What is Bariatric or weight
( Treatment for Obesity )
Article page |
Health page |
Fruits and Vegetables
Diseases and Remedies |
Bariatric sugery is now accepted as the best and
most effective treatment for obesity. About 65 percent of all bariatric surgery
patients are able to lose their excess weight and keep it off for more than five
More than 30 co-morbid conditions are associated with morbid obesity, the most
serious of which are hypertension, diabetes, heart disease, stroke, obstructive
sleep apnea, and degenerative joint disease. Two recent landmark studies in the
New England Journal of Medicine demonstrate significant evidence that bariatric
surgery reduces long-term mortality associated with obesity.1, 2
Bariatric surgery is not only successful for weight loss, but also for
preventing, improving or resolving type 2 diabetes. Recent studies demonstrate
that bariatric operations, particularly gastric bypass, can achieve a resolution
rate as high as 83 percent, rendering these patients normoglycemic.3,4 Other
studies have shown that patients with a BMI as low as 30 may have successful
resolution of diabetes with gastric bypass surgery or gastric banding.5
The actual weight a patient will lose after the procedure is dependent on
several factors. These include:
Weight before surgery
Overall condition of patient's health
Ability to exercise
Commitment to maintaining dietary guidelines and other follow-up care
Motivation of patient and cooperation of their family, friends and associates
Preparation for Surgery
What are the routine tests before surgery?
Certain basic tests are done prior to surgery: a complete blood count (CBC),
urinalysis and a chemistry panel, which gives a readout of about 20 blood
chemistry values. Other tests, such as pulmonary function testing,
echocardiogram, sleep studies, GI evaluation, cardiology evaluation or
psychiatric evaluation, may be requested when indicated.
What is the purpose of all these tests?
An accurate assessment of your health is needed before surgery. The best way to
avoid complications is to never have them in the first place. It's important to
know if your thyroid function is adequate since hypothyroidism can lead to
sudden death post-operatively. If you are diabetic, special steps must be taken
to control your blood sugar. Because surgery increases cardiac stress, your
heart will be thoroughly evaluated. These tests will determine if you have liver
malfunction, breathing difficulties, excess fluid in the tissues, abnormalities
of the salts or minerals in body fluids, or abnormal blood fat levels.
Why do I have to have a GI evaluation?
Patients who have significant gastrointestinal symptoms such as upper abdominal
pain, heartburn, belching sour fluid, etc., may have underlying problems such as
a hiatal hernia, gastroesophageal reflux or peptic ulcer. For example, many
patients have symptoms of reflux. Up to 15 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?
The most common reason a psychiatric evaluation is ordered is that your
insurance company may require it. Most psychiatrists will 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
Select a primary care physician if you don't already have one, and establish a
relationship with him or her. Work with your physician to ensure that your
routine health maintenance testing is current. For example, women may have a pap
smear, and if over 40 years of age, a breast exam. And for men, this may include
a prostate specific antigen test (PSA).
Make a list of all the diets you have tried (a diet history) and bring it to
Bring any pertinent 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. Surgical patients who use tobacco products are at a higher
Why does it take so long to get insurance approval?
After your final consultation is completed, it usually takes your doctor one to
two days to send a letter to your insurance carrier to start the approval
process. The time it takes to get an answer can vary from about three to four
weeks or longer if you are not persistent in your follow-up. Most treatment
centers have insurance analysts who will follow up regularly on approval
requests. It may be helpful for you to call the claims service of your insurance
company about a week after your letter is submitted and ask about the status of
How can they deny insurance payment for a life-threatening disease?
Payment may be denied because there may be a specific exclusion in your policy
for obesity surgery or "treatment of obesity." Such an exclusion can often be
appealed when the surgical treatment is recommended by your surgeon or referring
physician as the best therapy to relieve life-threatening obesity-related health
conditions, which usually are covered.
Insurance payment may also be denied for lack of "medical necessity." A therapy
is deemed to be medically necessary when it is needed to treat a serious or
life-threatening condition. In the case of morbid obesity, alternative
treatments — such as dieting, exercise, behavior modification, and some
medications — are considered to be available. Medical necessity denials usually
hinge on the insurance company's request for some form of documentation, such as
one to five years of physician-supervised dieting or a psychiatric evaluation,
illustrating that you have tried unsuccessfully to lose weight by other methods.
