Patient FAQs

Bariatric Surgery

Bariatric surgery is the medical term for weight loss surgery.
The latin root “baros” means “weight”. Bariatric Surgery is surgery for weight. The first barometers (Torricellian) that measured barometric pressure consisted of a container of mercury with an inverted glass tube. As barometric pressure rises, it pushes the pool of mercury higher up the inverted glass tube. The tube had markings to read the barometric pressure. Due to the heavy weight of mercury, higher barometric pressures are required to push the mercury up the tube. Modern barometers (aneroid) use an air-tight box that moves a needle as the box is squeezed by increasing pressure.
In the 1960s, operations for stomach ulcer complications were very common. Acid suppressing medications and the ulcer causing bacteria Helicobacter pylori had not been discovered. Patients suffered pain, bleeding and perforation from gastric (stomach) ulcers. The common operation for ulcer complications were to remove the acid producing section of the stomach and reconnect the remaining stomach to the small intestine. These resections removed the pylorus (stomach valve) and patients then suffered from alkaline reflux gastritis (bile bathing the stomach lining). These patients were miserable, and surgeons needed a solution. A Swiss surgeon, Cesar Roux, first had the idea in the early 1900s to route the bile farther down the GI tract to keep it out of the stomach. He diverted the bile by disconnecting the small intestinal limb containing bile and pancreatic juices and reconnecting it downstream. This intestinal rerouting operation proved to be very successful and surgeons around the world began performing the Roux operation to treat severe alkaline reflux gastritis. The operation became known as the Roux-en-Y operation as the reconfigured intestine formed the letter “Y”. Surgeons were impressed by the Roux-en-Y operation’s success at alleviating symptoms from alkaline reflux gastritis. They were also impressed that the patients struggled to maintain their weight. In 1966, Dr. Edward Mason, a surgeon at the University of Iowa, was the first to offer the Roux-en-Y operation to obese patients for the purpose of weight loss. He also made the stomach smaller for these patients and the operation became known as the gastric bypass. The original operations were performed using an open incision. The first laparoscopic gastric bypass in the United States was performed in 1993 in San Diego, California by Dr. Alan Wittgrove. The VBG (vertical banded gastroplasty) operation was first performed in the US in 1982. The VBG was designed to reduce the high complication rate associated with gastric bypass. VBG involves stapling the stomach into a small upper pouch but the stomach remains connected and there is no intestinal bypass. VBG was commonly called “stomach stapling”. The early results of the VBG were promising but many patients regained weight over time as the staples opened and the stomach regained its normal capacity. The Lap Band was the first adjustable gastric band approved by the FDA in the US in 1995. Adjustable gastric bands are placed around the upper stomach and have an adjustable inner balloon that can squeeze or relax its pressure on the stomach. The band is connected via tubing to an adjusting port under the skin. The band is adjusted by accessing the port with a needle and adding or removing saline to tighten or loosen the band. Gastric banding became very popular in the early 2000s due to its safety and adjustability. It was the first bariatric operation that could be done as an outpatient with significant cost savings compared to hospital-based procedures. The popularity of gastric banding has declined due to long-term device issues and weight regain. The laparoscopic sleeve gastrectomy was first performed in 1988 by Dr. Doug Hess in Bowling Green, OH. The sleeve is performed with surgical staplers by removing about 80% of the stomach leaving behind a smaller banana-shaped stomach. The term suggests that surgeons install a “sleeve” but the term sleeve simply describes the small tube of stomach left behind. The sleeve gastrectomy was first performed as part of a larger malabsorptive operation called the biliopancreatic diversion with duodenal switch. The duodenal switch bypasses large portions of the small intestine, which causes significant weight loss but also has significant potential complications (diarrhea, vitamin deficiencies) due to the extent of malabsorption. Due to the high complication rate of duodenal switch, surgeons began performing the sleeve operation as an initial stage with plans to perform the malabsorptive portion later after patients lose some initial weight. Surgeons were surprised at how much weight sleeve patients lost so they started offering sleeve gastrectomy as a primary weight loss operation. At the time, surgeons thought the sleeve simply had a restrictive effect, made patients full on a smaller portion of food. We now realize that the sleeve operation causes powerful changes in metabolic hormones that help weight loss. The sleeve operation blunts the appetite hormone, ghrelin, after a meal. It also increases the hindgut hormones, peptide YY and GLP-1 after a meal which is very successful at resolving type-2 diabetes. This powerful metabolic effect changed the name of the professional organization ASBS (American Society for Bariatric Surgery) to ASMBS (American Society for Metabolic and Bariatric Surgery). The sleeve operation has rapidly become the most popular weight loss operation in the United States because it has no implanted device like the gastric band and no malabsorption issues like the gastric bypass.
No. The most important thing to know about bariatric surgery is that it is a tool for weight loss. It is a very powerful tool and for many patients, it was the only way for them to achieve and maintain a healthy weight. Most patients say it is the best decision they ever made, and they only wish they had done it sooner. All bariatric operations reduce appetite and make you feel full on a smaller portion of food. All bariatric operations can be defeated by inactivity, drinking calories (sweetened beverages) and eating high calorie foods. The most successful bariatric surgery patients make healthy food choices and are very intentional about burning calories by increasing their activity.
Bariatric surgery will not make you increase activity, but it will make you feel less hungry and feel fuller after smaller portions. It also changes your metabolic hormones making it much easier to lose weight. It allows your body to release stored calories instead of going into famine survival mode. Many studies comparing bariatric surgery with intensive diet and exercise programs repeatedly show that bariatric surgery patients lose significantly more weight and maintain that weight loss over time. By far, bariatric surgery is the most effective treatment for obesity.
This is like saying I have cancer but I’m not going to treat it because its not affecting my life right now. Obese patients die at a younger age. They develop many obesity-related medical problems over time such as, diabetes, high blood pressure, high cholesterol, heart attacks, strokes, higher risk for cancer, joint problems (hips, knees, ankles), headaches, infertility, etc, etc. For many reasons, obesity is an unhealthy state and will have serious consequences if left untreated.
The best way to determine benefits is to call your insurance company. This can get confusing because some patients are told they have coverage, but the call center employee is looking at general coverage and not your specific policy purchased by your employer. Some patients qualify for coverage based upon their BMI but are later told they are not covered because they are only on two blood pressure medications and not three. Each policy has very specific coverage requirements and they can change. Some patients have coverage in December but lose the benefit in January. Bariatric surgery clinics have insurance experts that are familiar with most policies and know the right questions to ask your insurance company to determine true coverage of benefits and then what your policy requires before surgery before they will approve it.
You may have an exclusion on your policy. Most health insurance is purchased by employers and they frequently exclude certain benefits to save money. If your policy excludes bariatric surgery this means your employer paid less for your policy by excluding this benefit when they purchased your health insurance. Asking your insurance company to pay for bariatric surgery when it was excluded is like asking your insurance company to pay for a house fire when you didn’t buy fire insurance. Insurance companies are reluctant to pay for covered benefits, so they are certainly not going to pay for something you did not purchase.
Health insurance coverage of bariatric surgery is unique. They typically have other qualifying criteria such as your BMI (Body Mass Index) and obesity related health problems (co-morbidities). Even if you meet these criteria, most insurance companies require a 6-month physician supervised weight loss program before you can have surgery. Other common policy requirements include smoking cessation, a psychological evaluation, nutrition evaluation and education. The psychological evaluation is to make sure you do not have treatable conditions that could affect your weight loss results such as untreated depression, binge eating, etc. Some patients pay cash for the procedure if they do not have insurance coverage. This saves time without the insurance mandated supervised weight loss plan before surgery, but you still benefit from screening and education before surgery to maximize your weight loss results.

