While the below are general answers to common questions, based on standard guidelines, always talk to your doctor about what they recommend for your individual treatment. ### Can weight loss surgery help me live longer? Yes, weight loss surgery has been shown in recent publications to help people live longer. There is good evidence from scientific research that weight loss surgery may significantly prolong your life if you - Have type 2 diabetes (or other serious obesity-related health conditions) - Are at least 100 lbs. over ideal body weight - Can follow lifestyle changes (daily exercise and low-fat diet) ### How effective is surgery? The actual weight a patient will lose after the procedure is dependent on several factors. These include: - Patient's age - Weight before surgery - Overall condition of patient's health - Surgical procedure - Ability to exercise - Commitment to maintaining dietary guidelines and other follow-up care - Motivation of patient and cooperation of their family, friends and associates In general, weight loss surgery success is defined as achieving loss of 50 percent or more of excess body weight and maintaining that level for at least five years. Clinical studies show that, following gastric bypass surgery, most patients lose weight rapidly and continue to do so until 18 to 24 months after the procedure. - After gastric bypass, patients may lose 30 to 50 percent of their excess weight in the first six months and 68 percent of excess weight as early as 12 months after surgery. - Long- term studies show that patients can maintain a 50-60 percent loss of excess weight 10-14 years after surgery. - Patients with higher initial BMIs, greater than 60, tend to lose more total weight. Patients with lower initial BMIs, 40 to 45, will lose a greater percentage of their excess weight and will more likely come closer to their ideal body weight. - Patients with type 2 diabetes tend to show less overall excess weight loss than patients without type 2 diabetes, but in these patients, improvement and resolution of diabetes is our primary concern. ### Can weight loss surgery help other physical conditions? According to current research, weight loss surgery can improve or cure some related health conditions. ConditionPercentage of People Who Have Condition Before SurgeryPercentage of People with the Condition in Remission Two Years After SurgeryDiabetes or insulin resistance34 percent85 percentHigh blood pressure26 percent66 percentHigh triglycerides40 percent85 percentSleep apnea22 percent in males, one percent in females 40 percent### What is the youngest age for which weight loss surgery is recommended? Generally accepted guidelines from the American Society for Bariatric Surgery and the National Institutes of Health indicate surgery only for those 18 years of age and older. While surgery has been performed on patients 16 and younger, there is a real concern that young patients may not have finished growing or that they don’t have the emotional maturity to make this type of decision. It is important that young weight loss surgery patients have a full understanding of the lifelong commitment to the eating and lifestyle changes necessary for success. ### What is the oldest patient for whom weight loss surgery is recommended? Patients over 65 require very strong reasons for surgery and must also meet strict Medicare criteria. The risk of surgery in this age group is increased, and the benefits, in terms of reduced risk of death, are lower. ## Preparing for Surgery ### What tests do I need before surgery? Certain basic tests are done prior to surgery: a complete blood count (CBC), a chemistry panel, and other chemistry tests to make sure a patient doesn’t have a medically treatable cause for their obesity. All patients but the very young get a chest X-ray and an electrocardiogram. Other tests, such as an echocardiogram, sleep studies, GI evaluation, or cardiology evaluation may be requested when indicated. An accurate assessment of your health is needed before surgery. The best way to avoid complications is to never have them in the first place. It is important to know if your thyroid function is adequate since hypothyroidism can lead to obesity. If you are diabetic, special steps must be taken to control your blood sugar. Because surgery can increase cardiac stress, your heart will be thoroughly evaluated. These tests will determine if you have liver malfunction, breathing difficulties, excess fluid in the tissues, abnormalities of the salts or minerals in body fluids, or abnormal blood fat levels. ### Why do I have to have a GI evaluation? Patients who have significant gastrointestinal symptoms such as upper abdominal pain, heartburn, belching sour fluid, etc., may have underlying problems such as a hiatal hernia, gastroesophageal reflux or peptic ulcer. For example, many patients have symptoms of reflux. Up to 15 percent of these patients may show early changes in the lining of the esophagus, which could predispose them to cancer of the esophagus. It is important to identify these changes so a suitable surveillance or treatment program can be planned. ### Why do I have to have a sleep study? The sleep study detects a tendency for abnormal stopping of breathing, usually associated with airway blockage when the muscles relax during sleep. This condition is associated with a high mortality rate. After surgery, you will be sedated and will receive narcotics for pain, which further depress normal breathing and reflexes. Airway blockage becomes more dangerous at this time. It is important to have a clear picture of what