However, diarrhea is not a usual symptom of gallstones. If gallstones are causing the problem, the gallbladder can be removed safely, laparoscopically by most general surgeons. There is no need to travel to see your gastric bypass surgeon unless you have faith in him and he is willing to do your surgery. For more information see: Mayo Clinic article. Dr. Callery
  20. Dear Pilotswife, Bloody mucus in the stool is an important problem, and you should discuss it with your physician. There are many causes of bloody mucus some of which include colitis, infection, malignancy, and benign polyps. It is unlikely to be related to your gastric bypass. You may need a colonoscopy for diagnosis. Dr. Callery
  21. Dear Jordan, A nasogastric tube (NG tube) is a tube that is passed through the nose, down the esophagus, and into the stomach. A nasojejunal tube is longer. It passes through the nose, through the stomach, and into the jejunum (after gastric bypass). There are two reasons to pass such tubes: decompression and feeding. The first reason is to take pressure off of the stomach and intestines by removing fluid or air. This might be needed if there were an obstruction blocking the intestine further down. The second reason is for feeding. A feeding tube can deliver nutrition and medication into the stomach or Roux limb if a patient can't take food by mouth or if there is a narrowing in the connection between the stomach and jejunum (gastrojejunostomy). Medications can be administered through a feeding tube or NG tube if they can be prepared as a liquid or thin mixture. Pills that are simply crushed and mixed with water can be a problem if they clog the tube. An NG tube used to decompress the intestine is a fairly heavy duty tube. It is reasonably stiff and must be inserted carefully by a knowledgable nurse or physician. There is some risk that the tube can catch in the jejunum near the gastrojejunostomy and can even perforate the jejunum. In some cases the patient's physician may ask the radiologist to pass the NG tube under x-ray guidance. That way the radiologist can be sure it goes to the correct location and does not cause damage. An NG tube used for decompression can be left in place for a few days or week or two, but eventually causes quite a bit of irritation to the nose. A feeding tube has a fairly narrow diameter and is very flexible. It is usually passed through the nose, through the stomach, and into the jejunum by a radiologist using fluoroscopy (active x-ray guidance). Sometimes it is even necessary to ask a gastroenterologist to use endoscopy to guide the tube though a tight gastrojejunostomy. A feeding tube is usually well tolerated and can be left in place for weeks or longer. Other types of tubes include gastrostomy tubes and jejunostomy tubes. These can be inserted via surgery or endoscopy through the skin and directly into the stomach or jejunum. Gastrostomy tubes can be used to decompress the stomach or for feeding. Jejunostomy tubes are used for feeding. Both types of tubes are usually well tolerated and can be left in place for prolonged periods of time. Dr. Callery
  22. Dear Lori, It is extremely important that your bipolar symptoms be well controlled. If aripiprazole (Abilify) works well, you should plan to continue to take it after your sleeve gastrectomy. You and your psychiatrist may need to change the dose depending on how well it is absorbed and how your weight loss changes your response to the drug. It is annoying that Abilify seems to make you gain weight, but hopefully that will not be too big a factor after your surgery. Even if the surgery is not quite as effective with Abilify on board, you still will be much better off overall at a lower weight. I've attached an interesting review article that ranks the various newer psychological medications by their tendency to cause weight gain. Fortunately, aripiprazole is relatively low on the list. It causes a lot less weight gain than many other medications. Dr. Callery Expert Opin Drug Saf. 2015 Jan;14(1):73-96. doi: 10.1517/14740338.2015.974549. Epub 2014 Nov 15. Weight gain and antipsychotics: a drug safety review. Musil R1, Obermeier M, Russ P, Hamerle M. Abstract INTRODUCTION: Second-generation antipsychotics (SGAs) are widely used in several psychiatric disease entities and exert to a different extent a risk for antipsychotic-induced weight gain (AIWG). As AIWG is associated with an increase in metabolic syndrome or cardiovascular events, knowledge of these risks is crucial for further monitoring and the initiation of counteractive measures. AREAS COVERED: We searched PubMed and Web of Sciences for randomized-controlled trials and naturalistic observational studies published between 2010 and 2014 with sample sizes exceeding 100, including all marketed SGAs apart from zotepine, and providing data on weight increase. We also summarized relevant systematic reviews and meta-analyses of head-to-head comparisons. EXPERT OPINION: Recently published data still support the hierarchical ranking of SGAs already proposed in previous reviews ranking clozapine and olanzapine as having the highest risk, followed by amisulpride, asenapine, iloperidone, paliperidone, quetiapine, risperidone and sertindole in the middle, and aripiprazole, lurasidone and ziprasidone with the lowest risk. Number needed to harm varied considerably in our meta-analysis. Younger patients and patients with a lower baseline body mass index are most vulnerable. The greatest amount of weight gain occurs within the first weeks of treatment. AIWG occurs in all diagnostic groups and is also common in treatment with first-generation antipsychotics; therefore, awareness of this adverse event is essential for anyone prescribing antipsychotics.
