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Frequently Asked Questions

I. About the Period Before Surgery:

If you believe bariatric weight-loss surgery is the right choice for you, contact us at (408) 402-6276 or email at info@marczaremd.com. We will invite you to our office for your initial consultation with Dr. Zaré within one or two weeks of your inquiry.

In 1991, the National Institutes of Health recommended bariatric weight-loss surgery as a treatment option for severe obesity based on the following criteria:

  • 100 pounds or more above ideal body weight or a Body Mass Index (see our BMI calculator) of 40 or greater, or a BMI of 35 or greater with one or more obesity-related health conditions.
  • History of documented dietary weight loss attempts.
  • Lifelong commitment to dietary, exercise, and medical guidelines and follow-up care.
  • Psychological evaluation

At our program, we follow the NIH criteria and offer bariatric surgery to patients who have a Body Mass Index [BMI] of 40 or greater, or a BMI of 35 or greater with co-morbid conditions, and who have not had success with non-surgical modalities of weight loss such as diet, exercise, medications, etc. Additionally, we offer bariatric surgery to individuals with BMI 30-35 if they have Diabetes Mellitus and have been unsuccessful in controlling their Diabetes in spite of two diabetic medications. Candidates need to be between ages of 18-79, and should not have advanced or irreversible medical conditions such as end stage liver disease, disseminated cancer, etc.

Unlike some institutional programs that have lengthy waiting periods, at our practice we strive to make the preoperative process as timely and efficient as possible. It may take a few weeks to few months from the time you make the first phone call to the date of your surgery. Several factors determine this duration. They include type of insurance plan, patient’s health conditions, patient’s co-operation in fulfillment of the pre-authorization requirements (consultation with dietitian, psychologist, and other specialists), and completion of pre-operative tests.

Weight-loss surgery is similar to other major surgeries. You can prepare yourself by learning about various aspects of surgery including risks and benefits.

  • Understand the surgical process and what to expect afterward.
  • Keep in mind that your interaction with food will change after surgery.
  • Talk to people who have had bariatric surgery. Our bariatric surgery support group is a great resource.
  • Write down your reasons for having weight-loss surgery, outlining your plans to maintain your weight after surgery.
  • Start a journal. Record how you feel now, the challenges you face, and the things you hope to be able to do after surgery.
  • Get the support of your family. It helps to know you have people behind you, waiting to help.
  • Learn what vitamin supplements are required after surgery. For example for Sleeve gastrectomy, patients are required to take one multivitamin daily and one Vitamin B12 weekly.
  • Stay active and plan to increase your activities after surgery. Your exercise regimen will depend largely on your baseline level of fitness. Dr. Zare will be happy to devise a personal plan for you during your preoperative phase.
  • Learn about changes in behavior that will impact your success with weight loss. To help patients fully prepare for surgery, we will provide each patient a booklet of information containing useful information pertinent to our program and essential to long-term success with bariatric surgery.

Although not mandatory, we recommend that patients lose as much weight as they can before surgery. The reason behind this recommendation is that when patients lose weight before surgery, they decrease the size of their fatty liver, therebefore increasing the workspace for their surgeon. With this increase in workspace, there is increase in safety and ease with which laparoscopic surgery can be performed. Studies have shown significant shrinkage of the left lobe of the liver (which normally covers the stomach) with weight loss prior to surgery. We will provide you with an easy-to-follow 10-day liquid diet plan to help you reach the target weight loss of 10-20 lbs. Virtually all patients reach their target without much difficulty.

Bariatric surgery reshapes the stomach and changes the digestive process of the body in a positive way. It is performed while the patient is under general anesthesia.

For many people, the idea of “rebuilding” their stomach sounds good. A small stomach that can help control how much one eats can be a great tool. For others, the idea of surgery, anesthesia, and permanent change in stomach capacity can provoke anxiety. The potential for complications also can be a little frightening. This is perfectly normal. Before letting these fears prevent you from having surgery, you may want to examine them. In this section, you’ll learn strategies for working through these fears.

