Frequently Asked Questions (FAQ's)


These FAQ's are divided into the following topics:

Qualifying for Surgery

How overweight do I have to be to qualify for weight loss surgery?
Short Answer:
In 1991, the National Institutes of Health defined morbid obesity as a BMI of 35 kg/m2 or greater with severe obesity-related comorbidity (such as diabetes mellitus type II), or BMI of 40 kg/m 2 or greater without comorbidity. Insurance companies ultimately dictate whether they will pay for your operation based on your BMI, your weight loss attempt history, and your demonstration of commitment to a post-surgical weight loss program. The criteria that each insurance company uses individually is dynamic and subject to change at any moment.

Long Answer:
Severe obesity, sometimes known as "morbid obesity," is defined as being 100 pounds (45.5 kg) or 100% above ideal body weight according to the Metropolitan Life Insurance Company height and weight tables. Morbid obesity can also be defined as having a body mass index (BMI) greater than 40 kg/m2. BMI is a calculated number devised by using the formula - weight in kilograms divided by height in meters squared (kg/m2). Superobesity is used to define a patient who has a body weight exceeding ideal body weight by 225? or more, or a BMI of 50 kg/m2 or greater.

Calculate your BMI.
According to a large survey conducted by the Centers for Disease Control covering the years 2003-2004, 6.9% of all women and 2.8% of all men 20 years or older have a BMI which exceeds 40 kg/m2. By definition, all of these adults are considered to be morbidly obese.

Morbid obesity is associated with the development of life-threatening complications such as hypertension, diabetes, and coronary artery disease to name a few. Numerous therapeutic approaches to this problem have been advocated, including low calorie diets, drugs, behavioral modification and exercise therapy, but the only treatment proven to be effective in the long term management of morbid obesity is surgical intervention.

In 1991, the National Institutes of Health established the following guidelines for selecting patients for weight loss surgery:

  1. Patients should exceed ideal body weight by at least 100 pounds or 100% (BMI>40). Individuals who have a BMI between 35 and 40 and also have significant comorbidities such as diabetes, sleep apnea, or hypertension that is not responsive to medical management may also qualify for obesity surgery.
  2. They should have no known causative metabolic or endocrine causes for the obesity.
  3. They should have an objectively measurable complication (physical, psychological, social, or economic) that might benefit from weight reduction.
  4. They should be able to understand the full importance of the proposed surgical procedure, including all known and unknown risks.
  5. They should be willing to participate in long-term follow-up care.
  6. They should have attempted weight reduction using conservative treatment modalities without success.

Aside from qualifying on the basis of the criteria outlined above, each insurance company has their own set of criteria which define who they will allow to have weight loss surgery. Individual patients must contact their insurance plans to find out what additional criteria apply to them.

Preparation for Surgery

What are the most important things to know about a surgeon and a hospital prior to selecting one to perform my surgery?

Experience, commitment, and collaboration are critical. Because of the many health problems that obesity surgery patients have, most of the procedures are considered 'high risk.' The surgeon's experience is, therefore, crucial. You should ask your surgeon how many laparoscopic obesity operations he or she has performed. You should ask your surgeon how they trained to perform laparoscopic weight loss surgery. There have been several studies which have shown that at minimum, the learning curve for performing laparoscopic Roux-en-Y gastric bypass is 75-100 cases.

Another determining factor is the knowledge of your care team about weight loss surgery and collaboration among specialties. Weight loss surgery isn't just about losing weight. We believe that successful outcomes are best achieved if patients are educated by a multidisciplinary team, including nursing, dieticians and psychologists.

The University of Minnesota Weight Loss Surgery Center was named a Center of Excellence by the American Society for Bariatric Surgery (ASBS). The designation by the ASBS, the largest society for this specialty in the world, recognizes surgical programs with a demonstrated track record of favorable outcomes in bariatric surgery. Insurance payors use this designation as an indicator of where they will send patients and reimburse for treatment.

The Center's comprehensive services combine all aspects of weight loss, including surgical treatment options, pre-operative testing, education, nutritional counseling, psychological testing and support, and monthly support groups.

