Bariatric Surgery FAQs

Bariatric surgery is a procedure designed to make the stomach smaller so the patient feels satisfied with less food. It is intended for people who are 100 pounds or more overweight (with a Body Mass Index of 40 or greater) and who have not had success with other weight loss therapies such as diet, exercise, medications, etc. A person with a Body Mass Index (BMI) of 35 or greater and one or more co-morbid condition also may qualify for bariatric surgery.

Morbid obesity is a Body Mass Index (BMI) of 40 or more, which is roughly equal to 100 pounds or more over ideal body weight. The disease of morbid obesity interferes with basic physical functions such as breathing or walking. Long-term effects of the disease include shorter life expectancy, serious health consequences in the form of weight-related health problems (co-morbid conditions) such as type 2 diabetes and heart disease, and a lower quality of life with fewer economic and social opportunities.

The causes of morbid obesity are multiple and complex. Despite conventional wisdom, it is not simply a result of overeating. Research has shown that, in many cases, significant, underlying causes of morbid obesity are genetic, environmental, and social. Studies have demonstrated that, once the problem is established, efforts such as dieting and exercise programs have a limited ability to provide effective long-term relief.

BMI is a measure used to index a person’s height and weight. BMI allows healthcare professionals and patients to better understand health issues associated with a specific weight classification (classifications such as obesity and morbid obesity).

Patients should have:

• 100 pounds or more of excess weight; or a BMI of 40 or greater
• A BMI of 35 or greater with one or more co-morbid condition

Other common guidelines include:

• Understanding the risks of bariatric surgery
• Committing to dietary and other lifestyle changes as recommended by the surgeon
• Having a history of weight loss treatments having failed the patient
• Undergoing a complete examination including medical tests

Talk with your surgeon about the different surgical treatments, as well as the benefits and risks.

Remember:

• Bariatric surgery is not cosmetic surgery.
• Bariatric surgery does not involve the removal of adipose tissue (fat) by suction or surgical removal.
• The patient must commit to long-term lifestyle changes, including diet and exercise, which are key to the success of bariatric surgery.
• Problems after surgery are rare, but corrective procedures may be required.

As with any surgery, there are immediate and long-term complications and risks. Possible risks can include, but are not limited to:

• Bleeding
• Complications due to anesthesia and medications
• Deep vein thrombosis
• Dehiscence (separation of areas that are stitched or stapled together)
• Infections
• Leaks from staple lines
• Marginal ulcers
• Pulmonary problems
• Spleen injury
• Stenosis (narrowing of a passage, such as a valve)
• Death

Side effects include:

• Vomiting
• Dumping syndrome
• Nutritional deficiencies
• Gallstones
• Need to avoid pregnancy temporarily
• Nausea, vomiting, bloating, diarrhea, excessive sweating, increased gas, and dizziness

Open surgery involves the surgeon creating a long incision to open the abdomen and operating with "traditional” medical instruments. Laparoscopic, or minimally invasive, surgery is an approach that allows the surgeon to perform the same procedure using several small incisions, a fiber-optic camera, video monitor, and long-handled instruments.

Roux-en-Y (pronounced ROO-en-why) gastric bypass surgery is the most popular bariatric surgery in the United States. In this procedure, the surgeon creates a small stomach pouch and then constructs a “bypass” of some of the small intestine. The smaller stomach pouch restricts the amount of food the patient can comfortably eat, and the bypass decreases the number of nutrients and calories absorbed.

Gastric banding is a purely restrictive surgical procedure in which a silicone band is placed around the uppermost part of the stomach. The band is adjustable and can be periodically tightened or loosened depending on the patient’s needs.

Sleeve gastrectomy is a restrictive procedure which removes the majority of a patients’ stomach, decreasing the amount of food the patient can consume.

Studies show that bariatric surgery can effectively improve and resolve many co-morbid conditions. A review of more that 22,000 bariatric surgery patients showed:

• Improvement in or complete resolution of conditions including type 2 diabetes, hypertension, and sleep apnea
• 61.2% reduction of excess weight

+ Success measured as a loss of 10% of initial body weight.
++ Weight loss is not maintained once treatment ends.
+++ Success measured as a loss of 50% of excess body weight (equivalent to loss of approximately 20% to 25% of initial body weight).

Because every insurance policy is unique, it's important that you thoroughly understand your Certificate of Coverage to know exactly what is and isn't covered through your plan.

The qualification process includes a series of tests with your bariatric surgeon. You also will meet with a nutritionist, psychologist, and other support staff members in sessions leading up to surgery. Each healthcare professional will help you prepare for the changes and challenges that lie ahead. Most insurance companies require a 6 month physician directed weight loss attempt prior to surgery.

Certain basic tests typically are performed:

• Blood work
• Electrocardiogram
• Chest X-ray
• Nutrition consult
• Psychological evaluation

Other tests may include:

• Pulmonary function testing
• Sleep study
• GI evaluation
• Cardiology evaluation

Medical problems, such as serious heart or lung problems, can increase the risk of any surgery. On the other hand, many serious medical conditions may improve or resolve after successful bariatric surgery.

