Sept 16, 2022 - Weight Loss Surgery: Smoking and Alcohol After Bariatric Surgery

On today’s Bariatric Friday, Kemal Erkan, Chairman of American Surgery Center, is accompanied by Dr. Isaias Irgau, President of Christiana Institute of Advanced Surgery (CHRIAS). Dr. Irgau specializes in weight loss surgery, also known as bariatric surgery, and has for over 20 years. This is the most effective way to treat morbid obesity and the illnesses that come along with it. These related illnesses can include high blood pressure, type 2 diabetes, or sleep apnea. Today’s topic is smoking and alcohol use after bariatric surgery. Erkan mentions the three patients being monitored for these educational sessions throughout their bariatric surgery process -- Karen, Denise, and Patrick. Karen is undergoing a gastric bypass, Denise and Patrick will be receiving the gastric sleeve. The situations are real patient data but the patient’s names have been changed. The patients are now in the 18-19th week since they began their journey.

Smoking is a matter that can prevent a patient from being able to receive bariatric surgery. It is required that the patient quit smoking before the bariatric process begins. Dr. Irgau states, “smoking is bad regardless, whether you are having surgery or not… if a person is a smoker, they are likely to have way more complications during their surgery and then after recovery.” Erkan inquires why smoking would affect the surgery. Dr. Irgau responds by saying, “a person who is a smoker will have damaged lungs, and during their surgery the person’s breathing will actually be taken over by a machine because they will be intubated, they will be under general anesthesia”. Not only will a smoker’s overall recovery be delayed, but the person is at much higher risk of developing pneumonia and other infections after the surgery. Smoking also decreases blood flow to different parts of the body; good blood flow is paramount during recovery after surgery. “We rely on nature to do the healing as well,” Dr. Irgau explains that the body needs to heal itself, it is not just up to the surgeon. Erkan asks, in the situation of Patrick, if he had a one-time incident where he smoked four months prior to beginning the surgery journey, would that delay his process. Dr. Irgau explains that the surgery center uses common sense in a situation like this; “you are either a smoker or you’re not”.” In a one-off occasion like described, that will not stop the process assuming that he has been honest and has quit smoking other than that incident. The issue with this is that one cigarette can pull previous smokers back into the habit of smoking. Nicotine is an addictive substance, Dr. Irgau states, “so it is important to understand that if you are working to improve your health and undergo a procedure that has potential risks, you want to do everything you can so that that surgery is going to go as safely and as smoothly as possible and stopping smoking will do that…we have a zero-tolerance policy.” If a patient is continuing to smoke, we will not perform surgery because our first rule is to do no harm. Performing bariatric surgery on that patient will defeat the purpose of the overall goal, which is to make them healthy.

If an individual who received a gastric bypass continued to smoke after the surgery, they could cause damage to the connection between the intestine and the stomach which can ultimately lead to ulcers. Dr. Irgau states, “ulcers are like raw wounds that will happen right at that connection and those wounds will not heal if the person continues to smoke.” He further clarifies, “those wounds not only are dangerous, but they are very painful… their quality of life will be miserable with the ulcers.” These ulcers can eventually burst and cause perforation and sepsis, a life-threatening condition, or lead to erosion of a blood vessel that can result in massive bleeding, which is also life-threatening.

Erkan asks Dr. Irgau for advice on the best way to quit smoking. “We are talking here as if it’s easy to quit, it’s not… we have a lot of resources in our program but also in healthcare as a

whole to help people quit smoking.” Dr. Irgau mentions, “one of the great things we have in our setup, for instance, is we can put a smoking cessation order when we know and identify that a patient is a smoker in our network, and that will initiate a series of measures that will be set up by the nurses, by the care coordinators that will help provide resources for patients to quit smoking”. The pair explain that they want to help the patients and never speak to them in a punitive fashion. Erkan mentions yoga and deep breathing exercises as a method to assist in quitting. Dr. Irgau affirms those methods and also mentions programs that a lot of primary care setups offer. The individual is supported by not only medical staff but also peers going through the same situation. The reason for bariatric surgery is to be healthy by decreasing an individual’s risk of diabetes, high blood pressure, strokes, and more. Smoking sets the individual back to possibly incur life-threatening risks.

Erkan transitions to alcohol relating to bariatric surgery, “it’s a little bit different with alcohol especially before surgery versus after surgery.” There is a distinction between social drinkers and people with a dependency on alcohol. Individuals reliant on alcohol are not permitted to enter the bariatric surgery program. The recommendation for social drinkers prior to bariatric surgery is to limit their intake and slow down. Three weeks before the procedure an individual should stop alcohol consumption completely. It is also advised that six months after surgery the patient should refrain from drinking alcohol entirely. The body handles alcohol in a totally different way after the procedure due to the rerouting of the digestive system. In the instance of a patient who had a gastric bypass, like Karen is planning to receive, the stomach size has been reduced so much that alcohol would immediately enter the small intestine. Dr. Irgau explains, “once the alcohol enters the small intestine, it is reabsorbed in the bloodstream very quickly, so a person who has had a gastric bypass and has a couple sips of alcohol will feel the side effects almost immediately.” This can be very dangerous, as the individual will become inebriated very quickly and for much longer. “Even after the gastric sleeve there will be rapid progression of the alcohol from the stomach to the intestine, which is where the main processing of the alcohol occurs… there are real dangers to that,” Dr. Irgau states. He continues, “If you are driving, and if you were able to drive with one drink in the past without any problems, now that could be a serious issue.” Not only could one endanger themselves and others, but if the police were to pull said person over the alcohol would show up much faster and in higher levels in the blood.

Alcohol can also slow the progression of weight loss after bariatric surgery. Alcohol contains calories without any nutritional value and a lot of sugar. When people drink alcohol, their appetite increases as well. By drinking alcohol, a person is less likely to feel full and more likely to continue eating. The likelihood of alcohol reliance increases after surgery too. Dr. Irgau states, “alcoholism is obviously devastating for the individual, for their family, for anybody around them, and for their health, of course, but it is even more so after bariatric surgery -- particularly gastric bypass, because damage to the liver can occur much more quickly if a person becomes alcoholic after the gastric bypass than it would otherwise and lead to liver failure.” Not only alcohol but carbonated drinks, especially carbonated alcohols, are discouraged for a person who has received bariatric surgery. Erkan concludes the session by stating, “we don’t want to necessarily advise how much or how little they should be drinking, but not drinking would be the ideal situation for our patients. Seeing our patients in a healthier way is our goal, so we want to make sure that they actually follow these guidelines.”