What can I do to help the process?
Gather all the information (diet records, medical records, medical tests) your
insurance company may require. This reduces the likelihood of a denial for
failure to provide "necessary" information. Letters from your personal physician
and consultants attesting to the "medical necessity" of treatment are
particularly valuable. When several physicians report the same findings, it may
confirm a medical necessity for surgery.
When the letter is submitted, call your carrier regularly to ask about the
status of your request. Your employer or human relations/personnel office may
also be able to help you work through unreasonable delays.
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, a patient controlled analgesia (PCA),
which allows you to give yourself a dose of pain medicine on demand, may be used
by your physician. Various methods of pain control, depending on your type of
surgical procedure, are available. Ask your surgeon about other pain management
How long do I have to stay in the hospital?
This varies by procedure. The laparoscopic adjustable gastric band is done on an
outpatient basis with a possible overnight stay, two to three days for a
laparoscopic gastric bypass and sleeve gastrectomy, and five to seven days for
an open gastric bypass.
Will the doctor leave a drain in after surgery?
Most patients will have a small tube to allow drainage of any accumulated fluids
from the abdomen. This is a safety measure, and it is usually removed a few days
after the surgery. Generally, it produces no more than minor discomfort.
If I have surgery, what can I expect when I wake up in the recovery room?
Some doctors will provide a patient controlled analgesia (PCA) or a
self-administered pain management system, to help control pain. Others prefer to
use an infusion pump that provides a local anesthetic in the surgical site to
control pain without the side effects of narcotics. As with any major surgery,
you are in danger of death from a blood clot or other surgical side effects.
Statistically, the risk of death during these procedures is less than 1 percent.
Your doctors will have assessed you for risks and prepared accordingly. All
abdominal operations carry the risks of bleeding, infection in the incision,
thrombophlebitis of legs (blood clots), lung problems (pneumonia, pulmonary
embolisms), strokes or heart attacks, anesthetic complications, and blockage or
obstruction of the intestine. These risks are greater in morbidly obese
How soon will I be able to walk?
Almost immediately after surgery doctors will require you to get up and move
about. Patients are asked to walk or stand at the bedside on the night of
surgery, take several walks the next day and thereafter. On leaving the
hospital, you may be able to care for all your personal needs, but will need
help with shopping, lifting and with transportation.
How soon can I drive?
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
The Hospital Stay
What is done to minimize the risk of deep vein thrombosis/pulmonary embolism
Because a DVT originates on the operating table, therapy begins before a patient
goes to the operating room. Generally, patients are treated with sequential leg
compression stockings and given a blood thinner prior to surgery. Both of these
therapies continue throughout your hospitalization. The third major preventive
measure involves getting the patient moving and out of bed as soon as possible
after the operation to restore normal blood flow in the legs.
What should I bring with me to the hospital?
Basic toiletries (comb, toothbrush, etc.) and clothing may be provided by the
hospital, but most people prefer to bring their own. Choose clothes for your
stay that are easy to put on and take off. Because of your incision, your
clothes may become stained by blood or other body fluids. Other ideas:
reading and writing materials
crossword and other puzzles
Life After Surgery
What do I need to do to be successful after surgery?
The basic rules are simple and easy to follow:
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 able to eat solids, eat 2-3 meals per day, no more. Protein in the form of
lean meats (chicken, turkey, fish) and other low-fat sources should be eaten
first. These should comprise at least half the volume of the meal eaten. Foods
should be cooked without fat and seasoned to taste. Avoid sauces, gravies,
butter, margarine, mayonnaise and junk foods.
Never eat between meals. Do not drink flavored beverages, even diet soda,
Drink 2-3 quarts or more of water each day. Water must be consumed slowly, 1-2
mouthfuls at a time, due to the restrictive effect of the operation.
Exercise aerobically every day for at least 20 minutes (one-mile brisk walk,
bike riding, stair climbing, etc.). Weight/resistance exercise can be added 3-4
days per week, as instructed by your doctor.