What are the routine tests before surgery?
Please see our step by step guide for more details about pre-operative testing. We do not view weight loss surgery as a trivial undertaking and there are significant risks for patients who are by all other accounts relatively healthy. Making sure that all unknown health conditions are diagnosed prior to surgery lowers the risk of elective surgery.

Patients must have a primary care physician to coordinate the preoperative work-up. We require psychological evaluation, dietary counseling, and a sleep study for all patients. These are the most common impediments to scheduling a surgery date.

Laboratory evaluation which checks for anemia, iron or vitamin deficiencies, thyroid dysfunction, evidence of infection, and other various blood and urinary problems are performed in all patients.

Select patients undergo studies of the esophagus and stomach depending on their history of diagnosis and symptoms and choice of operation. Gallbladder ultrasound is required for patients who have had symptoms of gallstone disease. Occasionally CT or MRI scans are obtained depending on patient history.

We require cardiology clearance for all women and men over the age of 55 or those with a history of cardiac illness. The age is lowered to 45 for all patients with a history of diabetes.

Consultation with pulmonary, hematology, gastroenterology or endocrinology physicians is requested selectively.

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. This is the best way to provide patients with the safest possible surgery.

Why do I have to have an upper GI study or upper endoscopy?
Patients who have significant gastrointestinal symptoms such as upper abdominal pain, heartburn, belching, fluid regurgitation, etc., may have underlying problems such as a hiatal hernia, gastroesophageal reflux or peptic ulcer disease. Up to 15 percent of reflux patients may show early changes in the lining of the esophagus, which could predispose them to cancer of the esophagus.

More importantly, access to the stomach after laparoscopic Roux-en-Y gastric bypass surgery more difficult. It is important to identify any changes in the lining of the esophagus or stomach before weight loss surgery, so that 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 apparent and dangerous at this time. It is important to have a clear picture of what to expect and how to handle it.

Patients with a diagnosis of obstructive sleep apnea are typically treated preoperatively by pulmonologists with a CPAP mask which assists in keeping the airway open. Patients need to know how to use this breathing mask in the event that we find it necessary to use this breathing treatment in the hospital.

Why do I have to have a psychological evaluation?
The most common reason a psychological 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. It is rare for psychologists to find absolute contraindications for surgery, but their input in assessing issues that might come up around the time of surgery and post-operatively is crucial to offering our patients safe weight loss surgery.

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 two to three months in advance. Once a patient is seen, if the surgeon and patient agree it is appropriate, the operation can usually be scheduled within six weeks. The span of time between initial evaluation and surgery oftentimes depends on insurance company requirements.

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 mammogram. For men, this may include a prostate specific antigen test (PSA). For all patients, we abide by the guideline to clinical preventive services, which are a set of age and gender-specific guidelines for preventive check-ups and maintenance.
  • Make a list of all the diets you have tried (a diet history) and bring it to your surgeon
  • 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. Smoking increases pulmonary and cardiac risk, and decreases blood flow to surgically created intestinal connections which increases the possibility of a post-operative leak.

Insurance Issues

Why does it take so long to get insurance approval?
After your initial consultation is completed, it usually takes your doctor one to two 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 three to four weeks or longer if you are not persistent in your follow-up. Our schedulers can work with you to help with the pre-authorization process. It will 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. Oftentimes our office needs to write letters to your insurance company to help them understand your condition and our plan.

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 one to five 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

How is laparoscopic weight loss surgery performed?
The "laparoscopic" approach to obesity surgery is different from the traditional "open" approach only in the method of accessing the stomach and intestines. In other words, the operations are exactly the same except in the laparoscopic procedure there are five to six small incisions (1/4 to 3/4 inch) instead of the 10 to 12 inch abdominal incision in the open procedure. In a laparoscopic procedure, the laparoscope which is connected to a video camera is inserted through the small abdominal incisions, giving the surgeon a magnified view of the patient's internal organs on a television monitor. The surgical specialized laparoscopic instruments are inserted into separate incisions. The entire operation is performed "inside" the abdomen after gas has been inserted to expand the abdomen.

