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A FEW QUESTIONS REGARDING WEIGHT LOSS SURGERY:
Where do you do the weight loss surgery and Adjustments?
Dr. Armando Joya is based out of Puerto Vallarta Jalisco
Mexico. He does not practice in the United States and is
solely licensed in Mexico as a surgeon and Gastroenterologist.
He is the leading surgeons for Band, Bypass, and Gastric
Sleeve Surgery in all of Jalisco. He was the very first doctor
to do a Gastric Sleeve surgery in Mexico. He works at one of
Mexico's newest and finest Hospital's, The Amerimed Hospital.
He will only do surgery in Puerto Vallarta because of the
quality of the hospital. Dr. Joya offers free adjustments to
his patients only in Puerto Vallarta at his medical office.
There is a nominal fee for the Xray machine if the fill is
done at the hospital in Puerto Vallarta.
What
is Bariatric or weight loss surgery?
Bariatric
surgery is the area of surgery that focuses on operations to
reduce weight and treat obesity. The name comes from the Greek
words baros, meaning weight, and iatrike, meaning treatment.
How is weight loss surgery different than
liposuction?
Weight Loss Surgery is major surgery
involving the gastrointestinal tract. The stomach and
intestines are modified so that less food can be consumed or
absorbed, which leads to a substantial loss of weight that can
be maintained for years. Liposuction is a form of cosmetic
surgery in which areas of the body are reshaped or resculpted
by removing excess amounts of fat in those areas. The purpose
of liposuction is not to produce weight loss.
How do I know if I'm a candidate for this surgery?
Dr. Joya advises that you must have clinically severe
obesity, also known as morbid obesity. This means your BMI
must be higher than 35, or you must be at least 100 lbs above
your ideal body weight. You may be a candidate if you're less
than 100 pounds overweight, if you also have significant
health problems due to your weight, such as Type 2 diabetes.
Most people with clinically severe obesity are good candidates
for surgical treatment-as long as you understand the
procedure, don't have a severe, pathological eating disorder
and are willing to come back for follow-ups.
What is BMI?
It stands for Body Mass Index and it
determines someone's health risk related to their weight. A
BMI greater than 40 or greater than 35 with associated medical
problems means you have clinically severe obesity which is
associated with diabetes, heart disease, high blood pressure,
high cholesterol, heartburn, gallstones, arthritis, urinary
stress incontinence, infertility, and some types of cancer.
Does my weight alone justify such extreme
measures?
Yes. Morbid obesity is an independent
risk factor for premature death, with the risk rising as the
BMI increases. People with a BMI of 30 have a relative risk of
dying early that is 1.3 times greater than normal weight
individuals. By the time the BMI is 40, the risk is close to 3
times as great.
I feel so guilty about being
obese. . . is it all my fault?
No, obesity tends
to run in families. Identification of several genes and their
corresponding hormones (leptin) have been found to be at least
partially responsible for obesity. Therefore, there is
evidence that obesity is at least partially biological,
helping to reduce the misconception that it is a behavioral or
psychological disorder. I consider obesity a disease which
needs a cure, rather than a moral failing which is the fault
of the individual.
Why should
I consider WLS?
Because it works! Surgical treatment for obesity is the ONLY
treatment that reliably produces significant and sustained
weight loss. People with clinically severe obesity are at
great risk for developing many associated medical conditions.
Research has shown that surgical treatment results in
significant weight loss and improvement in most problems
associated with obesity. Surgical treatment for clinically
severe obesity has been endorsed by the National Institutes of
Health, the World Health Organization, Shape-Up America, the
American Heart Association, the American Dietetic Association,
and the American Obesity Association.
Why
not just
lose the weight through diet and exercise and skip the serious
complications that could result from surgery?
If you can
lose the necessary amount of weight (and keep it off) though
diet and exercise-more power to you! Ninety five percent of
the people considering WLS have tried (sometimes numerous
times) and failed.
Why not take drugs to combat
obesity?
Drug treatment does produce limited success
(usually weight loss of about 35 to 40 pounds). However,
concerns about safety of long-term treatment have limited the
drugs available and the length of time people can take them.
This in turn, limits their effectiveness because, as with any
chronic disease, such as diabetes or high blood pressure, the
drug is only effective as long as it is taken.
How this WLS promote weight loss?
Operations for the treatment
of obesity usually induce weight loss by limiting the amount
of food consumed, altering the normal absorption of nutrients,
and/or altering the way the body utilizes energy. A Band
Surgery or Gastric bypass does all three. They actually boost
your metabolism for the first 18 months, which is one reason
patients lose weight so quickly.
Is it unhealthy to
lose weight rapidly after WLS?
I like to answer this
question by asking another question: "Is it healthy to be 100
pounds overweight?" The rapid weight loss experienced after
WLS is extremely gratifying psychologically and physically. If
you eat properly, making sure you get enough protein, there
should be no ill effects from it.
Is
there any limit
on how heavy one can be to have weight loss surgery?
No.
Successfully operations have been done on patients who weighed
750lbs., who had a BMI of 100. The operative risks are higher
the more you weigh, but they still don't approach the risk of
remaining at such a high weight. I personally have operated on
one gentleman who weighed over 500 pounds and we were still
able to fit the Swedish Band on him.
How much
weight can one expect to lose after surgery?
Most
patients lose between 50 and 70% of their excess body weight
over about 1-1 ½ years. Some reach their ideal weight, but
some don't.
How long does it take to perform the
operation?
The Laparoscopic Band Surgery takes less than
30 minutes, and the Gastric Bypass usually takes between 2 and
4 hours, depending on the surgery and complications. The
Gastric Sleeve Surgery, takes about 1 hour. The BIB Balloon
procedure can be done in about 20 minutes.
Does
it
matter how long it takes?
The length of the operating
procedure may make a difference. Many studies have documented
an increase in the incidence of infectious complications, such
as pneumonia and wound infection, after prolonged surgical
procedures. Longer operations result in a fall in body
temperature that interferes with the immune system. In
addition, longer operative times mean increased exposure to
general anesthesia, which often results in the collapse of
portions of the lung and can lead to pneumonia. In general,
shorter operations are safer.
How long will I be in
the hospital? How long does it take to recuperate?
