What kind of doctor does bariatric surgery?

Contents

Bariatric Surgery and the Gastroenterologist

Srikantaiah Manjunatha, MBBS, MD, MRCP(UK)
Gastroenterologist
Gastroenterology Unit
Southern District Health Board
Dunedin, New Zealand

Michael Schultz, MD, PhD
Associate Professor
Department of Medicine
University of Otago
Dunedin, New Zealand

Obesity is a global problem of epidemic proportions. There were more than 1.9 billion overweight adults (BMI>25) in 2014 and 600 million of these were obese (BMI>30). Overall, 13% of the world’s adult population (11% males and 15% females) were obese and the prevalence of obesity has doubled between 1980-2014. In 2013, 42 million children under the age of 5 were overweight or obese 1. Obesity is a well-known risk factor for many pathological conditions, including hypertension, hyperlipidemia, diabetes mellitus, coronary artery disease, stroke, osteoarthritis, sleep apnea, and certain cancers, contributing substantially to health care costs. Clinicians are limited by ineffective treatment options as dietary and behavioral modifications, exercise, and pharmacotherapy all have relatively poor long term results 2. Bariatric surgery, though drastic, seems currently to be the only effective way of achieving long term persistent weight loss with improved or resolved comorbid conditions. According to recent recommendations, patients with a BMI >35kg/m2 and depending on obesity-related co-morbidities should be offered surgery 3.

Gastroenterologists are becoming increasingly involved in the care of obese patients. There is a significant association between obesity and various gastrointestinal problems, including reflux disease, vomiting, non-cardiac chest pain, diarrhea, etc. Obesity is also associated with a number of gastrointestinal and hepatobiliary conditions, like Barrett’s esophagus, esophageal adenocarcinoma, colonic polyps and cancer, gall stones, gall bladder cancer, pancreatic cancer, non-alcoholic fatty liver disease, hepatocellular cancer, etc., which are managed by gastroenterologists. Furthermore, besides the family doctor or general practitioner, increasingly in practice we may be the first medical contact for the obese or superobese and we should not be afraid to discuss (and even initiate discussion) about operative intervention or referral. However, this article is restricted to the role of gastroenterologist in bariatric surgery patients.

The mechanism of bariatric surgery generally involves restriction, malabsorption, or a combination of these two mechanisms. Restrictive procedures decrease the size of the stomach resulting in early satiety and reduced caloric intake. The restrictive operations include laparoscopic adjustable gastric band (LAGB) and vertical sleeve gastrectomy (VSG). In contrast, malabsorptive procedures bypass a large part of small intestine decreasing the degree of absorption of nutrients. These procedures include Biliopancreatic diversion (BPD) with or without Duodenal switch (DS). Roux-en-Y gastric bypass (RNYGBP), the most commonly performed bariatric procedure, involves both components of restriction and malabsorption. The procedure is technically demanding. VSG therefore is steadily gaining popularity due to technical advantages, perceived simplicity, and maintenance of anatomical continuity though the weight loss may be much less than after RNYGBP 4. The success and complication profiles of all these procedures are different. The postoperative mortality rate of a RNYGBP at 30 days has been reported between 0.2 – 0.5% depending on the technique (laparoscopic vs open) with leaks as the most common complication with a reported range of 0.4-4%. The technically less demanding VSG has a reported mortality rate of approximately 0.2%, again with leaks being the most common complication (1.9-2.4%) 5. A revisional procedure after bariatric surgery can be defined as a conversion, correction, or reversal. The indications for revisional surgery are treatment of severe side effects like persistent nausea, vomiting, dumping syndrome or complications of previous bariatric surgery like stricture, non-healing ulcers, or inadequate weight loss. Complications or weight loss failure after LAGB is the most common reason, making up to 75% of reversal operations 6.

Gastroenterologists play an integral role in the pre- and post-operative management of patients undergoing bariatric surgery. It is recommended that upper gastrointestinal endoscopy should be performed in all bariatric patients irrespective of symptoms, more so in patients undergoing RNYGBP or BPD/DS as it will be difficult to evaluate the excluded distal stomach and duodenum post operatively. It may also be important to detect abnormalities which may influence the choice of surgery or the development of post-operative symptoms and complications. VSG may be significantly more complicated by a hiatus hernia which requires additional repair, while Barrett’s esophagus is an absolute contraindication to VSG 4. Other, clinically, significant pathologies for consideration prior to surgery include reflux esophagitis, gastric ulcers, Helicobacter pylori infection, etc. To quote a few examples, H. pylori infection may increase the risk of anastomotic ulcers and VSG may worsen reflux 2.

With an ever increasing number of surgeries being performed, the absolute number of complications is also increasing. The immediate post-operative complications, like anastomotic leak, bleeding, small bowel obstruction, etc., may need surgical intervention, but lately there has been a trend to manage the stable patient preferably endoscopically. The most common location for leaks is the staple line, no matter which type of bariatric surgery was performed. The use of self-expandable, covered stents inserted to cover the defect has a reported success rate of >80%. These stents can be left in place for a prolonged time and patients may resume oral feeding after 1-3 days. Stent migration is a complication and the leak might recur. Fully covered stents can be removed endoscopically 7. Also post-operative bleeding, most often at the site of the anastomosis, and more likely in patients with underlying diabetes mellitus might be amenable to endoscopic therapy. The use of hemostatic clips is preferred over the use of diathermy 5,7. However, common symptoms prompting endoscopy six weeks or more after bariatric surgery include upper abdominal pain, nausea, vomiting, dysphagia, and diarrhea. The etiology of these symptoms are multifactorial and include marginal ulcers, chronic anastomotic leaks, fistulae, strictures, band stenosis, erosion or slippage, staple line dehiscence, bezoars, choledocholithiasis, etc. The endoscopic treatment of some of these conditions include balloon dilation of strictures, endoscopic removal of eroded bands, stenting of anastomotic leaks, endoscopic treatment of fistulae, and removal of bezoars and gall stones 2,4.

There may be also be a role for preoperative gastrointestinal motility studies in some patients to select the appropriate type of surgery. LAGB is notorious for postoperative worsening of gastro-esophageal reflux (GERD) and can cause pseudo-achalasia due to an increase of the lower gastro-esophageal pressure and aperistalsis. Similarly, VSG has been shown to aggravate GERD and can cause de novo GERD. In contrast, RNYGBP has been demonstrated to improve GERD-like symptoms and maintains motility of the esophagus 8. Small intestinal bacterial overgrowth can occur after RNYGBP and can result in a variety of symptoms. Early and late dumping syndromes are well reported late complications.

Post-operative nutritional and metabolic complications are quite common and may be seen in as many as 30% of patients. The most common nutritional deficiencies, particularly after bypass operations, are iron, calcium, vitamin D, vitamin B12, copper, zinc, and other vitamins and micronutrients, and may present as anemia, metabolic bone disease, protein energy malnutrition, steatorrhea, Wernicke’s encephalopathy, polyneuropathy, visual disturbances, and skin problems. There is evidence for routine screening for essential fatty acids and vitamin E or K deficiency. The etiology is multifactorial, including reduced intake, altered dietary choices, and malabsorption due to altered anatomy. The nature and severity of deficiencies is dependent on the type of surgery, dietary habits, and the presence of other surgery related complications like nausea, vomiting, or diarrhea. The frequency of nutritional follow-up depends largely on the surgical procedure performed. Following LAGB, frequent nutritional follow-up is recommended. Guidelines were reviewed and published in 2013 on the perioperative nutritional, metabolic, and non-surgical support of these patients 3. Routine post-operative nutritional monitoring and micronutrient supplementation is recommended in all bariatric patients particularly after malabsorptive procedures. Here, treatment with oral calcium and vitamin D is indicated to prevent secondary hyperparathyroidism. Hypophosphatemia is often associated with vitamin D deficiency. In individual cases, the monitoring of bone density is recommended. Hyperinsulinemic hypoglycemia is a rare complication after procedures like RNYGBP which is attributed to nesidioblastosis and needs to be differentiated from dumping syndrome 9. All patients should receive a multivitamin and mineral preparation 3.

