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Such an anatomical landmark gives the surgeon situational awareness and allows him or her to better estimate the localization of the vena cava erectile dysfunction drugs in development buy viagra plus 400mg fast delivery, esophagus erectile dysfunction pills non prescription discount 400mg viagra plus with amex, and aorta. This area is often distorted by the presence of foreign bodies in the form of anastomotic rings and bands. The presence of multiple staple lines and scarred or inflamed tissues predisposes to postoperative ischemia and leaks. It is then necessary to apply several technical modifications, such as increase in staple heights (4. Extensive dissection can lead to vascular compromise of the Roux limb, which should be fully dissected before starting the reconstructive part of the operation. Appropriate handling of thin or potentially ischemic tissues might prevent postoperative complications. Because of the known increased risk of anastomotic leak after reoperative surgery, routine use of an intraoperative anastomotic leak test should be utilized. The two commonly used methods include the use of methylene blue via a calibration tube and air leak via orogastric tube or endoscope. If a positive leak test is obtained, the anastomosis should be repaired or redone, and external drainage must be considered. If in primary operations a negative intraoperative leak test reduces the incidence of postoperative leak, the predictive value of leak test has not been well validated in reoperative surgery. Finally, the benefit of a remnant gastrostomy should be considered in every reoperative case of gastric bypass. The utility of the remnant gastrectomy tube is twofold; it provides enteral access in case of gastrojejunostomy complications, but also might decrease reoperation for remnant-related complications (functional emptying impairment from vagal injury or distention from distal obstruction). In fact, between 2004 and 2007 the reported cases went from 7 to 23 %, representing a 329 % increase [7]. Reasons accounting for the increase are the technical ease of the operation, the short hospital stay (commonly even outpatient now), the overall low short-term morbidity, the emphasized reversibility, the lower cost, and the positive weight loss results, especially in Europe, Australia, and Israel. Common reasons for reoperation include failure of weight loss and complications, which are classified as band or port related (Table 24. Nevertheless, additional parameters, such as resolution of comorbidities and quality of life, should be taken into consideration as well when defining failures. The lack of violation of the lesser sac resulted in elimination of the posterior prolapses. Also the structural changes of the band have been advocated as contributing factors to the decreased incidence of both prolapse and erosions. In fact, the wider high-volume low-pressure balloons, as well as the higher height of the band itself, create less pressure and potential ischemia to the gastric wall. More recently, the role of a missed hiatal hernia has been advocated by some as a potential precursor of band failure over time. At the time of revision, in fact, previously undiagnosed hiatal hernias have been found in 8. A more aggressive search for these occult hernias might reduce the complication rates of bands even further. Similarly, the incidence of band erosions, originally in the 11 % range, has dropped to 0. Suggestion of common pathophysiology between prolapse and erosion has been recently advocated. Early erosions occur within the first 7 months and can be due to technical complications or infection. In fact, subcutaneous port infection can be one of the first signs of a missed esophageal or gastric injury. Other contributing factors to erosion are band overfilling or tight gastric placation and, possibly, maladaptive eating behaviors. Late erosions can result from tight adjustment sometimes in the setting of lack of restriction secondary to a misdiagnosed band prolapse. The decision of the optimal procedure to offer after a failed band should be largely related to the causes of failure. Such revisions should be considered only in patients with adequate primary weight loss, now experiencing a band complication [16]. In spite of the fact that these procedures are considered among the simplest reoperations after bariatric surgery, a high incidence of morbidity has been reported [7].

