1: Who is a candidate for bariatric surgery? BMI of 35 or greater with one co-morbid such as Hypertension, Diabetes or Obstructive Sleep Apnea OR a BMI greater than 40 with or without a co-morbid. All insurance companies that follow medicare guidelines (i.e. Fidelis Dual Advantage, Medicare advantage plans and straight medicare) require a BMI of 35 and over with at least one co-morbid listed below:

  1. Congestive Heart Failure
  2. Coronary Artery Disease
  3. Hear Failure
  4. Asthma
  5. Osteoarthritis
  6. Reflux esophagitis
  7. Emphysema
  8. Chronic non-alcoholic liver disease
  9. Peripheral venous insufficiency

2: What happens if you're not a candidate for weight loss surgery? One of our board certified surgeons, Dr. Giannone, specializes in weight loss management and may consider weight loss medication for you if you haven't been able to lose weight though diet or exercise. You must have a BMI greater than 27 with a co-morbid, or BMI of 30 or higher. Some of these weight loss medications include:

  1. Phentermine
  2. Qsymia
  3. Contrave
  4. Belviq
  5. Saxenda
  6. Topiramate
  7. Metformin

3: What is BMI? Body Mass Index (BMI) is a standard measure of body fat. It is calculated based on height and weight. The formula to calculate BMI is mass (kg) divided by height (m) squared. Although BMI does not directly measure body fat, previous research has demonstrated a strong correlation between BMI and direct body fat measurements.

4: Types of Bariatric Surgeries:

  1. Laparoscopic Gastric Sleeve - Through 5 or 6 key-hole sized incisions, roughly 85% of the stomach organ is removed, making patients feel more full sooner and thus giving them better portion control. The segment of the stomach which is removed also houses hormone producing cells (Ghrelin- also known as a hunger hormone) which triggers hunger. Once that portion of stomach is removed, hunger levels/cravings also tend to diminish.
  2. Roux-en-Y Gastric Bypass - In this procedure, the surgeon creates a small stomach pouch the size of an egg and then constructs a “bypass” for food. The bypass allows food to skip parts of the small intestine. By skipping a large portion of the small intestine, the body cannot absorb as many calories, thus facilitating weight loss.
  3. Laparoscopic Adjustable Gastric Banding - The Laparoscopic Adjustable Gastric Banding procedure is a purely restrictive surgical procedure in which a band is placed around the uppermost part of the stomach. This band divides the stomach into two portions: one small pouch and one larger portion. Since the stomach is divided into a smaller pouch, most patients feel more full faster. As the name indicates, the band is adjustable. If the rate of weight loss is not acceptable, the band can be adjusted. Food digestion happens through normal digestion.
  4. Biliopancreatic Diversion with Duodenal Switch (BPD/DS) - In this version of BPD, stomach removal is limited to the outer margin, creating a sleeve of stomach. The duodenum, the first portion of the small intestine, is divided so that pancreatic and bile drainage are bypassed.

5: What is the benefits of Bariatric Surgery? The biggest benefit of Bariatric Surgery is weight loss and overall improved health. Quality of life improves in 95% of patients and mortality rates have decreased in 89% of patients in a 5-year period. Research reflects that with bariatric surgery the following comorbidities or other obesity related issues will improve or resolve by the following percentages:

  1. Obstructive Sleep Apnea: 74% - 98% resolved
  2. Type 2 Diabetes: 82% - 98% resolved
  3. Hypertension: 69% resolved
  4. Hypercholesterolemia: 63% resolved
  5. Non-alcoholic Fatty Liver Disease: 90% resolved
  6. Asthma: 69% resolved
  7. Migraines: 57% resolved
  8. Depression: 47% resolved
  9. Osteoarthritis/Degenerative joint disease: 41% resolved
  10. Venous Stasis Disease: 95% resolved
  11. Gout: 72% resolved
  12. Urinary Stress Incontinence: 44% resolved
  13. Metabolic Syndrome: 80% resolved
  14. Polycystic Ovarian Syndrome
  15. Resolution of hirsutism: 79% resolved
  16. Menstrual Dysfunction: 100% resolved

6: What are the risks of Bariatric Surgery?

  1. Leaks
  2. Hemorrhage (bleeding)
  3. Thrombus Formation (blood clots)
  4. Bowel function changes such as diarrhea or constipation
  5. Bowel Obstruction (hernia)
  6. Organ injury during surgery
  7. Wound infection

7: Is Bariatric Surgery covered by Insurance? Most insurance companies cover bariatric surgery; however, it is the patient’s responsibility to contact their insurance company and find out if they have bariatric benefits.

8: If I do not have bariatric benefits, how much would bariatric surgery cost out of pocket?

  1. Hospital fees are approximately $20,000, which needs to be paid up front. This amount does not include the Physicians fee. Please be sure to contact our billing department directly for further information.

9: How much weight can I expect to lose after bariatric surgery? 10-20lbs after the first 2 weeks and about 30-45lbs after the first 3 months. The amount and rate of excess body weight that you can lose depends on your starting weight, type of surgery, and your compliance with diet, exercise and vitamin intake.

10: How long is the hospital stay after surgery?

  1. Laparoscopic Gastric Sleeve: 2-3 days
  2. Roux-en-Y Gastric Bypass: 2-3days
  3. Biliopancreatic Diversion with Duodenal Switch (BPD/DS): 2-3 days

11: What is the recovery time for bariatric surgery?

  1. Laparoscopic Adjustable Gastric Banding: 2 weeks after surgery
  2. Laparoscopic Gastric Sleeve: 2-4 weeks after surgery
  3. Roux-en-Y Gastric Bypass: 2-4 weeks after surgery
  4. Biliopancreatic Diversion with Duodenal Switch (BPD/DS): 2-4 weeks after surgery

12: How soon can I drive after surgery? - For your own safety, do not drive while taking narcotics. You may resume driving within 5-7 days postoperatively.

13: Can I get pregnant after weight loss surgery? Obesity can make it difficult for some women to get pregnant, but bariatric surgery can actually improve fertility. Patients are advised not to get pregnant and use a reliable source of birth control for the first 18 months postoperatively.

14: When can I resume sexual activity? You may resume sexual activity as soon as your surgeon clears you. It is generally recommended that people wait about 2 weeks after bariatric surgery before they have sex. Please discuss this with your surgeon at your 2-week postoperative visit.

15: Can I drink Alcohol after undergoing bariatric surgery? We encourage our patients not to drink alcohol after surgery because it rapidly enters the intestines and can become toxic. Alcohol also contains many calories which can slow down your weight loss.

16: Can I smoke after bariatric surgery? We do not advise smoking after surgery. We recommend smoking sensation 3 months prior to surgery to reduce the risk of fatal blood clots, leaks, and pneumonia. Nicotine causes the blood vessels to constrict which decreases blood flow to the stomach. Carbon Monoxide reduces the ability of red blood cells to carry oxygen. These combined factors can cause healing following bariatric surgery to slow considerably. By continuing to smoke after surgery, a patient may experience many complications such as the following:

  1. Leaks
  2. Ulceration of the pouch
  3. Gastritis
  4. Inflammation
  5. Infection
  6. Pulmonary dysfunction
  7. Increased shortness of breath

17: What about E-Cigarettes? While e-cigarettes don't have all of the toxins that traditional cigarettes contain, the e-liquids used in these vaporizers may have nicotine ingredients. They are therefore not recommended.

18: When can I resume physical activity? It is extremely important that you walk as much as possible after surgery. Please refrain from going to the gym for the fist 2 weeks. Do not lift anything that weighs more than 20lbs in the first four weeks. Patient may resume full activity after 4 weeks without restrictions.

19: When can I take a shower? You may shower as soon as you get home. Do not use any soap, wash cloth, loofah etc. on your abdomen. Let the warm water run over the area and pat dry with a towel.

20: When can I return to work after bariatric surgery? Most patients who have a minimally invasive procedure may return to work and activity within 2 - 4 weeks. Patients who lift greater than 20-30lbs on a daily basis may return to work after 4 weeks without restriction.

21: Follow up appointments: It is important that you commit to coming back for regular follow up visits after having bariatric surgery. It is imperative that we check your diet, protein intake, vitamin levels, medications, exercise, etc. We also need to assess your need for further nutritional counseling. More importantly, we want to keep our relationship close to increase your long term chances for continued success.

  1. 2 weeks after surgery
  2. 4 weeks postoperative nutrition class with dietician
  3. 3 months after surgery
  4. 6 months after surgery
  5. 9 months after surgery
  6. 12 months after surgery
  7. Every year during the anniversary month of your surgery for life
    ** Vitamin levels are assessed every 3 months for the first year, and then yearly thereafter

22: What medications are prescribed after bariatric surgery?

  1. Norco as needed for pain
  2. Actigall, to decrease risk of gallstone formation.
  3. PPI - Proton Pump Inhibitors, to keep stomach acid levels down

23: What is the bariatric diet after surgery?

  1. Phase I: Full liquid diet with 3 protein shakes daily
  2. Phase II: 2 protein shakes and 1 soft protein meal daily
  3. Phase II: You may advance to 3 soft proteins daily between 3-6 weeks. Please note, not all patients advance at the same rate. Listen to your body and advance at your own rate, according to the dietician.

