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Albumin: This major protein constituent of blood is often given to individuals who need to retain more fluid in their bloodstream, such as burn victims or patients with liver failure or extremely heavy bleeding (hemorrhage). Albumin (along with clotting factors, growth factors, and immunoglobulins) is sometimes referred to as a minor blood fraction. If you are a Jehovah's Witness, whether or not you can accept treatment with a minor blood fraction may be considered an individual "matter of conscience."

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Allogeneic blood: Blood donated from another individual, which is typically stored and then provided through a transfusion. Jehovah's Witnesses do not accept allogenic blood.

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Anemia: A condition in which an individual's blood can't supply an appropriate amount of oxygen to their organs and tissues, either due to a low volume of blood, too few red blood cells in the blood, or too little hemoglobin or iron in the red blood cells. Patients who are suffering from severe anemia are sometimes more difficult to manage, unless they are treated by a team that is very experienced in transfusion-free medicine.

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Apheresis: A process used to obtain blood components (such as platelets) from a donor. The blood is removed from the donor, the necessary cells are harvested and retained, and the donor's plasma is returned to the donor. Donated platelets are considered a major blood fraction and are not acceptable to Jehovah's Witnesses. However, "therapeutic apheresis" may be acceptable to some Jehovah's Witnesses because it is a treatment performed on the patient's own blood.

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Blood banking: This is when blood is donated by a person for their own use or a specific individual's use at a later time. It is usually done because of fear that donor blood will not be available or might have contaminants, or because the person has a rare blood type. This procedure is not "bloodless medicine" because it involves blood storage and blood transfusions.

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Blood salvage: Blood salvage procedures collect blood lost during or after surgery. A variety of methods may be used to collect blood, including suction and drainage devices. The devices that are used are sometimes called "cell savers." Those who object to blood transfusions may feel comfortable with "closed loop" blood salvage, where the blood is never stored and retains a semblance of connection to the patient at all times.

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Cautery: Deliberate surgical destruction of tissue, either because the tissue is abnormal or to seal off a bleeding area. Cautery is a method of reducing bleeding during transfusion-free surgery. It may be achieved through heat, freezing, chemical scarring, electricity, light, and ultrasonic or microwave energy.

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Cell savers: Devices that capture and hold blood during or after surgery, so that the blood can be returned to the patient.

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Clotting: The complex chain of chemical events that produces a plug (clot) at the site of bleeding. It is important for a patient undergoing transfusion-free surgery to have good clotting ability, in order to reduce bleeding/blood loss. Certain medications may interfere with clotting, such as aspirin, ibuprofen, and other nonsteroidal anti-inflammatory drugs; anticoagulants (such as Coumadin); vitamin E; and herbal preparations containing garlic or ginkgo biloba.

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Clotting factors: Chemicals that circulate in the blood and interact together to help cause blood clotting at the site of an injury.

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Coagulation: The conversion of liquid (blood) into a somewhat solid plug that can prevent further bleeding from a particular site.

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Colloidal solutions: Intravenous fluid solutions that contain water, salts, sugars, and protein. They may be given to replace the fluids, salts, and sugars that you will invariably lose during the course of surgery. Some colloidal solutions contain albumin -- a protein whose use is a matter of personal conscience for Jehovah's Witnesses.

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Cryosurgery: A surgical technique that uses extreme cold to destroy abnormal tissues in the body. It is sometimes used as a bloodless medicine technique -- by freezing tissue, bleeding is minimized.

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Crystalloid solutions: Intravenous fluid solutions that contain water, salts, and sugars. They may be given to replace the fluids, salts, and sugars that you will invariably lose during the course of surgery. Jehovah's Witnesses find cystalloid solutions such as Ringer's lactate and normal and hypertonic saline acceptable therapy.

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Donor: A person who gives blood. The donated blood may be stored and distributed to hospitals and medical centers to be given to a patient when needed (as a transfusion). When a patient receives whole blood in this way, this is considered traditional medicine -- NOT "bloodless medicine." However, donated blood may be used to harvest blood components that may be used during some bloodless procedures.

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Embolotherapy: Refers to various methods of blocking a bleeding blood vessel, preventing further blood loss. These include chemical agents that scar the inside of the blood vessel; mechanical agents that block a bleeding vessel, including metal coils and latex or silicone balloons; particles or microspheres, including gelatin foam; and injected liquid that quickly turns into a thicker gel-like or spongy mass to prevent bleeding from a vessel.