What type of surgery is performed laparoscopically?
Laparoscopy refers to the small camera that is used inside the abdomen to guide the operation rather than a large incision which guides the surgeons eyes around the abdominal cavity.

We perform each of the operations for weight loss surgery laparoscopically. These include the Roux-en-y gastric bypass, laparoscopic adjustable banding, duodenal switch and the sleeve gastrectomy.

How safe is laparoscopic weight loss surgery?
No surgery is without risk and obesity surgery has particular risks. During the consultation visit, these risks will be discussed in detail so that an informed decision can be made. 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.

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.

What are the expected results after surgery for severe obesity?
Outcomes after weight loss surgery are a very important determinant of success for our patients and for us. The categories of outcome can be divided into different areas: 1.) weight loss at different time points, 2.) resolution or improvement of medical conditions caused by obesity, and 3.) risks of surgery, both short-term and long-term.

Weight Loss
Excess weight loss with the laparoscopic adjustable gastric band is lower than that with the gastric bypass or malabsorptive procedures, varying between 28% and 65% at 2 years and 54% at 5 years. The success rate for weight loss is reported as being slightly higher with the gastric bypass operation with 66-80% loss of excess body weight for the gastric bypass procedure. The patient's success with weight loss is dependent on appropriate food choices and a consistent exercise program.

Effect of surgery on associated medical conditions
Weight loss associated with bariatric surgery has been reported to improve conditions such as sleep apnea, diabetes, high blood pressure, and hypercholesterolemia. Many patients report an improvement in mood and other aspects of psychosocial functioning after surgery.

Because the laparoscopic approach is performed in a similar manner to the open approach, the long term results should be similar. Advantages of the laparoscopic approach include: reduced postoperative pain, shorter hospital stay (1-3 days), a faster return to work (5-10 days) and improved appearance.

What are the risks of obesity surgery?
The immediate operative mortality rate for the conventional operations, adjustable banded gastroplasty and gastric bypass has been relatively low in the reported case series (less than 1%). On the other hand, complications such as wound infections, wound breakdown, leaks from staple-line breakdown, stomal stenosis, marginal ulcers, various pulmonary problems, blood clots in the legs, band slippage, or port infection may be as high as 10% or more. In the latter postoperative period, other problems may arise that may require re-operative surgery. These problems may include pouch dilatation, persistent vomiting, gallstones, or failure to lose weight. Complication rates with re-operative surgery are higher than with primary operations.

In the long term, nutritional deficiencies such as vitamin B12, folate, and iron are common after gastric bypass and must be sought and treated. Another potential result of this operation is the so called "dumping syndrome," which is characterized by abdominal pain and diarrhea. Sometimes these symptoms may not respond to conservative measures and may be troublesome to the patient. Women who become pregnant after these surgical procedures need special attention from the clinical care team.

The preliminary data suggests that complication rates of the laparoscopic approach are equal to or less than the conventional approach. Following obesity surgery, patients must reorient themselves, and adjust to the effect of a changing body image.

What happens if the operation cannot be performed by the laparoscopic method?
Conversion of laparoscopic technique to open at the time of surgery is rare, occurring about 1% of the time. In all situations, the decision to convert to an open operation is based strictly on the patient's safety. Reasons for the surgeon to elect to convert to the open procedure include bleeding problems during the operation, or inability to visualize adequately.

For patients who have lost some weight before surgery and for patients who have never had abdominal surgery, intraabdominal infection, or radiation therapy to the abdomen, the rate of conversion to open surgery approaches zero.

Many of our patients have had gynecologic procedures such as tubal ligation, caesarian section, or hysterectomy. A history of these operations is associated with a very low conversion rate.

In almost all situations, we prefer a laparoscopic technique because recovery from surgery is quicker and the risk of infection and abdominal hernia is lower than with the open technique.

What should I expect if I choose to have laparoscopic weight loss surgery?

Before surgery:
A thorough pre-operative evaluation will be necessary as outlined in the step by step guide .
Directions for pre-operative preparation are outlined at this link.

