FAQ

Pre-Operative Phase

• How can I tell if I should have surgery for my weight?

  It is a two part decision process: if you meet the medical criteria for surgery, and if you have seriously tried non-surgical approaches to weight loss, and if you believe that the excess weight is a serious problem in your case, then the odds are good that surgery is a reasonable intervention for you to consider.

• What impact 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 major surgery. On the other hand, problems that are related to the patient’s weight may also increase the need for surgery. In other words, a variety of medical problems will usually not dissuade the surgeon from recommending Weight Loss Surgery (WLS) if it is otherwise appropriate, but your surgeon may estimate your risk as higher than average.

   

• Is there anything I can do to reduce my risk at the time of surgery?

  Yes.

  See Final Preparation for Surgery.

• What can I do before the appointment to accelerate the surgery preparation process?

  We suggest you take the following course of action:

  If you don’t already have one, establish a relationship with a physician who will be your primary care physician.

  Work with that physician to get caught up on your routine health maintenance testing. For example, anyone over 50 years old should undergo colonoscopy if they have not already done so. Also, consider whether you may have obstructive sleep apnea. If you have symptoms, then work with your primary care physician to get this evaluated and treated.

  Initiate contact with your health insurance company to learn about their criteria to cover bariatric surgery.

  Don’t be put off if the insurer tells you it is not covered. This is often a maneuver the insurer uses to reduce their cost of care.

  Write out your diet history and bring it with you.

  Bring any pertinent medical data with you to your appointment with the surgeon.

  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 dosing information and schedule.

  STOP SMOKING.

  We require patients to be tobacco-free before the surgeon will meet with you one-on-one, as there is a substantial increase in your operative risk associated with tobacco use.

• What if I live far away from San Antonio?

  First, we suggest you check to see if there are any surgeons in your area who perform bariatric surgery. You can find a Center of Excellence surgeon in your area on the web at:
  http://www.surgicalreview.org/locate.aspx

  If you live within driving distance of San Antonio or San Angelo, we will be happy to see you and discuss surgery! We can coordinate with your local physician on your preparation for surgery and arrange for him or her to assume some aspects of your follow-up care. In our opinion, there is no substitute for a face-to-face meeting to evaluate you and for you to make an informed decision about whether to pursue surgery. You will need to physically visit New Dimensions in San Antonio to investigate thoroughly and seriously consider bariatric surgery.

• What if I have had a previous bariatric surgical procedure and I’m experiencing problems?

  The first option is to contact your original surgeon. It is vastly preferable for the original surgeon to take care of a surgical problem because he or she is most likely to know the correct solution based on his or her knowledge of your surgical anatomy. If you have moved far from your original surgeon or there is some other reason that it is not reasonable for that surgeon to participate in your care, we may be able to help. We will need to have an operative report from your first operation, and you must obtain the report from the surgeon’s office. Also, we will want you to have support and an established relationship with a primary doctor, and we will want to see the results of an upper GI x-ray or upper scope to see if there is a correctable surgical problem.

• What about insurance coverage?

  Insurance companies and employers’ coverage for morbid obesity is constantly changing. New Dimensions provides a dedicated group of patient advocates who are happy to assist you throughout the insurance approval process.

• Should I donate my own blood to have it on hand in case I need it at the time of the operation?

  Generally not. Most patients lose very small amounts of blood, and even those who have unexpected bleeding during surgery do not usually lose enough blood that they need to receive a transfusion. Also, when giving one’s own blood for use in surgery, one must wait several weeks to allow the blood to replenish before undergoing surgery.

• My doctor doesn’t believe in surgery for weight loss. What should I say to him or her?

  Try to understand the origin of the negative opinion before inquiring further with your physician. Below are some issues to consider, and suggested questions for your primary care physician.

  Has the doctor seen bad outcomes in his patients after bariatric surgery?

  Bad outcomes do happen; however, in appropriately selected patients, the risk of surgery is less than the risk of continuing with morbid obesity.

