After we talked, I had to hide the tears coming down my face from my co-workers around me. Many of your words hit home in regards to the pain, shame, anguish and such, throughout your lifelong struggle. I know you're a busy guy but I wanted to say "thank you" for opening yourself up to help me and others. You have not only helped me prepare me for the upcoming surgery, but also helped me get in touch with deep-seated feelings I've carried around for years and never confronted.
— Robert

Your insights are so true. I eat for all of those reasons. I am sitting at my desk trying not to burst into tears. I can't even begin to describe or understand the raw emotions that you have brought out in me, I feel like you have stirred an emotional wave into my heart and it just keeps going! Thank you.
— Sue

Weight Loss Surgery FAQs (Frequently Asked Questions)

These WLS Frequently Asked Questions (FAQs) are intended to provide a general overview of morbid obesity and Weight Loss Surgery. They are not intended as a substitute for professional medical care. Definitive recommendations may vary among health care professionals. Any question or concerns should be discussed with your doctor and/or bariatric clinic.

Primary sources of information utilized include; University of Pittsburgh Medical Center Surgical Bariatric Surgery Program, http://horizon.upmc.com/Bariatric.htm; The Doctor’s Guide To Weight Loss Surgery, www.weightlosssurgeryguide.com; and Snyder Bariatric of Alaska, http://www.snyderbariatric.com. Special thanks to these sources for their information….

What is Bariatric Surgery?

What is "clinically severe obesity" or “morbid obesity”?

What causes morbid obesity?

Who is a candidate for Weight Loss Surgery?

What is BMI?

How do I calculate my BMI and “Ideal Body Weight”?

Will my insurance pay for my Weight Loss Surgery?

If I have to pay for this procedure myself, how much will it cost?

I feel guilty about my obesity, and I feel embarrassed that I can’t take off the excess weight myself? Isn’t this my fault?

Why Should I Consider WLS?

What are the risks of having Weight Loss Surgery?

What are the risks of NOT having the surgery?

Does my weight alone justify such extreme measures?

Can’t I lose my excess weight through diet and exercise, and avoid the risks and complications that can result from major surgery?

Why can’t I use prescription medications to take off my excess weight?

Can someone be too old to be considered a candidate for WLS?

How is morbid obesity treated?

How is laparoscopic Weight Loss Surgery different from “open” surgeries?

What will all the staples do inside my abdomen? 

How is Weight Loss Surgery different from liposuction?

What are the expected results after surgery for severe obesity?

What should I expect my life to be like after Weight Loss Surgery?

What and how will I eat after WLS?

When and how much should I exercise after surgery?

Can I become pregnant after WLS? Must I postpone pregnancy?

What kind of long-term post-operative medical follow-up will I need?

What’s the value of joining a WLS Support Group?

When should I call my doctor?

How do I find a qualified and experienced doctor to perform my Weight Loss Surgery?

What can I do before my initial appointment with my bariatric surgeon to speed up the process? [information source: www.sabariatric.com]

What exactly does the surgeon do in performing a Roun-en-Y gastric bypass procedure?

What exactly does the surgeon do in performing a VBG?

How long will I be in the hospital?

When I tell people I’m considering WLS, many have something negative to say. Why does WLS have such a bad reputation?

I love to eat. What will keep me from overeating after my WLS?

A year after surgery, are most people generally happier with their lives?

How can I know that I won't just keep losing weight until I waste away to nothing?  

How big will my stomach pouch be in the long run? 

Will I be hungry after WLS, since I'm not eating much? 

What can I do to prevent folds of excess hanging skin?   

Will I have to change my medications?   

What kinds of problems do WLS patients typically experience after their surgery?

What is Bariatric Surgery?

ariatric or Weight Loss Surgery (WLS) is major surgery. It’s a “last resort” that provides morbidly obese individuals with a realistic second chance for a better, healthier, and longer life. WLS can improve a patient's overall quality of life by increasing self-esteem and mobility. There are two common procedures used for weight loss surgery:
restrictive procedures - to reduce food intake; and/or malabsorptive procedures - to alter digestion.

Weight Loss Surgery comes with no guarantees. Every body reacts differently, and the surgery is neither a quick fix nor an easy way to lose weight. It is a tool, albeit a very powerful tool with proven effectiveness. A WLS patient will only succeed if they make and keep a lifelong commitment, and conscientiously make recommended dietary, exercise, and lifestyle changes.

To help patients achieve their goals and deal with the changes that surgery and weight loss can bring, most bariatric surgeons offer follow-up care that includes support groups, consultation by dietitians, and other forms of continuing education.

Many insurance providers offer coverage for bariatric surgery, providing the patient meets minimum requirements. Others do not. There is a growing trend to classify obesity as a disease, and many WLS patients and surgeons are advocating universal and mandatory insurance coverage of Weight Loss Surgery procedures.

What is "clinically severe obesity" or “morbid obesity”?

Severe obesity, often called "morbid obesity", is defined as being 100 lbs. or 100% above ideal body weight according to standard health care industry height and weight tables. Between 3 and 5% of the US adult population has severe obesity. This condition is associated with the development of life-threatening complications such as hypertension, diabetes, and coronary artery disease. Numerous treatment approaches have been explored, including low calorie diets, drugs, behavioral modification and exercise therapy, but the only treatment proven to be effective in the long term management of morbid obesity is surgical intervention.

