Our Frequently Asked Questions section refers to United States-based generally standard and accepted practices. As always, please check with your healthcare provider to determine their practices, guidelines and what they recommend for you.

Preparation for Surgery
Financial Issues
Surgery
The Hospital Stay
Recovering from Surgery
Life After Surgery

Preparation for Surgery

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.

Why do some people need bariatric surgery?
Obese individuals are at far greater risk of dying of an obesity-associated disease (such as diabetes, heart disease, arthritis, respiratory disease and others). Obesity accounts for more than 280,000 deaths annually in the United States and will soon overtake smoking as the primary preventable cause of death if current trends continue. Weight loss by conventional therapies, such as diet, exercise, behavioral modification, or by anti-obesity medications, have a less than one-percent long-term success rate for obese individuals. Weight-loss surgery can help the morbidly obese achieve long-term success.

What is the difference between being overweight and being obese?
By definition overweight is a body mass index (BMI) of 25-29 and obesity is defined as a BMI greater than or equal to 30. In general, morbidly obese is defined as a BMI greater than or equal to 40.

How many bypasses does Alabama Surgical Associates perform?
On average Alabama Surgical Associates performs approximately 10 to 18 procedures each week or 700 to 750 per year. This is why an exact surgery date will not be given until all medical clearances, testing, and paper work have been received and reviewed by your surgeon.

Will I be asked to stop smoking?
Patients are required to stop smoking at least 6 weeks before surgery. Smoking cessation decreases the risk of pneumonia, wound infections, and stomach leaks, and other medical problems. You should coordinate this treatment with your primary care physician as soon as possible

How long will I be in the hospital?
The length of stay for uncomplicated laparoscopic gastric bypass is one to three days. If a patient had to undergo a conversion to an open procedure the length of stay could be four to seven days. Typically Alabama Surgical Associates patients go home after a 23 hour stay.

What are the routine tests before surgery?
Certain basic tests are obtained prior to surgery. A Complete Blood Count (CBC) identifies anemia, infections and other related problems. Complete Metabolic Profile (CMP) gives a readout of about 20 blood chemistry values. All patients must also have an electrocardiogram.

Will other tests be required?
Other tests will be required depending on underlying medical conditions and age. Other tests may include: pulmonary function testing, sleep studies, arterial blood gasses, cardiac stress test, cardiac angiography, abdominal ultrasound, abdominal CT scan, HIDA scan, thyroid function test (TFT), venous doppler studies and cancer screening tests.

Which cancer screening tests are required?
The American Cancer Society recommends several age-related cancer screening tests. In women over 40, a breast screening is required which includes a mammogram and physical exam. In everyone over 50 years of age, a colon cancer screening test is required as well.

What is the purpose of all these tests?
An accurate health assessment is necessary to determine the risks of surgery. The best way to avoid complications is to never have them in the first place. A heart evaluation may be requested depending upon age and/or underlying medical problems. Tests include EKG, Cardiac Stress Test, echocardiogram,, Holter monitoring, and cardiac catheterization. If indicated, a cardiac clearance for surgery may be requested from your primary care physician and/or cardiologist. A lung evaluation also may be requested. Pulmonary function tests, arterial blood gasses, and chest x-rays may be obtained. If indicated, a pulmonary clearance for surgery may be requested from a pulmonologist. Other test may be requested to evaluate underlying medical problems. Tests include blood studies, ultrasound and/or CT scans, urine test to name a few. Your physician will determine which tests are needed, will review these test, and will make recommendations to minimize your surgical risk from medical problems. Medications maybe prescribed or modified for use before, during, and after surgery.

Are there any medical reasons I should not have this surgery?

• NIH consensus encourages bariatric surgical intervention for adults between the ages of 18 to 50. Age outliers will be considered on a case by case basis. At this time, child and adolescent bariatric surgery is experimental. Psychological factors need to be explored to determine the outcome of surgery in these age groups.
  
