Operative Surgery Manual.

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Gastric Bypass Surgery Gastric Bypass Also called: Stomach Bypass, Roux en Y Gastric Bypass, Gastric Bypass Procedure, Gastric Bypass Surgery, Gastric Bypass Operation Summary Gastric bypass surgery is used to treat severe obesity when techniques such as dietary changes, exercise and other methods have failed to control a patient’s weight. It is the most popular form of weight loss surgery (bariatric surgery) performed in the United States. This type of surgery typically is performed on patients with a body mass index (BMI) of 40 or more. This measure is a calculation of a person’s height and weight, and a BMI of 40 represents a man who is about 100 pounds overweight, or a woman who is about 80 pounds overweight. During a gastric bypass procedure, a patient’s digestive anatomy is surgically altered to restrict the amount of food they are physically able to eat at one time. In addition, the digestive tract is altered so that food bypasses part of the stomach and part of the small intestine, resulting in fewer calories being absorbed by the body. Gastric bypass surgery is performed using general anesthesia, which means the patient is asleep during the procedure and does not feel pain. Gastric bypass can be performed as either traditional open surgery or as less invasive laparoscopy. The latter technique requires smaller incisions and generally has a shorter recovery time than the traditional technique. Following surgery, patients are placed on a special diet that lasts for several months and progresses from liquids to pureed foods and soft foods. Eventually the patient will be allowed to eat solid foods. However, the changes to the digestive system brought on by surgery result in permanent restrictions on how much patients are able to eat and what kinds of food they can eat.

Patients may lose as much as 50 to 60 percent of their excess weight within the first two years of gastric bypass surgery. However, some patients experience complications after surgery, such as hernias or abdominal infections, some of which may be life threatening. In addition, a healthy diet, regular exercise and other physician-prescribed lifestyle changes are necessary to increase a patient’s chances of maintaining a healthy weight after the surgery.

About gastric bypass Gastric bypass surgery is the most commonly performed type of weight loss surgery (bariatric surgery) in the United States. This surgery alters the patient’s digestive anatomy to restrict the amount of food they are physically able to eat at one time. This promotes weight loss by causing the patient to feel full more quickly. The procedure also involves a bypass of part of the stomach and part of the small intestine that results in fewer calories being absorbed by the body.

Physicians generally encourage patients to lose weight through dietary modifications and lifestyle changes, including regular exercise. There are also a few medications that promote short-term weight loss. Bariatric surgery is considered only when these interventions prove insufficient to bring a severely obese patient’s weight to a healthy level. This type of surgery typically is performed on patients with a body mass index

(BMI) of 40 or more. BMI is a measure of a person’s height and weight, and a BMI of 40 represents a man who is about 100 pounds overweight, or a woman who is about 80 pounds overweight. A normal BMI is somewhere between 18.5 and 25. The digestive process begins as soon as a person swallows food. Once the food enters the digestive tract, digestive juices and enzymes digest food and help with the absorption of calories and nutrients. The food moves down the esophagus and into the stomach, where acid continues to digest the food. In the average person, the stomach can hold about 32 ounces (946 milliliters) of food at one time. As this food is digested, it moves to the first part of the small intestine (known as the duodenum), where bile and pancreatic juices facilitate digestion and absorption. Most of the remaining calories and nutrients are absorbed in the final two segments of the small intestine (jejunum and ileum). Any remaining food moves into the large intestine before it is eliminated from the body.

Bariatric surgery techniques promote weight loss in one of two ways: either by restricting food intake or by interrupting the digestive process. Some procedures (e.g., gastric bypass) combine stomach restriction with partial bypass of the small intestine. Gastric bypass is often the preferred form of weight loss surgery because it is considered to be safer and to have fewer complications than other alternatives. In this procedure, also known as Roux-en-Y gastric bypass (RGB), the surgeon first creates a small stomach pouch that serves to restrict food intake. A Y-shaped section of the small intestine is attached to the pouch. This allows food to bypass the lower stomach, the duodenum and the first portion of the jejunum, reducing the amount of calories and nutrients the body absorbs.

Gastric bypass can be performed as either traditional open surgery or as less invasive laparoscopy. In the latter technique, a small, tubular instrument called a laparoscope is inserted through a short incision in the abdomen. The laparoscope has a camera at the end that allows the physician to view the interior of the body. Surgical instruments are then passed through other short incisions to complete the surgery. Patients who undergo the laparoscopic technique usually require a shorter hospital stay than those who undergo open surgery. In addition, laparoscopy usually requires a shorter recovery period, and presents a lesser risk of wound-related complications. However, people who weigh more than 350 pounds (158 kilograms) or have a history of abdominal surgery may not be good candidates for laparoscopy. Only certain people are considered to be good candidates for gastric bypass surgery, such as those with a BMI of 40 or greater. Physicians may also permit gastric bypass for patients with a BMI of 35 to 39.9 who also have weight-related health problems such as diabetes, heart disease, severe sleep apnea (cessation of breathing during sleep) or high blood pressure (hypertension). A team of health professionals (e.g., physicians, surgeons, dietitians, psychologists) will work together to help determine if a patient is a good candidate for bariatric surgery. Factors to be considered include potential benefits to a patient’s health, potential risks involved in the surgery and whether or not the patient can comply with the lifestyle changes necessary to ensure that the weight stays off following surgery. The evaluation will include a thorough physical examination. The patient's medical history will be obtained, including a current list of medications and supplements. Blood tests and imaging tests (e.g., EKG, chest xray, upper gastrointestinal x-ray, gallbladder ultrasound) may also be performed. Patients with certain preexisting conditions (e.g., alcoholism, hepatic cirrhosis with impaired liver function) may not be good candidates. Individuals with correctable hormonal causes of obesity may also not qualify. A psychologist may help determine if a patient is able and willing to make the dietary and lifestyle adjustments necessary to ensure that the weight stays off, and to reduce the risk of complications. Patients with certain serious psychiatric conditions may be ruled out.