BMI=Body Mass Index. A healthy 6-foot-tall person will weigh much more than a healthy 4-foot-tall person. Therefore, BMI takes height and weight into account and is a better indicator for how unhealthy you are at a given weight. The BMI formula is your weight in kilograms divided by your height in meters squared. Most insurance policies that cover bariatric surgery will approve the surgery if your BMI is greater than 40, or 35 with two weight-related health conditions (diabetes, high blood pressure, etc).

The BMI ranges are as follows:

20-25 Normal weight
25-30 Overweight
30-35 Obesity
35-40 Severe obesity
40+ Morbid obesity

Patients with BMI greater than 40 are high risk for dying at a younger age, hence the term morbid obesity.

Calculate your BMI now.

Some patients with malabsorptive procedures such as gastric bypass or biliopancreatic diversion with duodenal switch have muscle wasting due to severe protein malnutrition. The human body is programmed for survival and very resourceful. If you don’t eat enough protein, the body will get the protein it needs from your muscle mass. Muscle wasting also lowers your metabolism. In a similar scenario, if you don’t get enough calcium in your diet, your body will get the calcium it needs from the bones, but this weakens the bones. Losing muscle mass in you face gives an unhealthy malnourished appearance. You can avoid this by choosing one of the bariatric surgeries without malabsorption like the sleeve gastrectomy. If you have a malabsorptive procedure, you must eat more protein to avoid malnutrition. One of the advantages of the sleeve gastrectomy is that it creates a healthy natural weight loss without muscle wasting. Protein and vitamin absorption are normal after sleeve gastrectomy. Vitamins are absorbed in the first part of the small intestine. After malabsorptive procedures (gastric bypass, BPD) food doesn’t travel through this area, so you must take a lot of vitamin supplements to avoid deficiencies. With sleeve gastrectomy, vitamin and protein absorption are normal.
A third of bariatric patients will have some type of loose skin surgery once they reach their goal weight. The common operations are abdominoplasty (“tummy tuck”), breast lift, breast reduction, breast augmentation, loose skin removal from arms and thighs. The need for loose skin surgery relates to your skin elasticity and how much weight you lose. Skin elasticity declines with age so younger patients require loose skin surgery less than older patients. If a patient goes from 600 to 200 pounds, they will have a lot of loose skin regardless of elasticity. Many young women lose 100 pounds with bariatric surgery and do not require loose skin surgery.
Before surgery, a liquid protein diet is required to reduce the size of your liver which will make your surgery easier and safer. Obesity causes hepatic steatosis (“fatty liver”) and the liver can get so big that surgeons are unable to retract it to operate on your stomach. The preop liquid protein diet will reduce the size of your liver making your surgery easier and safer. Initial weight loss comes from expenditure of stored calories in the liver. After surgery, the liquid diet is to allow the surgery to heal. Staples in the stomach need time to heal for maximum strength. Eating solid food soon after bariatric surgery can lead to leaks which will make you very sick and possibly require further procedures to repair.
Successful weight loss requires work whether you have surgery or not. Bariatric surgery makes weight loss much easier because you are less hungry and you get full on small meals. Weight loss after bariatric surgery is easier but it is not easy. Bariatric surgery is the most effective treatment for obesity. We take antibiotics for infection and blood pressure medications for hypertension because of the effectiveness of those therapies. If you learned of a successful treatment for cancer or diabetes, you would not hesitate to take advantage of that therapy. A highly successful treatment for obesity exists and you shouldn’t hesitate to take advantage of this. Bariatric surgery is not the easy way out; it is the most successful treatment for obesity. Without successful treatment, you are going to die at a younger age and are higher risk for diabetes, cancer, high blood pressure and many other health conditions.
Weight loss after bariatric surgery is a very successful treatment for infertility. Many infertile patients are able to have children after bariatric surgery. Since pregnancy requires good nutrition and vitamins for a healthy baby, it is best to choose procedures without malabsorption like the sleeve gastrectomy if you desire to have children. If a gastric bypass patient gets pregnant, you must watch your vitamin levels very closely with blood work and take extra supplements to prevent birth defects from vitamin malnutrition.
Having bariatric surgery in an accredited center with an experienced high-volume surgeon is much less risky than remaining obese. Most insurance companies will require you to have surgery in an accredited weight loss center because of superior outcomes.