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Endoscopy: A scope that can be used to visualize the inside of the body, either through insertion into a tiny incision or by passing the scope through a body opening (such as the mouth or anus). Endoscopy is used to examine, biopsy, or surgically treat a variety of conditions. Types of endoscopy include arthroscopy (joints); bronchoscopy (bronchial tubes, lungs); colonoscopy/sigmoidoscopy (large intestine); colposcopy (vagina, cervix); gastroscopy (stomach, small intestine); laparoscopy (abdomen); and others. Endoscopy is considered a "minimally invasive" procedure, which results in reduced bleeding. It is therefore a valuable bloodless medicine technique.

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Erythropoietin: Erythropoietin is the name of a chemical normally produced by your body, primarily by your kidneys. Erythropoietin stimulates the bone marrow to produce red blood cells. Laboratory-made synthetic erythropoietin (e.g., Procrit, Epoetin alfa, Epogen, or Aranesp) may be administered prior to a bloodless surgery procedure in order to maximize your bone marrow's production of red blood cells. Other synthetic chemicals that mimic the activity of erythropoietin are in development.

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Fibrin glue: A substance made from human clotting factors. These clotting factors can be harvested from donor blood plasma or from a patient's own blood plasma. Fibrin glue can be applied to a bleeding vessel. It both blocks the vessel from bleeding and activates normal clotting/coagulation activity. Because fibrin glue is made from blood products, each individual will need to examine their own conscience to decide if its use is personally acceptable.

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Fluid expanders: Intravenous fluid solutions that are used to increase the volume of fluid in the circulating blood. The result is that when you bleed during surgery, your diluted blood contains a lower concentration of red blood cells.

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Gamma knife: A high-tech surgical tool that can be used for brain surgery. This technique utilizes a powerful and precise form of radiation to destroy tumors or abnormal blood vessels with less blood loss than a traditional scalpel.

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Harmonic scalpel: A surgical tool that uses ultrasound waves to cut tissue and seal bleeding vessels at the same time -- a helpful characteristic in transfusion-free surgery, because it helps keep blood loss to a minimum.

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Hemodilution: The process of making blood more dilute than normal. The result is that when you bleed during surgery, your diluted blood contains a lower concentration of red blood cells.

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Hemoglobin: A chemical within red blood cells that allows oxygen to be carried throughout the body.

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Hemophilia: A disease in which the blood clotting system is defective, resulting in an increased likelihood of serious bleeding after even minor injury.

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Hemorrhage: Heavy bleeding.

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Hemostasis: To stop bleeding.

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Hyperbaric: To be at higher-than-normal atmospheric pressure. Hyperbaric oxygen therapy is used in some facilities to assist bloodless medicine in certain situations. You enter a chamber and breathe pressurized oxygen, which concentrates oxygen in your blood.

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Hyperoxic: Having higher-than-normal oxygen saturation.

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Hypotensive: Having low blood pressure. Hypotensive anesthesia is a technique that lowers a patient's blood pressure below normal during surgery. Blood loss tends to be slower when your blood pressure is low. However, blood pressure must be maintained at a particular threshold to ensure that all of your body's organs and tissues are receiving blood, so the practice of hypotensive anesthesia requires great skill and extraordinarily careful monitoring.

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Intraoperative: During the course of an operation.

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Iron: A nutrient that is required by your red blood cells for good oxygen-carrying capacity. Iron is important for bloodless surgery and can be obtained from dietary sources like red meat or through supplements, such as ferrous sulfate or ferrous gluconate.

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Kidney dialysis: A procedure in which the blood is cleansed of toxins through an outside machine, replacing work that the kidneys normally do.

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Laparoscopy: A surgical technique in which a lighted scope is inserted into a tiny incision in the abdomen. Laparoscopy can be used to visualize the inside of the abdomen for diagnosis, to retrieve tissue samples for biopsy, and to perform surgery using tiny instruments that are also passed into the abdomen through tiny "keyhole" incisions. Laparoscopy is considered a "minimally invasive" procedure, which results in reduced bleeding and may therefore be valuable for bloodless treatment of some conditions.

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Laser surgery: A surgical technique that uses the energy from light to cut through tissues. It can reduce bleeding compared to traditional scalpels and may therefore be valuable for bloodless treatment of some conditions.

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Major fractions: Blood products containing plasma, red blood cells, white blood cells, and platelets. Jehovah's Witnesses do not accept major blood fractions as part of any treatment.