The endoscopist may have a very important role in the future with less invasive endoscopic procedures as alternatives for bariatric surgery, based on the same principles. Endoscopic introduction of various types of restrictive gastric balloons, bypass procedures with placement of duodenojejunal bypass sleeve or bypass liner, implantable devices to delay transit time of nutrients through the duodenum, gastric stapling, endoluminal vertical gastroplasty, endoluminal gastric plication, transoral endoscopic restrictive implant system, etc. are only a few examples of endoscopic interventions as alternatives for surgical procedures 10.

The global increase in bariatric surgery procedures will no doubt generate more work for gastroenterologists and the endoscopy units and this needs to be taken into account in the management of capacity and increased demands 11,12. If the current research into endoluminal approaches demonstrates significant clinical advantages, gastroenterologists may have an ever increasing role and responsibility in the management of this global problem.

  1. WHO Fact sheet N 311, updated January 2015.
  2. DiBaise JK, Foxx-Orenstein AE Role of Gastroenterologist in managing obesity. Expert Rev Gastroenterol Hepatol 2013;7:439-451.
  3. Mechanick JI, Youdin A, Jones DB, Garvey TG, Hurley DL, McMahon MM, Heinberg LJ, Kushner R, Adams TD, Shikora S, Dixon JB, Brethauer S. Clinical practice guidelines for the perioperative nutritional, metabolic, and non-surgical support of the bariatric surgery patient – 2013 update: Cosponsored by American Association of Clinical Endocrinologists, The Obesity Society, and American Society for Metabolic & Bariatric Surgery. Endocr Pract 2013;19:337-372 .
  4. Rosenthal RJ. International Sleeve Gastrectomy Expert Panel Consensus Statement: best practice guidelines based on experience of >12,000 cases. Surg Obesity Rel Dis 2012;8:8-19.
  5. Eisendrath P & Deviere J. Major complications of bariatric surgery: endoscopy as first-line treatment. Nat Rev Gastroenterol Hepatol 2015;12:701-710.
  6. Ma IT, Madura II JA, Gastrointestinal complications after bariatric surgery. Gastroenterol & Hepatol 2015;11:526-535.
  7. Walsh C & Karmali S. Endoscopic management of bariatric complications: A review and update. WJGE 2015;7:518-523.
  8. Naik RD, Choksi YA, Vaezi MF. Consequences of bariatric surgery on oesophageal function in health and disease. Nat Rev Gastroenterol Hepatol 2015; epub ahead of print.
  9. Koch TR, Finelli FC. Post-operative metabolic and nutritional complications of bariatric surgery. Gastroenterol Clin N Am 2010;39:109-124.
  10. Mathus-Vilgen EMH Endoscopic treatment: Past, Present and Future. Best Pract Res Clin Gastroenterol 2014; 28:685-702.
  11. Steed H, Golar H, Manjunath S. The hidden endoscopic burden of Roux en Y gastric bypass surgery. Frontline Gastroenterol 2013;4:69-72.
  12. Arndtz K, Steed H, Hodson J, Manjunath S, The hidden endoscopic burden of sleeve gastrectomy and its comparison with Roux en Y gastric bypass. Ann Gastroenterol 2016;29(1):44-49.
  • How many bariatric surgeries have you done in the past year?
  • Do you participate in bariatric-specific continuing education?
  • Are you a member of the American Society for Metabolic and Bariatric Surgery (ASMBS)?
  • Are you board certified in general surgery?
  • Are you MBSAQIP, or Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program, qualified? Our partner hospitals (such as Scripps Health) are qualified members of MBSAQIP

Does the surgeon have testimonials from past patients?

It is only natural to want to hear from other patients about their experience with a surgeon. If you ask, your surgeon may be able to provide testimonials about the success of their past patients after bariatric surgery. Some might even be willing to talk to you about their experience.

Does the surgeon offer postoperative support?

Bariatric surgery isn’t an isolated event. It requires preparation beforehand, as well as lifestyle changes afterward. Surgeons who offer postoperative support can be a great resource to have on hand as you navigate a new phase of your life.

Questions to ask each bariatric surgeon you meet with

This is a lot of information, but it is all useful when you are choosing a bariatric surgeon. Also, it is a great idea to meet with several bariatric surgeons before choosing one. Here is a list of questions you can ask each surgeon you meet with:

  1. How many bariatric surgeries have you done in the past year?
  2. Do you participate in bariatric-specific continuing education?
  3. Are you a member of the American Society for Metabolic and Bariatric Surgery (ASMBS)?
  4. Are you board certified in general surgery?
  5. Are you MBSAQIP, or Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program, qualified? Our partner, Scripps Health, is a qualified member of MBSAQIP.
  6. Can I see reviews from your other patients?
  7. Do you offer postoperative support?
  8. What are your success, failure, and complication rates for each type of bariatric surgery you perform?
  9. Are my risks higher than other patients? Why?
  10. Which type of bariatric surgery do you recommend for me? Why?
  11. What pre- and post-op instructions do you give to patients having bariatric surgery?

Choosing a surgeon can be complicated, but when you book your bariatric surgery with your Carrum Health benefit, you will have access to the highest quality doctors in the country. They are carefully selected and have experience completing different types of bariatric surgery. You can schedule a free consultation to start the process of choosing a bariatric surgeon.

4 Types of Weight Loss Surgery

When you get weight loss surgery, your surgeon makes changes to your stomach or small intestine, or both. Here are the four methods surgeons typically use:

Gastric Bypass: Your doctor may call this “Roux-en-Y” gastric bypass, or RYGB. The surgeon leaves only a very small part of the stomach (called the pouch). That pouch can’t hold a lot of food, so you eat less. The food you eat bypasses the rest of the stomach, going straight from the pouch to your small intestine. This surgery can often be done through several small incisions using a camera to see inside (laparoscope). Doctors can also perform a mini-gastric bypass, which is a similar procedure also done through a laparoscope.

Adjustable Gastric Band: The surgeon puts a small band around the top of your stomach. The band has a small balloon inside it that controls how tight or loose the band is. The band limits how much food can go into your stomach. This surgery is done using a laparoscope.

Gastric Sleeve: This surgery removes most of the stomach and leaves only a narrow section of the upper part of the stomach, called a gastric sleeve. The surgery may also curb the hunger hormone ghrelin, so you eat less.

Duodenal Switch: This is complicated surgery that removes most of the stomach and uses a gastric sleeve to bypass most of your small intestine. It limits how much you can eat. It also means your body doesn’t get as much of a chance to absorb nutrients from your food, which could mean you don’t get enough of the vitamins and minerals you need.

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What is bariatric surgery?

Bariatric surgery is surgery that affects your stomach and how you digest food. It’s designed to make your stomach much smaller, which causes you to feel full after eating only a small amount of food. You eat less food and absorb fewer calories after bariatric surgery.

What are the types of bariatric surgery?

The most common types in Australia are lap band surgery (called gastric banding), gastric bypass and gastric sleeve surgery. The surgery is usually done as a keyhole procedure, in which there are a number of small cuts in your tummy. But sometimes, open surgery with larger cuts is needed.

In lap band surgery, an adjustable ring is put around the top part of the stomach to create a very small pouch that increases the time food remains in the top part of the stomach.