What causes morbid obesity?

Many factors seem to be involved. In obese persons, the “set-point” of stored energy is too high. This altered set-point may result from a low metabolism with low energy expenditure, excessive caloric intake, or a combination of both disorders. There is some scientific data that suggests obesity maybe be an inherited characteristic. Severe obesity is most likely a result of genetic, psychological, environmental, social, and cultural influences that interact -- resulting in the complex disorder of both appetite regulation and energy metabolism. Severe obesity is not simply a lack of self-control or willpower by the patient.

Who is a candidate for Weight Loss Surgery?

Usually a candidate for Weight Loss Surgery must have clinically severe obesity, also known as morbid obesity. This means your BMI must be higher than 40, or you must be at least 100 lbs above your ideal body weight. You may be a candidate if you're less than 100 pounds overweight, if you also have significant health problems due to your weight, such as Type 2 diabetes. Most people with clinically severe obesity are good candidates for surgical treatment -- as long as they understand the procedure, don't have a severe, pathological eating disorder and are willing to come back for life long follow-up. 

The following guidelines for selecting patients for obesity surgery were established by the National Institutes of Health:

1. Patients should exceed ideal body weight by at least 100 lbs. or 100%.
2. They should have no known causative metabolic or endocrine causes for the morbid obesity.
3. They should have an objectively measurable complication (physical, psychological, social, or economic) that might benefit from weight reduction.
4. They should be intelligent enough to understand the full importance of the proposed surgical procedure, including all known and unknown risks.
5. They should be willing to be observed for a prolonged period.
6. They should have attempted weight reduction, using conservative treatment modalities, without success. In rare circumstances, patients who are not quite 100 lbs. or 100% above the ideal body weight are candidates for surgical intervention if they have significant medical problems that might benefit from weight reduction.

What is BMI?

It stands for Body Mass Index and it determines someone's health risk related to their weight. A BMI greater than 40 -- or greater than 35 with associated medical problems -- means you have clinically severe obesity which is associated with diabetes, heart disease, high blood pressure, high cholesterol, heartburn, gallstones, arthritis, urinary stress incontinence, infertility, and some types of cancer.

How do I calculate my BMI and “Ideal Body Weight”?

Ideal Body Weight is equal to 100 lbs for the first 5 ft + 5 lbs for each additional inch for women, and 106 lbs for the first 5 ft + 6 lbs for each additional inch for men. BMI can be calculated using the following formula: Multiply your weight in pounds by 704, then divide by the square of your height in inches. For example, if you weigh 130 pounds and are 5'4" (64") tall, your BMI is (130 * 703)/(64 * 64) = 22.3. (If you use the metric system, divide your weight in kilograms by the square of your height in meters.) There are also height and weight tables that tell you your BMI, and the “Resource Links” on this website can connect you with online BMI Calculators. 

Will my insurance pay for my Weight Loss Surgery?

It depends. Some health insurance plans specifically exclude coverage for WLS. You can begin the process by calling your insurance carrier's 800 number and asking if "Weight Loss Surgery is covered for the morbidly obese?" Surgeons send each insurance carrier a comprehensive evaluation of the patient's health. The insurance company may approve appropriate candidates for the surgery on a case-by-case basis. Be aware that the insurance approval process can be difficult, and you should work with an experienced team. Your surgeon’s staff may help; there are also WLS email groups and organizations (see “Resource Links”) that may offer you help in convincing your insurance company to approve you for the surgery.

If I have to pay for this procedure myself, how much will it cost?

Costs vary by region and surgeon. Generally speaking, the surgery may cost $25,000 or more, depending upon your particular circumstances and needs.

I feel guilty about my obesity, and I feel embarrassed that I can’t take off the excess weight myself? Isn’t this my fault?

Morbid obesity is a medical condition requiring medical treatment. It is not a result of some character defect or weakness in you. There’s no reason to feel shame or guilt because you need a tool to deal with your excess weight. Obesity tends to run in families. Several genes, and their corresponding hormones (leptin), have been found to be at least partially responsible for obesity. Consequently, there is substantial evidence that obesity is at least partially biological, helping to reduce the misconception that it is a behavioral or psychological disorder.

Why Should I Consider WLS?

Weight Loss Surgery works! Numerous studies suggest that Weight Loss Surgery is the ONLY treatment that reliably produces significant and sustained weight loss. That’s why surgical treatment for clinically severe obesity has been endorsed by the National Institutes of Health, the World Health Organization, Shape-Up America, the American Heart Association, the American Dietetic Association, and the American Obesity Association. WISH Bariatric Centers have reported that their patients lose as much as 70 percent of their excess weight within one to two years after surgery. Other studies show that more than 92% of American WLS patients achieve and maintain long-term weight loss.

What are the risks of having Weight Loss Surgery?