What's so important about exercise?
When you have a weight loss surgery procedure, you lose weight because the
amount of food energy (calories) you are able to eat is much less than your body
needs to operate. It has to make up the difference by burning reserves or unused
tissues. Your body will tend to burn any unused muscle before it begins to burn
the fat it has saved up. If you do not exercise daily, your body will consume
your unused muscle, and you will lose muscle mass and strength. Daily aerobic
exercise for 20 minutes will communicate to your body that you want to use your
muscles and force it to burn the fat instead.
What is the right amount of exercise after weight loss surgery?
Many patients are hesitant about exercising after surgery, but exercise is an
essential component of success after surgery. Exercise actually begins on the
afternoon of surgery - the patient must be out of bed and walking. The goal is
to walk further on the next day, and progressively further every day after that,
including the first few weeks at home. Patients are often released from medical
restrictions and encouraged to begin exercising about two weeks after surgery,
limited only by the level of wound discomfort. The type of exercise is dictated
by the patient's overall condition. Some patients who have severe knee problems
can't walk well, but may be able to swim or bicycle. Many patients begin with
low stress forms of exercise and are encouraged to progress to more vigorous
activity when they are able.
Can I get pregnant after weight loss surgery?
It is strongly recommended that women wait at least one year after the surgery
before a pregnancy. Approximately one year post-operatively, your body will be
fairly stable (from a weight and nutrition standpoint) and you should be able to
carry a normally nourished fetus. You should consult your surgeon as you plan
What if I have had a previous weight loss surgical procedure and I'm now
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
How big will my stomach pouch really be in the long run?
This can vary by surgical procedure and surgeon. In the Roux-en-Y gastric
bypass, the stomach pouch is created at one ounce or less in size (15-20cc). In
the first few months it is rather stiff due to natural surgical inflammation.
About 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 3 to 7 ounces.
What will the staples do inside my abdomen? Is it okay in the future to have
an MRI test? Will I set off metal detectors in 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.
What if I'm not hungry after surgery?
It's normal not to have an appetite for the first month or two after weight loss
surgery. If you are able to consume liquids reasonably well, there is a level of
confidence that your appetite will increase with time.
Is there any difficulty in taking medications?
Most pills or capsules are small enough to pass through the new stomach pouch.
Initially, your doctor may suggest that medications be taken in liquid form or
Will I be able to take oral contraception after surgery?
Most patients have no difficulty in swallowing these pills.
Is sexual activity restricted?
Patients can return to normal sexual intimacy when wound healing and discomfort
permit. Many patients experience a drop in desire for about six weeks.
Is there a difference in the outcome of surgery between men and women?
Both men and women generally respond well to this surgery. In general, men lose
weight slightly faster than women do.
Will I be asked to stop smoking?
Patients are encouraged to stop smoking at least one month before surgery.
If I continue to smoke, what happens?
Smoking increases the risk of lung problems after surgery, can reduce the rate
of healing, increases the rates of infection, and interferes with blood supply
to the healing tissues.
How can I know that I won't just keep losing weight until I waste away to
Patients may begin to wonder about this early after the surgery when they are
losing 20 to 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. Ask your surgeon about your need for a skin removal
Will exercise help with excess hanging skin?
Exercise is good in so many other ways that a regular exercise program is
recommended. Unfortunately, most patients may still be left with large flaps of
Will I be miserably hungry after weight loss surgery since I'm not eating
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.
What if I am really hungry?
This is usually caused by the types of food you may be consuming, especially
starches (rice, pasta, potatoes). Be absolutely sure not to drink liquid with
food since liquid washes food out of the pouch.
Will I have to change my medications?
Your doctor will determine whether medications for blood pressure, diabetes,
etc., can be stopped when the conditions for which they are taken improve or
resolve after weight loss surgery. For meds that need to be continued, the vast
majority can be swallowed, absorbed and work the same as before weight loss
surgery. Usually no change in dose is required. Two classes of medications that
should be used only in consultation with your surgeon are diuretics (fluid
pills) and NSAIDs (most over-the-counter pain medicines). NSAIDs (ibuprofen,
naproxen, etc.) may create ulcers in the small pouch or the attached bowel. Most
diuretic medicines make the kidneys lose potassium. With the dramatically
reduced intake experienced by most weight loss surgery patients, they are not
able to take in enough potassium from food to compensate. When potassium levels
get too low, it can lead to fatal heart problems.
