In general, after the initial consultation in the office, it can take anywhere from 4-16 weeks to have the gastric bypass surgery. Once we have gathered the information that we need, we send a letter to your insurance company for pre-approval for the procedure. Once obtained, you would then undergo an in-depth history and physical examination as well as some laboratory tests and x-rays. Once those are done, provided there are no additional or unexpected medical problems that would require treatment first, we would schedule your gastric bypass operation.
There are two ways the gastrointestinal tract can be altered to cause weight loss. The stomach can be made smaller (gastric restriction), so that a person feels full after eating less food. An analogy would be reducing the gas tank of your car from a 15 gallon tank to a 1 gallon tank.
The second mechanism is reducing the amount of intestine that the food comes in contact with. As a result, less of what is eaten is absorbed. Thus, malabsorption occurs.
Different operations use these two mechanisms in various ways. Certain operations are pure gastric restrictive procedures. Many combine gastric restriction with moderate malabsorption. Pure malabsorptive procedures are rare today. It is important to realize that there is no perfect operation, therefore we discuss the advantages and disadvantages of all potential procedures with our patients at their office visits, be it gastric bypass surgery or Lap Band®. Then, together we can decide which best addresses your particular needs.
To try to reduce some risk, you can do the following at least two months before surgery: increase physical activity, lose 10% of body weight, quit smoking a minimum of 8 weeks prior and quit drinking alcohol. Doing these things can not only help to reduce your risk but will also help to optimize your recovery.
Some of the specific risks related to weight loss surgery include:
Anastomotic leak – This is leaking from the staple line around the newly form ed pouch or at any new connections that have been made, including to the small intestine.
Dehiscence – Occurs when there is an opening or splitting apart of the surgical suture line.
Gastric Fistula – Which may occur when there is abnormal connection with the stomach, usually to other organs in the body.
Marginal Ulcer – This is an ulcer which can bleed or cause pain or perforation. It usually occurs at the margin of the pouch where it joins the small intestine.
Pulmonary Embolism – This is one of the most common risks or complications of any surgery. Usually a blood clot that is causing blockage of an artery in the lungs that has normally formed in the legs, has moved its way up. The result of this can be a heart attack, or even death. It is very important to get patients out of bed quickly after surgery and moving around. In addition, anti-clotting medications are given.
Wound Infection – This is when there is a penetration of bacteria to the site of surgical incision.
Wound Seroma – This is when there is a mass at the site of surgical incision caused by fluid within the tissue.
Bleeding – Surgery involves the cutting of tissues and blood vessels. When this is combined with a low dose blood thinner as it is for bariatric surgery, the risk of bleeding at wound edges increases. Currently fewer than1% of our patients experience a post-operative bleeding episode.
The most helpful thing you can do is to arrange for copies of your previous medical records to be mailed, faxed, or brought to our office prior to the initial consultation. Your records will show documentation of your weight and medical problems. We must include this information in the prior approval letter to your insurance company. The sooner you gather this information, the sooner we can contact your insurance company.
If you can arrange for your internist or your family doctor to refer you to a cardiologist and pulmonologist for pre-operative clearance, this will also speed the process. Waiting for those appointments until after your initial meeting with the surgeon can often slow your progress greatly. Depending on which hospital you choose you may also enroll early in their weight loss surgery program.
You will meet your primary surgeon. This is the doctor who will be performing the operation. The two of you will discuss your surgical weight loss options and, if you have made a decision about which operation you think is right for you, then your doctor will review all the questions you may have left regarding it. Your surgeon will review your medical history with you and perform a physical exam. The surgeon will answer any remaining questions you have and make certain you have all the information necessary to make a well-informed decision. If you cannot decide which operation is best for you, your surgeon may find medical reasons why one would be better than the other or be aware of other information that may help to guide you. Ultimately the decision is yours. If you have not yet obtained cardiac and pulmonary clearance we can assist you in locating local physicians who care for bariatric patients.
Patients of older age require very strong indications for bypass surgery and must also meet stringent criteria. The chances of surgery risks increase as age increases, but weight loss surgery can reduce the risk of mortality from obesity-related health conditions.
