Criteria for Surgery
Q: Who is a candidate for bariatric surgery?
A: Insurance companies usually approve patients with a BMI greater than 35 with significant weight-related comorbidities (hypertension, sleep apnea, diabetes, high cholesterol, etc..) or a BMI greater than 40, regardless of medical issues. Use calculator below to see your BMI.
Supplied by BMI Calculator USA
Q: Will those criteria be enough for surgery to approved?
A: It really depends on your insurance company. Some insurance companies ask for your historical weights, others want you to be involved with nutritional counseling for a few months before surgery is approved. The easiest way to figure this out is to call your insurance company and ask for their criteria. Use the calculator to see your BMI.
Q: How long does a work-up take to complete prior to surgery?
A: These work-ups may take 6 weeks to 3 months, depending on any additional testing that is required. This is a much more comprehensive work-up than would be required for other types of abdominal surgeries. Most patients will been seen by their primary care doctor, cardiologist, and pulmonologist depending on sleep study results.
Hospital Stay and Complications
Q: How long does the surgery take to perform?
A: Gastric Bypass usually takes about 2 hours, a Lap Sleeve Gastrectomy takes about an hour, and an Adjustable gastric band is also about an hour to complete. These are estimates, prior surgeries can affect the O.R. time greatly.
Q: How long should I expect to be in the hospital?
A: Expected hospital stay is overnight, although occasionally patients stay longer.
Q: What are the major risks of surgery?
A: As with any surgery, bleeding and infection are inherent risks, but these are rare. The most serious risks specific to bariatric surgery are staple line leaks and DVT/PE (blood clots). Patients who are overweight and sedentary have a higher likelihood of developing blood clots after surgery, regardless of the type of surgery. Adjustable gastric band surgery has its own inherent risks beyond what is mentioned here, the best advice is to talk to your doctor. Attending the pre-op class helps address these risks.
Q: What is a staple line leak? How can it be prevented?
A: When the stomach is partitioned (separated) in bypass surgery or removed in Sleeve surgery, a stapling mechanism is used to seal the remaining stomach. If this seal is broken and leakage occurs, it must be addressed promptly. A staple line leak can occur because of mechanical dysfunction of the stapler, patient non-compliance (over-eating), and other reasons. Luckily, this is a very rare occurrence in modern bariatric practice and we are very good at treating this problem.
Q: How are staple line leaks treated?
A: For Sleeve surgery, most patients are treated with a 'Stent' placed endoscopically (non-surgical treatment). This is placed until the leaky area of the staple line heals. It essentially walls off the leak. In bypass surgery, treatment is more complicated and is related to the actual area of leak (there are multiple staple lines in bypass surgery). Usually, however, re-operation is necessary for a leak in bypass surgery.
Q: How can blood clots be prevented or treated?
A: We place everyone on subcutaneous heparin injections for two weeks after surgery to minimize the chances of significant blood clots. For patients at extremely high risk, we may recommend a prophylactic vena cava filter. For treatment, we usually ask the patient to be on a few months of anticoagulation after a DVT (a vein clot) is diagnosed, depending on the location of the DVT. Other interventions include compression stockings while in the hospital and a foot exercise called the "feet alphabet" which helps increase circulation in the legs (where clots usually start). All patients are up walking laps while in the hospital as well. Dr. Balsama sends his patient home on a medication for two weeks that also prevent blood clots.
Vitamins and Supplements
Q: How common are vitamin deficiencies after bariatric surgery?
A: Fairly uncommon, especially with Lap Sleeve Gastrectomy. Bypass patients have a slightly higher incidence of vitamin and mineral deficiency, due to the bypassed duodenum (where Iron and Calcium are normally absorbed).
Q: What vitamins are recommended after surgery?
A. There are many commercial bariatric vitamin formulations on the market. We don’t promote one company over another. We will, however, direct to choose an appropriate, easily dissolvable supplement with the correct amounts of vitamin and mineral dosages. All patients will require a multivitamin with iron, Vitamin B12 and calcium. Our nurse or dietitian will review these recommendations with you.