In gastric bypass, a small stomach pouch is created by stapling. This is joined directly to the small intestine after some of the intestine has been removed. Food bypasses most of the stomach and fewer calories are absorbed.

In gastric sleeve surgery, most of the stomach is removed, including the part that makes a hormone which makes you feel hungry.

Most people lose weight for 1 to 2 years after gastric bypass or gastric sleeve surgery, then they stop losing weight. With lap band surgery, the process takes longer.

Human digestive systems: a normal system (left), gastric bypass (centre) and lap band (right)

When should I consider bariatric surgery?

Bariatric surgery is usually offered to people who are very obese (with a body mass index over 40), or people with a body mass index over 35 who have other serious health problems like diabetes or heart disease.

You could consider bariatric surgery, but only after trying alternatives. The first step is usually to try changes to what you eat and drink, and what daily activity and exercise you do. There are some medicines that can help people lose weight. Surgery is usually thought about only after these other options have been tried.

The health benefits of weight loss include improvements in type 2 diabetes, lower blood pressure and improved heart health.

Which type of bariatric surgery is right for me?

Many factors will determine which type of surgery is the best type for you, including how much weight you need to lose and any illnesses you might have.

Your doctor will do a detailed assessment and discuss with you the best option, including the risks.

What can go wrong?

Every operation has risks. You might pick up an infection, lose a lot of blood, or react to the anaesthetic.

There are different specific risks for the different types of bariatric surgery. For example, lap band surgery is safer than gastric bypass. Ask your GP and surgeon what risks do you face?

What can I expect after bariatric surgery?

You will need to make significant lifestyle changes after bariatric surgery to lose weight and keep it off. For example, you will need to follow dietary guidelines, and you’ll probably take vitamins or other supplements for life. Your weight loss program will also involve increased physical activity.

After the surgery, you’ll start with liquid foods. Over the next few weeks you’ll change to pureed food, then solid food. Your meals will be much smaller and you may have to stop drinking with meals due to your small stomach.

In some cases, people will initially lose weight but then their body becomes used to the changes made during the surgery and they can regain some of the weight.

What are the alternatives to bariatric surgery?

The alternatives to bariatric surgery are lifestyle changes, such as diet and exercise, or lifestyle changes combined with weight-loss medicines. You can get professional help with this: ask your doctor.

The best reason to have bariatric surgery

This is not about looks – although I know you’ll look better than ever. It’s not about pleasing other people – although they will be pleased, and so will you.

The biggest benefit of weight-loss surgery is… drumroll… you’ll be healthier.

And you’ll live to see your grandchildren!

There’s no doubt about it – losing weight naturally helps keep blood sugar under control. That prevents a whole cycle of serious health problems related to diabetes – like vision, kidney, circulatory, nerve and other problems.

If you’ve had diabetes for less than five years, there’s an 80% chance the diabetes will go away following weight loss surgery – especially if you’re only taking pills to control blood sugar. Many patients can cut back on pills, but not completely. The surgery is just that effective! If you’re on insulin however, there’s less chance of completely getting off of it. Your blood sugar control will be better after the surgery, and with a few meds it can be even better. That’s good stuff!

Bariatric surgery has also been shown to:

  • Reduce sleep apnea by 90%
  • Reduce blood pressure in 60% of patients – with the rest taking fewer or lower-dose meds to control blood pressure
  • Decrease joint pain by 60 to 70%
  • Cut high cholesterol by 60 to 80% – with some getting off all meds, or significantly cutting the dose or number of meds

But wait, there’s more!

Migraines:

Patients with migraines tend to have fewer and less severe migraines. We believe that carrying all that weight pushes on the spinal fluid, which pushes on the brain, causing the headaches.

Asthma:

If you have asthma, you will likely have fewer asthma attacks. This is probably related to heartburn and reflux. When stomach acid gets high enough in the esophagus, it affects vocal chords and gets into lungs—causing asthma attacks. After surgery, heartburn goes away in 80-90 percent of patients. That should give you a better night’s sleep!

Cancer:

Cancers are linked to obesity—especially colon, breast, and endometrial cancers. We don’t have long-term studies to show that people who have been obese for 20 years, and then have weight-loss surgery, will have lower risk. However, we believe that operating earlier (and keep people leaner for 20 years) will reduce these cancer risks.

Bariatric:

Bariatric surgery patients also have fewer hospitalizations overall, shorter hospital stays, and are less likely to be admitted to the intensive care unit. That’s compared to obese patients who don’t have bariatric surgery. Studies show that a higher percentage of bariatric surgical patients are alive five years later, compared to those who didn’t have surgery.

We’ve also seen improvements in women with polyscystic ovary disease… infertility… ulcers… leg swelling. Every time we turn around we find health improvements!

In my office, we talk realistically about the risks of surgery – balanced with the risk of NOT having surgery. For many patients, it’s a risk they’re willing to take. In some ways, the sicker you are because of your weight, the bigger the benefit of having surgery.

People come to me with all types of reasons for wanting surgery. But almost always, one of them is, I want to see my children and grandchildren grow up and have fun with them. Bariatric surgery will get them closer to that goal.

Types of Bariatric Surgery

The type of surgery that may be best to help a person lose weight depends on a number of factors. You should discuss with your doctor what kind of surgery might be best for you or your teen.

What is the difference between open and laparoscopic surgery?

In open bariatric surgery, surgeons make a single, large cut in the abdomen. More often, surgeons now use laparoscopic surgery, in which they make several small cuts and insert thin surgical tools through the cuts. Surgeons also insert a small scope attached to a camera that projects images onto a video monitor. Laparoscopic surgery has fewer risks than open surgery and may cause less pain and scarring than open surgery. Laparoscopic surgery also may lead to a faster recovery.

Open surgery may be a better option for certain people. If you have a high level of obesity, have had stomach surgery before, or have other complex medical problems, you may need open surgery.

What are the surgical options?

In the United States, surgeons use three types of operations most often:

  • laparoscopic adjustable gastric band
  • gastric sleeve surgery, also called sleeve gastrectomy
  • gastric bypass

Surgeons use a fourth operation, biliopancreatic diversion with duodenal switch, less often.

Laparoscopic Adjustable Gastric Band

In this type of surgery, the surgeon places a ring with an inner inflatable band around the top of your stomach to create a small pouch. This makes you feel full after eating a small amount of food. The band has a circular balloon inside that is filled with salt solution. The surgeon can adjust the size of the opening from the pouch to the rest of your stomach by injecting or removing the solution through a small device called a port placed under your skin.

After surgery, you will need several follow-up visits to adjust the size of the band opening. If the band causes problems or is not helping you lose enough weight, the surgeon may remove it.

The U.S. Food and Drug Administration (FDA) has approved use of the gastric band for people with a BMI of 30 or more who also have at least one health problem linked to obesity, such as heart disease or diabetes.

Gastric Sleeve

In gastric sleeve surgery, also called vertical sleeve gastrectomy, a surgeon removes most of your stomach, leaving only a banana-shaped section that is closed with staples. Like gastric band surgery, this surgery reduces the amount of food that can fit in your stomach, making you feel full sooner. Taking out part of your stomach may also affect gut hormones or other factors such as gut bacteria that may affect appetite and metabolism. This type of surgery cannot be reversed because some of the stomach is permanently removed.

Gastric Bypass

Gastric bypass surgery, also called Roux-en-Y gastric bypass, has two parts. First, the surgeon staples your stomach, creating a small pouch in the upper section. The staples make your stomach much smaller, so you eat less and feel full sooner.