Most BAND patients are admitted to the hospital in the
afternoon of their arrival to Puerto Vallarta, which can be
any day of the week, around 3:00 pm. Dr. Curiel, the Internist
and the Anesthesiologist then can run tests on you while you
are in the Hospital, get the results to Dr. Joya who then will
prepare for surgery around 6:00 pm that very evening. You then
will remain in the hospital for 1 night, and ultimately move
to the Krystal Hotel, a 5 star hotel located across from the
hospital. You will then be free to go home the next day. You
may experience slight discomfort, but many patients have been
able to go to work the very next day after returning from the
surgery. The Laparoscopic Gastric Bypass Surgery follows a
similar process where you will enter the hospital the day of
your arrival, but will stay 3 nights in the hospital and then
move to the Krystal Hotel. Your recovery usually requires
between 2 and 6 weeks to recuperate before returning to work,
depending upon the type of job you have, but you will be able
to leave Vallarta 10 days after your surgery. The Gastric
Sleeve surgery requires 2 nights in the hospital and 2 in the
hotel and the recovery time is similar to that of the Gastric
Bypass. The BIB Balloon procedure allows you to return to work
the very next day.
A year after the surgery, are most
people generally happier with their lives?
Yes. Much
happier. Most patients say they would do it again "in a
heartbeat." Studies show that this kind of patient
satisfaction is a true test of the surgery.
When it's
over, will there be things I need to do after surgery?
Regular, follow-ups are needed to monitor weight loss, provide
dietary counseling, and to monitor for the occurrence of
nutritional deficiencies or complications. Also you will need
to have your Band Adjusted (or "filled') every few months. Dr.
Joya or one of his associates will be available in either
Puerto Vallarta for your adjustments and follow up
appointments. Dr. Joya also recommends that you get an Upper
GI done at least once a year for the first few years to ensure
that the band is fine.
Can someone be too young to be a
candidate for this surgery?
Yes. People can be too young.
You need to have stopped growing and you need to have a mature
bone age. In addition, you must understand the surgery and
want it. You can't have an operation because your friends or
your parents want you to. You need to be able to give
"informed consent", which means you make an educated decision
and then give your permission for the procedure. It is also
necessary that your parents are supportive of your decision
and understand the role they will need to play in your care
and recovery.
Can you be too old for this surgery?
Age is one factor that needs to be considered together with
all other aspects of a person's health. I would not give an
arbitrary or absolute cut off. Surgeries have been done on
several patients in their late 60s and early 70s, with
excellent results.
I am severely overweight, have
diabetes, hypertension, and congestive heart failure. My
internist tells me that I am "too sick" to be a candidate for
WLS.
If you are overweight with associated problems due to
obesity, you are not too sick not to have this operation! You
are too sick NOT to have it. The only chance you have for
improvement in your medical conditions is through weight loss
surgery.
GASTRIC BYPASS SPECIFIC
Pre-operative
Questions
Questions About the Surgery
Should I stop my
medications before surgery?
Some anti-inflammatory
medications make bleeding more of a problem and if they can be
discontinued without too much discomfort a week or two
preoperatively it is desirable.
Should my bowel be cleaned
out before surgery?
Some surgeons believe that a 'bowel
prep' decreases constipation after surgery and makes managing
a colon injury safer. In my experience colon injury is
extremely rare and constipation is not a post-surgical
problem. Therefore Dr. Joya does not recommend cleaning out
the bowel prior to surgery.
Can I shower after surgery?
The reason for not showering after surgery is fear that
infection will be introduced into the wound. However nearly
all wound infectins come from bacteria present at the time of
surgery and the incision itself is sealed within hours after
surgery. It is probably even safe to get the intravenous site
wet so long as it is reprepped and dressed after the shower.
Can I drive after surgery?
So long as discomfort does not
prevent you from rapidly hitting the brake or steering
effectively and you are not taking medications that impair
your reflexes or judgment, it is safe to drive after surgery.
What happens to the bypassed stomach?
The only change that
appears to be of clinical significance is a marked decrease in
the production of ghrellin and a consequent marked decrease in
hunger sensations.
Can I get pregnant after surgery?
As
a generality weight loss increases fertility and improves the
likelihood of a normal delivery. However, getting pregnant
while rapid weight loss is occurring may not be safe and
commonly results in less final weight loss.
How much time
should I take off work?
If you have had laparoscopic
surgery there are no limitations on your activity except the
presence of a drain and your general energy level. Most people
are quite ready to return to work in 10 days to two weeks,
right after the drain comes out. When circumstances permit
some people choose not to return to work until they feel
completely 'on top of their game' again and they may take
considerably more time off work than a week or two. Following
open or incision surgery, heavy lifting must be avoided for
eight weeks, Otherwise the timing of a return to work is as
for the laparoscopic patients.
What about drinking alcohol
after surgery?
The amount of alcohol absorbed before
gastric bypass is limited to about 50% by the presence of an
enzyme in the stomach which breaks down the alcohol before
absorption. After a gastric bypass this enzyme does not come
into contact with ingested alcohol and more is absorbed, so it
is easier to get drunk. Also alcohol is a significant source
of calories: 7 calories per gram as compared to 5 with
carbohydrates or protein. After the adjustable band alcohol is
digested the same as before surgery.
Are staples used
during surgery and, if so, how?
Surgeons use staples much
as they use stitches, to hold tissues together. Most abdominal
surgery today makes use of both stitches and staples and the
choice of which to use has more to do with the surgeon's
personal preference than anything else.
Are
carbonated
drinks bad after surgery?
There is no evidence that
carbonated drinks expand the pouch or otherwise impair the
surgical result. The bubbles make some people feel 'gassy' and
that seems to be commoner after weight loss surgery.
Is diarrhea a problem after weight loss surgery?
The first
weight loss procedure was an intestinal bypass and it commonly
caused diarrhea. Diarrhea is not a consequence of proximal
gastric bypass or the adjustable band. Some increase in the
frequency of bowel movements may occur after distal gastric
bypass.
Does weight loss surgery cause bad breath?
Weight loss and the breakdown of fats cause the formation of
ketones which are volatile and are partially exhaled. The odor
however is not unpleasant and has been likened to that of
Juicy Fruit chewing gum. It is important however to maintain
normal dental hygiene and to brush your teeth even when taking
only a liquid diet; otherwise, bacteria accumulate on the
tongue and between the teeth and can cause bad breath.