Day of surgery:
You will arrive at the hospital the morning of the operation. The nursing team, anesthesia team, OR team, and surgery team will all visit you in the pre-operative room and make sure that all of your questions and concerns are answered.

Preparation before surgery includes changing into a hospital gown, placing an IV and giving preoperative medications as necessary.

It usually takes about one half hour from the time you leave the pre-operative room to the time we start the operation. The anesthesia team will induce general anesthesia and the laparoscopic operation then takes about two hours. After the operation, you will be brought into the recovery room and awaken fully before going to your hospital room. The time required to wake up varies, but can take 1-3 hours for most patients.

The surgeons talk to families in person or by phone during this time to discuss the operation and expected recovery time.

Family Medical Leave Act (FMLA) Paperwork
 

Example #1 - Filled out FMLA paperwork
Example #2 - Filled out FMLA paperwork

Do I qualify for medical leave for weight loss surgery?
Please check with your human resources department with your employer to determine if you are eligible for FMLA leave.

Where do I obtain FMLA paperwork?
Your employer should provide you with the appropriate paperwork.

When should I get my FMLA paperwork completed?
Please view the examples above for assistance in completing your FMLA paperwork. You are expected to complete your portion of the document prior to submission to the surgeon's office for completion. Bring your completed FMLA documents with you to your preoperative Bariatric Nurse visit.

Where do I send my FMLA paperwork to be completed for submission to my employer?
Please give your completed FMLA documents to the CMA or nurse at your bariatric visit for one of our healthcare providers to sign them. You will then be responsible for returning them to your employer.

What part of the FMLA paperwork do I need to complete?
In general, all FMLA paperwork contains the same text, but each employer typically has a slightly different version. Most contain numbered boxes.

You should fill in boxes 1, 2, 3, 4, 5a, 5b, 6a, 7b, and provide the type of practice ("Surgery"), the address of the surgical practice, and our telephone number. Please refer to the examples provided above as well as the instructions on your FMLA documents. We are not able to complete your documents without your assistance.

How does my FMLA paperwork get to my employer?
You will return your paperwork to your employer. Please ensure that you have filled out all sections to the best of your ability according to the instructions provided in the examples so that we can do this during your visit.

Where can I fax FMLA paperwork that I have filled out already and just need a healthcare provider signature?
You will need to bring your paperwork in person to your appointment.

The Hospital Stay

How long is the hospital stay?
The hospital stay for all of our patients is variable depending on the type of operation and underlying health of the patient. After laparoscopic adjustable gastric banding, patients may go home the same day or stay overnight.

After laparoscopic Roux-en-Y gastric bypass, the hospital stay is typically two days (48 hours). Before discharge, all patients must tolerate pain with just oral medications, be capable of ambulating independently, be able to urinate spontaneously, and have a bowel movement.

After laparoscopic duodenal switch, the hospital stay is between two and four days. Because we more typically perform this operation on patients who have a higher BMI (50+), these patients frequently have more medical problems and tend to require longer hospital stays.

Patients who undergo laparoscopic sleeve gastrectomy stay in the hospital for two to four days as well. Again, the indication for sleeve gastrectomy implies that the patient is more sick than patients on whom we perform gastric bypass. This means that we need to watch them more closely in the hospital before discharging them.

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. Various methods of pain control, depending on your type of surgical procedure, are available. Ask your surgeon about the pain management options.

Will the doctor leave a drain in after surgery?
Occasionally, 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 within the first 7 days after the surgery. Generally, it produces no more than minor discomfort.

What should I expect when I get home?
Patients are encouraged to engage in light activity and continue breathing exercises while at home after surgery. Pain after laparoscopic surgery is generally mild although some patients may require pain medications. At the first follow-up visit the surgeon will discuss with you any dietary changes.

How do I take care of my incisions?
After laparoscopic surgery, there are 5 or 6 small incisions on your upper abdomen and these are stapled closed at the end of the operation. The dressings are removed and steri-strips (special pieces of tape) are used to close the wounds. These may be removed after two weeks. You may shower after surgery.