Next, the surgeon cuts your small intestine and attaches the lower part of it directly to the small stomach pouch. Food then bypasses most of the stomach and the upper part of your small intestine so your body absorbs fewer calories. The surgeon connects the bypassed section farther down to the lower part of the small intestine. This bypassed section is still attached to the main part of your stomach, so digestive juices can move from your stomach and the first part of your small intestine into the lower part of your small intestine. The bypass also changes gut hormones, gut bacteria, and other factors that may affect appetite and metabolism. Gastric bypass is difficult to reverse, although a surgeon may do it if medically necessary.

Duodenal Switch

This surgery, also called biliopancreatic diversion with duodenal switch, is more complex than the others. The duodenal switch involves two separate surgeries. The first is similar to gastric sleeve surgery. The second surgery redirects food to bypass most of your small intestine. The surgeon also reattaches the bypassed section to the last part of the small intestine, allowing digestive juices to mix with food.

This type of surgery allows you to lose more weight than the other three. However, this surgery is also the most likely to cause surgery-related problems and a shortage of vitamins, minerals, and protein in your body. For these reasons, surgeons do not perform this surgery as often.

Most Common Weight-loss Surgeries

What it is

Surgeon places an inflatable band around top part of stomach, creating a small pouch with an adjustable opening.

Pros

  • Can be adjusted and reversed.
  • Short hospital stay and low risk of surgery-related problems.
  • No changes to intestines.
  • Lowest chance of vitamin shortage.

Cons

  • Less weight loss than other types of bariatric surgery.
  • Frequent follow-up visits to adjust band; some people may not adapt to band.
  • Possible future surgery to remove or replace a part or all of the band system.

Surgeon removes about 80 percent of stomach, creating a long, banana-shaped pouch.

  • Greater weight loss than gastric band.
  • No changes to intestines.
  • No objects placed in body.
  • Short hospital stay.
  • Cannot be reversed.
  • Chance of vitamin shortage.
  • Higher chance of surgery-related problems than gastric band.
  • Chance of acid reflux.

Surgeon staples top part of stomach, creating a small pouch and attaching it to middle part of small intestine.

  • Greater weight loss than gastric band.
  • No objects placed in body.
  • Difficult to reverse.
  • Higher chance of vitamin shortage than gastric band or gastric sleeve.
  • Higher chance of surgery-related problems than gastric band.
  • May increase risk of alcohol use disorder.

What should I expect before surgery?

Before surgery, you will meet with several health care providers, such as a dietitian, a psychiatrist or psychologist, an internist, and a bariatric surgeon.

  • The doctor will ask about your medical history, do a thorough physical exam, and order blood tests. If you are a smoker, he or she will likely ask you to stop smoking at least 6 weeks before your surgery.
  • The surgeon will tell you more about the surgery, including how to prepare for it and what type of follow-up you will need.
  • The dietitian will explain what and how much you will be able to eat and drink after surgery and help you to prepare for how your life will change after surgery.
  • The psychiatrist or psychologist may do an assessment to see if bariatric surgery is an option for you.

These health care providers also will advise you to become more active and adopt a healthy eating plan before and after surgery. In some cases, losing weight and bringing your blood sugar levels closer to normal before surgery may lower your chances of having surgery-related problems.

Some bariatric surgery programs have groups you can attend before and after surgery that can help answer questions about the surgery and offer support.

What should I expect after surgery?

After surgery, you will need to rest and recover. Although the type of follow-up varies by type of surgery, you will need to take supplements that your doctor prescribes to make sure you are getting enough vitamins and minerals.

Walking and moving around the house may help you recover more quickly. Start slowly and follow your doctor’s advice about the type of physical activity you can do safely. As you feel more comfortable, add more physical activity.

After surgery, most people move from a liquid diet to a soft diet such as cottage cheese, yogurt, or soup, and then to solid foods over several weeks. Your doctor, nurse, or dietitian will tell you which foods and beverages you may have and which ones you should avoid. You will need to eat small meals and chew your food well.

How much weight can I expect to lose?

The amount of weight people lose after bariatric surgery depends on the individual and on the type of surgery he or she had. A study following people for 3 years after surgery found that those who had gastric band surgery lost an average of about 45 pounds. People who had gastric bypass lost an average of 90 pounds.1 Most people regained some weight over time, but weight regain was usually small compared to their initial weight loss.

Researchers know less about the long-term results of gastric sleeve surgery, but the amount of weight loss seems to be similar to or slightly less than gastric bypass.

Your weight loss could be different. Remember, reaching your goal depends not just on the surgery but also on sticking with healthy lifestyle habits throughout your life.

Weight-loss Devices

The FDA has approved several new weight-loss devices that do not permanently change your stomach or small intestine. These devices cause less weight loss than bariatric surgery, and some are only temporary. The devices may have risks, so talk with your doctor if you’re thinking about any of these options. Researchers haven’t studied any of them over a long period of time and don’t know the long-term risks and benefits.

  • The electrical stimulation system uses a device implanted in your abdomen, by way of laparoscopic surgery, that blocks nerve activity between your stomach and brain. The device works on the vagus nerve, which helps signal the brain that the stomach feels full or empty.
  • The gastric balloon system consists of one or two balloons placed in your stomach through a tube inserted through your mouth. Your doctor or nurse will give you a sedative before the procedure. Once the balloons are in your stomach, doctors inflate them with salt water so they take up space in your stomach and help you feel fuller. You will need to have the balloons removed after 6 months or a year.
  • A new device uses a pump to drain part of the food in your stomach after a meal. The device includes a tube that goes from the inside of your stomach to a port on the outside of your abdomen. The port is a small valve that fits over the opening in your abdomen. About 20 to 30 minutes after eating, you attach tubing from the port to the pump and open the valve. The pump drains your stomach contents through a tube into the toilet, so that your body doesn’t absorb about 30 percent of calories you ate. You can have the device removed at any time.

1 Inge TH, Courcoulas AP, Jenkins TM, et al. Weight loss and health status 3 years after bariatric surgery in adolescents. The New England Journal of Medicine. 2016;374(2):113–123.

10 Things Your Doctor Won’t Tell You About Weight Loss Surgery

If you’re considering weight-loss surgery, there’s a good chance you’re getting plenty of pre- and post-op guidance from a doctor you trust. But that’s not always the case, and for many people who have this type of procedure, life after surgery can be full of surprises — the good, the bad, and even the downright embarrassing. If you’re thinking about undergoing bariatric surgery, here are a few things you should know that the doctor may forget to mention.

1. You may get very depressed post-surgery.

There’s a proven link between obesity and depression, and while the majority of patients who undergo bariatric surgery do experience an overall improvement in their well-being after surgery, feelings of depression can worsen for some. Researchers from Yale University published a study in the Obesity Journal in which 13 percent of patients studied reported an increase in Beck Depression Inventory – a numerical rating that measures eating disorder behavior, self-esteem, and social functioning – six to 12 months after gastric bypass surgery, a time frame that the authors conclude is an important period to assess for depression and associated symptoms.

2. Excess skin can be an issue — and corrective surgery is costly.

Though the post-surgery weight loss may be gradual enough that your body and skin can adjust slowly, many people are left with such an excess that it requires cosmetic surgery to fix. And unless it’s deemed medically necessary (such as a surplus of droopy skin causing a rash or infection), your insurance company will not be footing the bill. According to the American Society of Plastic Surgeons, in 2013 member surgeons performed nearly 42,000 body contouring operations — reshaping of breasts, arms, thighs, and stomachs — for patients who lost substantial amounts of weight. Body contouring operations can cost anywhere from $4,000 to much, much higher.