Will
I lose more weight on some place of my body than others?
Yes. There is a general tendency for weight loss to occur from
the head and neck first and thereafter from the upper body and
abdomen but people differ and where you lost weight before is
likely where you will experience the most weight loss again.
What about loose skin after surgery?
The amount of loose
skin after surgery depends on the amount of weight loss, your
age - younger skin is more elastic than older skin - and
individual differences. When weight loss is rapid, skin
tightening may continue to occur after weight loss has
stopped. In general, if you have lost a lot of weight you are
likely to have some loose skin and may want some plastic
surgery to correct it.
What causes hernias?
Hernias
occur where the abdominal wall is weaker and from increased
intraabdominal pressure. It is somewhat speculative but most
incisional hernias probably occur with straining and coughing
while the patient is waking up from anesthesia. Patients
waking from anesthesia are pain free so when they strain their
effort is not restrained. Sudden severe straining after
surgery which happens more quickly than can be modified by
reaction to discomfort is another likely cause for hernias.
Examples include straining from falling, coughing, or
vomiting. A sudden response to an unexpected weight (child
jumps into your lap) can also cause hernias. A smaller
contribution to the development of hernias can come from
ordinary efforts that rely on abdominal musculature such as
lifting and other forms of exercise. Standard advice is that
following open surgical procedures with abdominal incisions,
one should not lift a weight greater than 10 lbs for the first
month and not greater than 30 lbs for the second month. Risk
of hernia after laparoscopy is so low that full activity can
be resumed almost immediately.
What
type of previous
surgeries would prevent me from having laparascopic surgery?
All previous abdominal operations make abdominal laparoscopic
surgery more difficult but most do not force us to make an
incision. A few, mostly those on the upper stomach like
previous weight loss operations, make laparoscopic surgery so
difficult that usually we find it is safer to make and
incision in order to do the surgery.
What
is the
significance of the drainage tube?
With regards to the
drain: The amount of drainage is not of much significance. If
the drainage begins to look like oral intake that is of
concern and should be confirmed by drinking something blue or
purple (food coloring or grape juice) and seeing if the color
appears in the drainage. If it does it should occasion a call
to the physician. Drainage or wetness outside and around the
drain tubing is usual and does not signify that anything is
wrong, in particular it is not a sign of infection. Redness
extending more than two inches from the drain site should be
seen by the surgeon. The drain is protection against a wound
infection at the drain site and against the life threatening
consequences of a leak. Leaks are very rare after two weeks.
Removal of the drain before two weeks after surgery entails
some extra risk. Patients who want the drain removed early
should consider the risk. About 2% of patients will develop a
leak. It is ok to shower and get incision sites or drain sites
wet and soapy after surgery. The area should be dried off
afterwards and dressed if wetness at the site might stain
clothing. A temperature greater than 101 degrees is reason to
call the doctor. Lower temperatures are not usually of much
significance. Patients often complain that the drain site
hurts and that relates to two considerations: First, the drain
is brought out the largest and therefore the most tender port
site. Second, the drain is sutured to the skin so that it will
not be accidentally pulled out and if it is not taped so that
pulling on the drain does not pull on the suture a good deal
of discomfort can result from normal activity
What if I'm
having constipation?
Constipation after gastric bypass
surgery is a common complaint. It is caused by decreased food
and water intake and, in some people, supplemental iron, or
narcotic pain killers, tranquilizers, and antidepressants. It
is often aggravated by weak abdominal muscles or busy
schedules wherein people defer having a bowel movement when
the urge exists. Our approach is to provide the following
advice:
Do exercises that strengthen the abdominal
muscles and assist in bearing down. Most people experience the
need for a bowel movement after breakfast and that is the
natural and easiest time to have a bowel movement and should
not be ignored. Increase water intake. An increased intake of
any vitamin except B12 and vitamin A tends to produce diarrhea
and has not significant other side effects and is helpful in
eliminating constipation. Especially useful in this regard is
Vitamin C or ascorbic acid since in addition to preventing
constipation it enhances the absorption of iron in Trinsicon
or other forms. Next add fiber to the diet: Eat high fiber
breakfast (bran-based cereals, oatmeal) add vegetables to
other meals. Miller's unprocessed bran found in the cereal
section of the grocery store can be taken with juice, or
sprinkled into salad, meatloaf, cereal, etc. The same thing
can be done with Metamucil, or psyllium seed. These are more
expensive forms of non-digestible cellulose or fiber. The
water content of stool can also be increased with a stool
softener, docusate sodium, marketed as Colace, or Peri-Colace
or P-Col-Rite. If the above measures are still not correcting
the problem the electrolyte laxatives such as Fleet Phospho-Soda,
Magnesium citrate, Milk of Magnesia, or Colyte, to name a few,
should be tried. Avoid laxatives that directly stimulate the
bowel smooth muscle eg. Senecot, as tolerance develops and
more and more is required over time.
What
if I'm having
gas?
Excessive air swallowing is probably the commonest
cause and may result from deliberately belching to relieve a
sense of fullness or from swallowing frequently as sometimes
occurs with anxiety and nervousness. A deliberate change in
behavior is usually effective. Simethicone, marketed as Gas X,
helps reduce large bubbles of gas to small ones and may
relieve the cramping sensations. Nullo which is a chlorophyll
derivative also may be helpful.
After gastric bypass,
excessive dietary intake of fat increases intestinal transit
time and delivers undigested food to the colon. Food in the
colon is broken down by resident bacteria and results in a
very malodorous gas. A restriction of dietary fat intake may
be sufficient to eliminate the problem. Bismuth subgallactate
marketed as Devrom (1-800-972-5184) is also helpful. If the
problem occurs soon after a distal gastric bypass, Pancrease -
a pancreatic enzyme supplement - taken with meals may be
useful.
Milk sugar called lactose is digested by an
enzyme called lactase the production of which declines with
age and following gastrointestinal surgery. Lactase tablets,
drops and milk products with pre-added lactase are available.