  23. Dear Jb, As a general rule, age is only a relative factor. Most surgeons think more of "physiological" age than chronological age. In other words, one's general health and ability to tolerate the surgery is the key, and age is just one of many factors to take into consideration. There may be higher complication rates in the elderly, but not to the extent that surgery should not be considered. We have done Lap-Bands, sleeve gastrectomies, and gastric bypasses in patients in their 70's with good results. These patients have all passed careful medical evaluation including cardiac and pulmonary testing. I've included the summaries of three journal articles on the subject. Dr. Callery Obes Surg. 2014 Oct;24(10):1662-9. doi: 10.1007/s11695-014-1247-5. Gastric bypass for obesity in the elderly: is it as appropriate as for young and middle-aged populations? Robert M1, Pasquer A, Espalieu P, Laville M, Gouillat C, Disse E. Abstract BACKGROUND: Obesity prevalence increases in elderly population. Bariatric surgery has been underused in patients over 60 because of fears of complications and lower weight loss. We postulated worse outcomes in the elderly in comparison to young and middle-aged population 1 year after gastric bypass. METHODS: We retrospectively analyzed gastric bypass outcomes in young (<40 years), middle-aged (40 to 55 years), and elderly (>60 years) patients between 2007 and 2013. Each subject over 60 (n = 24) was matched with one subject of both the other groups according to gender, preoperative body mass index (BMI), surgical procedure, and history of previous bariatric surgery (n = 72). RESULTS: Older subjects demonstrated higher prevalence of preoperative metabolic comorbidities (70 vs 30 % in the <40-year-old group, p < 0.0001). Mean duration of the surgical procedure, mean length of stay, and early and late complication rates were similar between age groups. A trend towards fewer early complications and less-severe complications in the younger groups was noted. One-year weight loss results were similar between young, middle-aged, and elderly patients (percentage of excess BMI loss (EBL%), 74.4 ± 3.5; 78.9 ± 4.5, and 73.7 ± 4.5 respectively, p = 0.69). Age was not predictive of weight loss failure 1 year after surgery. Remission and improvement rates of comorbidities were similar between age groups 6 months after surgery. CONCLUSIONS: Our study confirms weight loss efficacy of gastric bypass in the elderly with acceptable risks. Further studies evaluating the benefit-risk balance of bariatric surgery in the elderly population will be required so as to confirm the relevance of increasing age limit. _______________________________________________________________________________________________________________ Obes Surg. 2015 Mar;25(3):406-12. doi: 10.1007/s11695-014-1462-0. Advanced Age as an Independent Predictor of Perioperative Risk after Laparoscopic Sleeve Gastrectomy (LSG). Qin C1, Luo B, Aggarwal A, De Oliveira G, Kim JY. Abstract BACKGROUND: While the safety of many bariatric procedures has been previously studied in older patients, we examine the effect of advancing ageon medical/surgical complications in laparoscopic sleeve gastrectomy, a relatively unstudied procedure but that is trending upwards in use. METHODS: Patients undergoing laparoscopic sleeve gastrectomy (LSG) and laparoscopic gastric bypass (RYGB) were extracted from the National Surgical Quality Improvement Program 2005-2012 database. Pre- and postoperative variables were analyzed using chi-square and student t test as appropriate to determine the comparative safety of LSG to RYGB in the elderly. Multivariate regression modeling was used to evaluate whether age is associated with adverse 30-day events following LSG. RESULTS: Of the patients that met the inclusion criteria, 56,664 (84 %) patients underwent RYGB and 10,835 (16 %) underwent LSG. In the LSG cohort, incidence of overall complications, medical complications, and death significantly increased with increasing age (p < 0.05). No statistically significant differences in rates of 30-day complications, return to the OR, and mortality exist between RYGB and LSG cohorts in patients older than 65 years. The age group of over 65 years independently predicted increased risk for overall and medical complications (OR, 1.748; OR, 2.027). Notably, age was not significantly associated with surgical complications in LSG. CONCLUSION: In this large, multi-institutional study, advanced age was significantly associated with overall and medical complications but not surgical complications in LSG. Our findings suggest that the risk conferred by advancing age in LSG is predominantly for medical morbidity and advocate for improved perioperative management of medical complications. LSG may be the preferable option to RYGB for elderly patients as neither procedure is riskier with regards to 30-day morbidity while LSG has been shown to be safer with regards to long-term reoperation and readmission risk. ________________________________________________________________________________________________________________ J Am Assoc Nurse Pract. 