  With age over fifty, risk of surgery increases. Therefore, an extensive preoperative evaluation will be pursued to include heart, lung, liver, kidney and hematological factors to determine each person’s risk for surgery. Medical clearance for surgery also will be requested from a primary care physician and/or specialist. Preoperative colon and breast cancer screening must be up to date.
• Severe underlying co morbidities. An extensive preoperative evaluation will be pursued to determine each person’s risk for surgery.
• Terminal disease - HIV/AIDS, advanced cancer, hepatic cirrhosis, etc.
• Significant gastrointestinal abnormalities - Crohn's disease, certain intestinal dysmotilities, intractable peptic ulcer disease, and
• Alcoholism and/or Substance abuse.
• Untreated hypothyroidism - must be controlled prior to consideration for surgery.
• Certain steroid-producing tumors. If any symptoms exist that may indicate one of these tumors is present, a complete evaluation would be requested.
• Medications with severe withdrawal side effects. These medications must be discontinued well in advance of surgery in order to eliminate this risk. Conversion to other medications without side effects related to withdrawal may be considered.

Why do I have to have a nutritional consultation?
Insurance carriers commonly request a nutritional evaluation prior to approving this surgery. Furthermore, the nutritionist will be able to educate you about appropriate foods and amount of intake. You are highly encouraged to begin adjusting the types and amount of food intake prior to surgery so the transition after surgery is not such a shock. Finally, the nutritionist will be able to help with menus specific to you to make sure you are getting the appropriate amounts of vitamins, minerals and protein. If you have been seeing a nutritionist please provide documentation at the time of your consultation. Remember, long-term successful weight loss depends on a long term dietary plan.

Why do I need a GI Evaluation?
Patients who have significant gastrointestinal symptoms such as upper abdominal pain, heartburn, belching sour fluid, etc., may have underlying problems such as a hiatal hernia, gastroesophageal reflux or peptic ulcer. For example, many patients have symptoms of reflux. Up to 15% of these patients may show early changes in the lining of the esophagus, which could predispose them to cancer of the esophagus. It is important to identify these changes so a suitable surveillance or treatment program can be planned.

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 following surgery.

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 maybe associated with a higher 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. In people with breathing disorders, it is important to have a clear picture of what to expect and how to manage it. These studies are ordered on a case by case basis.

Why do I have to have a Psychiatric Evaluation?
Although the most common reason is insurance related, certain psychiatric conditions also require psychiatric evaluation. These conditions include the following:

• Acute and/or chronic psychiatric illnesses - schizophrenia, borderline personality disorder, psychosis, unmanageable major depression, etc. A psychiatric clearance is required for anyone who has had an acute, chronic, or significant past psychiatric illness. Continued long term psychiatric care is required.
• Eating disorders such as bulimia which are either poorly controlled or unmonitored. Psychiatric counseling and long term care would be required to minimize the risk of potential life threatening complications related to relapse.
• Persistent maladaptive eating behavior and dietary indiscretion. Eating as a coping mechanism could cause serious complications post-operatively. Participation in a bariatric support group and/or psychiatric consultation is required. Nutritional consultation is required to ensure adequate knowledge of dietary restrictions and required supplements. Compliance with nutritional recommendations is mandatory to obtain optimal results and minimize the risk for dietary postoperative complications.
• Mental retardation.
• Self destructive behavior. Smoking cessation must occur at least 6 weeks prior to surgery and maintained postoperatively.
• Active substance/alcohol abuse requires psychiatric consultation for detoxification and monitoring for long term cessation.
• Acute major stress event - death of family member or friend, major marital difficulties, major monetary difficulties, etc.

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 preclude undergoing gastric bypass surgery if it is otherwise appropriate, but those conditions will make a patient's risk higher than average.

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.

If I want to undergo a gastric bypass, how long do I have to wait?
New evaluation appointments are booked daily. The process typically begins with an informative Bariatric Symposium or private consultation. After this information gathering session, the following appointments are required:

• Initial Bariatric Counselor Consultation
• Initial Nutritional Consultation
• Initial Surgical Consultation
• Pre-operative Surgical Consultation
• The average time from symposium to surgery is 4-6 months.