  Does the doctor simply not know much about the operation?

  Physicians are just like other people – they do not trust what they do not know. Even though bariatric surgery is fairly widely accepted in the medical community, many physicians do not have much exposure to it.

  Is the doctor prejudiced against fat people?

  Again, physicians reflect the general culture (for better or for worse). This is the only situation in which it is probably appropriate to select another doctor.

  Once you understand the objection, ask your doctor two questions:

  Is the excess weight a significant medical problem, or does it put you at significant risk for development of weight-related medical problems? The response to this is “yes” by definition in people with a BMI of greater than 40.

  What treatment does the doctor propose? The fact is – there is no therapy other than surgery that has demonstrated significant weight loss for longer than two years in morbidly obese patients.

  Direct your physician to this website.

Surgical Procedures and Effects

• How should I choose which procedure is best for me?

  Read about our surgical procedures here.

• What is dumping syndrome?

  See Dumping Syndrome.

• How do the surgeons minimize the chance of leaks from the Gastric Bypass?

  Our surgeons know that the best treatment for a serious problem like a leak is prevention. The key area of concern for a leak is the gastric pouch and the connection of the Roux limb to the pouch. In order to minimize the chance of a leak, during surgery the surgeon will make sure that:

  • the intestinal sections fit together without stretch or tension
  • all of the tissues have good blood supply to promote healing or “fusing” of the cut tissues
  • everything is watertight when the surgery is complete
  • The surgeon will always check this area at the end of surgery using some type of pressure test (air or blue dye) and possibly a scope to look at the area.
  • Surgery is not complete until there is no sign of leakage whatsoever.
• If a leak occurs, how does it show up? What tests are done for a leak? Do the surgeons re-operate to repair a leak?

  If a leak occurs after Gastric Bypass, it nearly always shows up within the first 48 hours. Thus, patients don’t need to worry about this complication happening 2-3 weeks later when they are at home – we will know about this during the initial hospital stay if it is going to happen at all.

  The initial signs of leakage are similar to infection. The saliva and other liquids that are supposed to be inside the intestine leak out into the abdomen and create inflammation, which is technically called “peritonitis.” The patient has an increased heart rate, usually fever, usually pain, and often shortness of breath.

  If a drain tube is present near the gastric pouch, then the appearance of fluid in that tube may change away from normal bloody fluid toward a whitish foamy fluid (like saliva).

  If there is concern about a leak, then the best test (unless surgery is immediately necessary) is a CT scan with a small amount of contrast (X-ray dye) swallowed before the CT. Although our patients have a leak rate that is much less than 1%, we order a CT if there is any suggestion of a problem so that there will be very little delay in diagnosis.

  If a leak happens at the gastric pouch, surgery may be necessary but it is often not the first option. On many occasions, a leak is better handled by using a skinny plastic tube drain to bring the leak fluid out of the body, and then the surgeon and patient wait to allow the leak to heal.

• What happens to the lower part of the stomach that is bypassed?

  We leave the lower stomach in place with intact blood supply, so that it remains healthy and unchanged. the blood vessels also tether the lower stomach in place so that it does not twist around or move out of place. The lower stomach still contributes to the function of the intestines even though it does not receive or process food. The lower stomach makes Intrinsic Factor, which is necessary to absorb Vitamin B12, and contributes to hormone balance and motility of the gut in ways that are not entirely delineated.

• After Gastric Bypass, where does digestion occur? What important functions do people lose when the lower stomach is bypassed?

  In normal anatomy with no surgery and in Gastric Bypass patients, absorption of nutrients takes place in the small intestine. In the standard version of the Gastric Bypass, which is performed in our practice, the mixing of digestive juices (such as bile and pancreatic juice) with nutrients and the absorption of those nutrients is essentially normal. The functions lost when the lower stomach is bypassed are capacity and acid production functions. These functions help a person digest large bulky meals. This ability was necessary in evolutionary times when meals were not regularly available, but it represents excess capacity in today’s society, where food is constantly available and easily digested. The bypassed stomach and small intestine do play important roles in the absorption of Iron, Calcium and Vitamin B12, thus we require patients to take supplements, and we follow blood levels of these and other nutrients.