Beans, cauliflower, onions, broccoli and other vegetables
contain complex carbohydrates (oligosaccharides) which are
broken down in the colon to form gas. Beano contains a-galactosidase
which helps to convert the oligosaccharides to simple sugars
which can be absorbed and gas is thereby prevented.
An
alteration in intestinal flora usually caused by antibiotics
may produce gas. Ultraflora - a bacterial preparation - may be
given to repopulate in intestinal tract normally. When the
cause is fungal overgrowth, Diflucan (fluconazole) may be
effective. Flagyl is sometimes tried to suppress anaerobic
bacterial growth in bypassed portions of the intestine.
Other causes are gallstones, diverticulosis, irritable
bowel syndrome, and parasites, and, rarely, cancer of the
ovary or bowel.
Is hair loss typical?
Hair loss is
commonly assumed to be due to lack of adequate dietary protein
but a clear cause and effect relationship is lacking.
Nevertheless, one should measure the prealbumin, and if it is
low, increase protein intake. Ephedrine is said to be
effective in restricting protein weight loss and enhancing fat
weight loss. Hair loss due to dietary restriction is nearly
always temporary. Rogaine and Nexium shampoo have both been
reported to be effective and should be tried if the loss is
excessive.
How is laparoscopic gastric bypass
different than open gastric bypass?
Laparoscopic gastric
bypass is accomplished with 5 small incisions rather than one
long incision. A camera is placed through one of the incisions
and long instruments through the others. The operation is
performed while watching a video screen. The actual operation
on the stomach and intestine is the same with both approaches.
The gastric bypass open incision is approximately 3/4 of
the distance from the breastbone to the belly button. That is
about 4-5 inches in some people and as much as 15 inches in
others.
Is laparoscopic gastric bypass safe?
Many
studies done by experienced laparoscopic bariatric surgeons
have demonstrated laparoscopic gastric bypass to be safe.
Laparoscopic gastric bypass is technically demanding and
studies show that the amount of experience a surgeon has
contributes to safety.
How does laparoscopic gastric bypass
compare to open gastric bypass?
Laparoscopic gastric bypass
results in a shorter hospital stay, less pain, less scarring,
and a quicker return to usual activities. Complications such
as wound infections and wound hernias are nearly eliminated
with the laparoscopic approach. The risk for serious
complications (such as leak) is similar with both laparoscopic
and open gastric bypass.
Why aren't all gastric bypasses
done laparascopically?
Laparoscopic gastric bypass is a
difficult operation to learn to do safely. It also takes
longer and is more expensive. The result is that most gastric
bypasses in the United States are done open at this time. For
most patients laparoscopic surgery is better (less pain,
shorter hospital stay, less scarring, quicker return to usual
activities). As more surgeons learn to do laparoscopic gastric
bypass safely and patients demand it, more laparoscopic
gastric bypasses will be done.
Is
laparoscopic surgery
right for me?
Laparoscopic surgery is a good choice for
most people. People who have had previous bariatric surgery or
surgery on the stomach are probably better candidates for the
open approach. People with BMI > 60 (more than 200-250 pounds
overweight) may be better candidates for open surgery.
Can the surgery be reversed?
Yes, but it would take another
operation. No one, in my experience, has asked to have the
surgery reversed.
What are the main risks of surgery after
gastric bypass?
Put simply the main risks are death and
complications. Mortality risk reported across the US is 0.5%
or 1 patient in every 200. By recent count our mortality risk
is less than one patient in every 500 gastric bypasses. The
commonest causes for death are pulmonary emboli and
infections. The commonest complications are wound infections,
strictures, and hernias. The risks after adjustable band
surgery and after gastric bypass are different (see
Information Seminar). The major problems that occur with any
frequency after gastric bypass are 1) leakage from the bowel
connection to the pouch, 2) pulmonary emboli, 3) bowel
obstruction or kinking, 4) bleeding, 5) stricture. The major
problems after an adjustable band are 1) erosion, 2) slippage
or herniation of the stomach up through the band, 3) pulmonary
emboli, 4) esophageal dilatation.
What are the symptoms of
a leak?
The symptoms can vary from sudden severe abdominal
pain, weakness, chills, and abnormal drainage to no symptoms
and unusual looking material coming from the drain site. The
treatment depends on the severity of the leak but varies from
no treatment, to hospitalization and iv's, to re-operation.
What are the symptoms of a pulmonary embolus?
Shortness of
breath and pain on breathing. Treatment involves giving 'blood
thinners,' anti-coagulants, and hospitalization.
What are
the symptoms of a bowel obstruction?
Waves of abdominal
pain, nausea and vomiting sometimes preceded by a loose bowel
movement. Treatment involves surgery, usually laparoscopic,
and correction of the kink or obstruction.
What
are the
symptoms of a stricture?
A stricture or too much narrowing
at the connection of the pouch to the intestine is usually
experienced as progressive difficulty with swallowing: first
solid foods, then soft foods, finally liquids won't pass
through. The treatment is endoscopy and balloon enlargement of
the opening.
How would I know if I was bleeding?
Bleeding usually occurs in the first day or two after surgery
and is recognized by a fast heart rate, weakness, paleness,
and abnormal blood tests.
How is erosion recognized and
treated?
If the band rubs on the stomach too much it can
wear through into the lumen of the stomach where it can
contact swallowed food and saliva. This may result in an
infection which usually is seen as redness and swelling at the
adjustment site. Sometimes no infection results and weight
loss and a sense of restriction disappear. Treatment is
removal of the band surgically. It can be replaced later or a
gastric bypass can be done later.
What happens if
'slippage' occurs?
Slippage usually occurs in the first two
weeks after surgery and is experienced as vomiting everything
that is swallowed. It can be treated by taking the fluid out
of the band and in most cases it can be re-inflated in two or
three weeks. Sometimes surgery is necessary.
How do I know
if I have 'esophageal dilitation' or enlargement?
A
difficulty with swallowing is the usual experience. It is
corrected by deflating the band, taking the fluid out, for a
week or two. Sometimes the band has to be removed.
Are
there long term risks after surgery?
Any abdominal
operation sets the stage for a possible bowel obstruction the
lifetime frequency of which is approximately 8%. Vitamin and
mineral deficiencies can occur if calcium, B12, and iron
supplements are not taken as prescribed. Less commonly protein
deficiency can occur.