Fear of surgery is a completely normal phenomenon. If the idea of surgery or anesthesia scares you, counter the fear by improving your knowledge base about modern bariatric surgery. Research the risks and benefits of surgery and anesthesia, especially those related to our practice. Once you do that, you will be pleasantly surprised to learn how safe modern bariatric surgery truly is and how successful we have been over the past two decades. At present time, mortality rate for commonly performed bariatric procedures is very similar to that of gall bladder surgery (mortality rate=0.1%). What is more re-assuring is to know that with our experience dating back to our start in 2002, we have never lost a patient to surgery and have never had the need to perform bariatric surgery through an open approach. Each procedure has been completed successfully via laparoscopic approach. We are highly dedicated to the safety of each and every patient and work very hard to make sure our pristine record is maintained. If you are still afraid of surgery, talk to us. We can address many of your concerns. Additionally, we encourage you to attend a hospital support group (preferably with your significant other) and speak with patients who have been through this journey. There is nothing more powerful than the real stories of success narrated by individuals just like yourself. Finally, if needed, a psychologist or therapist can help you work through your fears and concerns.

Sleeve gastrectomy and other weight-loss operations permanently reduce the size of the stomach. This requires that patients reduce their portion size after surgery. The permanent change in stomach size and the need for reduction in portion size can cause anxiety for some. But there is good news. After Sleeve Gastrectomy (and Gastric Bypass), the appetite hormone Ghrelin is reduced in the blood stream and as a result appetite is suppressed for life. In addition to reduction in appetite, there is an increase in the sense of fullness or satiety after meals, thanks to increase in a hormone called peptide YY. Together, these changes in metabolic hormones result in increased satisfaction with meals, in spite of reduced portion size.

Many successful patients say their support network helped them immensely in maintaining their new healthy lifestyle. From family and friends to bariatric support groups, there are many options available to you. The first step is talk to your family and friends about bariatric surgery. You might find that they are open and supportive of your decision. While this is always ideal, you might also find that some family members or friends are not fully on board or simply against your decision. Often, this is because your loved ones are concerned about you or have negative preconceived notions about gastric reduction surgery. Explaining the benefits and low risks of surgery may help open their minds to the importance of your decision.

If you find that they are still not supportive, support groups are excellent alternative sources. You’ll find people there who share in your goal of becoming healthy. Support groups are forums for celebrating successes and are devoted to people who have common experiences and interested in sharing their feelings in a safe environment. Our bariatric program includes support groups for patients both before and after surgery. Dana Schroeder, the bariatric coordinator at Good Samaritan Hospital, and Karen Thomas, the coordinator at El Camino Mountain View Hospital manage their respective programs. Admission is free for life for our patients. Please ask our office for additional information. Our program also includes psychologists, who can provide guidance.

Complete Blood Count (CBC), Chemistry panel, and Urine analysis are among tests performed routinely before surgery. Often, a blood glucose test is done for diabetic patients. Except for the very young, all patients receive an electrocardiogram. You may receive a gallbladder ultrasound to look for gallstones if have a history of gallstones. Other tests include pulmonary function testing, echocardiogram, sleep study, endoscopy, and cardiac stress test.

Patients who have frequent gastrointestinal symptoms, such as upper-abdominal pain, heartburn, belching sour fluid, etc., may have problems such as a hiatal hernia, gastroesophageal reflux, or peptic ulcer. Correct identification of the cause for your symptoms can help us devise a treatment plan before surgery. If a hiatal hernia is identified, repair of hiatal hernia will be performed at the same time as bariatric surgery.

If you snore at night and feel excessively tired or fall asleep frequently during the day, you may be suffering from Obstructive Sleep Apnea. A sleep study identifies abnormal cessation of breathing because of airway obstruction during sleep. This problem may be exaggerated after surgery when patients receive pain medications. It is therefore important to identify and treat Obstructive Sleep Apnea with a CPAP machine before and after surgery. Talk to your doctor if you think you may obstructive sleep apnea.

Bariatric surgery will affect you physically, medically and psychologically for the rest of your life, although in a very positive way. The decision to have surgery is one that requires serious consideration. It also requires dedication to a permanent change in lifestyle. It is considered the standard of care for each potential bariatric patient to undergo an evaluation by a mental health specialist to ensure they have emotional stability and cognitive ability to undertake bariatric surgery.

A clear picture of your health is needed before surgery. For example, if you have a diagnosis of hypothyroidism, it is important to test your thyroid function because hypothyroidism can lead to adverse outcomes after surgery. If you are diabetic, special steps must be taken to being your blood sugar under control to ensure proper healing and to decrease risk of infection. If you have a history of heart problems, you may need a cardiac evaluation. Other tests will show if you have liver malfunction, breathing difficulties, excess fluid in the tissue, or abnormalities of the salts or minerals in body fluids.