• What happens to all the staples inside my abdomen after surgery? Is it okay in the future to have an MRI test? Will I set off metal detectors in airports?

  The first thing to understand about the staples used on the stomach and the intestines is that they are very tiny in comparison to the staples you’re used to seeing at your office. Each staple is a tiny piece of metal that is so small, it’s hard to see other than as a tiny bright spot on an x-ray. The staples are made of either titanium or stainless steel and they are totally inert in the body, meaning that people are not allergic to staples and they do not cause any problems in the long run. The staple materials are also non-magnetic, so they are not affected by MRI. Also, the staples will not set off airport metal detectors.

Hospital Stay, Usual Course and Care

• What is done to minimize the risk of Deep Venous Thrombosis and Pulmonary Embolus (DVT/PE)?

  Because a DVT begins to form on the operating table, we begin therapy before a patient enters the operating room. We treat patients both with sequential leg compression stockings and a blood thinner. Both of these therapies continue throughout hospitalization. The third major preventive measure involves getting the patient mobilized and out of bed as soon as possible after the operation, to restore normal blood flow in the legs.

   

• How is pain managed?

  Laparoscopic surgery means that pain is kept to a minimum from the beginning.

  Depending on which operation is done, patients receive a combination of IV pain meds and meds by mouth. We routinely use Morphine in a patient controlled analgesia (PCA) pump. We usually add a 24-hour course of Ketorolac, with works synergistically with IV medicines such as morphine. Pain meds by mouth, usually Lortab, are offered beginning on post-op day 1, and the patient uses these to transition off the PCA. A prescription for oral pain medicine is provided at the time of discharge.

  In addition to the standard combination therapy above, for many operations we implant a tiny plastic tube into the tissues near the source of pain. This tiny plastic tube carries numbing medicine (such as marcaine) directly to the source of the pain for 2-5 days after surgery. The device used is called the On-Q Pain Buster.

• I am very big. Will I have trouble with hospital gowns, hospital beds, etc.?

  This is a common issue for patients in our practice. The hospitals where we conduct all of our bariatric surgical procedures are prepared for patients who suffer from serious obesity. These hospitals have the ability to accommodate extra large patients in terms of wheelchairs, hospital beds and even most equipment. The gowns fit all sizes and, of course, you are welcome to bring your own comfortable clothing.

  The only exception to this reassurance is that no manufacturer makes a CT scanner that has a weight capacity greater than 450 pounds. For patients over this weight, the inability to perform a CT scan after surgery makes it more difficult to find or to manage problems after surgery if they arise. We are inclined to operate more readily on patients of extra large size if we have a concern and if a CT cannot be done.

• What should I bring with me to the hospital?

  Basic toiletries including a comb, toothbrush, etc., and clothing are provided by the hospital, but most people prefer to bring their own. Choose clothes for the hospital that are easy to put on and take off, and that can stand staining by blood or other body fluids. Bring slippers so you can begin walking as soon as possible after surgery. Other items you may want:

  • A small fan (room temperature control can be variable)
  • A water spray bottle – can help with the feeling of cotton mouth
  • Reading material
  • Portable music, laptop, etc.
  • Notepad – keep track of questions you may have and information you receive
  • Moisturizing skin lotion

Post-Operative Recovery & Restrictions

• When will I get some mobility back after surgery? What is the right amount and type of exercise after Gastric Bypass?

  Many patients are hesitant about exercise after surgery. In reality, exercise is an absolutely essential component of success after this surgery, and it begins on the afternoon of surgery when the patient must get out of bed and walk around following surgery. The goal is for the patient to walk further the day after surgery, and progressively further every day thereafter, including the first few weeks at home. About two weeks after surgery, the patient is released from medical restrictions and encouraged to begin exercising – limited only by the level of incisional discomfort. Exercise from this time on will not cause any medical damage, even with aggressive exercise or heavy physical contact (there may still be the sensation of soreness).