In medicine, there are no absolutes and each operation has advantages and disadvantages. For example, weight loss on average is better with a bypass than with a band. On the other hand, iron and calcium absorption are much easier following a band. A band is adjustable. Thus, it is important during your consultation that you and your doctor discuss your major health problems, concerns and expectations. If you want the operation that gives you the best chance to lose the most weight, a bypass is preferable. If you want to try something that probably will work and not change your anatomy, a band may be a better choice. Laparoscopy may be ideal for certain individuals and not others. Your surgeon will outline a strategy that works best for you.
All weight loss surgery patients require a full medical examination by a bariatric multidisciplinary team; including a psychologist, nutritionist, cardiologist, pulmonologist and medical doctor with experience with bariatric patients. Mandatory preoperative testing includes a complete blood count, blood chemistry, thyroid function tests, EKG, upper GI x-ray, possibly a gastroscopy, and chest X-ray. Females must have a pregnancy test to confirm they are not pregnant.
Weight loss surgery is considered successful when 50% of excess weight is lost and the loss is sustained up to five years. For example, a patient who is 100 pounds overweight should lose at least 50 pounds; a patient who is 200 pounds overweight should lose at least 100 pounds. And they should be able to maintain loss successfully for the following five years. Ninety-five percent of patients reach that goal after gastric bypass surgery. Furthermore, 85% of gastric bypass patients go on to lose 2/3 or more of their excess weight. Seventy-five percent of patients attain the goal after gastric banding.
Surgery should be considered for morbidly obese people who have failed non-operative weight loss options. They should be obese for several years and not have any active drug or alcohol addictions or major psychiatric disorders. In addition, the risk and emotional cost of their obesity should exceed the risk of having an invasive operation. Potential patients of CHRIAS should realize that while surgery provides the best chance of lasting weight loss, it comes at the cost of an invasive operation that carries risk.
People will have different reasons for exploring surgery for their obesity. Some have serious illnesses such as diabetes, sleep apnea, hypertension or degenerative joint disease caused by excess weight. For others, the primary motivation is the psychological impact the weight is having on their lives. Whatever the reason, it is essential to realize that surgery for obesity is a major operation that can have complications. Making the decision to have surgery requires careful thought.
The primary reason for our gastric bypass and Lap Band® surgery patients to see a psychologist is that obesity surgery is a tremendous adjustment. It results in many behavior modifications and takes away what is to many their drug of choice–food. This can cause frustration and depression.
Another reason is that most insurance companies require consultation before certifying your bariatric surgery procedure.
If you have a relationship with a psychologist or psychiatrist, or wish to see one that is in your plan, we may be able to accommodate this. We will require a written clearance. Since most insurers require this clearance, we suggest you make arrangements as soon as you can, since this can frequently delay surgery. Finally, the doctor you see should be familiar with obesity surgery.
Obesity is a serious medical disease. Severe obesity can negatively affect many aspects of an individual’s life. The strain of excess obesity can damage muscle, bones, and internal organs. The chances of heart disease, diabetes, sleep apnea, infertility, osteoarthritis, venous insufficiency, gallbladder disease, and certain cancers are increased by obesity. These risks increase as your weight increases. Obesity can also have social and psychological implications. Morbidly obese individuals face prejudice at school and at the work place. Social options are limited. When obesity gets very severe, people can become housebound, as they have difficulty walking and breathing. Obesity has become a major cause of disability. Additionally, there is an increased incidence of depression in those affected by morbid obesity.
The surgeons at CHRIAS stress that gastric bypass, banding or sleeve surgery for obesity is not the first option that should be used to treat your weight problem. In fact, if you can lose weight without an operation, we are overjoyed. Unfortunately, for many individuals who have been unsuccessful with diets, liquid preparations, pharmaceutical agents, nutritional counseling and exercise programs, long term weight loss is not possible without surgery. Surgery does not replace the need to exercise and make better food choices, but makes these goals realistic and provides a long-term control mechanism to assist in managing this chronic problem.