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Taken together impotence from steroids discount generic viagra plus uk, bariatric surgery was shown to decrease the Framingham risk score for at least 7 years after surgery [69] erectile dysfunction and diabetes a study in primary care cheap viagra plus online amex, absolute risk of a cardiovascular event, mortality from all causes in general, and from cardiovascular causes specifically. Weight loss surgery resulted in a sustained reduction of 10-year cardiovascular risk, with the impact greatest in those patients with preexisting risk factors [70]. With long-term follow-up extending beyond a decade, bariatric surgery in general was associated with reduced number of fatal cardiovascular deaths and lower incidence of firsttime myocardial infarction or stroke [74]. In addition, obese patients with already known clinically significant cardiomyopathy seemed to benefit from weight loss surgery [75]. Association of midlife obesity and cardiovascular risk with old age frailty: a 26-year follow-up of initially healthy men. Central obesity and survival in subjects with coronary artery disease: a systematic review of the literature and collaborative analysis with individual subject data. An update of the 1997 American Heart Association scientific statement on obesity and heart disease from the obesity committee of the council on nutrition, physical activity, and metabolism. Visceral fat accumulation and its relation to plasma Conclusion Cardiovascular disease is a leading cause of death in American adults. Obesity has emerged as a major modifiable risk factor for future fatal and nonfatal cardiovascular events. Other than obesity, multiple factors have been identified as predictors of cardiovascular risk. Bariatric surgery is the most effective treatment of obesity and results in improvement in all known modifiable risk factors for cardiovascular disease. Comparison of C-reactive protein and low-density lipoprotein cholesterol levels in the prediction of first cardiovascular event. Prospective Studies Collaboration, Lewington S, Whitlock G, Clarke R, Sherliker P, Emberson J, Halsey J, et al. Blood cholesterol and vascular mortality by age, sex, and blood pressure: a metaanalysis of individual data from 61 prospective studies with 55,000 vascular deaths. Evaluating novel cardiovascular risk factors: can we better predict heart attacks Exercise training and cardiac rehabilitation in primary and secondary coronary prevention. Clinical implications of obesity with specific focus on cardiovascular disease: a statement for professionals from the American Heart Association Council on Nutrition, Physical Activity, and Metabolism: endorsed by the American College of Cardiology Foundation. Prognostic importance of weight loss in patients with coronary heart disease regardless of initial body mass index. Preoperative factors predictive of complicated postoperative management after Roux-en-Y gastric bypass for morbid obesity. Prevalence and correlates of posterior extra echocardiographic spaces in a free-living population based sample (the Framingham study). Transthoracic dobutamine stress echocardiography in patients undergoing bariatric surgery. Short-term medication cost savings for treating hypertension and diabetes after gastric bypass. Remission of type 2 diabetes after gastric bypass and banding: mechanism and 2 year outcomes. Lipid profile in the severely obese: changes with weight loss after lap-band surgery. Prompt reduction in use of medications for comorbid conditions after bariatric surgery. One year improvement in cardiovascular risk factors: a comparative trial of laparoscopic Roux-en-Y gastric bypass vs. B-type natriuretic peptide increases after gastric bypass surgery and correlates with weight. Bariatric surgery improves cardiac function in morbidly obese patients with severe cardiomyopathy. To understand the role of endoscopy in the preoperative workup of the bariatric patient. To understand the intraoperative diagnostic and therapeutic possibilities with flexible endoscopy. To understand the role of endoscopy in assessing and treating bariatric patients in the short-term postoperative period.

