FAQ's about Morbid Obesity
Our Frequently Asked Questions section refers to United States-based
generally standard and accepted practices. As always, please check with your
healthcare provider to determine their practices, guidelines and what they
recommend for you.
Preparation for Surgery
What are the
routine tests before surgery?
Certain basic tests are done prior to surgery: a Complete Blood Count (CBC),
Urinalysis, and a Chemistry Panel, which gives a readout of about 20 blood
chemistry values. Other tests, such as pulmonary function testing,
echocardiogram, sleep studies, GI evaluation, cardiology evaluation, or
psychiatric evaluation, may be requested when indicated.
What is the
purpose of all these tests?
An accurate assessment of your health is needed before surgery. The best way
to avoid complications is to never have them in the first place. It is important
to know if your thyroid function is adequate since hypothyroidism can lead to
sudden death post-operatively. If you are diabetic, special steps must be taken
to control your blood sugar. Because surgery increases cardiac stress, your
heart will be thoroughly evaluated. These tests will determine if you have liver
malfunction, breathing difficulties, excess fluid in the tissues, abnormalities
of the salts or minerals in body fluids, or abnormal blood fat levels.
Why do I
have to have a GI Evaluation?
Patients who have significant gastrointestinal symptoms such as upper
abdominal pain, heartburn, belching sour fluid, etc., may have underlying
problems such as a hiatal hernia, gastroesophageal reflux or peptic ulcer. For
example, many patients have symptoms of reflux. Up to 15% of these patients may
show early changes in the lining of the esophagus, which could predispose them
to cancer of the esophagus. It is important to identify these changes so a
suitable surveillance or treatment program can be planned.
Why do I
have to have a Sleep Study?
The sleep study detects a tendency for abnormal stopping of breathing,
usually associated with airway blockage when the muscles relax during sleep.
This condition is associated with a high mortality rate. After surgery, you will
be sedated and will receive narcotics for pain, which further depress normal
breathing and reflexes. Airway blockage becomes more dangerous at this time. It
is important to have a clear picture of what to expect and how to handle it.
Why do I
have to have a Psychological Evaluation?
The most common reason a psychological evaluation is ordered is that your
insurance company requires it. Most psychologists and behavioral counselors will
evaluate your understanding and knowledge of the risks and complications
associated with weight loss surgery and your ability to follow the basic
do my medical problems have on the decision for surgery, and how do the medical
problems affect risk?
Medical problems, such as serious heart or lung problems, can increase the
risk of any surgery. On the other hand, if they are problems that are related to
the patient's weight, they also increase the need for surgery. Severe medical
problems may not dissuade the surgeon from recommending gastric bypass surgery
if it is otherwise appropriate, but those conditions will make a patient's risk
higher than average.
If I want to
undergo a gastric bypass, how long do I have to wait?
Depending on your insurance company requirements, it may take from 4 – 12
months from the time of initial contact with our office until the time your
surgery is scheduled.
What can I
do before the appointment to speed up the process of getting ready for
- Select a primary care physician (PCP) 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). Have your PCP
document monthly weight loss attempts.
- Make a list of all the diets you have tried (a diet history) and bring it
to your doctor.
- Bring any pertinent medical data to your first appointment - this would
include reports of special tests (echocardiogram, sleep study, etc.) or
hospital discharge summary if you have been in the hospital.
- Bring a list of your medications with dose and schedule.
- Stop smoking. Surgical patients who use tobacco
products are at a higher surgical
Insurance Issues <back to top>
Why does it
take so long to get insurance approval?
The St. Mary’s Bariatric insurance specialist contacts every patient’s
insurance company. Insurance companies have different plans and criteria.
Gathering medical records and documenting consecutive months of weight loss
attempts may take 6 – 12 months, depending upon the requirements of your
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.
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 majority of insurance companies are now requiring 6 – 12 months of
pre-surgery medically supervised weight loss attempts.
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.
<back to top>
Laparoscopic Surgery decrease the risk?
Somewhat. Laparoscopic operations carry the same risk as the procedure
performed as an open operation. The benefits of laparoscopy are typically less
discomfort, shorter hospital stay, earlier return to work and reduced scarring.
Another benefit, laparoscopic surgery decreases the risk of incisional site
Will I have
a lot of pain?
Every attempt is made to control pain after surgery to make it possible for
you to move about quickly and become active. This helps avoid problems and
speeds recovery. Often several drugs are used together to help manage your
post-surgery pain. While you are still in the hospital, a Patient Controlled
Analgesia (PCA), which allows you to give yourself a dose of pain medicine on
demand, may be used by your physician. Various methods of pain control,
depending on your type of surgical procedure, are available. Ask your surgeon
about other pain management options.
How long do
I have to stay in the hospital?