Foregut Surgery

GERD is a medical acronym for Gastroesophageal Reflux Disease. GERD is also commonly referred to as “heartburn” or “reflux”. GERD is when gastric and intestinal contents flow backward up into the esophagus. This causes a burning sensation in the lower chest (heartburn). Patients can also have hoarse voice, bronchitis, aspiration pneumonia, chronic cough, night cough, asthma worsening, sensation of something in the throat, food getting stuck, sinus and dental issues. Some patients will describe gastric contents (or vomit) in the throat when they bend down to pick something up or seeing gastric contents on their pillow in the morning. These issues are related to irritating acid and bile in the throat, windpipe, sinuses and teeth. The esophageal lining is designed for exposure to neutral pH liquids such as saliva and mucous. With GERD, the esophageal lining is exposed to gastric acid and bile which causes irritation and chronic inflammation. This can ultimately lead to esophageal cancer if left untreated for a prolonged period.
A hiatal hernia is an abnormally large opening in the diaphragm muscle (hernia) at the hiatus. This allows the stomach to herniate up into the chest. This allows acid and bile to reflux into the esophagus. The hiatus is the only opening in the diaphragm and is where the esophagus transits from the thoracic cavity to the abdominal cavity. The diaphragm, a large domed muscle for breathing, separates the thoracic (chest) cavity from the abdominal cavity (belly). The word hiatus means “gap”. The esophagus squeezes swallowed food from the mouth into the stomach. The normal size of the hiatus is about the size of a quarter (25 cent coin), just large enough for the esophagus. GERD patients commonly have a hiatus the size of a lemon or bigger. Some patients have significant reflux with a normal sized hiatus.
No. Some patients have a hiatal hernia seen on x-ray or on EGD (stomach scope) but they have no reflux symptoms.
Yes. Some patients have significant GERD without a hiatal hernia.
Most patients with significant GERD have a hiatal hernia but you can still have significant GERD without a hiatal hernia. The body has many ways to keep acid and bile out of the esophagus. We have a lower esophageal sphincter (LES), which is a group of muscle fibers that act like a valve in the lower esophagus. When the hiatus is intact, it helps to keep the stomach and a portion of the esophagus in the abdominal cavity. Normal esophageal motility is a coordinated muscular contraction that squeezes food down from the mouth into the stomach. When part of the lower esophagus is in the abdominal cavity, this also serves as a valve to keep acid and bile from getting into the esophagus. Think of the stomach like a cake decorator’s icing bag. When you squeeze the bag (stomach), icing shoots out the tip (esophagus). As upright mammals, we frequently increase the intra-abdominal pressure each time we strain, cough, laugh, lift or bend over. This squeezes on the stomach like an icing bag which causes acid and bile to shoot up the esophagus like icing out of the tip. Imagine, however, if someone also squeezed the tip of the icing bag, this would prevent icing from shooting out of the tip. An intra-abdominal portion of the lower esophagus works in this way, like someone squeezing on the tip of the icing bag. No icing, no acid. A hiatal hernia allows the esophagus and top of the stomach to herniate up into the thoracic cavity. This reduces our ability to keep irritating acid and bile out of the esophagus.
Some patients with no reflux symptoms are discovered to have evidence of significant GERD during medical tests done for other symptoms. An example would be a patient found to have esophagitis on EGD (stomach scope) performed for another reason. Another example would be a patient having laryngoscopy (scope of the larynx) for hoarseness and is found to have chronic inflammation typical of chronic reflux.
Yes. Some reflux is normal. If you eat a large spicy tomato sauce meal with two glasses of wine and then go straight to bed, you will likely experience some heartburn. This is normal.
Longstanding reflux can chronically irritate the lower esophagus to the point that scar tissue builds causing a stricture (narrowing). Patients will typically complain of swallowing difficulty. EGD (stomach scope) will find the stricture and can dilate this at the same procedure.
PPI = Proton pump inhibitor. PPI’s were a new class of drugs that dramatically decrease acid secretion in the stomach, much more than the medications that preceded them. These medications required a prescription when they were first approved by the FDA but many of them are now OTC (over the counter) medications that can be purchased without a prescription.
Shutting off acid secretion to such a great extent is not how our bodies normally function. As you might imagine, there are consequences to this. PPIs can cause vitamin and electrolyte deficiencies and increase the risk for certain infections. The known consequences are calcium and magnesium vitamin deficiencies from malabsorption, change in normal healthy bacteria in our intestines (the microbiome), multiple hyperplastic polyps in the stomach, hypergastrinemia, diarrhea and increased risk for clostridium difficile colitis and pneumonia. The associated calcium deficiency can affect bone health.
PPI’s don’t stop reflux; they simply increase the pH of the GI (gastrointestinal) contents that are refluxing. PPI’s reduce the impact of the acid that is refluxing but do not address the bile and other irritating GI secretions that are bathing the esophageal lining. The only thing that will stop the abnormal reflux is surgery.
Barrett’s esophagitis is when the lining of the esophagus changes to combat the chronic irritation of acid and bile. Normally, the esophageal mucosa (lining) is squamous cells that can handle neutral pH substances like mucous and saliva. They are not designed to combat acid and bile. Gastric mucosa (stomach lining) consists of columnar cells which are designed to handle acid and bile. In patients with chronic GERD, the squamous cells lining the esophagus can change to columnar cells as a protective mechanism against acid and bile irritation. The medical term for this process is “metaplasia”. The main problem with this is that the shift to new columnar cells can progress to esophageal cancer. If you are found to have Barrett’s esophagus during EGD (stomach scope) biopsy, you will need to have repeated endoscopies done at some interval defined by your doctor. If Barrett’s progresses to cancer, you want to diagnose this early. Barrett’s esophagus gets its name from Norman Barrett, the surgeon who first described this condition. Norman Barrett was an Australian-born British thoracic surgeon.