What is a hernia and what is the probability of an abdominal hernia after
A hernia is a weakness in the muscle wall through which an organ (usually small
bowel) can advance. Approximately 20 percent of patients develop a hernia. Most
of these patients require a repair of the herniated tissue. The use of a
reinforcing mesh to support the repair is common.
Is blood transfusion required?
Infrequently: If needed, it is usually given after surgery to promote healing.
What is phlebitis and is it preventable?
Undesired blood clotting in veins, especially of the calf and pelvis. It is not
completely preventable, but preventive measures will be taken, including:
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 fourth and the eighth month after surgery. Consistent intake
of protein at mealtime is the most important prevention method. Also recommended
are a daily zinc supplement and a good daily volume of fluid intake.
Does hair growth recover?
Most patients experience natural hair regrowth after the initial period of loss.
What are adhesions and do they form after this surgery?
Adhesions are scar tissues formed inside the abdomen after surgery or injury.
Adhesions can form with any surgery in the abdomen. For most patients, these are
not extensive enough to cause problems.
What is the "candida syndrome?"
Some patients have a type of yeast present on the surface of their skin,
intestine or vagina at the time of surgery. This leads to overgrowth in certain
circumstances. A whitish coating may occur on the tongue or throat. This
syndrome is associated with a frothy mucous, nausea, difficulty swallowing, sore
throat, loss of taste and appetite, and occasionally abdominal bloating and
What causes it to appear?
It is promoted by the use of most antibiotics and some other medications, by
stress, by reduced immune response, and by diabetes.
Can it be cured?
There are several effective medications now available for treating the
overgrowth of candida.
What is sleep apnea (SA)?
It is the interruption of the normal sleep pattern associated with repeated
delays in breathing. Sleep apnea often shows rapid improvement after surgery. In
most patients, there is a complete resolution of symptoms by six months
How long will I be off of solid foods after surgery?
Most surgeons recommend a period of four weeks or more without solid foods after
surgery. A liquid diet, followed by semi-solid foods or pureed foods, may be
recommended for a period of time until adequate healing has occurred. Your
surgeon will provide you with specific dietary guidelines for the best
What are the best choices of protein?
Eggs, low-fat cheese, low-fat cottage cheese, tofu, fish, other seafood, chicken
(dark meat), turkey (dark meat).
Why drink so much water?
When you are losing weight, there are many waste products to eliminate, mostly
in the urine. Some of these substances tend to form crystals, which can cause
kidney stones. A high water intake protects you and helps your body to rid
itself of waste products efficiently, promoting better weight loss. Water also
fills your stomach and helps to prolong and intensify your sense of satisfaction
with food. If you feel a desire to eat between meals, it may be because you did
not drink enough water in the hour before.
What is dumping syndrome?
Eating sugars or other foods containing many small particles when you have an
empty stomach can cause dumping syndrome in patients who have had a gastric
bypass or BPD where the stomach pylorus is removed. Your body handles these
small particles by diluting them with water, which reduces blood volume and
causes a shock-like state. Sugar may also induce insulin shock due to the
altered physiology of your intestinal tract. The result is a very unpleasant
feeling: you break out in a cold clammy sweat, turn pale, feel "butterflies" in
your stomach, and have a pounding pulse. Cramps and diarrhea may follow. This
state can last for 30 to 60 minutes and can be quite uncomfortable — you may
have to lie down until it goes away. This syndrome can be avoided by not eating
the foods that cause it, especially on an empty stomach. A small amount of
sweets, such as fruit, can sometimes be well tolerated at the end of a meal.
Is there a problem with consuming milk products?
Milk contains lactose (milk sugar), which is not well digested. This sugar
passes through undigested until bacteria in the lower bowel act on it, producing
irritating byproducts as well as gas. Depending on individual tolerance, some
persons find even the smallest amount of milk can cause cramps, gas and
Why can't I snack between meals?