  • Speak to your insurance company. Ask them to specify if bariatric surgery is a covered benefit in your policy. You will need to provide them the surgical code CPT-43775 for sleeve gastrectomy to receive this information. Insurance companies vary in their coverage of weight-loss procedures. Some may have “exclusion clauses” and may not cover bariatric surgery.
  • Gather all information related to any formal dietary program you may have participated in the past 2-5 years. This may reduce the chance of being denied pre-authorization by your insurance carrier due to failure to provide necessary information. Letters from your personal physician and professionals supporting the medical necessity of treatment are particularly valuable. When several physicians report the same findings, it may confirm a medical necessity for surgery.
  • Bring all relevant medical data including reports of special tests (echocardiogram, sleep study, etc.) or hospital discharge summary if you have been in the hospital for weight-related health problems.
  • Bring a list of your medications, including dosage and schedule.
  • Choose a primary care physician if you don’t have one already and establish a relationship with him or her. Work with your physician to ensure that your routine health maintenance testing is current. Results of diagnostic and routine screening for co-morbid conditions such as diabetes and high cholesterol may be needed for documentation of medical necessity. Make sure your primary care physician is documenting your weight loss efforts and your weight in your medical records at every visit.
  • Quit smoking. Surgical patients who use tobacco products are at a greater surgical risk. Talk to a doctor for help with this.

For most patients, the long-anticipated day of surgery is truly exciting. You will receive specific instructions from our office several days prior to the day of surgery. These include:

  • Do not eat anything beginning the midnight before surgery. Do not drink liquids a few hours before. Specific details will be provided to you.
  • Most medicines can be taken the day of surgery with a small sip of water. However, your doctor may have other instructions regarding specific medications.
  • Bring a list of your medications with you to the hospital.
  • If you use a CPAP machine, bring it with you to the hospital for use during your stay.
  • Arrive early, no later than two hours before surgery.
    When you arrive, you will undergo a few preoperative steps. You will change out of your clothes. You will meet your nurses, and you will meet your anesthesiologist. An IV line will be started to keep you hydrated and to administer medications such as antibiotics. The preoperative experience is often a short one, after which you will be taken to the operating room. There, your bariatric surgeon will accompany with you throughout the length of your stay.

After surgery is completed, your healthcare team will arrange for you to be taken to a recovery room.

II. About the Period After Surgery

Recovery from bariatric surgery typically takes a few days. Each day, you will make incremental progress and by the end of the second week, you will be fully independent.

Postoperative pain and discomfort: Many people think that bariatric surgery will be followed by a long and painful recovery. In reality, many patients describe their pain as more of a discomfort or soreness. This may vary from one patient to the next. You may want to speak with your surgeon if you are concerned about postoperative pain.

Return to normal activities: As with any major surgery, there will be a period of time when you will be limited in your physical abilities. Remember that this is essential in your journal to return to normal activity. Recovery times vary from one patient to next.

You can expect to be up and moving within hours of your surgery. While you may move slowly at first, many patients find that each day brings improvements. You may return to normal activities, such as driving, cooking, and caring for children, as well as work, one to two weeks surgery. You will be required to avoid lifting objects heavier than 20 lbs and doing strenuous activities for six weeks after surgery.

Whether it’s family, friends, or coworkers, build a support network for all aspects of your recovery. Those supporting you are dedicated to helping you achieve better health and wellness. Show your appreciation by accepting their help and allowing yourself to heal.

Many patients report that during the first 12 to 18 months following surgery, they feel highly motivated and energized. During this time, they are making substantial lifestyle changes such as eating new foods and smaller portions, taking vitamins daily, and exercising regularly. While these changes are healthy, they may be overwhelming for some patients. This is where our support team of specialists can guide you. Experts including your surgeon, bariatric coordinator, dietitian and psychologist can provide advice and insight that will educate you and help you make healthy choices.

The key to success after surgery is having a deep understanding of bariatric surgery and the changes in lifestyle required for long-term success. While surgery provides many powerful tools, patients have to make good decisions and incorporate lifestyle changes in order for those tools to be fully effective. The primary tool provided by surgery is restriction of portion size to 5 oz. Secondarily, there is decreased hunger, increased self of fullness, and increased metabolic rate. While these are very powerful tools, patients still need to avoid eating larger than prescribed portions, consume excessive amount of fat and added sugar, eat emotionally, eat late at night, or indulge in other eating behaviors that result in consumption of excessive amounts of calories.