If your required an open incision, staples will be used for closure and left in place for about 10 days. The staples will usually be removed by the surgeon on the first postoperative visit.

If I have surgery, what can I expect when I wake up in the recovery room?
Pain will be addressed at your doctor's direction. 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 one percent. Your doctors will have assessed you for risks and prepared accordingly.

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. We do not encourage sitting in the chair for the entire duration of your hospital stay for fear of developing blood clots in your legs. 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 seven to 14 days after surgery.

Is blood transfusion required?
Infrequently - If needed, it is usually given after surgery to promote healing.

What is thrombophlebitis and is it preventable?
Thrombophlebitis, also called deep venous thrombosis (DVT) is undesired blood clotting in veins, especially of the calf and pelvis due to prolonged inactivity. It can cause a condition called pulmonary embolism (PE) if pieces of clot break off from the calf and get impacted in the lung. It is not completely preventable, but preventive measures will be taken, including:

  • Early ambulation
  • Special stockings
  • Blood thinners
  • Pulsatile boots

What is done to minimize the risk of deep vein thrombosis/pulmonary embolism or DVT/PE?
Answer: 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

Surgical Treatment
A number of weight loss operations have been devised over the last 54 years. The most common procedure performed today is the Roux-en-Y gastric bypass. Laparoscopic Adjustable Banding (LapBand) and the Duodenal Switch are also common procedures. The gastric bypass procedure involves constructing a small gastric pouch which is constructed of a Y-shaped limb of small bowel of varying lengths (Roux-en-Y gastric bypass). Choosing between these procedures involves the surgeons' preference and consideration of the patient's eating habits and health history. The gastric bypass procedure generally results in greater weight loss but has a higher risk of nutritional deficiencies.

Life after Surgery

When should I call the surgeon after my operation?
Be sure to call your doctor if you develop any of the following:

  • Persistent fever (over 101? F)
  • Bleeding or excessive drainage from incision
  • Increased abdominal swelling or pain
  • Persistent nausea or vomiting
  • Chills
  • Persistent cough and shortness of breath
  • Difficulty swallowing that doesn't go away within a few weeks

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 30 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.

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 (15-30cc). In the first few months it is rather stiff due to natural surgical inflammation. About six to 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 three to seven 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 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 six weeks.

Can I get pregnant after weight loss surgery?
It is strongly recommended that women wait at least two years after the surgery before a pregnancy. Approximately 18 months to two years 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.

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. We might even consider canceling your surgery if you do not show compliance.

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 to 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 four to six 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 percent 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.

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 obstructive sleep apnea (OSA)?
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 will my diet be advanced after surgery?
The basic rules are simple and easy to follow.
Stage 1: Clear liquids
Drink only clear liquids for the first 7 to 10 days after surgery.
All medications need to be crushed for 2 weeks after surgery.
Stage 2: Pureed foods
Progress to a pureed diet 7 to 10 days after surgery at 1 week f/u appointment with Dr. and Dietitian. You will continue with this diet for about 3 weeks.
Start Chewable Multivitamin 7 days after surgery when seen in clinic and advanced to pureed diet.
Stage 3: Semi-soft foods
If your body can handle pureed foods, you will progress to semi-soft foods at the 1 month follow-up appointment. You may continue eating semi-soft foods from 2 weeks to several months.
Stage 4: Regular diet
After the 1 month follow-up appointment you will begin a soft diet and gradually advance to a regular diet about 6 weeks after surgery. Patients should never start a regular diet before 6 weeks after surgery.

How can I improve my chances of losing (and keeping) the weight off?
Adopting a healthy lifestyle, such as exercising, eating well-balanced meals, avoiding sugar and fatty foods, and following our other recommendations will improve your chances of losing and maintaining weight. Our multidisciplinary program, which has evolved over the past 40 years, includes thorough education in order to teach you how to succeed. In addition to a 2 1/2 hour educational class, each patient receives a reference book, written by our experts, about gastric bypass surgery.

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?
50 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 six 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?
Yes, Vitamin supplementation will need to be taken for the rest of your life.