24: How common is constipation after weight loss surgery? Constipation is actually a fairly common side effect that patients experience after surgery. There are several reasons constipation exists after surgery, but the symptoms usually improve after the first 3 months.

25: What are the causes of constipation after bariatric surgery? The most common causes of constipation after surgery are as follows:

  1. Decreased food intake
  2. Decreased water intake
  3. Decreased physical activity<
  4. Side effect of iron supplements or iron containing supplements
  5. Side effect of pain medication

26: How can bariatric surgery patients treat constipation? As soon as you get home from the hospital, you can start taking Colace (docusate sodium, docusate calcium), which is a stool softener. Take 1-3 per day until constipation improves. This should be taken daily and does not act like a laxative.  If you have not had a bowel movement in 3-4 days of being on the Colace, you can take a laxative like Dulcolax or Milk of Magnesia. It is normal after surgery to not have a daily bowel movement since you aren;t eating solid foods or high fiber foods. Laxatives are to be used to treat short term effects of constipation.There are several things patients can do to prevent constipation long term.

27: How can bariatric patients prevent constipation?

  1. Stay well hydrated - drinking water throughout the day will help you soften your stool. Aim for 64 oz non-carbonated, sugar-free, and decaffeinated liquids per day.
  2. Get enough fiber in your diet -immediately post op you will need to get your fiber in through supplements. Once you are one-month post op you can add fruits and vegetables to your diet which will help naturally with constipation. Increase fiber slowly to prevent bloating or gas. Do not add fiber unless you are getting adequate fluids, or your constipation can become worse.
  3. Exercise regularly - regular exercise with help with digestive health and can reduce the likelihood of constipation. Immediately after surgery, start with some light walking.
  4. Use ferrous fumarate or ferrous gluconate iron supplements - if you need additional iron, these forms of iron are less constipating.

28: Are you at risk for kidney stones after bariatric surgery? Some patients are at higher risk of developing oxalate kidney stones after bariatric surgery. Factors which may increase your risk include:

  1. Previous history of kidney stones
  2. Low fluid intake
  3. Severe fat malabsorption of fatty stools
  4. Low calcium intake and absorption
  5. High oxalate diet
  6. Excessive sodium intake
  7. Increased intake of animal protein <
  8. High dose supplements of vitamin C, turmeric or cranberry pills

29: When can I travel after bariatric surgery? Following bariatric surgery, we recommend waiting 6 weeks before traveling by air. Most jet flights are pressurized to about 8,000 feet and this is a significant change in atmospheric pressure that can adversely affect the abdominal surgery site. One of the biggest risks associated with air travel is deep vein thrombosis or DVT, which are blood clots in the veins of the legs. The relative immobility of air travel can cause circulation to slow. This can cause small clots to cluster together into larger clots, which might travel to your lungs and cause a pulmonary embolism. Make sure you've been mobile before the flight, stay hydrated, and avoid caffeine and alcohol. Walk the aisles or move to the lavatory area where you can stand and stretch your legs.

30: Why am I experiencing hair loss after surgery? Hair loss is due to hormonal changes and nutritional changes. It occurs between 3-6 months and may persist for up to 12 months. In most cases your hair will begin to grow back after your weight stabilizes.
31: When can I go on a road trip? Following bariatric surgery, we recommend waiting one week before driving a car, and never drive while taking any form of narcotic pain medication. Break up your drive and add in a little activity. We recommend that for every hour of drive-time, you get out of the car and walk around for 15-20 minutes.

32: Will I need to have plastic surgery? You may have some loose skin, but whether you get plastic surgery depends on several factors: how much weight you loss, your age, your genetics, and whether or not you exercise or smoke. Most surgeons recommend waiting at least 18 months, but you can be evaluated before that. Plastic surgery for removal of excess abdominal and breast skin is often covered by insurance for reasons of moisture, hygiene, rash issues, and back pain.

33: Will I have to take vitamin and minerals after surgery? You will need to take multivitamins for life. You will have your vitamin levels routinely checked every 3 months for the first year after surgery and yearly thereafter.

34: If I have a Lap Band, can I have it removed and get a sleeve or bypass? Yes, revision surgery is an option as long as the patient meets criteria, has the benefit for weight loss surgery, and is approved by his/her insurance company.

35: If I have had Bariatric Surgery before and have re-gained weight, can I have more surgery? Yes. Surgery is always an option as long as criteria is met, patient compliance has been demonstrated, and the revision surgery is approved by insurance. Just remember, there are higher risks associated with revision bariatric surgery that your surgeon will explain in detail.

Personal Preparation for Weight Loss Surgery

Now that you have decided to proceed with surgery, there are certain steps to take before your operation to ensure that you are in the best possible readiness for the procedure. Start taking multivitamins once daily to improve your general health. Further, take 500 mg of Calcium Citrate (CitraCal®) three times daily. Vitamin and mineral intake is especially important after Bariatric surgery in order to maintain good nutrition and health. We have found that if you start taking these supplements before surgery, it will be easier remembering them after surgery

Another important way to prepare for surgery is exercise. The best time to begin your exercise program is before your surgery. Walking on a daily basis improves your circulation and makes breathing easier during recovery. Should you be unable to walk daily due to joint pain, then you may want to look into an aquatics program. Water exercises still condition your breathing, but are not weight bearing and are therefore easier for people who have joint problems. You will also benefit from having a plan in place, so you don’t have to figure out your routine during the recovery phase.

You should begin taking two showers per day for a few days before you enter the hospital. Careful attention must be given to cleaning the entire trunk from the neck and armpits to the groin, making sure to clean between any folds of skin. Use antibacterial soap such as Dial®or Hibiclens. Pat dry any reddened areas or use a blow dryer on low heat to dry difficult to reach places.

Medicines and Weight Loss Surgery

It is important to avoid aspirin and all aspirin-containing medicines for 7 to 10 days prior to surgery. Remember to check the label, since certain over-the-counter medicines can contain aspirin, too. If in doubt, please check with your pharmacist or your surgeon. Make sure that you keep your surgeon and other specialists informed of the complete list of medicines that you are taking. Include herbal supplement and vitamins in this list. Some herbal supplement must be discontinued before surgery, so be certain to check with your surgeon.

For two days prior to surgery you may drink only liquids. The day before surgery, you may drink only clear liquids. Clear liquids include water, coffee, tea, apple juice, grape juice, cranberry juice, bouillon, broth, clear Popsicles, soda and gelatin. Further instructions will be given to you at your pre-operative appointment. It is important that you follow these instructions completely. After midnight you must take nothing by mouth except medicines that have been approved by your anesthesiologist and your surgeon. Your stomach must be empty at the start of the procedure to avoid the risk of food particles going in to your windpipe.

Smokers who undergo anesthesia are at increased risk for complications. Patients are required to stop smoking eight weeks before surgery. Patients must agree to permanently refrain from smoking after surgery. Ask your Primary Care Physician to write you a prescription for a smoking cessation aide.

Alcohol causes gastric irritation and can cause liver damage. During periods of rapid weight loss the liver becomes especially vulnerable to toxins such as alcohol. You may find that only a couple of sips of wine can give you unusually quick and strong effects of alcohol intolerance. In addition, alcoholic beverages are high in empty calories and may cause “dumping syndrome”. For these reasons, we recommend complete abstinence from alcohol for one year after surgery and avoiding frequent consumption thereafter.

Work and Disability

Expected return to work time is about two to six weeks. This varies from person to person depending on the kind of work you do, your general state of health, how badly your work needs you, how badly you need your work (i.e. the money), your general state of motivation, and your energy level. Some patients do not wish to tell the people with whom they work what kind of surgery they are having, and this is perfectly appropriate. Although you do not need to tell your employer that you are having weight loss surgery, it is recommended to reveal that you are having major abdominal surgery. Do not tell your employer that you are having gall bladder surgery, since you would be expected to return to work within two weeks. Explain that you will need four or more weeks to recover. Your employer should have the relevant forms for you to complete if you would like to have some form of financial compensation during your absence. You may want to indicate that you will not be able to do any heavy lifting for several months after surgery.

Pre-op Weight Loss Surgery Evaluation Procedures

Before you can have your surgery, you will need a consultation with your surgeon. This is a good time to have questions reviewed with your medical team. Remember, your team consists of many participants, the most important of which is you. In addition your surgeon, a physician assistant, an anesthesiologist, nurses, physical therapists, respiratory therapists, lab technicians, social workers, pharmacists and dietary consultants will all take part in your care. You will also have the required pre-op specialists appointments with a cardiologist, pulmonologist, nutritionist, and a behavioral health specialist. In some cases appointments with an endocrinologist and a vascular specialist are also necessary. You will need to have the following tests prior to surgery: a pulmonary function test, an arterial blood gas test, pre-op blood work, an Ultrasound of your gallbladder, a chest x ray, an EKG, and an Echo cardiogram. If you have previously had any of these tests performed in the last 6 months please notify our office, as you may not need to have them repeated. We will also need a letter of medical necessity from your Primary Care Provider.__Please bring with you insurance cards, a detailed list of your medications, including herbal supplements and vitamins, which you may be taking. You can discuss advance directives and living wills with the pre-admitting nurse.