Before and during the gastric bypass procedure Gastric bypass surgery takes place in a hospital. Prior to the surgery, patients should follow all preparatory steps recommended by their physician. These may include modifications to diet, engaging in an exercise program and limiting or stopping use of alcohol and nicotine products. Patients may also be asked to refrain from taking certain medications, such as anticoagulants (e.g., aspirin) which inhibit the ability of the blood to clot. Fasting will also be necessary on the day of the procedure. Patients are placed under general anesthesia, which means they are not awake for the procedure and feel no pain. A tube is inserted through the nose and into the upper stomach and connected to a suction machine, which will help in the healing process following surgery. During the procedure, the stomach is made smaller by dividing it into a smaller upper section and a larger lower section. The surgeon uses surgical staples to seal off the upper part of the stomach from the remainder of the stomach. This creates a small pouch at the top of the stomach that is about the size of a walnut and is able to hold about 1 ounce (30 milliliters) of food.

The surgeon then cuts the small intestine and sews part of it onto the pouch. This arrangement allows food to bypass most of the stomach and the first section of the small intestine, known as the duodenum. Instead, the food travels from the surgically created pouch through the new connection (known as a Roux limb) and directly into the second segment of the small intestine, known as the jejunum. This limits the amount of calories absorbed into the body. In rare cases, the gallbladder may also be removed (cholecystectomy) during a gastric bypass to prevent formation of gallstones that sometimes result from rapid weight loss. However, this is more often achieved through medications that dissolve these stones. Gastric bypass surgery usually takes about four hours to complete. The incisions will be closed with stitches or surgical staples and then covered with a sterile bandage. The patient will have the stitches or staples removed at a later time during a follow up visit.

After the gastric bypass procedure Following surgery, the patient will awaken in a recovery room and will be monitored for any post-surgery complications. Patients are typically required to remain in the hospital for three to five days. The tube that was inserted through the nose into the upper stomach before the procedure will help keep the new stomach pouch empty so that the staple line can heal. In some cases, a second tube will have been inserted into the bypassed stomach during surgery. This tube is usually removed four to six weeks after surgery. Pain medication will be administered as needed, either intravenously or orally. Patients will be encouraged to move around as much as possible while in the bed, and ultimately to get up and walk around as they recover. It may take several weeks before a patient displays the same level of stamina they exhibited before the procedure. Patients typically cannot eat solid foods for a day or two after surgery. Once their stomach has had some time to heal, patients will be placed on a special diet. This will last for several months and begins with two to three days of clear liquids (e.g., water, juice, broth), followed by three or four weeks of thicker liquids (e.g., pudding, cream soups) and pureed foods (which have the consistency of a smooth paste) and then eight weeks of soft foods (e.g., finely diced meats, canned fruits, cooked vegetables). Eventually, patients return to eating some regular foods, avoiding those that are high in fats and sugar. Patients will initially find that they need to eat very small meals through the day, although the stomach will stretch a bit over time. Gastric bypass patients must also drink plenty of liquids, but liquids cannot be consumed at mealtimes because the stomach is so small. For the first six months following surgery, patients often find that they may vomit or feel pain under the breastbone if they eat too much or eat too fast. Aching may also occur at the incision site and within the abdominal muscles, particularly with deep breathing, coughing or exertion. In general, patients should refrain from strenuous activity, such as lifting heavy items, for several months after surgery to prevent strain on the abdominal muscles and incision site.

Patients may experience other signs and symptoms during this period as well, including: • • • • • • • • • •

Nausea Body aches Feeling of tiredness similar to flu Feeling cold Dry skin Hair thinning or hair loss Mood changes Changes in bowel movements Constipation Loss of muscle mass

Patients should contact their physician if they experience any of the following: • •

Fever Chills

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Redness or swelling at the incision site

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Bleeding or other drainage from the incision site

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Increased pain at the incision site

Physicians monitor gastric bypass patients closely for several years after surgery. Continued attention to weight loss and diet is essential for a successful outcome, and the patient is likely to consult with a registered dietitian or other dietary expert in planning appropriate meals. Patients may participate in support groups or use other methods to help adjust to their new lifestyle. As people lose weight over the next one to two years they may develop excess skin. These patients may benefit from plastic surgery aimed at correcting the condition.

Potential benefits of gastric bypass Patients who have gastric bypass surgery often lose more weight, lose weight more quickly and keep more weight off for longer periods of time than those who have other forms of bariatric surgery. However, individual results depend on many factors, including the type of procedure performed and the commitment of the patient to making the necessary dietary and lifestyle adjustments. Age, gender and initial weight at the time of the surgery may also play a role in the outcome. Patients often report higher self-esteem and better general health, including having more endurance to carry out daily tasks. Gastric bypass surgery may also lengthen a patient’s lifespan and help improve symptoms of conditions related to obesity, including:

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Gastroesophageal reflux disease (GERD) Type 2 diabetes High cholesterol High blood pressure (hypertension) Obstructive sleep apnea (breathing cessation caused by enlarged tonsils)

Even when patients fail to reach their ideal weight, these medical conditions are usually improved following surgery.

Potential risks with gastric bypass Although gastric bypass surgery can create many health benefits for patients, it also includes some serious health risks. Patients are at risk for complications associated with all surgeries, such as infection or allergy to anesthesia. Gastric bypass procedures are more difficult to perform than some other forms of bariatric surgery and are more likely to cause long-term nutritional deficiencies, particularly in regard to iron and calcium. This means that menstruating women are more likely to develop anemia. Osteoporosis and other bone diseases may result from calcium deficiency. Recent research also shows that nutritional deficiencies related to gastric bypass surgery may result in serious neurological conditions. To guard against nutritional deficiencies, patients may be given nutritional supplements such as a multivitamin, vitamin B-12 and minerals such as calcium and iron.

