Frequently Asked Questions | About Morbid Obesity
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Preparation
for Surgery
Insurance
Issues
Surgery
The
Hospital Stay
Life
After Surgery
Diet
General
Preparation for Surgery
What are the routine tests before surgery?
Certain basic tests are done prior to surgery: a Complete Blood
Count (CBC), Urinalysis, and a Chemistry Panel, which gives a
readout of about 20 blood chemistry values. Often a Glucose Tolerance
Test is done to evaluate for diabetes, which is very common in
overweight persons. All patients but the very young get a chest
X-ray and an electrocardiogram. Women may have a vaginal ultrasound
to look for abnormalities of the ovaries or uterus. Many surgeons
ask for a gallbladder ultrasound to look for gallstones. Other
tests, such as pulmonary function testing, echocardiogram, sleep
studies, GI evaluation, cardiology evaluation, or psychiatric
evaluation, may be requested when indicated.
What is the purpose of all these tests?
An accurate assessment of your health is needed before surgery.
The best way to avoid complications is to never have them in
the first place. It is important to know if your thyroid function
is adequate since hypothyroidism can lead to sudden death post-operatively.
If you are diabetic, special steps must be taken to control
your blood sugar. Because surgery increases cardiac stress,
your heart will be thoroughly evaluated. These tests will determine
if you have liver malfunction, breathing difficulties, excess
fluid in the tissues, abnormalities of the salts or minerals
in body fluids, or abnormal blood fat levels.
Why do I have to have a GI Evaluation?
Patients who have significant gastrointestinal symptoms such
as upper abdominal pain, heartburn, belching sour fluid, etc.,
may have underlying problems such as a hiatal hernia, gastroesophageal
reflux or peptic ulcer. For example, many patients have symptoms
of reflux. Up to 15% of these patients may show early changes
in the lining of the esophagus, which could predispose them
to cancer of the esophagus. It is important to identify these
changes so a suitable surveillance or treatment program can
be planned.
Why do I have to have a Sleep Study?
The sleep study detects a tendency for abnormal stopping of breathing,
usually associated with airway blockage when the muscles relax
during sleep. This condition is associated with a high mortality
rate. After surgery, you will be sedated and will receive narcotics
for pain, which further depress normal breathing and reflexes.
Airway blockage becomes more dangerous at this time. It is
important to have a clear picture of what to expect and how
to handle it.
Why do I have to have a Psychiatric Evaluation?
The most common reason a psychiatric evaluation is ordered is
that your insurance company may require it. Most psychiatrists
will evaluate your understanding and knowledge of the risks
and complications associated with weight loss surgery and your
ability to follow the basic recovery plan.
What impact do my medical problems have on the decision
for surgery, and how do the medical problems affect risk?
Medical problems, such as serious heart or lung problems, can
increase the risk of any surgery. On the other hand, if they
are problems that are related to the patient's weight, they also
increase the need for surgery. Severe medical problems may not
dissuade the surgeon from recommending gastric bypass surgery
if it is otherwise appropriate, but those conditions will make
a patient's risk higher than average.
If I want to undergo a gastric bypass, how long do I
have to wait?
New evaluation appointments are usually booked 4-8 months in
advance. Once a patient is seen, if the surgeon and patient agree
it is appropriate, the operation can usually be scheduled within
8 weeks. Why so long? There is more need for weight loss surgery
than there are qualified bariatric surgeons.
What can I do before the appointment to speed up the process of getting ready for surgery?
- Select a primary care physician if you don't already have one, and establish a relationship with him or her. Work with your physician to ensure that your routine health maintenance testing is current. For example, women may have a pap smear, and if over 40 years of age, a breast exam. And for men, this may include a prostate specific antigen test (PSA).
- Make a list of all the diets you have tried (a diet history) and bring it to your doctor.
- Bring any pertinent medical data to your appointment with the surgeon - this would include reports of special tests (echocardiogram, sleep study, etc.) or hospital discharge summary if you have been in the hospital.
- Bring a list of your medications with dose and schedule.
- Stop smoking. Surgical patients who use tobacco products are at a higher surgical risk.
Insurance Issues
Why does it take so long to get insurance approval?