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Each member of the team should be dedicated to convey his or her expertise to the bariatric patient erectile dysfunction in the young buy generic viagra plus line. Each patient needs to understand that morbid obesity is a chronic disease impotence emedicine order 400 mg viagra plus with mastercard, one for which we have no cure. It is equally important that the patient has a clear understanding that lifelong treatment and lifelong follow-up are required. Learning to utilize the tool appropriately can help them change their relationship with food, exercise, and improving overall health. Like any chronic disease, lifelong attention and ongoing effort is imperative to keep morbid obesity under control with weight loss and weight maintenance. All team members should standardize education objectives and document that it has been done. Often group classes can be more stimulating for the patient as they interact with others as well as efficient for the staff. Currently, more hospitals who perform bariatric surgery are implementing bariatric nursing competencies. Competencies for bariatric nurses should address the unique knowledge base that a bariatric nurse should possess. These include true/false test questions, multiple choice questions, and case studies with priority action questions. It is essential that patients not only understand what to do but also understand why it is important (Table 19. For example, a patient must understand that after undergoing gastric bypass, B12 supplementation is required for life. They must also be educated that noncompliance with B12 supplementation can lead to neuropathy that may be permanent. Support Group One of the many misunderstandings about those who suffer from the disease of morbid obesity is that they have an excessive percentage of psychological illness. On the contrary, studies of severely overweight persons conducted before seeking treatment have shown that there is no single personality type that characterizes the severely obese [37]. Often society shows the ignorant belief that if a patient ate less and exercised more, then they could control their weight. Nonsurgical weight management does not demonstrate sustained weight loss long-term in those suffering from severe obesity [38]. Twin studies show that two-thirds of the variation in body weight can be attributed to genetic factors [39]. The psychological aspects due to the bias of this disease are as important as the more publicized major medical comorbid conditions when one considers the quality of life of the severely obese [40]. Martinez Successful support groups should provide ongoing education and support for this unique peer group. In addition, most importantly, support group meetings should create a safe and empathetic environment to help individuals through their journey. If your support group is created with this in mind, your patients will be more likely to return and successfully continue along their postoperative path while maximizing their own success potential. The Purpose of a Support Group Patients who attend a support group regularly have better postoperative success [41]. There are numerous reasons why support groups are conducted in bariatric programs. One is to educate the prospective patient on the postoperative lifestyle as they interact with postoperative patients. The preoperative patient who attends a support group prior to surgery may have a significant advantage because they are in a less stressful environment to absorb information. Having patients attend support groups preoperatively is another aspect of the numerous ways in which informed consent may be provided.

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With regard to the vital signs impotence specialists discount viagra plus 400 mg line, tachycardia is often the first vital sign to be abnormal [6] erectile dysfunction pills cost discount 400 mg viagra plus free shipping. Tachycardia in the early postoperative period should raise suspicion for possible gastrointestinal leaks. Laboratory examination suggestive of a leak includes leukocytosis and an elevated C-reactive protein level. In a study of 17 patients with leaks after gastric bypass, C-reactive protein level of greater than 229 mg/l was able to reliably indicate a leak [7]. Therefore, the position statement suggested that laparoscopic or open reexploration should be an appropriate diagnostic option when gastrointestinal leak is suspected, as reliance on false-negative imaging studies may delay operative intervention. The treatment options for postoperative leaks after bariatric surgery depend on the timing of leaks at presentation. Management of early and acute leaks includes conservative nonoperative management, reoperation with abdominal washout, closure of the defect or placement of a T-tube to intubate the defect, and wide peritoneal drainage. For late and chronic leaks, management may require performing a proximal gastrectomy with esophagojejunostomy [16]. Nonoperative Treatment Nonoperative treatment can be considered for small, contained leaks, particularly in hemodynamically stable patients. Acute presentations can often be managed successfully with (a) insertion of intraluminal stent to cover the staple-line defect or (b) drainage and T-tube insertion. Armstrong Resolution of leaks following stent insertion (%) Endoscopic stent with laparoscopic drainage 75 % Overall mortality 9. In a relatively large study of leaks after gastric bypass, Gonzalez and colleagues reported successful nonoperative treatment in 23 of 26 patients, with an overall morbidity of 62 % and no mortality [17]. Reoperation and Drainage the mainstay of surgical treatment includes drainage of all fluid collections and placement of abdominal drains. Additionally, some surgeons make an attempt at closure of the defect; however, these closures tend to break down due to poor tissue integrity at the leak site. Leaks at the jejunojejunostomy or the gastric remnant may be more amenable for primary closure, and revision of the