If you are ill before Weight Loss Surgery

Should you develop a cold, persistent cough, fever or any changes in your condition during the days before your surgery, please notify the physician who medically cleared you for surgery immediately. You will need to be re-evaluated for surgical readiness. You need to be in the best possible shape for anesthesia. Scheduling can be adjusted to your condition if necessary.

Before Leaving Home

We recommend that you shower in the morning on the day of surgery, but do not use any moisturizers, creams, lotions, or make-up. Remove your jewelry and do not wear nail polish. You may wear dentures, but you will need to remove them just prior to surgery. Please bring your eyeglasses and a case if possible.

Hospital Admitting Procedures

Check-in at the Ambulatory Care Unit (ACU). At the ACU, you will be asked to change your clothing and put on a hospital gown and slippers. If you wear dentures, corrective lenses, or hearing aids you will be asked to remove them for safety reasons. Please bring your own container. The hospital staff will keep all your personal belongings in a safe place and give them back to you promptly after surgery.

You will be asked to sign an operative consent form, even though you may already have done so at your surgeon’s office. Your signature indicates that the procedure has been explained to you, that you understand it, and that you have no further questions. Your blood pressure, pulse, respiration, oxygen saturation, temperature, height and weight will be measured. An intravenous (IV) line will be placed in your forearm. This allows fluids and/or medications into your blood stream. You may also be given some medicine to help you relax.

Anesthesia

The anesthesiologist will meet with you before your surgery to discuss the general anesthetic you will receive. Once you are settled on the operating table, you will be connected to several monitors for your heart and blood pressure. Compression boots are also applied at this time. A quick acting sedative will be given through the IV tubing after you have breathed pure oxygen for a few minutes. When general anesthesia is used, you will be sound asleep and under the care of your anesthesiologist throughout the operation.

After you fall asleep, your anesthesiologist will slip an endotracheal tube through your mouth into your windpipe to guarantee that your breathing is unimpeded. A small plastic tube will be placed thru your mouth to empty your stomach and another tube called a urinary catheter will be placed to drain your bladder. An anesthetic gas that you will breathe and other medications that will be given through the IV catheter will keep you asleep and pain free. Your surgery will take 2-3 hours.

After Surgery

When your surgery has been completed, you will be moved to the recovery room. It is common for patients to be drowsy and sometimes confused when they first wake up. During this period, fully trained recovery room nurses will remain with you at all times. Most patients will come out of the OR without the NG tube. You will still have the urinary catheter in place. The urinary catheter will usually be removed on the first post-operative day, or when you are comfortable enough to walk to the bathroom. Following surgery you will receive blood thinner medication to prevent clots. Your vital signs will be monitored regularly. You will also be encouraged to do breathing exercises, and to get out of bed several times a day.

You will remain in the recovery room or Bariatric Unit over night until a swallow study is conducted the following morning. This study allows the doctors to confirm there are no leaks in your new digestive tract. Once this is determined you will be able to drink. When your initial recovery is completed and all your vital signs are stable, you will be transported to your room.

Pain Control

Pain management is a primary concern for all members of your care team. While some level of discomfort is expected, keeping your pain under control is necessary for your recovery. It is normal that you will feel some pain following the surgery, particularly where the incisions were made or from the position your body was in during surgery. Your pain will be greatest the day following surgery, but will decrease over the next several days.

When you feel pain you will be able to push a button to administer pain medication to yourself. This method of administration is called “patient-controlled analgesia” (PCA). As soon as you tolerate pills by mouth, your medical team will add oral pain medication. Pain medication by mouth may be prescribed for the first few weeks following your hospital discharge as well.

Weight Loss Surgery Recovery at the Hospital

The hospital stay for gastric bypass and sleeve gastrectomy averages two to three days. Patients undergoing gastric banding usually leave the same day of surgery. The first few days after the operation are a critical time for your stomach and intestines to heal.

Your nurses will encourage and assist you in performing deep breathing, coughing, leg movement exercises, and getting you out of bed after surgery. With the help of your nurse or Physical Therapist, you should sit up and dangle your feet the first night of surgery and stand at your bedside. You will be asked to get out of bed and walk the first post-operative day.

The following leg exercise are helpful in preventing problems with circulation after surgery. You should attempt to do these at least 10 times each hour while you are awake.

  • Ankle pumps: move your foot up, toes to the ceiling, keeping your knee straight, then point your toes down towards the bed, as though stepping on the gas pedal of your car. Also roll your ankle around in circles.
  • Quad sets: press the back of your knee down onto our bed by making the muscles in your thighs tighten. Hold in place for a count of 5, then relax and repeat.
  • Gluteal sets: lie on your back and bend your knees so your feet are flat on the bed, then squeeze your buttocks together causing your hips to be lifted slightly. Hold in place for a count of 5, then relax and repeat.

After the first post-operative day, you will be required to walk at least three times per day and to do your leg and breathing exercises hourly. Getting up, walking and doing your post-operative exercises will speed up your recovery and minimize complications.

Be certain to report any symptoms of nausea, anxiety, muscle spasms, increased pain or shortness of breath to your nurse.  To varying degrees, it is normal to experience fatigue, nausea and vomiting, sleeplessness, surgical pain, weakness and lightheadedness, loss of appetite, gas pain, flatus, loose stools, and emotional ups and downs in the early days and weeks after surgery. You may discuss specific medical concerns with your surgeon or physician. Our staff at Obesity Surgery Specialists will provide you emotional support, answer questions and give you encouragement.

Diet at the Hospital

At the hospital, you will be served clear liquids and eventually full liquids as your new stomach pouch begins to heal. Most likely, you will not feel hungry the first week or so after surgery. This is normal, no reason for concern and may last a few weeks. However, it is very important to keep drinking water and to eat protein to prevent dehydration and to promote healing.

What to Expect on Your 1st Weight Loss Surgery Post-op Day

The nursing staff will check your wounds, monitor your vital signs, and check that you are doing your breathing and leg exercises. You should get out of bed and walk at least 3 times. The urinary catheter will be removed when you are comfortable enough to walk to the bathroom. Your pain medicine will be available either by the PCA pump or by injection. A technician may be by to draw your blood. Once you have had a successful swallow study performed you may begin eating clear liquids. If you are tolerating liquids well, your IV may be removed.

What to Expect on Your 2nd Post-op Day

Again today, the nursing staff will check your wounds, monitor your vital signs, and check that you are doing your breathing and leg exercises. You should get out of bed, preferably by yourself, and walk at least 3 times. Your pain medicine most likely be administered as a pill, and we will begin planning your discharge for home.

How Will I Know When I’m Ready to Go Home?

When you are tolerating your diet, are able to walk by yourself, can get in and out of bed independently, climb stairs, and can follow all your at home instructions you will be discharged from the hospital.

Going Home

Your date of discharge will be determined by your surgeon based on your individual progress. Prior to your discharge, specific dietary and activity instructions will be reviewed with you, along with precautions and situations when your surgeon should be notified. Please give some thought to your living environment and tell the hospital staff so they can prepare your discharge home with your specific needs in mind.

Preparing Your Home

You should take time before your surgery to make sure your home is equipped for you return. Make sure you have tried several protein shakes and found one you like for use after surgery. You should have this available when you get home. Keep a phone list ready with important numbers. You may want to add numbers of some member of your support network to the back page of your patient handbook where important numbers are listed. When possible you may want to have some friends available to check on you your first few days home if you live alone.

Follow Up Weight Loss Surgery Care

Your first office visit with your surgical team should be two weeks after your surgery. Your surgeon’s discharge instructions will give your specific information to make an appointment. Our office will contact you following your discharge to check on your progress. You will be seen by your surgical team on a periodic basis after that, usually at 4 weeks, 6 weeks, 3 months, 6 months, 9 months, 12 months, and then annually thereafter. Please call your surgeon’s office with any concerns between scheduled visits. Also, don’t hesitate to contact your primary care physician with medical concerns.

Urgent Symptoms after a Weight Loss Surgery

If you experience any of these symptoms, contact your surgeon right away.

  • Fever of 101 degrees Fahrenheit or above
  • Yellow/green, purulent and/or odorous wound drainage
  • Chest or shoulder pain
  • Shortness of breath
  • Rapid breathing or pulse
  • Vomiting for more than 24 hours
  • Leg pain or swelling
  • Any unusual symptom

Specific Recovery Instructions

When you get home, your activity will be restricted to no strenuous activity for 3 to 6 weeks after the operation. Change positions frequently while sitting, and walk around while standing to help prevent blood clots from forming in your legs. You may walk and perform light household duties as tolerated upon your return home. Avoid lifting anything heavier than 20 to 30 pounds during the first six weeks. Patients undergoing the laparoscopic method are more frequently able to return to all activities within a shorter time frame. You may be tired, weak, nauseated or have vomiting the first few weeks after surgery. Keep up your fluid intake with small, frequent sips as necessary. 1 to 2 Liters a day is the recommended minimum intake. We suggest carrying a bottle of water with you at all times to help you achieve this. Resume traveling short distances as soon as you feel strong enough to make the trip. Do not drive a motor vehicle until you are off the prescription pain medicines, usually about one week after your surgery.