Patients who have gastric bypass surgery may also suffer from dumping syndrome, which occurs when a meal high in simple carbohydrates moves too quickly through the small intestine, leading to nausea, bloating, abdominal pain, weakness, sweating, faintness and diarrhea. Patients may also develop an infection such as peritonitis, in addition to abdominal hernia, dehydration, gallstones or stomach ulcer. Research also shows that patients may be at increased risk of developing kidney stones following gastric bypass surgery. Some of these complications may require additional surgery. Other risks associated with bariatric surgery include:

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Death. Patients have died as a result of these surgeries. Risk levels vary depending upon a person’s age, general health and other medical conditions. According to the National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK), the risk of death from gastric bypass surgery is less than 1 percent.

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Blood clots in the legs. These clots may form in the legs before traveling to the lungs and into the arteries found there. This can cause a pulmonary embolism, which can be fatal. Walking and wearing leg wraps can reduce this risk. Leg exercises may also be recommended.

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Leaking from a staple line. This severe complication is usually treated with antibiotics, and some cases may require emergency surgery.

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Narrowed opening connecting the stomach and small intestine. This complication is rare and often can be corrected by an outpatient procedure in which a tube (endoscope) is inserted through the mouth to widen the opening. In some cases, corrective surgery may be necessary.

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Pneumonia. Patients may have a higher risk of this disease after surgery.

Lifestyle considerations with gastric bypass The changes to the digestive system brought on by surgery result in permanent restrictions on how much patients are able to eat and what kinds of food they may eat. Although the average stomach can hold 32 ounces (946 milliliters) of food, a stomach that has undergone gastric bypass surgery holds only 4 to 8 ounces (118 to 236 milliliters) of thoroughly chewed food. Eating too much food can result in pain, nausea, vomiting, abdominal cramps, bloating and diarrhea. The dietary restrictions required after gastric bypass surgery may present problems for some patients. Most postsurgical diet problems are caused by foods high in fats and sugars, which may have represented a large part of the diet that caused patients to gain weight before surgery. Following surgery, patients will likely be urged to eat foods that are high in protein and low in fat, fiber, calories and sugar. Patients must learn to eat and drink extremely slowly, taking at least 30 minutes to consume a meal and 30 to 60 minutes to drink a cup of liquid. Chewing food thoroughly can help prevent blockages that can otherwise form at the new opening from the stomach to the intestine. By eating and drinking small amounts slowly, patients can also reduce the risk of dumping syndrome, which occurs when a meal high in simple carbohydrates moves too quickly through the small intestine, leading to nausea, bloating, abdominal pain, weakness, sweating, faintness and diarrhea. This is especially important when consuming high-sugar foods and drinks, such as ice cream and soda. Drinking beverages between meals rather than with them can reduce the risk of dumping syndrome and other symptoms. Patients may lose as much as 50 to 60 percent of their excess weight within the first two years after surgery. However, there is no guarantee that patients will keep the weight off over the long term. A healthy diet, regular exercise and making other physician-prescribed lifestyle changes will increase a patient’s chances of maintaining a healthy weight level. It is important to note that women should not become pregnant in the first year following the surgery. The rapid weight loss associated with gastric bypass can pose a risk to the fetus.

Questions for your doctor about gastric bypass Preparing questions in advance can help patients to have more meaningful discussions with their physicians regarding their conditions. Patients may wish to ask their doctor the following questions related to gastric bypass: 1.

Am I a good candidate for gastric bypass surgery?

2.

What form of gastric bypass surgery to you recommend for me and why?

3.

Can you explain the procedure to me in detail?

4.

What are the risks associated with gastric bypass surgery?

5.

How long will it be before I can eat solid foods following surgery?

6.

How will my long-term eating habits change following gastric bypass surgery?

7.

How can I avoid nutritional deficiencies that are sometimes associated with gastric bypass surgery?

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How much weight might I lose? Is there a chance I will gain back the weight later?

9.

How can I increase my chances of keeping off the excess weight?

10. How many gastric bypass procedures have you performed? 11. What complications have you seen in your surgical patients? 12. What type of follow-up care do you provide?

Bariatric Surgery Also called: Weight Loss Procedures, Restrictive Bariatric Procedures, Weight Loss Surgery, Malabsorptive Bariatric Procedures Summary Bariatric surgery is a procedure used to restrict food intake or interrupt the digestive process in patients who are severely obese (typically more than 100 pounds overweight). It is used only after other methods, such as dietary changes, exercise and medication, have failed to bring an individual’s weight under control.

There are two major types of bariatric surgery: •

Restrictive operations. Reduce food intake by narrowing the passage between the upper and lower parts of the stomach. Adjustable gastric banding, in which the passage is narrowed with a hollow band of silicone rubber, is an example of a restrictive operation.

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Restrictive/malabsorptive operations. Also called combined operations, these alter the small intestine so that less of it is involved in the digestive process. A Roux-en-Y gastric bypass, in which a small stomach pouch is created and attached to a Y-shaped section of the small intestine, is an example of a combined operation. This procedure allows food to bypass the lower stomach, the duodenum and the first portion of the jejunum.

These surgeries can help obese patients lose significant amounts of weight. However, they present certain health risks such as nutritional deficiencies, infection, blood clots and pneumonia. In some cases, bariatric surgery has led to death. However, death or infection occurs relatively rarely, according to the American Obesity Association. Patients who have successful bariatric surgery will gradually return to a healthful diet after a period of time. There is no guarantee that patients will keep off the weight they have lost. The best way to increase the likelihood of maintaining weight loss is to eat a healthful diet, exercise regularly and make other physician-recommended lifestyle changes.