After your consultations are completed, and
we get all reports it usually takes your doctor 1-2 days
to send a letter to your insurance carrier to start the approval
process. The time it takes to get an answer can vary from about 3-4 weeks or longer
if you are not persistent in your follow-up. Most treatment
centers have insurance analysts who will follow up regularly
on approval requests. It may be helpful for you to call the
claims service of your insurance company about a week after
your letter is submitted and ask about the status of your request.
How can they deny insurance payment for a life-threatening
disease?
Payment may be denied because there may be a specific exclusion
in your policy for obesity surgery or "treatment of obesity." Such
an exclusion can often be appealed when the surgical treatment
is recommended by your surgeon or referring physician as the
best therapy to relieve life-threatening obesity-related health
conditions, which usually are covered.
Insurance payment may also be denied for lack of "medical
necessity." A therapy is deemed to be medically necessary
when it is needed to treat a serious or life-threatening condition.
In the case of morbid obesity, alternative treatments - such
as dieting, exercise, behavior modification, and some medications
- are considered to be available. Medical necessity denials usually
hinge on the insurance company's request for some form of documentation,
such as 1 to 5 years of physician-supervised dieting or a psychiatric
evaluation, illustrating that you have tried unsuccessfully to
lose weight by other methods.
What can I do to help the process?
Gather all the information (diet records, medical records, medical
tests) your insurance company may require. This reduces the
likelihood of a denial for failure to provide "necessary" information.
Letters from your personal physician and consultants attesting
to the "medical necessity" of treatment are particularly
valuable. When several physicians report the same findings,
it may confirm a medical necessity for surgery.
When the letter is submitted, call your carrier regularly to
ask about the status of your request. Your employer or human
relations/personnel office may also be able to help you work
through unreasonable delays.
Surgery
Does Laparoscopic Surgery decrease the risk?
No. Laparoscopic operations carry the same risk as the procedure
performed as an open operation. The benefits of laparoscopy
are typically less discomfort, shorter hospital stay, earlier
return to work and reduced scarring.
Will I have a lot of pain?
Every attempt is made to control pain after surgery to make it
possible for you to move about quickly and become active. This
helps avoid problems and speeds recovery. Often several drugs
are used together to help manage your post-surgery pain. While
you are still in the hospital, a Patient Controlled Analgesia
(PCA), which allows you to give yourself a dose of pain medicine
on demand, may be used by your physician. Various methods of
pain control, depending on your type of surgical procedure,
are available. Ask your surgeon about other pain management
options.
How long do I have to stay in the hospital?
As long as it takes to be self-sufficient. Although it can vary,
the hospital stay (including the day of surgery) can be 1-2
days for a laparoscopic band, 2-3 days for a laparoscopic gastric
bypass, and 5-7 days for an open gastric bypass.
Will the doctor leave a drain in after surgery?
Most patients will have a small tube to allow drainage of any
accumulated fluids from the abdomen. This is a safety measure,
and it is usually removed a few days after the surgery. Generally,
it produces no more than minor discomfort.
If I have surgery, what can I expect when I wake up
in the recovery room?
Some doctors will provide a Patient Controlled Analgesia (PCA)
or a self-administered pain management system, to help control
pain. Others prefer to use an infusion pump that provides a local
anesthetic in the surgical site to control pain without the side
effects of narcotics. As with any major surgery, you are in danger
of death from a blood clot or other surgical side effects. Statistically,
the risk of death during these procedures is less than 1 percent.
Your doctors will have assessed you for risks and prepared accordingly.
All abdominal operations carry the risks of bleeding, infection
in the incision, thrombophlebitis of legs (blood clots), lung
problems (pneumonia, pulmonary embolisms), strokes or heart attacks,
anesthetic complications, and blockage or obstruction of the
intestine. These risks are greater in morbidly obese patients.
How soon will I be able to walk?
Almost immediately after surgery doctors will require you to
get up and move about. Patients are asked to walk or stand
at the bedside on the night of surgery, take several walks
the next day and thereafter. On leaving the hospital, you may
be able to care for all your personal needs, but will need
help with shopping, lifting and with transportation.
How soon can I drive?
For your own safety, you should not drive until you have stopped
taking narcotic medications and can move quickly and alertly
to stop your car, especially in an emergency. Usually this
takes 7-14 days after surgery.