With a disciplined approach to eating, and with a perfectly created Sleeve Gastrectomy, you will be able to keep the weight off indefinitely and with ease.

Immediately after surgery, you can expect to have some discomfort and feel the effects of the surgery. This can last for 1-2 days. By the end of the first week, most patients begin to feel more energetic, but will not be ready for a full day of work or a long period outside the house. By the end of two weeks, most patients are no longer taking pain medications and are driving themselves. They begin to appreciate the effect of early weight loss with improved sleep quality, increased physical tolerance, and an overall sense of wellbeing. It will take several months before the full impact of surgery can be realized. Be patient and enjoy the ride.

The changes made to your gastrointestinal tract will require changes in your eating habits that must be followed for successful weight loss. We will provide you with detailed guidelines after you enroll in the program. It is important that you follow the guidelines carefully. The following is a very brief example of some of the dietary guidelines you will be provided with.

  • During the first month after surgery, you will be on a full liquid diet followed by puree diet. After that, you will start eating solid foods. At this stage, it is important to chew your food thoroughly and eat very slowly. It is important to wait two to three minutes after swallowing before taking the next bite. In the beginning, you will not be able to digest steaks or similar types of meat if they are not ground or chewed thoroughly.
  • Try not to drink fluids while eating. They will make you feel full before you have eaten enough food.
  • Cut out added sugar, and limit carbohydrates to no more than 8 gms per 100 calories.
  • Avoid carbonated drinks as best as you can.
  • Avoid foods high in fat, and foods that have no nutritional value.
  • Avoid excessive alcohol.
  • Limit snacking between meals.
  • Limit late night eating.
  • Limit emotional eating.

In the beginning, most patients are instructed to eat 2-4 ounces of food each time (one half of one cup to one cup). As time goes on, you can eat slightly more (as instructed by your bariatric surgeon). Most people can eat approximately 1 full cup of food each time, after a year. As a general guideline, if it fits on the palm of your hand the portion size is correct.

The guidelines are designed to improve safety early on, and increase chances of success with losing weight long term. If you don’t follow the guidelines, you may not lose the desired amount of weight, or regain some of the weight back.

Soon after surgery, within 2-3 hours, we will encourage you to get up and move around. Patients are asked to walk at the bedside the evening of surgery and take several walks starting from the next day. Upon leaving the hospital, you may be able to care for some of your personal needs, but you will need help with things like shopping, lifting, and transportation.

You should not drive until you have stopped taking pain medications prescribed after surgery. You should also not drive if you are unable to be alert and move quickly. Usually, this takes about ten days to two weeks after surgery.

Your ability to resume your normal levels of activity depends on your physical condition, the nature of the activity, and the type of bariatric surgery you had. Many patients return to normal levels of activity within 1-2 weeks of surgery.

It is extremely important that women of childbearing age use the most effective forms of birth control during the first 18 months after surgery. The goal is to avoid getting pregnant during the most rapid phase of weight loss. Please discuss with your OB/Gyn doctor about your options. Mechanical forms of contraception are preferred, but with sleeve gastrectomy oral contraceptives get absorbed normally and can be taken too.

Bariatric surgery does not guarantee weight loss. It provides tools, which when used appropriately result in sustainable weight loss. These tools include restriction of portion size, decreased hunger, and increased metabolic rate. Maintaining your weight loss requires dedication to a healthy lifestyle using the tools provided by surgery. At least two-thirds of patients who have sleeve gastrectomy are able to keep off at least 60 percent of their excess weight at 10 years and beyond.

Your bariatric surgeon, nutritionist, and psychologist will be able to provide you necessary support. Also, you are encouraged to take part in patient support groups with, where you can share experiences, insights, and concerns.

After bariatric surgery, you lose weight since the caloric value of ingested value is below what is necessary for your day to day function. Your body has to make up the difference by burning unused fat or muscle tissue. Your body will tend to burn any unused muscle before it begins to burn the fat. Without daily exercise, your body will burn unused muscle, and you will lose muscle mass and strength. Daily aerobic exercise for 20 minutes can prevent loss of muscle mass.