About bariatric surgery Bariatric surgery is a procedure used to treat severe obesity in people who have failed to maintain a healthy body weight through diet, exercise and medication. Although bariatric surgery typically results in greater and faster weight loss than these methods, it is usually considered an option of last resort for most individuals because the surgery itself presents potential health risks. Bariatric surgery is generally reserved for people who are more than 100 pounds overweight, or have a body mass index (BMI) over 40. BMI is a calculation of a person’s height and weight that is used to determine whether the person is within a normal weight range. A healthy BMI is between 18 and 25. Some people with a BMI of 35 or more will be considered for the surgery if they have certain illnesses that could be improved with weight loss, such as type 2 diabetes, sleep apnea and heart disease. Researchers recently devised a new scoring system that helps to determine which candidates are at greatest risk of experiencing complications from gastric bypass surgery. However, this tool requires additional study before it can be routinely used by physicians. Even though research shows that bariatric surgery has tripled among adolescents in recent years, concerns about the potential long-term effects usually preclude them from receiving bariatric surgery. However, it is sometimes considered for severely overweight adolescents who have significant health problems related to obesity (such as type 2 diabetes or heart disease) and for whom weight-loss efforts remain unsuccessful after a period of at least six months. A patient must reach adult height (around age 13 for girls and 15 for boys) before the surgery will be considered. Some research also suggests that the risk of complications following bariatric surgery increases proportionately for each year of age for individuals over age 60. A team of health professionals, including physicians, surgeons, dieticians and psychologists, work together to help determine if a patient is a good candidate for this surgery. Bariatric surgery promotes weight loss through one of two methods: by restricting food intake or by interrupting the digestive process. The digestive process begins as soon as a person swallows food. Once the food enters the digestive tract, digestive juices and enzymes begin digestion, and calories and nutrients are absorbed in the small intestine. The food moves down the esophagus and into the stomach, where acid continues to digest the food. In the average person, the stomach can hold about 3 pints of food at one time.

As food is digested, it moves to the first part of the small intestine (known as the duodenum), where bile and pancreatic juices promote digestion and absorption of nutrients including the minerals iron and calcium. Most of the remaining calories and nutrients are absorbed in the final two segments of the small intestine (jejunum and ileum). Any leftover food particles move into the large intestine before they are eliminated from

the body.

Types and differences of bariatric surgery There are two types of bariatric surgery performed today: restrictive operations and restrictive/malabsorptive operations. Restrictive operations reduce food intake by narrowing the passage between the upper and lower parts of the stomach. This limits the amount of food that can be held in the stomach (to about one ounce) and delays the passage of food through the stomach. Restrictive operations do not interfere with the normal digestive process. The two major types of restrictive operations include:

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Adjustable gastric banding (AGB). A hollow band of silicone rubber is placed around the upper end of the stomach. This creates a small pouch and a narrow passageway into the rest of the stomach. Once the band is in place, a connecting tube is used to inflate it with a salt solution. The size of the passage can be altered by increasing or decreasing the amount of salt solution.

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Vertical banded gastroplasty (VBG). A band is combined with staples to create a small stomach pouch. This procedure is not as common as it once was and typically results in less weight loss than bariatric surgery with a malabsorptive component.

The restrictive procedures are often performed using a laparoscope, which involves smaller incisions and

shorter recovery time than traditional surgery. Malabsorptive operations, also known as intestinal bypasses, alter the small intestine so that much of it is not involved in the digestive process. This reduces the amount of calories and nutrients absorbed from food. Today, experts usually do not recommend these procedures because they can result in nutritional deficits for the patient. Although pure malabsorptive operations are no longer recommended, many patients undergo a combined restrictive/malabsorptive operation. In fact, these are the most commonly performed bariatric procedures, and they both restrict food intake and the amount of calories and nutrients the body absorbs. The two major combined operations are:

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Roux-en-Y gastric bypass (RGB). The surgeon first creates a small stomach pouch that is sealed off from the rest of the stomach, restricting food intake. Then, the amount of calories and nutrients the body absorbs is reduced by attaching a Y-shaped section of the small intestine to the pouch. This allows food to bypass the lower stomach, the duodenum and the first portion of the jejunum. In some cases, the gallbladder may be removed (cholecystectomy) to prevent the gallstones that sometimes result from rapid weight loss. The development of gallstones after bariatric surgery can sometimes be prevented with medication.

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Biliopancreatic diversion (BPD). More complicated than RGB, it involves removing the lower portion of the stomach and connecting the small pouch that remains to the final segment of the small intestine. In this procedure, the duodenum and jejunum are completely bypassed. Although this procedure leads to weight loss, it is not performed as frequently as an RGB because there is a higher risk of nutritional deficiency.

All of these procedures have pros and cons. Restrictive operations are easier to perform and are usually safer than malabsorptive procedures. They can also be reversed and do not create major nutritional deficiencies. However, patients tend to lose less weight after these procedures than after malabsorptive operations, and they are less likely to keep the weight off over long periods of time. Patients may also experience vomiting whenever they eat too much, and the band and tubing are subject to slippage and wear, which may result in the need for a second surgery. In rare cases, infection and bleeding may follow AGB. Patients who have a combined restrictive/malabsorptive operation tend to lose more weight than those who have purely restrictive operations. In addition, they typically lose weight more quickly and keep more of it off for longer periods of time. The fact that these patients lose more weight may offer added benefits for those with health problems such as high blood pressure (hypertension), sleep apnea, type 2 diabetes and osteoarthritis. However, these procedures are more difficult to perform than purely restrictive operations and are more likely to cause long-term nutritional deficiencies in patients, particularly iron and calcium deficiencies. This

means that many patients (especially menstruating women) are likely to develop anemia. All bariatric surgery patients are more likely to develop osteoporosis and other bone diseases. Nutritional supplements may help prevent these disorders. Patients who have RGB or BPD surgery may also suffer from dumping syndrome, which occurs when a meal high in simple carbohydrates (e.g., bread) moves too quickly through the small intestine, leading to nausea, bloating, abdominal pain, weakness, sweating, faintness and diarrhea. Patients are also at risk for developing an infection or abdominal hernia. Patients usually are urged not to have bariatric surgery unless the health risks of obesity are greater than the risks of having the surgery. Deaths and other illness have occurred as a result of these surgeries. However, the risk of death or infection is relatively low, according to the American Obesity Association. Research from the International Bariatric Surgery Registry (IBSR) show that death within 30 days of surgery occurs in less than one-quarter of 1 percent (0.17 percent) of all vertical banded gastroplasty and Roux-en-Y gastric bypass surgeries. Research also indicates that the risk of developing kidney stones and Wernicke encephalopathy (a rare brain condition associated with thiamine deficiency) may increase following bariatric surgery. Other risks associated with bariatric surgery include blood clots in the legs and pneumonia, both of which have the potential to become fatal.