As long as it takes to be self-sufficient. Although it can vary, the hospital
stay (including the day of surgery) can be 2-3 days for a laparoscopic gastric
bypass, and 3-5 days for an open gastric bypass.
doctor leave a drain in after surgery?
Most patients will have a small tube to allow drainage of any accumulated
fluids from the abdomen. This is a safety measure, and it is usually removed a
few days after the surgery. Generally, it produces no more than minor
If I have
surgery, what can I expect when I wake up in the recovery room?
The surgeon will provide a Patient Controlled Analgesia (PCA) or a
self-administered pain management system, to help control pain. As with any
major surgery, you are in danger of death from a blood clot or other surgical
side effects. Statistically, the risk of death during these procedures is less
than 1 percent. Your doctors will have assessed you for risks and prepared
All abdominal operations carry the risks of
bleeding, infection in the incision, thrombophlebitis of legs (blood clots),
lung problems (pneumonia, pulmonary embolisms), strokes or heart attacks,
anesthetic complications, and blockage or obstruction of the intestine. These
risks are greater in morbidly obese patients.
will I be able to walk?
Almost immediately after surgery doctors will require you to get up and move
about. Patients are asked to walk or stand at the bedside on the night of
surgery, take several walks the next day and thereafter. On leaving the
hospital, you may be able to care for all your personal needs, but will need
help with shopping, lifting and with transportation. There are less lifting
restrictions with Laparoscopic surgery.
How soon can
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
Stay <back to
What is done to minimize the risk of deep vein
thrombosis/pulmonary embolism or DVT/PE?
Because a DVT originates on the operating table, therapy begins before a
patient goes to the operating room. Generally, patients are treated with
sequential leg compression stockings and given a blood thinner prior to surgery.
Both of these therapies continue throughout your hospitalization. The third
major preventive measure involves getting the patient moving and out of bed as
soon as possible after the operation to restore normal blood flow in the
What should I bring with me to the
Basic toiletries (comb, toothbrush, etc.) and clothing may be provided by the
hospital, but most people prefer to bring their own. Choose clothes for your
stay that are easy to put on and take off. Because of your incision, your
clothes may become stained by blood or other body fluids. Other ideas:
- Post-op manual provided by the Bariatric Center
- Reading and writing materials
- Crossword and other puzzles
- Personal toiletries
Surgery <back to
What do I need to do to be successful after
The basic rules are simple and easy to follow:
- Immediately after surgery, the dietitian will provide you with special
dietary guidelines. You will need to follow these guidelines closely. Patients
begin with liquid diets, moving to semi-solid foods and later, sometimes weeks
or months later, solid foods can be tolerated without risk to the surgical
procedure performed. Allowing time for proper healing of your new stomach
pouch is necessary and important.
- When able to eat solids, eat 2-3 meals per day, no more. Protein in the
form of lean meats (chicken, turkey, fish) and other low-fat sources should be
eaten first. These should comprise at least half the volume of the meal eaten.
Foods should be cooked without fat and seasoned to taste. Avoid sauces,
gravies, butter, margarine, mayonnaise and junk foods.
- Protein snacks are encouraged between meals. Do not drink flavored
beverages, even diet soda, between meals.
- Drink 2-3 quarts or more of water each day. Water must be consumed slowly,
1-2 sips at a time, due to the restrictive effect of the operation.
- Exercise aerobically every day for at least 20 minutes (one-mile brisk
walk, bike riding, stair climbing, etc.). Weight/resistance exercise can be
added 3-4 days per week, as instructed by your doctor.
What's so important about exercise?
When you have a weight loss surgery procedure, you lose weight because the
amount of food energy (calories) you are able to eat is much less than your body
needs to operate. It has to make up the difference by burning reserves or unused
tissues. Your body will tend to burn any unused muscle before it begins to burn
the fat it has saved up. If you do not exercise daily, your body will consume
your unused muscle, and you will lose muscle mass and strength. Daily aerobic
exercise for 20 minutes will communicate to your body that you want to use your
muscles and force it to burn the fat instead.
What is the right amount of exercise after weight
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.
Can I get pregnant after weight loss
It is strongly recommended that women wait at least 12 – 18 months after the
surgery before a pregnancy. Approximately one year post-operatively, your body
will be fairly stable (from a weight and nutrition standpoint) and you should be
able to carry a normally nourished fetus. You should consult your surgeon as you
plan for pregnancy.
What if I have had a previous weight loss surgical
procedure and I'm now having problems?
Contact your original surgeon - he or she is most familiar with your medical
history and can make recommendations based on knowledge of your surgical
procedure and body.
What happens to the lower part of the stomach that
The stomach is left in place with intact blood supply. In some cases it may
shrink a bit and its lining (the mucosa) may atrophy, but for the most part it
remains unchanged. The lower stomach still contributes to the function of the
intestines even though it does not receive or process food - it makes intrinsic
factor, necessary to absorb Vitamin B12 and contributes to hormone balance and
motility of the intestines in ways that are not entirely known.