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Mediastinal autotransfusion: A procedure performed most commonly after heart surgery, in which the fluids (including blood) that collect in the chest during and after surgery are collected and then given back to the patient through an IV.

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Minimally invasive surgery: Procedures that use small surgical cuts and holes, or no cuts at all. These methods can greatly reduce the amount of bleeding and are therefore of great importance to bloodless medicine. An example is endoscopy, which uses scopes inserted into small cuts or body openings. Another example is lithotripsy, which uses sound waves to break up a kidney or other stone into smaller bits, allowing it to pass out of the urinary system without having created any incision at all.

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Minor fractions: Blood products containing clotting factors, albumin, growth factors, and immunoglobulins. Some Jehovah's Witnesses accept minor blood fractions as an individual "matter of conscience."

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Normothermia: Normal body temperature.

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Normovolemia: All people maintain a particular volume of fluid circulating throughout their bodies; this is referred to as "normovolemia." During surgery, you will be given balanced intravenous solutions (volume expanders) to replace the fluids, salts, and sugars that you will invariably lose during the course of surgery.

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Oximeter: A device that monitors the amount of oxygen carried by the hemoglobin in red blood cells. In bloodless medicine, any blood a patient loses is not replaced by transfusion, so it is extremely important to monitor how much oxygen the patient's body is receiving from the remaining blood.

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Plasma: The fluid component of blood, in which the various types of blood cells are suspended. Jehovah's Witnesses consider plasma to be a major blood fraction and do not consider it to be an acceptable part of treatment.

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Plasmapheresis: A type of apheresis that is used to separate plasma from blood. Blood is removed from a donor, the plasma is harvested and retained, and the donor's blood cells are returned to him or her. Plasmapheresis may also be performed on a patient's own blood as a treatment for certain conditions.

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Platelet: A component of blood responsible for blood clotting at the point of an injury to a blood vessel. Without platelets, our blood would not be able to clot and hemorrhaging or uncontrolled bleeding would result. Platelets are considered a major blood fraction and are not acceptable to Jehovah's Witnesses as part of any treatment.

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Platelet gel: A concentrate made from a patient's own blood plasma, mixed with calcium and clotting compounds produced in cows. Platelet gel concentrates can be applied during the course of surgery to control bleeding. As with fibrin glue, platelet gel concentrates are produced from plasma, so their use by some individuals is a matter of conscience.

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Primary blood components: Red cells, white cells, plasma, and platelets (also called major fractions). Jehovah's Witnesses do not accept primary blood components (major fractions) as part of any treatment.

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Procuren solution: A solution made from an individual's own blood. The growth factors in the patient's own platelets are harvested, and reproduced in a laboratory to create the procuren solution. This solution is then applied to a wound to improve healing capacity and shorten duration of healing.

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RBC nuclear scan: A test in which the individual's own red blood cells are harvested, tagged with radioactive material, and then returned to the individual. Imaging scans are then performed that will highlight areas of bleeding, because the tagged red blood cells will be seen leaking from these areas.

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Scalpel: Originally, a scalpel was a very sharp, small knife used to perform surgery. Now a scalpel can use a variety of energy sources to cut through tissue, including light (laser scalpel), microwaves (microwave-coagulating scalpel), ultrasonic energy (ultrasonic and harmonic scalpels), and radiation (gamma knife).

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Stereotactic/Stereotaxic: A technique for locating the exact area needing treatment by using advanced imaging techniques that verify the three-dimensional coordinates of the abnormal area. By pinpointing the exact area, the surgeon can minimize the amount of cutting (and hence bleeding) that occurs during surgery.

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Transfusion: The delivery of blood products to an individual to replace blood that is lost during surgery or from injury. The blood or blood products are usually donated anonymously or through blood banking, then stored until the time they are needed. At that point, the blood products are administered through an intravenous (IV) line into a patient's vein. A blood transfusion is what bloodless medicine seeks to avoid.

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Ventilation: To provide a patient with oxygen.

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WBC nuclear scan: A test in which an individual's own white blood cells are harvested, tagged with radioactive material, and then returned to the individual. Imaging scans are then performed that will highlight areas of infection, because the tagged white blood cells will migrate to these areas.

Severe obesity is a chronic condition that is difficult to treat through diet and exercise alone. Gastrointestinal surgery is a good option for people who are severely obese and cannot lose weight by traditional means or who suffer from serious obesity-related health problems. The surgery promotes weight loss by restricting food intake and, in some operations, interrupting the digestive process. As in other treatments for obesity, the best results are achieved with healthy eating behaviors and regular physical activity.