Personal Hygiene

Due to the nature of abdominal surgery, you may need some help with toileting. Flushable baby wipes tend to be gentler for personal hygiene, as is a peri-bottle. You can use a small sports-top water bottle as well. A long sponge stick can also be very helpful.

Wound Care

Your wound needs minimal care. If sutures were used, they dissolve, so there is no need to remove any stitches. You will notice some tape called “steri-strips®” on your wound. They will fall off on their own. It is important to keep the wound clean and dry to promote faster healing. You may shower, but pat dry the incision area well. After about three weeks, the incision is usually ready for immersion. Ask your surgeon before you take a bath. Despite the greatest care, any wound can become infected. If your wound becomes reddened, swollen, shows pus or red streaks, has yellow/green, purulent and/or odorous drainage, feels increasingly sore or you have a fever above 101°F, you must report to your surgeon right away. Please do not use any Neosporin®or other occlusive ointment on your incision.

Sexuality / Pregnancy

The following questions and answers respond to common concerns of patients and their partners after obesity surgery.

When will I be able to resume sexual relations after a Weight Loss Surgery?

You may resume sexual activity when you feel physically and emotionally stable. Women need to use a mechanical form of birth control, as fertility may be increased with weight loss and oral contraceptives may not be fully absorbed.

Why am I more likely to conceive now if I was infertile before the Weight Loss Surgery?

Many severely obese women are also infertile, because the fatty tissue soaks up the normal hormones and makes some of its own as well. This completely confuses the ovaries and uterus, and causes a lack of ovulation. However, as weight loss occurs, this situation may change quickly.

How soon after Weight Loss Surgery is it safe to become pregnant?

Following the operation your body will be undergoing may rapid changes. For this reason we recommend you delay pregnancy until your body is adjusted and adequate nutrition has been established. You may start planning a pregnancy after 18 months. It is important not to become pregnant before this time, since we want both you and the baby to be healthy and safe.

Post-Operative Diet – General Information

FOOD AMOUNT & SELECTION Now that you have had a procedure to decrease the size of your stomach, what you eat is more important than ever. Because you will be eating less, it is important to choose your foods carefully so that you will obtain all the vitamins, minerals, and protein you need. Meals should be well-balanced. Be sure to have measuring utensils on hand in your kitchen so that you are eating no more than what is recommended. If you’d like, take home a few of the small 1 oz. plastic cups from the hospital that patients use to help you at home, too.

FOOD TEXTURE All the foods you eat must be of the proper consistency to avoid damage to the sutures and to avoid clogging up the small opening in between your stomach and your intestines. Initially your diet will consist of liquids only. After about two weeks you should be able to tolerate a small amount of solid foods. These solids will be soft, pureed and/or blenderized. It is very important that you make sure everything is chewed to the consistency of baby food, if it requires chewing. Any foods that cannot be chewed this finely, such as celery, lettuce, etc., should be avoided. Meals should be eaten very slowly, allowing 5 minutes between bites. You will not be drinking liquids with your meals. You must be sure to STOP EATING as soon as you feel full (no longer hungry).

VITAMINS & MINERALS It is difficult to get all of the essential vitamins and minerals your body needs from the small volume which you will be allowed to eat, so IT IS IMPORTANT TO TAKE A VITAMIN AND MINERAL SUPPLEMENT DAILY. Ask your surgeon if it should be in liquid form, which is available at your local pharmacy. It is recommended to take a chewable, powdered or liquid mulitivitamin after surgery. Make sure your MVI has 100% of the DV (daily value) for zinc and biotin.

Multivitamin Suggestions: • “Building Blocks” • “Bariatric Advantage” • “One-A-Day Energy”

Additional vitamin and mineral supplements are also recommended, such as iron, zinc, calcium (especially important for women in preventing osteoporosis), and vitamin B12.

Iron: Bypass patients take 65 mg of ferrous fumarate (which is the least constipating form of iron) per day. Banding/sleeve patients can take 18 mg ferrous fumarate or if your multivitamin contains 18 mg of iron, you do not need additional. Taking Colace or a fiber supplement with plenty of water may also help to prevent constipation. Try to get iron with vitamin C to increase absorption. (The Department of Surgery has a chewable iron supplement with vitamin C available.) (continued)

Calcium: Take 1200 to 1500 mg per day. Gastric bypass and gastric sleeve patients must take calcium in the form of calcium citrate. (Look for calcium supplements that also contain Vitamin D. Do not take your calcium supplement when you take your iron supplement because calcium decreases the absorption of iron.) • “Building Blocks” • “Bariatric Advantage Chewable Calcium Citrate” • “Citrucal”

Folic Acid: You do not need to take a separate folic acid supplement as long as it is included in your multivitamin.

Zinc: Make sure the multivitamin you are taking contains zinc. This will help to prevent hair loss that can sometimes occur with significant weight loss.

Vitamin B12: If your doctor says you need to, take at least 350 micrograms (mg) per day, or 500 micrograms (mg) per week, or by injection. Vitamin B12 is also available in tablets that melt under your tongue (sub-lingual).

BYPASS PATIENTS ONLY

Vitamin A: Take a total of 10,000 IU’s per day. This amount includes what is in your multivitamin.

PROTEIN It is important to consume at least 60-80 grams of protein in your diet per day. Protein aides in healing, provides energy, prevents hair loss, and fights infection. This is where your protein shakes come in handy. Your protein shake must initially contain at least 40-50 grams of protein. Other foods high in protein that will be allowed at various stages of the diet include:

LIFESTYLE CHANGES You need to make long-term lifestyle changes in order to help you maintain your new weight and a healthy body. Don’t forget, it is very possible to regain a significant amount of weight if you continue the lifestyle you had before your procedure! A registered dietitian (“RD”) can help you make positive dietary changes such as decreasing saturated fat and salt and increasing fiber. Seeing an RD post-op as an outpatient is recommended. You should also be increasing your activity level with your doctor’s permission, and finding an exercise that you can do for the rest of your life. A certified personal trainer or exercise physiologist can help you.

A gastric procedure for weight loss is only the short-term cure for morbid obesity. What YOU do in months and years to come will ensure its long-term success!

Post-Operative Diet – Specific Guidelines

THE DAY AFTER SURGERY: WATER ONLY • Once you have passed your swallow evaluation (usually the morning after surgery) you will be allowed to take ice chips, sips of water, and then start on clear liquids.

STAGE 1: LIQUIDS (WEEKS 1 AND 2 POST–OP) CLEAR LIQUID DIET ~ ONLY WHILE YOU ARE IN THE HOSPITAL

• chicken or beef broth • Crystal Lite • sugar-free Italian ices (frozen fruit ice) or sugar-free popsicles • sugar-free jello

Consume 3 ounces for breakfast, 3 ounces for lunch, and 3 ounces for dinner (total of 9 ounces per day). FULL LIQUID DIET ~ ONCE YOU ARE DISCHARGED FROM THE HOSPITAL • high protein, low sugar protein shake (such as Perfect Low Carb Isopure)

• skim or 1% low-fat milk, or sugar-free yogurt (blended, and without chunks of fruit – it can be fruit flavored such as Dannon Lite Raspberry)

• farina thinned with skim or 1% low-fat milk (not oatmeal)

• strained cream soup

HOW TO MAKE PROTEIN SHAKE: Mix 9-10 ounces of skim or 1% milk with 2 scoops of powder. This one shake will last you the whole day. If you chose anything listed above besides the protein shake, it is recommended that you add one scoop of unflavored whey protein powder to provide additional protein. Your unflavored whey protein powder should have approximately 15 grams of protein per scoop.

• It is important to consume at least 60-80 grams of protein per day.

• For bypass/sleeve patients, consume no more than 3 ounces (90 cc) of shake for breakfast, 3 ounces for lunch, and 3 ounces for dinner.

• For banding patients, start off consuming three 3-ounce meals, and if needed you can increase to 6-8 ounces per meal. Only increase if you start to feel hungry!

• Do not drink liquids with your meals. No liquids should be consumed 30 minutes before a meal and 30 minutes after a meal.

• Consume at least 64 ounces of non-carbonated, sugar free liquid per day (water, Crystal Light, Diet Snapple, Fruit2O, Dasani flavored water, Propel)

• Avoid Gatorade-type beverages, hard candy, and chewing gum.

• “Skim Plus” is a creamy tasting milk with no fat! If you are used to 2% or whole milk, this brand may make switching to skim milk easier. “Lactaid” can help with lactose intolerance.

• Don’t forget your vitamin and mineral supplement!

Why Sugar-free? ~ The “Dumping Syndrome”

This only occurs in patients who have had gastric bypass/sleeve, not gastric banding. Even if you are not diabetic, you should avoid sugary foods and drinks. This is to avoid the “dumping syndrome”, which is a condition in which a person may experience symptoms of dizziness, weakness, sweating, rapid heartbeat, dropped blood pressure and/or diarrhea shortly after eating. Later on the person’s blood sugar might drop.

It happens when a large amount of a sugary food or liquid gets “dumped” quickly into the small intestines. Why would that happen? Well, before your procedure, your stomach was large enough to hold food for a while, allowing it to enter the intestines slowly – a little at a time. Now it is too small to hold much of anything, and the intestines are not designed to receive concentrated sugary foods all at once like this. So when it does, it tries to dilute the food by bringing water into the intestines from surrounding tissues and blood vessels. This causes a fluid shift in the body that can result in the unpleasant symptoms described above. This means that although eventually you are allowed to have fruit juice, you should go easy on it.

