Bariatric Surgery FAQs

Bariatric Surgery FAQs

You may have many questions if you’re prepare for bariatric surgery or you and your physician are considering the procedure.
You may have many questions if you’re prepare for bariatric surgery or you and your physician are considering the procedure.

These FAQs will cover some of them. The answers are based on standard practices for bariatric surgery.

Check with your physician to learn about their approach to the procedure and to discuss specific recommendations about your health.

  • Effectiveness of weight-loss surgery
  • Preparation for bariatric surgery
  • Insurance issues with bariatric surgery
  • Questions about the surgery
  • Hospital stay
  • Life after bariatric surgery
  • Diet after bariatric surgery
  • General questions about bariatric surgery

Effectiveness of weight-loss surgery

Bariatric surgery is the best and most effective treatment for morbid obesity (BMI of 40 or more). About 65% of people who have bariatric surgery lose excess weight and keep it off for more than five years.

More than 30 conditions are associated with morbid obesity, including hypertension, diabetes, heart disease, stroke, obstructive sleep apnea and degenerative joint disease.

Diabetes

Bariatric surgery is not only successful for weight loss but also for preventing, improving or resolving Type 2 diabetes. Recent studies show that bariatric operations, particularly gastric bypass, can achieve a resolution rate (normal amount of glucose in the blood) as high as 83%.

Other studies have shown that people with a BMI as low as 30 may have successful resolution of diabetes after undergoing gastric bypass surgery or gastric banding.

Weight loss factors

The amount of weight you will lose after the procedure depends on several factors, including the following:

  • Age
  • Ability to exercise
  • Commitment to maintaining dietary guidelines and other follow-up care
  • Motivation and cooperation of family and friends
  • Overall health
  • Weight before surgery

Preparation for bariatric surgery

What are the routine tests before surgery?

Basic tests are done prior to surgery: complete blood count, urinalysis and a chemistry panel. Other tests, including the following, may also be needed: pulmonary function testing, echocardiogram, sleep studies, GI evaluation, cardiology evaluation or psychiatric evaluation.

What is the purpose of these tests?

The best way to avoid complications is to never have them in the first place, so an accurate assessment of your health is needed before surgery.

For example, it's important to know if your thyroid function is adequate, because hypothyroidism can lead to sudden post-operative death. If you are diabetic, special steps must be taken to control your blood sugar. Your heart will be thoroughly evaluated because surgery increases cardiac stress.

Other 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.

Why do I need a GI evaluation?

Gastrointestinal symptoms (upper abdominal pain, heartburn, belching sour fluid, etc.) may be a sign of an underlying health problem, such as a hiatal hernia, gastroesophageal reflux or peptic ulcer.

For example, many patients have symptoms of reflux. Up to 15% of them may show early changes in the lining of the esophagus, which could put them at risk of esophageal cancer.

It is important to identify these changes so a surveillance or treatment program can be planned.

Why do I need a sleep study?

A sleep study detects abnormal stoppage of breathing, which is usually associated with airway blockage when the muscles relax during sleep, or sleep apnea. 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, so it is important to have a clear picture of your usual breathing patterns during sleep.

Why do I need a psychiatric evaluation?

Your insurance company may require a psychiatric evaluation. Most psychiatrists will evaluate your understanding of the risks associated with weight loss surgery and your ability to follow the recovery plan.

What impact do my medical problems have on the decision for surgery, and how do the medical problems affect risk?

Medical conditions, such as serious heart or lung problems, can increase the risk of any surgery. If the problems are weight related, however, they may increase the need for surgery.

Severe medical problems doesn't mean you are not a candidate for surgery, but they do make your risk for complications higher.

What can I do before the surgery day to speed up the preparation process?

  • Select a primary care physician if you don't already have one and work with your physician to ensure that your routine health maintenance testing is current. For example, women may have a pap smear, and if over 40 years of age, a breast exam. For men, this may include a prostate specific antigen test, or PSA.
  • Make a list of all the diets you have tried and bring it to your doctor.
  • Bring any relevant medical information to your appointment with the surgeon. This includes reports of special tests (echocardiogram, sleep study, etc.) or a hospital discharge summary if you have had a hospital stay.
  • Bring a list of your medications with dosage and schedule.
  • Stop smoking. Surgical patients who use tobacco products are at a higher surgical risk.

Insurance for bariatric surgery

Why does it take so long to get insurance approval?

After your final consultation is completed, it usually takes your doctor one to two days to send a letter to your insurance carrier to start the approval process. The time it takes to get an answer can vary from about three to four weeks, or longer.

