Preparation for Obesity Surgery
Insurance Issues
Laparoscopic Bariatric Surgery
The Hospital Stay
Life After Obesity Surgery
Diet
General
Preparation for Obesity Surgery
What does evaluation for obesity surgery involve?
Your evaluation will start with an initial visit with your surgeon and/or nurse
practitioner. A medical history and physical exam will be completed. You
will then be asked to see our nutritionist and psychologist who will help
evaluate your knowledge about nutrition and your commitment to change.
These assessments are most often a requirement of insurance companies in the
approval process and help prepare you for the process of lifestyle changes
needed to succeed with postoperative weight loss.
What impact do my medical problems have on the decision for obesity surgery,
and how do the medical problems affect risk?
Medical problems, such as serious heart or lung problems, can increase the risk
of any surgery. On the other hand, if they are problems that are related to the
patient's weight, they also increase the need for surgery. Severe medical
problems may not dissuade the surgeon from recommending gastric bypass surgery
if it is otherwise appropriate, but those conditions will make a patient's risk
higher than average.
What can I do before the appointment to speed up the process of getting ready for obesity surgery?
- Select a primary care physician if you don't already have one, and establish a relationship with him or her. Work with your physician to ensure that your routine health maintenance testing is current. For example, women may have a pap smear, and if over 40 years of age, a breast exam. And for men, this may include a prostate specific antigen test (PSA).
- Make a list of all the diets you have tried (a diet history) and bring it to your doctor.
- Bring any pertinent medical data to your appointment with the bariatric surgeon - this would include reports of special tests (echocardiogram, sleep study, etc.) or hospital discharge summary if you have been in the hospital.
- Bring a list of your medications with dose and schedule.
- Stop smoking. Surgical patients who use tobacco products are at a higher surgical risk.
Which weight loss surgery is right for me?
Several factors may affect your eligibility for a particular type of surgery,
including previous abdominal surgeries, body size and configuration and other
health problems. Your surgeon will help you determine your individual
options at the time of your initial consultation.
Insurance Issues
Is the surgery covered by most insurances?
There are many different levels of coverage for obesity surgery. Here are
some key steps you should take to obtain information form your insurance
company.
- Read and understand the "certificate of coverage" that your insurance company is required by law to give you. If you do not have one, consult your company's benefits administrator or ask your insurance company directly.
- You may be required to start with your primary care provider. In some cases, he or she is the only one you can ask for a referral to a qualified bariatric surgeon. Even if you are not required to get a referral, it is a good idea to have support of your primary care provider.
- Before visiting the bariatric surgeon, organize you medical records, including your history of dieting efforts. They will be valuable documents to have at every stage of the approval process.
- Document every visit you make to a healthcare professional for obesity-related issues or visits to supervised weight loss programs. Document "other" weight loss attempts made through diet centers and fitness club memberships. Keep good records, including receipts.
Why do insurance companies deny approval for obesity surgery?
Payment may be denied because there may be a specific exclusion in your policy
for obesity surgery or "treatment of obesity." Such an exclusion can often be
appealed when the surgical treatment is recommended by your bariatric 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 1 to 5 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) 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 delays.
What if my insurance company denies approval?
Even if your initial request for pre-authorization is not approved, you still
have options available. Insurers provide an appeal process that allows
you to address each specific reason they have given for denying your request.
It is important that you reply quickly. It is also recommended
that, at this point, you enlist the help of an experienced insurance attorney
or insurance advocate to properly navigate the complexities of the appeal
process. Some insurers place limits on the number of appeals you may
make, so it is important to be well prepared and that you clearly understand
the appeal rules of your specific plan.
Laparoscopic Bariatric Surgery
Does Laparoscopic Surgery decrease the risk?
No. Laparoscopic operations carry the same risk as the procedure performed as
an open operation. The benefits of laparoscopic surgeries are typically less
discomfort, shorter hospital stay, earlier return to work and reduced scarring.
Will the doctor leave a drain in after laparoscopic 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 is usually removed a
few days after the obesity surgery. Generally, it produces no more than minor
discomfort.
If I have laparoscopic bariatric surgery, what can I expect when I wake up
in the recovery room?
Most patients will receive a Patient Controlled Analgesia (PCA) or a
self-administered pain management system, to help control pain. As with any
major surgery, you are in danger of death from a blood clot or other surgical
side effects. Statistically, the risk of death during these procedures is less
than 1 percent. Your doctors will have assessed you for risks and prepared
accordingly.
All abdominal operations carry the risks of bleeding, infection in the
incision, thrombophlebitis of legs (blood clots), lung problems (pneumonia,
pulmonary embolisms), strokes or heart attacks, anesthetic complications, and
blockage or obstruction of the intestine. These risks are greater in morbidly
obese patients.