STAGE 2: MOSTLY LIQUID, SOME PURE_D AND/OR BLENDERIZED SOLID FOOD (WEEKS 3 AND 4 POST-OP)

• When first starting solid foods, you may have one soft meal per day. The other two meals must remain liquid.

• For bypass/sleeve patients, only 3 oz. of soft high protein food per day is allowed at this stage. Each liquid meal should still be 3 oz. (90 cc) as in Stage 1.

• For banding patients, only 4-6 ounces of soft high protein food per day is allowed at this stage. You can increase your other 2 liquid meals (protein shake) to 6-8 ounces per meal.

• Be sure to include HIGH PROTEIN foods and liquids in your diet. Continue to use the protein shakes.

• Chew your food well if chewing is required.

• Gradually your intake will increase, but this is based on individual tolerance.

• If your surgeon allows solid (non-pureed) food, any high-carbohydrate foods you eat should be WHOLE-GRAIN. Avoid processed carbohydrate foods such as white bread, white rice, white pasta, etc.

• Don’t forget your vitamin and mineral supplements!

ONE SOLID MEAL:

• Begin with pureed foods. Please use the attached list as a guide to make sure you get the required 15-20 grams of protein per meal. Herbs, seasonings, and broth may be added to pureed foods for flavor.

• NO red meat, leafy vegetables, celery, nuts

• NO high-calorie milkshakes, ice cream, cakes or cookies.

TWO LIQUID MEALS:

• Bypass/Sleeve patients: 3 ounces of protein shake • Banding patients: 6-8 ounces of protein shake

PLEASE NOTE: Tolerance to solid foods varies from person to person. If you find you cannot tolerate certain foods, AVOID THEM. If you cannot tolerate solid food altogether, go back to the all-liquid diet, supplement with “Pedialyte”, and call your physician. Low-sugar, high protein shakes (8 oz.) may also be substituted for a complete meal if you are having problems with solid food.

STAGE 3: PURE_D AND/OR BLENDERIZED SOLID FOOD (FROM 1 – 3_ MONTHS POST-OP)

• Foods should be soft (pure_d) or blenderized.

• Eat meals very slowly.

• If foods require chewing, chew your food very well.

• Between meals sip on non-carbonated, sugar-free liquids.

• Include HIGH PROTEIN foods in your diet (low fat dairy products, lean meat and chicken, fish, eggs, tofu, and legumes such as kidney beans or lentils).

• If you become constipated, you may take Milk Of Magnesia.

• If your surgeon allows solid (non-pureed) food, any high-carbohydrate foods you eat should be WHOLE-GRAIN. Avoid processed carbohydrate foods such as white bread, white rice, white pasta, etc.

• Don’t forget your vitamin and mineral supplement!

• Always consume protein containing foods first, vegetables or fruit second, and carbohydrates last.

• Bypass/Sleeve patients, you might not be able to tolerate the additional fruit at this stage. Make sure you get your protein in first, then consume the soft fruit or soft cooked vegetables.

• Banding patients can add a _ cup of starch (mashed potatoes, whole wheat pasta or Barilla Plus pasta) to the meal pattern listed below. In addition, if you are hungry in between meals, you can add 4 ounces of protein shake as a snack.

• The minimum amount of protein per meal is 3 ounces. You will gradually work up to 4 ounces. Do not go below 3 ounces of protein per meal. It can take you as long as you need to consume those 3 ounces.

EXAMPLE of a “PUREED” OR BLENDERIZED DIET

Breakfast:

• cup (4 ounces) of soft protein foods (See accepted food list above.) • cup (2 ounces) of soft or blenderized fruit

Lunch:

• cup (4 ounces) soft protein food (See accepted food list above.) • cup (2 ounces) soft cooked or blenderized vegetables, or blenderized fruit Dinner:

• cup (4 ounces) soft protein food (See accepted food list above.) • cup (2 ounces) soft cooked or blenderized vegetables, or blenderized fruit

FOODS APPROPRIATE FOR A PURE_D/BLENDERIZED DIET (STAGE 2 AND STAGE 3)

Higher protein options: • Cottage cheese – 1% or 2% fat

• Ricotta cheese – Lite or part skim

• Eggs – scrambled, poached, or soft boiled. Mix with water or milk to make sure they are light and fluffy.

• Egg whites

• Egg beaters

• Low fat cheese (soft)

• Tuna salad – made with lite mayonnaise and no vegetables. Use chunk lite tuna not solid white albacore.

• Egg salad – made with lite mayonnaise and no vegetables

• Poached chicken – cooked in chicken stock, marinara sauce, or in a crock pot. The meat should not be grilled or baked at this stage as it is too dry and tough that way. “Perdue Fit-n-Easy” thin sliced cutlet works well for most patients.

• Poached chicken salad – made with lite mayonnaise and no vegetables

• Hummus – any flavor except ones with chunks of vegetables (i.e. eggplant)

• Tofu

• Beans – Chickpeas, lentils, kidney beans, cannellini beans, black beans – mashed

• Soft cooked white fish -flounder, sole, tilapia. Avoid dry, thick fish like salmon, swordfish, or tuna steak.

• Pureed or blenderized meats blended with broth or milk

• Cold cuts: turkey, ham, low fat cheese

Lower Protein options: If you chose anything listed below, add an unflavored whey protein powder. Examples include GNC brand unflavored whey protein and Beneprotein. You want to check the label for the amount of protein per scoop to make sure you get at least 15-20 grams of protein per meal.

• Oatmeal – made with skim or 1% milk

• Yogurt – any Lite and Blenderized brand (i.e. Dannon Lite, Yoplait Lite)

• Farina, Cream of wheat, or grits – made with skim or 1% milk

• Mashed potatoes thinned with broth or milk

• Sweet potatoes thinned with broth or milk

• Cream or puree soups – low fat

• Unsweetened applesauce

• Sugar free pudding

• Pureed or very soft cooked vegetables

• Jarred or blenderized fruits

EXERCISE As soon as your doctor has given you permission, you must start a regular exercise program. This is essential to maintaining – among many other things – a healthy weight, a healthy heart, and a healthy mind.

Choose exercise that you enjoy. At first, exercise in which you don’t have to hold up your own weight makes it easier, such as swimming, or riding a stationary bike. As you grow stronger and your weight comes down, you can add walking, hiking, skiing, dancing, or playing tennis to name just a few fun activities.

Start out very slowly. Do only a few minutes each day at first, and over the next several months gradually work your way up to 10 minutes, then 15 minutes, then 20 minutes and so on. Only do what you can tolerate. Work both your muscles (weight training), and your heart (cardiovascular exercise). Your intensity and duration will increase slowly over time. Remember, a certified personal trainer can help you in creating a safe and effective exercise program that you will enjoy for years to come.

STAGE 4: REGULAR DIET ~ WITH SMALL PORTIONS (3-4 MONTHS POST-OP)

• At this stage, it is recommended to set up an individual nutrition appointment to develop a personalized plan for you to follow. This appointment should be made approximately 3 to 3_ months post-op.

• You should be able to tolerate any food consistency at this stage. However, your portion sizes should be much smaller now than they were before you had your procedure.

• It is extremely important to chew your foods very well and eat slowly. If a food feels like it “got stuck”, it usually means you didn’t chew that food enough or the food was too dry or tough.

• Continue taking a daily multivitamin.

• Your doctor may recommend that you continue to avoid chewing gum. If swallowed, it might obstruct the opening between your stomach and your intestines.

• Be sure to stop eating when you are full. Think of this often during your meal. Ask yourself if you need to continue eating, or if you should save the rest for later.

• Eat small meals and healthy snacks. Do not let yourself get to the point of “starving”, which is when a person naturally loses control over food choices and portion sizes.

• Choose foods low in saturated fat and sodium for a healthy diet. Consume lots of whole grains, fruits and vegetables (foods usually high in fiber).

• Avoid processed carbohydrate foods such as white bread, white rice, white pasta, etc.

• Drink plenty of water. Two liters a day is recommended.

• Be sure you are exercising regularly!

First Steps after your Weight Loss Surgery

You will be restricted to no strenuous activity for 3 to 6 weeks after the operation. You may walk and perform light household duties as tolerated upon your return home. Usually frequent walks of short duration are tolerated better than one or two long walks that go to or past the point of fatigue. Increase the distance that you walk gradually. By the time of your sixth week office visit you should be walking regularly two miles a day or more unless you have specific problems with your weight bearing joints. In the later case, water exercises are recommended. You can start water activities about three weeks after surgery.

Starting an Exercise Program

In order to receive the maximum benefits from your surgery, you must incorporate exercise into your daily routine. If it has been some time since you have exercised regularly, then it is best to start slowly. Begin with as little as 5 minutes a day and add 5 more minutes a week until you can stay active for 30 minutes per day. There are three forms of exercise: cardiovascular, strength building, and flexibility.