anastomosis is rarely needed [2]. An alternative approach to control the leak site is placement of a T-tube directly into the defect [14]. This technique consists of obtaining a conventional T-tube drain and placing the T part of the drain directly into the defect. Oral contrast passed entirely through the stent without evidence of contrast extravasation the idea here is to create a track along the drain, hence creating a controlled fistula. Upon withdrawal of the tube, the well-formed fistulous track will collapse and eventually close. Endoscopic Stent Endoscopic stenting for management of bariatric leaks is a relatively new concept and was initiated from the experience of using endoscopic stenting in management of esophageal anastomotic leaks after esophagectomy [19]. Serra and colleagues reported on the use of coated selfexpanding stents for management of leaks after sleeve gastrectomy or duodenal switch in six patients with control of leaks in 83 % of cases [11]. Casella and colleagues reported the use of endoscopic stent for leak at the gastroesophageal junction after sleeve gastrectomy in three patients, with complete healing occurring in all patients [18]. Oshiro and colleagues reported successful management of proximal gastric leak using a covered endoscopic stent in two patients who underwent prior unsuccessful laparoscopic treatment for the leak [13]. In contrast, the largest series of eight cases of endoscopic stent for leak after sleeve gastrectomy was reported by Tan and colleagues [14]. They reported a 50 % success rate for closure of the leak, with four patients requiring premature removal of the stent due to either migration, hematemesis, or obstruction from kinking at the proximal aspect of the stent. One of the major difficulties with usage of stents for control of leaks is their ability to migrate.

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These patients have the potential to suffer from a "mesocolic hernia" in which the Roux limb herniates up through the defect in the mesocolon through which the Roux limb passes erectile dysfunction treatment with injection discount viagra plus 400mg without prescription. If the Roux limb is placed in an antecolic position occasional erectile dysfunction causes best viagra plus 400mg, no such opening is created, and there is no potential for mesocolic herniation. While the majority of bariatric surgeons close these internal hernia spaces with permanent suture, some do not. A Mount Sinai study from 2005 found that sutured closure of the defects reduced the internal hernia rate from 3. It is important to remember that even if hernia spaces have been sutured closed, hernia defects may still form at these sites. If small bowel becomes entrapped within an internal hernia, its venous outflow may become partially or completely occluded, ultimately resulting in bowel ischemia and severe abdominal pain far out of proportion to the physical exam findings. Typically, patients complain of intense pain in the midepigastrium, often radiating to the back. The pain may occasionally be relieved by leaning forward or getting "down on all fours," maneuvers that serve to reduce the compression on the entrapped bowel. Entrapped bowel may reduce itself from the hernia spontaneously, bringing with it rapid resolution of symptoms, or it may persist until surgical intervention. Bowel obstruction may be absent even with a severe internal hernia causing intestinal ischemia. Definitive diagnosis of internal hernia can only be achieved through surgical exploration, either laparoscopic or open. If a significant length of bowel is entrapped within an internal hernia, intestinal anatomy may become so distorted that it becomes difficult to reduce the herniated bowel. In this situation, it is helpful to start by locating the ileocecal junction, then running the bowel in a retrograde fashion until the distal anastomosis is identified and the anatomy clarified. Once the herniated bowel is reduced, the hernia defect should be securely closed with a nonabsorbable running continuous suture. Some surgeons advocate the addition of a second layer of suture material or fibrin sealant to reinforce the hernia closure. Adhesions may form anywhere within the abdomen and can potentially obstruct the Roux limb, biliopancreatic limb, or common channel. If the Roux limb is placed in a retrocolic position at the time of surgery, it must necessarily pass through a surgically created defect in the mesocolon. In the Cleveland Clinic series, this was the second most common cause of bowel obstruction in bypass patients, comprising 20 % of all obstructions [8]. The risk of mesocolic stricture formation or mesocolic hernia can be completely eliminated at the time of initial surgery, if the surgeon places the Roux limb in an antecolic position. A recent publication from Coimbatore, India, reported a series of 37 patients who underwent concomitant permanent mesh repair of ventral hernia at the time of bypass and sleeve gastrectomy, with excellent results [12]. While promising, bariatric surgery with concomitant mesh repair of ventral hernia does not yet constitute the standard of care. Intussusception Small bowel intussusception is a far less common cause of bowel obstruction after gastric bypass, with scattered case reports in the literature. If surgery is required, the intussusception should be reduced, with resection or revision of the presumed lead point if identifiable. Obstruction from Intraluminal Blood Clot or Bezoar Intraluminal causes of obstruction are exceedingly rare after gastric bypass. Intraluminal blood clots, or hemobezoars, may form in the immediate postoperative period and can cause occlusion at the distal anastomosis. If the location of the bezoar is accessible endoscopically, the obstruction can be relieved nonsurgically. Otherwise, surgical exploration may be required with evacuation of the bezoar and confirmation of hemostasis. Incisional Hernia Incisional hernias may form at open incisions or laparoscopic trocar sites or may exist as a sequelae of earlier surgery.

