What to expect after weight-loss surgery
Host Amber Smith: Upstate Medical University in Syracuse, New York invites you to be The Informed Patient with the podcast that features experts from Central New York's only academic medical center. I'm your host, Amber Smith. If you or someone you care about has made the decision to have weight loss surgery, today, I'm talking with a surgeon about what you can expect afterward. Dr. Timothy Shope is chief of bariatric surgery at Upstate. Thank you for making time for this interview, Dr. Shope.
Timothy Shope, MD: Thank you, Amber, for the opportunity.
Host Amber Smith: What is the most common reaction your patients have when you see them after surgery, after they've awoken from anesthesia?
Timothy Shope, MD: Well, they're usually just glad to be awakeand have this fresh start for themselves. They've gotten, they, many of them have spent months and months in a program working through a process to get the surgery. And now it's finally the day of surgery. And now they've finally got this opportunity to really get this new lease on life.
Host Amber Smith: Well, I know many bariatric surgeries, maybe all of them, are done laparoscopically now through small incisions. So what impact does that have on how long a person recovers and how soon they go home from the hospital?
Timothy Shope, MD: We do the overwhelming majority of our procedures through what's called a minimally invasive approach, which includes standard laparoscopy and robotic approaches. An open operation is still done sometimes. Usually those are more for you know, revisional type surgeries where patients have had surgery before maybe they've had other kinds of surgery in their upper abdomen. So the majority of our surgeries are done through these small incisions. And what that means for the patients is that basically recovery is dramatically accelerated. Most of our patients are only in the hospital for a day or two. The overall physical recovery you know, we tell them to take probably a few weeks off of work. But honestly they're up and moving around at the same day of surgery.
Host Amber Smith: What determines when they're okay to go home?
Timothy Shope, MD: So there's a fair amount of medical, things that we have to consider, is their heart OK? Is their breathing OK? But those things are generally not really a big issue. And honestly the biggest hurdle for the patient is whether or not they're able to hydrate themselves, whether or not they're able to drink enough, essentially, so that we can take them off of the IV (intravenous line) and, allow them to do it on their own.
Host Amber Smith: Okay. And I was going to ask, how soon can they drink? How soon can they get eat?
Timothy Shope, MD: The drinking starts again, as soon as they're awake enough from surgery. We, we encourage them to get about an ounce or so fluid. So that's around 30 milliliters or 30 CC's which is basically one of those little cups that you'll see on the top of the cough medicine dispensers, for example. If they can get one of those down every 15 to 20 minutes then they should be able to hydrate themselves. Sounds pretty easy. But after these operations you really have a lot of difficulty getting any volume in at any one time. So we're not doing shots. We're talking about sips of those 15- to 30-milliliters of fluid which can actually take a good 10, 15 minutes if they're pacing themselves well.
Host Amber Smith: And you say fluid. Is it water, or is there a particular drink or beverage that you advocate?
Timothy Shope, MD: Initially, it's just water or clear liquid, something very low calorie and noncarbonated, something like Crystal Light or a no-sugar containing Gatorade or something like that. Within a few days, they're usually on protein shakes, which are a little bit heavier, a little bit more difficult to get to go down. But again they, if they commit to it, they can certainly do it.
Host Amber Smith: Now, once someone goes home on their own, do you have instructions for how they should eat in the first days after surgery and how soon, they'll kind of get into a new type of eating?
Timothy Shope, MD: Absolutely, Amber. Realistically, those months before surgery that I was mentioning before are largely meant to help educate the patients and help them reframe how they approach the eating process after surgery. They work extensively with our registered dietician staff. And so they know what to expect afterwards. Again, knowing what to expect and actually experiencing it is two different things. But they certainly are well-prepared for it. So the process really is roughly two weeks worth of those liquids that we were talking about. And then again, about two weeks more of softer foods. And then after about a month or so they can be back on normal types of foods, usually just significantly reduced portions. We ask them to concentrate on proteins first and fluids, a close second. And as they advance that diet, they will come back to us, they'll be coached about what to eat next, what things to try, what things to avoid. So the process is really, again, we set them up ahead of time for success in the pre-operative program, and we give them full support post-operatively to make sure that they have that success.
Host Amber Smith: So it sounds like it's a transition process.