The Hospital Stay
What is done to minimize the risk of deep vein thrombosis/pulmonary
embolism or DVT/PE?
Because a DVT originates on the operating table, therapy begins
before a patient goes to the operating room. Generally, patients
are treated with sequential leg compression stockings and given
a blood thinner prior to surgery. Both of these therapies continue
throughout your hospitalization. The third major preventive
measure involves getting the patient moving and out of bed
as soon as possible after the operation to restore normal blood
flow in the legs.
What should I bring with me to the hospital?
Basic toiletries (comb, toothbrush, etc.) and clothing may be
provided by the hospital, but most people prefer to bring their
own. Choose clothes for your stay that are easy to put on and
take off. Because of your incision, your clothes may become
stained by blood or other body fluids. Other ideas:
- reading and writing materials
- crossword and other puzzles
- personal toiletries
- bathrobe
Life After Surgery
What do I need to do to be successful after surgery?
The basic rules are simple and easy to follow:
- Immediately after surgery, your doctor will provide you with special dietary guidelines. You will need to follow these guidelines closely. Many surgeons begin patients with liquid diets, moving to semi-solid foods and later, sometimes weeks or months later, solid foods can be tolerated without risk to the surgical procedure performed. Allowing time for proper healing of your new stomach pouch is necessary and important.
- When able to eat solids, eat 2-3 meals per day, no more. Protein in the form of lean meats (chicken, turkey, fish) and other low-fat sources should be eaten first. These should comprise at least half the volume of the meal eaten. Foods should be cooked without fat and seasoned to taste. Avoid sauces, gravies, butter, margarine, mayonnaise and junk foods.
- Never eat between meals. Do not drink flavored beverages, even diet soda, between meals.
- Drink 2-3 quarts or more of water each day. Water must be consumed slowly, 1-2 mouthfuls at a time, due to the restrictive effect of the operation.
- Exercise aerobically every day for at least 20 minutes (one-mile brisk walk, bike riding, stair climbing, etc.). Weight/resistance exercise can be added 3-4 days per week, as instructed by your doctor.
What's so important about exercise?
When you have a weight loss surgery procedure, you lose weight
because the amount of food energy (calories) you are able to
eat is much less than your body needs to operate. It has to
make up the difference by burning reserves or unused tissues.
Your body will tend to burn any unused muscle before it begins
to burn the fat it has saved up. If you do not exercise daily,
your body will consume your unused muscle, and you will lose
muscle mass and strength. Daily aerobic exercise for 20 minutes
will communicate to your body that you want to use your muscles
and force it to burn the fat instead.
What is the right amount of exercise after weight loss
surgery?
Many patients are hesitant about exercising after surgery, but
exercise is an essential component of success after surgery.
Exercise actually begins on the afternoon of surgery - the patient
must be out of bed and walking. The goal is to walk further on
the next day, and progressively further every day after that,
including the first few weeks at home. Patients are often released
from medical restrictions and encouraged to begin exercising
about two weeks after surgery, limited only by the level of wound
discomfort. The type of exercise is dictated by the patient's
overall condition. Some patients who have severe knee problems
can't walk well, but may be able to swim or bicycle. Many patients
begin with low stress forms of exercise and are encouraged to
progress to more vigorous activity when they are able.
Can I get pregnant after weight loss surgery?
It is strongly recommended that women wait at least one year
after the surgery before a pregnancy. Approximately one year
post-operatively, your body will be fairly stable (from a weight
and nutrition standpoint) and you should be able to carry a
normally nourished fetus. You should consult your surgeon as
you plan for pregnancy.
What if I have had a previous weight loss surgical procedure
and I'm now having problems?
Contact your original surgeon - he or she is most familiar with
your medical history and can make recommendations based on knowledge
of your surgical procedure and body.
What happens to the lower part of the stomach that is
bypassed?
In some surgical procedures, the stomach is left in place with
intact blood supply. In some cases it may shrink a bit and its
lining (the mucosa) may atrophy, but for the most part it remains
unchanged. The lower stomach still contributes to the function
of the intestines even though it does not receive or process
food - it makes intrinsic factor, necessary to absorb Vitamin
B12 and contributes to hormone balance and motility of the intestines
in ways that are not entirely known. In the BPD procedures, some
portion of the stomach is completely removed.