Most treatment centers have insurance analysts who will follow up regularly on approval requests. It may be helpful for you to call your insurance company about a week after your letter is submitted and ask about the status of your request.

Can my insurance company deny payment for treatment of a life-threatening disease?

Payment might be denied because if there is an exclusion in your policy for obesity surgery or "treatment of obesity." An exclusion can often be appealed if the surgery is recommended by your surgeon or referring physician as the best therapy to relieve life-threatening, obesity-related health conditions, which usually are covered.

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 psychiatric evaluation, illustrating that you have tried unsuccessfully to lose weight by other methods.

What can I do to help the process?

Gather all the information (diet records, medical records, medical tests, etc.) 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.

When the letter is submitted, call your carrier regularly to ask about the status of your request. Your employer or human relations/personnel office may also be able to help you work through unreasonable insurance delays.

Questions about bariatric surgery

Does laparoscopic surgery decrease surgical risk?

No. Laparoscopic operations carry the same risk as the procedure performed as an open operation. Typically, the benefits of laparoscopy are less discomfort, shorter hospital stay, earlier return to work and reduced scarring.

Will I have a lot of pain?

Every attempt is made to control pain after surgery to make it possible for you to become active quickly. This helps avoid problems 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, or 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.

How long do I have to stay in the hospital?

This varies by procedure. The laparoscopic adjustable gastric band is done on an outpatient basis, with a possible overnight stay. There is two-to-three-day stay for a laparoscopic gastric bypass and sleeve gastrectomy, and five to seven days for an open gastric bypass.

Will the doctor leave a drain in after surgery?

Most patients will have a small tube to allow drainage of any accumulated fluids from the abdomen. This is a safety measure, and it generally produces only minor discomfort.

The drain is usually removed a few days after the surgery.

What can I expect when I wake up in the recovery room?

Some doctors will provide a patient-controlled analgesia, or 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. The risk of death during these procedures is less than 1%. 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.

How soon will I be able to walk?

Doctors will require you to get up and move about almost immediately after surgery. Patients are asked to walk or stand at the bedside on the night of surgery, and to take several walks the next day and thereafter.

After leaving the hospital, you may be able to care for all your personal needs, but you will need help with shopping, lifting and transportation.

How soon can I drive?

You should not drive until you have stopped taking narcotic medications and can move quickly and alertly to stop your car.

Hospital stay

What is done to minimize the risk of deep vein thrombosis/pulmonary embolism, or DVT/PE?

Because a DVT originates on the operating table, therapy begins before a patient goes to the operating room. Generally, patients are provided with 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. That will help restore normal blood flow in the legs.

What should I bring with me to the hospital?

Basic toiletries (comb, toothbrush, etc.) and clothes 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.

You may also want to bring the following:

  • Bathrobe
  • Crosswords and other puzzles
  • Reading and writing material

Life after bariatric surgery

What do I need to do to be successful after surgery?

The basic rules are 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, then move to semi-solid foods and later, sometimes weeks or months later, solid foods can be tolerated. Proper healing of your new stomach pouch is important.
  • When you are able to eat solids, eat two to three meals per day, and no more. Protein in the form of lean meats (chicken, turkey, fish) and other low-fat sources should be eaten first. These should make up at least half the volume of your meal. Foods should be seasoned to taste and cooked without fat. Avoid sauces, gravies, butter, margarine, mayonnaise and junk foods.
  • Never eat between meals. Do not drink flavored beverages (even diet soda) between meals.
  • Drink 2-3 quarts or more of water each day. Water must be consumed slowly, one to two mouthfuls at a time, due to the restrictive effect of the operation.
  • Exercise aerobically every day for at least 20 minutes (1-mile brisk walk, bike riding, stair climbing, etc.). Weight and resistance exercise can be added three to four days per week, as instructed by your doctor.

What's so important about exercise?

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, including muscle.

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, which forces it to burn fat instead.

What is the right amount of exercise after weight loss surgery?

Exercise actually begins on the afternoon of surgery — you must be out of bed and walking. The goal is to walk even more the next day and progressively more every day after that, including the first few weeks at home.

You are often released from medical restrictions and encouraged to begin exercising about two weeks after surgery. You are limited only by the level of wound discomfort.

The type of exercise is dictated by your overall condition. You may have severe knee problems and can't walk well, but you are be able to swim or bicycle. You will likely begin with low-stress forms of exercise and are encouraged to progress to more vigorous activity when they are able.

Can I get pregnant after weight loss surgery?