Bariatric surgery is like other major abdominal surgery. You can best prepare by knowing the benefits and risks of surgery, and by closely following your doctor's instructions.

• Understand the surgical process and what to expect afterward.
• Keep in mind that you’ll never be able to eat the way you did before, and that you’ll have to watch what and how you eat for the rest of your life.
• Talk to people who have had bariatric surgery.
• Write down your reasons for having bariatric surgery and outline your plans to maintain your weight loss after surgery.
• Practice the post-op diet, including the transition from an all-liquid diet, to pureed food, to a normal diet of smaller portions with 4 ounces of protein.
• Start a journal. Record how you feel now, the challenges you face, and the things you hope to be able to do after bariatric surgery.
• Ask your family and friends for their support. Talk to them about why you want to have bariatric surgery. It helps to have people behind you, waiting to help.

The surgeon will instruct you to undergo an aggressive two week pre-op diet, which has minimal carbohydrates. This will eliminate the body’s storage tank for carbohydrates, which is in the liver, in the form of glycogen. Decreasing the glycogen in the liver cause the liver to shrink, allowing better visualization during surgery and decreasing potential surgical complications.

There are two definitions for a co-morbid condition: the presence of one or more disorder or disease in addition to a primary disorder or disease; or, the presence of a disorder or disease that is caused by or otherwise related to another condition in the same patient. Common examples are diabetes, hypertension, sleep apnea, and GERD.

Type 2 diabetes is a long-term metabolic disorder where the body produces insulin, but resists it. Insulin is necessary for the body to utilize sugar.

• 83.8% of patients who had gastric bypass surgery experienced complete resolution of type 2 diabetes.4
• 47.8% of patients who had gastric banding surgery experienced complete resolution of type 2 diabetes.4
• Patients who had bariatric surgery had lower insulin resistance, and their risk for metabolic syndrome, high blood pressure, and high amount of fats in the blood also decreased.

Excess body weight is associated with an increased risk of heart disease, elevated cholesterol, and high blood pressure. These conditions can lead to heart attacks, strokes, and heart and kidney damage. Bariatric surgery reduces excess body weight over time, which decreases strain on the heart.

• 75.4% of patients who had gastric bypass surgery experienced complete resolution of high blood pressure.
• 38.4% of patients who had gastric banding surgery experienced complete resolution of high blood pressure.
• Changes in diet and exercise after surgery can lead to significant improvement of cardiovascular problems.

High cholesterol is a disorder of lipids—the fat-like substances in the blood. A common form of dyslipidemia is hyperlipidemia (or high cholesterol), the condition that exists when someone has too much of certain lipids in the blood. As these lipids build up inside the artery walls, harmful scar tissue and other debris begin thickening and hardening the walls. Long-term, this can lead to heart disease and high blood pressure.

• 95% of patients who had gastric bypass surgery experienced improved cholesterol health.
• 78.3% of patients who had gastric banding surgery experienced improved cholesterol health.

Obstructive sleep apnea is when breathing suddenly stops because soft tissue in the back of the throat collapses and closes during sleep. Morbid obesity can cause sleep apnea and other respiratory problems that may result in chronic fatigue. LINK TO GLOSSARY: MORBID OBESITY

• 86.6% of patients who had gastric bypass surgery experienced complete resolution of sleep apnea.
• 94.6% of patients who had gastric banding surgery experienced complete resolution of sleep apnea.

Acid reflux, also known as gastroesophageal reflux disease, is injury to the esophagus caused by chronic exposure to stomach acid. It is a serious disease that can cause esophagitis, Barrett’s esophagus, and esophageal cancer (adenocarcinoma).

• 98% of patients who had gastric bypass surgery experienced complete resolution of acid reflux/GERD.
• 32.3% of patients who had gastric banding surgery experienced complete resolution of acid reflux/GERD.

Morbid obesity may put you at a higher risk for several types of cancer, such as colon, breast, and kidney cancer. In 2003, an article in the New England Journal of Medicine estimated that obesity could account for:

• 14% of all deaths from cancer in men
• 20% of all deaths from cancer in women

Depression is an illness that involves the body, mood, and thoughts. It affects the way a person eats, sleeps, thinks, and feels. There are many reasons people with morbid obesity experience depression. Emotional health goes hand in hand with physical health. Lifestyle improvements and renewed health can help resolve depression. Weight loss, combined with counseling, can be very helpful in improving mental health.

• 47% of patients who had gastric bypass surgery experienced improvement of depression symptoms.

Osteoarthritis is one of the most common forms of arthritis. Known as the wear-and-tear kind of arthritis, osteoarthritis is a chronic condition in which there is a breakdown of joint cartilage. For anyone who is living with morbid obesity, the excess body weight placed on joints, particularly knees and hips, results in rapid wear and tear, and pain caused by inflammation. Bariatric surgery can reduce much of this weight over a long period of time and can be very effective in treating osteoarthritis.

• 41% of patients who had gastric bypass surgery experienced complete resolution of osteoarthritis.