Exercise begins on the afternoon of bariatric surgery, when patient is encouraged to get out of bed and walk. The goal is to walk longer each day. You are encouraged to begin exercising, limited only by discomfort, about two weeks after surgery. The type of exercise depends on your overall condition. Patients who have severe knee problems may not be able to walk well but may be able to swim or ride a bicycle. Many patients begin with low-stress forms of exercise and move on to more demanding activity when they are able.

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. High water intake protects you and helps your body get rid of waste efficiently. Water also fills your stomach and helps create a feeling of fullness. If you feel a desire to eat between meals, it may be because you did not drink enough water in the hour before.

The two affiliate hospitals provide their own support groups. If interested, ask us for additional details. Support groups give patients an excellent chance to talk about personal and professional issues. Most patients learn, for example, that bariatric surgery will not fix existing emotional issues right away or heal the years of damage that morbid obesity might have caused to their emotional wellbeing. Ongoing support after surgery helps achieve the greatest level of success for their patients.

Bariatric surgery, by reducing excess body weight and improving overall health, can improve patients’ lives in many ways. Some benefits are common among patients; others are unique to each individual patient.

Here are some of the benefits patients have described:

  • Reduced shortness of breath
  • Increased energy level
  • Improved quality of sleep
  • Increase self confidence
  • Improved social life
  • Greater variety in choice of clothes
  • Increase sense of reward after exercise
  • Improved career prospects
  • Increased enjoyment of outdoor activities.
  • Increased endurance with walking and other aerobic activities.
  • Increase variety of exercise options, including riding a bike, hunting and fishing.
  • Ability to ride roller coasters with loved ones.
  • Ability to participate in family games and activities.
  • Increased enjoyment while traveling.

To ensure success, we require that you make follow-up visits every four months within the first year, and then biannually or annually thereafter. Frequent follow-up visits have been shown to improve outcomes after bariatric surgery. Prior to your visits, you will have blood tests to determine levels of various vitamins and essential nutrients.

Dietary counseling after surgery is important as you experiment with your new eating style. At our practice, we provide access to a number of registered dietitians with experience and expertise. We encourage you to meet with them periodically.

III. About Benefits of Bariatric Surgery

Obesity-related health conditions that may be improved or resolved with bariatric surgery include:

  • Type 2 diabetes
  • High blood pressure/heart disease
  • Dyslipidemia (lipid metabolism abnormalities)
  • Osteoarthritis of weight-bearing joints
  • Depression
  • Sleep apnea/respiratory problems
  • Gastroesophageal reflux/heartburn
  • Infertility
  • Urinary stress incontinence
  • Menstrual irregularities
  • Asthma
  • Skin breakdown
  • Swollen legs/skin ulcers

A sample of scientific evidence on the effects of bariatric surgery is included below:

  • A meta-analysis of more than 22,000 patients showed that over 80% of patients who experienced complete resolution or significant improvement of their co-morbid conditions including diabetes, hyperlipidemia, hypertension, and obstructive sleep apnea.
  • A study of 20,000 individuals, one half of whom had undergone bariatric surgery and the other half had not, revealed that the individuals who underwent surgery had 40% lower risk of death seven years after surgery compared to those who did not. This risk reduction was even more pronounced (92% lower risk of death) for diabetic individuals.
    • 83.7 percent of type 2 diabetes cases were resolved.
    • In the studies analyzed, the control group that didn’t have bariatric surgery was at a higher risk for type 2 diabetes: 3.7 times higher.
    • Resolution of type 2 diabetes often occurred within days of the surgery.
    • Over 80 percent of cases of high cholesterol were resolved.
    • 75 percent of hypertension cases were resolved.
    • Substantial weight reduction occurred; 61.6 percent of excess weight was lost.
  • A study of 500 patients showed that 96 percent of co-morbidities (the study looked specifically at back pain, sleep apnea, high blood pressure, type 2 diabetes, and depression) were improved or resolved.
    • A great deal of excess weight was lost, and patients experienced resolution of co-morbidities, and improved appearance, social opportunities, and economic opportunities.

Type-2 diabetes is a long-term metabolic disorder in which there is resistance to insulin, the naturally produced hormone that controls blood sugar. While type 2 diabetes may occur regardless of someone’s age, gender, or body mass, the disease tends to be more severe in the obese. Because of excess weight, obese individuals develop a resistance to insulin.