What are the risks of hernias after
surgery?
Less than 1% after laparoscopic surgery and about
10% after the open procedure.
What is the risk of an ulcer?
Pretty small. We see one about every year or two.
Optional
Surgical Procedures
Can I have a hysterectomy at the same
time?
We do routine pelvic ultrasounds in patients who have
not previously had a total hysterectomy. When the findings
indicate the need a gynecologic surgeon may scrub in and do
the appropriate surgery at the same time as the bypass.
Under what conditions is the gallbladder removed?
In
patients who do not have gallstones at the time of surgery
only 4% subsequently develop stones. We therefore only remove
the gallbladder in patients who have stones diagnosed before
or during surgery. In general we do not remove the gallbladder
unless it is diseased or there is a strong family history or
gallstones and gallbladder removal.
Are there medications
available for gallstones?
Yes, ursodiol is given to prevent
gallstones in high risk patients. Because it is expensive, we
do not prescribe it for every patient.
Other Issues
How
can stomach surgery cause me not to crave ice cream or
mayonnaise?
Food preferences change for many patients after
surgery; others have to make do with discipline. The reasons
for changes in food preferences are unknown.
I have
irritable bowel syndrome. Will that go away after surgery?
Irritable bowel syndrome is neither improved nor worsened by
surgery.
What if my friends accuse me of taking the easy
way out?
You and your friends should be aware that there is
no easy way out. Surgery makes the discipline of exercise and
dietary control effective when it would not otherwise be
effective. Obviously, surgery also entails risk and the
courage to take that risk.
Will my sex life improve?
Not
guaranteed, but it is a common experience.
The Early
Post-Operative Period (the first month)
Diet
Do all
medications need to be crushed after surgery?
Yes, with a
few exceptions. Small tablets, the size of the end of a pencil
or smaller, will pass readily through the pouch into the
intestine and are not a concern. Examples include thyroid
medication, BDP's, and other hormone tablets. Many larger
tablets may stop in the pouch and sit in one spot, will slowly
disolve. As some are quite caustic, they will burn an ulcer,
and cause pain that will last for days, until the ulcer is
healed. It is therefore important to crush them prior to
swallowing.
What is dumping?
Foods high in sugar and
some fats will cause the intestine to release vasoactive
chemicals which cause sweating, flushing, weakness, fatigue,
and sometimes abdominal cramps and diarrhea - a phenomenon
called 'dumping.' This is not a problem after LAP-BAND®
placement.
After gastric bypass but not
after placement of the adjustable band (LAP-BAND®) absorption
of iron, B12, and calcium is impaired and extra amounts need
to be taken. Trinsicon is an iron, B12, folate and intrinsic
factor combination which is simply a convenient way to get
iron and B12 which certainly can be taken separately and are
available over the counter. Calcium should not be taken at the
same time as iron since they compete for absorption. Iron
absorption is enhanced if taken with vitamin C (ascorbic
acid).
What is the reason for protein shakes after surgery?
The shakes ensure adequate protein and calorie intake after
surgery which is important for healing and other reasons. A
liquid diet ensures that the pouch and opening will not be
stretched early on when that is more easily accomplished. The
shakes also interpose a significant change between the way you
have eaten and the way we hope that you will eat in the
future. Because the shakes are somewhat monotonous when you
switch to a low fat more healthy diet it is 'tasty' by
comparison and therefore more likely to be preferred in the
long run.
How long do I have to take the shakes?
Four
weeks; and it is a good test of your willingness to make some
dietary changes. Taking the shakes for a week or two before
surgery will shrink the liver and make surgery easier and
safer. This is advised in some very heavy patients.
How
long do I have to take vitamins?
A daily multivitamin is
probably a good idea for everyone to take to prevent the
fairly common and widely varied deficiencies seen as people
get older.. The iron, B12, and calcium supplements should be
taken for life, if you have had a gastric bypass, but are not
necessary if you have an adjustable band(LAP-BAND®).
How
much food can I eat after surgery?
The gastric pouch
although initially very small has a hole in the bottom so that
a reasonable amount of food can be eaten if taken slowly. As
time passes the pouch enlarges and where initially only one or
two bites could be taken without a sense of fullness, later a
small adult meal can be consumed. As it becomes possible to
eat more food it becomes also more important to have developed
good habits with regards to food choices.
Are there
specific foods or drugs that I should avoid after surgery?
Except for the tiny hormone replacement pills most tablets
should be crushed after surgery. Foods high in sugar and some
fats will cause the intestine to release vasoactive chemicals
which cause sweating, flushing, weakness, fatigue and
sometimes abdominal cramps and diarrhea - a phenomenon called
'dumping.'.
What prevents wound infections?
Wound
infections occur because bacteria inevitably get into the
wound during surgery . Some types of bacteria may be difficult
for the body to eliminate. Also, local factors like variations
in tissue blood supply, small amounts of blood, sutures, and
othe things beyond the surgeon or patient's control, influence
the likelihood of wound infection. Antibiotics are routinely
given and used to irrigate wounds. Wound infections occur
about one time in ten after open gastric bypass. They are
quite unusual after laparoscopic bypass because the wounds are
much smaller.
Is it possible to rupture the staples after
surgery?
Vomiting may sometimes cause a tear and a leak,
but usually does not. After about three weeks it is nearly
impossible to rupture the staples.
Why
don't people just
keep losing weight until they get sick or die?
Everyone who
has gastric bypass surgery has a strong genetic capacity to
use calories efficiently. So it is always possible to provide
high calorie foods and induce weight gain. In practice what
happens is that with time people are able to eat more at a
time, they lose weight and require fewer calories just to move
around and their metabolism becomes even more efficient that
it was preoperatively.
How can I prevent stretching out my
new stomach?
Don't eat after you feel full.
Does surgery
affect how well I absorb my medications?
Generally speaking
not, but with certain medications it may be wise to check
blood levels after surgery.
Can I drink carbonated
beverages after surgery?
They may make you feel gassy, but
I know of no other problems. They idea that they may stretch
the pouch seems to me illogical, since no real pressure
buildup can occur when both ends are unobstructed. Try blowing
up a balloon with a hole in the end; it is impossible and
similarly it is impossible to distend your pouch unless the
inlet and outlet are completely obstructed.