Surgery for weight loss can technically be reversed, but reversal procedures are usually more dangerous than the original ones. We have not yet considered reversal of any of our patients. It is important to note that anyone who has the operation reversed will regain the weight they lost after the first surgery.
It depends on which procedure and whether you have had previous abdominal operations. Our gastric bypass operations are usually completed in less than 2 hours and our band operations are complete in 60 to 90 minutes.
The amount of weight a patient will lose depends on a wide range of variables and cannot be predicted. It depends on your genetic makeup, how active you’ve become, what operation you select and numerous other factors. We do not accurately know how much you eat before surgery, how much you will be able to eat after, how much exercise you will do and what your metabolic rate is, thus no accurate prediction can be done.
On average, people lose approximately 75% of their excess weight after one year following a gastric bypass. With a gastric band weight loss is 45-55% of excess weight.
You should be reminded that an operation does not replace the need to make good decisions. Patients who adhere to a vigorous exercise routine frequently can reach a weight close to their ideal body weight and maintain it. Those that only rely on surgery and do not change their behavior and become more active will not have the same result.
It is our practice to do procedures safely with as minimally invasive an approach as is practical. Gastric bypass surgery is performed via the laparoscopic method where 6 tiny incisions are made in the abdomen and surgical instruments are inserted through ports. The Lap Bands® are also placed via the laparoscopic method. Surgeons reserve the right to perform standard open surgery when uncertain anatomy or safety concerns warrant a larger incision.
Obviously, the incision varies by patient size, health and whether the patient has had previous abdominal operations. For certain patients a minimally invasive approach is not possible. However, even when incisions are slightly larger, most are able to be discharged from the hospital in 3 to 4 days and require minimal pain medication at home.
Surgery should be considered when you feel you have explored all other options, or your condition is so severe that it requires rapid, urgent treatment. Nutritional counseling, exercise and group programs should all be considered prior to surgery. Local hospitals have weight loss centers that emphasize a behavioral and medical approach and may be better suited to some patients. Most insurance companies require substantial attempts at non- operative weight loss be documented prior to certifying surgery. Stated differently, if you can lose weight without an operation you are better off. If you cannot and obesity is affecting your health or quality of life, then surgery should be considered.
With laparoscopy, it is not necessary to cut through the muscle and the surgery is done through small incisions. The surgeon is able to clearly see the magnified operative field using a television monitor. Advantages include a reduction in potential wound complications, less pain, fewer hernias and a faster return to full activity. For gastric bypass patients, this approach is ideal for appropriate candidates. It is important to emphasize that even when surgery is done through small incisions, it is still a major operation. While we are doing more operations in this minimally invasive manner, time in the hospital, as well as immediate post-operative pain appear similar. Additionally, since the operation is the same with the exception of the size and number of abdominal incisions, a substantial part of the recovery is adjustment to new diet.
Patients will have a drain placed inside the abdomen during the surgery if they have bypass surgery. These are usually removed on the day of discharge. Bypass patients will also have a catheter overnight to monitor their urine output. This is removed on the first post operative day. It is our intention to make you as comfortable as possible while obtaining the information we need to safely monitor your postoperative care.
You will come to the hospital on the day of your bariatric surgery. The hospital will notify you one to two days before and give you your instructions. It is essential that all your preoperative testing is complete. You will be given instructions on where your family should wait during your surgery. Be sure to give your family those instructions, so we can locate them after surgery.
Patients are transported to the recovery room and remain there for several hours. After this they are transported to a regular hospital bed. All Lap Band® and gastric bypass surgery patients are sent to the same floor so that they can enjoy the benefits of a courteous staff familiar with their unique needs. The floor has been equipped with special equipment to monitor blood pressure, oxygenation, and heart rhythm. Rarely, our most ill patients may have to go to the ICU.
Your primary surgeon who you met at your first office appointment and likely at your pre-op second visit will be the lead surgeon. The CHRIAS practice is unique for their belief that the presence of 2 surgeons during your operation enhances the likelihood of your best outcome. This means that your primary surgeon will have one of his or her partners as their assistant. There may be a resident, physician assistant or nurse present in the room, however they are not doing your surgery.