Among women, morbid obesity is a risk factor for stress urinary incontinence, or uncontrollable urine loss. A large, heavy abdomen and relaxation of the pelvic muscles due to morbid obesity may cause the valve on the urinary bladder to weaken, leading to leakage of urine with coughing, sneezing, or laughing. Bariatric surgery has been found to improve stress urinary incontinence. Less weight is placed on the bladder, and other physical changes take place to improve this condition.

• 44% of patients who had gastric bypass surgery experienced complete resolution of stress urinary incontinence.

Reproductive health can be a concern for women struggling with morbid obesity. Issues such as infertility (the inability or reduced ability to produce children) and menstrual irregularities may occur due to morbid obesity. Fertility issues include possible miscarriage, reduced success with fertility treatments, and polycystic ovarian syndrome (PCOS). Additionally, women living with morbid obesity are more likely to have children with certain birth defects.30 A recent study of women following gastric bypass surgery showed improvement of multiple clinical problems related to infertility and PCOS.

• 100% of patients who had gastric bypass surgery experienced complete resolution of menstrual dysfunction due to PCOS.
• 79% of patients who had gastric bypass surgery experienced complete resolution of excess hair due to PCOS.
• Patients who had gastric bypass surgery experienced restored ovulation and fertility.

For many people, bariatric surgery is affordable because it is covered by their health insurance plan. People who do not have insurance coverage for bariatric surgery must pay for it on their own. This is called self-pay or cash-pay. Even without insurance, many people feel that the surgery is worth the investment in their health and seek out alternative financing options.

• Generally, the out-of-pocket costs for gastric bypass are between $20,000 and $30,000.
• Generally, the out-of-pocket costs for gastric banding and sleeve gastrectomy are between $14,000 and $18,000.
• The majority of the above expenses are from the hospital, not the surgeon.

Few people are able to pay cash up front for bariatric surgery. If you do not have health insurance coverage for bariatric surgery, there are alternative financing options available, such as medical loans.

It varies from person to person. Generally, the hospital stay (including the day of surgery) can be one or two days for a gastric band, two to three days for a laparoscopic gastric bypass and sleeve gastrectomy.

Most doctors recommend that women wait at least one year after the surgery before a pregnancy. Approximately one year postoperatively, your body should be fairly stable (from a weight and nutrition standpoint), and you should be able to carry a normally nourished fetus. Consult your surgeon as you plan for pregnancy.

Many people think bariatric surgery will be followed by a long and painful recovery period. However, most patients report experiencing only discomfort and soreness rather than pain. Recovery does, however, vary from patient to patient.

As with any major surgery, there will be a recovery period. Remember that this is a necessary step, and the better care you take during recovery, the more quickly you’ll return to normal activity.

In general, you can return to work 1 week after a lap band, and 2 weeks after a sleeve gastrectomy or gastric bypass

Bariatric surgery is not a quick fix. It’s an ongoing journey toward transforming your health through lifestyle changes. After surgery, you will feel satisfied and fuller with less food. Positive changes in your body, your weight, and your health will occur, if you maintain the diet and exercise routines recommended by your bariatric program.

The typical post-op instructions after a lap band are: Clear liquids for two days after surgery, then full liquids (protein shakes, yogurt, apple sauce, pureed foods, etc.) for two weeks, then regular diet. You should not drink with your meal, or for at least one hour after your meal once on a regular diet.

General post-op diet for the gastric bypass, and sleeve gastrectomy: Clear liquids for one week, then full liquid diet for 5 weeks. More elaborate diet plans and suggestions are available in hand-outs given by the surgeon’s office and / or the dieticians.

Your ability to resume presurgery levels of activity depends on your physical condition, the nature of the activity, and the type of bariatric surgery you had. Many patients return to normal levels of activity within three weeks of surgery.

Exercise is an important part of success after surgery. You may be encouraged to begin exercising, limited only by discomfort, about two weeks after surgery. The type of exercise depends on your overall condition, but the long-term goal is to get 30 minutes of exercise three or more days each week.

Most pills or capsules are small enough to pass through the new stomach pouch. At first, your doctor may suggest that medications be taken in crushed or liquid form.

Eating simple sugars (such as sugar, honey, and corn syrup) or high-fat foods can cause dumping syndrome in patients who have had gastric bypass surgery. This occurs when these products, which have a small particle size, are “dumped” from the stomach into the intestine at a rapid rate. Water is pulled into the intestine from the bloodstream to dilute the sugar load. This flush of water causes symptoms that can include diarrhea, rapid heart rate, hot flashes or sweating and clammy skin, and dizziness.

Band patients need to work with their surgeons to have their band adjusted ever 6-12 weeks during the first 18 to 24 months after surgery. The frequency of adjustments are then reduce, but a minimum of an annual adjustment is recommended for the rest of the patients life.

Bypass patients typically see their surgeons for three to five follow-up appointments the first year, then once per year thereafter. Over time, gastric bypass patients will need regular checks for anemia (low red blood cell count) and vitamin B12, folate, and iron levels.