Lifestyle considerations with bariatric surgery Prior to the surgery, patients are encouraged to follow all preparatory steps recommended by their physician. These may include modifications to diet, engaging in an exercise program and limiting or stopping use of nicotine products. Following surgery, patients will have a short hospital stay. The length of the stay will depend on the type of surgery performed and the patient’s recovery. Patients will be placed on a special diet for several months that begins with liquids and progresses through pureed foods and soft foods before returning to regular foods. Patients will initially find that they need to eat very small meals throughout the day, although the stomach will stretch a small amount over time. However, the amount of food a patient can eat is permanently restricted following surgery. For the first six months following surgery, patients often find that they may vomit or feel pain under the breastbone if they eat too much or eat too quickly. Patients may experience other symptoms during this period as well, including:

• • • • • •

Body aches Feeling of tiredness similar to flu Feeling cold Dry skin Hair thinning or hair loss Mood changes

Patients may lose as much as 50 to 60 percent of excess weight within the first two years of surgery. However, there is no guarantee that patients will keep the weight off over the long term. Bariatric surgery patients are urged to eat a healthy diet, exercise regularly and make other physician-prescribed lifestyle changes that can increase their chances of maintaining a healthy body weight

Questions for your doctor on bariatric surgery Preparing questions in advance can help patients to have more meaningful discussions with their physicians regarding their conditions. Patients may wish to ask their doctor the following questions related to bariatric surgery: 1.

Am I a good candidate for bariatric surgery?

2.

Which type of bariatric surgery is best for me?

3.

Can you please describe the procedure to me in detail?

4.

What are the risks associated with bariatric surgery?

5.

How will my eating habits change following bariatric surgery?

6.

Will I have to exercise regularly after bariatric surgery?

7.

How much weight can I expect to lose with bariatric surgery?

8.

Is there a chance I will gain the weight back at a later date?

9.

How can I increase my chances of keeping off the excess weight?

10. How long is the recovery period after bariatric surgery?

Anal & Rectal Problems Anal & Rectal Problems Reviewed By: David Friedel, M.D., AGA

Summary Many gastrointestinal problems may involve the anus and rectum. The rectum is the end of the large intestine, between the sigmoid colon and the anus. The anus is located at the very end of the digestive tract, where stool exits the body. The anal sphincters are the rings of muscle that keep the anus closed between bowel movements. Changes in the frequency, consistency, composition or volume of bowel movements may signify a gastrointestinal problem.

Many anal and rectal problems involve abnormal structures and can be identified by a visual or manual examination. These include hemorrhoids, obstruction and congenital problems where there is no anal opening (imperforate anus) or the anal opening is abnormally small. Some problems occur due to malfunctioning muscles, nerves or other structures in the anus or rectum. Problems related to the function of the anus and rectum include fecal incontinence, proctalgia fugax or rectal pain, and painful bowel movements (dyschezia). Anal and rectal problems may also result from infectious or inflammatory causes such as anorectal abscesses and proctitis. While the causes of anal and rectal problems are quite diverse, these problems may produce very similar symptoms. The most common of these are anal itching, constipation, pain and bleeding. The diagnosis of anal and rectal problems typically involves an evaluation of the patient's medical history, a physical examination and a series of diagnostic tests. While gathering the patient’s medical history, physicians and gastroenterologists generally ask about symptoms, bowel habits and changes in bowel patterns. The physical examination usually involves the examination of the anal area and a digital rectal exam. The most common diagnostic tests include anoscopy and sigmoidoscopy. Most anal and rectal problems can be treated successfully when diagnosed early. Many simple alterations in diet (e.g., eating more fiber) and daily habits (e.g., better bowel hygiene) can help to both treat and prevent many anal and rectal problems. Many medications, including laxatives or antibiotics, may be used. A sitz bath is commonly used in the treatment of many anal and rectal problems associated with pain. Many anal and rectal problems can be treated with minor procedures in the office of a physician or gastroenterologist. Some of these problems require surgery.

About anal & rectal problems The anus and rectum are the final portions of the gastrointestinal tract in relation to digestion and excretion of food products, and are subject to numerous problems. However, many patients are reluctant to ask or speak about these problems with their physician or gastroenterologist. Some anal and rectum problems can become quite serious if they are not treated.

The rectum is at the end of the large intestine, between the sigmoid colon and the anus. It is lined with tissue that contains glands that secrete mucus to protect and lubricate the rectum.