Dysplastic cells are abnormal cells that can progress to cancer. A known progression to esophageal cancer is when normal esophageal mucosa squamous cells evolve into columnar Barrett’s esophagus, then dysplasia, then cancer cells. Dysplastic progression starts with Barrett’s with no dysplasia, then low grade dysplasia, then high grade dysplasia then cancer. A patient with Barrett’s esophagitis with low grade dysplasia needs to be monitored more closely than a patient with no dysplasia. Closer monitoring involves repeating EGD (stomach scope) at shorter intervals (3 - 6 months vs 12 months).
EGD = esophagogastroduodenoscopy. EGD is also commonly called “stomach scope”. This term describes the organs that it examines: the esophagus (E), the stomach (G for gastric) and the duodenum (D). The duodenum is the first portion of the small intestine beyond the stomach.
The two main types of treatment for GERD are medical and surgical. Medical (non-operative) treatment involves taking an acid-suppressing medication (PPI’s etc) and diet and lifestyle modifications. Examples of lifestyle modifications include: don’t eat before lying flat or bedtime, avoid large meals, avoid wearing tight-fitting garments, avoid foods known to cause reflux such as caffeine, chocolate, peppermint, spearmint, alcohol, spicy foods and avoid smoking. Gravity can help reduce reflux by elevating the head of your bed. Losing weight will help to reduce the higher intra-abdominal pressure associated with obesity. Surgical treatment involves repairing the hiatal hernia and wrapping the upper stomach around the lower esophagus (Nissen fundoplication).
The most common surgical treatment for GERD refractory to medical management is a Nissen fundoplication. This is where the top part of the stomach (fundus) is wrapped completely (360-degrees) around the lower esophagus and stitched to itself (plication). The operation is done laparoscopically or robotically through 5 small incisions. Most patients go home the next day.
Many patients have adequate symptom control with diet and lifestyle modifications and taking acid-suppressing medications. If patients continue to have significant symptoms despite maximal medical therapy, then surgical repair should be considered. Some patients desire to stop taking PPIs due to the serious side effects but their symptoms are too severe off medications so they pursue surgical management in order to discontinue medications.
Obese patients have elevated intra-abdominal pressure. That pressure squeezes on the stomach forcing acid and bile up into the esophagus. Obese patients can have significant GERD without a hiatal hernia. Losing weight can reduce GERD symptoms.
This study measures the number and severity of acid reflux episodes. This is a very objective way to determine if you have abnormal reflux or not and if so, how severe. There are different ways to do this such as passing a small catheter down your nose into your esophagus or having a BRAVO probe placed by EGD (stomach scope) onto the esophageal lining which sends data to an external device, while you record your symptoms to see if they match reflux epidoses. The BRAVO probe eventually falls away from the esophageal lining and is passed in the stool. There is also an impedance test that can measure non-acidic reflux as well.
The esophagus (swallowing tube) has a simple task of getting swallowed food from your mouth to your stomach, but it is a very complex organ. Normal esophageal motility involves a coordinated contraction of esophageal muscle that squeezes the swallowed food in synchrony until the bolus reaches the stomach. Dysmotility is when this process is uncoordinated. Esophageal dysmotility can cause heartburn symptoms that are not related to acid or bile reflux. The manometry test can identify patients whose symptoms are related to esophageal dysmotility and not acid or bile exposure.
Before any surgery, it is important to determine if the potential benefits from the operation outweigh the potential risks. One aspect of this is to make sure you have a condition that will benefit from an operation. Since there are many conditions that can mimic GERD, it is important to determine if your GERD symptoms are caused by acid and/or bile refluxing into your esophagus or from something else. If you have a really large hiatal hernia or a paraesophageal hernia which can lead to strangulation of the stomach then the pH probe may not be necessary, though manometry study is still useful since it determines the type of anti-reflux procedure best suited for each patient. A Nissen fundoplication is highly successful at treating symptoms caused by acid and bile reflux into the esophagus. If a pH probe determines that you do not have acid or bile refluxing into your esophagus, a surgery that treats this is not likely to improve your symptoms. Manometry is important for two reasons. It will determine if your symptoms may be caused by an esophageal dysmotility syndrome and it can also determine if your esophageal motility is strong enough to handle a wrap of the stomach around the lower esophagus. If you perform a full 360-degree Nissen wrap on an esophagus with dysmotility, weak esophageal muscle or uncoordinated muscular contraction, the patient may have severe swallowing difficulties after the procedure. It is important to determine before surgery if the esophagus is strong and coordinated enough to handle a stomach wrap.
10-20% of patients with chronic GERD will develop Barrett’s esophagitis.
Relief from acid and bile reflux after Nissen fundoplication is dramatic and immediate. Nissen patients are some of the happiest patients after surgery. The most common nuisance symptom after Nissen is difficulty swallowing. This is due to edema (swelling) of the esophagus, wrap and hiatal hernia repair making things tighter until the edema resolves. The degree of swallowing difficulty and the time for it to resolve varies widely from one patient to the next. The severity of this symptom depends on the individual patient’s edema reaction to surgery and their inherent esophageal motility. Some patients will develop gas bloat syndrome. Before surgery, swallowed air or carbonation could be easily relieved with a belch. After surgery, this air now must work its way through the GI tract. This can cause symptoms of gas and bloating.
Some patients have weakened or uncoordinated muscle function of the esophagus. The pre-op motility study (manometry) demonstrates that the esophagus will not tolerate a complete 360-degree wrap. In these cases, surgeons may choose to perform a partial wrap. There are several different partial wraps such as Dor or Toupet that encircle the esophagus less than 360 degrees.
Most patients are discharged the same day or the next day. Large hiatal hernia or paraesophageal hernia repair patients are more likely to stay overnight or for a day or two after surgery.
There are no major lifting restrictions after laparoscopic or robotic surgery. Most patients are off pain medications within a few days and back to work within a week.