While there are risks inherent in any major surgery, the rates of death (0.5 - 1%) or complications (5-10%) from Weight Loss Surgery are comparable to those for most other major surgeries. Virtually 100% of WLS patients experience some limitations of their food choices, and most experience limited stomach capacity. The two most important factors with respect to mortality and complication rates seems to be the experience and proven competence of the bariatric surgeon, and the patients’ willingness to follow their surgeons’ instructions for post-op care and eating.

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

In the long term, nutritional deficiencies with respect to vitamin B-12, folate, and iron are common after gastric bypass (RNY) and must be treated. Another potential result of this particular operation is the so-called "dumping syndrome", which is characterized by abdominal pain and diarrhea. Sometime these symptoms may not respond to conservative measures and may be troublesome to the patient. Women who become pregnant after these surgical procedures need special attention from the clinical care team.

The preliminary data suggests that complication rates of the laparoscopic approach are equal to or less than the conventional approach.

What are the risks of NOT having the surgery?

The risks to the health and life of a morbidly obese individual from NOT losing their excess weight seem to be far greater than the risks of death or complications from having WLS. People with clinically severe obesity are at great risk for developing many associated medical conditions. Research has shown that morbid obesity is associated with such debilitating and costly diseases as diabetes, heart disease, high blood pressure, high cholesterol, heartburn, gallstones, arthritis, urinary stress incontinence, infertility, and some types of cancer.

Does my weight alone justify such extreme measures?

Yes. Morbid obesity is an independent risk factor for premature death, with the risk rising as the BMI increases. People with a BMI of 30 have a relative risk of dying early that is 1.3 times greater than normal weight individuals. By the time the BMI is 40, the risk is close to 3 times as great.

Can’t I lose my excess weight through diet and exercise, and avoid the risks and complications that can result from major surgery?

If dieting and exercising worked for many morbidly obese people, it would be a sensible and preferable alternative. Unfortunately, 95% of diets fail and that is why WLS is currently the only viable weight loss option for many morbidly obese people, according to endocrinologist David Cummings of the Veterans Affairs Puget Sound Health Care System. Most people can lose no more than 5-10% off their "natural" body weight by exercising and eating wisely. Decades of diet studies show that more than 90% of people who lose weight by dieting gain it all back within 5 years. At some point, dieting and exercise may stop being viable options.

Why can’t I use prescription medications to take off my excess weight?

Drug treatment does produce limited success (usually weight loss of about 35 - 40 pounds). However, concerns about the safety of long-term treatment have limited the drugs available and the length of time people can take them. This in turn, limits their effectiveness because, as with any chronic disease, such as diabetes or high blood pressure, a medication is only effective as long as it is taken.

Can someone be too young to be considered a candidate for WLS? People can be too young. They need to have stopped growing and must have a “mature bone age”. Of course patients must be old and mature enough to understand the surgery and choose it. This is not a surgery to have to please friends or parents. The patient must be able to give "informed consent", which means they have made an educated decision and given their permission for the procedure. It is also vital that the parents of a young patient support their decision and understand the role they will need to play in their child’s post-op care and recovery. 

Can someone be too old to be considered a candidate for WLS?

Age is one factor that needs to be considered together with all other aspects of a person's health. There should not be arbitrary or absolute cut offs. Many surgeons have performed WLS on patients in their late 60s and early 70s, with excellent results.

If I am severely overweight, have diabetes, hypertension, and congestive heart failure, am I "too sick" to be a candidate for WLS? If you are overweight with associated problems due to obesity, you are not too sick to have this operation! You may be too sick NOT to have it. The only chance you have for improvement in your medical conditions is through weight loss. Surgery deserves consideration.

Medical problems such as serious heart or lung problems can increase the risk of any major surgery.  If they are problems that are related to the patient's weight they also increase the need for surgery.  In other words, severe medical problems will usually not dissuade the surgeon from recommending bariatric surgery if it is otherwise appropriate, but he/she will estimate your risk as higher than average.

Is there a limit on how heavy a patient can be and still have WLS? Bariatric surgeons have successfully operated on patients who weight up to 800 lbs., with a BMI of 100. Of course the operative risks are higher the more you weigh, but they still don’t approach the risk of remaining morbidly obese.

How is morbid obesity treated?

Medical Treatment: In 1992, the National Institutes of Health concluded that non-surgical methods of weight loss for morbidly obese patients are generally not effective in the long term. Data reviewed at that time showed that nearly all participants in any non-surgical weight loss program for severe obesity regained their lost weight within five years. Although prescription and non-prescription medications are available to induce weight loss, no one seriously suggests their long-term use in the management of morbid obesity. Drugs that reduce appetite can result in an 11 to 22 pound weight reduction; however, weight regain is rapid once medication is withdrawn. Behavior modification techniques, in conjunction with low calorie diets and increased physical activity, are used by various professional weight loss programs. Weight loss of one to two pounds per week have been reported; however, nearly all weight loss is regained after five years.

Surgical Treatment: A number of weight loss operations have been devised over the last 40 years. The two operations recognized by most surgeons today include the vertical banded gastroplasty (VBG) and the Roux-en-y gastric bypass (RNY). The vertical banded gastroplasty involves the construction of a small pouch with a restricted outlet to the lower stomach. The outlet maybe externally reinforced to prevent disruption and dilation. The gastric bypass procedure involves constructing a small gastric pouch which is constructed of a Y-shaped limb of small bowel of varying lengths (Roux-en-y gastric bypass). Choosing between these procedures involves the surgeons' preference and consideration of the patient's eating habits. The gastric bypass procedure generally results in greater weight loss, but poses a higher risk of nutritional deficiencies.