How big will my stomach pouch really be in the long
run?
This can vary by surgical procedure and surgeon. In the Roux-en-Y
gastric bypass, the stomach pouch is created at one ounce or
less in size (15-20cc). In the first few months it is rather
stiff due to natural surgical inflammation. About 6-12 months
after surgery, the stomach pouch can expand and will become more
expandable as swelling subsides. Many patients end up with a
meal capacity of 3-7 ounces.
What will the staples do inside my abdomen? Is it okay
in the future to have an MRI test? Will I set off metal detectors
in airports?
The staples used on the stomach and the intestines are very tiny
in comparison to the staples you will have in your skin or staples
you use in the office. Each staple is a tiny piece of stainless
steel or titanium so small it is hard to see other than as a
tiny bright spot. Because the metals used (titanium or stainless
steel) are inert in the body, most people are not allergic to
staples and they usually do not cause any problems in the long
run. The staple materials are also non-magnetic, which means
that they will not be affected by MRI. The staples will not set
off airport metal detectors.
What if I'm not hungry after surgery?
It's normal not to have an appetite for the first month or two
after weight loss surgery. If you are able to consume liquids
reasonably well, there is a level of confidence that your appetite
will increase with time.
Is there any difficulty in taking medications?
Most pills or capsules are small enough to pass through the new
stomach pouch. Initially, your doctor may suggest that medications
be taken in liquid form or crushed.
Will I be able to take oral contraception after surgery?
Most patients have no difficulty in swallowing these pills.
Is sexual activity restricted?
Patients can return to normal sexual intimacy when wound healing
and discomfort permit. Many patients experience a drop in desire
for about 6 weeks.
Is there a difference in the outcome of surgery between
men and women?
Both men and women generally respond well to this surgery. In
general, men lose weight slightly faster than women do.
Will I be asked to stop smoking?
Patients are encouraged to stop smoking at least one month before
surgery.
If I continue to smoke, what happens?
Smoking increases the risk of lung problems after surgery, can
reduce the rate of healing, increases the rates of infection,
and interferes with blood supply to the healing tissues.
How can I know that I won't just keep losing weight
until I waste away to nothing?
Patients may begin to wonder about this early after the surgery
when they are losing 20-40 pounds per month, or maybe when they've
lost more than 100 pounds and they're still losing weight. Two
things happen to allow weight to stabilize. First, a patient's
ongoing metabolic needs (calories burned) decrease as the body
sheds excess pounds. Second, there is a natural progressive increase
in calorie and nutrient intake over the months following weight
loss surgery. The stomach pouch and attached small intestine
learn to work together better, and there is some expansion in
pouch size over a period of months. The bottom line is that,
in the absence of a surgical complication, patients are very
unlikely to lose weight to the point of malnutrition.
What can I do to prevent lots of excess hanging skin?
Many people heavy enough to meet the surgical criteria for weight
loss surgery have stretched their skin beyond the point from
which it can "snap back." Some patients will choose
to have plastic surgery to remove loose or excess skin after
they have lost their excess weight. Insurance generally does
not pay for this type of surgery (often seen as elective surgery).
However, some do pay for certain types of surgery to remove
excess skin when complications arise from these excess skin
folds. Ask your surgeon about your need for a skin removal
procedure.
Will exercise help with excess hanging skin?
Exercise is good in so many other ways that a regular exercise
program is recommended. Unfortunately, most patients may still
be left with large flaps of loose skin.
Will I be miserably hungry after weight loss surgery
since I'm not eating much?
Most patients say no. In fact, for the first 4-6 weeks patients
have almost no appetite. Over the next several months the appetite
returns, but it tends not to be a ravenous "eat everything
in the cupboard" type of hunger.
What if I am really hungry?
This is usually caused by the types of food you may be consuming,
especially starches (rice, pasta, potatoes). Be absolutely
sure not to drink liquid with food since liquid washes food
out of the pouch.
Will I have to change my medications?
Your doctor will determine whether medications for blood pressure,
diabetes, etc., can be stopped when the conditions for which
they are taken improve or resolve after weight loss surgery.
