• Select a primary care physician if you don't already have one, and establish a relationship with him or her. Work with your physician to ensure that your routine health maintenance testing is current. For example, women may have a pap smear, and if over 40 years of age, a breast exam. And for men, this may include a prostate specific antigen test (PSA).
• Make a list of all the diets you have tried (a diet history) and bring it to your doctor.
• Forward any pertinent medical data to our office - this would include reports of special tests (echocardiogram, sleep study, etc.) or hospital discharge summary if you have been in the hospital.
• Forward a list of your medications with dose and schedule.
• Stop smoking!! Surgical patients who use tobacco products are at a higher surgical risk.
• Start an exercise program! This will increase your strength and endurance and improve your overall cardio-vascular system. Some patients, of course, will need to have medical clearance even for an exercise program.

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Insurance Issues

Why does it take so long to get insurance approval?
After your telephone interview consultation is completed, it usually takes us 1-2 days to send a letter to your insurance carrier to start the approval process. The time it takes to get an answer can vary from about 3-4 weeks or longer if you are not persistent in your follow-up. Our insurance analysts, Shirley and Sandra, will follow up regularly on approval progress and keep you updated throughout. It may be helpful for you to call the claims service of your insurance company about a week after your letter is submitted and ask about the status of authorization, as well. Be your own advocate. The insurance companies need to talk / listen to you.

How can they deny insurance payment for a life-threatening disease?
Payment may be denied because there may be a specific exclusion in your policy for obesity surgery or "treatment of obesity." Such an exclusion can often be appealed when the surgical treatment is recommended by your surgeon or referring physician as the best therapy to relieve life-threatening obesity-related health conditions, which usually are covered. It is important to request authorization in the correct way and we have trained staff to assist in that process.

Insurance payment may also be denied for lack of "medical necessity." A therapy is deemed to be medically necessary when it is needed to treat a serious or life-threatening condition. In the case of morbid obesity, alternative treatments - such as dieting, exercise, behavior modification, and some medications - are considered to be available. Medical necessity denials usually hinge on the insurance company's request for some form of documentation, such as 1 to 5 years of physician-supervised dieting or a psychiatric evaluation, illustrating that you have tried unsuccessfully to lose weight by other methods. The ways of appealing the insurance company’s denial depend greatly on the terminology of the denial. At times legal assistance is ones best option.

The medical community is trying to provide better and more complete information to the insurance companies so they have a better understanding of the global issues and the ways surgery can help.

What can I do to help the process?
Gather all the information (diet records, medical records, medical tests) your insurance company may require. This reduces the likelihood of a denial for failure to provide "necessary" information. Letters from your personal physician and consultants attesting to the "medical necessity" of treatment are particularly valuable. When several physicians report the same findings, it may confirm a medical necessity for surgery.

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

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Surgery

Does Laparoscopic Surgery increase the risk?
No. Laparoscopic operations carry the same risk as the procedure performed as an open operation. This has been confirmed by many studies, including our data. The benefits of laparoscopy are typically less discomfort, shorter hospital stay, earlier return to work and reduced scarring. Additionally, the incidence of incisional hernias is significantly reduced by using the laparoscopic techniques.

Though there has been shown to be a significant “learning curve” with the Laparoscopic Gastric Bypass, we were the first in the world to do the Laparoscopic Gastric Bypass, in 1993, and so we have significant experience with the operation and the results. Our group has performed over 3000 such cases and we have published our results. Our surgeons are trainer, instructors and course directors for many national and international courses on obesity and laparoscopic surgery.

Will I have a lot of pain?
Every attempt is made to control pain after surgery to make it possible for you to move about quickly and become active. This helps avoid problems and speeds recovery. Often several drugs are used together to help manage your post-surgery pain and these may include narcotics. We try to avoid narcotics since they have negative effects on bowel function, brain function and lung function. Our current method of pain control is designed to relieve the pain while minimizing the ill effects of narcotics. We often place tiny catheters (called “On Q”) in the wound and these “soak” the wound with local anesthetic. We add a non-narcotic medication and the result is very effective. Often our patients require minimal to no narcotic use post-operatively.