How is laparoscopic Weight Loss Surgery different from “open” surgeries?

The laparoscopic approach to obesity surgery differs from the traditional "open" approach -- which uses a 10-12” incision -- only in the method of accessing the stomach and intestines. The operations are exactly the same as the open approach except that 5-6 small incisions (1/4 - 1/2 inch) are used instead of the 10 – 12” abdominal incision. In a laparoscopic procedure, the laparoscope, which is connected to a video camera, is inserted through the small abdominal incisions, giving the surgeon a magnified view of the patients internal organs on a TV monitor. The entire operation is performed "inside" the abdomen after gas has been inserted to expand the abdomen. The use of laparoscopic surgery for obesity is relatively new and therefore current experience is limited.

What will all the staples do inside my abdomen? 

Is it OK in the future to have an MRI test?  Will I set off metal detectors in airports?  The first thing to understand about the staples used on the stomach and the intestines is that they 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 that is so small it is hard to see other than as a tiny bright spot.  Because the metals used (titanium or stainless steel) are totally inert in the body, people are not allergic to staples and they 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.

How is Weight Loss Surgery different from liposuction?

Bariatric surgery is major surgery involving the gastrointestinal tract. The stomach and intestines are modified so that less food can be consumed or absorbed, which leads to a substantial loss of weight that can be maintained for years. Liposuction is a form of cosmetic surgery in which areas of the body are reshaped or resculpted by removing excess amounts of fat in those areas. The purpose of liposuction is cosmetic, and is not designed or intended to produce weight loss. 

What are the expected results after surgery for severe obesity?

Weight Loss: Most patients lose between 50 and 70% of their excess body weight over about the first 18 months after surgery. Some reach their “ideal weight”, but most don't. The success rate for weight loss is reported as being slightly higher with the gastric bypass (RNY) operation than the gastroplasty (VBG). Most reports indicate a 43 to 48% loss of excess weight for the vertical banded gastroplasty and a 66 to 80% loss of excess body weight for the gastric bypass procedure.

Substantial weight loss generally occurs for both procedures until 18 to 24 months after surgery. Some regain of weight is common about two to five years after surgery. Regain of weight may be more common after the gastroplasty than after the gastric bypass. Long-term results after Roux-en-Y gastric bypass and VBG surgery have shown that 10 years after surgery, patients have usually regained less than 15% of their lost weight. However, if a patient resumes their old eating habits, and doesn't exercise at all, they might regain more than that. 

Effect of surgery on associated medical conditions: WLS has been reported to improve conditions such as sleep apnea, diabetes, high blood pressure, and hyper cholesterol. Many patients report an improvement in mood and other aspects of psychosocial functioning after surgery.

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

What should I expect my life to be like after Weight Loss Surgery?

After surgery, patients will experience many lifestyle changes. Some of the most important are:

What and how will I eat after WLS?

The modifications made to your gastrointestinal tract will require permanent changes in your eating habits that must be kept for successful weight loss. It is important to remember that dietary guidelines will be different for each surgeon and each type of procedure. What is most important is that you adhere strictly to your surgeon's recommended guidelines. The following are some of the generally accepted dietary guidelines a WLS patient may receive from their doctor:

• When you start eating solid food, it is essential that you chew thoroughly. You will not be able to eat steaks or other chunks of meat if they are not ground or chewed thoroughly.
• Do not drink fluids while eating. They will make you feel full before you have consumed enough food.
• Omit desserts and other items with sugar listed as one of the first three ingredients.
• Omit carbonated drinks, high-calorie nutritional supplements, milk shakes, high-fat foods and foods with high-fiber content.
• Avoid alcohol.
• Limit snacking between meals.

When and how much should I exercise after surgery?

Your ability to resume pre-surgery levels of activity will vary according to your physical condition, the nature of the activity, and your particular WLS procedure. Many patients return to full pre-surgery levels of activity within six weeks of their procedure. Patients who have had a minimally invasive laparoscopic procedure may be able to return to these activities within a few weeks.  

Many patients are hesitant about exercise after surgery, but in reality exercise is an absolutely essential component of post-operative success.  Exercise actually begins on the afternoon of surgery, when the patient is usually expected to get out of bed and start walking around the ward.  The goal is for the patient to walk further on the next day and progressively further every day after that, including the first few weeks at home.

In most cases patients are encouraged  to begin exercising about two weeks after surgery, limited only by their level of discomfort. The type of exercise may be dictated by the patient’s overall condition. Some patients who have severe knee problems can’t even walk well, but almost all can 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.  Sexual activity is OK from two weeks onward, again as dictated by comfort level. 

Can I become pregnant after WLS? Must I postpone pregnancy?

It is strongly advised that women of childbearing age use the most effective forms of birth control during the first 16 to 24 months after weight loss surgery. The added demands pregnancy places on your body, and the potential for fetal damage, make this a most important requirement. One year after surgery 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 be in contact with your surgeon as you plan for pregnancy. 