The anus is located at the end of the rectum. It is the opening where stool exits the body. The anal tissue includes both surface skin layers and intestinal tissues. The nerves in this area are very sensitive to pain. Rings of muscles called anal sphincters keep the anus closed between bowel movements. The interior sphincter is located closer to the rectum and is controlled subconsciously. The exterior sphincter is closer to the skin and can be controlled voluntarily. Stool that passes through the digestive system is stored in the descending colon. When this becomes full, the stool moves through the sigmoid colon into the rectum, which stretches as it fills. As the rectum senses the presence of stool, it causes an urge to defecate. Older children and adults can hold stool in the rectum until an appropriate time and place for a bowel movement. However, infants and younger children do not

have the necessary muscle control and cannot withstand the urge to defecate. Bowel patterns vary greatly from person to person. Further, a person will generally have different bowel patterns at different times. Factors such as diet, stress, medications and disease can affect bowel patterns. Regular frequency of bowel movements in Western societies may range from two or three a week to two or three a day. In most cases, it is easiest to defecate in the morning, particularly 30 minutes to an hour after the first morning meal. Chronic or sudden changes in the frequency, consistency or volume of bowel movements may signify a gastrointestinal problem. The presence of blood, mucus, pus or excessive oil or grease in the stool may be warning signs of a problem anywhere in the gastrointestinal tract. Problems that originate in the rectum or anus are usually related to abnormal structures, improper function or infections or inflammations. Some problems may fall into more than one category. For example, an anal fissure (tear) originates as a structural problem, but if left untreated may affect anal function.

Structural anal & rectal problems Many anal and rectal problems involve abnormal structures and can be identified by a visual or manual examination. These include:

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Hemorrhoids and anorectal varices. Hemorrhoids are stretched, dilated veins in the walls of the anus and rectum. They may remain inside the anus or protrude. Hemorrhoids occur when pressure in the affected vein increases due to a variety of factors (e.g., straining during defecation, frequent heavy lifting, pregnancy). Anorectal varices are small, swollen veins located just under the inner mucosa layer in the anus and rectum. While they appear similar to hemorrhoids, anorectal varices are not directly related to them. They are the result of high blood pressure in the portal vein (portal hypertension).

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Obstruction and fecal impaction. Obstruction occurs when something blocks the stool and impedes defecation. Fecal impaction occurs when obstruction is caused by hardened stool in the colon or rectum. This occurs more frequently in older adults and pregnant women. Possible causes of other forms of obstruction include anal stenosis, dysfunction of the pelvic muscles, Crohn's disease, injury or inflammation following radiation therapy, infection and cancer.

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Anal fissure and ulcer. An anal fissure is a tear in the lining of the anus. If the fissure does not heal, it becomes an ulcer. Anal fissures cause spasms in the anal sphincter, which make healing difficult. They may be caused by a hard or large bowel movement or by sexual penetration of the anus.

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Anorectal fistula. An abnormal passageway between the anus or rectum and the skin around the anus or another organ, especially the vagina (rectovaginal fistula). While these may be birth defects, they are usually caused by an abscess. Congenital (birth defect) fistulas are more common in boys. Anorectal fistulas may develop after injury during childbirth, after radiation therapy or as a result of certain diseases (e.g., diverticulitis, Crohn's disease, tuberculosis, cancer).

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Rectal prolapse and rectocele. Rectal prolapse occurs when the rectum turns inside out and protrudes through the anus. In children, it may occur while they are straining to defecate, which is usually temporary and not serious. However, in adults, prolapse typically persists and worsens. In some cases, the entire rectum may prolapse (procidentia). In women, rectocele occurs when the rectum protrudes into the vagina. Rectal prolapse and rectocele in adults are generally believed to be caused by a loss of strength in the tissues that hold the rectum in place. This is more common with advancing age. Rectocele occurs as a result of damage after vaginal childbirth, the strains to the tissue caused by constipation, obesity or heavy lifting.

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Anal stenosis. The narrowing of the anal canal. This may occur as a birth defect in infants or from scarring after anal surgeries among adults. Current treatments can either dilate the anus or surgically remove scar tissue.

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Imperforate anus. A birth defect where the anal and rectal region is not properly developed. This occurs in around 1 in 5,000 infants, according to the National Institute of Diabetes and Digestive

and Kidney Diseases (NIDDK). In some cases, the rectum does not connect to the anus (anorectal atresia). It may simply end or connect elsewhere, such as the urethra, bladder or vagina. In other cases, the anus may be very narrow or missing (anal atresia). In girls, a single opening may incorporate the rectum, vagina and bladder (congenital cloaca). These conditions require surgical correction.

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Hirschsprung’s disease. A rare congenital abnormality where the nerves to anal sphincters are not normally developed and infants are severely constipated because the sphincters do not relax. Occasionally, a milder form is found in adults. Surgery is usually required.

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Foreign bodies. Sometimes, objects may become stuck in the rectum or anus. These may be objects that have been swallowed (e.g., toothpicks) or objects inserted through the anus (e.g., enema tips, thermometers, objects used for sexual stimulation).

Functional anal & rectal problems Many anal and rectal problems are the result of improper function of the muscles, nerves or other structures in the area. These functional problems of the anus and rectum include: Fecal incontinence. The inability to control bowel movements. According to the American College of Gastroenterology, more than 5.5 million Americans experience fecal incontinence. This condition generally occurs when the anal sphincter muscles weaken or are damaged, the nerves supplying the sphincter muscles are damaged, or the rectum thickens so that it cannot stretch properly. Diarrhea and fecal impaction may cause brief episodes of fecal incontinence. Persistent fecal incontinence may occur as a symptom of many problems, such as spinal or anal injuries, anorectal abscess or fistula, rectal prolapse, dementia, radiation therapy or certain illnesses (e.g. Crohn's disease, multiple sclerosis, diabetes). The sphincter muscles become weaker with age, making this more common in older adults. The external sphincter is also thinner and more susceptible to injury in women.

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Proctalgia fugax. Severe, episodic pain around the rectum and anus. This pain usually occurs at night and lasts from a few seconds up to 30 minutes. While the cause is not known, spasms in the muscles around the rectum are generally believed to be involved.

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Levator ani syndrome. Persistent, aching, pressure-oriented pain around the rectum and anus. The pain may be initiated by bowel movements or sitting for long periods of time. It is believed to be caused by spasms in the muscles around the anus.