Activities
How long before I can go to work? Exercise? Drive a car? Have
sex?
We advocate walking and light weight lifting
immediately after surgery. If you've had laparoscopic surgery
you can lift weights immediately. If you've had open surgery,
do not lift more than 10lbs for the first six weeks. After
that, you can increase to 30 lbs. for 2 weeks and no limit
after 8 weeks. This is because hernias almost never occur
after laparoscopic surgery, but are quite common after open
surgery with an incision. It is unlikely that effort that does
not cause abdominal pain will affect the likelihood of hernia.
Similarly, if you can hit the brake hard without discomfort
and are not taking painkillers then it is ok to drive a car.
The discomfort standard should be applied to sex as well: if
it doesn't hurt, go for it.
Will I ever eat normally again?
It depends on what you mean by normal. Many overweight people
eat more and make higher calorie food choices than the rest of
the population. So it is possible that you were not eating
'normally' to begin with. After surgery although you can eat
small amounts of anything, we hope that you will choose low
fat foods for the most part. Also you will in general consume
fewer calories than someone your size who was not previously
overweight. Your could eat frequent small amounts of high
calorie foods and gain your weight back.
What kind of
exercise should I do after surgery?
We advocate increasing
two kinds of exercise as part of a post surgical lifestyle
change: 1) Increase the difficulty of unscheduled everyday
activities. For example, try to walk farther - a pedometer is
helpful in this regard - climb the stairs instead of taking
the elevator; volunteer for small tasks that you might not
otherwise choose. 2) Schedule workouts two or three or four
times a week simply for the purpose of exercising. Although
any activity is helpful, weightlifting is the most efficient
for extra weight loss.
How soon after surgery can I bathe
or shower?
Infections virtually always come from bacteria
present in the wound at the time of closure. Wounds seal to
the outside within hours after surgery so it is safe to bathe
or shower the next day. Similarly, iv and drain sites can be
cleansed and redressed with minimal likelihood of infection.
Psychological Concerns
What will the support group do for
me?
It provides people with similar experiences to use as a
sounding board for common problems. Like Church attendance
serves to remind you to behave morally, support groups serve
as a reminder to maintain a healthy lifestyle. Support groups
can also educate you in what constitutes a healthy lifestyle.
What if my overweight friends reject me?
This is a
difficult area. If you change your activity and dietary
behaviors so as to be more healthy you may at the same time
change what you had in common with your friends. Moreover,
what you do may be threatening to them. In some cases it may
be easier to find new friends. The support groups can help you
make the change.
Cosmetic Concerns
How about my scar?
Can I make it go away or become smaller?
Except for using
steroid injections to stop keloiding I have heard of no tested
way to diminish scarring, but lots of remedies are tried and
perhaps some work. In any case it seems harmless to try.
Will I need plastic surgery after I lose weight to remove
loose skin?
Whether plastic surgery is desirable depends on
how old you are (skin is less elastic with age) how much
weight you lose (the more the more skin) and individual
differences in elasticity. Loose skin bothers some more than
others, but there is nothing shameful about wanting to look
your best and we will try to help anyway that we can. Getting
rid of loose skin requires plastic surgery, some types of
which we do ourselves.
Does exercise help prevent loose
skin?
Exercise is wonderful for many things but unfortunately
does very little for loose skin.
The Late
Post-Operative Period
Weight Regain
What
causes some people to regain their weight?
Most often it is forgetting that weight control is a lifelong
project. But obviously the genetic pressure to gain is greater
in some than others and although we cannot currently recognize
it the surgery may be better for certain types of obesity than
it is for others.
ADVICE ON ACCELERATING EARLY WEIGHT LOSS,
MAINTAINING AFTER WEIGHT LOSS AND REVERSING LATER REGAIN
Current understanding is that the tendency to gain weight is
largely genetic with a whole lot of modifiers or triggers like
upbringing, stress, advertising, etc. Not surprisingly, short
of genetic re-engineering, to effectively lose weight and
maintain, it takes surgery and a lot of personal effort. In my
opinion, the main component responsible for roughly 50%-60% of
weight loss is the surgery. Weight loss in the first 10 to 12
months after surgery is much easier than later on and can be
accelerated with dietary discipline and exercise. In general
you lose weight in the first ten to twelve months and not much
thereafter, so it is worth making an effort to maximize the
early weight loss and not test the surgery with dietary lapses
as many poorly committed patients do.
Another 20%-30% of
weight loss is due to a combination of dietary discipline,
exercise, and behavior modification:
Dietary discipline
means making a consistent effort to maintain a very low fat
diet. Ideally it means three to five protein and produce meals
a day and no 'grazing in between'. Trying to be a vegetarian,
eat no salt, and avoid sugars, noble as it sounds, distracts
from avoiding fats and processed carbohydrates and is likely
to be counterproductive. Replace high cal snacks like cheese,
nuts, crackers, seeds, with proteins like shakes (Carnation
non-fat breakfast, Trader Joe's soy protein, HMR, etc), hard
boiled eggs, jerky esp turkey, non-fat milk, non-fat yogurt,
non-fat cottage cheese. Other snacks like baby carrots,
lettuce with salt, fruits etc are low calorie and crisp
substitutes but not as satisfying as proteins. Chocolate
cravings can be managed somewhat with bananas or other fruit
dipped in chocolate syrup - it makes a little chocolate ago a
long way.
Exercise, exercise, exercise is the mantra of
long-term success and short term weight loss acceleration. It
should be one of life's rituals like showering or combing
one's hair. If you have never exercised, pick any activity
schedule it and try to increase the intensity and duration.
Any exercise that you can do week in and week out is desirable
but the best exercises are muscle building. Muscle has a
higher resting energy expenditure than many other tissues and
an increase in muscle mass, most effectively produced through
weight lifting, can elevate resting energy expenditure for
days rather than hours as is true with other forms of
exercise.
Behavior modification in practical terms means
struggling with your habits and inner demons. It is going to
support groups to remind yourself that obesity is a chronic
illness that requires lifelong attention. It is sessions with
a counselor of your choice to discover and deal with the
reasons you eat. It is part of your prayers and it is helping
others to find a means to lose weight.