Cardiovascular exercise uses your large muscles and raises your heard rate to a level where you can still talk, but you start to sweat a little. For example, walking, jogging, swimming, and cycling are cardiovascular activities. If your goal is to loose weight, you will need to do some form of cardiovascular exercise for 4 or more days a week for 30 to 45 minutes or longer.

Strength-building exercises make your muscles and bones stronger and increase your metabolism. People who lift weights or use any type of equipment that requires weights are doing strength-building exercise. If you strength train regularly, you will find that your body looks leaner and you will loose fat. Strength building exercises should be performed 2 to 3 times a week for best results. Always warm up your muscles for 5 to 10 minutes before you begin lifting any type of weight or before performing any resistance exercises.

Flexibility exercises tone your muscles through stretching and can prevent muscle and joint problems later in life. A well-balanced exercise program should include some type of each exercise from each category.

Remember to stretch before and after activity. Muscles need time to adjust to the demands placed on them. Rather than hitting the treadmill running, for example, take a few minutes to warm up by walking, build up stamina and then hit your stride. Take a few minutes to also cool down and lower your heart rate and stretch your muscles again to improve flexibility and help prepare the body for your next workout. Drink plenty of water before, during and after your workout.

The Walking Workout

Walking is the first type of exercise that we recommend both before and after surgery. If you are new to exercise and you are also recovering from surgery, you can walk ten to 20 minutes four or five days a week. As you get stronger, you can increase the distance and the speed to your comfort level. Water Fitness

You can start water activities about three weeks after surgery. Water programs are great, since they are non-weight bearing and therefore are gentle to painful joints. Water fitness can improve strength, flexibility, cardiovascular health, decrease body fat, facilitate rehabilitation after surgery, improve functional living and even enhance other sports skills. Hospitals usually offer arthritis or heart disease related classes through their physical therapy program and usually will let you join the class with a prescription from your Primary Care Physician.

Choosing a Personal Trainer

Working with a personal trainer is one of the fastest, easiest, most successful ways to improve your health. A qualified personal trainer can help you set realistic goals, determine strategies, and provide motivation and the encouragement you need. Most personal trainers are familiar with the special needs of morbid obesity, arthritis and diabetes. Your trainer can work with your physician, physical therapist and with Bariatric Program Services to plan a safe, efficient program that will enable you to reach your health goals.

Ten Tricks for Sticking with the Weight Loss Surgery Exercise Program

  1. Look at exercise like a prescription medication. If you have a condition that requires a medication every day, you are going to take this medicine every day. Your body needs exercise every day, so you have to give it what it needs.
  2. Do research. Find out what types of classes your local gym is offering. You are going to have a greater likelihood to stick to an exercise that is tailored to your needs and that you enjoy. Explore new types of exercise.
  3. Change your routine. So you love to walk, but you are bored with it. Sometimes, just changing the direction of your route can make all the difference.
  4. Find a buddy. We all need someone to budge us and make us go the extra mile, especially when it comes to exercise. Find a friend, a neighbor and personal trainer to meet you at the gym or in the park.
  5. Find your rhythm. Listen to music or books on tape or meditation while you exercise. With the right music to occupy your brain, 30 minutes will not seem so long.
  6. Participate in group sports. Participating in a group activity increases the chances that you will stick to it. Choose water exercise, yoga, or stretching classes at places and times where there are other people who are actively involved in exercise.
  7. Know what makes you give up the program. If going on vacation throws you off you fitness plan, try incorporating exercise into your vacation. If boredom makes you give up, stay interested by changing types of exercise and times.
  8. Make a schedule. If you don’t put exercise into your daily schedule, most likely you will do everything but exercise. Plan in baby-sitters. Schedule specific activities on specific days, like walking 20 minutes on Monday, yoga class on Tuesday, etc…
  9. Use a workout log. Write down the exercise you do and see how you have improved. Write down the number of repetitions, the weight used, the length of walk, the time, etc…
  10. Stay active between workouts. Walk as much as possible between workouts. Park farther away. Get off the bus a couple of stops early. Always keep a good pair of walking shoes in your car, should you have unexpected time to take a walk.

Emotional Considerations

The range of emotions you experience following surgery may include denial, anger, bargaining, depression, and finally, acceptance. Feelings of sadness and crying episodes can be common occurrences. Adapting to the changes taking place in your body and in your relationship to food can take many months. Expect to have ups and downs as the weeks go by.

Your adjustment and acceptance will also be eased by the realization that bariatric surgery, with resultant weight loss, will by itself not solve your personal or relationship problems. You cannot expect a perfect body or a perfect life after the weight loss. In fact, many new problems will develop because of the many new opportunities. These will need to be recognized and attended to. Try to be as positive as possible. As new challenges pop up, recognize them and develop a problem solving approach.

In the past, one of the best methods for you to cope with life stress may have been for you to eat. This method will no longer be useful. Replacement methods for coping will need to be learned, but this will take time. Use the journal in this guide to get you started.

Counseling after a Weight Loss Surgery

Emotional counseling may be needed during the phase of adjusting to the new physique and the many changes that follow the surgery for morbid obesity. We can help recommend counselors who are qualified and experienced in working with people who have had weight reduction surgery. Please use the Counseling and Support Group shortcut.

Family and Friends

You can expect your family and friends to have variable reactions to your surgical experience and to the weight loss that follows. Although you hope your loved ones will be supportive and helpful during your ups and downs, this may not always be the case. Friends and family may have become secure in your obesity and will have difficulty adjusting to the new body you are developing. They may envy your courage or physical health. Be open about your appreciation of them and their concerns for you. Recognize their ambivalence and talk with them about their own feelings. And finally, let people pull away if they need to for a while. Your main responsibility is to care for yourself. Others are responsible for their own feelings and actions. Hopefully, most close family members and friends will eventually adjust.

The Internet

Group support and being connected to other patients is vital to a successful surgical result. The Internet is a way to help fill the void between group meetings. Please, be cautious about what you read. We urge you to ask us directly if you have any questions.

Weight Loss Surgery  Group Meetings

Group meetings provide peer support, allow you to learn about the surgery first hand from others who have had gastric bypass, let you share your experiences and provide periodic guest speakers to expand your knowledge on obesity surgery related topics. These support groups are a wonderful opportunity to make new friends and be with people who share what you are experiencing. Please use our Counseling and Support Group shortcut.

Expected Weight Loss after a Weight Loss Surgery

Most patients experience a fairly rapid weight loss in the first 3 to 6 months following surgery. Most studies suggest that patients lose about 2/3 to 3/4 of their excess weight over the first two years. In other words, weight loss slows, but generally continues up to 12 to 18 months after surgery, averaging 65% to 80% of excess weight by some reports. At that time, the stomach pouch has stretched to hold more food and it is critical to adhere to the low fat, low sugar diet and exercise recommendations to maintain your weight loss.

Maintaining the Weight

We have been referring to the gastric bypass surgery as a tool to help you lose weight. It is not automatic, and your behavior after surgery plays a very large part in your outcome. Your responsibility is to avoid snacking, grazing (continuous nibbling), choose healthy foods, be active and exercise daily, and make psychological adjustments. Be sure to keep your regular office appointments so that your weight loss can be monitored.

Changes

As you lose weight, you may notice other changes in your body. You should experience increased energy levels, especially if you have continued a regular walking or other type of exercise program. Your fatigue level should decrease and you should sleep better at night. Ongoing exercise will be important for calorie burning, muscle tone maintenance and a sense of well being.

Plastic Surgery after a Weight Loss Surgery

You may notice excess skin folds and wrinkles where the greatest weight loss has occurred. This is especially noticeable on the face, upper arms and abdomen. Reconstructive surgery to improve your appearance should be delayed until sometime after the weight loss has stabilized, usually 18-24 months. We will be glad to recommend an experienced surgeon.

Gastric bypass surgery reshapes your stomach and changes the digestive process of your body for life. It is major surgery, performed while the patient is under general anesthesia.

For many people, the idea of “rebuilding” their stomach sounds good—a small stomach that can help you control how much you eat sounds like a great tool.

For other people, the idea of surgery and anesthesia can provoke anxiety. The potential for complications also can be a little frightening.

This is perfectly normal. Before letting these fears prevent you from having this surgery, you may want to examine them. In this section, you’ll learn strategies for working through these fears and hear from patients who have had gastric bypass surgery as they describe their own ways of working through these challenges.

The fear of surgery is not irrational or abnormal; in fact, it’s very common. Bariatric surgery reroutes the digestive system and permanently alters the stomach—all while the patient is under general anesthesia.

If the idea of surgery or anesthesia scares you, counter the fear by finding out more. Research the surgeon or surgeons who will be performing the operation. If anesthesia is an issue, you also can research the anesthesiologist. You may be reassured if you find out that your surgeon has performed hundreds or thousands of surgeries.

If you are still afraid of surgery, but would otherwise like to have it, you may want to schedule an appointment with your primary care physician. Your physician can recommend a bariatric program and once there, you can attend support groups and speak with a psychologist. The psychologist is there to help you work through your fears and concerns.

Fear of short- or long-term complications is valid. As with any surgery, complications may occur.

If you are concerned about short- or long-term complications, you can talk about them with your surgeon. Every surgery has risks, and your surgeon should discuss the benefits and risks of bariatric surgery with you.