Gallbladder Surgery

The gallbladder’s function is to add a small amount of stored bile to a meal when it reaches the duodenum (the first part of the small intestine after the stomach). The gallbladder is like a cul-de-sac along the main road of the common bile duct. The common bile duct drains bile made by the liver into the duodenum. The gallbladder is a small branch off the main duct as it courses from the liver to the intestine.

A common myth is that the gallbladder stores all bile made by the liver, but it only stores a small amount.  The liver is the largest internal organ in the body and makes about 35 ounces of bile per day (about one liter - half of a 2-liter soda bottle).  The gallbladder only holds 1-2 ounces of fluid.  The most common cause of gallbladder disease is inflammation due to gallstones.  When the gallbladder is diseased, it no longer functions as a temporary storage for a small amount of extra bile.  When the gallbladder goes bad, the bile made by the liver simply bypasses the diseased gallbladder and flows into the duodenum throughout the day.  This is the same bile flow after the gallbladder is removed.  Many people do not realize that removing a diseased, non-functioning gallbladder does not change bile flow.  This change has already occurred as an inflamed gallbladder loses function.  If a neighborhood cul-de-sac was obstructed with cars (gallstones), you would continue driving on the main road (common bile duct).

Bile helps break down fats into fatty acids to aid digestion and absorption.  The same amount of bile is available after gallbladder removal surgery as before.

After the gallbladder is removed, bile made by the liver still flows normally down the main bile duct (common bile duct) into the duodenum (first part of the small intestine after the stomach). The only difference is that after gallbladder removal, it no longer stores a small amount of bile to add to a meal. You still have normal digestion and absorption after gallbladder removal.
The gallbladder is about the size of a small pear.
Imbalances in the chemical composition of bile causes precipitation crystals which grow gallstones within the gallbladder. Sludge or gritty, sandy bile can also form via the same process and causes the same problems as gallstones. The bile system is composed of small ducts designed to handle liquid. Stones or sludge debris can cause obstruction and inflammation of the gallbladder and bile ducts. Hormonal changes affect the chemical balance of bile and therefore gallstones are more common in women. Weight gain and rapid weight loss change bile composition as well.
The main thing you can do to reduce the risk of getting gallstones is to avoid serious weight gain followed by rapid weight loss.