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Dyschezia. The inability to properly control the muscles in the pelvis and anus, leading to difficulty in defecating. This may be caused by rectal prolapse, rectocele, failure of the sphincters to relax during defecation (anismus) or a disturbance in pelvic muscle coordination (pelvic floor dyssynergia).

Infectious/inflammatory anal & rectal problems Anal and rectal problems may also result from infectious or inflammatory causes. These include:

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Anorectal abscess. An abscess is an enclosed, infected cavity filled with pus. Anorectal abscesses typically develop in the deep mucus glands located in the wall of the anus or rectum. They may occur deep in the rectum or close to the skin around the anus. Abscesses near the skin may be visible as red, tender lumps. Most anorectal abscesses are caused by bacterial infections. Abscesses may eventually form an anorectal fistula, an abnormal channel in the anus or rectum.

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Proctitis. Inflammation of the lining of the rectum (rectal mucosa). This may be chronic or acute. There may be a number of causes, including Crohn's disease and ulcerative colitis. Other causes

include rectal injury, allergies, nerve malfunction, sexually transmitted diseases (e.g., gonorrhea, syphilis, chlamydia, herpes) and bacterial infection (e.g., salmonella). Radiation therapy and antibiotics may cause proctitis by changing the balance of naturally occurring bacteria in the rectum, called the intestinal flora, allowing other bacteria to grow in their place. Patients with weakened immune systems have an increased risk for proctitis.

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Inflammatory bowel disease (IBD). Chronic inflammation of the intestine. These conditions may affect the anus and rectum as well as other parts of the bowel. The primary types of IBD are ulcerative colitis and Crohn’s disease. Ulcerative colitis usually begins in the rectum or sigmoid colon and spreads to other areas of the colon. However, it may affect the rectum alone (ulcerative proctitis). Crohn’s disease and other forms of colitis may also inflame the rectum and colon.

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Anal warts. Cauliflower-like warts may develop on the skin around the anus. These are typically caused by an infection of condylomata acuminata, which is usually transmitted sexually.

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Anal and rectal cancer. Colorectal cancer may affect the anus and rectum. Anal cancers are very rare.

Signs and symptoms of anal & rectal problems While the causes of anal and rectal problems are quite diverse, they may produce very similar symptoms. For instance, anal itching (pruritus ani) is extremely common and affects nearly everyone at some time. Anal itching has numerous causes. Certain foods, such as spices, citrus fruits, coffee or beer, can cause itching. Poor or excessive hygiene can irritate the anus, causing itching. More serious causes include draining fistulas, infections and cancers. In some cases, the cause is not directly related to the anus or rectum. For instance, diabetes and liver disease have been associated with anal itching. Significant changes in bowel consistency or frequency are also common symptoms of anal or rectal problems. For instance, constipation is a common symptom of obstruction and dyschezia. Because the stool cannot pass from the body, it remains in the intestine and becomes hard and dry. This form of constipation is often accompanied by a frequent or constant urge to defecate. Pseudodiarrhea may occur when watery mucus or liquid stool oozes around an obstruction. Anal stenosis may cause bowel movements to be very thin and difficult and may lead to bloating. Loss of appetite, nausea, vomiting and abdominal bloating may also occur when constipation results from an inability to pass stool from the body. However, diarrhea is usually caused by medical issues occurring higher in the intestines rather than the anus or rectum. Mild to severe pain is a common symptom of several anal and rectal problems. Anal fissures often result in severe, tearing or burning pain that begins during a bowel movement and lasts for minutes or hours. Sudden, severe pain during bowel movements may also be a symptom of a foreign object in the rectum or anus. An anorectal abscess may produce severe, continuous, throbbing pain that gets worse when walking or straining during a bowel movement. Other potential causes of anal or rectal pain include hemorrhoids, anorectal fistula, proctitis and fecal impaction. Many anal and rectal problems may cause streaks of blood in the stool or on toilet paper. Bleeding may be painless. Blood in the stool is usually associated with other gastrointestinal problems, such as polyps or peptic ulcers. Anorectal problems that may cause bleeding include hemorrhoids, fissures, proctitis or anorectal varices. These generally result in only small amounts of blood, but anorectal varices may cause massive, life-threatening bleeding. When bleeding is extensive, anemia may result. Any rectal bleeding could also signify more serious problems (e.g., cancer) and require a thorough evaluation by a physician or gastroenterologist. Mucus discharge may occur in some anal and rectal problems such as hemorrhoids or proctitis. Pus discharge may result from other problems (e.g., anorectal fistulas). This discharge may seep through the anus or appear on the side of the stool. Some anal and rectal problems (e.g., hemorrhoids, proctitis) may cause a feeling that the rectum is not completely empty after a bowel movement. A fever may occur with some infectious anal and rectal problems, such as certain forms of proctitis.

Diagnosis methods for anal & rectal problems Although most anal and rectal problems can be diagnosed by a physician, many patients are referred to a gastroenterologist, colorectal surgeon or proctologist. The diagnosis of anal and rectal problems typically involves an evaluation of the patient’s medical history, a physical examination and a series of diagnostic tests. While gathering the patient’s medical history, physicians and gastroenterologists generally ask about symptoms, bowel habits and changes in bowel patterns. They may ask if the patient has had similar symptoms in the past or if he or she has a family member with similar symptoms. Patients may be reluctant to discuss these factors, but need to be open and honest to obtain an accurate diagnosis. The physical examination usually begins with an examination of the anal area. The skin around the anus is examined for any abnormalities. The physician or gastroenterologist will generally test (palpate) for anal reflexes by using light pressure or even tiny pinpricks around the anus. A digital rectal exam is generally performed. A gloved finger is inserted into the rectum to feel for any abnormalities. This may be accompanied by a visual and manual examination of the vagina in women. Imaging tests help diagnose many anal and rectal problems. The most common of these involve a tiny, lighted camera on a thin tube connected to a monitor. An anoscope or proctoscope uses a short, rigid tube to examine just the anus and rectum. A sigmoidoscope uses a longer, flexible tube capable of extending deeper into the colon. These tools are inserted through the anus. While these procedures may be uncomfortable, they are typically not painful. If the anal and rectal area is sensitive due to a condition, anesthesia may be used. Tissue and stool samples may be obtained during these procedures for biopsy.

