For this Bariatric Friday, Kemal Erkan, Chairman of American Surgery Center, is joined by Dr. Isaias Irgau, President of Christiana Institute of Advanced Surgery (CHRIAS). They start by acknowledging the team of professionals at American Surgery Center, including Dr. Gail Wynn, Dr. Michael Peters, Dr. Rahul Singh, Dr. George Ibrahim, and Dr. Sachin Vaid; they also introduce the registered dietitians, Amy Wilcoxon, Beth Wright, and Fran Taccone, who support their patients. The purpose of Bariatric Friday is to help patients follow possible issues and gain a better understanding of the bariatric surgery process. Today’s topic focuses on smoking and alcohol relating to patients undergoing bariatric surgery. 

  Generally, it is known smoking is bad for you, and moderate consumption of alcohol may be acceptable depending on the individual. Bariatric patients go through extensive preparation prior to surgery and have a significant change in diet following surgery; therefore, it is important to discuss the implications of smoking and drinking pre and post bariatric surgery.

  Dr. Irgau emphasizes the importance of this topic and brings to light a few questions that patients may have about the subject such as, “can I drink alcohol?” and “how much is too much?”. Erkan and Dr. Irgau begin discussing alcohol and its relation to bariatric surgery. “An important thing to understand is that after weight loss surgery there is a change in the anatomy of the digestive tract,” especially with the gastric sleeve and the gastric bypass procedures. When an individual who has not undergone bariatric surgery consumes alcohol, it mainly enters the stomach; the stomach is a large container that holds the alcohol and slowly empties it into the pylorus to then goes to the intestine before entering the bloodstream. In comparison, when a patient who has undergone a sleeve gastrectomy drinks alcohol, the alcohol cannot remain in the stomach for a very long time because a large portion of the organ has been removed. The alcohol quickly passes into the intestine. The stomach cannot act as a buffer to process the alcohol for someone who has had weight loss surgery. With a gastric bypass, the difference in the journey of alcohol post-consumption is much more drastic. This is because the stomach is even smaller and has been divided to create a pouch and attaches to the intestine; therefore, the alcohol goes directly to the intestine causing it to move through the body and into the bloodstream even more quickly. A person who drinks after a gastric bypass “will get drunk much more quickly with much less alcohol, and they will stay drunk for much longer,” Dr. Irgau explains. This causes the person to have a very high alcohol level with a very small amount consumed. 

  “There are other things that have to be considered,” Dr. Irgau continues, “alcohol itself can damage the lining of the stomach; after a gastric bypass they have a much smaller stomach,” which is more likely to be damaged. The purpose of bariatric surgery is for the patient to lose weight; however, when the patient consumes alcohol they are consuming extra calories that are not needed. Not only this, but Dr. Irgau explains how drinking alcohol increases one’s appetite. A person who aims to lose weight but continues to drink alcohol negates the goal of weight loss. 

  Erkan then mentions the pressure of alcohol being present in various environments. Dr. Irgau conveys patients in the bariatric program are told to avoid alcohol entirely following bariatric surgery and to avoid situations where alcohol is present. Knowing that this is not always possible, he offers some advice. If the patient is having a gathering where alcohol is present, he suggests taking a cocktail glass, filling it with water and adding a lime instead of choosing to consume an alcoholic beverage. Another option would be to for the patient to indulge in their first drink when others have finished consuming one or two drinks. As mentioned previously, the reason behind this logic is alcohol affects the bariatric patient much more quickly, and the patient will be much more drunk than the other guests if they have their first drink along with everyone else. Erkan draws on his personal experience, “this is like my approach on eating too much at parties… I eat egg whites before I go so I feel full before I go”. This is a similar logic. It is important for the patients to know their limit and understand how to approach a situation. Overall, alcohol is present in society, so it may be difficult to completely abstain; however, the effects are so much stronger that the patient must be very careful.  