What vitamins will I need to take after surgery?
Our surgeons recommend: Daily chewable multivitamin, B12 (under the tongue for better absorption), B complex, ferrous sulfate (iron tablet) and chewable calcium tablets.

Is it important to take 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?
Our 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?
Yes. 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 causes severe obesity?
Short Answer:
Severe obesity is most likely a result of genetic, psychological, environmental, social, and cultural influences that interact resulting in the complex disorder of both appetite regulation and energy metabolism. In obese persons, the set-point of stored energy is too high. This altered set-point may result from a low metabolism with low energy expenditure, excessive calorie intake, or a combination of both disorders. Most obesity experts do not think that severe obesity is simply a lack of self-control by the patient.

Long answer:
The cause of severe obesity is poorly understood and there are probably many factors involved. The most basic explanation for weight gain is often attributed to the first law of thermodynamics, which states that "the energy within a closed system remains constant." This law is often interpreted as follows: "if you eat it (energy intake), then you must burn it (energy expended), or you will store it as potential energy (weight gain)."

This interpretation of the first law of thermodynamics allows society to place responsibility for pathologic behavior (gluttony and sloth) on the obese individuals and absolves government, policy makers, and society of all blame.

A different interpretation of the first law of thermodynamics takes into consideration the fact that in many cases, we are genetically driven to store energy. In this paradigm, "if your must store potential energy to survive (necessary weight gain) because your body anticipates a need to burn calories (energy expenditure), then you must eat it (calorie intake).

There is scientific data that suggests obesity may be an inherited characteristic. It is known, for example, that children of parents with normal weight have a 10% chance of becoming obese while 80-90% of children of obese parents become obese themselves.

We also consume food that is very high in calories, and we consume too much food overall in the United States. Fast food restaurants have become a daily routine for most Americans and the meals sold in fast food restaurants have increased dramatically in calorie load. An average "happy meal" provides 1440 calories. Comparing current numbers with 1950s numbers, the average person now drinks 200 gallons of soda compared to 10 gallons, and we now consume 75 pounds of high fructose corn syrup compared to 0 pounds. The average portion size for a burger, soda, and popcorn were 6 ounces, 32 ounces, and 16 cups in 2001. The portions for the same orders were 1 ounce, 8 ounces, and 3 cups in 1957.

Our everyday behaviors have become more sedentary as hard work jobs have been replaced by heavy machinery, sidewalks are rarely constructed in suburban settings, and we are more and more reliant on automobiles.

All of these factors explain, in part, why morbid obesity has increased in prevalence in the United States.

What about medical treatment for morbid obesity?
In 1991, the National Institutes of Health Conference concluded that non-surgical methods of weight loss for patients with severe obesity are not effective in the long term, except in rare instances. Nearly all participants in any non-surgical weight loss program for severe obesity regained their lost weight within five years.

Although prescription and non-prescription medications (such as orlistat and sibutriamine) are available to induce weight loss, average weight loss in different studies has ranged from 5 to 11 pounds, and weight regain is rapid once the medication is stopped. More importantly, there is no established role for long-term medical therapy in the management of morbid obesity.

Behavior modification techniques, in conjunction with low calorie diets and increased physical activity, are used by various professional weight loss programs. Weight loss of one to two pounds per week has been reported; however, nearly all weight loss is regained after five years.

In the largest ongoing prospective study (SOS study) of non-surgical versus surgical therapy for weight loss, weight actually increased at both the 2 year time point (0.1% gain) and at the 10 year time point (1.6% gain) for patients who were in the medical group. In the surgery group, weight loss was 23.4% and 16.1% at the same time points, respectively.

What is the youngest age for which weight loss surgery is recommended?
Although 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, we currently offer surgery to those at least 20 years of age. 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 60 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 pounds. 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?

Disclaimer
This information is intended to provide a general overview of severe obesity and laparoscopic surgery. It is not intended as a substitute for professional medical care. Definitive recommendations may vary among health care professionals. Any question or concerns can be discussed with your doctor.


 
 

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