Timothy Shope, MD: It is. And again, it takes at least a month, if not six weeks until they're back on those quote unquote regular foods. But again, those are much smaller portions, and hopefully they make a substantial change in the types of foods that they're choosing.
Host Amber Smith: Now do patients feel hunger since they're going to be eating so much less than they did before surgery?
Timothy Shope, MD: Actually, they don't. In addition to not being able to eat very much at any one particular time after these operations, the procedures themselves actually change around how our GI tract hormones are available to us and how they function basically. So, one of the operations in particular, called the sleeve gastrectomy, we remove about three quarters or so of the stomach, the organ, the stomach. And in that part of the stomach that's removed is where the vast majority of a hormone called ghrelin is produced. And it's not exactly correct, but the way to think about this is that that hormone basically does one thing. It tells our bodies it's time to go find some food. And so if that signal isn't there, most of those patients experienced a dramatic reduction in their hunger. And we see similar improvements in hunger, also in the gastric bypass, even though we're not actually removing that part of the stomach.
Host Amber Smith: This is Upstate's The Informed Patient podcast. I'm your host, Amber Smith talking with Dr. Timothy Shope, the chief of bariatric surgery. And we're talking about what things are like after someone completes the operation.
Host Amber Smith: Now, how soon would you advise people, typically, to get back to work and school and how soon can they resume an exercise routine?
Timothy Shope, MD: Well, it really depends what kind of work they do. I've had people go back if they're, if they own their own small business and their kids won't eat if they don't go back to work, I've had folks back as early as a week. That's pushing it a little bit. But I think most people can probably do OK on that. If you're, you know, in manual labor, construction work, that kind of thing, you're going to want to take at least several weeks off. These incisions will need to heal even though they're small and generally heal very well. And physically, your body's going through a lot of changes with these operations and the change in the caloric intake and the types of calories and such. And so people will feel a little bit you know, a little bit fatigued. That's pretty normal. But again, it's something that they can certainly overcome. My advice to patients usually is when you come back for your post-op visit, which is sometime around 10 days to two weeks after they leave the hospital, let's decide together if it's time for you to go back to work. And look, if they call me five days after they leave the hospital and say that they have to get back to work because the walls are closing in on them at home, I don't have any problem with them going back. As long as again, it's not sort of a physical labor type job.
Host Amber Smith: And if someone has an exercise routine or wants to start one, what would your advice be?
Timothy Shope, MD: Well, again, it really depends on the type of exercise that they'd like to do. We really do encourage activity of all kinds, even very early on. As I mentioned well, they're going to be up and moving around the same day of surgery. When they go home, they can go up and down stairs. They can go out for short walks and as they recover over that first week or two, they can certainly increase that as much as their body tolerates and as much as they're able to keep themselves hydrated. If they want to get back to true aerobic type activity or maybe even weightlifting type activities that should probably wait for at least a few weeks. And it's another one where I would encourage them to have that conversation with their provider at their initial post-op follow-up visit.
Host Amber Smith: How soon will patients notice weight loss?
Timothy Shope, MD: Well, it's not immediate. But the majority of people will notice a substantial amount of weight coming off within that first month or so. When we talk about the weight loss for these operations it's generally a year to a year and a half is the timeframe that we talk about for maximum weight loss.
Timothy Shope, MD: But that is pretty well front-loaded, meaning that the first six or eight months is where are they going to experience the majority of that weight loss, and then the next eight months or so, a little bit here and there will come off. It really depends on the starting weight as far as how much weight they will lose in that first month. But I think on average, somewhere around 20 to 30 pounds in the first month is pretty typical.
Host Amber Smith: So in the surgery that you do, you're not removing any tissue or anything that would put weight on a person.
Timothy Shope, MD: Well again, in the sleeve gastrectomy operation we remove a portion of the stomach, but the weight of that is, yeah, it's way less than a pound. So no, we don't actually remove. They don't wake up lighter from surgery. In fact, because of the fluid that we give during surgery and during the hospital stay, some patients will go home up a pound or two. That's not not unusual, but realistically within that, those first couple of weeks they are really starting to drop that weight.
Host Amber Smith: Now if a patient had diabetes, how quickly after surgery does that resolve?