How long do I have to stay in the hospital?
As long as it takes to be self-sufficient. Generally, you will be in the hospital for as long as there are benefits from being in the hospital. Although it can vary, the hospital stay is 2-3 days for a laparoscopic gastric bypass, and 3 - 4 days for an open gastric bypass.

Will the doctor leave a drain in after surgery?
We place a surgical drain in most patients. This will allow drainage of any accumulated fluids from the abdomen. This is a safety measure, and it is usually removed a few days after the surgery. Generally, it produces no more than minor discomfort.

How soon will I be able to walk?
Almost immediately after surgery we will require you to get up and move about. Patients are asked to walk the night of surgery, take several walks the next day and thereafter. On leaving the hospital, you may be able to care for all your personal needs, but will need help with shopping, lifting and with transportation.

How soon can I drive?
This is more of a medical / legal question than strictly medical question. For your own safety, you should not drive until you have stopped taking narcotic medications and can move quickly and alertly to stop your car, especially in an emergency. Usually this takes 7-14 days after surgery.

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The Hospital Stay

What is done to minimize the risk of deep vein thrombosis/pulmonary embolism or DVT/PE?
Because a can DVT originate on the operating table, therapy begins before a patient goes to the operating room. We treat patients with sequential leg compression stockings and given a blood thinner (Fragmin) prior to surgery. Both of these therapies continue throughout your hospitalization. The third major preventive measure involves getting the patient moving and out of bed as soon as possible after the operation to restore normal blood flow in the legs.

What should I bring with me to the hospital?
This will be covered in pre-operative communications with the office once your surgery has been scheduled. Choose clothes for your stay that are easy to put on and take off. Because of your incision, your clothes may become stained by blood or other body fluids. Keep it VERY simple. Other ideas:
• reading and writing materials
• crossword and other puzzles
• personal toiletries
• bathrobe
• Shoes that are secure but easy to put on

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What's so important about exercise?
When you have a weight loss surgery procedure, you lose weight because the amount of food energy (calories) you are able to eat is much less than your body needs to operate. It has to make up the difference by burning reserves or unused tissues. Your body will tend to burn any unused muscle before it begins to burn the fat it has saved up. If you do not exercise daily, your body will consume your unused muscle, and you will lose muscle mass and strength. Therefore resistance training (weight lifting) along with daily aerobic exercise will communicate to your body that you want to use your muscles and force it to burn the fat instead. Tricia, our exercise coordinator, will assist in individualizing this part of the program for you.

What is the right amount of exercise after weight loss surgery?
Many patients are hesitant about exercising after surgery, but exercise is an essential component of success after surgery. Exercise actually begins on the afternoon of surgery - the patient must be out of bed and walking. The goal is to walk further on the next day, and progressively further every day after that, including the first few weeks at home. Patients are often released from medical restrictions and encouraged to begin exercising about two weeks after surgery, limited only by the level of wound discomfort. The type of exercise is dictated by the patient's overall condition. Some patients who have severe knee problems can't walk well, but may be able to swim or bicycle. Many patients begin with low stress forms of exercise and are encouraged to progress to more vigorous activity when they are able. Again, Tricia, our exercise coordinator, will assist in this program.

Can I get pregnant after weight loss surgery?
Yes, however it is imperative that women wait at least one year after the surgery before a pregnancy! Approximately one year post-operatively, your body will be fairly stable (from a weight and nutrition standpoint) and you should be able to carry a normally nourished fetus. You should consult your surgeon as you plan for pregnancy. Many women experience healthy pregnancies after weight loss. Our study shows there is a lower incidence of cesarean sections, gestational diabetes and gestational hypertension in post-operative women than in morbidly obese females.

What if I have had a previous weight loss surgical procedure and I'm now having problems?
Contact your original surgeon - he or she is most familiar with your medical history and can make recommendations based on knowledge of your surgical procedure and body. If you are not satisfied with that evaluation, a second opinion might be your best option. This might give you a different direction but it might simply confirm the original recommendation. Either way there may be comfort in the assessment.