For meds that need to be continued, the vast majority can be
swallowed, absorbed and work the same as before weight loss
surgery. Usually no change in dose is required. Two classes
of medications that should be used only in consultation with
your surgeon are diuretics (fluid pills) and NSAIDs (most over-the-counter
pain medicines). NSAIDs (ibuprofen, naproxen, etc.) may create
ulcers in the small pouch or the attached bowel. Most diuretic
medicines make the kidneys lose potassium. With the dramatically
reduced intake experienced by most weight loss surgery patients,
they are not able to take in enough potassium from food to
compensate. When potassium levels get too low, it can lead
to fatal heart problems.
What is a hernia and what is the probability of an abdominal
hernia after surgery?
A hernia is a weakness in the muscle wall through which an organ
(usually small bowel) can advance. Approximately 20% of patients
develop a hernia. Most of these patients require a repair of
the herniated tissue. The use of a reinforcing mesh to support
the repair is common.
Is blood transfusion required?
Infrequently: If needed, it is usually given after surgery to
promote healing.
What is phlebitis and is it preventable?
Undesired blood clotting in veins, especially of the calf and
pelvis. It is not completely preventable, but preventive measures
will be taken, including:
- Early ambulation
- Special stockings
- Blood thinners
- Pulsatile boots
Will I lose hair after surgery? How can I prevent it?
Many patients experience some hair loss or thinning after surgery.
This usually occurs between the fourth and the eighth month
after surgery. Consistent intake of protein at mealtime is
the most important prevention method. Also recommended are
a daily zinc supplement and a good daily volume of fluid intake.
Does hair growth recover?
Most patients experience natural hair regrowth after the initial
period of loss.
What are adhesions and do they form after this surgery?
Adhesions are scar tissues formed inside the abdomen after surgery
or injury. Adhesions can form with any surgery in the abdomen.
For most patients, these are not extensive enough to cause
problems.
What is the "Candida Syndrome?"
Some patients have a type of yeast present on the surface of
their skin, intestine or vagina at the time of surgery. This
leads to overgrowth in certain circumstances. A whitish coating
may occur on the tongue or throat. This syndrome is associated
with a frothy mucous, nausea, difficulty swallowing, sore throat,
loss of taste and appetite, and occasionally abdominal bloating
and diarrhea.
What causes it to appear?
It is promoted by the use of most antibiotics and some other
medications, by stress, by reduced immune response, and by
diabetes.
Can it be cured?
There are several effective medications now available for treating
the overgrowth of Candida.
What is sleep apnea (SA)?
It is the interruption of the normal sleep pattern associated
with repeated delays in breathing. Sleep apnea often shows
rapid improvement after surgery. In most patients, there is
a complete resolution of symptoms by six months following surgery.
Diet
How long will I be off of solid foods after surgery?
Most surgeons recommend a period of four weeks or more without
solid foods after surgery. A liquid diet, followed by semi-solid
foods or pureed foods, may be recommended for a period of time
until adequate healing has occurred. Your surgeon will provide
you with specific dietary guidelines for the best post-surgical
outcome.
What are the best choices of protein?
Eggs, low-fat cheese, low-fat cottage cheese, tofu, fish, other
seafood, chicken (dark meat), turkey (dark meat).
Why drink so much water?
When you are losing weight, there are many waste products to
eliminate, mostly in the urine. Some of these substances tend
to form crystals, which can cause kidney stones. A high water
intake protects you and helps your body to rid itself of waste
products efficiently, promoting better weight loss. Water also
fills your stomach and helps to prolong and intensify your
sense of satisfaction with food. If you feel a desire to eat
between meals, it may be because you did not drink enough water
in the hour before.
What is Dumping Syndrome?
Eating sugars or other foods containing many small particles
when you have an empty stomach can cause dumping syndrome in
patients who have had a gastric bypass or BPD where the stomach
pylorus is removed. Your body handles these small particles
by diluting them with water, which reduces blood volume and
causes a shock-like state. Sugar may also induce insulin shock
due to the altered physiology of your intestinal tract. The
result is a very unpleasant feeling: you break out in a cold
clammy sweat, turn pale, feel "butterflies" in your
stomach, and have a pounding pulse. Cramps and diarrhea may
follow. This state can last for 30-60 minutes and can be quite
uncomfortable - you may have to lie down until it goes away.