The 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 treated with
sequential leg compression stockings and given a blood thinner prior to
surgery. Both of these therapies continue throughout your hospitalization. The
third major preventive measure involves getting the patient moving and out of
bed as soon as possible after the operation to restore normal blood flow in the
legs.
Will I have a lot of pain?
Every attempt is made to control pain after surgery to make it possible for you
to move about quickly and become active. This helps avoid 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 (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?
As long as it takes to be self-sufficient. Although it can vary, the hospital
stay (including the day of surgery) can be 1-2 days for a laparoscopic band,
2-3 days for a laparoscopic gastric bypass, and 3-5 days for an open gastric
bypass.
How soon will I be able to walk?
Almost immediately after surgery doctors will require you to get up and move
about. Patients are asked to walk or stand at the bedside on the night of
surgery, take several walks the next day and thereafter. On leaving the
hospital, you may be able to care for all your personal needs, but will need
help with shopping, lifting and with transportation.
How soon can I drive?
For your own safety, you should not drive until you have stopped taking
narcotic medications and can move quickly and alertly to stop your car,
especially in an emergency. Usually this takes 7-14 days after surgery.
What should I bring with me to the hospital?
Basic toiletries (comb, toothbrush, etc.) and clothing may be provided by the
hospital, but most people prefer to bring their own. Choose clothes for your
stay that are easy to put on and take off. Because of your incision, your
clothes may become stained by blood or other body fluids. Other ideas:
- reading and writing materials
- crossword and other puzzles
- personal toiletries
- bathrobe and slippers
- a list of your current medications
Life After Obesity Surgery
What do I need to do to be successful after surgery?
The basic rules are simple and easy to follow:
- Immediately after obesity surgery, your doctor will provide you with special dietary guidelines. You will need to follow these guidelines closely. Many bariatric surgeons begin patients with liquid diets, moving to semi-solid foods and later, sometimes weeks or months later, solid foods can be tolerated without risk to the surgical procedure performed. Allowing time for proper healing of your new stomach pouch is necessary and important.
- When able to eat solids, eat 2-3 meals per day, no more. Protein in the form of lean meats (chicken, turkey, fish) and other low-fat sources should be eaten first. These should comprise at least half the volume of the meal eaten. Foods should be cooked without fat and seasoned to taste. Avoid sauces, gravies, butter, margarine, mayonnaise and junk foods.
- Never eat between meals. Do not drink flavored beverages, even diet soda, between meals.
- Drink 2-3 quarts or more of water each day. Water must be consumed slowly, 1-2 mouthfuls at a time, due to the restrictive effect of the operation.
- Exercise aerobically every day for at least 20 minutes (one-mile brisk walk, bike riding, stair climbing, etc.). Weight/resistance exercise can be added 3-4 days per week, as instructed by your doctor.
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. Your body will tend to burn any unused muscle before it begins
to burn the fat it has saved up. If you do not exercise daily, your body will
consume your unused muscle, and you will lose muscle mass and strength. Daily
aerobic exercise for 20 minutes will communicate to your body that you want to
use your muscles and force it to burn the fat instead.
What is the right amount of exercise after weight loss surgery?
Many patients are hesitant about exercising after surgery, but exercise is an
essential component of success after surgery. Exercise actually begins on the
afternoon of weight loss surgery - the patient must be out of bed and walking.
The goal is to walk further on the next day, and progressively further every
day after that, including the first few weeks at home. Patients are often
released from medical restrictions and encouraged to begin exercising about two
weeks after surgery, limited only by the level of wound discomfort. The type of
exercise is dictated by the patient's overall condition. Some patients who have
severe knee problems can't walk well, but may be able to swim or bicycle. Many
patients begin with low stress forms of exercise and are encouraged to progress
to more vigorous activity when they are able.
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 post-operatively, your body will be
fairly stable (from a weight and nutrition standpoint) and you should be able
to carry a normally nourished fetus. You should consult your surgeon as you
plan for pregnancy.
What if I have had a previous weight loss surgical procedure and I'm now
having problems?
Contact your original surgeon - he or she is most familiar with your medical
history and can make recommendations based on knowledge of your surgical
procedure and body.
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 its lining (the mucosa) may
atrophy, but for the most part it remains unchanged. The lower stomach still
contributes to the function of the intestines even though it does not receive
or process food - it makes intrinsic factor, necessary to absorb Vitamin B12
and contributes to hormone balance and motility of the intestines in ways that
are not entirely known. In the BPD procedures, some portion of the stomach is
completely removed.
How big will my stomach pouch really be in the long run?
This can vary by surgical procedure and bariatric surgeon. In the Roux-en-Y
gastric bypass, the stomach pouch is created at one ounce or less in size
(15-20cc). In the first few months it is rather stiff due to natural surgical
inflammation. About 6-12 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 3-7 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 on the stomach and the intestines are very tiny in comparison
to the staples you will have in your skin or staples you use in the office.