What kind of long-term post-operative medical follow-up will I need?

Although the short-term effects of weight loss surgery are well understood, there are still questions to be answered about the long-term effects on nutrition and body systems. Nutritional deficiencies that occur over the course of many years will need to be studied. Over time, you will need periodic checks for anemia (low red blood cell count) and Vitamin B12, folate, and iron levels. Follow-up tests will be conducted as needed.

What’s the value of joining a WLS Support Group?

he widespread use of support groups has provided WLS patients with an excellent opportunity to discuss their various personal and professional issues.
Most learn, for example, that WLS 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. Many patients find that ongoing support makes the critical difference in supporting their physical and emotional well-being in order to maintain permanent healthier life style.

When should I call my doctor?

Be sure to call your doctor if you develop any of the following:

• Persistent fever (over 101 F);
• bleeding;
• increased abdominal swelling or pain;
• persistent nausea or vomiting;
• chills;
• persistent cough and shortness of breath; or
• difficulty in swallowing that doesn't go away within a few weeks

How do I find a qualified and experienced doctor to perform my Weight Loss Surgery?

Ask your primary care physician for a referral or contact the American Society for Bariatric Surgery (see “Resource Links” on this website) and look for a surgeon in your area. Go to the surgeon's free orientation session and support groups, and talk to his patients to find out what their experiences have been. Ask for patients you can call for references. A great source of referrals is www.obesityhelp.com (available through this website’s Resource Links), where WLS patients rate and recommend their bariatric surgeons. You can also join WLS email groups at www.yahoogroups.com and seek referrals there.  If you “google” search Weight Loss Surgery for your area, you’ll find many bariatric websites, surgeons and clinics to seek other referrals and leads.

Selecting a bariatric surgeon is a difficult decision. What qualities should I look for in selecting my WLS surgeon? Your ideal bariatric surgeon will be someone who specializes in these procedures; who has performed many procedures with a very low mortality and complications rate; and who offers a comprehensive program of pre- and after-care to his/her patients. Certification as a specialist is highly desirable; membership in the ASBS does not necessarily mean that a surgeon has the experience and training you want in your surgeon. Look for a person who seems to be sincerely committed to caring for severely obese patients. Testimonials from post-op patients may be important considerations.

Anyone who is considering weight loss surgery should ask these basic questions of the treatment center:

• How thorough is the screening process?
• Will a psychological or therapist, nutritional, exercise and behavioral treatment team be assigned to support you before and after surgery?
• Are there patients from that particular practice you can speak with in advance?
• How much pre-operative teaching is involved?
• How mush post-operative teaching is involved?
• How many surgeries are being performed monthly
• How experienced are the surgeons? Is bariatric surgery the core of their practice?

What can I do before my initial appointment with my bariatric surgeon to speed up the process? [information source: www.sabariatric.com]

First, establish a relationship with your care primary physician, if you don't already have one.  Work with that physician to get "caught up" on your routine health maintenance testing (for women, this is a bimanual exam and Pap smear and (if over 40) a mammogram; for men, this might include a PSA.)

Second, write out your diet and weight history (documenting, as best you can, the historical progression of your weight/weight loss; diets you’ve tried and their results; other medical treatments you’ve tried and their results) and bring it with you to your initial consultation. Also, bring any other pertinent medical data, including reports of special tests you’ve had (echocardiogram, sleep apnea study, etc.) or your hospital discharge summary if you have been hospitalized. Also, bring a complete list of your medications with dose and schedule.

Finally, STOP SMOKING.  Many bariatric surgeons and clinics require patients to be tobacco-free for at least one month prior to surgery, because that substantially reduces your operative risks.

What exactly does the surgeon do in performing a Roun-en-Y gastric bypass procedure?

The Roux-en-Y Gastric Bypass (RNY) is a combination of a restrictive (inhibiting the amount of food that can be eaten), and malabsorptive (limiting the amount of food that is absorbed into the system) procedure. The restrictive component consists of creating a small pouch at the top of the stomach with a surgical stapler. The malabsorptive portion is created by dividing the small intestine and re-routing it so that one portion is connected to the small stomach pouch (Roux limb) and the remaining portion, which delivers the bile and pancreatic juice, is reconnected to the small intestine at a predetermined distance from the stomach.  The only long term adverse affects of Roux-en-Y surgery are vitamin and iron deficiencies. These can be treated with vitamins, iron and B12 supplements. 

What exactly does the surgeon do in performing a VBG?

Vertical banded gastroplasty (VGB), which is only restrictive, is another common form of WLS. This operation is performed by creating a 1 ounce pouch near the junction of the stomach and esophagus using a vertically placed staple line. How long does it take to perform the surgery, and why is the duration of the procedure important? The open Roux-en-Y gastric bypass usually takes between 1 and 2 hours, depending on the surgeon. The VBG should take less time and more complicated procedures should take longer.  The length of the operating procedure may make a difference. Many studies have documented an increase in the incidence of infectious complications, such as pneumonia and wound infection, after prolonged surgical procedures.