Psychologic
counseling: An occasional patient will be losing weight quite
satisfactorily and then without explanation begin to sabotage
the process. An underlying anxiety with regards to the
danger—often sexual—of being thin may be the cause and can be
helped with counseling. Other causes of an emotional nature
are not uncommon and counseling is often helpful.
Fine tuners: Five to ten percent of weight loss can be ascribed to
a number of `fine tuners' some of which can become habits
while others can be used when regain threatens:
Pills.
Chromium may be particularly helpful to diabetics but is also
of some small benefit to others. Two hundred micrograms three
or four times a week appears safe and may aid in weight loss.
DHEA in people over fifty has beneficial immune stimulation
properties and may help slightly in weight loss and body fat
distribution. Anorectic medications like phentermine have a
role if you aren't where you want to be and some appear to be
safe for long term administration. Ephedrine although
victimized with a lot of bad press is inexpensive, relatively
safe, and a very effective way to increase metabolic rate and
decrease appetite over the long haul. Feeling like you had too
much coffee is an early side effect that disappears after
about 8 weeks. The metabolic effect increases slowly for at
least one year.
Eating behaviors. If you must snack
choose a protein. Hardboiled eggs, jello as a drink, deli
turkey or beef jerky provide longer periods of freedom from
hunger and lower your metabolic rate less than do other foods.
High paid models drink lots of water to turn off hunger and
the same technique is available to the rest of us. Coffee, and
tea may be better choices even than water as they contain
caffeine and theophylline which speed the metabolism and
increase the rate at which calories are burned and therefore
promote weight loss. Unprocessed bran mixes well with juices,
salads, cereals, meat loaf casseroles, pastas etc. and it
prevents constipation, diverticulosis, and colon cancer as
well as lowering cholesterol and decreasing appetite.
Casual exercise, the stairs instead of the elevator, kind of
exercise is always available and an excellent habit to
acquire. If you are desk bound all day long, do five minutes
of isometrics two or three times a day against the desk even
just flex and hold; it's exercise and it is every bit as
effective as exercise that moves you if done for the same
amount of time. A pedometer can be very useful as a means to
recording and increasing the total number of miles you walk
every day.
Self-analysis. If you are tending to regain,
start a diary and record your intake. Analyze what you eat:
some innocent looking foods are actually quite high in fat and
therefore calories. Examples include many crackers, nearly all
cheese, nuts, and grain bars. Look at where you store what you
eat. Do you keep it in your desk or somewhere quite handy or
is some effort necessary to make it available? If stress is
making you eat, identify the stressor and find ways to
eliminate or reduce the stress. Nothing invigorates like a few
decisions even if some of them are wrong and have to be
changed later.
Pregnancy- When is it safe to
get pregnant?
Ideally, pregnancy should be
delayed until weight loss is maximal, usually around 12 to 18
months after surgery. Weight loss makes women more fertile and
decreases the likelihood of complications related to
pregnancy.
It is safest to get pregnant after weight loss
is complete as there is some theoretical risk to the fetus
with rapid weight loss
How much weight should I gain?
Enough to account for the baby, the placenta, and some
amniotic fluid - about 35 lbs. Ask your obstetrician.
Will
I be able to lose my pregnancy weight?
Excess weight is
hard to lose. It is best to gain only the amount necessary for
a normal baby and pregnancy.
Other
Issues
How long after surgery before it is
desirable to think about cosmetic surgery?
Results are best
after weight loss has maximized - 12 to 18 months after
surgery.
Will I lose hair after surgery? If I do will it
come back?
Hair loss is common and has never been
conclusively related to any particular deficiency although
many suspect that protein intake is important. If you do not
have an ongoing tendency to baldness, it will all come back.
I don't have a support group where I live. What is the best
way to stay in contact?
It is very important to try to
follow up with us at least once and better twice a year. At
those times support groups can also be attended. We don't cure
the tendency to gain excess weight; we manage it with
discipline, support groups, accountability and sometimes
adjunctive medications like ephedrine.
What
post op blood tests are needed at each major post op visit?
The tests I do are Ferritin, B12, PTH (parathyroid hormone),
Calcium and cbc. I usually do tests 6 months after surgery and
repeat every 6 months to a year thereafter. I do it sooner if
the patient is not taking supplements as they should, or if
the patient has an abnormal result that I am trying to
correct.
METABOLIC
SURGERY SPECIFIC
1. What are the
requirements to qualify for the surgery?
- If you are under
55 with a BMI of 28 or higher, and have been taking insulin
and a diabetic for less than 3 years Dr. Joya says that you
qualify for this procedure.
GASTRIC SLEEVE SPECIFIC
1. Why does Dr. Joya use
a drain when other doctors do not?
- The drain
according to Dr. Joya is very important to show whether or not
there is a leak post op. The drain is usually used by
experienced surgeons and at a minimum is a backup to let you
know if a leak exists.
2. How does Dr. Joya
check for leaks?
- First, since Dr. Joya is an
experienced Bypass doctor who is also the pioneer doctor for
the Gastric Sleeve surgery, he does the exact same tests
required for Gastric Bypass patients. He does not cut costs
and corners by not using a drain. The first tests is a blue
dye test. Secondly there is a Flouro Xray that includes a
swallow (this allows him to see your stomach and fluids
flowing through it). Don't be fooled by inexperienced doctors
who do not use drains, these are usually lapband doctors who
are trying to start out with a new surgery. Leaks are
important and a drain and blue dye test is critical.
3.
Does Dr. Joya hand stitch the sleeve after using the
staples?
- Any and every Gastric Sleeve surgeon
hand stitches behind the triple line of surgical titanium
staples. There is only one staple gun that is used for the
Gastric Bypass and Sleeve surgery and this is made by Johnson
and Johnson. This device is used by Dr. Joya, who then hand
stitches the sleeve behind the staples to help prevent leaks.
ALL DOCTORS SHOULD STITCH BEHIND THE STAPLES.
4.
Why do other doctors require a shorter stay?
- The main reason is money. They want to make more money while
risking your life. Dr. Joya who pioneered the Gastric Sleeve
surgery has implemented the ideal number of nights for
recovery from the surgery prior to sending you home so that
there is very little risk of having a complication once you
get home. This in turn will reduce any future costs you may
have to spend to return. Other doctors go with a shorter stay
so they can either charge a lower price, or provide inferior
care.