Most insurance companies will cover this surgery. Some will fight coverage, but we have had great success in getting insurers to realize that this is necessary.
We give the insurance providers the information they need to understand why the surgery is necessary and what it involves. These operations are not being done for cosmetic purposes; they are being done to improve overall health and take the morbidity out of morbid obesity. Since obesity surgery can actually lessen the risk of death, it is medically necessary. After significant weight loss there is often a lot of excess skin.
Surgery to remove that skin will often not be covered by insurance. If, however, a hernia should have occurred after surgery and this requires additional surgery, removal of this skin can be done simultaneously and may be partially covered.
If we offer you a weight loss surgery procedure, it is because bariatric surgery is medically indicated. As a result insurance denials are uncommon. Independent health plans, such as unions, have their individual criteria and are far more unpredictable than major carriers. Additionally, certain plans have an exclusion for the treatment of obesity. This is becoming far less common, but still occurs. In terms of out of pocket expense, this is based on the plan that you have and on your insurance company.
After leaving the hospital, if you have fever and chills, severe abdominal pain or cannot hold liquids, it is important to call us as soon as possible. Our office phone is answered 24 hours a day, every day of the year. You should also call to schedule your follow-up appointment with your doctor. Your doctor will want to see you 2 weeks after your discharge from the hospital and schedule your regular follow ups.
Bypass and Sleeve Patients: Year 1: 2 weeks post-op, 4 weeks post-op, 3 months, 6 months, 9 months, 12 months Year 2: Every 6 months Year 3 and up: Once a year. Band Patients: Year 1: 2 weeks post-op, 6 weeks post-op and then a varied number of time intervals depending on whether your band needs to be adjusted. At a minimum, you will need to be seen once a year.
Yes. In the post-operative period, especially while using any pain medication, we recommend that you do not drive. Depending on how well you are recovering from your surgery, lifting may or may not be restricted. Certainly for the first two weeks most patients are not comfortable enough to do any heavy lifting. After that, if all is going well, you can lift as tolerated. We recommend that bypass patients not drive for the first two weeks post-op. Band patients may drive when they are off their pain medication and appropriately comfortable.
Yes. Many patients have given birth following bariatric surgery. However, several rules should be followed. You should not become pregnant until your weight loss has stabilized. While you are actively losing weight you would not want to support a growing fetus. Therefore, you should wait 18 months to 2 years before trying. You should make sure you are taking vitamins, iron and folate, and make sure your OB/GYN is familiar with gastric bypass surgery. We request that our patients follow with our surgeons, their ob-gyn doctor and be seen by a maternal fetal specialist.
Additionally, patients are now being referred for gastric bypass and/or Lap Band® surgery having abnormal hormone levels and infertility. While it is early, several with a variant of polycystic ovary syndrome have successfully conceived.
Another option, for females concerned with future pregnancies, is the Lap Band®. Since this is adjustable, it can be manipulated if caloric intake needs to be increased. Additionally, with this procedure, vitamin and mineral absorption is unchanged.
After gastric banding, almost any type of food is tolerated if chewed well enough. This is part of the reason that this surgery may not have as high a success rate as gastric bypass. Gastric bypass requires that you greatly reduce your intake of sweets and fats. You will experience “dumping syndrome” – physical symptoms such as abdominal cramping, sweating and general weakness when you consume too much fatty food or too many sweets.
Since part of the operation that you had slows the emptying of the stomach, and these agents can be harmful to the lining of the stomach we do not want you to take any NSAID medications again. These include aspirin, Motrin, ibuprofen, Advil, Aleve, and Nuprin. Tylenol and acetaminophen products may be used instead.
Yes. Vitamin and mineral supplements are required to help prevent nutritional deficiencies. Because of your limited intake and some malabsorption from the gastric bypass, certain vitamins and minerals will not be absorbed as well. Most people will require a multi-vitamin, calcium, and vitamin B12 supplement. The need for other vitamin and mineral supplements will be determined on an individual basis.