It is strongly recommended that women wait at least one year after the surgery before a pregnancy. Approximately one year after the surgery, your body will be fairly stable (from a weight and nutritional standpoint), and you should be able to carry a normally nourished fetus.

You should consult your surgeon as you plan for pregnancy.

What if I have had a previous weight loss surgical procedure and I'm now having problems?

Contact your original surgeon. They will be familiar with your medical history and can make recommendations based on knowledge of your surgical procedure and body.

If you want to consult with a surgeon at Rush about issues from a previous surgery done at a different facility, you can see a list of our bariatric surgeons online.

What happens to the lower part of the stomach that is bypassed?

In some surgical procedures, the stomach is left in place with intact blood supply. In some cases it may shrink a bit and the lining (mucosa) may atrophy, but it generally 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 BPD procedures, some portion of the stomach is completely removed.

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

This can vary by surgical procedure and surgeon. In a Roux-en-Y gastric bypass, the stomach pouch is created at 1 ounce or less in size (15-20 cc). 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.

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?

The staples used in 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.

Most people are not allergic to the staples, so they usually do not cause any problems in the long run. The staple materials are also non-magnetic, so they will not be affected by MRI.

The staples will not set off airport metal detectors.

What if I'm not hungry after surgery?

It is normal to not have an appetite for the first month or two after weight loss surgery. If you are able to consume liquids reasonably well, your appetite will likely increase with time.

Will there be problems with taking medications?

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.

Will I be able to take oral contraception after surgery?

Most patients have no difficulty swallowing these pills.

Is sexual activity restricted?

You can return to normal sexual activity when wound healing and discomfort permit. Some patients experience a drop in desire for about six weeks.

Is there a difference in the outcome of surgery between men and women?

Both men and women generally respond well to this surgery. In general, men lose weight slightly faster than women do.

Will I be asked to stop smoking?

You are encouraged to stop smoking at least one month before surgery.

If I continue to smoke, what happens?

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.

Will I keep losing weight until I waste away to nothing?

Early after the surgery, you are losing 20 to 40 pounds per month. Perhaps you have lost more than 100 pounds and are still losing weight.

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: If there are no surgical complication, you are very unlikely to lose weight to the point of malnutrition.

What can I do to prevent excess hanging skin?

Many people heavy enough to meet the surgical criteria for weight loss surgery have stretched their skin beyond the point where it can snap back. Some patients 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 excess skin folds.

Ask your surgeon if you might benefit from body contouring surgery, which includes removal of excess skin and fat, in addition to tightening and reshaping underlying tissue.

The weight loss team at Rush includes plastic surgeons who have special expertise in surgery for patients who have lost a great deal of weight through bariatric surgery.

Will exercise help with excess hanging skin?

Unfortunately, you may still be left with large flaps of loose skin. Exercise, though, is good in so many other ways that a regular exercise program is recommended.

Will I be miserably hungry after weight loss surgery since I'm not eating much?

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 type of hunger.

What if I am really hungry?

This is usually caused by the types of food you are consuming, especially starches (rice, pasta, potatoes). Be sure not to drink liquid with food, because liquid washes food out of the pouch.

Will I have to change my medications?

Your doctor will determine whether medications for blood pressure, diabetes, or other health problems can be stopped when the conditions for which they are taken improve or resolve after weight loss surgery.

For medications that need to be continued, the vast majority can be swallowed and 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.

What is a hernia and what is the probability of an abdominal hernia after surgery?

A hernia is a weakness in the muscle wall through which an organ (usually small bowel) can push through. Approximately 20% 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.

Is blood transfusion required?

Infrequently. If needed, it is usually given after surgery to promote healing.

What is phlebitis, and is it preventable?

Undesired blood clotting in veins, especially of the calf and pelvis. It is not completely preventable, but preventive measures will be taken:

  • Blood thinners
  • Early ambulation
  • Pulsatile boots
  • Special stockings

Will I lose hair after surgery? How can I prevent it?

You may experience some hair loss or thinning after surgery. This usually occurs between the fourth and eighth month after surgery.

Including protein in your diet is the most important prevention method. A daily zinc supplement and sufficient fluid intake are also recommended.

Does hair growth recover?

Natural hair regrowth generally occurs after the initial period of hair loss.

What are adhesions, and do they form after surgery?

Adhesions are scar tissues inside the abdomen after surgery or injury. Adhesions can form with any surgery in the abdomen. These are generally not extensive enough to cause problems.

What is the candida syndrome?

Some patients have a type of yeast present on the surface of their skin, intestine or vagina at the time of surgery. This sometimes leads to overgrowth of the yeast.