What happens to the lower part of the stomach that is bypassed?
In the gastric bypass procedure, the stomach is left in place with intact blood supply. In some cases it may shrink a bit and its muscle or lining (the mucosa) may atrophy, but for the most part it remains unchanged. Remember the stomach has two main functions. First it is a reservoir for food. Secondly, it is a chemical factory on the inside. The lower stomach still contributes to the function of the intestines even though it does not receive or process food - it makes intrinsic factor, necessary to absorb Vitamin B12 and contributes to hormone balance and motility of the intestines in ways that are not entirely known.

How big will my stomach pouch really be in the long run?
This can vary by surgical procedure and surgeon. We feel the size of the pouch is very important to the overall success of the operation. Because we feel so strongly about this, we measure the small stomach pouch in every case. Even though we have done literally thousands of these operations we measure every one. The size starts at 15 cc and over time will stretch slightly but not much. Like blowing up a balloon, the pouch is easier to distend if it is bigger. The pouch size does appear to be a very important part of the operation’s long-term success. Even though the pouch stays small, patients will be able to eat more as the months go by because scars become more supple with time and the outlet will enlarge slightly giving the additional capacity needed so that patients can avoid the loss to too much weight and the risk of becoming malnourished.

What will the staples do inside my abdomen? Is it okay in the future to have an MRI test? Will I set off metal detectors in airports?
The staples used on the stomach and the intestines are very tiny in comparison to the staples you will have in your skin or staples you use in the office. Each staple is a tiny piece of stainless steel or titanium so small it is hard to see other than as a tiny bright spot. Because the metals used (titanium or stainless steel) are inert in the body, most people are not allergic to staples and they usually do not cause any problems in the long run. The staple materials are also non-magnetic, which means that they will not be affected by MRI. The staples will not set off airport metal detectors. For the most part, the staples are imbedded in scar and cause no ill effects or reactions.

What if I'm not hungry after surgery?
The operation works by having an impact on the appetite / hunger feelings. It's normal not to have an appetite for the first month or two after weight loss surgery. If you are able to consume liquids reasonably well, there is a level of confidence that your appetite will increase with time.

Is there any difficulty in taking medications?
Most pills or capsules are small enough to pass through the new stomach pouch, or they dissolve rapidly enough. At times it may be more convenient or more comfortable to take liquids but capsules are generally fine.

Will I be able to take oral contraception after surgery?
Most patients have no difficulty in swallowing these pills.

Is sexual activity restricted?
Patients can return to normal sexual intimacy when wound healing and discomfort permit. Remember, it is normal for patients to have a generalized drop in desire following any surgery, for a period of time.

Is there a difference in the outcome of surgery between men and women?
Both men and women generally respond well to this surgery. In general, men lose weight faster than women do.

Will I be asked to stop smoking?
Patients are required to stop smoking at least one month before surgery. Smokers have significantly higher post-operative complications including pneumonia, stricture formation, and ulcers to name a few.

How can I know that I won't just keep losing weight until I waste away to nothing?
Patients may begin to wonder about this early after the surgery when they are losing 20-40 pounds per month, or maybe when they've lost more than 100 pounds and they're still losing weight. Two things happen to allow weight to stabilize. First, a patient's ongoing metabolic needs (calories burned) decrease as the body sheds excess pounds. Second, there is a natural progressive increase in calorie and nutrient intake over the months following weight loss surgery. The stomach pouch and attached small intestine learn to work together better, and there is some expansion in pouch size / anastomosis over a period of months. The bottom line is that, in the absence of a surgical complication, patients are very unlikely to lose weight to the point of malnutrition.

What can I do to prevent lots of excess hanging skin?
Many people heavy enough to meet the surgical criteria for weight loss surgery have stretched their skin beyond the point from which it can "snap back". This varies significantly, however. Remember that water intake and exercise may help in this process so do your part to minimize these effects. If you do have overhanging skin, you will know you have done all you can to prevent it. Some patients will choose to have plastic surgery to remove loose or excess skin after they have lost their excess weight. Insurance generally does not pay for this type of surgery (often seen as elective surgery). However, some do pay for certain types of surgery to remove excess skin when complications arise from these excess skin folds. Ask your surgeon about your need for a skin removal procedure.