2015 Mar 4. doi: 10.1002/2327-6924.12235. [Epub ahead of print] A review of the safety and efficacy of bariatric surgery in adults over the age of 60: 2002-2013. Caceres BA1, Moskowitz D, O'Connell T. Abstract PURPOSE: The purpose of this review is to compare outcomes of bariatric surgery in adults over 60 to younger patients. This analysis is important to determine if nurse practitioners (NPs) and other providers should recommend bariatric surgery to obese older adults. DATA SOURCES: This review included 15 studies published between 2002 and 2013. CONCLUSIONS: Although older adults seem to experience less weight loss, bariatric surgery has potential benefits for these patients. Significant improvements in hypertension, diabetes, and, to a lesser extent, dyslipidemia are noted. Mortality and surgical complications in older adults are low, while differences in length of hospital stay are inconclusive. IMPLICATIONS FOR PRACTICE: The risks of bariatric surgery in older adults need to be carefully evaluated based on individual medical condition. Overall the evidence suggests that bariatric surgery can be safely performed in older adults but more research is needed to determine which older adult patients are the best candidates for bariatric surgery. As bariatric surgery among older adults increases, interdisciplinary teams will continue to serve an important role in the management of bariatric surgery patients. NPs must be aware of trends in this emerging population of bariatric surgery patients.
  24. Dear Bikewash, Revision surgery is always more challenging and carries a higher complication rate than primary surgery. I can only imagine how much scar tissue was present after so many failed fundoplication surgeries. I can't comment about the specifics on your case, but if you are working with a qualified bariatric or general surgeon and gastroenterologist, I'd rely on their advice and encouragement. As a rule, there is very little choice this soon after revision surgery but to continue conservative management with endoscopic dilation as needed. Trying to reoperate now may be fraught with danger. If you need nutritional support, a G-tube could be inserted into the bypassed portion of the stomach. If you remain nutritionally crippled, at some point your surgeons may consider going back. It might be possible to reverse your gastric bypass, or they might advise removing the remainder of the gastric pouch and bringing the roux limb up to the esophagus. Either would be difficult and potentially dangerous surgery, but would restore your ability to eat. If the bypass were reversed, you might well have renewed reflux problems, and you would probably regain weight. Patients who have total removal of the stomach maintain weight loss to a greater or lesser extent. If the roux limb is long enough, they usually don't have problems with bile reflux. They can do quite well. Best of luck to you with this most challenging problem. Dr. Callery
  25. Dear DeeDee, As I read your post, you have two problems. The first is abdominal pain of unclear origin, and the second is a systems problem: you can't find a physician to treat you because you are a "gastric bypass patient". I can't give you personal medical advice. I do think you are doing the right thing. Your are being persistent and conscientious by going back to the ER because you are not improving. Any good general surgeon and any good gastroenterologist should be able to help you. There is very little difference between a gastric bypass and a partial gastrectomy other than the bypassed portion of the stomach is left in place with gastric bypass. Having said that, there are some surgeons and some gastroenterologists that duck the care they should provide. (Never assume malice until you rule out ignorance ... or laziness.) If a surgeon or gastroenterologist feels insecure about how to proceed, he or she can always call a bariatric surgeon and ask for advice. If you go to your local hospital, and if you need acute care that isn't available locally, you should be transferred to a center that can provide the care. It would be prudent for you to call your insurance company at the time to inform them. If you are an outpatient and can't find local care, call your insurance company and ask them how to proceed. They have the responsibility to see that there is an adequate network of qualified physicians to care for their insured. If you are having trouble getting the care you need at your local hospital, you can contact the chief of the medical staff, the medical director of the hospital, or the chief administrator of the hospital. If your insurance company is not helpful, you can contact your state's insurance commissioner or department of managed care. Your situation finding a qualified and caring doctor is not unique. The federal government is forcing rapid change on the healthcare system in the name of cost containment. As we go from a fee for service model where at times too many services were provided, we are moving to a rationing system where good care will be less accessible and less timely. I encourage you to stick up for yourself and insist on proper care. Dr. Callery