How big will my stomach pouch really be in the long
This can vary by surgical procedure and surgeon. In the Roux-en-Y gastric
bypass, the stomach pouch is created at one ounce or less in size (15-20cc). In
the first few months it is rather stiff due to natural surgical inflammation.
About 6-12 months after surgery, the stomach pouch can expand and will become
more expandable as swelling subsides. Many patients end up with a meal capacity
of 3-7 ounces.
What will the staples do inside my abdomen? Is it
okay in the future to have an MRI test? Will I set off metal detectors in
The staples used on the stomach and the intestines are very tiny in
comparison to the staples you will have in your skin or staples you use in the
office. Each staple is a tiny piece of stainless steel or titanium so small it
is hard to see other than as a tiny bright spot. Because the metals used
(titanium or stainless steel) are inert in the body, most people are not
allergic to staples and they usually do not cause any problems in the long run.
The staple materials are also non-magnetic, which means that they will not be
affected by MRI. The staples will not set off airport metal detectors.
What if I'm not hungry after surgery?
It's normal not to have an appetite for the first month or two after weight
loss surgery. If you are able to consume liquids reasonably well, there is a
level of confidence that your appetite will increase with time.
Is there any difficulty in taking
Most pills or capsules are small enough to pass through the new stomach
pouch. Initially, your doctor may suggest that medications be taken in liquid
form or crushed.
Will I be able to take oral contraception after
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. Many patients experience a drop in desire for about 6
Is there a difference in the outcome of surgery
between men and women?
Both men and women generally respond well to this surgery. In general, men
lose weight slightly faster than women do.
Will I be asked to stop smoking?
Patients must stop smoking at least 6 – 8 weeks before surgery.
If I continue to smoke, what happens?
Smoking increases the risk of lung problems after surgery, can reduce the
rate of healing, increases the rates of infection, and interferes with blood
supply to the healing tissues. Surgery will not be scheduled until nicotine
level lab test is normal.
How can I know that I won't just keep losing weight
until I waste away to nothing?
Patients may begin to wonder about this early after the surgery when they are
losing 20-40 pounds per month, or maybe when they've lost more than 100 pounds
and they're still losing weight. Two things happen to allow weight to stabilize.
First, a patient's ongoing metabolic needs (calories burned) decrease as the
body sheds excess pounds. Second, there is a natural progressive increase in
calorie and nutrient intake over the months following weight loss surgery. The
stomach pouch and attached small intestine learn to work together better, and
there is some expansion in pouch size over a period of months. The bottom line
is that, in the absence of a surgical complication, patients are very unlikely
to lose weight to the point of malnutrition.
What can I do to prevent lots of excess hanging
Many people heavy enough to meet the surgical criteria for weight loss
surgery have stretched their skin beyond the point from which it can "snap
back." Some patients will choose to have plastic surgery to remove loose or
excess skin after they have lost their excess weight. Insurance generally does
not pay for this type of surgery (often seen as elective surgery). However, some
do pay for certain types of surgery to remove excess skin when complications
arise from these excess skin folds. Ask your surgeon about your need for a skin
Will exercise help with excess hanging
Exercise is good in so many other ways that a regular exercise program is
recommended. Unfortunately, most patients may still be left with large flaps of
Will I be miserably hungry after weight loss surgery
since I'm not eating much?
Most patients say no. In fact, for the first 4-6 weeks patients have almost
no appetite. Over the next several months the appetite returns, but it tends not
to be a ravenous "eat everything in the cupboard" type of hunger.
What if I am really hungry?
This is usually caused by the types of food you may be consuming, especially
starches (rice, pasta, potatoes). Be absolutely sure not to drink liquid with
food since liquid washes food out of the pouch. The dietitian will work with you
after surgery in assisting with proper food choices.
Will I have to change my medications?
Your doctor will determine whether medications for blood pressure, diabetes,
etc., can be stopped when the conditions for which they are taken improve or
resolve after weight loss surgery. For meds that need to be continued, the vast
majority can be swallowed, absorbed and work the same as before weight loss
surgery. Usually no change in dose is required. Two classes of medications that
should be used only in consultation with your surgeon are diuretics (fluid
pills) and NSAIDs (most over-the-counter pain medicines). NSAIDs (ibuprofen,
naproxen, etc.) may create ulcers in the small pouch or the attached bowel. Most
diuretic medicines make the kidneys lose potassium. With the dramatically
reduced intake experienced by most weight loss surgery patients, they are not
able to take in enough potassium from food to compensate. When potassium levels
get too low, it can lead to fatal heart problems.
What is a hernia and what is the probability of an
abdominal hernia after surgery?