Longer operations result in a fall in body temperature that interferes with the immune system. In addition, longer operative times mean increased exposure to general anesthesia, which often results in the collapse of portions of the lung and can lead to pneumonia. In general, shorter operations are safer.

How long will I be in the hospital?

How long does it take to recuperate? Most patients are admitted to the hospital on the morning of surgery, remain in the hospital for 2 or 3 days, and require between 2 and 6 weeks to recuperate before returning to work, depending upon the type of job they have. However, every body reacts differently, and some individuals may require a longer recovery.

When I tell people I’m considering WLS, many have something negative to say. Why does WLS have such a bad reputation?

The operations that were performed thirty years ago achieved weight loss, but carried a high complication and mortality rate. Those procedures are no longer in use. Bariatric surgeries performed today achieve comparable weight loss and are generally safe.

I love to eat. What will keep me from overeating after my WLS?

Because your stomach will be smaller, it will fill up with food sooner. When the food touches the walls of the stomach, it sends a message to the brain that you don't want any more to eat. The brain will receive this signal after eating much less food and consequently, you'll eat less. Most people just don't feel hungry. The procedures also offer what some call “negative reinforcement”. If you do overeat, or eat too quickly, you may experience physical discomfort which will discourage future overeating or overly rapid eating.

A year after surgery, are most people generally happier with their lives?

Most post-op patients report that they are much happier, and that would do it again "in a heartbeat." Studies show that this kind of patient satisfaction is a true test of the surgery.

How can I know that I won't just keep losing weight until I waste away to nothing? 

Patients may begin to wonder about this early after the surgery when they are losing 20-40 pounds per month, or maybe when they've lost more than 100 pounds and they're still losing.  Two things happen to allow weight to stabilize.  First, a patient's ongoing metabolic needs (calories burned) decrease as the body sheds the load imposed by the many excess pounds.  Second, there is a natural progressive increase in calorie and nutrient intake over the months following gastric bypass; basically the stomach pouch and the attached small intestine learn to work together better, along with slight 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 down to a point of malnutrition. 

How big will my stomach pouch be in the long run? 

The stomach pouch is created at one ounce or less in size, and in the first few months it is rather stiff due to natural surgical inflammation.  From about 6 - 12 months after surgery, the stomach pouch expands a bit and becomes more pliable as the inflammation subsides, and most patients end up with a meal capacity of 3 - 7 ounces. 

Will I be hungry after WLS, since I'm not eating much? 

Most patients don’t report feeling hungry.  In fact, for the first 4-6 weeks patients have almost no appetite.  Over the next several months the appetite returns, but it tends not to be a ravenous hunger.  If, however, you haven’t yet dealt with the emotional causes of your overeating, you may experience “head hunger” or “emotional hunger” – a phantom hunger suggesting that you may still have unfinished emotional work to complete.

What can I do to prevent folds of excess hanging skin?   

Unfortunately, most people who have gotten heavy enough to merit WLS have stretched their skin beyond a point from which it can "snap back."   Even after regular exercise, the unfortunate reality is that most patients are left with large flaps of loose skin.  For them, corrective plastic surgery may be the only option.

Will I have to change my medications?   

Many medications (for blood pressure, diabetes, etc.) can be stopped at some point after Weight Loss Surgery.  For medications that need to be continued, the vast majority can be swallowed, absorbed and work the same as before surgery.  Some patients choose to crush pills, and others ask for their medication in elixir (liquid) form. 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 NSAID's (most over-the-counter pain medicines).  The issue with NSAID's (ibuprofen, naproxen, and their cousins) is that they can create ulcers in the small pouch or the attached bowel.  Most diuretic medicines make the kidneys lose potassium, and with the dramatically reduced intake experienced by most gastric bypass patients, they are not able to take in enough to compensate. If a person's potassium gets too low it can lead to fatal heart rhythm problems.

What kinds of problems do WLS patients typically experience after their surgery?

Nausea

One of the most frequent problems patients experience after surgery is nausea. The nausea after surgery caused by using narcotics for pain control disappears when you stop taking these medications. A second type of nausea is seen about two weeks after surgery, about the time you advance your diet beyond the liquid stage.

The cause of this nausea is unclear. Some surgeons recommend that patients be routinely placed on acid lowering medications, such as Prilosec, for a month or so following surgery despite the fact that the pouch secretes only minimal gastric acid. They claim there is less chance of patients developing an inflammation of the lining of the pouch if patients take the medications. Many patients get relief of their symptoms by taking low dose Pepcid, an over-the-counter remedy that is much less expensive.

It’s possible that over-distension of the pouch by accidentally eating too much at one time may be a cause of nausea, especially during the first post-operative month. Patients must learn to stop eating at the first sensation of fullness, but this is difficult to learn because patients cannot initially believe the small amounts that will fill their pouches. The nausea seems to resolve by the second month after surgery, but if it persists or if you develop nausea several months after surgery, you may ask for an endoscopy procedure to look directly at the lining of the pouch.

Belching

Belching is the regurgitation of swallowed air. Some patients are habitual air swallowers (aerophagia). Patients break this habit after several months, but you may choose to use a straw to drink your liquids if this is a major problem. Gulping your liquids will tend to make this problem worse. Carbonated beverages can also cause belching and you should let all such drinks "go flat" to prevent this.

