Preparation for Surgery
Certain basic tests are done prior to surgery: a complete blood count (CBC), urinalysis and a chemistry panel. Other tests, such as pulmonary function testing, echocardiogram, sleep studies, GI evaluation, cardiology evaluation or psychological evaluation, may be requested when indicated.
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.
The most common reason a psychological evaluation is ordered is that your insurance company may require it. Most psychologists evaluate your understanding and knowledge of the risks and complications associated with weight loss surgery and your ability to follow the basic recovery plan.
- 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.
- Make a list of all the diets you have tried (a diet history) and bring it to your doctor.
- Bring any pertinent medical data to your appointment with the surgeon - this would include reports of special tests (echocardiogram, sleep study, etc.) or hospital discharge summary if you have been in the hospital.
- Bring a list of your medications with dose and schedule.
- Stop smoking. Surgical patients who use tobacco products are at a higher surgical risk.
Insurance
Payment may be denied because there may be a specific exclusion in your policy for obesity surgery or "treatment of obesity." 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 psychological evaluation, illustrating that you have tried unsuccessfully to lose weight by other methods.
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.
Surgery
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 complications and speeds recovery. Often several medications are used together to help manage your post-surgery pain. While 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.
This varies by procedure. The laparoscopic adjustable gastric band is done on an outpatient basis with a possible overnight stay. The sleeve gastrectomy usually requires a one to two night stay. And you can usually expect a two to three day stay for the gastric bypass and biliopancreatic diversion with duodenal switch.
Depending on your surgeon and the procedure performed you may 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.
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.
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.
The Hospital Stay
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.
Basic toiletries (comb, toothbrush, etc.) and clothing may be provided by the hospital, but most people prefer to bring their own. Choose clothes for your stay that are easy to put on and take off. Because of your incision, your clothes may become stained by blood or other body fluids. Other ideas:
- Reading and writing materials
- Crossword and other puzzles
- Personal toiletries
- Bathrobe
Life after Surgery
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, include a protein at every meal and snack. Protein in the form of lean meats (chicken, turkey, fish) and other low-fat sources (should be eaten first. These should comprise of at least half the volume of the meal eaten. Reduce or eliminate your intake of simple/refined sugar and high fat junk foods.
- Drink at least 64 oz of water each day. Water must be consumed slowly, 1-2 mouthfuls at a time, due to the restrictive effect of the operation.
- Increase you activity and develop a routine. Aerobic activity is encouraged and weight/resistance training as instructed by your doctor.
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. Exercise will communicate to your body that you want to use your muscles and force it to burn the fat instead.
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.
This can vary by surgical procedure and surgeon. Immediately after surgery the pouch is limited due to natural surgical inflammation. Over time this increases by about six to 12 months after surgery, the stomach pouch can expand and most patients end up with a meal capacity of 3 to 7 ounces depending on procedure and technique.
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 on X-ray. 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 and they will not set off airport metal detectors.
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.
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. It is recommended that chewable vitamins be taken for improved absorption.
Patients are encouraged to stop smoking at least one month before surgery. 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.
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.
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.
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.
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 medicines that need to be continued, the vast majority can be swallowed, absorbed and work the same as before weight loss surgery. 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.
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. There are also nutritional supplements that are found effective in reducing hair loss.
Sleep apnea 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
This varies by procedure and surgeon. A liquid diet, followed by semi-solid foods or pureed foods, may be recommended for a period of time until adequate healing has occurred. Generally with the gastric band the progression is faster and with the bypass it’s the slowest. Your surgeon will provide you with specific dietary guidelines for the best post-surgical outcome.
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.
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. 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 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 amount of sweets, such as fruit, can sometimes be well tolerated at the end of a meal.
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.
60-80 grams a day are generally sufficient for most people but some patients may have higher dietary requirements. Check with your surgeon to determine the right amount for your type of surgery.
Most patients are able to enjoy spices after the initial 6 months following surgery.
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 should only partake of alcohol in moderation.
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.
Yes. All insurance companies require a Dietary evaluation with a registered dietitian, and certain plans may require a supervised diet prior to bariatric surgery. This time can vary from three months up to one year depending on your specific insurance plan. Following up with a dietitian after surgery can assist you to stay on track and encourage ongoing success.
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
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. Patients over 65 require strong indications for surgery and must also meet stringent Medicare criteria. The risk of surgery is weighed against the benefits for quality of life. A discussion with your surgeon is required to determine your individual benefits of surgery.
Statistically patients can expect maintain significant weight loss long term. It is rare to regain all the weight lost if proper nutrition and lifestyle changes are maintained. However, the disease of obesity causes biological changes that make one more susceptible to weight regain. Therefore follow up and support are essential to long term success.