  The type of exercise may be dictated by the patient’s overall condition. Some patients who have severe knee problems can’t even walk well, but almost all can 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. Sexual activity is okay from two weeks onward, again according to comfort level.

• Can I get pregnant after bariatric surgery?

  Women can safely carry a baby after bariatric surgery, but we strongly recommend that you wait until at least one year after the surgery. At approximately one year, your body will be fairly stable from a weight and nutrition standpoint and should be able to carry a normally nourished fetus. You should be in contact with your surgeon as you plan for pregnancy. It is especially important for a woman to take her vitamin supplements regularly PRIOR TO becoming pregnant. It is recommended that a reliable method of birth control be utilized to avoid carrying a baby within the first year following surgery. If you have undergone placement of an Adjustable Gastric Band, you may still be in a brisk weight loss mode at one year. In which case, it is proper to wait longer to get pregnant until you reach a stable weight.

• Can I eat fruit after surgery or will it cause dumping syndrome?

  Fruit does contain sugar which interferes with weight loss even though the sugar is natural. This sugar may or may not cause dumping syndrome for gastric bypass patients. Fruit intake should be kept to a minimum after any bariatric surgery. Fruit should be thought of as a treat, and the nutrients one might receive from fruit are replaced by routine vitamins.

• What will happen if I overeat?

  After surgery, there is a delay of 10-15 minutes from the time your stomach pouch gets comfortably filled to the time that your brain realizes you are satisfied. When you overeat, your pouch will be overfilled and you will experience nausea. Realistically, every patient will experience an overfilled feeling at least once or twice, and it will not damage your stomach if it does not become a pattern. The goal is to learn from the experience – remember how much and what kind of food you consumed. Next time, use your memory and your eyes to know when to stop eating, before you feel full.

• What can I do about my hair loss?

  You may notice visible hair loss or hair in your brush or comb. Hair loss is a result of rapid weight loss due to a very low caloric intake during the first six months, when hair is not a priority. As your stomach pouch matures, you will be able to eat more food. As a result, your body will begin to produce new hair. The best prevention is to maintain adequate nutrition by eating your protein at each meal and taking your vitamins and minerals as directed.

Long-Term Outcomes & Instructions

• How much protein should eat after bariatric surgery?

  We don’t set a specific target for protein intake on any particular day. We are aware that many bariatric surgery programs recommend liquid protein supplements for their patients during the recovery phase after surgery. We disagree with such recommendations for the following reasons:

  Specific daily protein intake is not necessary.

  The body is able to handle short term starvation without difficulty. Think about it. Our bodies evolved in the context of irregular food supply. Our ancestors, not so long ago, frequently went for days or weeks with no food at all. Our bodies carry stores of protein and other nutrients to live on, in addition to the fat stores that we aim to burn. Primarily, it is necessary to drink steadily to remain hydrated.

  Scheduled eating of any kind works against the idea of relearning eating habits to follow the hunger cues from the little stomach.

  In the long run, most bariatric surgery patients struggle with too much eating and too much interest in food. Patients also have a continuing battle against the lifetime habits of eating on schedule, or for social reasons, or to satisfy stress, etc. We want patients to use the surgery recovery phase as an opportunity to relearn eating habits that take signals only from the little stomach and allow the patient to comfortably minimize eating for life.

  Protein drinks include calories.

  More calories lead to less weight loss.

  Adequate protein intake will come naturally with time.

  For those who have undergone bariatric surgery, regular hunger will return in due time after surgery. Patients are advised to eat only if they are hungry; and at that time they are advised to eat foods that are protein focused. In most cases, we recommend that patients eat regular food, and not specially processed protein drinks or baby food.

  We have not observed that protein drinks result in any significant preservation of lean body mass, or prevent hair loss, or any other benefits.