Come to the support group and speak to them. That is probably the best way to get insight. Most are extremely happy. Losing a substantial amount of weight has changed many parts of their lives. They report having more energy and many are able to do things that they were unable to do prior to surgery. Some feel that they have gotten parts of their lives back. There is an adjustment, but a substantial majority feels that the sacrifice is well worth it.
The dramatic results experienced by some of our Lap Band® and gastric bypass patients in the Tri-State area have been featured in newspapers, as well as in local and national television stories.
However, it is important to remember that certain people have a very difficult time after surgery. For some, food was their drug of choice and obesity surgery makes it unpleasant to eat. They become frustrated and depression can occur. Unfortunately, there is no medical test that can accurately predict how an individual will adjust. It is best to surround yourself with a good support system, come to support group and select a program that has a good aftercare program.
Fortunately, with the progressive way that laparoscopic bands are tightened and with gastric bypass surgery in general, our patients often do not throw up or vomit. After bariatric surgery however, nausea and vomiting are not uncommon following the procedure. Since the staple lines and band are placed above the area where most acid is produced, vomiting is not as harmful in the way that it is in bulimia.
Vomiting can have a mechanical cause such as food being stuck in the pouch or a narrowing in the area where the small bowel and stomach are attached. More frequently, vomiting occurs when you eat too much or too fast. To avoid this, put very small amounts of food on your plate and eat very slowly. Call your doctor if you are continuously having difficulty, and have problems even with liquids. Patients sometimes require an endoscopy to check the opening and gently stretch it if it is narrowed. By design this opening is very small and there is a fine line between narrowing and a stricture and the desired outcome of the operation. Nausea and vomiting after banding can usually be treated by adjustment and band deflation. Remember if you cannot tolerate liquids call your doctor immediately before you become dehydrated.
Regaining weight or even minimal weight loss does and can occur. This is usually directly related to consuming high fat and high sugar foods. Weight loss surgery will only help you lose weight. It is important to follow the nutritional guidelines as a part of your new lifestyle. It is best to avoid the following foods:
The widespread use of support groups has provided many weight loss surgery patients an excellent opportunity to discuss their various personal and professional issues. Most patients learn in support groups, for instance, that weight loss surgery will not immediately resolve existing emotional issues or heal the years of damage that morbid obesity might have inflicted on their emotional well-being. Most bariatric surgeons who frequently perform weight loss surgery will tell you that ongoing post-surgical support helps produce the greatest level of success for their patients.
Remember, alcohol is high in calories and can be absorbed into the blood stream faster after gastric bypass surgery. Thus we ask that our bariatric patients refrain from any alcohol after their operation.
You should get out of bed and start walking as soon as possible after surgery. We recommend that you exercise every day. Whether you have surgery or not, exercise is important to overall health. The more you exercise, the healthier you will be and the more weight you will lose. Since walking greatly accelerates weight loss, specifically fat loss, we suggest you walk every day. A good goal, after you have recovered fully, is to walk two hours each day.
Fruit juice is not generally considered a wise nutritional choice for the surgical weight loss patient. Juice takes the bulky fiber out leaving the high calorie, unfilling sugar part of the fruit. Calories taken with regular soda and juices are usually underestimated and should be avoided after obesity surgery. The juice industry has convinced you that you require orange juice for vitamin C. We suggest you eat fresh fruit that is far more filling, less fattening and has more nutritional value.
Prior to discharge, a dietitian will meet with you and give you dietary instructions. You need to eat plenty of protein. This can be obtained by eating 3 to 4 dairy products daily or a low calorie protein shake. Band patients will maintain a liquid diet for 4 weeks before progressing to pureed food then regular food and bypass patients will maintain a pureed or soft diet for 1 month before progressing to regular food.
You will receive a handout with dietary instructions when you are in the hospital.
