Q: What is the effectiveness of weight-loss surgery?
A: The actual weight a patient will lose after the procedure is dependent on several factors. These include:
Weight before surgery
Overall condition of patient’s health
Ability to exercise
Commitment to maintaining dietary guidelines and other follow-up care
The motivation of patient and the cooperation of their family, friends and associates
Bariatric surgery is now accepted as the best and most effective treatment for morbid obesity. About 65 percent of all bariatric surgery patients are able to lose their excess weight and keep it off for more than five years.
More than 30 co-morbid conditions are associated with morbid obesity, the most serious of which are hypertension, diabetes, heart disease, stroke, obstructive sleep apnea, and degenerative joint disease.
Bariatric surgery is not only successful for weight loss, but also for preventing, improving or resolving type 2 diabetes. Recent studies demonstrate that bariatric operations, particularly gastric bypass, can achieve a resolution rate as high as 83 percent, rendering these patients normoglycemic. Other studies have shown that patients with a BMI as low as 30 may have a successful resolution of diabetes with gastric bypass surgery or gastric banding.
Preparation for Bariatric Surgery
Q: What are the routine tests before surgery?
A: 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. Other tests, such as pulmonary function testing, echocardiogram, sleep studies, GI evaluation, cardiology evaluation or psychiatric evaluation, may be requested when indicated.
Q: What is the purpose of all these tests?
A: 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’s 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.
Q: Why do I have to have a GI evaluation?
A: 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 percent of these patients may show early changes in the lining of the oesophagus 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 the 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.
Q: Why do I have to have a psychiatric evaluation?
A: 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.
Q: What impact do my medical problems have on the decision for surgery, and how do the medical problems affect risk?
A: 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.
Q: What can I do before the appointment to speed up the process of getting ready for surgery?’
• 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.
Questions about bariatric surgery
Q: Does laparoscopic surgery decrease the risk?
A: 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 stays, earlier return to work and reduced scarring.
Q: Will I have a lot of pain?
A: 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 pro 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.
Q: How long do I have to stay in the hospital?
A: This varies by procedure. Two to three days for a laparoscopic gastric bypass and sleeve gastrectomy.
Q: Will the doctor leave a drain in after surgery?
A: Not necessarily but 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.
Q: If I have surgery, what can I expect when I wake up in the recovery room?
A: 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.
Q: How soon will I be able to walk?
A: 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.
Q: How soon can I drive?
A: 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.
Q: What is done to minimize the risk of deep vein thrombosis/pulmonary embolism or DVT/PE?
A: 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.
Q: What should I bring with me to the hospital?
A: Basic toiletries (comb, toothbrush, etc.) and clothing, 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.
Life after bariatric surgery
Q: What do I need to do to be successful after surgery?
A: 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 flavoured 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.
Q: What’s so important about exercise?
A: 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.
Q: What is the right amount of exercise after weight loss surgery?
A: 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.
Q: Can I get pregnant after weight loss surgery?
A: 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.
Q: What if I have had a previous weight loss surgical procedure and I’m now having problems?
A: 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.
Q: What happens to the lower part of the stomach that is bypassed?
A: 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.
Q: How big will my stomach pouch really be in the long run?
A: 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 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 3 to 7 ounces.
Q: 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?
A: 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.
Q: What if I’m not hungry after surgery?
A: 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.
Q: Is there any difficulty in taking medications?
A: 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.
Q: Will I be able to take oral contraception after surgery?
A: Most patients have no difficulty in swallowing these pills.
Q: Is sexual activity restricted?
A: Patients can return to normal sexual intimacy when wound healing and discomfort permit. Many patients experience a drop in desire for about six weeks.
Q: Is there a difference in the outcome of surgery between men and women?
A: Both men and women generally respond well to this surgery. In general, men lose weight slightly faster than women do.
Q: Will I be asked to stop smoking?
A: Patients are encouraged to stop smoking at least one month before surgery.
Q: If I continue to smoke, what happens?
A: 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.
Q: How can I know that I won’t just keep losing weight until I waste away to nothing?
A: 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 the 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.
Q: What can I do to prevent lots of excess hanging skin?
A: 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.
Q: Will exercise help with excess hanging skin?