to expect and how to handle it. ### Why do I have to have a psychiatric evaluation? Prior to weight loss surgery, underlying psychiatric disorders must be ruled out. Most psychiatrists will also evaluate your understanding and knowledge of the risks and complications associated with weight loss surgery and your ability to follow the basic recovery plan. ### 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 surgery. On the other hand, if they are problems that are related to the patient's weight, they also increase the need for surgery. Severe medical problems may not dissuade the surgeon from recommending gastric bypass surgery if it is otherwise appropriate, but those conditions will make a patient's risk higher than average. ### What can I do before the appointment to speed up the process of getting ready for surgery? New evaluation appointments are usually booked in a matter of days. Once a patient is seen, if the surgeon and patient agree it is appropriate, the patient is enrolled in our weight loss surgery program. You can help speed up the process by selecting a primary care physician if you don't already have one, and establishing a relationship with him or her. Work with your physician to ensure that your routine health maintenance testing is current. You should also - Make a list of all the diets you have tried (a diet history) and bring it to your doctor. - Bring any relevant medical data 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 dose and schedule. - Stop smoking for at least two months before surgery. Surgical patients who use tobacco products are not candidates. Please note that resuming smoking after surgery is very dangerous and predisposes gastric bypass patients to ulcer formations that can be very difficult to treat. ### How should I prepare myself mentally for surgery? Weight loss surgery is like other major surgeries. The best preparation is to understand the risks and potential benefits and to closely follow your doctor’s instructions. - Understand the surgical process and what to expect afterwards. - Talk to people who have had weight loss surgery (click here for information on support groups). - Write a letter to yourself and your surgeon explaining your reasons for having the surgery and outlining your plans to maintain your weight loss after surgery. - Start a journal about your experience. Record how you feel now, the obstacles you encounter, and the things you hope to be able to do after surgery. - Get a letter of support from your family. It helps to know that you have people behind you, waiting to help. ## Diet ### How long will I be off of solid foods after surgery? You will be given a handout on the diet stages by the dietitian. You will be on stage 2 diet (high-protein liquid diet) for the first two weeks. Stage 3 (high-protein soft foods) follows and until the sixth week after surgery. At that point, you will be advanced to stage 4 which includes a wide variety of healthy foods. ### What are the best choices of protein? The best choices of protein after surgery are eggs, low-fat cheese, low-fat cottage cheese, tofu, fish, other seafood, chicken (dark meat), and turkey (dark meat). ### Why do I need to drink so much water? When you are losing weight, there are many waste products to eliminate, mostly in the urine. Some of these substances tend to form crystals, which can cause kidney stones. A high water intake protects you and helps your body to rid itself of waste products efficiently, promoting better weight loss. Water also fills your stomach and helps to prolong and intensify your sense of satisfaction with food. If you feel a desire to eat between meals, it may be because you did not drink enough water in the hour before. ### What is dumping syndrome? Eating sugars or other foods containing many small particles when you have an empty stomach can cause dumping syndrome in patients who have had a gastric bypass or BPD where the stomach pylorus is removed. Your body handles these small particles by diluting them with water, which reduces blood volume and causes a shock-like state. Sugar may also induce insulin shock due to the altered physiology of your intestinal tract. The result is a very unpleasant feeling: you break out in a cold clammy sweat, turn pale, feel "butterflies" in your stomach, and have a pounding pulse. Cramps and diarrhea may follow. This state can last for 30-60 minutes and can be quite uncomfortable - you may have to lie down until it goes away. This syndrome can be avoided by not eating the foods that cause it, especially on an empty stomach. A small amount of sweets, such as fruit, can sometimes be well tolerated at the end of a meal. ### Can I have milk products/dairy? Milk contains lactose (milk sugar), which some people don't digest well. This sugar passes through undigested until bacteria in the lower bowel act on it, producing irritating byproducts as well as gas. Depending on individual tolerance, some people find even the smallest amount of milk can cause cramps, gas and diarrhea. ### Why can't I eat red meat after surgery? You can, but you will need to be very careful, and we recommend that you avoid it for the first several months. Red meats contain a high level of meat fibers (gristle) which hold the piece of meat together, preventing you from separating it into small parts when you chew. The gristle can plug the outlet of your stomach pouch and prevent anything from passing through, a condition that is very uncomfortable. ### Why can't I snack between meals? Snacking, nibbling or grazing on foods, usually high-calorie and high-fat foods, can add hundreds of calories a day to your intake, defeating the restrictive effect of your operation. Snacking will slow down your weight loss and can lead to regain of weight. ### How can I be sure I am eating enough protein? 