3. You’re going to poop more — a lot more.

About 85 percent of patients who undergo Roux-en-Y Gastric Bypass (RNYGB) surgery will experience extreme bouts of diarrhea known as dumping syndrome at some point post-surgery, according to The American Society for Metabolic and Bariatric Surgery (ASMBS). It’s usually the result of poor food choices (including refined sugars, fried foods, and some fats or dairy), and can have mild-to-severe symptoms that also include sweating, flushing, lightheadedness, desire to lie down, nausea, cramping, and active audible bowels sounds. Sound like a nightmare? Unfortunately, that’s not all: Loose stools, constipation, and embarrassing gas (or as experts refer to it, malodorus flatus) are other common bowel-related complaints after surgery.

4. It could boost your risk for alcohol use or abuse.

One study published in JAMA examined people who had gastric bypass surgery at one, three, six, and 24 months after surgery and found that patients’ risk for increased alcohol use after the procedure was significantly higher. This may be because patients have higher peak alcohol levels, and reach those levels more quickly, after bariatric surgery, although other theories do exist to explain the connection.

5. You’ll still need that gym membership.

Many doctors will counsel patients on a proper post-surgery diet to help promote weight-loss success after surgery, but that’s not the only lifestyle change patients have to make. The Obesity Action Coalition recommends that once a patient is cleared by his or her doctor to introduce physical activity into a daily routine, gradually working up to 60 minutes of exercise six days per week is ideal for promoting post-surgery weight loss success. In other words, don’t think you’re getting off easy; this surgery isn’t a quick fix.

6. You’ll have to say goodbye to soda.

That’s right: Carbonated beverages are a big no-no because they introduce air into your belly, creating gas that can put pressure on your stomach and cause it to expand unnecessarily, thereby undoing the surgery results. Instead of soda, drink lots and lots of water, as dehydration is the most common reason for a patient’s readmission to the hospital, according to the ASMBS.

7. It could put a strain on your marriage.

Drastic physical transformations can lead to a variety of emotional changes that can affect not just you but your relationships as well. At least one study has found an uptick in divorce rates among couples with a bariatric surgery partner, especially in the first year after surgery. So in addition to great post-operative medical care, you also may need to think about seeking emotional guidance for you and your spouse — either via counseling with a therapist or by joining a support group, which can help limit the negative effects on your relationships.

8. You could be a candidate for new hunger-controlling device that can treat obesity.

The FDA just approved a first-of-its-kind pacemaker-like weight loss device called the Maestro Rechargeable System, which helps suppress appetite by sending electronic pulses to the nerve of the body that communicates hunger to the brain. Though less invasive than bariatric surgery, the device does require an hour-long outpatient surgery to implant the device in the patient’s abdomen. Since it’s not yet widely available, and weight loss results aren’t nearly as impressive as bariatric surgery, it may not replace your need for bariatric surgery; still, it could be a good option for severely obese patients who need help getting to a weight where they can safely undergo bariatric surgery, or for those who need help with post-surgery weight control, so it’s worth discussing with your doctor.

9. The risks of surgery are low compared with doing nothing at all.

Though weight-loss surgery has a reputation for being risky, the procedures have improved over the years and are a lot safer now; the ASMBS reports that the chances of having a major complication are only about 4.3 percent. The risks of staying obese — heart disease, diabetes, stroke, and even death – are far more dangerous.

10. Most people say they’d do it again in a heartbeat.

Though success is a long-term project for patients who undergo this serious procedure, most people say that if they could go back in time, they’d choose to have the surgery again. Many people report that after the surgery and subsequent weight loss they feel better, are more active, and take fewer medications to treat the complications of obesity — all of which can greatly improve a person’s quality of life.

Frequently Asked Questions

If you have a question that isn’t answered below, contact us. We’re happy to help.

Questions About Bariatric Surgery

What is the success rate for weight loss surgery?
75-80% of patients achieve success over the long term after undergoing a gastric restrictive surgical procedure, such as RY gastric bypass or LAP-BAND (laparoscopic banding).

Does weight loss surgery guarantee permanent weight loss?
No. A small percentage of patients will regain a substantial portion of the weight that is lost. This is occurs primarily when the patient does not follow the dietary guidelines in the months and years following the procedure.

Can weight loss surgery be reversed?
The LAP-BAND and gastric bypass procedures are both potentially reversible. Reversal requires an operation of the same magnitude and risk as the original procedure. Reversal of other bariatric operations, such as the gastric sleeve, is rare.

How long does the operation take?
Gastric banding (LAP-BAND) and sleeve gastrectomy can be performed in 1-2 hours while gastric bypass is generally performed in 2-3 hours.

What are the different types of weight loss surgery?
There are four main types of procedures.

  1. Gastric Bypass Surgery separates the stomach into two unequal compartments with less than 5% of the stomach remaining usable for food consumption. During digestion, the food empties from this tiny stomach pouch into the upper intestine. Read More
  2. Laparoscopic Banding is a procedure in which the stomach is encircled with an inflatable plastic band (such as the LAP-BAND® or REALIZE® Band), restricting food intake. Read More
  3. Sleeve Gastrectomy (more commonly referred to as the Gastric Sleeve) is a procedure in which about 85% of the stomach is removed, leaving 15% of the original capacity which is shaped like a sleeve. Read More
  4. Biliopancreatic Diversion creates a smaller stomach (similar to gastric bypass surgery), but in addition there is less absorption of ingested food inside the intestine. Read More

Which bariatric procedure is right for me?
This decision is typically made during the initial consultation between you and one of our bariatric surgeons. Many other surgeons perform only one type of procedure, limiting your options. But at NJ Bariatrics, we specialize in nearly all types of weight loss surgery.

What are the risks of weight loss surgery?
All abdominal operations carry these risks:

  • Bleeding
  • Infection of the incision and abdomen
  • Potential problems with the heart and/or lungs, including blood clots
  • Obstruction (blockage) of the intestine caused by adhesions (scar tissue) or internal hernia
  • Hernia through the incision or inside abdomen
  • Rejection of suture material
  • The risks associated with general anesthesia; anesthesia risks are not significantly greater in most morbidly obese patients than in normal weight patients

The risk of death associated with weight loss surgery is extremely low — less than 0.5%.

Must I be in good health to qualify for the surgery?
No. Many of our patients are in poor health because of diseases caused by their obesity. These diseases include diabetes, high blood pressure, heart problems, lung problems, and kidney difficulties.

Will I need any preoperative tests?
To ensure the best possible outcome, we’ll administer specific blood tests, a chest x-ray, and an electrocardiogram (EKG). We’ll also test you for a bacteria that causes ulcers (known as H.pylori) and for gall stones. In some cases, we may also require a sleep study (for sleep apnea) or a psychological evaluation.

Are there different ways the surgery can be performed?
Yes. The preferred minimally invasive method is laparoscopy, in which the operation is performed through 4 to 6 very small incisions. There is also the traditional, open approach, in which a large incision is made.

What exactly is laparoscopy?
Laparoscopy is a minimally invasive surgical procedure in which a surgeon gains access to the abdominal cavity by way of 4 to 6 small incisions in the abdominal wall. An instrument called a laparoscope is used to give the surgeon an exceptionally clear view of the inside of the abdominal cavity. This surgical approach is considered “minimally invasive” because of the very small incisions used.
Nearly all of the operations performed by our bariatric surgeons are performed via laparoscopy.

How does the doctor decide which surgical approach to take?
Some surgeons only perform weight loss surgery using one approach (i.e., open or laparoscopically). Surgeons who perform both types of procedures usually prefer laparoscopic surgery, except in the heaviest of patients or those who require revisional surgery (second or third time operations).

Can you do corrective bariatric procedures?
Yes. Surgeons at the Center for Metabolic & Bariatric Surgery at PMC perform revisional bariatric surgery to correct previous surgical weight loss procedures. If you’re in need of corrective bariatric surgery, contact us.