Snacking, nibbling or grazing on foods, usually high-calorie and high-fat foods,
can add hundreds of calories a day to your intake, defeating the restrictive
effect of your operation. Snacking will slow down your weight loss and can lead
to regain of weight.
Why can't I eat red meat after surgery?
You can, but you will need to be very careful, and we recommend that you avoid
it for the first several months. Red meats contain a high level of meat fibers
(gristle) which hold the piece of meat together, preventing you from separating
it into small parts when you chew. The gristle can plug the outlet of your
stomach pouch and prevent anything from passing through, a condition that is
How can I be sure I am eating enough protein?
60-75 grams a day are generally sufficient. Check with your surgeon to determine
the right amount for your type of surgery.
Is there any restriction of salt intake?
No, your salt intake will be unchanged unless otherwise instructed by your
primary care physician.
Will I be able to eat "spicy" foods or seasoned foods?
Most patients are able to enjoy spices after the initial 6 months following
Will I be allowed to drink alcohol?
You will find that even small amounts of alcohol will affect you quickly. It is
suggested that you drink no alcohol for the first year. Thereafter, with your
physician's approval, you may have a glass of wine or a small cocktail.
What vitamins will I need to take after surgery?
A daily multivitamin is recommended for the rest of your life. Depending on the
type of surgery you have, B12, calcium with vitamin D, iron, and other trace
elements may also be needed.
Do I meet with a nutritionist before and after surgery?
Yes. All insurance companies require supervised nutrition counseling prior to
bariatric surgery. This time can vary from three months up to one year depending
on your specific insurance plan. There also are dietitians on staff to see
patients for follow-up care.
Will I get a copy of suggested eating patterns and food choices after
Surgeons 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.
What is the youngest age for which weight loss surgery is recommended?
Generally accepted guidelines from the American Society for Bariatric Surgery
and the National Institutes of Health indicate surgery only for those 18 years
of age and older. Surgery has been performed on patients 16 and younger. There
is a real concern that young patients may not have reached full developmental or
emotional maturity to make this type of decision. It is important that young
weight loss surgery patients have a full understanding of the lifelong
commitment to the altered eating and lifestyle changes necessary for success.
What is the oldest patient for whom weight loss surgery is recommended?
Patients over 65 require very strong indications for surgery and must also meet
stringent Medicare criteria. The risk of surgery in this age group is increased,
and the benefits, in terms of reduced risk of mortality, are reduced.
Can weight loss surgery prolong my life?
There is good evidence from scientific research that if you have Type 2 diabetes
(or other serious obesity-related health conditions), are at least 100 pounds
over ideal body weight, and are able to comply with lifestyle changes (daily
exercise and low-fat diet), then weight loss surgery may significantly prolong
Can weight loss surgery help other physical conditions?
According to current research, weight loss surgery can improve or resolve
associated health conditions.
1. Adams TD, Gress RE, Smith SC, et. al. Long-term mortality after gastric
bypass surgery. N Engl J Med. 2007; 357:753-761
2. Sjostrom L, Narbro K, Sjostrom D, et. al. Effects of Bariatric surgery and
mortality in Swedish obese subjects. N Engl J Med. 2007; 357-741-752
3. Schauer PR, Ikramuddin S, Gourash W, et. al. Outcomes after laparoscopic
Roux-en-Y Gastric Bypass for morbid obesity. Ann Surg. 2000; 232(4): 515-529
4. Schauer PR, Burguera B, Ikramuddin S, et al. Effect of laparoscopic Roux-en-Y
Gastric bypass on type 2 diabetes mellitus. Ann Surg. 2003; 238(4):467-484
5. Dixon JB, O'Brien PE, Playfair J, et. al. Adjustable gastric banding and
conventional therapy for Type 2 Diabetes. JAMA. 2008;299(3):316-323
Khristi Autajay, RD, LDN- Bariatric Program Coordinator
Rush University Medical Center
1653 W. Congress Parkway, Suite 785 Jelke-Southcenter
Chicago, IL 60612
( Courtesy: Rush University Medical Center