60 grams a day is generally enough. Check with your surgeon to determine the right amount for your type of surgery. ### Do I need to eat less salt? No, your salt intake will be unchanged unless otherwise instructed by your primary care physician. ### Will I be able to eat "spicy" foods or seasoned foods? Most patients are able to enjoy spices after the first six months following surgery. ### Will I be allowed to drink alcohol? You will find that even small amounts of alcohol will affect you quickly. It is suggested that you don't drink any alcohol for the first three to six months after surgery. Then, with your physician's approval, you may have a glass of wine or a small cocktail. ### What vitamins will I need to take after surgery? We recommend a daily multivitamin and calcium (calcium citrate) for the rest of your life. ### Will I get a copy of suggested eating patterns and food choices after surgery? Yes, we provide patients with materials that clearly outline their expectations regarding diet and compliance to guidelines for the best outcome based on your surgical procedure. After surgery, health and weight loss are highly dependent on patient compliance with these guidelines. You must do your part by restricting high-calorie foods, by avoiding sugar, snacks and fats, and by strictly following the guidelines set by your surgeon. ## Surgery ### What are the risks of surgery? Surgery should not be considered until you and your doctor have evaluated all other options. As with all surgeries, there are risks associated with this procedure. If complications occur during the operation, your doctor may choose to perform open surgery. Your doctor must determine if you are an appropriate surgical candidate. As with any surgery, there are operative and long-term complications and risks associated with weight loss surgical procedures that should be discussed with your doctor. Possible risks include, but are not limited to: - Bleeding - Complications due to anesthesia and medications - Deep vein thrombosis - Infections - Leaks from staple line breakdown - Marginal ulcers - Pulmonary problems - Stenosis - Internal hernia - Band slip/erosion - Failure to lose weight If surgery is performed laparoscopically and complications occur during the operation, your doctor may choose to perform open surgery. At Boston Medical Center all surgeries are scheduled as laparoscopic and fewer than one percent need to be converted to an open procedure. ### Does laparoscopic surgery decrease the risk? No. Laparoscopic operations carry the same risk as the procedure performed as an open operation. The benefits of laparoscopy are typically less discomfort, shorter hospital stay, earlier return to work and reduced scarring. ### Will I have a lot of pain? Every attempt is made to control pain after surgery to make it possible for you to move about quickly and become active. This helps avoid problems and speeds recovery. Often several drugs are used together to help manage your post-surgery pain. While you are still in the hospital, you may have a patient-controlled analgesia (PCA), which allows you to give yourself a dose of pain medicine on demand. Various methods of pain control, depending on your type of surgical procedure, are available. Ask your surgeon about other pain management options. ### Will the doctor leave a drain in after surgery? For most surgeries, you will only have an IV placed for fluids. It is not typical for drains or catheters to be placed after bariatric surgery. ### What can I expect when I wake up in the recovery room? After surgery, you will be taken to the recovery room. You will spend a few hours there as you wake up from the general anesthesia. You will then be moved to your room where your family can see you. During the first night you will be connected to a continuous oxygen saturation monitor. Obesity, general anesthesia, and preexisting lung conditions (asthma, sleep apnea) make it likely that you will need oxygen the first night to keep your saturation above 90%. The night of surgery you will be asked to walk. This is very important to help prevent blood clots in your legs from forming. This condition is called a deep venous thrombosis or DVT. Wearing the lower leg compression devices while in bed also prevents DVTs. It is normal to feel uncomfortable during the first few days after surgery, but each day you will feel stronger and more active. You will be given pain medication to ease your discomfort. Your nurse will teach you how to use your PCA (patient controlled analgesia) pump. This allows you to give yourself pain medication through your IV as needed. There is no danger of overdosing, and it allows you to control the pain yourself. Your mouth might feel dry the first 24 hours after surgery. This is usually due to the medication administered during anesthesia. You will be allowed to swab your mouth, but not to drink anything until the first day after surgery. While you are in the hospital, your surgeon, surgical residents, and nurses will provide your medical care. You might be assigned nursing or medical students as well. Your surgeon will visit you daily, so have questions ready. You will be visited by a dietitian while in the hospital. They will provide a written quiz, which you will be asked to complete. It is a good idea to involve family members in learning about the diet after surgery. ### How