People who may consider gastrointestinal surgery include those with a body mass index (BMI) above 40 -- about 100 pounds overweight for men and 80 pounds for women (see our BMI chart). People with a BMI between 35 and 40 who suffer from type 2 diabetes or life-threatening cardiopulmonary problems, such as severe sleep apnea or obesity-related heart disease, may also be candidates for surgery.

The concept of gastrointestinal surgery to control obesity grew out of results of operations for cancer or severe ulcers that removed large portions of the stomach or small intestine. Because patients undergoing these procedures tended to lose weight after surgery, some physicians began to use such operations to treat severe obesity.

The first operation that was widely used for severe obesity was the intestinal bypass. This operation, first used 40 years ago, produced weight loss by causing malabsorption. The idea was that patients could eat large amounts of food, which would be poorly digested or passed along too fast for the body to absorb many calories. The problem with this surgery was that it caused a loss of essential nutrients and its side effects were unpredictable and sometimes fatal. The original form of the intestinal bypass operation is no longer used.

How does surgery promote weight loss?

Gastrointestinal surgery for obesity, also called bariatric surgery, alters the digestive process. The operations promote weight loss by closing off parts of the stomach to make it smaller. Operations that only reduce stomach size are known as restrictive operations because they restrict the amount of food the stomach can hold.

Some operations combine stomach restriction with a partial bypass of the small intestine. These procedures create a direct connection from the stomach to the lower segment of the small intestine, literally bypassing portions of the digestive tract that absorb calories and nutrients. These are known as malabsorptive operations.

There are several types of restrictive and malabsorptive operations. Each one carries its own benefits and risks.

Restrictive operations

Restrictive operations serve only to restrict food intake and do not interfere with the normal digestive process. To perform the surgery, doctors create a small pouch at the top of the stomach where food enters from the esophagus. Initially, the pouch holds about 1 ounce of food and later expands to 2 - 3 ounces. The lower outlet of the pouch usually has a diameter of only about 0.75". This small outlet delays the emptying of food from the pouch and causes a feeling of fullness.

As a result of this surgery, most people lose the ability to eat large amounts of food at one time. After an operation, the person usually can eat only 0.75 to 1 cup of food without discomfort or nausea. Also, food has to be chewed well.

Restrictive operations for obesity include adjustable gastric banding (AGB) and vertical banded gastroplasty (VBG).

Adjustable gastric banding

In this procedure, a hollow band made of special material is placed around the stomach near its upper end, creating a small pouch and a narrow passage into the larger remainder of the stomach. The band is then inflated with a salt solution. It can be tightened or loosened over time to change the size of the passage by increasing or decreasing the amount of salt solution.

Vertical banded gastroplasty

VBG has been the most common restrictive operation for weight control. Both a band and staples are used to create a small stomach pouch.

Although restrictive operations lead to weight loss in almost all patients, they are less successful than malabsorptive operations in achieving substantial, long-term weight loss. About 30 percent of those who undergo VBG achieve normal weight, and about 80 percent achieve some degree of weight loss. Some patients regain weight. Others are unable to adjust their eating habits and fail to lose the desired weight. Successful results depend on a patient's willingness to adopt a long-term plan of healthy eating and regular physical activity.

A common risk of restrictive operations is vomiting, which is caused when the small stomach is overly stretched by food particles that have not been chewed well. Band slippage and saline leakage have been reported after adjustable gastric banding. Risks of VBG include wearing away of the band and breakdown of the staple line. In a small number of cases, stomach juices may leak into the abdomen, requiring an emergency operation. In less than 1 percent of all cases, infection or death from complications may occur.

Malabsorptive operations

Malabsorptive operations are the most common gastrointestinal surgeries for weight loss. They restrict both food intake and the amount of calories and nutrients the body absorbs.

Roux-en-Y gastric bypass (RGB)

This operation is the most common and successful malabsorptive surgery. First, a small stomach pouch is created to restrict food intake. Next, a Y-shaped section of the small intestine is attached to the pouch to allow food to bypass the lower stomach, the duodenum (the first segment of the small intestine), and the first portion of the jejunum (the second segment of the small intestine). This bypass reduces the amount of calories and nutrients the body absorbs.