Fatty Food Intolerance

Fifty percent or more of patients develop a distinct intolerance to fats following Roux-en-Y surgery. Patients describe a "heavy" sensation in the upper abdomen, a "lead" ball in their stomach, nausea, bloating and sometimes diarrhea if they eat too much fat. This is most likely caused by the fact that the bile salts, which help digest fats, are not mixed with your food until the food is much father along in your intestines than was the case before surgery. This results from the rerouting of your intestinal tract by the proximal Roux-en-Y gastric bypass. This intolerance seems to be permanent, but is not necessarily an undesirable side effect.

One of the major problems with Americans' diets today is the excessive amounts of fatty food we consume, particularly "fast foods". Most patients tell us about a year after surgery that they are eating much better quality foods than prior to surgery and us that they are avoiding nearly all fast foods and foods with high fat content. You should try to purchase only the leanest of beef, always discard the skin of chicken, cut the fat from all meat prior to cooking and grill, rather than pan fry, whenever possible. Deep fried foods may likewise cause adverse symptoms. Breading, such as that on deep fried shrimp or halibut should be removed before eating.

Sweets

Between 20 to 30% of WLS patients develop side effects when eating concentrated sugars after Gastric Bypass surgery. Some surgeons feel the incidence is even higher and go so far as recommending certain operations, mainly the duodenal switch, to prevent these symptoms. If you experience a true dumping syndrome attack you will be very careful about the quantity of sweets you eat forever after. The dumping syndrome consists of a feeling of faintness, or like you are about to pass out, often a cold sweat, a rapid heart beat and perhaps explosive diarrhea. The symptoms are very dramatic and extremely annoying. They can be controlled by limiting the amount of sugar you eat at any given time.
Pain and vomiting after eating

By six weeks after your surgery you will probably have advanced to an unrestricted diet following your surgeon’s guidelines. This is when you relearn how to eat, what to avoid, and when to stop eating. It seems to take another two months for most patients to finally learn what works for them, and a support group can be especially valuable during this phase.

Pain and vomiting is nearly always the result of filling the pouch too full. Over-filling the pouch is usually caused by eating too fast, eating too much, or not chewing well enough. If you chew twice as much as you have in the past, you will eat more slowly and recognize that the pouch is getting full and then stop before you eat too much. If you are vomiting after eating solid foods, but can eat chips and popcorn without problems, this highly suggests you are not chewing the solids well enough. Another reason that you may over fill the pouch is that you become distracted while eating. It may help to focus on your meal and be alone while eating. You should not be watching a TV program, reading, talking on the phone, etc. while you are eating.

Another common mistake is to "forget" to eat all day or to skip meals during the day. You may then think you are starving and will have a tendency to eat too rapidly and over distend the pouch. You will gradually learn these lessons, but it requires several months of "accidents" for you to break old habits.

Weakness

During the first 6 to 8 weeks following surgery you may feel relatively weak. This is because your diet has been restricted to soft type foods, your body is healing from the trauma of major surgery, and you may be relatively anemic following the surgery. If you have been able to take the liquid protein supplements, this side effect will be minimized, but may still occur. Once you are 3 months post-operative, your weight loss should be associated with an increased energy level and the feeling that you are much stronger. If you begin to experience weakness after this the possibility of anemia secondary to iron or B12 deficiency becomes a more likely explanation. You must take your vitamins. If you are not consuming adequate protein in your diet, you may become protein malnourished and this will cause you to feel weak. Your doctor must know about these symptoms so they can perform the appropriate blood tests to rule out (or treat) these problems.

Dizzy spells

A small number of patients complain of dizziness several months after surgery, even though they did not have anemia or any vitamin or protein deficiencies. Some surgeons feel the dizzy spells are secondary to either dehydration or salt deficiency. It has been recommended that these patients try eating high salt foods and increasing their fluid intake. We don’t yet know if this is effective.

Hunger

After Weight Loss Surgery many patients report that they have lost their sensation of hunger. This is transient and lasts for about nine to twelve months. This is one of the reasons that patients "forget" to eat and skip meals. During this "grace" or "honeymoon" period as it is called, you will have your most rapid weight loss, but eventually the sensation of hunger will return. It is critical during this time that you adopt a permanent change in your eating habits and behavior so that these new habits become so ingrained in your lifestyle that you no longer think about them.

If you have not adopted new eating patterns by the time your hunger returns you will have a tendency to turn to snacking or "grazing" and your weight loss will stop and you will potentially start to regain some, if not all of your lost weight. Post-op WLS patients must learn to distinguish between "head hunger" and true physiological hunger. Head hunger is the "munchies" or impulse to eat between meals simply to have the taste or something to do with your mouth, i.e. chewing. Food commercials on TV and in magazines tend to stimulate this craving, as does boredom and anxiety. You must find substitute activities for eating at these times and try to avoid such commercials.

