Dietitians: Setting the Stage for Bariatric Surgery

This one is for those endlessly curious about the anatomy -

Have you ever seen a human stomach?

Do you know what color it is, what shape it is, where it sits in relation to the rest of our organs, how big it is, and whether it really moves on its own?

I had the unique opportunity to shadow a surgical procedure while interning under a bariatric dietitian. Though bariatrics and metabolic health may be a polarizing topic for dietetics, working with them and their clients was fascinating. Hearing my preceptor say that the surgeon allowed me to observe a procedure in the operating room was equally exciting. 

An operating room table in the hospital.

“He loves students,” she said. “He’ll be happy to have you.”

It never occurred to me that I hadn’t seen a surgery before. Of course, I hadn’t. It is easy to get lost in the false reality that you know for sure what human anatomy looks like after growing up with medical dramas like General Hospital, Grey’s Anatomy, or even House. There is nothing but movie magic behind those scenes (even if the rumors are true that they used bovine parts for some surgeries). Now that I had the chance, I jumped for my turn in the theater.

I want to emphasize that surgical intervention can be a necessary step for many people battling obesity. This facility met people at the end of their line after grasping for straws in the diet industry for years. They exercised, they dieted, they restricted, they used medications, all of it. No matter what they did, the weight always came back. In this particular clinic, bariatric dietitians know that their clients are not coming in for another dieting plan to shed one or one hundred pounds. Clients are coming to these dietitians to prepare for surgery and for the rest of their lives post-op. 

Casting and Rehearsal

Preparation for bariatric surgery is no walk in the park, either. Clients must complete a checklist of tasks to qualify through their insurance. This includes all sorts of screenings (cardiopulmonary, psychological, and endocrine), lab work, chest x-rays, and diet counseling. Some insurance companies require several months of physician-guided dieting to consider clients for bariatric surgery. If you miss an appointment, you have to start the process all over. 

Motivational interviewing goes a long way with bariatric clients. Most of them are at the change stage of their life, but some come in without full understanding that bariatric surgery isn’t a quick fix. To get to surgery, the following goals are made:

Keeping a diet journal helps dietitians keep clients accountable in their goals, and can encourage clients to make behavior changes on their own.

• Keep a daily food journal.

• Eat at regular intervals.

• Include a lean protein source at all meals. 

• Include a fiber source at all meals.

• Decrease or eliminate sugary and carbonated beverages.

• Meet fluid goals of 64 ounces per day.

• Decrease or eliminate sugary or refined carbohydrates.

• Try protein supplements to find the ones you like.

• Take a multivitamin/mineral supplements daily. 

• Work on healthy coping skills and identify triggers for unhealthy eating.

• Take time at meals and chew foods well.

• Get regular exercise and activity.
  

Examples of items that can be used in the liver-shrinking diet. University of Maryland does not endorse the use of one product over another.

Two weeks leading up to surgery, clients receive more goals: the liver-shrinking diet. Two weeks of a highly restricted diet with protein shakes, a serving of dairy, a serving of fruit, and a single meal of three to six ounces of lean protein, soft-cooked vegetables, and a quarter-cup of starch. This diet is meant to reduce the chance of surgical complications related to the liver’s proximity to the stomach. 

Showtime!

I understand why they call it surgical theater. Everyone has a part to play, stage left, right, and center. Stand in the wrong place, and you interrupt everyone’s unspoken language. I arrived at the end of the first of three procedures and observed with my back to the wall. The nursing team disposed of materials and cleaned the room spotless in less than forty minutes. The scrub nurse prepared the surgical instruments, medications, and solutions. The anesthesiologist waved me over and asked me to identify the vocal cords for intubation once the patient arrived (I didn’t see them, but I saw the bronchial rings!). 