5. When did Dr. Joya start doing the
Gastric Sleeve?
- The initial Gastric Sleeve
surgery was done in Europe in 2006. Dr. Joya started doing the
Gastric Sleeve surgery that year. There are doctors who claim
to be doing surgery since 2004 (with 4 years of experience),
these Doctors are lying to you and are providing false
information. These are most likely Lapband doctors who have
only been doing surgeries for 4 years at most.
6.
Why choose Dr. Joya
- If you want the
doctor with the most experience with regards to the Gastric
Sleeve, and a doctor who is a surgeon and gastroenterologist,
a pioneer in his field and an instructor in the Gastric Sleeve
surgery for other Mexican doctors, then these are all reasons
to choose the very best Gastric Sleeve doctor in Mexico.
LAP-BAND SPECIFIC
1. How many people reach their goals?
- About 70% of Dr. Joya's patients reach their goal with the
lapband. Those who do not reach their goal normally lose a lot
of weight, but just lose about 60-80% of their weight with the
Lapband and 80-90% with the Bypass. You need to set your goal
reasonably and diet. The band is a tool, and as such, you need
to work with it, it is not a miracle pill.
2.
How many people keep their weight off for ever and never gain
it back.
- Many, actually you should never gain
weight using the band, unless you start eating high calorie
liquid food (milk shakes, ice cream, beer, etc.)
3.
How many people have the band slip and the surgery is
unsuccessful?
- Less than 1%
4. How
many people have the band be to irritating to keep and have to
have it removed.
- Less than 1%
5. How
much does it cost if it does need to be removed.
-
The cost is comparable to placing the band. If it can be done
via an endoscopic procedure then the cost would be much less,
but on average it will cost around $4500 if you have to go to
the hospital.
6.Will I never be able to drink
Pop again?
- Yes, some patients have trouble with
Pop and carbonated products however others have no problem
other than a little gas, side effect.
7. Which
surgery is right for me.
- The depends on your
eating habits. If you are a sweet eater, than maybe you are a
Bypass Candidate, if you are a large quantity and non sweet
eater than the band or Sleeve is perfect.
8.
Why are people so hungry at first
- They are
hungry usually because they have not eaten for a few days
because of the diet related to the preparation for surgery.
However, you should feel full after consuming small amounts of
water or juice. |
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• Cirugía Bariatrica
• Bypass Gástrico
• Cirugía de Manga Gástrica
• Cirugía de Banda Gástrica
• Revisiones Bariatricas
• Cirugía de Hernia
• Trabajo Dental Disponible
• Cirugía Plástica Disponible |
• Vacación en Hotel de Playa
• Equipo Medico Visitándote al Hotel
• Volando Directamente a PVR
• No esperar 3 horas en la frontera para cruzar
• Recogerte en el Aeropuerto
• Todos tus exámenes incluidos
• R/T Vuelo Disponible
• US Pasaporte Requerido! |
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Por favor siéntete con toda la confianza de contactarnos si tienes
alguna pregunta,
Comentario, acerca de nuestros servicios.
Si
gustas contactarnos vía correo electrónico, por favor mándanosla a la
siguiente dirección:
info@drjoya.com
y un amigable miembro de nuestro equipo se pondrá en contacto contigo
directamente o atreves de correo electrónico dentro de 24 horas. Podemos
además proveerte con un presupuesto sin compromiso basado en la
información que nos proporciones. Además puedes llamarnos totalmente
gratis a los siguientes teléfonos: 866-509-0571 o al 817-405-2778. |
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En Dr.Joya.com estamos bien entrenados, somos bilingües, hablamos
ingles y español. Hemos estado trabajando en la Industria del
Turismo Medico por más de 13 años. Seleccionando a Dr. Joya no solo
tienes el mejor doctor en Puerto Vallarta que puede asistirte
durante tu cirugía, sino también tienes un excelente servicio al
cliente antes de realizar tu cirugía, donde tus preguntas serán
respondidas usualmente en menos de 24 horas, así como excelente
servicio al cliente cuando tu cirugía haya sido realizada. Si no
tienes cobertura de seguro medico y estas buscando salir fuera del
país para realizarte el procedimiento de pérdida de peso, déjanos
brindarte un servicio médico de primer nivel, un servicio al cliente
de excelencia y traerte a este hermoso puerto mexicano llamado
Puerto Vallarta, Jalisco. Mx. Nuestro equipo responderá todas tus
dudas o comentarios y podrá asistirte para realizar toda la
preparación necesaria para que puedas venir a realizarte tu
procedimiento de pérdida de peso a este hermoso lugar. Nuestro
equipo te asistirá con todos y cada uno de los requerimientos
especiales que necesites.
Todos los doctores y el equipo que
trabaja con Dr. Joya hablan Ingles y tiene entrenamiento
Universitario. El Hospital está acreditado y está localizado en el
corazón de Puerto Vallarta, Jalisco. Siendo muy accesible para todos
los Hoteles. El Hotel y el Hospital están localizados a una
distancia de 10 minutos desde el Aeropuerto.
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Notros
hacemos lo mejor, por un precio razonable.
Nosotros
estamos comprometidos con la entrega de un servicio médico de
alta calidad desde el punto de vista del paciente. Con Dr. Joya
no solamente tienes a un Doctor que sea destacado por ser líder
en la realización de Cirugía de Manga Gástrica y de Bypass, sino
tienes a un doctor que fue el primero en realizar la Cirugía de
Manga Gástrica en México. Dr. Joya siempre a gustado de usar la
más alta tecnología en el mercado. Trabajando así en la cura de
la Diabetes Tipo Dos en pacientes no obesos, siendo además
Gastroenterólogo. Habiendo realizado más de 7500 diferentes
procedimientos por cirugía no invasiva – Procedimientos por
Laparoscopia. Dr. Joya ha ayudado pacientes de todo el mundo a
perder miles de libras por año y todos estos procedimientos
pueden ser realizados a bajo costo comparado con los que se
realizan en U.S.A. El Hospital Amerimed en Puerto Vallarta ha
tenido la certificación y aprobación requerida para trabajar con
las mayores Compañías Americanas de seguros.
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