Other diagnostic tests for anal and rectal problems include: •

Barium enema. A solution containing barium is inserted into the rectum and colon. Barium acts as a contrast medium to allow the internal structures to show up more clearly on an x-ray.

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Endoscopic ultrasonography. An ultrasound probe is inserted into the rectum to generate images of the rectal and anal structures including the sphincter muscles.

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Defecography (proctography). A barium solution is used, followed by an x-ray of the anal and rectal region that is taken while the patient sits on a specially designed toilet. The patient is generally asked to cough, press the buttocks together, defecate and bear down as if trying to defecate. Images can show the muscle movements in the anus and rectum.

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Anal electromyography. The electrical nerve function of the anus is assessed using tiny needle electrodes inserted into the muscles around the anus.

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Anorectal manometry. A test that measures the strength of the anal sphincter muscles and rectal sensation. A short, flexible tube is inserted into the anus and rectum to assess the pressure generated by the muscles at rest and when squeezing.

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Blood and fecal tests. Can be used to identify the presence of infection and rule out other possible causes of symptoms.

Treatment & prevention Most anal and rectal problems can be treated successfully when diagnosed early. Many simple alterations in diet and daily habits can help to both treat and prevent many problems of the anus and rectum. A diet with plenty of fiber and water is important. Fiber and fluids help maintain proper bulk and consistency of stool, reducing the chance of constipation and problems linked to constipation. Soft, consistent stool is also much less likely to irritate the lining of the rectum and anus. Loose, lightweight cotton underwear is better for hygiene purposes. Tight underwear can cause anal itching and irritation. Regular bowel habits may help alleviate or avoid many problems. When feeling a need to have a bowel movement, patients should not wait any longer than is necessary to find a toilet. A bowel movement should not be forced. It is best to allow plenty of time rather than straining. When cleaning the anal area after bowel movements, absorbent cotton or soft, plain toilet or facial tissue may be used to gently dab and wipe. Women should wipe front to back to avoid transmitting bacteria from the anus to the vagina. The cotton or tissue may be moistened with warm water. Aggressive rubbing or the use of harsh, scented tissue can

cause irritation. The anal area should be washed with plain water without soaps. It is best to keep it dry. A small amount of cornstarch or talc may be used to absorb moisture. Many medications may be used to treat anal and rectal problems. Stool softeners or bulking agents are frequently used to combat constipation, although some causes of constipation (e.g., fecal impaction) do not respond well to these. Medicated suppositories and creams may be used to speed healing and ease discomfort, pain and itching. Anal and rectal problems caused by infections (e.g., certain forms of proctitis, anorectal abscess) may be treated with antibiotics. Anti-inflammatory drugs may be used to treat pain and inflammation. A sitz bath is commonly used to treat many anal and rectal problems associated with pain, including hemorrhoids and anal fissure. The patient sits in a bath or special container filled with warm water that covers the hips and abdomen. It eases discomfort and increases blood flow. Anal and rectal problems caused by weakness of the sphincter muscles (e.g., fecal incontinence) may be treated with bowel training and exercise therapies. These help to establish regular bowel movements and improve the strength and tone of the muscles around the anus. The anal muscles are exercised by squeezing and releasing them. Biofeedback may also be used to retrain the anal sphincters and increase rectal sensation. Fecal impaction may be treated with digital fecal removal. This involves using a gloved finger in the anus to remove hardened stool. This and other causes of constipation may also be treated with enemas to clean the stool from the rectum and colon. Many anal and rectal problems can be treated with minor procedures in the office of a physician or gastroenterologist. An injection with Clostridium botulinum toxin may be used to reduce sphincter spasms so that anal fissures may heal. Hemorrhoids may be shrunken using rubber band ligation, in which a tiny rubber band is wrapped around the base of the hemorrhoid to make it shrink. Bleeding caused by hemorrhoids or proctitis, may be stopped using electrocoagulation or laser coagulation. Foreign objects may be grasped and pulled removed. In some cases, a rectal retractor may be used to spread the anal canal wider in order to make it easier to remove a foreign object. If an object cannot be removed by these means, surgery may be necessary. There are many surgeries available for anal and rectal problems. In a number of these, the problem itself is surgically removed (e.g., hemorrhoidectomy to remove hemorrhoids). Abscesses are usually surgically drained. For rectal prolapse, part of the rectum may be removed or the rectum may be stitched to a bone in the pelvis. Alternatively, a wire or plastic loop may be inserted around the anal sphincters to keep the rectum in place. Imperforate anus is treated through surgery to reconstruct the anus. In severe cases of anal and rectal problems, a colostomy may be necessary. Here, the anus may be sealed off and the intestine is diverted to an opening (ostomy) in the abdominal wall. Stool passes through this hole into an ostomy pouch. A colostomy may be permanent, but is often only temporary.

Questions for your doctor Preparing questions in advance can help patients to have more meaningful discussions with their physicians regarding their conditions. Patients may wish to ask their doctor the following anal and rectal problemrelated questions: 1.

What kind of anal or rectal problem do I have?

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Is this problem likely to lead to more serious complications?

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What may be the best treatment for my problem?

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How long will it take to treat my problem?

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What activities should I avoid during treatment?

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When will I be able to resume my normal daily activities?

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Is my particular medical issue hereditary? Should members of my family be screened?

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Are my child’s (or infant’s) bowel habits in the normal range or is there the possibility of a problem?

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How may I prevent this and other anal and rectal problems in the future?

10. Which signs or symptoms should I report to you immediately? 11. Is this problem related to other gastrointestinal problems?