A hernia is a weakness in the muscle wall through which an organ (usually
small bowel) can advance. Approximately 20% of patients develop a hernia. Most
of these patients require a repair of the herniated tissue. The use of a
reinforcing mesh to support the repair is common.
Is blood transfusion required?
Very rarely: If needed, it is usually given after surgery to promote healing.
What is phlebitis and is it preventable?
Undesired blood clotting in veins, especially of the
calf and pelvis. It is not completely preventable, but preventive measures will
be taken, including:
- Early ambulation
- Special stockings
- Blood thinners
- Pulsatile boots
Will I lose hair after surgery? How can I prevent
Many patients experience some hair loss or thinning after surgery. This
usually occurs between the fourth and the eighth month after surgery. Consistent
intake of protein at mealtime is the most important prevention method. Also
recommended are a daily zinc supplement and a good daily volume of fluid
Does hair growth recover?
Most patients experience natural hair regrowth after the initial period of
What are adhesions and do they form after this
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 the "Candida Syndrome?"
Some patients have a type of yeast present on the surface of their skin,
intestine or vagina at the time of surgery. This leads to overgrowth in certain
circumstances. A whitish coating may occur on the tongue or throat. This
syndrome is associated with a frothy mucous, nausea, difficulty swallowing, sore
throat, loss of taste and appetite, and occasionally abdominal bloating and
diarrhea. This is a very rare occurrence.
What causes it to appear?
It is promoted by the use of most antibiotics and some other medications, by
stress, by reduced immune response, and by diabetes.
Can it be cured?
There are several effective medications now available for treating the
overgrowth of Candida.
What is sleep apnea (SA)?
It is the interruption of the normal sleep pattern associated with repeated
delays in breathing. Sleep apnea often shows rapid improvement after surgery. In
most patients, there is a complete resolution of symptoms by six months
Diet <back to top>
How long will I be off of solid foods after
Most surgeons recommend a period of four weeks or more without solid foods
after surgery. A liquid diet, followed by semi-solid foods or pureed foods, may
be recommended for a period of time until adequate healing has occurred. Your
dietitian will provide you with specific dietary guidelines for the best
What are the best choices of protein?
Eggs, low-fat cheese, low-fat cottage cheese, tofu, fish, other seafood,
chicken (dark meat), turkey (dark meat).
Why drink so much water?
When you are losing weight, there are many waste products to eliminate,
mostly in the urine. Some of these substances tend to form crystals, which can
cause kidney stones. A high water intake protects you and helps your body to rid
itself of waste products efficiently, promoting better weight loss. Water also
fills your stomach and helps to prolong and intensify your sense of satisfaction
with food. If you feel a desire to eat between meals, it may be because you did
not drink enough water in the hour before.
What is Dumping Syndrome?
Eating sugars or other foods containing many small particles when you have an
empty stomach can cause dumping syndrome in patients who have had a gastric
bypass 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 sometimes be well tolerated at the end of a meal.
Is there a problem with consuming milk
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
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
60 to 80 grams a day are generally sufficient. Check with your dietitian to
determine the right amount for your type of surgery.
Is there any restriction of salt intake?
No, your salt intake will be unchanged unless otherwise instructed by your
primary care physician.
Will I be able to eat "spicy" foods or seasoned
Most patients are able to enjoy spices after the initial 6 months following
Will I be allowed to drink alcohol?
You will find that even small amounts of alcohol will affect you quickly. It
is suggested that you drink no alcohol for the first year. Thereafter, with your
physician's approval, you may have a glass of wine or a small cocktail.
Will I need supplemental vitamins?
B12 injections are sometimes suggested once a month for the first year and
every six months thereafter. B12 may also be taken orally or sublingually (under
the tongue) by many patients.
What vitamins will I need to take after
Most surgeons recommend a daily multivitamin for the rest of your life.
Is it important to take calcium, iron, trace
elements or female hormone replacements?
Some patients require these supplements, but your need for these can be
determined by your surgeon.
Do I meet with a dietitian and behavioral counselor
before and after surgery?
We require that patients consult with a dietitian before and after surgery.
Counseling visits are required before surgery and after surgery as needed.
Will I get a copy of suggested eating patterns and
food choices after surgery?
The dietitian provides patients with materials that clearly outline their
expectations regarding diet and compliance to guidelines for the best outcome
based on your surgical procedure. After surgery, health and weight loss are
highly dependent on patient compliance with these guidelines. You must do your
part by restricting high-calorie foods, by avoiding sugar, snacks and fats, and
by strictly following the guidelines set by your dietitian.
<back to top>
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 21 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
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
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
According to current research, weight loss surgery can improve or resolve
associated health conditions.
Percentage found in preoperative individuals
Percentage cured 2 years after surgery
|Diabetes or insulin resistance
High blood pressure
22% in males, 1% in females