What can I do before the appointment to speed up the process of getting ready for surgery?

• Select a primary care physician if you don't already have one, and establish a relationship with him or her. 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 mammogram. For men, this may include a prostate specific antigen test (PSA). Colon cancer screening (colonoscopy) for everyone over 50 years of age may be completed.
• Make a list of all the diets you have tried (a diet history) and bring it to your doctor.
• Bring any pertinent medical data to your appointment with the surgeon - this would include reports of relevant tests (echocardiogram, sleep study, etc.), operative notes, and/or hospital discharge summary if you have been in the hospital.
• Bring a list of your medications with dose and schedule.
• Stop smoking. Surgical patients who use tobacco products are at a higher surgical risk. Smoking cessation is required at least 6 weeks prior to surgery.
• If you have a third party payor, contact your insurance provider to inquire about the status of approval, rather than our office. Insurers will not give us the information they will only mail a response. Therefore, it is typically better for you to monitor the insurance approval process by contacting the insurance provider yourself. Occasionally the insurer will tell you they have not received the request, at that time you should contact the insurance analyst preferably by e-mail.

What should I bring with me to the hospital?
Gowns are provided by the hospital. Basic toiletries (comb, toothbrush, etc.) and clothing (for discharge) are typically all that is needed from home. Choose clothes to wear home that are easy to put on and take off. Because of your incisions, your clothes may become stained by blood or other body fluids. Other ideas:

• reading and writing materials
• crossword and other puzzles
• personal toiletries
• bathrobe

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 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 lbs. over ideal body weight, and are able to comply with lifestyle changes (daily exercise and low-fat diet), then weight loss surgery may significantly prolong your life.

How much weight can I expect to lose after gastric bypass surgery?
The majority of patients lose approximately fifty to eighty-five percent of their excess body weight. Our Roux-en-Y gastric-bypass patients typically achieve a loss of at least 60% of excess body weight after six months, and after 12 months at least 75% of excess weight is lost. Excess body weight is the amount of weight above your ideal body weight. Very few people reach their ideal body weight. However, after the surgery your weight will be at a much healthier level.
When I diet, I regain the weight. Will this happen with a gastric bypass?
Roux-en-Y Gastric bypass surgery is currently the most reliable method used to treat severe obesity. Using diet alone, nearly all patients with significant short term weight loss will regain the lost weight. After gastric bypass, maximum weight loss occurs between one and two years after surgery. You may regain a small amount of weight two to five years after bypass surgery, but it is much less than the initial weight loss providing dietary restrictions are maintained. If you are diligent to your diet and exercise you have a greater chance of sustained weight loss.

Can weight loss surgery help other physical conditions?
According to current research, weight loss surgery can improve or resolve associated health conditions.

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Financial Issues
Why does it take so long to get insurance approval?
The process of insurance approval is variable. Some insurance companies do not require pre-certification. For those insurance companies requiring pre-authorization, a 2-4 week wait is typical. After your initial consultation is completed, it usually takes your doctor 1-2 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 2-4 weeks or longer if you are not persistent in your follow-up. 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 your request.

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 1 to 5 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.

If my insurance company does not provide coverage for obesity surgery, is there financing available?
Yes. You may finance any or all of your bariatric surgery costs, including pre- and post-operative visits. Financing is provided by a third-party financial company at competitive rates. Rates and further information are available through our office. If you are interested in financing, you may set up an appointment to talk with the Financial Coordinator.

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Surgery
Can I have my surgery done laparoscopically?
Laparoscopic gastric bypass surgery is the procedure of choice because of the shortened recovery time, decreased pain, earlier ambulation, and a decreased risk of most post-operative complications. If you have had prior abdominal surgery the laparoscopic approach is much more difficult. However, when you are evaluated during your initial consultation and examination, this will be discussed. Please make sure to deliver all records from previous abdominal surgeries prior to your consultation with your surgeon. If you have had a vertical banded gastroplasty or other gastric bypass procedure, you are not a candidate for laparoscopy.