A whitish coating may occur on the tongue or throat. This syndrome is also associated with a frothy mucous, nausea, difficulty swallowing, sore throat, loss of taste and appetite, and occasionally abdominal bloating and diarrhea.

What causes candida syndrome to appear?

Most antibiotics and some other medications, stress, reduced immune response and diabetes.

Can candida syndrome be cured?

There are several effective medications available for treating candida overgrowth.

What is sleep apnea?

Repeated delays in breathing interrupt the normal sleep pattern. 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

How long do I need to avoid solid foods after surgery?

Most surgeons recommend four weeks or more without solid food. A liquid diet, followed by semi-solid food or pureed food, may be recommended until adequate healing has occurred.

Your surgeon will provide you with dietary guidelines.

What are the best protein choices?

Eggs, low-fat cheese, low-fat cottage cheese, tofu, seafood, chicken (dark meat) and turkey (dark meat).

Why do I need to drink so much water?

There are many waste products to eliminate when you are losing weight, and most of them are eliminated through urine. Some of these substances form crystals, which can cause kidney stones.

Drinking plenty of water helps your body get rid of waste products, which promotes better weight loss. Water also fills your stomach and helps prolong and intensify your sense of satisfaction after eating. If you feel a desire to eat between meals, it may be because you did not drink enough water in the hour before.

What is dumping syndrome?

Eating sugar or other foods containing many small particles on an empty stomach can cause dumping syndrome in patients who have had a gastric bypass or BPD with the stomach pylorus 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 state 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 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.

Is there a problem with consuming milk products?

Milk contains lactose (milk sugar), which is not easily digested. This sugar passes through undigested until bacteria in the lower bowel interact with it, which produces irritating byproducts, as well as gas.

Depending on your tolerance level, you may find even the smallest amount of milk can cause cramps, gas and diarrhea.

Why can't I snack between meals?

Snacking on foods, usually high-calorie and high-fat foods, can add hundreds of calories a day to your intake, which defeats the restrictive effect of your operation. Snacking will slow down your weight loss and can lead to regaining weight.

Why can't I eat red meat after surgery?

You can, but you will need to be very careful. We recommend that you avoid it for the first several months.

Red meat contain a high level of meat fibers (gristle) that hold the piece of meat together, and they prevent 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.

How can I be sure I am eating enough protein?

A sufficient amount of protein is generally 60-75 grams a day. Check with your surgeon to determine the right amount for your type of surgery.

Is salt intake restricted?

No. Your salt intake will be unchanged unless instructed by your primary care physician.

Will I be able to eat spicy or seasoned foods?

Most patients are able to enjoy spices six months following surgery.

Will I be allowed to drink alcohol?

You will find that even small amounts of alcohol will affect you quickly. We suggest that you drink no alcohol for the first year. After the first year, with your physician's approval, you may have a glass of wine or a small cocktail.

What vitamins will I need to take after surgery?

A daily multivitamin is recommended for the rest of your life. Depending on the type of surgery you have, vitamin B12, calcium with vitamin D, iron and other trace elements may also be needed.

Do I meet with a nutritionist before and after surgery?

Yes. All insurance companies require supervised nutrition counseling prior to bariatric surgery. Depending on your insurance plan, your time with a nutrition counselor can vary from three months to one year.

There also are dietitians on staff to see patients for follow-up care.

Will I get instructions for my diet after surgery?

You will receive materials that clearly outline your diet and guidelines for the best outcome based on your surgical procedure. After surgery, health and weight loss highly highly depend on patient compliance with these guidelines.

You must do your part by restricting high-calorie foods; avoiding sugar, snacks and fats; and strictly following the guidelines set by your surgeon.

General questions about bariatric surgery

What is the youngest age for which weight loss surgery is recommended?

Guidelines from the American Society for Bariatric Surgery and the National Institutes of Health indicate surgery only for people who are at least 18 years old. Surgery has been performed on patients 16 years old and younger, but there is concern that young patients may not have reached the developmental or emotional maturity level to make a proper decision about surgery.

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.

What is the oldest patient for whom weight loss surgery is recommended?

Patients over 65 years old 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 (reduced risk of mortality) are reduced.

Can weight loss surgery prolong my life?

There is evidence from scientific research that shows weight loss surgery may significantly prolong your life if you have Type 2 diabetes (or other serious obesity-related health conditions), are at least 100 pounds over your ideal body weight and are able to comply with lifestyle changes (daily exercise and low-fat diet).

Can weight loss surgery help other physical conditions?

According to current research, weight loss surgery can improve or resolve associated health conditions.