Each staple is a tiny piece of stainless steel or titanium so small it is hard
to see other than as a tiny bright spot. Because the metals used (titanium or
stainless steel) are inert in the body, most people are not allergic to staples
and they usually do not cause any problems in the long run. The staple
materials are also non-magnetic, which means that they will not be affected by
MRI. The staples will not set off airport metal detectors.
What if I'm not hungry after weight loss surgery?
It's normal not to have an appetite for the first month or two after weight
loss surgery. If you are able to consume liquids reasonably well, there is a
level of confidence that your appetite will increase with time.
Is there any difficulty in taking medications?
Initially, most medications will be taken in liquid form or crushed. Your
surgeon will advise you when you may take whole pills.
Is sexual activity restricted?
Patients can return to normal sexual intimacy when wound healing and discomfort
permit, at about 4-6 weeks after surgery.
Is there a difference in the outcome of obesity 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?
Patients must stop smoking at least one to two months before surgery Smoking
increases the risk of lung problems after surgery, can reduce the rate of
healing, increases the rates of infection, and interferes with blood supply to
the healing tissues.
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 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 is that, in the absence of a surgical complication,
patients are very unlikely to lose weight to the point of malnutrition.
What can I do to prevent lots of excess hanging skin?
Many people heavy enough to meet the surgical criteria for weight loss surgery
have stretched their skin beyond the point from which it can "snap back." Some
patients will choose to have plastic surgery to remove loose or excess skin
after they have lost their excess weight. Insurance generally does not pay for
this type of surgery (often seen as elective surgery). However, some do pay for
certain types of surgery to remove excess skin when complications arise from
these excess skin folds. Ask your surgeon about your need for a skin removal
procedure.
Will exercise help with excess hanging skin?
Exercise is good in so many other ways that a regular exercise program is
recommended. Unfortunately, most patients may still be left with large flaps of
loose skin.
Will I be miserably hungry after weight loss surgery since I'm not eating
much?
Most patients say no. 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 "eat everything in the cupboard" type of hunger.
What if I am really hungry?
This is usually caused by the types of food you may be consuming, especially
starches (rice, pasta, potatoes). Be absolutely sure not to drink liquid with
food since liquid washes food out of the pouch.
Will I have to change my medications?
Your doctor will determine whether medications for blood pressure, diabetes,
etc., can be stopped when the conditions for which they are taken improve or
resolve after weight loss surgery. For meds that need to be continued, the vast
majority can be swallowed, absorbed and work the same as before weight loss
surgery. Usually no change in dose is required. Two classes of medications that
should be used only in consultation with your surgeon are diuretics (fluid
pills) and NSAIDs (most over-the-counter pain medicines). NSAIDs (ibuprofen,
naproxen, etc.) may create ulcers in the small pouch or the attached bowel.
Most diuretic medicines make the kidneys lose potassium. With the dramatically
reduced intake experienced by most weight loss surgery patients, they are not
able to take in enough potassium from food to compensate. When potassium levels
get too low, it can lead to fatal heart problems.
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 advance. 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, including:
- Early ambulation
- Special stockings
- Blood thinners
- Pulsatile boots
Will I lose hair after obesity surgery? How can I prevent it?
Many patients experience some hair loss or thinning after surgery. This usually
occurs between two to six months after surgery. Consistent intake of protein at
mealtime is the most important prevention method. Also recommended are a daily
zinc supplement and a good daily volume of fluid intake.
Does hair growth recover?
Most patients experience natural hair regrowth after the initial period of
loss.
What are adhesions and do they form after this surgery?
Adhesions are scar tissues formed inside the abdomen after surgery or injury.
Adhesions can form with any surgery in the abdomen. For most patients, these
are not extensive enough to cause problems.
What is sleep apnea (SA)?
It is the interruption of the normal sleep pattern associated with repeated
delays in breathing. Sleep apnea often shows rapid improvement after surgery.
In most patients, there is a complete resolution of symptoms by six months
following surgery.
Diet
How long will I be off of solid foods after obesity surgery?
Most bariatric surgeons recommend a period of four weeks or more without solid
foods after weight loss surgery. A liquid diet, followed by semi-solid foods or
pureed foods, may be recommended for a period of time until adequate healing
has occurred. Your surgeon will provide you with specific dietary guidelines
for the best post-surgical outcome.
What are the best choices of protein?
Eggs, low-fat cheese, low-fat cottage cheese, tofu, fish, other seafood,
chicken (dark meat), turkey (dark meat).
Why drink so much water?
When you are losing weight, there are many waste products to eliminate, mostly
in the urine. Some of these substances tend to form crystals, which can cause
kidney stones. A high water intake protects you and helps your body to rid
itself of waste products efficiently, promoting better weight loss. Water also
fills your stomach and helps to prolong and intensify your sense of
satisfaction with food. If you feel a desire to eat between meals, it may be
because you did not drink enough water in the hour before.