Does Laparoscopic Surgery decrease the risk?
Yes. Laparoscopic operations can carry less risk as compared to the open operation. The benefits of the laparoscopic approach are typically less discomfort, less risk of infection, less risk of hernias, shorter operative time (typically 60-90 minutes), shorter hospital stay (23 hours), earlier return to work, and reduced scarring, among others. The key to realizing these benefits is to seek bariatric surgical care from an experienced, high volume, bariatric surgeon.

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

Will I have a drain in after surgery?
No, drains are not necessary after initial gastric bypass surgery due to the low leak rate (< 0.1%). Drains are left in place in cases where an increased leak risk is present, such as in the rare case (< 0.2%) of a re-operation due to complications.

If I have surgery, what can I expect when I wake up in the recovery room?
Nurses will be present to provide you with comfort measures, including pain and nausea management medications. You will be provided with a Patient Controlled Analgesia (PCA) pump or a self-administered pain management system, to help control pain shortly after waking up. You will be wearing Sequential Compression Devices (SCDs) on your legs. You may have an oxygen mask over your mouth.

Is blood transfusion required?
Transfusions are very rarely required. Excessive bleeding during surgery is a risk. However, this risk is <0.1%. Postoperative bleeding also can occur due to ulcers (<0.5%). However, transfusion is only rarely required in these patients.

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The Hospital Stay
What is done to minimize the risk of deep vein thrombosis/pulmonary embolism or DVT/PE?
Because a DVT originates on the operating table, therapy begins before a patient goes to the operating room. All patients are treated with sequential leg compression stockings prior to surgery. This is continued throughout your hospitalization. Decreasing operating times also decreases your risk of DVT/PE. Another 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.

If there is an increased risk of developing DVT/PE due to family history and/or personal history of DVT/PE and/or clotting disorders, then it is recommended to have a vena cava filter placed pre-operatively. Blood thinners can be used, but do not completely eliminate the risk of DVT/PE. Blood thinners do increase the risk of intra-operative bleeding and transfusion, and therefore we rarely recommended by them in laparoscopic surgery.

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) pump, which allows you to give yourself a dose of pain medicine on demand, may be used. Oral pain medicines will be prescribed for home use as needed.

How long do I have to stay in the hospital?
The length of stay for uncomplicated laparoscopic gastric bypass is one to three days. If a patient had to undergo a conversion to an open procedure the length of stay could be four to seven days. Over 99% of Alabama Surgical Associates patients go home after a 23 hour hospital stay.

How soon will I be able to walk?
Almost immediately after surgery you will be required to get up and move about. Patients are asked to walk or stand at the bedside on the night of surgery, and take several walks the next day. 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.

Will I be able to eat after surgery?
You will not be able to eat or drink anything until the day after surgery. This allows the stomach pouch and intestines to heal.

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Recovering from Surgery
What do I need to do to be successful after surgery?
The basic rules are simple and easy to follow:

• Prior to surgery, your doctor will provide you with special post-operative dietary guidelines. You will need to follow these guidelines closely. You will begin with a clear liquid diet, moving to semi-solid foods and 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. This process usually takes 6 weeks.
• Vitamin, mineral and protein supplements need to be started on post-op day 8.
• Protein in the form of lean meats (chicken, turkey, fish) and other low-fat sources should always be eaten first.
• Avoid junk foods and any other foods which are composed of processed sugars and can cause dumping syndrome.
• Do not drink carbonated and/or sweetened beverages.
• Drink 64 onces 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.
• Starting two weeks after surgery, exercise five days per week for at least 30 minutes per day. The exercise should begin with continuous walking for 30 minutes. Once this baseline is established, then intensity and/or duration can be increased. Lifting should be limited to no more than 15 pounds for the first 6 weeks after surgery. Straining and other vigorous exercises can be started after this 6 week interval.

