075 Bariatric Surgery Rules? A talk with Dr Walter Medlin

by reeger on September 11, 2016


In this episode I have a conversation with Dr. Walter Medlin about bariatric surgery rules. You may remember Dr. Medlin from episode 53. He is a bariatric surgeon at the Bariatric Medicine Institute in Salt Lake City, Utah. He is also a bariatric surgery patient having had sleeve gastrectomy.

During this conversation Dr Medlin and I share our thoughts on bariatric surgery rules from the perspective of what is known from the scientific evidence, what we have seen in our own practices or heard about (anecdoctal evidence), and what rules Walt applies to his own bariatric surgery journey.

The Bariatric Surgery Rules Discussed In This Episode:

No Straws:
Concern: swallowing of air, stretching of stomach, too fast rapid ingestion of water or beverage
Our Conclusions: No evidence to support No Straw rule, but we both feel straw use too early can cause unneeded discomfort but after that, each person will need to explore on their own.

No Gum:
Concern: Swallowing of gum can cause obstruction, swallowing of air with gum (see above), chewing action leads to increased hunger, sugar alcohols cause bowel issues.
Our Conclusions: No published evidence that gum chewing is a problem. We are neutral on if gum-chewing increases hunger but Dr Medlin personally avoids gum after eating due to his own concern for gum chewing “chasing food out of the stomach.”

No Caffeine:
Concerns: Caffeine is considered to be a gastric acid stimulator possibly worsening reflux/heartburn/ulcers. Also caffeine is a type of a diuretic (makes you pee) and can therefore increase dehydration. It is addictive (transfer addiction?). Designer coffee drinks can come with a lot of calories. Perpetuates the cycle of stimulant/crash/stimulant crash.
Our Conclusions: We both agree the time to withdrawal from caffeinated drinks is BEFORE going into the hospital for your surgery. After surgery,Dr Medlin allows his patients to have caffeine shortly after bariatric surgery. For himself he avoided caffeine in his first year after gastric sleeve because of taste preference. I requests my patients wait 6 months after surgery before bring caffeine into their diet because I want them to focus on drinking fluids that stay in their bodies, not force fluids out.

No Carbonation:
Concerns: Stretching of the new stomach? Increasing risk of heartburn and reflux? If calorie drinks- empty calorie.
Our Conclusions: There is no evidence to support carbonation stretches the new stomach. It may cause heart burn or discomfort for some people. Avoid calorie-laden drinks.

SIDE NOTE: Both Dr Medlin and I agree that dehydration is a very common issue for people early post-op and therefore setting people up to receive a liter or two of IV fluid a few days after bariatric surgery helps them out significantly.

No NSAIDs (Ibuprofen, Advil, Aleve, etc)
Concerns: NSAIDs increase the risk for stomach ulcers. Highest risk is in gastric bypass patients.
Our Conclusions: The risk is very real. Avoid NSAIDs if at all possible. If a person must take them they should understand the risks and seriously consider a “stomach protective” medication like a proton pump inhibitor, histamine 2 blocker, +/or Carafate.

No Nicotine
Concerns: Nicotine causes many problems within the body.
Our Conclusions: Early post-op Dr Medlin has concern for increased risk of blood clots, poor wound healing, and increased risk for pneumonia. I agree. Long-term we are both concerned that nicotine increases the chances of stomach ulceration. This is a very real risk! We both want our patients to be off nicotine as much as possible, including smoking cigarettes, e-vaping with nicotine, patches, gum, chew, and second-hand smoke.

No Ice
Concerns: Ice triggers stomach spasms or cramping? Excessive cooling of a fresh staple line causes reduced blood flow and impairs healing?
Our Conclusions: Probably best to avoid excessive ice in the early post-op period for no other reason than avoiding the possibility of stomach cramping but otherwise ice is not something we are concerned about (aka- best to explore on ones own.) There is no evidence that swallowed cool or cold liquids in the new stomach reduced blood flow and impairs healing.

SIDE NOTE: Obsessive ice chewing can be an indication of iron deficiency anemia. Medically this is known as PICA- the eating of non-food items and specifically it is known as PAGOPHAGIA- the eating of ice.

Vitamins and Medicine:
The Rules: All medicine/vitamins need to liquid, chewable, or capsules (avoid extended release) AND do not take iron and calcium together AND take only bariatric-formulated vitamins AND what about transdermal vitamin patches?
Concerns: Liquid, chewable, capsules are the easier to digest than tablets. One should avoid extended release medicines because of slower disintegration times intended for full-length GI track. If medicine/vitamins are tablets they have an increased risk for getting “stuck” in the new stomach and/or slower digestion times. Regarding calcium and iron, they bind to each other thereby reducing their absorption. Is there any proof that transdermal vitamin patches work?
Our Conclusions: Follow your program and dietician recommendations but we have not encountered frequent complaints of vitamins “getting stuck.” Nor have we seen significant vitamin deficiencies in patients who are taking tablet forms. Sometimes if a person is taking an extended release medication, they may experience reduced absorption (less drug effect) if they have a shorten intestine (think RYGB). Regarding calcium and iron (together or no?) and any vitamin for that matter: The vitamin you cannot absorb is the one you do not take- best take together than to not take at all. When in doubt, take vitamins, even if they are not bariatric formulated. However, probably best to avoid vitamin patches until more evidence is brought forth that proves they actually work. Get your labs drawn at least annually, and talk with your bariatric program, dietician, and/or obesity medicine specialist.

No Alcohol
Concerns: Rapid intoxication. Impaired judgment. Addiction. Addiction transfer (food to alcohol). Less behavior inhibition can result in risky sex, risky driving, risky food/beverage choices, to name a few). Empty calories.
Our Conclusions: Rapid intoxication is proven to be worse after bariatric surgery. Alcohol is known to impair judgment and can be addictive. Alcohol is “empty” calories. Dr Medlin did not drink at all during his first year after bariatric surgery. We both agree that a hard rule of “No Alcohol” after bariatric surgery is most likely not practical. However, we also agree, be very, very careful/user-beware! When doubt, do not drink!

Bonus: Listen all the way through to hear the bonus content.

Reeger’s Take Home Message: Know Thyself (she stole this one from the ancient Greeks)
Dr Medlin’s Take Home Message: Find Your Rules

Connecting with Dr Walter Medlin
Website: Bonuslife
Bariatric Medicine Institute

Click HERE to become a member Obesity Action Coalition
Click HERE to view the winning video: A Disease Called Obesity

Connecting with me
WLSP Facebook
Southern Oregon Bariatric Center Facebook
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I believe in you!

{ 5 comments… read them below or add one }

Diana September 12, 2016 at 7:48 pm

Good article and advice.
(I had PICA when my iron deficiency was severe. I was seriously enjoying toothpaste and brushing my teeth! anything minty) so weird.


reeger September 19, 2016 at 3:58 am

Hi Diana, Yes PICA when having IDA is actually pretty common. Even though I have never heard of anyone having “cravings” for minty tooth paste it does not surprise me. Take care, Reeger


Jennie January 16, 2017 at 11:41 am



reeger January 17, 2017 at 4:38 am

You’re welcome! Reeger


reeger January 20, 2017 at 3:04 pm

Hi Jennie, I have had some technical difficulties and am now working with a video editor who is helping me. I hope the powerpoint will be fully functional (video paired with audio) by this weekend, 1/21-22/17.


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