For many people who have spent years suffering from morbid obesity, gastric bypass surgery sounds like a lifesaver. However, it’s important to be prepared for all aspects of the treatment. Gastric bypass surgery changes your body. Your surgeon will reduce your stomach to a very small pouch. The small intestine is then rerouted, so the digestive process allows fewer calories and nutrients to be absorbed by the body. The combination of restrictive and malabsorptive mechanisms allows for significant weight loss.

After gastric bypass surgery, the amount of food that you eat is less than what you could eat presurgery. At the same time, a feeling of satisfaction, or satiety, is achieved with these small quantities of food. If you eat a large meal or foods high in fat and/or sugar, you very likely will have a painful bout of dumping syndrome, which is an uncomfortable feeling of nausea, lightheadedness, upset stomach, and diarrhea associated with ingestion of sweets, high-calorie liquids, or dairy products. This physical reaction provides a deterrent to large meals and unhealthy foods.

Because your stomach will be a fraction of its original size and your digestive process will be changed, you will have the opportunity to lose excess weight. Dangerous co-morbidities, such as type 2 diabetes, GERD, and sleep apnea, are often resolved or improved. As you recover, you may find that clothes that fit a week ago or even a few days earlier suddenly are too large. You also may find that a walk in the park no longer leaves you breathless, that you do remember how to ride a bike, and that you can keep up with your kids.

A typical comprehensive bariatric program will consist of a combination of the following healthcare professionals: a program coordinator, psychologist, dietician, exercise physiologist, and other healthcare professionals to help with your case. Each expert is dedicated to providing support for gastric bypass patients both before and after surgery.

Many patients report that during the first 12 to 18 months following surgery, they feel highly motivated and energized. During this time, they are making substantial lifestyle changes such as eating new foods and smaller portions, taking vitamins daily, and exercising regularly. Many of these changes will be discussed before surgery and should come as no surprise following surgery.

While these changes are healthy, they may be overwhelming for some patients. This is where your bariatric program support team can guide you. Each expert can provide advice and insight that will educate you and help you make healthy choices.

Many successful gastric bypass surgery patients say that their support network helped them immensely in maintaining their new healthy lifestyle changes. From family and friends to bariatric program support groups, there is a wealth of options available for people interested in gastric bypass surgery.

The first step in getting support is talking to your family and friends about gastric bypass surgery and your interest in it. You might find that they are completely supportive. While this is always ideal, you might find that some family members and friends are against your decision. Often, this is because your loved ones are concerned about you or have preconceived notions about gastric bypass surgery. Explaining the advantages, benefits, and risks of gastric bypass surgery may open their minds to its importance.

If you find that they are unsupportive, it doesn’t mean you are alone. Many people have had gastric bypass surgery and have been very successful with the care they received from the healthcare professionals on their bariatric program team. Bariatric programs usually include a support group for gastric bypass surgery patients both pre- and postsurgery.

Support groups are an excellent resource. You’ll find people who share your goals of health and wellness. A support group is a forum for celebrating successes, such as the improvement or resolution of co-morbidities. The support group is devoted to people who have common experiences, who can share their feelings in a safe environment, and develop relationships that can contribute to improved physical and emotional health.

If you are thinking about gastric bypass surgery, and you want to learn more about the patient’s perspective or help reluctant family and friends understand, attending a support group meeting can be invaluable.

It’s important to realize that for many people, not just patients, surgery can be frightening. For gastric bypass surgery patients, family and friends may not be supportive in the beginning because, as with all surgical procedures, they are concerned about possible risks and complications.

If you find that your family and friends are not supportive, providing information and education may calm many of their fears. In addition to support groups, many bariatric surgery programs provide information sessions and encourage the attendance of prospective patients, their family, and their friends. Seeing and hearing the successes of others can help people understand the importance of gastric bypass surgery.

Unfortunately, some gastric bypass patients find that their family and friends do not support their decision. It can be very disappointing, but it doesn’t have to alter the patient’s decision to have gastric bypass surgery.

Bariatric surgery programs often include two components that can help a patient: a psychologist and support groups. A psychologist can provide tips and techniques for dealing with unsupportive people and listens to your frustrations without judgment.

Support groups are a wonderful place to meet people and get perspective on bariatric surgery. You’ll hear about successes, frustrations, plateaus, and special moments, and have a chance to share your own experiences.

Gastric bypass surgery is a major procedure, and recovery doesn’t happen overnight. Therefore, it’s important to follow your surgeon’s postoperative recovery instructions.

Bariatric Surgery Postoperative Pain and Discomfort

Many people think that bariatric surgery will be followed by a long and painful recovery period. However, postsurgery patients usually do not have that experience. In fact, many patients who were interviewed spoke of discomfort and soreness rather than pain. Recovery does, however, vary from patient to patient. You may want to speak with your surgeon if you are very concerned about postoperative pain.

Being out of Commission

As with any major surgery, there will be a recovery period when you’ll have to take it easy. Remember that this is a necessary step, and the better care you take during recovery, the more likely and quickly you’ll return to normal activity. Recovery time varies from patient to patient and also is based on the type of surgery you have.

You can expect to be up and moving within hours of your gastric bypass surgery. While you may move slowly at first, many patients have found that each day often brings improvements. Many patients return to normal activities, such as driving, cooking, and caring for children, three to six weeks after surgery.

Whether it’s family, friends, or coworkers, build a support network for all aspects of your life. Those supporting you are dedicated to helping you achieve better health and wellness. Show your appreciation by accepting their help and allowing yourself to heal.

The recovery period varies among patients and is dependent on many different factors. For example, many patients choose to have laparoscopic, or minimally invasive, gastric bypass surgery because the recovery period generally is shorter than with open surgery. In some patients, the laparoscopic, or minimally invasive, approach to surgery cannot be used. The decision to perform the open procedure is a judgment made by your surgeon either before or during the actual operation, and is based on patient safety.

Other factors for recovery time include pain tolerance, preoperative health, preoperative BMI, any complications that may occur, and even the patient’s level of compliance to the surgeon’s recovery instructions.

If you find yourself struggling with one or more obesity-related health condition, bariatric surgery could be right for you.

If you choose to have bariatric surgery, your choice should be based on discussions between you and your doctor, including goals and strategy for long-term care. Patient selection for bariatric surgery is based on the National Institutes of Health (NIH) criteria:1 • 100 pounds or more above ideal body weight or a BMI of 40 or greater

• BMI of 35 or greater with one or more obesity-related health condition

Other factors your doctor may consider include:

• History of documented dietary weight loss attempts

• Lifelong commitment to dietary, exercise, and medical guidelines and follow-up care

Psychological evaluation

Studies show that bariatric surgery effectively can improve and resolve many weight-related health conditions.3 A review of more than 22,000 bariatric surgery patients showed improvement in or complete resolution of conditions including type 2 diabetes, hypertension, and sleep apnea.

What is Type 2 Diabetes? Type 2 diabetes is a long-term metabolic disorder where the body produces insulin, but resists it. Insulin is necessary for the body to be able to use sugar. Because of excess weight, obese individuals develop a resistance to insulin, which controls blood sugar. While type 2 diabetes may occur regardless of someone’s age, gender, or body mass, the disease tends to be more severe in the obese.

How is it affected by bariatric surgery?  Patients who had gastric bypass surgery had lower insulin resistance. Their risk for metabolic syndrome, high blood pressure, and a high amount of fats in the blood also decreased. In fact, a landmark study found that resolution of diabetes often occurred within days following gastric bypass surgery, even before marked weight loss was achieved. What success have patients found through bariatric surgery? A recent meta-analysis showed 76.8 percent of gastric bypass patients found complete resolution of type 2 diabetes, and 86 percent found improvement or resolution.3 Many gastric bypass surgery patients with type 2 diabetes have demonstrated little or no need for continuing medication.

What is High Blood Pressure/Heart Disease?

Excess body weight keeps the heart from working properly. The result can be high blood pressure (hypertension), which can cause strokes and heart and kidney damage. Evidence shows that the age-related lifetime risk of hypertension in men and women ages 45 to 54 will double as their average BMI increases from 25 to 35.7 While hypertension may occur regardless of someone’s age, gender, or body mass, it tends to be more severe in the obese.

How are they affected by bariatric surgery?

Bariatric surgery reduces excess body weight over time, which takes away some of the strain on the heart. Changes in diet and exercise after surgery can lead to significant improvement of hypertension and other cardiovascular problems. Studies have shown reductions in total cholesterol and LDL levels and increased HDL levels. Even a weight loss of 10 percent can lower blood pressure significantly.

What success have patients found through bariatric surgery?

A recent meta-analysis showed hypertension was resolved or improved in 78.5 percent of patients.3 A study of 500 patients showed 92 percent resolution of hypertension.

What are Dyslipidemia and High Cholesterol?

Dyslipidemia is a disorder of lipids—the fat-like substances in the blood. A common form of dyslipidemia is hyperlipidemia (or high cholesterol), the condition that exists when someone has too much of certain lipids in the blood. As these lipids build up inside the artery walls, harmful scar tissue and other debris begin thickening and hardening the walls. Doctors call this condition atherosclerosis or hardening of the arteries. While dyslipidemia may occur regardless of someone’s age, gender, or body mass, the disease tends to be more severe in the obese.