Life After Surgery
Q: How quickly may I return to work following bariatric surgery?
A: The majority of patients may return to work within two weeks of surgery, but this varies. Some patients go back earlier than this, especially if they have jobs which do not require much physical labor.
Q: How quickly may I start an exercise routine after surgery?
A: Because most of our surgeries are performed laparoscopically, I usually grant permission to exercise at the first post-op visit in 2 week’s time.
Q: How long do I follow-up after surgery? At what intervals?
A: Our usual schedule of follow-up is 2 weeks, 6 weeks, 3 months, 6 months, 1 year, and then bi-annually after that. We prefer to follow-up with our patients for a minimum of 5 years. During this period of time, all patients will consult with either the bariatric nurse or bariatric dietitian to learn about the nutrition and lifestyle requirements after surgery.
Q: What is my expected weight loss after surgery?
A: This varies, depending on the type of surgery performed. Average weight loss for Gastric Bypass patients is 70% of the patients excess body weight in the first year (70 pounds if someone starts at 100 pounds overweight). Lap Sleeve Gastrectomy produces results that are close to this (60-70% of excess body weight in the first year, on average), and Lap Band surgery is considerably lower (40-50% of excess body weight in the first year). Q: Is there a chance that the bariatric patient may gain weight back, long term? A: Yes, this is always a possibility, but patients rarely gain ALL of their weight back, despite popularization of this notion. Most patients without surgery would continue to gain weight over time, also, which needs to be taken into consideration for long term results. Bariatric surgery is just a tool to help someone lose weight, it is not a 'magic bullet' for weight loss. Patients need to embrace a healthier lifestyle for long-term benefits. This includes healthy diet and exercise. Surgery will never be successful without these components.
Q: What are the best strategies to use for long-term success after weight loss surgery?
A: Bariatric surgery is the most successful treatment for obesity. It remains, however, a tool that can be abused, misused or used successfully. 90% of weight loss surgery success comes from the tool user - the patient! The following are behaviors of our most successful patients: Protein - Eating adequate lean protein everyday at every meal. 30/30 fluid rule - Never eat and drink together nor 30 minutes before and after a meal. Movement - Those who move the most lose the most! Exercise is key to long term weight loss success.
Nutrition for the Bariatric Patient
Q: What kind of food intolerances will I have after surgery?
A: Many bariatric patients have trouble with breads, pasta, rice, and meat (especially red meat/ground meat), although most of my patients enjoy these foods in small quantities. Patients have told me in the past that their cravings for these foods diminish after surgery and they start to crave more nutritious foods, such as salads, even if they didn't like them in the past.
Q: What is the diet like in the first month after surgery?
A: The diet after surgery consists of four stages that our nurse or dietitian will explain to you. The first week (stage 1) consists of clear liquids, Second week (stage 2) is full liquids, third and fourth weeks (stage 3) is soft diet. The 5th week ushers in (stage 4) the regular diet which is a diet high in lean protein, low in carbohydrates/sugars and fats.
Q: What is a 'Pre-Op Diet'?
A: We ask patients to do a 2 week pre-op diet for two reasons. First, it allows the patient to become comfortable with the diet after surgery. Secondly, it shrinks the liver to allow for an easier surgery. Most patients lose 15-40 pounds on this diet prior to surgery! (This does not affect insurance coverage for the surgery, don't worry!)
Second Chance Surgery
Q: What is revisional ('re-do') surgery? Why is it performed?
A: Revisional surgery involves modifying a previously performed bariatric surgery, usually in a way that introduces another type of bariatric surgery. As the Lap Band has fallen out of favor, the most popular procedure has become 'Band removal with Sleeve Gastrectomy'. Bypass surgery may also be performed after Band surgery. The two most common reasons for performing revisional surgery are lack of weight loss and severe reflux (indigestion). Sleeve procedures and Bypasses may also be revised, although this is not as commonly performed. Insurance companies vary in coverage of this procedure, but most of these surgeries are covered if the indication is clear.