long will I have to stay in the hospital? As long as it takes to be able to take care of yourself. Although it can vary, the hospital stay for all procedures (including the day of surgery) is typically two to three days. ## After Surgery ### What do I need to do to be successful after weight loss surgery? The basic rules are simple: - Immediately after surgery, your doctor will provide you with special dietary guidelines. You will need to follow these guidelines closely. Many surgeons begin patients with liquid diets, moving to semi-solid foods and later, sometimes weeks or months later, solid foods can be tolerated without risk to the surgical procedure performed. Allowing time for proper healing of your new stomach pouch is necessary and important. - When you're able to eat solids, eat two or three meals per day, no more. Protein in the form of lean meats (chicken, turkey, fish) and other low-fat sources should be eaten first. These should comprise at least half the volume of the meal eaten. Foods should be cooked without fat and seasoned to taste. Avoid sauces, gravies, butter, margarine, mayonnaise and junk foods. - Never eat between meals. Do not drink flavored beverages, even diet soda, between meals. - Avoid alcohol. Drink two to three quarts or more of water each day. Water must be consumed slowly, one to two mouthfuls at a time. - Exercise aerobically (cardio) every day for at least 20 minutes (one-mile brisk walk, bike riding, stair climbing, etc.). Weight/resistance exercise can be added three to four days per week, as instructed by your doctor. ### When can I return to normal activities? Your ability to resume pre-surgery levels of activity will vary according to your physical condition, the nature of the activity, and the type of weight loss surgery you had. Most patients return to full pre-surgery levels of activity within six weeks of their procedure. Patients who have had a minimally invasive laparoscopic procedure may be able to return to these activities within a few weeks. #### Walking Almost immediately after surgery doctors will require you to get up and move about. Patients are asked to walk or stand at the bedside on the night of surgery, take several walks the next day and thereafter. After leaving the hospital, you may be able to care for all your personal needs, but will need help with shopping, lifting, and with transportation. #### Driving For your own safety, you should not drive until you have stopped taking narcotic medications and can move quickly and alertly to stop your car, especially in an emergency. Usually this takes seven to 14 days after surgery. #### Sexual Activity Patients can return to normal sexual intimacy when wound healing and discomfort permit. Many patients experience a drop in desire for about six weeks. ### What if I'm not hungry after surgery? It's normal not to have an appetite for the first few months after weight loss surgery. If you are able to consume liquids reasonably well, there is a level of confidence that your appetite will increase with time. ### Why is exercise important? When you have a weight loss surgery procedure, you lose weight because the amount of food energy (calories) you are able to eat is much less than your body needs to operate. It has to make up the difference by burning reserves or unused tissues. Your body will tend to burn any unused muscle before it begins to burn the fat it has saved up. If you do not exercise daily, your body will consume your unused muscle, and you will lose muscle mass and strength. Daily aerobic exercise (cardio) for 20 minutes will communicate to your body that you want to use your muscles and force it to burn the fat instead. The goal is to walk further on the next day, and progressively further every day after that, including the first few weeks at home. Patients are often released from medical restrictions and encouraged to begin exercising about two weeks after surgery, limited only by the level of wound discomfort. The type of exercise is dictated by the patient's overall condition. Some patients who have severe knee problems can't walk well, but may be able to swim or bicycle. Many patients begin with low stress forms of exercise and are encouraged to progress to more vigorous activity when they are able. ### Will I be very hungry after weight loss surgery since I'm not eating much? 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 bad type of hunger. If you are really hungry, this is usually caused by the types of food you may be consuming, especially starches (rice, pasta, potatoes). Be absolutely sure not to drink liquid with food since liquid washes food out of the pouch. ### Can I get pregnant after weight loss surgery? If you are a woman you will have an increased chance of becoming pregnant. It is difficult to maintain a healthy pregnancy during the rapid weight loss phase (first year after surgery for bypass patients). If you are planning to have a gastric bypass, we recommend that you postpone pregnancy plans for at least one year after surgery or until your weight is stable. ### What if I have had a previous weight loss surgical procedure and I'm now having problems? Contact your original surgeon - he or she is most familiar with your medical history and can make recommendations based on knowledge of your surgical procedure and body. ### What happens to the lower part of the stomach that is bypassed? In some surgical procedures, the stomach is left in place with intact blood supply. In some cases it may shrink a bit and its lining (the mucosa) may atrophy, but for the most part it remains