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.

Is there any difficulty in taking medications?
Initially, medications must be taken in liquid form or crushed. Most pills or capsules are small enough to pass through the new stomach pouch after healing has occurred (6 weeks). It is important to crush pills after the procedure. You should discuss your medications and any alterations that may be required after surgery with your primary care physician or specialist prior to surgery. Consult your pharmacist to see if the pills are crushable. Sugar free Tylenol liquid is suitable. Vioxx, Celebrex, and Bextra are also suitable. Vioxx is the smallest of the three. Celebrex and Bextra will need to be crushed. Also, pay attention to labels on medications. Some cough syrups contain sugar. Sugar-free versions are available, and are more appropriate alternatives.

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. This is typically 7-14 days. However, birth control measures are recommended for 18 months.

If I resume smoking, what happens?
Smoking increases the risk of lung problems after surgery, reduces the rate of healing, increases the rates of infection, and interferes with blood supply to the healing tissues. Gastric bypass surgery decreases the blood flow to the stomach pouch. Smoking further decreases blood supply, thereby increasing the risk of leaks and associated complications.

Will I be miserably hungry after weight loss surgery since I'm not eating much?
Most patients say no. In fact, for the first 4-6 weeks patients have almost no appetite. Over the next several months the appetite returns, but it tends not to be a ravenous "eat everything in the cupboard" type of hunger.

What if I am really hungry?
This is usually caused by the types of food you may be consuming, especially starches (rice, pasta, potatoes). Be absolutely sure not to drink liquid with food since liquid washes food out of the pouch. Consult with your dietician to help with these issues.

What is deep venous thrombosis 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:

1. Early ambulation
2. Special stockings
3. Sequential compression devices
4. Minimizing surgical times

How soon can I drive?
For your own safety, you should not drive until you have stopped taking narcotic medications and your pain has resolved completely. You must be able to move quickly and alertly to stop your car, especially in an emergency. Usually this takes about one week.

How long will I be off of solid foods after surgery?
A period of six weeks or more without solid foods after surgery is recommended. A liquid diet, followed by semi-solid foods or pureed foods, is recommended for a period of time until adequate healing has occurred. Your bariatric nutritionist will provide you with specific dietary guidelines for the best post-surgical outcome.

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Life After Surgery
What are the best choices of protein?
Eggs, low-fat cheese, low-fat cottage cheese, tofu, fish, other seafood, chicken (dark meat), turkey (dark meat).

Why drink so much water?
When you are losing weight, there are many waste products to eliminate, mostly in the urine. Some of these substances tend to form crystals, which can cause kidney stones. A high water intake protects you and helps your body to rid itself of waste products efficiently, promoting better weight loss. Water also fills your stomach and helps to prolong and intensify your sense of satisfaction with food. If you feel a desire to eat between meals, it may be because you did not drink enough water in the hour before.

What is Dumping Syndrome?
Eating sugars or other foods containing many small particles when you have an empty stomach can cause dumping syndrome in patients who have had a gastric bypass or BPD where the stomach pylorus is removed. Your body handles these small particles by diluting them with water, which reduces blood volume and causes a shock-like state. Sugar may also induce insulin shock due to the altered physiology of your intestinal tract. The result is a very unpleasant feeling: you break out in a cold clammy sweat, turn pale, feel "butterflies" in your stomach, and have a pounding pulse. Cramps and diarrhea may follow. This state can last for 30-60 minutes and can be quite uncomfortable - you may have to lie down until it goes away. This syndrome can be avoided by not eating the foods that cause it, especially on an empty stomach.

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 diarrhea.

Why can’t I have caffeine?
Caffeine is a diuretic. It is very important to stay well hydrated so you should avoid any liquid or food that acts as a diuretic.

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 very uncomfortable.