Gallstones can cause serious problems if they become lodged and block the bile ducts. Gallstones can obstruct the gallbladder duct, the main bile duct or the opening into the duodenum that causes increased back pressure into the pancreatic duct. Gallbladder removal is recommended once gallstone patients develop symptoms. These symptoms are warning signs that you are headed for serious problems if left untreated. Typical symptoms include abdominal pain, bloating, nausea and vomiting. Gallbladder symptoms typically get worse with meals, especially greasy or fried foods. These symptoms are warning signs that you are headed for serious complications caused by the gallstones. The three main potential health risks of gallstones include cholecystitis, choledocholithiasis or gallstone pancreatitis.

Cholecystitis (inflammation of the gallbladder) occurs when a gallstone is lodged in the cystic duct (duct connecting the gallbladder to the common bile duct).  This can lead to infection in the gallbladder and become severe if not treated.  When gallstones migrate out of the cystic duct and become lodged in the common bile duct, this is called choledocholithiasis (gallstones in the main bile duct).  Since the common bile duct drains bile made in the liver into the intestine, a stone lodged here can cause jaundice (yellow skin color), light colored stool since bile is not mixing with the foods we eat and/or cholangitis (bacterial infection in the bile duct).  These can cause severe illness if not promptly treated.  If a common bile duct stone gets lodged in the sphincter of Oddi (bile duct valve leading into the small intestine), this causes back pressure in the pancreatic duct causing gallstone pancreatitis.  The common bile duct and pancreatic duct share an opening into the duodenum (first part of the small intestine beyond the stomach).  Gallstone pancreatitis can become severe if not promptly treated. The pancreatic tissues designed to digest protein in your intestines seep into your own tissues and essentially digest them. This can be a life threatening life changing event.     

If a patient has gallstones but no related symptoms, generally, you can observe for symptoms to develop.  The exception to this is if you have diabetes.  Diabetic patients have decreased sensation of sensory nerves.  This can lead to a “silent MI”, a heart attack without typical symptoms or a diabetic patient can step on a thumbtack unaware due to the decreased sensation in their feet and get a severe infection of their foot that can lead to amputation even in this day and age.  Similarly, diabetic patients can develop severe cholecystitis without typical symptoms.  This can lead to complications by waiting until the inflammation becomes severe.  Therefore, patients with gallstones and diabetes should consider gallbladder removal to prevent complications due to severe gallbladder disease. 

This would be like trying to salvage the appendix in appendicitis.  Like the appendix, when serious inflammation or infection affect the gallbladder, it will never function normally and needs to come out.  Once appendix and gallbladder tissue reach this degree of inflammation, they need to be removed to avoid serious complications.  At this point the organs have no function and may create a serious problem if left untreated.

Yes.  Some patients have classic symptoms of cholecystitis (inflammation of the gallbladder) with no gallstones on ultrasound.  In these cases, a HIDA scan (gallbladder function study) can diagnose acalculous cholecystitis (gallbladder inflammation without stones).  The HIDA scan is a nuclear medicine study where a radiotracer that is excreted in the bile is injected through an IV (intravenous) catheter.  As this tracer works its way through, the scan will highlight the liver, the bile duct, and the gallbladder.  Then, an IV medication (CCK-cholecystokinin) is administered that causes the gallbladder to contract or empty.  If the HIDA scan is completely normal, generally, the patient’s symptoms are not caused by the gallbladder.  There are several findings on the HIDA scan that may indicate the need for gallbladder removal.  1.) If the gallbladder does not appear on the scan (non-visualization), this is consistent with cholecystitis.  2.) If the ejection fraction after CCK administration is less than 35%, this is consistent with acalculous cholecystitis.  3.) If the CCK administration causes the same symptoms the patient has been having, this strongly suggests that gallbladder inflammation is causing the patients symptoms and correlates with symptom resolution after cholecystectomy (gallbladder removal).  This is true even if the ejection fraction was normal.    

The classic symptoms of gallbladder disease include nausea and attacks of pain in the right upper abdomen that radiates around to the back, usually between the shoulder blades. Vomiting can occur with severe attacks. These symptoms are worse with eating, especially greasy or fried foods. High fat and high protein meals maximally stimulate the gallbladder to empty. Commonly, patients will have attacks of pain that occur a couple of hours after dinner. It is also common to have vague symptoms. Some patients have right sided scapular (shoulder blade) pain. Some patients have heartburn as their main symptom. Some patients say they have a “sensitive” stomach and certain foods do not agree with them. Some patients have excruciating chest pain and race to the emergency room thinking they are having a heart attack. Their cardiac workup is normal, and they then learn they have gallstones as the cause of their symptoms.
Endoscopic Retrograde Cholangiopancreatography. The word endoscopic describes the procedure done with a flexible scope that is passed down through the mouth into the small intestine to access the bile duct opening. The term retrograde is used because the scope can look sideways to find the duct opening. Cholangiopancreatography is a fancy way to say that dye is injected to x-ray the bile and pancreatic ducts. ERCP procedures can diagnose gallstones in the common bile duct and remove them. A sphincterotomy describes cutting of the sphincter muscle during ERCP to facilitate stone removal.