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Risk factors that increase the likelihood of respiratory failure are congestive heart failure impotence at 46 discount 400mg viagra plus fast delivery, open surgery impotence remedy order cheapest viagra plus and viagra plus, chronic renal failure, peripheral vascular disease, male gender, age >50 years, alcohol abuse, chronic lung disease, diabetes, and smoking [2]. At baseline, morbidly obese subjects may be mildly hypoxemic, with higher respiratory rates and lower tidal volumes. The compliance of the respiratory system is reduced and work of breathing increased. In addition to the changes in respiratory mechanics and lung volumes, the prevalence of sleep apnea in bariatric patients can be as high as 75 % [5]. Well-planned and rational management of patients undergoing bariatric surgery requires detailed knowledge of how morbid obesity affects anesthesia care. Not only the mechanical effects of the increased body size but also the physiological changes and comorbidities impact safe management and decision making by the anesthesiologist. The aim of this chapter is to provide a practical approach to the problems that require special consideration in morbidly obese patients. An echocardiogram should be performed to assess right ventricular function and pulmonary hypertension. Poor right ventricle function and high mean pulmonary artery pressures (>35 mmHg) are associated with an unacceptable perioperative anesthesia-related mortality risk. The compromised respiratory status of the obese requires special precautions to prevent oxygen desaturation at induction of anesthesia, during surgery, and in the postoperative phase. Immediately after induction of anesthesia, atelectasis develops mainly in the dependent lung. In addition, release of inflammatory cytokines associated with atelectasis may contribute to postoperative ventilator-associated lung injury such as pneumonia and respiratory failure. The total blood volume is increased, but on a per kg total body weight basis, the blood volume is actually decreased. The increased total blood volume of the morbidly obese results in an increased cardiac output. Cardiac output affects the early pharmacokinetics, the front-end kinetics of drug distribution and dilution in the first minutes after administration. An increased cardiac output decreases the fraction of drug distributed to the brain and increases the rate of redistribution, which will result in lower concentrations, faster awakening, and increased dose requirement. This phenomenon has important implications for the induction dose of intravenous anesthetic agents. Obesity may lead to abnormal cardiac function through pathways that are associated with hypertension or independent of hypertension. The mechanisms of decreased cardiac contractility associated with obesity independent of hypertension are related to metabolic dysregulation but not completely understood. The increased body mass, the metabolic syndrome, insulin resistance, type 2 diabetes, and physical inactivity all contribute to systolic and diastolic dysfunction even in otherwise healthy young obese subjects, which may eventually progress to left and/or right heart failure. Congestive heart failure, peripheral vascular disease, and chronic renal failure are predictive 8 Anesthetic Considerations 87 Table 8. Obesity is also associated with an increased risk of atrial fibrillation and ventricular ectopy. Cardiac events can be a significant cause of 30-day mortality after bariatric surgery. Pharmacological Considerations Until recently, obese subjects have been routinely excluded from clinical trials to obtain regulatory approval for investigational drugs. This has resulted in package insert dosage recommendations based on total body weight, valid for normal-weight patients but not for the obese. Morbid obesity alters the pharmacokinetics and drug response of anesthetic agents. In addition, the decreased pulmonary and cardiac reserve of the morbidly obese decreases the margin of safety of anesthetic agents significantly. Obesity is not only associated with an increase in tissue mass but also changes in body composition and tissue perfusion. The increased cardiac output of the morbidly obese increases the dose requirements of induction agents.