  Some health professionals are concerned that patients with decreased protein intake will lose lean body mass. This is true. We find that all bariatric surgery patients lose some lean body mass during their rapid weight loss phase, but also that patients regain their lean body mass as their weight stabilizes in the long run after surgery. We have been following the system of recommending against artificial protein supplements for almost 10 years and have not observed any ill effects for patients. We are currently in discussions that may permit us to study this question in a scientific way.

   

• What if I’m not hungry after surgery?

  It’s normal not to have an appetite for the first month or two after gastric bypass. If you can take in liquids reasonably well, we can have a good level of confidence that your eating will come along in time.

• How much weight should I expect to lose?

  See Results of Surgery.

• How can I achieve the best weight loss?

  The best results are seen in patients who take the bariatric surgery as an opportunity to make sweeping changes in their life habits. Specifically, the most successful patients will exercise regularly (at least 20 minutues per day, at least 5 days each week) and comply with the diet which entails: eating three meals per day, eating healthy solid food, taking 20 to 30 minutes per meal, not mixing fluid with food, and minimizing and/or eliminating carbohydrates.

• 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 lose 20 to 40 pounds in the first month, or maybe when they’ve lost more than 100 pounds and they’re still losing. Two things happen to allow weight to stabilize. First, a patient’s ongoing metabolic needs (calories burned) decrease as the body sheds the load imposed by the excess pounds. Second, there is a natural progressive increase in calorie and nutrient intake over the months following bariatric surgery. Basically, the stomach pouch and the attached small intestine learn to work together better, along with slight expansion in pouch size over a period of months. Ultimately, in the absence of a surgical complication, patients are VERY unlikely to lose down to a point of malnutrition.

• How big will my stomach pouch really be in the long run?

  The stomach pouch is created at one ounce or less in size, and in the first few months it is rather stiff due to natural surgical inflammation. From about six to 12 months after surgery, the stomach pouch expands a bit and becomes more pliable as the inflammation subsides. Most patients end up with a meal capacity of three to seven ounces.

   

• What can I do to prevent lots of excess hanging skin? Will exercise help?

  Unfortunately, most people who have gotten heavy enough to need bariatric surgery have stretched their skin beyond a point from which it can “snap back.” Exercise is good in so many other ways that we definitely recommend a regular exercise program, but the unfortunate reality is that most patients are left with large flaps of loose skin.

   

• Will I be miserably hungry after gastric bypass since I’m not eating much?

  Most patients say “no.” In fact, for the first four to six 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. Usually, this is caused by the types of food you are consuming, especially carbohydrates like rice, pasta, or potatoes. Also avoid drinking liquid with food – this just washes food out of the pouch. If hunger persists, there may be a psychological problem with the lack of food in your life and this issue may require further investigation and treatment.

• Will I have to change my medications?

  Your surgeon and the nursing staff will give you specific instructions on how to handle your medications before surgery and following surgery.

  Most diabetic medications can be reduced or eliminated very soon after surgery. Medications for blood pressure can often be reduced, though it usually takes several months for the blood pressure to go down

  Many blood pressure, diabetes or other medications for the treatment of medical problems associated with a patient’s previous obesity may be stopped at some point after gastric bypass. Medications that must be continued can be swallowed and absorbed and work as effectively as before gastric bypass. 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 (many over-the-counter pain medicines like ibuprofen, naproxen, and others). Most diuretic medicines make the kidneys lose potassium. Most gastric bypass patients experience dramatically reduced intake and are not able to take in enough to compensate for the potassium loss caused by diuretic medicines. If a person’s potassium gets too low, it can lead to fatal heart rhythm problems. The issue with NSAIDs is that they can create ulcers in the small pouch or the attached bowel.

• Does it hurt when the skin staples are removed?

  New Dimensions patients rarely have skin staples. If surgery is accomplished laparoscopically, then the incisions will be closed with sutures under the skin, so there are no staples to remove. If you have staples, removal involves only minor discomfort. The level of pain is very similar to tweezing your eyebrows.