Yes.  Gallbladder perforation is rare, but it can happen.  You typically see this in patients who wait too long before seeking medical care for their symptoms.     

Yes.  Gallbladder cancer is rare, but it does happen.  The gallbladder is always sent to the pathology lab after surgery and examined microscopically for malignant cells.  If cancer cells are found in the gallbladder, this typically requires resection of the gallbladder liver bed and adjacent lymph nodes.    

In general, gallbladder polyps less than 1cm in size can be followed with repeat ultrasound in 6-12 months to monitor for size increase.  If a polyp grows rapidly on repeat ultrasound or grows larger than 1cm, the gallbladder should be removed so that it can be sent to the lab for microscopic testing.  Polyps greater than 1 cm in size are more likely to be malignant (cancerous) and should be removed.  If a patient has biliary symptoms (attacks of pain, nausea, vomiting with eating), the gallbladder should be removed regardless of polyp size.  In this case, the “polyp” seen on ultrasound is more likely to be a stone.  If the ultrasound sees a movable density in the gallbladder, it is likely a gallstone.  If the density does not move, it is more likely to be a polyp.  Many “polyps” on ultrasound are stones that are adherent to the gallbladder wall and do not move.  If a patient has gallbladder polyps and biliary symptoms, the gallbladder needs to be removed.  The microscopic examination of the gallbladder after surgery will then determine if the polyps are benign or malignant.       

Gallbladder removal surgery (cholecystectomy) is performed using minimally invasive surgery, also called laparoscopic surgery or robotic-assisted laparoscopy.  This involves 4 small incisions and is usually done as an outpatient procedure (home the same day).  Until the 1990s, gallbladder removal was done through a large open incision and patients spent a few days in the hospital. 

Diseased gallbladders that require removal are not working normally.  These gallbladders are typically full of stone and sludge debris and chronically inflamed.  They are not functioning normally to add a small amount of bile to a meal.  As gallbladder disease progresses, bile simply flows from the liver to the small intestine ignoring the gallbladder.  In many diseased gallbladders the cystic duct (gallbladder duct) is completely blocked with stones, sludge, or scar from chronic inflammation.  Many patients with diseased gallbladders have not had normal gallbladder function for years.  They ask how they can live without a gallbladder not realizing they have not had normal bile storage function for a long time.  A diseased gallbladder will reach the point where it is not providing any function other than pain, nausea, vomiting and the risk for cholecystitis, cholangitis, or gallstone pancreatitis, all of which can make you much sicker.    

Most patient do not have diarrhea after gallbladder surgery because they had no gallbladder function long before it was removed.  The body has already adapted.  Even when the gallbladder is normal and healthy, most of the bile produced by the liver drains into the duodenum (small intestine after the stomach) throughout the day.  The gallbladder holds a small amount of bile that it adds to a meal but plenty of bile is always available for digestion.  There are many causes for diarrhea after surgery (antibiotics, etc) but it is commonly blamed on gallbladder removal.  Some patients do get diarrhea after gallbladder removal that is related to the new bile flow.  This typically improves over time as the body adapts.  Most patients have already adapted to this long before removal as the gallbladder’s function declined over time.        

You can pass gallstones out of the gallbladder into the main bile duct, but they can cause severe problems with blockage of the bile or pancreatic ducts.  The difference with kidney stones is that once kidney stones pass, they generally do not cause further problems.   

Through the years there have been many attempts at dissolving gallstones, “flushing” the gallbladder, breaking them apart with different energy sources, pulling them out of the gallbladder with endoscopy, etc.  The reason these methods do not work is that they leave the diseased gallbladder behind and the stone formation and symptoms will continue.  This would be like trying to save the appendix in appendicitis.  Once the appendix and gallbladder go bad, the best treatment is removal of the diseased organ.   

Most patients go home the same day (outpatient) and are off pain medications within a few days. 

The lifting restriction in 15 lbs. in each hand and no core exercises.  You should take it easy for a few days to reduce pain.  Patients are typically back to work within 3-7 days for office type jobs, 7-10 days for light duty jobs and 4-6 weeks for high intensity physical work. 

Hernia Surgery

A hernia is a hole in a muscle through which intestines can herniate.  

An inguinal hernia (groin hernia) is where the intestines can herniate through a hole in the muscle of the inguinal region (groin). 

An incarcerated hernia is when the intestine herniates through the hole in the muscle and is unable to be reduced.  This can be caused by edema (swelling) of the intestine due to irritation such that the intestine is too large to retract back through the hole in the muscle. 

Edema from an incarcerated hernia can get so severe that the blood supply to the intestine is cut off as it swells inside the fixed ring of the hole in the muscle.  This acts like a tourniquet and leads to intestinal necrosis (the intestine tissue dies) which can perforate.  This can be life-threatening.  Avoiding strangulation is the main reason to repair inguinal hernias. 

Direct, indirect and femoral.  These are the three potential spaces that can herniate in the groin.   