Patients who have metabolic bariatric surgery such as Sleeve Gastrectomy have lower insulin resistance due to increased levels of GLP-1 hormone and other incretins that help insulin function more efficiently. Their risk for metabolic syndrome, high blood pressure, and a high amount of fats in the blood is also decreased. In fact, a landmark study found that resolution of diabetes often occurred within days following gastric reduction surgery, even before marked weight loss was achieved. A large meta-analysis of more than 22,000 patients showed over 75% percent of bariatric surgery patients found complete resolution of type 2 diabetes, and 86 percent found improvement or resolution. Majority of patients with type 2 diabetes have demonstrated little or no need for continuing medication.

Excess body weight keeps the heart from working properly. The result can be high blood pressure (hypertension), which can cause strokes and heart and kidney damage. Evidence shows that the age-related lifetime risk of hypertension in men and women ages 45 to 54 will double as their average BMI increases from 25 to 35.7 While hypertension may occur regardless of someone’s age, gender, or body mass, it tends to be more severe in the obese.

Bariatric surgery reduces excess body weight over time, which takes away some of the strain on the heart. Changes in diet and exercise after surgery can lead to significant improvement of hypertension and other cardiovascular problems. Studies have shown reductions in total cholesterol and LDL levels and increased HDL levels. Even a weight loss of 10 percent can lower blood pressure significantly.

A recent meta-analysis showed hypertension was resolved or improved in 78.5 percent of patients. A study of 500 patients showed 92 percent resolution of hypertension.

Hypercholesterolemia, or high cholesterol, is a condition in which there is excess of certain lipids in the blood. As these lipids build up inside the artery walls, harmful scar tissue and other debris begin thickening and hardening the walls. Doctors call this condition atherosclerosis or hardening of the arteries. While this may occur regardless of someone’s age, gender, or body mass, the disease tends to be more severe in the obese.

Research on the impact of bariatric surgery has found that hyperlipidemia and hypercholesterolemia are improved in more than 90 percent of patients.

Osteoarthritis is one of the most common forms of arthritis. It is a chronic condition in which there is a breakdown of a joint’s cartilage. For anyone who is suffering from morbid obesity, the excess body weight placed on joints, particularly knees and hips, results in wear and tear and pain. Similarly, bones and muscles of the back constantly are strained, causing disk problems, pain, and decreased movement ability. While osteoarthritis may occur regardless of someone’s age, gender, or body mass, the disease tends to be more severe in the obese.

As less weight is placed on joints, the strain placed on these joints is reduced. Bariatric surgery can reduce much of this weight over a long period of time and can be very effective in treating osteoarthritis.

A recent study of 500 patients showed a 90 percent resolution of arthritis among surgical patients.

Depression is an illness that involves the body, mood, and thoughts. It affects the way a person eats and sleeps, the way one feels about oneself, and the way one thinks about things. There are many reasons why people with morbid obesity experience depression. Many of the everyday activities people with healthy body weight take for granted are big challenges for a person suffering from morbid obesity. These activities may include walking, social interaction, finding clothes that fit, and fitting in public seats. While depression may occur regardless of someone’s age, gender, or body mass, it tends to be more severe in the obese.

Emotional health goes hand in hand with physical health. Lifestyle improvements and renewed health can help resolve depression. Weight loss, combined with counseling, can be very helpful in improving mental health.

Patients who have had bariatric surgery report improved quality of life, social interactions, psychological well-being, employment opportunities, and economic conditions. Psychological screening before surgery may help prepare you for the changes that come with surgery, and help you set realistic goals and expectations.

Obstructive sleep apnea is when breathing suddenly stops because soft tissue in the rear of the throat collapses and closes during sleep. Morbid obesity can cause sleep apnea and other respiratory problems. The greater your excess body weight, the greater the amount of fat pressing down on your chest and lungs. While sleep apnea may occur regardless of someone’s age, gender, or body mass, the disease tends to be more severe in individuals with excess weight.

Reducing overall excess body weight reduces fat deposits in the tongue and neck that cause sleep apnea. Clinical data show that sleep apnea is present in 60 percent of patients undergoing bariatric surgery.

Recent research found that obstructive sleep apnea was resolved in over 85 percent of patients through bariatric surgery.

Many people suffering from sleep apnea are undiagnosed. If you have excess weight, and feel tired excessively during the day and fall asleep frequently, talk to your physician about ordering a test to diagnose obstructive sleep apnea.