A: 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.
Q: Will I be miserably hungry after weight loss surgery since I’m not eating much?
A: 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.
Q: What if I am really hungry?
A: 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 wash food out of the pouch.
Q: Will I have to change my medications?
A: 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.
Q: What is a hernia and what is the probability of an abdominal hernia after surgery?
A: 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.
Q: Is blood transfusion required?
A: Infrequently: If needed, it is usually given after surgery to promote healing.
Q: What is phlebitis and is it preventable?
A: 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.
Q: Will I lose hair after surgery? How can I prevent it?
A: 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.
Q: Does hair growth recover?
A: Most patients experience natural hair regrowth after the initial period of loss.
Q: What are adhesions and do they form after this surgery?
A: 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.
Q: What is obstructive sleep apnea (OSA)?
A: 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 after bariatric surgery
Q: How long will I be off of solid foods after surgery?
A: 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.
Q: What are the best choices of protein?
A: Eggs, low-fat cheese, low-fat cottage cheese, tofu, fish, other seafood, chicken (dark meat).
Q: Why drink so much water?
A: 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.
Q: What is dumping syndrome?
A: 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 diarrhoea may follow. This state can last for 30 to 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 number 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 diarrhoea.
Q: Why can’t I snack between meals?
A: 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 regaining 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 fibres (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.
Q: How can I be sure I am eating enough protein?
A: 60-75 grams a day are generally sufficient. Check with your surgeon to determine the right amount for your type of surgery.
Q: Is there any restriction of salt intake?
A: No, your salt intake will be unchanged unless otherwise instructed by your primary care physician.
Q: Will I be able to eat “spicy” foods or seasoned foods?
A: Most patients are able to enjoy spices after the initial 6 months following surgery.
Q: Will I be allowed to drink alcohol?
A: 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.
Q: What vitamins will I need to take after surgery?
A: A daily multivitamin is recommended for the rest of your life. Depending on the type of surgery you have, B12, calcium with vitamin D, iron, and other trace elements may also be needed.
Q: Do I meet with a nutritionist before and after surgery?
A: Yes. All patients require supervised nutrition counselling prior to bariatric surgery. This time can vary from three months up to one year depending on your specific insurance plan. There also are dietitians on staff to see patients for follow-up care.
Q: Will I get a copy of suggested eating patterns and food choices after surgery?
A: 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 questions about bariatric surgery
Q: What is the youngest age for which weight loss surgery is recommended?
A: 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.
Q: What is the oldest patient for whom weight loss surgery is recommended?
A: 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.
Q: Can weight loss surgery prolong my life?
A: 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.
Q: Can weight loss surgery help other physical conditions?
A: According to current research, weight loss surgery can improve or resolve associated health conditions like diabetes, hypertension, sleep apnea, infertility and hyperlipidemia.
Q: Is Bariatric Surgery Right For You?
A: Bariatric surgery may be the next step if you remain severely obese after trying non-surgical approaches, or if you have an obesity-related disease. According to the National Institutes of Health, bariatric surgery should be considered only for a person diagnosed with morbid obesity; it is not for those with a mild weight problem. It is a serious undertaking, not a cosmetic procedure. Anyone thinking about undergoing this type of operation should understand that the surgery will cause a reduction in the number of calories you may consume, and you must commit to lifestyle and dietary changes to derive maximum benefit from the procedure. The surgery is not a cure, it is only a tool. Success is possible only with your full cooperation and commitment to behavioural change and medical follow-up, which must be carried out for a long time.
The following questions may help you decide whether weight-loss surgery is right for you:
• Do you meet the weight and health guidelines established to determine eligibility?
• Are you determined to lose weight and improve your health?
• Have you been unsuccessful at long-term weight loss using non-surgical methods?
• Are you well informed about the surgical procedure and the effects of treatment?
• Do you fully realize how your life may change after the operation, such as requiring you to chew food well and eat smaller meals?
• Have you been informed of the potential for serious complications, dietary restrictions, and occasional failures?
• Are you committed to lifelong medical follow-up and vitamin/mineral supplementation?
• Your doctor has told you that you have diabetes or prediabetes (your blood sugar level is higher than normal but not as high as with diabetes).