Indirect inguinal hernias are present at birth. When children have an inguinal hernia repair at a young age, this is for an indirect inguinal hernia.  The indirect inguinal hernia sac is a remnant of a process called testicular migration.  As a male fetus develops before birth, the testicles migrate from just beneath the kidneys to the scrotal sac.  The purpose of this migration is that sperm cannot survive at body temperature.  The testicles drag the abdominal cavity lining with them (processus vaginalis) and this defect is supposed to close once migration is complete.  An inguinal hernia sac results from incomplete closure of the inguinal canal after migration.  The embryologic medical term for this is called “patent processus vaginalis”.  Even though indirect inguinal hernias are present at birth, if the hernia defect is small, the intestines won’t herniate and it could take many years to cause symptoms.  Over time, as we increase intra-abdominal pressure with lifting, coughing and straining, the small hernia gradually dilates until the intestines enter the inguinal canal through the hernia sac and the patient will notice a bulge and/or discomfort in the groin.  Indirect inguinal hernias are the most common hernia type in men and women.     

Direct inguinal hernias are acquired from tearing of the abdominal wall fascial and muscle due to heavy lifting or repetitive straining.  Chronic coughing can contribute to direct inguinal hernia formation due to the repetitive strain on the inguinal muscles. 

Femoral hernias occur when the intestines try to follow the blood vessels (femoral artery and vein) from the groin into the leg.  Whereas femoral hernias are more common in women than men, indirect inguinal hernias are still the most common inguinal hernia in women.   

  Indirect inguinal hernias are present at birth but the hole in the muscle grows larger over time so lifting can cause them to have symptoms at a younger age.  Direct inguinal hernias are due to heavy lifting or chronic straining and wear and tear of the abdominal wall.  Femoral hernias are a weakness in the femoral canal that can develop over time. 

Yes, but they are much less common than in men.  Femoral hernias are more common in women but the most common inguinal hernia in women is indirect.  

The main reason to surgically repair inguinal hernias is to avoid complications from herniation of the intestine such as incarceration and strangulation, as well as manage the pain and discomfort that hernias can cause.

Mesh is used commonly in inguinal hernia repairs to reduce the chance for recurrence.  The invention of mesh has drastically reduced the risk for recurrence. It has been used to reinforce hernia repairs for over 40 years. As the mesh heals, scar tissue embeds in the weave of the mesh which results in a repair that is stronger than our native tissue.  With proper technique, mesh can be used without causing chronic pain.  Non-mesh repairs can be done but they have a higher recurrence rate.  There are improper techniques that can cause chronic pain after mesh repairs but this is mostly avoidable with proper techniques.     

Open inguinal hernia repairs will heal to about 80% of maximum strength at 4 weeks.  This is the reason to avoid lifting over 15 pounds for 4 to 6 weeks.  Many people return to light duty work such as desk work after one week or less. For laparoscopic repairs, recreational lifting can start at 2 weeks post operatively, awkward heavy lifting can start after 4-6 weeks, with no restrictions on walking or lifting up to 15 pounds immediately after surgery.

It takes about six weeks for an inguinal hernia repair to reach maximum strength.  Heavy lifting or overdoing it can cause the hernia repair to rip apart and cause a sudden recurrence or heal weaker and then recur later. 

Laparoscopic surgery is done through several small incisions instead of one larger incision.  The benefits of laparoscopic repair include, small scars, less pain, quicker recovery and the mesh is placed on the inside of the muscle which is a stronger repair and covers all 3 potential hernia spaces (direct, indirect and femoral).  Bilateral repair (fixing both left and right sides) can be done through the same 3 small incisions.  An open repair would require two larger groin incisions to fix both sides at the same operation and has a higher chance of causing chronic groin pain, though this is a rare event. Open repairs can be safer in a patient that needs to avoid general anesthesia or a patient is on certain blood thinners or blood thinners that cannot be stopped safely before and after surgery.

The two main ways to reduce recurrence after inguinal hernia repair is to avoid lifting over 15 pounds for 4- 6 weeks and to use mesh in the repair. Once the mesh scars in, the repair is stronger than our own tissue. 

Many things can mimic an inguinal hernia. An experienced surgeon is invaluable to determine if a patient’s symptoms are due to a hernia that needs repair. Surgeons evaluate many patients with groin pain or bulge and find there is no hernia that needs surgical repair. Muscle, fascia and tendon inflammation or tears from overuse can mimic the symptoms of a hernia. Enlarged lymph nodes, skin cysts or benign fatty tumors can cause a bulge in the groin that mimics an inguinal hernia. An evaluation from an experienced hernia surgeon can determine if your symptoms are due to a hernia that needs surgical repair or something else that may need additional evaluation.

The biggest thing to worry about is strangulation where the herniated intestines swell to the point of cutting off the blood supply. This causes the intestines to die and rupture which can be life threatening.  Several studies have been done where men with proven inguinal hernias are randomized to surgical repair versus no surgery. Typically, within two years most of the men in the non-surgical group crossover and have the hernia repaired due to increasing symptoms. It is also better to repair hernias when they are small instead of waiting for the muscle defect to be so large and chronically inflamed that you increase potential complications from surgery.

The bottom line is, if you are healthy and an inguinal hernia is impacting your lifestyle, you should get it repaired.   

 

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