How can I be sure I am eating enough protein?
40 to 65 grams a day are generally sufficient. Check with your bariatric nutritionist 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 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 drink no alcohol for the first year. Thereafter, with your physician's approval, you may have a glass of wine or a small cocktail. Alcoholic beverages have “sugar” and may cause dumping syndrome and/or dehydration. You should avoid alcohol as much as possible.

When can I have carbonated beverages?
Carbonated beverages should be avoided since carbonation puts pressure on the “gastric pouch” and can cause pain or uncomfortable pressure and result in stretching your pouch.

Will I need supplemental vitamins?
B12 injections are sometimes suggested once a month for the first year and every six months thereafter. B12 may also be taken orally or sublingually (under the tongue) by many patients. Consult with your bariatric nutritionist and he will individualize your requirements.

What vitamins will I need to take after surgery?
Most surgeons recommend a daily multivitamin for the rest of your life.

Is it important to take calcium, iron, trace elements or female hormone replacements?
Some patients require these supplements, but your need for these can be determined by your bariatric nutritionist.

Do I meet with a nutritionist before and after surgery?
Most surgeons require patients to consult with a nutritionist before surgery. Counseling after surgery is available on an individual basis as needed or required by your physician.

Will I get a copy of suggested eating patterns and food choices after surgery?
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.

Will I experience plateaus of weight loss?
Yes. You will experience plateaus of weight loss as you would with any other diet or exercise regimen. Do not become discouraged and start overfilling or stop exercising! Plateaus are perfectly normal and almost every patient will have this experience intermittently. Every patient is different. Some will lose weight more quickly than others. Some will experience plateaus that last longer than others. Remember to stick to your diet and exercise as recommended. Your surgeon strongly encourages attendance to support groups and follow ups with the nutritionist and bariatric counselors.

What's so important about exercise?
After weight loss surgery, 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.

Can I get pregnant after weight loss surgery?
It is strongly recommended that women wait at least 18 months after the surgery before becoming pregnant. Approximately 18 months 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 OB/GYN as you plan for pregnancy.

How big will my stomach pouch really be in the long run?
In the Roux-en-Y gastric bypass, the stomach pouch is created at one ounce or less in size (20-30cc). In the first few months it is rather stiff due to natural surgical inflammation. About 6-12 months after surgery, the stomach pouch can expand and will become more expandable as swelling subsides. Many patients end up with a meal capacity of 3-7 ounces.

What will the staples do inside my abdomen? Is it okay in the future to have an MRI test? Will I set off metal detectors in 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 titanium so small it is hard to see. Because the titanium is inert in the body, most people are not allergic to staples and they usually do not cause any problems in the long run. The staples will be overgrown by your body's tissues and scarred in place. 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?
The Roux-en-Y surgery has been found to decrease the hunger stimulation hormone called ghrelin. Although hunger will be suppressed, your appetite will return at a reduced level over time. It's normal not to have an appetite for the first month or two after weight loss surgery.

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 or medical 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 classified as elective surgery). However, some do pay for certain types of surgery to remove excess skin when complications arise from these excess skin folds. It is typically recommended that plastic surgery be postponed for 2 years following surgery. Consult your plastic surgeon about your specific need for a skin removal procedure.

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 loose skin.

What is a hernia and what is the probability of an abdominal hernia after surgery?
A hernia is a weakness in the muscle wall through which an organ (usually small bowel) can advance. Approximately 20% of patients develop a hernia after open gastric bypass surgery. Most of these patients require a repair of the herniated tissue. The use of a reinforcing mesh to support the repair is common. Hernia's are rare following laparoscopic surgery.

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 and chromium 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.

How much weight can one expect to regain after surgery?
Studies show that bariatric patients can have long-term success with their weight loss, but this is dependant on a life-long commitment to better health and adherence to a multidisciplinary program. The multidisciplinary program at Bariatric Wellness Institute has been recognized as one of the most comprehensive in the U.S., helping to ensure the long-term success of our patients.

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