This syndrome can be avoided by not eating the foods that cause
it, especially on an empty stomach. A small amount of sweets,
such as fruit, can sometimes be well tolerated at the end of
a meal.
Is there a problem with consuming milk products?
Milk contains lactose (milk sugar), which is not well digested.
This sugar passes through undigested until bacteria in the
lower bowel act on it, producing irritating byproducts as well
as gas. Depending on individual tolerance, some persons find
even the smallest amount of milk can cause cramps, gas and
diarrhea.
Why can't I snack between meals?
Snacking, nibbling or grazing on foods, usually high-calorie
and high-fat foods, can add hundreds of calories a day to your
intake, defeating the restrictive effect of your operation.
Snacking will slow down your weight loss and can lead to regain
of weight.
Why can't I eat red meat after surgery?
You can, but you will need to be very careful, and we recommend
that you avoid it for the first several months. Red meats contain
a high level of meat fibers (gristle) which hold the piece
of meat together, preventing you from separating it into small
parts when you chew. The gristle can plug the outlet of your
stomach pouch and prevent anything from passing through, a
condition that is very uncomfortable.
How can I be sure I am eating enough protein?
40 to 65 grams a day are generally sufficient. Check with your
surgeon to determine the right amount for your type of surgery.
Is there any restriction of salt intake?
No, your salt intake will be unchanged unless otherwise instructed
by your primary care physician.
Will I be able to eat "spicy" foods or seasoned
foods?
Most patients are able to enjoy spices after the initial 6 months
following surgery.
Will I be allowed to drink alcohol?
You will find that even small amounts of alcohol will affect
you quickly. It is suggested that you drink no alcohol for
the first year. Thereafter, with your physician's approval,
you may have a glass of wine or a small cocktail.
Will I need supplemental vitamins?
B12 injections are sometimes suggested once a month for the first
year and every six months thereafter. B12 may also be taken
orally or sublingually (under the tongue) by many patients.
What vitamins will I need to take after surgery?
Most surgeons recommend a daily multivitamin for the rest of
your life.
Is it important to take calcium, iron, trace elements
or female hormone replacements?
Some patients require these supplements, but your need for these
can be determined by your surgeon.
Do I meet with a nutritionist before and after surgery?
Most surgeons require patients to consult with a nutritionist
before surgery. Counseling after surgery is available on an
individual basis as needed or required by your physician.
Will I get a copy of suggested eating patterns and food
choices after surgery?
Surgeons provide patients with materials that clearly outline
their expectations regarding diet and compliance to guidelines
for the best outcome based on your surgical procedure. After
surgery, health and weight loss are highly dependent on patient
compliance with these guidelines. You must do your part by restricting
high-calorie foods, by avoiding sugar, snacks and fats, and by
strictly following the guidelines set by your surgeon.
General
What is the youngest age for which weight loss surgery
is recommended?
Generally accepted guidelines from the American Society for
Bariatric Surgery and the National Institutes of Health indicate
surgery only for those 18 years of age and older. Surgery has
been performed on patients 16 and younger. There is a real
concern that young patients may not have reached full developmental
or emotional maturity to make this type of decision. It is
important that young weight loss surgery patients have a full
understanding of the lifelong commitment to the altered eating
and lifestyle changes necessary for success.
What is the oldest patient for whom weight loss surgery
is recommended?
Patients over 65 require very strong indications for surgery
and must also meet stringent Medicare criteria. The risk of surgery
in this age group is increased, and the benefits, in terms of
reduced risk of mortality, are reduced.
Can Weight Loss Surgery prolong my life?
There is good evidence from scientific research that if you have
Type 2 diabetes (or other serious obesity-related health conditions),
are at least 100 lbs. over ideal body weight, and are able
to comply with lifestyle changes (daily exercise and low-fat
diet), then weight loss surgery may significantly prolong your
life.
Can weight loss surgery help other physical conditions?
According to current research, weight loss surgery can improve
or resolve associated health conditions.
| Condition | Percentage found in preoperative individuals | Percentage cured 2 years after surgery |
| Diabetes or insulin resistance | 34% | 85% |
| High blood pressure | 26% | 66% |
| High triglycerides | 40% | 85% |
| Sleep apnea | 22% in males, 1% in females | 40% |