  There are other issues that coincide with consuming alcohol after having bariatric surgery. The patient can become addicted and begin to rely on alcohol. For a patient who relied on consumption of food before the surgery, they may switch the reliance and replace that with alcohol. This can be a very dangerous situation, as it is more likely that someone who has had bariatric surgery will ultimately have liver failure. Patients who are social drinkers can consume alcohol up until two weeks before the operation, until they begin their restrictive diet. Erkan mentions, “if they have issues, then we should look for counseling, but hopefully we provide enough education that they need to stop; otherwise, they will have a lot of difficulty physically”.  In reference to drinking alcohol after the surgery, Dr. Irgau states, “abstention, if possible, is the best policy… if I were to really recommend a particular alcoholic drink, I would say red wine is probably the best, but in moderation”. Overall, it is best practice for the patient to stay away from alcohol for several months, if not longer.

  “Smoking is a different issue,” Erkan says as he sheds light on the topic, “smoking has adjustment requirements prior to the surgery… our patients may be exposed to some danger if they don’t stop”. He then asks Dr. Irgau, for patients, “why does it matter to stop smoking before the surgery”. Dr. Irgau elaborates on the impact smoking has on the rate of complications after surgery; the rate of infection could rise, as well as the rate of sepsis. There could be problems with the patient's respiratory system, and this would increase the risk for the patient to be dependent on a breathing tube after surgery, leading to a longer stay in the intensive care unit. “We have a zero tolerance policy in our bariatric surgery program because it is dangerous for patients to be smokers and then undergo bariatric surgery”. With this, he also mentions that tobacco is an extremely addictive substance. This can be very difficult for someone, but Dr. Irgau states that he always warns his patients that stopping smoking will be the hardest part of the preparation for the surgery. “There are clearly direct dangers to the safety of the surgery when a person is a smoker and they want to undergo bariatric surgery,” Dr. Irgau states. If the patient is able to quit, not only will this be beneficial in regard to the surgery, but this also improves the patient’s overall health. By quitting smoking, the patient will prevent the likelihood of lung cancer, heart disease, strokes, etc.  “Let’s say we have a former smoker… then one of our nurses finds out that the patient had three cigarettes before the surgery,” Erkan mentions. American Surgery Center will take punitive action towards the patient because the issue will ultimately affect the safety of the surgery. “Smoking, in my view, is all or nothing… we will be satisfied when we see complete abstention; I think that is an important policy for us to maintain,” Dr. Irgau clarifies. Other issues, however, will arise after the bariatric surgery if the patient is a smoker. Smoking itself damages the stomach’s lining; this is a problem because, after bariatric surgery, the stomach is still healing. The stomach cannot afford to be damaged by smoking, especially after a gastric bypass. Since the stomach and the intestine are connected after that procedure, smoking could lead to an ulcer. Not only do ulcers cause pain and discomfort when eating, they could be life threatening if they burst. There are real dangers that coincide with smoking and these surgeries. “I have had patients, unfortunately, who have resumed smoking and have ended up with ulcers that have made their lives so miserable,” Dr. Irgau communicates. “Eventually that ulcer can lead to scar tissue that makes the ulcer opening so tight; that person may be unable to eat now… which may require surgery to fix it”. A repeat surgery to the same area will lead to the tissue not healing as well as the first time around. 

  Erkan then poses the question, “what is smoking cessation?,” to which Dr. Irgau answers, “as soon as we identify someone who is a smoker, our nurses will follow up with that by providing materials and resources that will help the patient to quit smoking… we really bring the seriousness of this issue to the patients”. These educational materials are aimed to help the patient realistically stop smoking. Dr. Irgau then mentions, “I have yet to meet a patient that hasn’t been able to stop smoking before bariatric surgery; in twenty years, they have always been able to quit smoking because they understand the importance”. Medical marijuana has not been studied for as long as nicotine and tobacco have been, but it is known that patients who are smoking marijuana will have issues as well. 

  “This is a life changing event,” Erkan announces, in regards to patients who smoke, it “is not because we are trying to be difficult… we want them to have a good, pleasant experience… it is an important change that they are going to go through, and we don’t want anyone to lose the opportunity of using what is available to them”. It is important for people to understand that safety is paramount; all of these preparations and stipulations mentioned are for the benefit and safety of the patient undergoing bariatric surgery.