Will I be miserably hungry after weight loss surgery since I'm not eating much?
Most patients say “NO”. In fact, for the first 4-6 weeks many patients have almost no appetite. Over the next several months the appetite returns, but it tends not to be a ravenous type of hunger and “satisfaction” is gained by eating less.

What if I am really hungry?
This is usually caused by the types of food you may be consuming, especially starches (rice, pasta, potatoes). Protein tends to turn off hunger (offers more satisfaction) the best and the effect lasts the longest. Be absolutely sure not to drink liquid with food since liquid washes food out of the pouch.

Will I have to change my medications?
Your doctor will determine whether medications for blood pressure, diabetes, etc., can be stopped when the conditions for which they are taken improve or resolve after weight loss surgery. For meds that need to be continued, the vast majority can be swallowed, absorbed and work the same as before weight loss surgery. Usually no change in dose is required. Two classes of medications that should be used only in consultation with your surgeon are diuretics (fluid pills) and NSAIDs (most over-the-counter pain medicines). NSAIDs (ibuprofen, naproxen, etc.) may create ulcers in the small pouch or the attached bowel. Most diuretic medicines make the kidneys lose potassium. With the dramatically reduced intake experienced by most weight loss surgery patients, they are not able to take in enough potassium from food to compensate. When potassium levels get too low, it can lead to fatal heart problems. Sustained release types of medications may need to be changed.

What is a hernia and what is the probability of an abdominal hernia after surgery?
A hernia is a weakness in the muscle wall (actually the fascia or gristle layer of the abdominal wall) through which an organ (usually small bowel) can advance. Approximately 20% of patients develop a hernia after an open bariatric operation. The incidence of hernia formation after Laparoscopic Bariatric Surgery is less than 1%. Most patients who develop a hernia require a repair. The use of a reinforcing mesh to support the repair maybe needed.

Is blood transfusion required?
Infrequently: If needed, it is usually given after surgery to promote healing.

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

1. Early ambulation
2. Special stockings
3. Blood thinners
4. Pulsatile boots

Will I lose hair after surgery? How can I prevent it?
Many patients experience some hair loss or thinning after surgery. This usually occurs between the third and the sixth month after surgery. Hair grows on a three month cycle and the stress of surgery and the following starvation will result in hair loss three months later. Consistent intake of protein at mealtime is the most important way to at least be sure you have done everything possible to avoid excess loss. Some recommend daily zinc supplementation as well. Remember this is generally not an issue by the ninth month as stabilization occurs around month six and hair re-growth begins.

Does hair growth recover?
Most patients experience natural hair re-growth after the initial period of loss.

What are adhesions and do they form after this surgery?
Adhesions are scar tissues formed inside the abdomen after surgery or injury. Adhesions can form with any surgery in the abdomen. For most patients, these are not extensive enough to cause problems.

What is sleep apnea (SA)?
It is the interruption of the normal sleep pattern associated with repeated delays in breathing. Fat accumulation in the face and neck tend to obstruct the flow of air as the respiratory muscles relax during restful sleep. This causes patients to snore (often dramatically) as they fall asleep and then as they go into restful sleep the snoring, the breathing, stops. Obviously this is not healthy. It leads to hypertension in some, sleep deprivation symptoms in many, enlarged hearts and sudden death in some. Sleep apnea often shows rapid improvement after surgery. In most patients, there is a complete resolution of symptoms by six months following surgery.

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Diet

How long will I be off of solid foods after surgery?
We place patients on a liquid diet for about a week following surgery. After that time, patients are advanced to soft solid foods.

What are the best choices of protein?
Eggs, low-fat cottage cheese, tofu, fish, other seafood, lean beef and pork, chicken, and turkey.

Why drink so much water?
When you are losing weight, there are many waste products to eliminate, mostly in the urine. Some of these substances tend to form crystals, which can cause kidney stones. A high water intake protects you and helps your body to rid itself of waste products efficiently, promoting better weight loss. Water also fills your stomach and helps to prolong and intensify your sense of satisfaction with food. If you feel a desire to eat between meals, it may be because you did not drink enough water in the hour before (there maybe a confusion between hunger and thirst).

