Bloating and Excessive Gas

The relationship between the food consumed and bloating and excessive gas  is the subject that comes up frequently. In our practice, this is a complaint that usually  is raised after year 3 or 4 after the duodenal switch operation. It appears that patient's start wondering away from the recommendations  made for healthier diet.

In general carbohydrate, carbonated drinks, artificial sweeteners (such as splenda), vegetables, excessive amount of food, and fat intake will cause significant gas and bloating. This is not to be taken out of context and assumed that one can not consume any of these products.

When a patient reports these problems, my recommendations are as following. All carbonated drinks should be stopped. No patient should consume any carbonated drink of any sort. Artificial sweeteners should also be avoided all together. A good alternative would be honey, or Stevia. Minimize or reduce the carbohydrate intake.

It has been our experience that a majority of the cases, the excessive gas and bloating is a result of dietary indiscretion. In some patients, once the dietary sources have been ruled out, it would be further evaluated by a barium enema to rule out the diagnoses of redundant colon.

The best  approach would be to first go back to a high protein low fat low carbohydrate. This should allow a patient to rule out any dietary sources for the bloating and excessive gas. Then the recommendation would be to be seen by your physician for further  workup.

Feeding Jejunostomy Tube

Feeding jejunostomy tubes are temporary tubes that are inserted in the small bowel for the purpose of nutritional support. These are usually places surgically, most often at the time of the Revisional Weight loss surgery from a failed Gastric Bypass to the Duodenal Switch operation.
Once these tubes are inserted, they have to stay in for six weeks to allow for the scar tissues to form around it, so that when it is removed there is no spillage of the gastrointestinal content in the abdominal cavity.
The removal of a feeding jejunostomy tube is very easy, especially compared to that of a JP drain.
Feeding tubes were discussed in a newsletter posted on our website.

Please see the video for further detail.

Gastric Emptying after the Duodenal switch and the Sleeve Gastrectomy

I am frequently asked what the transit time is from the time food is ingested to the time stomach empties. The emptying of the stomach depends on a number of complex factors including the function of the pylorus, the type of the food ingested, and a number of known and possibly unknown regulatory hormones.

In a previously published newsletter we have already discussed a number of hormones that play a role in the regulatory function of the GI track.

The detail of information that is not available is posted in the newsletter section of our website.

Adjustable Gastric Banding Revision

There has been continuous flow of information on the outcome of the Adjustable Gastric Banding procedures. I am asked if I have an opinion on the choice of patient who should consider revving from one Band to another one because of inadequate weight loss or complications of the first procedure.
In my opinion, there is almost no reason why a band should be removed and be replaced with another one. More detail is located in the newsletter section of the website.

Sleeve Gastrectomy post operative diet

A relatively common  question asked post operatively  is regarding the pace at which the diet should be advanced.

In our practice, patients are given a simple list  that describes 3 broad categories.  They are Bariatric 1, Bariatric 2, and Bariatric soft diet.

Each patient should advance their diet over a matter of 1-4 weeks. The most  important point to remember is that each one of us individually will respond differently to the food at a given point after surgery. The safest  method to advance the diet would be to pay attention to what your body is telling you. If a patient is tolerating Bariatric 1 and Bariatric 2 diet, then they should be able to advance to soft diet as outlined in one or 2 weeks. Alternatively if the patient is having difficulty getting they required water in on daily basis, then advancing to soft diet may not necessarily be correct at that point.

The basic order of the foods is  water, protein, everything else. What this essentially means ease that  a large salad is only healthy and useful to a patient bodies needs if adequate amount of protein has been consumed.

How do different medication that treat constipation work?

General Surgery News, November 2011

Constipation is a prevalent problem in adult US population. This however is not an issue for most duodenal switch patients. Constipation is defined as having less than three bowel movements per week, and is considered sever if there is less that one bowel movements per week. The benchmark for normal bowel function is considered, to be one bowel movement a day. Most of the time the cause of the constipation is considered to be idiopathic (no underlying origin identified). In these cases the treatment is symptomatic.

The treatment options for constipations are outlined in the table below:

Treatment option	Pros	Cons
Lubricants (Mineral Oil)	·      Facilitated bowel movements ·      Promotes soft bulk	·      Limits fat soluble vitamin absorption ·      Interaction with Birth control pill and Coumadin
Emollients (Colace, Docusate)	·      Penetrates stool ·      Effective for painful anal fissure	·      May cause increased gas and bloating
Hyperosmolar Laxatives (Miralax)	·      Promotes water retention in stool	·      May cause increased gas and bloating
Saline Laxatives (Fleet, MOM, Mag. Citrate)	·      Rapid acting	·      May casue of electrolyte imbalances
Stimulants (Dulcolax, Senekot, Ex-Lax)	·      Increase water in stool	·      Prolonged use can cause dependence of the GI track
Herbs (Green Tea)	·      Natural in origin	·      Prolonged use can cause dependence
Bulking agents	·      Absorbs water, softens and bulkens the stool	·      May cause increased gas and bloating

Increased rates of Alcoholism is seen in Gastric bypass patients

This study comes from Dr. Östlund of the Department of Molecular Medicine and Surgery of the Stockholm.  He studied over 12,000 patients that either had the Gastric bypass or a gastric restrictive procedure, and looked at their follow up data for and average of 8.9 years. There were more than 122,000 data points that were matched for a number of variables, including age, gender and type of the procedure. “…Patient undergoing gastric bypass were 2.3 times more likely that those receiving banding procedures to get inpatient treatment for alcohol-Related diagnosis.” The significance of this study, as pointed out by the authors, is that the data is very reliable because of the fact that the majority of the patients could be followed up over a very long period of time.