This is one of the most common questions. As you start losing weight, you may notice excess skin. The amount of excess skin you experience is due to your weight loss, age, and smoking habits. Sometimes, patients choose to have plastic surgery to have this skin removed. There are several local surgeons who work very closely with our patients regarding plastic surgery.
This term refers to the emptying of concentrated food directly into the small intestine. Gastric bypass surgery empties food from the small stomach pouch directly into the small intestine without first being diluted with fluids in the rest of the stomach. Therefore, whatever you eat empties directly into the small intestine. Sweets and fatty foods irritate the small intestine and cause discomfort. Eating and drinking fluids simultaneously will also cause this dumping syndrome. This is why we recommend waiting half an hour between eating and drinking.
The worst thing that can happen is that someone can die. This is unusual, and the chance that it can happen is reduced by selecting physicians that specialize in bariatric surgical procedures and are experienced in handling complications that can arise during obesity surgery. Our CHRIAS bariatric surgery specialists certainly meet these criteria. Potential complications include, but are not limited to, the risk of anesthesia, infection, bleeding, blood clots, hernias, and wound complications. This is not stated to frighten you, but to remind you that this is a big decision and not without risk.
We advise all our patients, following gastric bypass surgery, to start taking a multi-vitamin and a calcium supplement. Many patients will also require iron supplementation. Frequently, after gastric bypass, patients are placed on anti-ulcer medications to prevent marginal ulceration where the stomach and intestine are attached. Finally, a medication called Actigal or Ursoforte is often given for 6 months to prevent the formation of gallstones during rapid weight loss. If you have had your gallbladder removed, this medication is unnecessary. Certain patients will require blood thinners for a brief time to inhibit the formation of blood clots and this is determined on an individual basis.
You should be as active as possible following bariatric surgery. This includes walking as much as possible. You can drive when you no longer are taking narcotic pain medications. Avoid heavy lifting. This means no more than 20 pounds for six weeks. This is the time it takes for the abdominal wall to heal. Sexual relations can be resumed when you feel up to it, and again plan on two to three weeks. Wait at least one month until swimming in a chlorinated pool. As stated above, bypass patients should not return to work for 4 weeks and band patient can return to work typically after 2 weeks.
There is no specific time limit when a post-operative patient can return to work. Certain patients, who have jobs that are not physically strenuous, have returned to work or school in one week. This is uncommon, and in general, it takes at least two to three weeks and occasionally more. The reason for delay is not pain, but lack of strength and difficulty making the adjustment to a different way of eating. Obviously, any medical complication can cause delay. For scheduling purposes, we suggest that you plan to be away from your job for a minimum of four weeks after bypass and 2 weeks after banding.
For patients with strenuous physical jobs, 6 weeks is necessary to allow for adequate healing. If arrangements can be made, you can return to light duty earlier.
Obviously there is discomfort. Most of our patients say that after having bariatric surgery, they experienced less pain than expected. It is our goal to make everyone comfortable so they can walk, take deep breaths, and expand their lungs. We utilize a variety of ways to maximize our patients’ comfort. These include patient-controlled analgesia pumps, epidural catheters similar to those used in childbirth, and medications administered by the nursing staff.
Hair loss after bariatric surgery is, unfortunately, common. There are a number of reasons why you may lose hair but it is generally reflective of poor protein intake. Until the shortened intestine learns to work effectively, you will be malabsorbing some nutrients–including protein. Hair loss tends to present itself around three to five months after surgery, but will stop if enough protein is consumed. Each meal should focus on protein intake, especially immediately following surgery. The nutrition team will help you with a protein-rich diet. There are many theories including shortage of zinc and protein. It is our belief that none of these are entirely accurate and the hair loss is secondary to changes in certain hormone levels with rapid weight loss.
At the beginning you will likely only eat approximately a few ounces of food. You will gradually advance your diet and by six to eight weeks you should be eating “regular” food. Your capacity will increase over the first six to nine months of surgery. The stomach pouch and small intestine learn how to work together over a period of months. Many patients notice a dramatic increase in the amount of food they can handle comfortably. This is normal in most cases. This is the time when the good habits developed in the first few months will support further weight loss.