What is Dumping Syndrome?
Eating sugars or other foods containing many small particles when you have an empty stomach can cause dumping syndrome in patients who have had a gastric bypass or BPD where the stomach pylorus is removed. Your body handles these small particles by diluting them with water, which reduces blood volume and causes a shock-like state. Sugar may also induce insulin shock due to the altered physiology of your intestinal tract. The result is a very unpleasant feeling: you break out in a cold clammy sweat, turn pale, feel "butterflies" in your stomach, and have a pounding pulse. Cramps and diarrhea may follow. This state can last for 30-60 minutes and can be quite uncomfortable - you may have to lie down until it goes away. This syndrome can be avoided by not eating the foods that cause it, especially on an empty stomach. A small amount of sweets, such as fruit, can usually be well tolerated at the end of a meal.

Is there a problem with consuming milk products?
Milk contains lactose (milk sugar), which is not well digested. This sugar passes through undigested until bacteria in the lower bowel act on it, producing irritating byproducts as well as gas. Depending on individual tolerance, some persons find even the smallest amount of milk can cause cramps, gas and diarrhea.

Why can't I snack between meals?
Snacking, nibbling or grazing on foods, usually high-calorie and high-fat foods, can add hundreds of calories a day to your intake, defeating the restrictive effect of your operation. Snacking will slow down your weight loss and can lead to regain of weight.

Why can't I eat red meat after surgery?
You can, but you will need to be very careful, and we recommend that you avoid it for the first several months. Red meats contain a high level of meat fibers (gristle) which hold the piece of meat together, preventing you from separating it into small parts when you chew. The gristle can plug the outlet of your stomach pouch and prevent anything from passing through, a condition that is very uncomfortable.

How can I be sure I am eating enough protein?
60 to 70 grams a day during rapid weight loss and 40 grams thereafter are generally sufficient amounts. During rapid weight loss, supplementation is generally required to achieve those levels.

Is there any restriction of salt intake?
No, your salt intake will be unchanged unless otherwise instructed by your primary care physician.

Will I be able to eat "spicy" foods or seasoned foods?
Most patients are able to enjoy spices within a short time after surgery.

How will alcohol affect me after surgery?
You will find that even small amounts of alcohol will affect you quickly. Even one standard bar drink maybe too much! You will have higher blood levels with smaller amounts consumed and this is also more toxic on your liver.

Will I need supplemental vitamins?
B12 is an important supplement following a gastric bypass surgery. We recommend that B12 be taken sublingually (under the tongue).

What vitamins will I need to take after surgery?
We recommend that our patients take an adult formula, high potency multivitamin for the rest of their life.

Is it important to take calcium, iron, trace elements or female hormone replacements?
It is important to replace calcium. Iron requirement may vary but needs to be taken by menstruating women. Non-menstruating women and men may require iron supplementation as well, especially right after surgery. Trace elements are generally covered in a good multivitamin. Female hormones should be covered by ones GYN but there is no contraindication, as such, following gastric bypass.

Will I get a copy of suggested eating patterns and food choices after surgery?
You will attend Educational Seminar on dietary advancement. You will also obtain written documents relating to the issues of food choices and dietary advancement.

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General

What is the youngest age for which weight loss surgery is recommended?
Generally accepted guidelines from the American Society for Bariatric Surgery and the National Institutes of Health indicate surgery only for those 18 years of age and older. Surgery has been performed on patients 16 and younger. There is a real concern that young patients may not have reached full developmental or emotional maturity to make this type of decision. It is important that young weight loss surgery patients have a full understanding of the lifelong commitment to the altered eating and lifestyle changes necessary for success.

What is the oldest patient for whom weight loss surgery is recommended?
Patients over 65 require very strong indications for surgery and must also meet stringent Medicare criteria. The risk of surgery in this age group is increased, and the benefits, in terms of reduced risk of mortality, are reduced.

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

Can weight loss surgery help other physical conditions?
According to current research, weight loss surgery can improve or resolve associated health conditions.

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