Social issues

Your interpersonal relationships can change after you experience radical weight loss. Some patients lose some friendships, and may be rejected by even close relatives. Reasons for these reactions may include other people’s jealousy, envy, anger and fear of change. Any real friend will respond to your weight loss and surgical success with happiness for you. As you make the decision whether or not to have Weight Loss Surgery, know that some of your social relationships may be radically altered following your operation. Many post-op patients report that they try to de-emphasize socializing organized around food or meals.

Relationship With Your Partner

In addition to altered relationships with friends, some patients find that their relationship with their husband or wife changes dramatically following massive weight loss, and not necessarily for the better. It is not uncommon for a spouse to develop a sense of insecurity when their partner suddenly develops an entirely different body image. This is more prominent when the female undergoes the surgery and becomes more physically attractive than when the male is the patient.

After surgery, women may notice that other men are "looking" at them. Although this usually pleases them, at least on some level, they may also feel threatened and verbalize these emotions in a fashion that tends to inadvertently provoke insecurity in their partners. It’s important to recognize this as a potential problem and to be prepared to deal with the issue after surgery. If a spouse is adamantly against the partner undergoing the surgery for reasons other than the potential risks associated with the operation, this may be a clue of pending feelings of insecurity after surgery, and pre-operative counseling may be indicated.

Changing Self-Identity

When patients undergo a dramatic change in their physical appearance, they may also experience a personality change. This may, in part, explain some of the altered relationships that occur. For example, some patients will become more assertive and outspoken following weight loss. This is probably secondary to greater self-confidence, but may surprise co-workers, employers and friends. It is not necessarily a negative change, but needs to be recognized as a potential side effect. If used constructively this can be beneficial. Remember who and what you are is "inside", and not how you look. Your appearance does not define who you are.

Antidepressants

Studies reveal that a significant percentage of WLS patients are on chronic antidepressants before their surgery. Sometimes patients become euphoric during the first few months after surgery and decide to independently stop their medications. This is usually a mistake. Several studies have now shown that simple weight loss does not eradicate all of a patient's "troubles" and stopping these medications prematurely can result in a rebound and an even more severe depression. You should discuss with your physician the timing of stopping any of your medications and how best to proceed with reducing them before completely discontinuing them.

Constipation

Constipation is a common complaint after Weight Loss Surgery.   It is caused by decreased food and water intake and, in some people, supplemental iron, or narcotic pain killers, tranquilizers, and antidepressants.  It is often aggravated by weak abdominal muscles or busy schedules wherein people defer having a bowel movement when the urge exists. 
Bariatric surgeons and clinics generally encourage WLS patients to do exercises that strengthen the abdominal muscles and assist in bearing down.  Most people experience the need for a bowel movement after breakfast and that is the natural and easiest time to have a bowel movement, and should not be ignored.  Increase water intake.  An increased intake of any vitamin except B12 and vitamin A tends to produce diarrhea and has not significant other side effects and is helpful in eliminating constipation.  Especially useful in this regard is Vitamin C or ascorbic acid since in addition to preventing constipation, it enhances the absorption of iron in Trinsicon or other forms. 

Next add fiber to the diet:  Eat high fiber breakfast (bran-based cereals, oatmeal) and add vegetables to other meals. Miller’s unprocessed bran found in the cereal section of the grocery store can be taken with juice, or sprinkled into salad, meatloaf, cereal, etc.  The same thing can be done with Metamucil, or psyllium seed.   These are more expensive forms of non-digestible cellulose or fiber.  The water content of stool can also be increased with a stool softener, docusate sodium marketed as Colace, or Peri-Colace or P-Col-Rite.  If the above measures are still not correcting the problem, the electrolyte laxatives such as Fleet Phospho-Soda, Magnesium citrate, Milk of Magnesia, or Colyte, to name a few, should be tried.  Avoid laxatives that directly stimulate the bowel smooth muscle eg. Senecot, as tolerance develops and more and more is required over time.

Hair Loss

Hair loss is commonly assumed to be due to lack of adequate dietary protein, but a clear cause and effect relationship is lacking.  Some doctors measure the patient’s prealbumin, and if it is low, increase their protein intake.   Hair loss due to dietary restriction is nearly always temporary.  Rogaine and Nexium shampoo have both been reported to be effective and should be tried if the loss is excessive. 

An alteration in intestinal flora usually caused by antibiotics may produce gas.  Ultraflora—a bacterial preparation—may be given to repopulate in intestinal tract normally.  When the cause is fungal overgrowth, Diflucan (fluconazole) may be effective. Flagyl is sometimes tried to suppress anaerobic bacterial growth in bypassed portions of the intestine.  Other causes are gallstones, diverticulosis, irritable bowel syndrome, and parasites, and, rarely, cancer of the ovary or bowel.

Is hair loss typical?

Hair loss is commonly assumed to be due to lack of adequate dietary protein but a clear cause and effect relationship is lacking.  Nevertheless, one should measure the prealbumin, and if it is low, increase protein intake.   Ephedrine is said to be effective in restricting protein weight loss and enhancing fat weight loss.  Hair loss due to dietary restriction is nearly always temporary.  Rogaine and Nexium shampoo have both been reported to be effective and should be tried if the loss is excessive. 

Copyright, © 2003, Glenn Goldberg. All rights reserved.
Disclaimer & Notices