unchanged. The lower stomach still contributes to the function of the intestines even though it does not receive or process food - it makes intrinsic factor, necessary to absorb Vitamin B12 and contributes to hormone balance and motility of the intestines in ways that are not entirely known. In the BPD procedures, some portion of the stomach is completely removed. In the Roux-en-Y gastric bypass, the stomach pouch is created at one ounce or less in size (15-20cc). In the first few months it is rather stiff due to natural surgical inflammation. About six to 12 months after surgery, the stomach pouch can expand and will become more expandable as swelling subsides. Many patients end up with a meal capacity of three to seven ounces. ### Will I have any trouble taking medications? During the first few months after surgery we recommend patients crush their medications or take them in a liquid form. Medications that cannot be crushed are long acting medications usually designated by "XR" or "CR" after the name of the medication. These will be converted to the shorter released medication which can be crushed. Before surgery, please check with your PCP and mental health provider, and/or your pharmacist, to see which medications can and cannot be crushed. ### Will I have to change my medications? Your doctor will determine whether medications for blood pressure, diabetes, etc., can be stopped when the conditions for which they are taken improve or resolve after weight loss surgery. For medications that need to be continued, the vast majority can be swallowed, absorbed and work the same as before weight loss surgery. Usually no change in dose is required. Two classes of medications that should be used only in consultation with your surgeon are diuretics (fluid pills) and NSAIDs (most over-the-counter pain medicines). NSAIDs (ibuprofen, naproxen, etc.) may create ulcers in the small pouch or the attached bowel. Most diuretic medicines make the kidneys lose potassium. With the dramatically reduced intake experienced by most weight loss surgery patients, they are not able to take in enough potassium from food to compensate. When potassium levels get too low, it can lead to fatal heart problems. ### How can I know that I won't just keep losing weight until I waste away to nothing? Patients may begin to wonder about this early after the surgery when they are losing 20-40 pounds per month, or maybe when they've lost more than 100 pounds and they're still losing weight. Two things happen to allow weight to stabilize. First, a patient's ongoing metabolic needs (calories burned) decrease as the body sheds excess pounds. Second, there is a natural progressive increase in calorie and nutrient intake over the months following weight loss surgery. The stomach pouch and attached small intestine learn to work together better, and there is some expansion in pouch size over a period of months. The bottom line is that, in the absence of a surgical complication, patients are very unlikely to lose weight to the point of malnutrition. ### What can I do to prevent lots of excess hanging skin? Many people heavy enough to meet the surgical criteria for weight loss surgery have stretched their skin beyond the point from which it can "snap back." Some patients will choose to have plastic surgery to remove loose or excess skin after they have lost their excess weight. Insurance generally does not pay for this type of surgery (often seen as elective surgery). However, some do pay for certain types of surgery to remove excess skin when complications arise from these excess skin folds, such as recurrent yeast infections that are not well treated with medications. Ask your surgeon about your need for a skin removal procedure. ### What will the staples do inside my abdomen? Is it okay in the future to have an MRI test? Will I set off metal detectors in airports? The staples used on the stomach and the intestines are very tiny in comparison to the staples you will have in your skin or staples you use in the office. Each staple is a tiny piece of stainless steel or titanium so small it is hard to see other than as a tiny bright spot. Because the metals used (titanium or stainless steel) are inert in the body, most people are not allergic to staples and they usually do not cause any problems in the long run. The staple materials are also non-magnetic, which means that they will not be affected by MRI. The staples will not set off airport metal detectors. ### Will I lose hair after surgery? How can I prevent it? Many patients experience some hair loss or thinning after surgery. This usually occurs between the third and the eighth month after surgery. Consistent intake of protein at mealtime is the most important prevention method. Also recommended are a daily zinc supplement and a good daily volume of fluid intake. An oral supplement called biotin has also been shown to help some patients. Most patients experience natural hair regrowth after the initial period of loss. ### How often will I return for follow-up visits? Although the short-term effects of weight loss surgery are well understood, there are still questions to be answered about the long-term effects on nutrition and body systems. You will receive a written schedule listing your appointments with your surgeon and dietitian. During the first year, your appointments will be fairly frequent. After the first year you will be seen at 18 months and then two years. After that you will be seen yearly. It is critical to continue to see your surgeon on a yearly basis to check for nutritional deficiencies and follow your weight.