Timothy Shope, MD: So that really depends on the type of procedure that they have. And I'm not trying to convince anybody to have any particular operation here. That's a conversation you should have individually with your surgeon. But with the gastric bypass operation there's good data from decades ago that show that the patient's sugars, that level when we check their sugars, and also their insulin use or their medication use drops dramatically even within the first couple of days. And all of us across the country have had patients that are diabetic when they come to the hospital and are off of medication when they leave the hospital within a couple of days. And what that really tells you is that, with regard to the gastric bypass operations specifically, the improvement in your diabetes isn't just about the loss of weight. We just talked about how that doesn't happen immediately, yet, and you could possibly go home -- not everybody -- but some patients can go home off of their medications. So it's really about the rearrangement of the GI (gastrointestinal) tract that comes with the gastric bypass. And again, the modulation of those hormones that we were talking about earlier. The other operations that we offer, the sleeve gastrectomy, lap bands other operations that are available, also will improve in most patients, the diabetic profiles, but they don't happen as quickly and they're really basically dependent on the amount of weight that's lost. So as you continue to lose weight, your diabetic profile should improve as well.
Host Amber Smith: Does the new way that people digest food after this surgery affect medications that they take?
Timothy Shope, MD: It might. The biggest, change is, basically their ability to get those medications in in the early time period or whether or not they actually need them. So again, if patients are, working hard to get enough hydration in and they're on medications, for example, that cause them to urinate more, adiuretic or water pill maybe they need to back off on some of those medications. The gastric bypass operation, where we actually change anatomy we reroute intestine that one potentially could, for some medications change how they're absorbed. And so, we gotta be very careful with that, that those patients that have that operation make sure that they're working with their other medical docs, as far as how those medications are absorbed. And it doesn't mean that they can't have those operations. It just may mean that they need either a different medication or, ideally, let's do this operation help you lose weight so you get healthier and don't need those medications at all.
Host Amber Smith: I was going to ask, because I've heard that vitamin B12 and folate and iron, those levels are tracked in someone who's had bariatric surgery, but you just explained, sort of, the reason, right?
Timothy Shope, MD: Well, yeah, so the biggest issue with that is you know, again, the ability to absorb things and actually we track multiple vitamins and micronutrients for patients. The ones you mentioned, but also thiamine, which is vitamin B one, vitamin D, zinc. Ah, There's a whole host of vitamins that we check for patients on a regular basis. All of our patients are encouraged to be on a standard multivitamin. If we identify that there is a deficiency of some kind, either based on our clinical evaluation or the laboratory studies that we get on at least a yearly basis we're going to supplement those as well.
Host Amber Smith: Now, a certain percentage of patients will have the surgery and lose the weight, but then they regain. So I wanted to ask you to talk about where they go, where they went wrong, and whether you have some advice that will help someone avoid making the same mistakes.
Timothy Shope, MD: Sure. So the first thing is I wouldn't say that they went wrong. I'd never blame it on the patient. In fact, when I have a patient that has that situation, I'm going to look at myself first. You want to make sure that the anatomy that you've created for them is proper and that is that they still have a quality tool if you will at their disposal to use. And if they use it properly then they should be able to get some of that weight regain back off. Most times the patient you're talking about there is maybe a couple of years out from surgery, and maybe they haven't been following up as frequently.They've slipped back into some old patterns of behavior and they're just not making the, the proper food choices. Those kinds of things are things that, if they come back into the fold, essentially, and get back with their providers, get back with their dieticians again, usually -- again, assuming the anatomy is fine -- t hey can usually get back on track and lose some of that weight again. And so really that's the advice, is come back and see us, come back, go back to your provider, make sure that we have an opportunity to, make sure that we've done everything we can do for you, and that we provide you with all of the, support structure that you need to have success. You know, especially if somebody did it before, if they lost a hundred pounds and regained 25 of it, they should be able to get a decent portion of that back off, if we can get them back into those behavioral patterns that they had early after surgery.
Host Amber Smith: Well, this has been very informative, and I appreciate your time, Dr. Shope.
Timothy Shope, MD: Well, thank you very much again for the opportunity, Amber.
Host Amber Smith: My guest has been Dr. Timothy Shope. He's the director of bariatric surgery at Upstate. The Informed Patient is a podcast covering health, science and medicine brought to you by Upstate Medical University in Syracuse, New York. I'm your host, Amber Smith, thanking you for listening.