What success have patients found through bariatric surgery?

Recent research on the impact of gastric bypass surgery found that hyperlipidemia and hypercholesterolemia were improved in more than 93 percent of patients.

What is Osteoarthritis of Weight-Bearing Joints?

Osteoarthritis is one of the most common forms of arthritis. Known as the wear-and-tear kind of arthritis, osteoarthritis is a chronic condition in which there is a breakdown of a joint’s cartilage. For anyone who is suffering from morbid obesity, the excess body weight placed on joints, particularly knees and hips, results in rapid wear and tear, and pain caused by inflammation. Similarly, bones and muscles of the back constantly are strained, causing disk problems, pain, and decreased movement ability. While osteoarthritis may occur regardless of someone’s age, gender, or body mass, the disease tends to be more severe in the obese.

How is it affected by bariatric surgery?

As less weight is placed on joints, the strain placed on these joints is reduced. Bariatric surgery can reduce much of this weight over a long period of time and can be very effective in treating osteoarthritis.

What success have patients found through bariatric surgery?

A recent study of 500 patients showed a 90 percent resolution of arthritis among surgical patients.

What is Depression?

Depression is an illness that involves the body, mood, and thoughts. It affects the way a person eats and sleeps, the way one feels about oneself, and the way one thinks about things.9 There are many reasons people with morbid obesity experience depression. Many of the everyday activities people with healthy body weight take for granted are big challenges for a person suffering from morbid obesity. These activities may include walking, social interaction, finding clothes that fit, and fitting in public seats. While depression may occur regardless of someone’s age, gender, or body mass, it tends to be more severe in the obese.

How is it affected by bariatric surgery?

Emotional health goes hand in hand with physical health. Lifestyle improvements and renewed health can help resolve depression. Weight loss, combined with counseling, can be very helpful in improving mental health.

What success have patients found through bariatric surgery?

Patients who have had bariatric surgery report improved quality of life, social interactions, psychological well-being, employment opportunities, and economic conditions. Psychological screening before surgery may help prepare you for the changes that come with surgery, and help you set realistic goals and expectations.

What are Sleep Apnea and Respiratory Problems ?

Obstructive sleep apnea is when breathing suddenly stops because soft tissue in the rear of the throat collapses and closes during sleep. Morbid obesity can cause sleep apnea and other respiratory problems. The greater your excess body weight, the greater the amount of fat pressing down on your chest and lungs. When you are morbidly obese, you are likely to have a greater buildup of fat deposits in the tongue and neck. While sleep apnea may occur regardless of someone’s age, gender, or body mass, the disease tends to be more severe in the obese.

How are they affected by bariatric surgery?

Reducing overall excess body weight reduces fat deposits in the tongue and neck that cause sleep apnea. Clinical data show that sleep apnea is present in 60 percent of patients undergoing bariatric surgery.10

What success have patients found through bariatric surgery?

Recent research found that obstructive sleep apnea was resolved in 85.7 percent of patients through gastric bypass surgery.3

Many people suffering from sleep apnea go undiagnosed. If you are obese and feel tired and fall asleep during the day, talk to your physician about sleep apnea.

What is Gastroesophageal Reflux Disease (GERD)?

Gastroesophageal Reflux Disease is injury to the esophagus caused by chronic exposure to stomach acid. While the symptom of heartburn is often associated with this disease, GERD is more than an annoyance. It is a serious disease that can cause esophagitis, Barrett’s esophagus, and esophageal cancer. Occasional heartburn does not indicate GERD.

Excess body weight may weaken the valve at the top of the stomach, allowing acid to escape into the esophagus. This escape is known as gastroesophageal reflux. While GERD may occur regardless of someone’s age, gender, or body mass, the disease tends to be more severe in the obese.

A five- to 10-year follow-up study that included 16,191 participants showed that there is an independent relationship between obesity, nighttime GERD and habitual snoring, and the onset of asthma and respiratory symptoms in adults.11 A 130-patient study found that people who suffer from GERD experienced a worsening of symptoms as their weight increased.12

How is it affected by bariatric surgery?

Obesity increases a person’s risk of GERD. Bariatric surgery improves GERD by reducing the amount of stomach acid produced.

What success have patients found through bariatric surgery?

A 2000 study of 500 patients showed complete resolution of GERD in 98 percent of patients.8 While there is anti-reflux surgery, it fails more often in people with morbid obesity and only addresses one co-morbidity.13 Another study found that all participants who had gastric bypass surgery reported an improvement in or no symptoms of GERD.

What is Urinary Stress Incontinence?

Among women, morbid obesity is a big risk factor for urinary stress incontinence, or uncontrollable urine loss. A large, heavy abdomen and relaxation of the pelvic muscles due to morbid obesity may cause the valve on the urinary bladder to weaken, leading to leakage of urine with coughing, sneezing, or laughing. While urinary stress incontinence may occur regardless of someone’s age, gender, or body mass, the condition tends to be more severe in the obese.

How is it affected by bariatric surgery?

Bariatric surgery has been found to improve urinary stress incontinence. Less weight is placed on the bladder, and other physical changes take place to improve this condition.

What success have patients found through bariatric surgery?

A 2000 study of 500 patients showed 97 percent resolution of urinary stress incontinence in patients after gastric bypass surgery.

What are Asthma and Pulmonary Conditions?

Asthma is a disease of the respiratory system in which the airways unexpectedly narrow. Adult-onset asthma is closely associated with GERD. Common symptoms of asthma include wheezing, coughing, and chest tightness. While asthma may be found regardless of someone’s age, gender, or body mass, the disease tends to be more severe in the obese.

What success have patients found through bariatric surgery?

While asthma remains a treatable but incurable disease, research has shown improvement in asthmatic symptoms through significant weight loss.

What is Reproductive Health?

Reproductive health can be a concern for women struggling with morbid obesity. Issues such as infertility (the inability or reduced ability to produce children) and menstrual irregularities may occur due to morbid obesity. Menstruation issues include cycle interruption, abnormal flow, and additional pain during your menstrual cycle. Fertility issues include possible miscarriage, reduced success with fertility treatments, and polycystic ovarian syndrome (PCOS).

PCOS is an endocrine disorder in women of childbearing age that can cause infertility and other reproductive health conditions. Classic symptoms include obesity, an increase of facial and body hair (hirsutism), acne, irregular menstrual cycles, and infertility.

How is it affected by bariatric surgery?

Bariatric surgery has been found to improve or resolve conditions that may interfere with pregnancy, such as PCOS and hypertension. This procedure also reduces weight on reproductive organs and influences other physiological changes affecting fertility.

Surgeons commonly will request that female bariatric patients take steps to prevent pregnancy during the first year after surgery. Therefore, it’s important to know about any changes in fertility after surgery so that you don’t become pregnant too soon.

What success have patients found through bariatric surgery?

A recent study of women following gastric bypass surgery showed improvement of multiple clinical problems related to infertility and PCOS. All women continued to have normal menstrual cycles after about three months following surgery. Of the women who experienced hirsutism, 52 percent had complete resolution. In overweight women, weight loss (as little as 5 percent) may restore ovulation and fertility.

Indications

Bariatric surgery is intended for people who are 100 pounds or more overweight (with a Body Mass Index of 40 or greater) and who have not had success with other, less risky weight loss therapies such as diet, exercise, medications, etc. In some cases, a person with a Body Mass Index (BMI) of 35 or greater and one or more co-morbid condition may be considered for bariatric surgery.

Important Considerations

Bariatric surgery should not be considered until you and a doctor have looked at all other options. Considering bariatric surgery calls for discussion of the following with your doctor:

  • Bariatric surgery is not cosmetic surgery and should not be thought of in any way as cosmetic surgery.
  • Bariatric surgery does not involve the removal of adipose tissue (fat) by suction or surgical removal.
  • The patient and doctor should discuss the benefits and risks together.
  • The patient must commit to long-term lifestyle changes, including diet and exercise, which are key to the success of bariatric surgery.
  • Problems after surgery may require more operations to correct them.

Complications of Bariatric Surgery

As with any surgery, there are immediate and long-term complications and risks. Your healthcare team can speak with you further about the benefits and risks. Possible risks can include, but are not limited to:

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

* To control operative bleeding, removal of the spleen may be necessary.

According to the American Society for Bariatric Surgery 2004 Consensus Statement, the operative morbidity (complications) associated with Roux-en-Y Gastric Bypass in the hands of a skilled surgeon is roughly 5 percent and the operative mortality (death) is roughly 0.5 percent.26 For Laparoscopic Adjustable Gastric Banding, the same consensus statement reported that, in the hands of a skilled surgeon, the operative morbidity is approximately 5 percent and operative mortality is approximately 0.1 percent.

Risks and Possible Side Effects

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

Why Would I Have an Open Procedure?

In some patients, the laparoscopic, or minimally invasive, approach to surgery cannot be used. Here are reasons why you may have an open procedure, or that may lead your surgeon to switch during the procedure from laparoscopic to open:

  • Prior abdominal surgery that has caused dense scar tissue
  • Inability to see organs
  • Bleeding problems during the operation

The decision to perform the open procedure is made by your surgeon either before or during the actual operation and is based on patient safety.