Questions About Recovery

How long should I expect to be in the hospital?
Anywhere from two to four days, depending upon how you’re feeling post-surgery.

Will I need special care when I arrive home?
You should be able to function on your own after your discharge. A small number of patients with physical disabilities before surgery sometimes require extra assistance.

How soon can I drive after surgery?
You should not drive until you can move quickly and alertly and are no longer taking medications associated with your surgery. Usually this takes about one to two weeks.

When can I return to work after surgery?
Some patients with sedentary-type jobs have returned to work as early as one to two weeks following surgery. But if your job is more physically demanding, it may take as long as six weeks before you can return to work.

How many follow-up visits are necessary after surgery?
Typically, you’ll attend four to six follow-up meetings during your first post-surgery year. Then visits are scheduled at six to twelve month intervals for an indefinite period of time.

Who will attend the follow-up meetings?
The operating surgeon and nutritionist will meet together with you during each follow-up visit.

Life After Surgery

What kind of weight loss can I expect?
Many patients lose more than 100 lbs during their first year. Some patients lose weight for more than two years following the procedure, and may lose in excess of 200 lbs during that time. Results vary from patient to patient, with the best results coming from those who are committed to lifestyle change. Keep in mind, weight loss surgery isn’t a miracle cure. It’s important to set realistic weight loss goals for yourself right from the start. A loss of about 2 to 3 pounds a week in the first year after the operation is possible, but a pound a week is more likely. You’re aiming for gradual, steady weight loss.

How can I obtain the best results?
For best results, follow the advice of your operating surgeon and the nutritionist. We also encourage you to join our support group. Our support groups will provide you with additional advice and motivation to fuel your long-term weight loss. Our most successful patients (those who have lost the most weight and maintained their weight loss) are highly focused on Life Change, the 4th step of our 4 step process. If you’re willing to make some changes to your lifestyle and adopt some healthier habits, you can achieve amazing results.

Will I need to take nutritional supplements?
Yes. Following any bariatric surgery, we recommend that you take a daily multivitamin supplement containing the minerals necessary for good health. These should be taken for life. Read More

Can I still go out to eat?
Absolutely. You’ll want to order only a small amount of food and eat slowly. Try to finish at the same time as your table companions. You might want to let your waiter or waitress know that you cannot eat very much.

What about pregnancy?
Becoming pregnant can be easier after losing weight. Your menstrual cycle may also become more regular. However, we don’t recommend becoming pregnant during the weight loss phase after your surgery (up to 18 months after the operation). Should you become pregnant, we encourage communication between your obstetrician and bariatric surgeon.

General Questions

How long does it take to get an appointment for my consultation?
Approximately one to two weeks. Click here to request a consultation.

Can I fill out any paperwork before I visit your office?
Yes. We provide our patient questionnaire online. It may be printed and filled out at your leisure.

After my consultation, how long will it be before I can undergo the procedure?
The waiting period is generally about two to six months, depending upon precertification approval. During your initial consultation, the surgeon will determine whether health-related factors might delay your surgery.

What is precertification approval?
This is the procedure by which the insurance company reviews your medical and dietary history prior to approving you for surgery.

Will my insurance company pay for the surgery?
Because this type of surgery is considered medically necessary, insurance companies will often cover it. Read More

Will I have to pay any out-of-pocket expenses?
Yes and no. No, not for your initial consultation. Your insurance provider should cover 100% of this cost. Yes, there is a prepayment deposit required for your surgery. This will be applied against the total bill paid by your insurance company.

Questions About Revisional Surgery

For questions and answers about revisional bariatric surgery, click here.

Weight loss surgery: do the benefits really outweigh the risks?

Obesity prevalence is the highest it has ever been. The Centers for Disease Control and Prevention (CDC) states that more that one-third of American adults are affected. And with the increase in obesity comes an increase in the number of weight loss surgery procedures. But how safe are the procedures, and do the benefits outweigh the risks?

There is no doubt that obesity is a major cause of a number of serious and potentially life-threatening diseases.

The condition can lead to type 2 diabetes, heart disease, stroke, and it has also been linked to some cancers, including breast cancer and colon cancer. A recent study reported by Medical News Today even suggested a .

Furthermore, the condition can severely damage a person’s quality of life, leaving them immobile and often triggering depression.

Based on these factors, it is not difficult to understand why excessively overweight individuals look to various weight loss interventions in order to combat their obesity.

And weight loss surgery, also known as bariatric surgery, is now one of the most common interventions to which obese individuals turn.

According to the American Society of Metabolic and Bariatric Surgery (ASMBS), the number of surgical weight loss procedures carried out in the US has increased from 13,000 in 1998 to more than 200,000 in 2008.

Bariatric surgery refers to a series of weight loss procedures that an obese individual can have in order to reduce their food intake, therefore causing them to lose weight.

A person is classed as obese if their body mass index (BMI) is over 30. If their BMI is over 40, they are deemed severely obese.

Share on PinterestObesity in the US has more than doubled since the 1960s, and this has prompted an increasing number of people to seek weight loss surgery.

There are three main bariatric surgery procedures that are widely used. These are gastric bypass, gastric banding and sleeve gastrectomy.

Gastric bypass is the most commonly used bariatric procedure worldwide, according to the ASMBS. The procedure involves re-routing the digestive system past the stomach in order to promote satiety and suppress hunger.

The gastric band procedure involves having an inflatable band placed around the top portion of the stomach. This creates a smaller stomach pouch, meaning eating less will make a person feel full and satisfy their hunger.

With a sleeve gastrectomy, around 80% of the stomach is removed to create a smaller stomach pouch. This reduces the amount of food that can be consumed.

Recovery time from these procedures varies from patient to patient. But it could take months for a patient to resume their normal daily activities following surgery, and many will have to follow a liquid diet and introduce normal foods slowly.

This prompts the question – why does bariatric surgery appear to be the preferred option over other weight loss interventions?

‘Most effective option’ for obese patients

According to Dr. Elliot Fegelman, medical director for Ethicon, a Johnson & Johnson company that designs and manufactures medical devices, standard diet and exercise strategies only lead to significant weight loss in 5% of the US population.

He adds:

“Surgery for weight loss and control of associated diseases, has been shown to be the most effective option available for patients suffering from obesity and related diseases.”

Bariatric surgery has indeed demonstrated positive results in the past. Medical News Today recently reported on a study published in the BMJ suggesting that weight loss surgery is significantly more effective, compared with non-surgical methods.

Furthermore, studies have shown that weight loss surgery is associated with fewer cardiovascular events, such as heart attack and stroke, and it has even been suggested that the procedure is linked to improved sex drive in patients.

Dr. Fegelman notes that because of various studies demonstrating the positive effects of bariatric surgery, acceptance of the procedure has greatly increased.

But are patients overlooking the potential negative effects associated with the surgery?

Positives ‘outweigh’ the negatives

Bariatric procedures themselves present an array of possible complications.

Share on PinterestBariatric surgery poses risks to the patient, but medical professionals say the benefits far outweigh the health risks associated with obesity.

For example, the ASMBS notes that a side effect of gastric banding may involve dilation of the esophagus (food pipe) if the patient overeats. This means patients need to stick to a strict diet for the rest of their lives and have regular postoperative follow-up visits.

Gastric bypass procedures also have their disadvantages. The ASMBS states that the surgery can lead to long-term vitamin and mineral deficiencies, and patients must have lifelong supplementation as a result.

Studies have also suggested that bariatric surgery may increase the risk of other health conditions.

Medical News Today recently reported on a study suggesting that women who have undergone weight loss surgery are more likely to give birth prematurely and have babies who are small in size for gestational age.

But Dr. Fegelman says that all surgeries present their risks, and these vary with each patient.