Among women, severe obesity is a big risk factor for urinary stress incontinence, or uncontrollable urine loss. A large, heavy abdomen and relaxation of the pelvic muscles due to severe obesity may cause the valve on the urinary bladder to weaken, leading to leakage of urine with coughing, sneezing, or laughing. While urinary stress incontinence may occur regardless of someone’s age, gender, or body mass, the condition tends to be more severe in the obese.

Bariatric surgery has been found to improve urinary stress incontinence. Less weight is placed on the bladder, and other physical changes take place to improve this condition.

A 2000 study of 500 patients showed 97 percent resolution of urinary stress incontinence in patients after bariatric surgery.

Asthma is a disease of the respiratory system in which the airways unexpectedly narrow. Adult-onset asthma is closely associated with GERD. Common symptoms of asthma include wheezing, coughing, and chest tightness. While asthma may be found regardless of someone’s age, gender, or body mass, the disease tends to be more severe in the obese. While asthma remains a treatable but incurable disease, research has shown improvement in asthmatic symptoms through significant weight loss.

Reproductive health can be a concern for women struggling with severe obesity. Issues such as infertility (the inability or reduced ability to produce children) and menstrual irregularities may occur due to severe obesity. Menstruation issues include cycle interruption, abnormal flow, and additional pain during your menstrual cycle. Fertility issues include possible miscarriage, reduced success with fertility treatments, and polycystic ovarian syndrome (PCOS).

PCOS is an endocrine disorder in women of childbearing age that can cause infertility and other reproductive health conditions. Classic symptoms include obesity, an increase of facial and body hair (hirsutism), acne, irregular menstrual cycles, and infertility.16

Bariatric surgery has been found to improve or resolve conditions that may interfere with pregnancy, such as PCOS and hypertension. This procedure also reduces weight on reproductive organs and influences other physiological changes affecting fertility.

Female bariatric patients will be required to take steps to prevent pregnancy during the first 18-24 months after surgery. Therefore, it’s important to know about any changes in fertility after surgery so that you don’t become pregnant too soon.

A recent study of women following gastric bypass surgery showed improvement of multiple clinical problems related to infertility and PCOS. All women continued to have normal menstrual cycles after about three months following surgery. Of the women who experienced hirsutism (excessive hair), 52 percent had complete resolution.15 In overweight women, weight loss (as little as 5 percent) may restore ovulation and fertility.16

Yes. In a landmark study in the New England Journal of Medicine, bariatric surgery was shown to reduce the risk of death 7 years after surgery by 40% from all causes, and by 92% from Diabetes. 28

Reduced life span due to obesity is important to consider. Compared to a person of normal weight, a 25-year-old obese man has a reduced life span, and he can expect a loss of about 12 years of life.3

Bariatric surgery continues to benefit people struggling with severe obesity worldwide. Most importantly, bariatric surgery saves lives. Recent studies show that bariatric surgery patients are living longer lives than severely obese individuals. You also can see the benefits of bariatric surgery when you look back on how individual lives have improved.

Bariatric surgery is an effective weight loss treatment. A recent study established the following criterion for successful bariatric surgery: the ability to achieve and maintain loss of at least 50 percent of excess body weight without significantly undesirable effects. Typical results for bariatric surgery meet this success criterion. The majority of people who have bariatric surgery are able to keep off at least half of their excess body weight long term.

The amount of weight a patient will lose after the procedure depends upon several factors. These include:

  • Patient’s age
  • Weight before surgery
  • Overall condition of the patient’s health
  • Surgical procedure
  • Ability to exercise
  • Commitment to maintaining dietary guidelines and follow-up care
  • Motivation of patient and help from family, friends, and associates

Bariatric surgery such as Sleeve Gastrectomy work by restricting the capacity to eat large meals and by altering metabolic hormones that control appetite and satiety. The mechanical restriction is complemented by reduced sense of hunger and augmented sense of fullness. In spite of consuming few calories, patients experience reduced hunger. This is in contrast with regular dieting in which consuming reduced calories results in excess hunger.

Bariatric surgery has been performed for many decades. For many of those years, the surgery was performed as an open procedure. An open procedure means a surgeon creates a large incision. As medical technology evolved, laparoscopic or minimally invasive surgery became a possibility. With laparoscopic surgery, the surgeon creates small incisions. Both approaches have similar success rates in reducing excess weight and improving or resolving co-morbidities. However, laparoscopic surgery has significantly lower rate of wound complications and other short and long-term complications.