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Most of the patients requiring these types of procedures present with failure of weight loss or weight regain [7] erectile dysfunction pump order viagra plus canada. Examples of conversion include modification from one restrictive procedure to another restrictive procedure or from a restrictive procedure to a malabsorptive procedure erectile dysfunction by race discount viagra plus 400 mg otc, and vice versa. Reversal the intent of the reversal procedure is to reestablish the original anatomy as closely as possible. Usual indications in this category include nutritional and metabolic complications (such as macronutrient and micronutrient malnutrition, liver failure) or patient noncompliance. Most of the bariatric oper- Indications In general, the success rate of a reoperation for a chronic complication of a primary operation (such as gastric outlet obstruction, marginal ulcer, gastro-gastric fistula, malnutrition, etc. This is largely due to the persistence of the noncompliant behaviors that led to failure of the original procedure. In the chronic complication group, instead, the reoperation is largely successful in eliminating the anatomic derangement causing the preoperative symptoms. Type of Primary Procedure the type of primary operation can also influence the weight loss of the secondary one. This could be explained by the superior initial benefit of the malabsorptive procedure not accounted toward the total weight loss after the revision. Instead, patients who failed the primary restrictive procedure never had significant weight loss, so most of the weight loss after the revisional malabsorptive operation is accounted for. A similar speculation can be applied to comorbidity resolution, which might have already occurred after the primary operation and not present at the time of reoperation. It is also important to mention how possible maladaptive eating behaviors that developed during the primary operation can be carried out after the re-intervention. Type of Re-intervention A wide variety of re-interventions are available (Table 24. It is important to adopt this distinction in an effort to stratify the complexity of the procedure, which influences both the morbidity and the overall results. In fact, re-interventions have a higher conversion from laparoscopic to open (up to 47. He found significantly higher operating times, blood loss, and hospital stay in the reoperative group, but no differences in postoperative morbidity, resolution of comorbidities, mortality, and weight loss at 1 year. Possible reasons accounting for this difference have been attributed to several factors. The morbidity related to leaks after revisional surgery is likely related to the more fibrotic and possibly inflamed tissue encountered during the second operation. Furthermore, possible tissue ischemia can develop secondary to crossing of multiple staple lines, devascularization and trauma to the tissues, and inadvertent presence of staple lines too close to each other. Other studies, instead, found no weight loss difference between primary and secondary operations, maybe because the maladaptive dietary and lifestyle behaviors persist after the reoperation [15]. The potential benefits and the possible specific indications will be outlined later in the chapter. The meta-analysis indicates a statistically significant shorter hospital stay, but higher reoperation rate and surgical time for the laparoscopic group [17]. However, no direct randomized comparison of laparoscopic versus open revisional surgery data is available at this time to draw a definitive conclusion. Surgeon Experience Similarly to other fields in surgery, surgeon experience has been well correlated to outcomes in bariatric surgery. A population-based study of the bariatric cases in the state of Pennsylvania has confirmed earlier findings of decreased perioperative mortality after bariatric surgery in the hands of experienced surgeons. In particular, surgeons who performed fewer than ten procedures per year had a twofold increase in 30-day mortality compared to surgeons performing more than 100 procedures per year [18]. Furthermore, the benefit of experience has also been extended to the hospital where the procedure takes place. In fact, the same authors, in recent analysis, reported how an experienced surgeon in a high-volume hospital has the lowest in-hospital and 30-day mortality (0. Although no direct analysis has been published on reoperative surgery, we could apply similar concepts for the even more complex reoperations. Preoperative Evaluation In order to reduce the perioperative morbidity and mortality, as well as increase the success rate of reoperations, a comprehensive preoperative evaluation is necessary. The primary reason for the comprehensive evaluation is to identify and correct the reason(s) for failure of the primary operation.