He adds:

“However, in the appropriate patients, the health risks from obesity far outweigh the risks associated with bariatric surgery.

Metabolic and bariatric surgery is associated with major reductions in risk of premature death over a 5-year period versus not having surgery, and in the US, the risk of bariatric surgery is now no greater than laparoscopic gall bladder surgery.”

Patients ‘need better advice to make decisions’

But Dr. Fegelman says he believes better communication is needed between doctors and obese patients, in order to ensure patients are better informed about the risks associated with bariatric surgery and whether the procedure is right for them.

“Bariatric and metabolic surgery is a major decision, and patients need time to consider it and explore their options. However, if a patient waits too long in their disease progression, the benefits from surgery may be impacted,” says Dr. Fegelman.

In an attempt to help patients make their decision regarding bariatric surgery and help doctors inform patients about the benefits and risks, Ethicon have created a new online tool called The Ethicon Bariatric Surgery Comparison Tool.

The tool requires individuals to enter information such as their height, weight, ethnicity and age, and to select whether they have any weight-related health conditions, such as asthma, depression, liver disease or diabetes.

The online tool then searches over 75,000 bariatric surgery results of patients with similar health conditions.

Information is then presented to the user, detailing what their bariatric surgery options are, and the weight loss of similar patients over a period of 6, 12, 18 and 24 months after surgery.

Dr. Fegelman says the tool gives the user the opportunity to explore these results with their physician, enabling them to make better decisions.

“It’s my hope that this tool will give doctors even more opportunity to explain the potential benefits and risks associated these procedures,” he adds.

“The investment of surgeons in developing their skills, investment from hospitals in developing high quality teams, and investment from companies like Ethicon in the development of instruments and tools used every day in the operating room, contribute to the safety and efficacy of bariatric procedures.”

Development of new bariatric procedures

There is no doubt that obese individuals are looking to bariatric surgery as a weight loss intervention now more than ever. And from this, researchers are looking for new surgical routes to aid weight loss.

A new study from researchers at Harvard Medical School has detailed one potential option – using a form of transarterial embolization.

The procedure is commonly used to treat a variety of medical conditions. It involves inserting an obstructive agent through a catheter and into an artery in order to stop blood flowing from the artery into a specific area of the body.

In this study, the investigators carried out embolization of the left gastric artery for gastrointestinal bleeding. It was found that patients who underwent this procedure experienced a 7.9% decrease in body weight 3 months following surgery.

The researchers say this procedure could be a potential bariatric treatment for weight loss and could be an alternative to other invasive procedures, such as gastric bypass.

“This is an important data point in the development of a new clinical tool for the treatment of obesity,” says Dr. Rahmi Oklu, assistant professor of radiology at Harvard Medical School.

And with the rate of obesity in the US more than doubling since the 1960s, according to the US Department of Health and Human Sciences, it seems there is a desperate need for further weight loss interventions.

All treatment options should be discussed

Whether these interventions are in the form of bariatric surgery or more traditional non-surgery methods, one thing is clear – individuals who are obese need to talk to their doctors about their treatment options and be clear of the risks associated with them.

Dr. Fegelman says:

“We know that in the time-constrained environment of the doctor’s office, talking about obesity can be a challenge.

Now that we have good information showing the improvements in health from, and the safety of , it is critical that doctors speak to their patients about the threat obesity represents and the options patients have to treat it.”

Although there are many surgical options available to assist with weight loss, there is no denying the importance of following a healthy diet in order to maintain a healthy weight.

The US Department of Health and Human Services recommends that calories should be balanced with physical activity for healthy weight maintenance. Furthermore, they recommend increasing intake of fruit, vegetables and whole grains, and reducing intake of foods with high amounts of salt, saturated fats, trans fats, cholesterol, added sugars and refined grains.

Following a Mediterranean diet has also shown many benefits for weight and overall health. This diet mainly consists of high consumption of beans, nuts, cereals and seeds, consuming 25-35% of calorie intake from fat, and consuming cheese and yogurt as the main dairy foods.

Earlier this year, Medical News Today reported on a study suggesting that the Mediterranean diet reduces heart attack and stroke in groups that are high-risk, while another study has linked the diet to longer lifespan and better health.

How long after metabolic and bariatric surgery will I have to be out from work?

After surgery, most patients return to work in one or two weeks. You will have low energy for a while after surgery and may need to have some half days, or work every other day for your first week back. Your surgeon will give you clear instructions. Most jobs want you back in the workplace as soon as possible, even if you can’t perform ALL duties right away. Your safety and the safety of others are extremely important – low energy can be dangerous in some jobs.

Many patients are worried about getting hernias at incisions. That is almost never a problem from work or lifting. Hernias are more often the result of infection. You will not feel well if you do too much.

When can I start exercising again after surgery?

Right away! You will take gentle, short walks even while you are in the hospital. The key is to start slow. Listen to your body and your surgeon. If you lift weights or do sports, stay “low impact” for the first month (avoid competition, think participation). Build slowly over several weeks. If you swim, your wounds need to be healed over before you get back in the water.

Can I have laparoscopic surgery if I have had other abdominal surgery procedures in the past, or have a hernia, or have a stoma?

The general answer to this is yes. Make sure to tell your surgeon and anesthesiologist about all prior operations, especially those on your abdomen and pelvis. Many of us forget childhood operations. It is best to avoid surprises!

Sometimes your surgeon may ask to see the operative report from complicated or unusual procedures, especially those on the esophagus, stomach, or bowels.

Does type 2 diabetes make surgery riskier?

It can. Be sure to follow any instructions from your surgeon about managing your diabetes around the time of surgery. Almost everyone with Type 2 Diabetes sees big improvement or even complete remission after surgery. Some studies have even reported improvement of Type 1 Diabetes after bariatric procedures.

Can I have laparoscopic surgery if I have heart disease?

Yes, but you may need medical clearance from your cardiologist. Bariatric surgery leads to improvement in most problems related to heart disease including:

  • High Blood Pressure
  • Cholesterol
  • Lipid problems
  • Heart enlargement (dilated heart, or abnormal thickening)
  • Vascular (artery and vein) and coronary (heart artery) disease

During the screening process, be sure to let your surgeon or nurse know about any heart conditions you have. Even those with atrial fibrillation, heart valve replacement, or previous stents or heart bypass surgery usually do very well. If you are on blood thinners of any type, expect special instructions just before and after surgery.

When can I get pregnant after metabolic and bariatric surgery? Will the baby be healthy?

Most women are much more fertile after surgery, even with moderate pre-op weight loss. Birth control pills do NOT work as well in patients who are overweight. Birth control pills are not very reliable during the time your weight is changing. For this reason, having an IUD or using condoms and spermicide with ALL intercourse is needed. Menstrual periods can be very irregular, and you can get pregnant when you least expect it!

Most groups recommend waiting 12-18 months after surgery before getting pregnant.

Many women who become pregnant after surgery are several years older than their friends were when having kids. Being older when pregnant does mean possible increased risks of certain problems. Down syndrome and spinal deformities are two examples. The good news is that, after surgery, there is much less risk of experiencing problems during pregnancy (gestational diabetes, eclampsia, macrosomia) and during childbirth. There are also fewer miscarriages and stillbirths than in women with obesity who have not had surgery and weight loss.

Kids born after mom’s surgery are LESS at risk of being affected by obesity later, due to activation of certain genes during fetal growth (look up “epigenetics” – for more information). There is also less risk of needing a C section.

Will I need to have plastic surgery? Does insurance pay for plastic surgery?

Most patients have some loose or sagging skin, but it is often more temporary than expected. You will have a lot of change between 6 and 18 months after surgery. Your individual appearance depends upon several things, including how much weight you lose, your age, your genetics and whether or not you exercise or smoke. Generally, loose skin is well-hidden by clothing. Many patients wear compression garments, which can be found online, to help with appearance.