Biliopancreatic diversion (BPD)

In this more complicated malabsorptive operation, portions of the stomach are removed. The small pouch that remains is connected directly to the final segment of the small intestine, completely bypassing the duodenum and the jejunum. Although this procedure successfully promotes weight loss, it is less frequently used than other types of surgery because of the high risk for nutritional deficiencies.

A variation of BPD is a "duodenal switch." This operation leaves a larger portion of the stomach intact, including the pyloric valve that regulates the release of stomach contents into the small intestine. It also keeps a small part of the duodenum in the digestive pathway.

Malabsorptive operations produce more weight loss than restrictive operations, and are more effective in reversing the health problems associated with severe obesity. Patients who have malabsorptive operations generally lose two-thirds of their excess weight within 2 years.

In addition to the risks of restrictive surgeries, malabsorptive operations also carry greater risk for nutritional deficiencies. This is because the procedure causes food to bypass the duodenum and jejunum, where most iron and calcium are absorbed. Menstruating women may develop anemia because not enough vitamin B12 and iron are absorbed. Decreased absorption of calcium may also bring on osteoporosis and metabolic bone disease. Patients are required to take nutritional supplements that usually prevent these deficiencies. Patients who have the biliopancreatic diversion surgery must also take fat-soluble (dissolved by fat) vitamins A, D, E, and K supplements.

RGB and BPD operations may also cause "dumping syndrome." This means that stomach contents move too rapidly through the small intestine. Symptoms include nausea, weakness, sweating, faintness, and sometimes diarrhea after eating. Because the duodenal switch operation keeps the pyloric valve intact, it may reduce the likelihood of dumping syndrome.

The more extensive the bypass, the greater the risk for complications and nutritional deficiencies. Patients with extensive bypasses of the normal digestive process require close monitoring and life-long use of special foods, supplements, and medications.

Explore the benefits and risks

Surgery to produce weight loss is a serious undertaking. Anyone thinking about surgery should understand what the operation involves. Patients and physicians should carefully consider the following benefits and risks.

Benefits

  • Right after surgery, most patients lose weight quickly and continue to lose for 18 - 24 months after the procedure. Although most patients regain 5 - 10% of the weight they lost, many maintain a long-term weight loss of about 100 pounds.
  • Surgery improves most obesity-related conditions. For example, in one study blood sugar levels of 83 percent of obese patients with diabetes returned to normal after surgery. Nearly all patients whose blood sugar levels did not return to normal were older or had lived with diabetes for a long time.

Risks

  • Ten to 20% of patients who have weight-loss surgery require follow-up operations to correct complications. Abdominal hernia was the most common complication requiring follow-up surgery, but laparoscopic techniques seem to have solved this problem. In laparoscopy, the surgeon makes one or more small incisions through which slender surgical instruments are passed. This technique eliminates the need for a large incision and creates less tissue damage. Patients who are superobese (greater than 350 pounds) or who have had previous abdominal surgery may not be good candidates for laparoscopy, however. Less common complications include breakdown of the staple line and stretched stomach outlets.
  • Some obese patients who have weight-loss surgery develop gallstones. Gallstones are clumps of cholesterol and other matter that form in the gallbladder. During rapid or substantial weight loss, your risk of developing gallstones increases. Taking supplemental bile salts for the first 6 months after surgery can prevent gallstones.
  • Nearly 30% of patients who have weight-loss surgery develop nutritional deficiencies such as anemia, osteoporosis, and metabolic bone disease. These deficiencies usually can be avoided if vitamin and mineral intakes are high enough.
  • Women of childbearing age should avoid pregnancy until their weight becomes stable because rapid weight loss and nutritional deficiencies can harm a developing fetus.

- Created by the National Institutes of Health, NIH Publication No. 01-4006, December 2001. Illustrations copyright A.D.A.M., Inc.

 

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Review Date: 4/17/2007

Reviewed By: Patrika Tsai, M.D., M.P.H., Assistant Clinical Professor, Pediatric Gastroenterology, Hepatology and Nutrition, University of California, San Francisco, San Francisco, CA. Review provided by VeriMed Healthcare Network.


The information provided herein should not be used during any medical emergency or for the diagnosis or treatment of any medical condition. A licensed medical professional should be consulted for diagnosis and treatment of any and all medical conditions. Call 911 for all medical emergencies. Links to other sites are provided for information only -- they do not constitute endorsements of those other sites. © 1997- A.D.A.M., Inc. Any duplication or distribution of the information contained herein is strictly prohibited.

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