What is Dumping Syndrome?
Eating sugars or other foods containing many small particles when you have an
empty stomach can cause dumping syndrome in patients who have had a gastric
bypass. Your body handles these small particles by diluting them with water,
which reduces blood volume and causes a shock-like state. Sugar may also induce
insulin shock due to the altered physiology of your intestinal tract. The
result is a very unpleasant feeling: you break out in a cold clammy sweat, turn
pale, feel "butterflies" in your stomach, and have a pounding pulse. Cramps and
diarrhea may follow. This state can last for 30-60 minutes and can be quite
uncomfortable - you may have to lie down until it goes away. This syndrome can
be avoided by not eating the foods that cause it, especially on an empty
stomach. A small amount of sweets, such as fruit, can sometimes be well
tolerated at the end of a meal.
Is there a problem with consuming milk products?
Milk contains lactose (milk sugar), which is not well digested. This sugar
passes through undigested until bacteria in the lower bowel act on it,
producing irritating byproducts as well as gas. Depending on individual
tolerance, some persons find even the smallest amount of milk can cause cramps,
gas and diarrhea.
Why can't I snack between meals?
Snacking, nibbling or grazing on foods, usually high-calorie and high-fat
foods, can add hundreds of calories a day to your intake, defeating the
restrictive effect of your operation. Snacking will slow down your weight loss
and can lead to regain of weight.
Why can't I eat red meat after surgery?
You can, but you will need to be very careful, and we recommend that you avoid
it for the first several months. Red meats contain a high level of meat fibers
(gristle) which hold the piece of meat together, preventing you from separating
it into small parts when you chew. The gristle can plug the outlet of your
stomach pouch and prevent anything from passing through, a condition that is
very uncomfortable.
How can I be sure I am eating enough protein?
40 to 65 grams a day are generally sufficient. Check with your surgeon to
determine the right amount for your type of surgery.
Is there any restriction of salt intake?
No, your salt intake will be unchanged unless otherwise instructed by your
primary care physician.
Will I be able to eat "spicy" foods or seasoned foods?
Most patients are able to enjoy spices after the initial 6 months following
surgery.
Will I be allowed to drink alcohol?
You will find that even small amounts of alcohol will affect you quickly. It is
suggested that you drink no alcohol for the first year. Thereafter, with your
physician's approval, you may have a glass of wine or a small cocktail.
What vitamins will I need to take?
You will need to take a daily multivitamin for the rest of your life. B12 may also need to be taken orally or sublingually
(under the tongue) by many patients and calcium supplementation is recommended to help prevent bone calcium loss.
Other supplements may be prescribed by your surgeon.
Do I meet with a nutritionist before and after surgery?
Most surgeons require patients to consult with a nutritionist before surgery.
Counseling after surgery is available on an individual basis as needed or
required by your physician.
Will I get a copy of suggested eating patterns and food choices after
surgery?
You will be provided with materials that clearly outline their expectations
regarding diet and compliance to guidelines for the best outcome based on your
surgical procedure. After surgery, health and weight loss are highly dependent
on patient compliance with these guidelines. You must do your part by
restricting high-calorie foods, by avoiding sugar, snacks and fats, and by
strictly following the guidelines set by your surgeon.
General
What is the youngest age for which weight loss surgery is recommended?
Generally accepted guidelines from the American Society for Bariatric Surgery
and the National Institutes of Health indicate surgery only for those 18 years
of age and older. Surgery has been performed on patients 16 and younger. There
is a real concern that young patients may not have reached full developmental
or emotional maturity to make this type of decision. It is important that young
weight loss surgery patients have a full understanding of the lifelong
commitment to the altered eating and lifestyle changes necessary for success.
What is the oldest patient for whom weight loss surgery is recommended?
Patients over 65 require very strong indications for surgery and must also meet
stringent Medicare criteria. The risk of surgery in this age group is
increased, and the benefits, in terms of reduced risk of mortality, are
reduced.
Can Weight Loss Surgery prolong my life?
There is good evidence from scientific research that if you have Type 2
diabetes (or other serious obesity-related health conditions), are at least 100
lbs. over ideal body weight, and are able to comply with lifestyle changes
(daily exercise and low-fat diet), then weight loss surgery may significantly
prolong your life.
Can weight loss surgery help other physical conditions?
According to current research, weight loss surgery can improve or resolve
associated health conditions.
| Condition | Percentage found in preoperative individuals | Percentage cured 2 years after surgery |
| Diabetes or insulin resistance | 34% | 85% |
| High blood pressure | 26% | 66% |
| High triglycerides | 40% | 85% |
| Sleep apnea | 22% in males, 1% in females | 40% |