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In part impotence injections purchase 400 mg viagra plus with visa, this is due to having just had major abdominal surgery erectile dysfunction 31 years old order 400 mg viagra plus with amex, but their low intake of protein and calories is an obvious factor. Age is certainly a factor, with older patients often taking longer to recover than younger ones. If the patient is a premenopausal female and experiencing fatigue or morning nausea, especially if it is beyond 2 months after surgery and they are getting adequate protein, you may encourage them to consider checking for pregnancy. Constipation may occur in the first couple weeks postoperatively, due to the lack of residue during the liquid phase. Constipation is also due to the low intake of solid foods and lack of fiber early out from surgery. The patients are encouraged to take one to two stool softeners after surgery to help promote and soften their stool, especially while they are still using narcotics, which are a main contributor to early constipation. When counseling patients with diet solutions, applesauce, hot cereals such as oatmeal, berries, and peas or legumes are usually well-tolerated, high-fiber options. As always, ensure that they are staying hydrated and that they start slowly increasing their physical activity, which is of primary importance in increasing bowel motility. They may need to add a fiber supplement (consider methylcellulose, polycarbophil, or wheat dextrin, which are best tolerated); make sure to recommend sugar-free products to avoid excess calories and dumping syndrome. The cause may be due to ingestion of high-fiber or high-fat foods, but sometimes it is a sign of temporary lactose intolerance, too much malabsorption (in the case of a shorter common limb), or small bacteria overgrowth. LeBrun If your patient complains of diarrhea, have them avoid dairy, high-fiber (whole grains, fruits, and vegetables with skins), and high-fat foods, as well as caffeine and alcohol. Ensure that they are getting adequate sugar-free or lowsugar fluids (64 oz per day). Despite these changes, if their diarrhea persists for more than several days, have them come in to see a member of the healthcare team. Hair loss, alopecia, or telogen effluvium is one of the most feared side effects of many bariatric patients prior to surgery and can be very frustrating to most when it occurs. Normally, 90 % of our hair is growing and only 10 % is dormant, which means we have a small and somewhat tolerating amount of hair shedding at any one time. However, whenever our bodies are put into an extremely stressful state (such as surgery or rapid weight loss), for self-preservation purposes, we stop putting energy into things that are not necessary to live, like hair growth. During stressful states, more of our hair is shifted into the telogen stage, which is also called "telogen effluvium. Some other causes of alopecia are high fevers, severe infection, acute physical trauma, chronic debilitating illness (such as cancer), hormonal disruption (like pregnancy, childbirth, or stopping hormone therapy), anorexia, thyroid or autoimmune disease heavy metal toxicity, and certain medications like beta-blockers, anticoagulants, retinoids, and immunizations. It is important to have a medical professional rule these possibilities out, especially if there is no nutritional cause detected. When alopecia occurs between 3 and 6 months after surgery, it is most likely a result of the stress of major surgery and low calorie intake. Therefore, cholelithiasis or cholesterol gallstone formation is very common after bariatric surgery. Any patient who complains of right upper quadrant pain and nausea should be evaluated for gallstones. It is prudent to put all patients on a gallstone-solubilizing agent such as Actigall for the first 6 months after bariatric surgery. Alternately, a minimum of 10 g of fish oil per day has been found to reduce gallstone formation [28].

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