Some patients will choose to have plastic surgery to remove excess skin. 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 and rash issues.

Arms and other areas may not be covered if they are considered “purely” cosmetic by your insurer. Some of these “less invasive” operations can be done in the clinic, however – so they can be much more affordable!

Will I lose my hair after bariatric surgery?

Some hair loss is common between 3 and 6 months following surgery. The reasons for this are not totally understood. Even if you take all recommended supplements, hair loss will be noticed until the follicles come back. Hair loss is almost always temporary. Adequate intake of protein, vitamins and minerals will help to ensure hair re-growth, and avoid longer term thinning.

Will I have to take vitamins and minerals after surgery? Will my insurance pay for these?

You will need to take a multivitamin for life. You may need higher doses of certain vitamins or minerals, especially Iron, Calcium, and Vitamin D. You will also need to have at least yearly lab checks. Insurance almost never pays for vitamin and mineral supplements but usually does pay for labs. You can pay for supplements out of a flex medical account.

If my insurance company will not pay for the surgery, are payment plans available?

There are loan programs available to cover the cost of health expenses such as metabolic and bariatric surgery. Appeals to insurance companies or directly to your employer may reverse a denial of coverage. Metabolic and Bariatric surgery is a health expense that you can deduct from your income tax.

If you are not able to qualify for a loan, the Obesity Action Coalition (OAC) produces a helpful guide titled “Working with Your Insurance Provider – A Guide to Seeking Weight-loss Surgery.” This guide can help you work with your provider and advocate for your surgery to be covered. You can view the OAC guide on their website.

If I am self-pay but I have health insurance, will my insurance company pay the cost of post-operative complications?

Complications are often reported under a separate medical billing code. The insurance company may not cover these costs. Appeal is often very helpful, and direct contact with your hospital can make a big difference for final costs. Many surgeons also offer a special insurance policy to cover unexpected additional costs.

Will I have to go on a diet before I have surgery?

Yes. Most bariatric surgeons put their patients on a special pre-operative diet, usually 2 or 3 weeks just before surgery. The reason for the pre-operative diet is to shrink the liver and reduce fat in the abdomen. This helps during the procedure and makes it safer.

Some insurance companies require a physician-monitored diet three to six months prior to surgery as part of their coverage requirement. These diets are very different from the short term diets, and usually are more about food education and showing a willingness to complete appointments and to learn.

Will I have to diet or exercise after the procedure?

No and Yes.

Most people think of a “diet” as a plan that leaves you hungry. That is not the way people feel after surgery. Eventually, most patients get some form of appetite back 6-18 months after surgery. Your appetite is much weaker, and easier to satisfy than before.

This does not mean that you can eat whatever and whenever you want. Healthier food choices are important to best results, but most patients still enjoy tasty food, and even “treats.”

Most patients also think of exercise as something that must be intense and painful (like “boot camp”). Regular, modest activity is far more useful in the long term. Even elite athletes can’t stay at a “peak” every week of the year. Sometimes exercise is work, but if it becomes a punishing, never-ending battle, you will not keep going. Instead, work with your surgeon’s program to find a variety of activities that can work for you. There is no “one-size-fits-all” plan. Expect to learn and change as you go!

For many patients (and normal weight people, too) exercise is more important for regular stress control, and for appetite control, than simply burning off calories. As we age, inactivity can lead to being frail or fragile, which is quite dangerous to overall health. Healthy bones and avoiding muscle loss partly depends on doing weekly weight bearing (including walking) or muscle resistance (weights or similar) exercise.

I am unable to walk.

Almost everyone is able to find some activity to “count” as moderate exercise, even those who are partially paralyzed, or who have arthritis or joint replacement or spine pain. Special therapists may be needed to help find what works for you.

How do I get a letter of necessity?

Some insurance requires this type of letter from either your surgeon or primary care provider before final approval for surgery. Many will just accept your surgeon’s consultation summary note. It is best to ask your insurer directly. Most companies want information pertaining to current weight, height, body mass index, the medical problems related to obesity, your past diet attempt history and why the physician feels it is medically necessary for you to have bariatric surgery. Your bariatric surgeon will often have a sample letter of necessity for you to take to your primary care physician.

Can I go off some of my medications after surgery?

As you lose weight, you may be able to reduce or eliminate the need for many of the medications you take for high blood pressure, heart disease, arthritis, cholesterol, and diabetes. If you have a gastric bypass, sleeve gastrectomy or a duodenal switch, you may even be able to reduce the dosage or discontinue the use of your diabetes medications soon after your procedure.

Additional Information

ASMBS encourages you to talk to an ASMBS member surgeon, physician or integrated health professional if you have more specific questions. You can find an ASMBS member in your area by using our ASMBS provider search tool.

Further Reading

  • Bariatric Surgery Procedures
  • Adolescent Obesity
  • Bariatric Surgery Misconceptions

​Gastric Bypass Versus Gastric Sleeve Surgery

Individuals who are considering bariatric surgery for weight loss have multiple options. From traditional gastric bypass surgery to laparoscopic band surgery to gastric sleeve, each type of surgery has its own benefits and risks.

At UPMC Bariatric Services, our team of board certified surgeons will explain the pros and cons of gastric sleeve vs gastric bypass surgeries.

They’ll help you to make the right decision when considering bariatric surgery.

When deciding which surgery is right for you, it is essential to compare your options. You should understand the similarities and differences between the two types of bariatric procedures. When reviewing gastric bypass vs sleeve, there are a number of factors to consider:

Gastric Bypass Procedure vs. Gastric Sleeve Procedure: The Similarities

Gastric bypass and gastric sleeve are very similar procedures. In both cases, the expected hospital stay ranges from 2-3 days and the procedures are not reversible. Although the methods differ, both operations reduce the amount of food you can eat before feeling full.

Gastric Bypass Procedure vs. Gastric Sleeve Procedure: The Differences

  • Procedure: A doctor attaches a small pouch to the intestine in order to bypass the stomach.
  • Recovery Time: 2 to 4 weeks
  • Risks and Complications: Risk of dumping syndrome
  • Weight Loss Results: Patients can expect to lose 60 to 80 percent of excess weight within the first year to year and a half.
  • Procedure: The surgeon removes a portion of the stomach, producing a tube-shaped stomach (sleeve).
  • Recovery Time: 2 to 4 weeks
  • Risks and Complications: Lower risk of dumping syndrome
  • Weight Loss Results: Patients should expect to lose weight at a slower, steadier rate. In the first 12 to 18 months, they may lose 60 to 70 percent of excess weight.

Whether you select gastric bypass or gastric sleeve, it’s important that you follow a strict post-surgery diet.

Gastric Bypass vs. Gastric Sleeve: Results and Benefits

Both gastric bypass and gastric sleeve surgeries can be effective tools in achieving long-term weight loss. Both procedures can help improve obesity-related conditions, including:

  • Diabetes
  • High blood pressure
  • High cholesterol
  • Sleep apnea

Gastric Bypass vs. Gastric Sleeve: Which Surgery Is Better?

You should work alongside your doctor to choose the best weight loss procedure for you.

  • Gastric bypass patients lose between 50 to 80 percent of excess bodyweight within 12 to 18 months, on average.
  • Gastric sleeve patients lose between 60 and 70 percent of their excess body weight within 12 to 18 months, on average.
  • Gastric bypass surgery is generally recommended for very obese patients with a Body Mass Index over 45.

Learn more about our surgery options and review a full comparison chart for the differences between bariatric surgery procedures offered at UPMC Bariatric Services.

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