They would perform a laparoscopic robotic sleeve gastrectomy, also known as the gastric sleeve, the most common bariatric surgery in the United States [1]. Contrary to what I believed, the ‘sleeve’ is not some external mesh that compresses the stomach to restrict its volume. The surgeon showed me the tools he uses: the blades, robot, and laparoscope. He drew out the surgery for me and handed me the Sharpie afterward. “This is how big the stomach is after extraction,” he said before scrubbing in. Then, they took their time out and agreed on the patient’s identity, the procedure to be performed, and the medical necessity of it.

A rough drawing of a gastric sleeve procedure (left) in comparison to a Roux-en-Y gastric bypass (right).

To say that my jaw was on the floor the entire time is an understatement. The laparoscope transmitted to massive screens throughout the room to show us the abdominal cavity in minute detail. Some of me thought the abdomen was a fluid-filled cavity, but it was rather hollow. The surgeon pointed out gross anatomy to me. There’s the splenic artery. That soft mass that looks like popcorn is the pancreas. The heart is beating just on the other side of the diaphragm. The dark organ there, lifted by a piece of metal (it makes me cringe thinking about it), that’s the liver. The nurses and surgeons pointed out the fatty deposits and the cirrhosis present despite the patient’s compliance with the liver-shrinking diet. 

There’s no way a YouTube video of this surgery could beat front-row seats. 

The first assistant walked me through the procedure, and I asked everything I could think of. I watched as the surgeon maneuvered the robotic arms to lift the stomach and separate the adipose tissue from the muscle. He cauterized vessels as he went to minimize bleeding. Then came a sound I couldn’t comprehend - the sound of the stapling tool used to separate the stomach from the remaining sleeve. Watching the excised stomach grow greyer and greyer felt strange as the surgeon sutured the sleeve around the staple line. It was equally strange to see them remove it from the incisions and place it in a specimen cup smaller than a cereal bowl. 

There it was. Less than an hour later.

Intermission

To minimize the risk of blood clots, patients are up and out of bed within six hours post-op. They’re on a clear liquid diet for two days in the hospital, then discharged home with the instructions to walk every hour and begin a full liquid diet of high-protein fluids like yogurt and protein shakes. Sipping on even a capful of water at every opportunity is necessary to prevent dehydration. After a few weeks, they can begin reintroducing one-quarter cup (total) of solid pureed foods at meals, then move up in texture until regular food is tolerated. Meal sizes increase over time; it can take twelve to eighteen months to eat a full cup of food thrice daily. 

Yes. One cup. The stomach is reduced to the size of a highlighter pen. Not much can fit in that space, and the risk of ripping stitches is real if a client overeats. This is why dietitians encourage practicing regular, small meals throughout the day prior to surgery. Habits cannot change overnight in most cases.

Final

All of this work and restriction ultimately leads to weight loss, though. The final goal. Clients can expect 60-70% of their excess weight (actual body weight at surgery - ideal body weight) to fall off in the next eighteen months. With work and consistency, it can stay off. I met two individuals for their annual checkups several years post-op to see an ideal case of bariatric surgery. Both were doing exceptionally well in their lives, had healthy relationships with food, and could maintain their nadir weight (or lowest weight after surgery). 

Unfortunately, not everyone will have this success, as there are some side effects of the surgery. Dumping syndrome, novel lactose intolerance, dehydration, protein malnutrition, and weight regain are a few potential risks of bariatric surgery. Even with these risks, I have heard clients express their excitement for the procedure. I met people who struggled with their weight for the majority of their lives - some citing issues stemming from early childhood. Speaking with them and learning about how weight affects their lives made obesity more than a descriptor of body composition. It ultimately taught me that obesity truly is a chronic disease driven by evolutionary biology gone wrong that deserves compassion, kindness, and relief.

References:

1. Howard R, Chao GF, Yang J, et al. Comparative Safety of Sleeve Gastrectomy and Gastric Bypass Up to 5 Years After Surgery in Patients With Severe Obesity. JAMA Surgery. 2021;156(12):1160-1169. doi:10.1001/jamasurg.2021.4981