Open Surgery: Open surgery involves the surgeon creating a long incision line to open the abdomen and operating with “traditional” medical instruments. Because of the incision, the patient’s stay in the hospital will be several days longer than with minimally invasive surgery. The recovery time is also longer. Patients generally will need to heal for several weeks before returning to work and regular physical activities. With a longer wound, there is more of a chance of wound complications such as infections and hernias. A long incision leads to a long scar. To date, 100% of patients in our practice have been able to avoid open bariatric surgery.

Laparoscopic or Minimally Invasive Surgery: A laparoscopic operation involves making several small incisions for different instruments to be used. There are, on average, 5 ports created. The instruments, including a small video camera, are inserted through the ports. The surgeon uses a monitor to perform the procedure. Due to reduced pain, patients recover from laparoscopic surgery in a shorter time than from open surgery. Many return to day to day activities and light work in 1-2 weeks. Patients generally have very small scars. There is also a lower chance of wound complications such as infection and hernia.

IV. About Insurance coverage

Since every insurance policy is unique, it’s important that you thoroughly understand your certificate of coverage to know exactly what is and isn’t covered through your plan. As a first step, speak to your insurance company. Ask them to specify if bariatric surgery is a covered benefit in your policy. You will need to provide them the surgical CPT-43775 for sleeve gastrectomy to receive this information. Not only insurance companies vary in their coverage of weight loss procedures, individual policies may also vary in their nature. Some policies may have “exclusion clauses” and may not cover bariatric surgery. It is very important that you ask your insurance company to be very specific about their company’s policy and your own policy as they pertain to bariatric surgery.

To qualify for insurance coverage, some insurers require patients to have documentation of having been morbidly obese for 5 years as well as having undergone a medically supervised weight-loss program in the past 12 months. To meet these two important criteria, you will need to gather all the information your insurance company requires. This may include diet records, medical records, medical tests going back at least 2-5 years depending on the insurance company. Letters from your personal physician and professionals supporting the medical necessity of treatment are particularly valuable. When several physicians report the same findings, it may confirm a medical necessity for surgery.

Keep track of every visit to a healthcare professional for weight-related issues. Similarly get records related to medically supervised weight loss programs. Make note of other weight-loss attempts made through diet centers and fitness club memberships. Keep all your receipts. Once you complete these requirements, we will communicate with your insurance carrier to obtain a preauthorization. The goal of our pre-authorization letter is to establish medical necessity for bariatric surgery and gain approval for the procedure. The following information is generally included in the preauthorization letter:

  • Your height, weight, and Body Mass Index, and any documentation you might have as to how long you have been overweight.
  • A full description of all your weight-related health conditions, including records of treatment, a history of medications taken, and documentation of how these conditions affect your everyday life.
  • A detailed report of how your excess weight affects daily activities, such as walking, tying your shoes, or maintaining personal hygiene.
  • A detailed history of the results of your dieting efforts, including medically and non-medically supervised programs, medical records, and records you may have kept of payments to and meetings you’ve attended with commercial weight loss programs.
  • A history of exercise programs, including receipts for gym memberships.
  • Normally, your insurance provider will respond to our request within 30 days.

If your insurance company turns down a pre-authorization request for bariatric surgery, you may be able to appeal the decision. Many people do not take advantage of the appeals process or know of the laws that govern insurance companies in their state. Your health is worth the time and energy it takes to advocate coverage. At this point, consider hiring an insurance lawyer or insurance advocate, both of whom can be very helpful. An insurance lawyer or advocate should have an in-depth understanding of the appeals process, as well as any laws that apply, and how to go about responding to the insurance company.

It’s critical that you understand your health insurance policy thoroughly, including the number of appeals you are allowed and what constitutes an appeal. The number of denials varies among policies and is detailed in your Certificate of Coverage. With some insurance carriers, the number of appeals that you can make is limited. So be sure to learn as much as possible about the appeals process ahead of time.

Assistance is key. We will assist you in this very important process and to help you adhere to your policy’s requirements. Even when patients have exhausted their appeals processes, they may still have options. Options can include an independent review board, arbitration, litigation, or self-finance.

Independent Review Board: This option is available to people in more than 40 states. Look on your state’s website for filing instructions. No lawyer is required. Judgments usually are issued in 60 days.

Arbitration: Some health plans require patients to use a third party, other than the patient’s lawyer and the insurance company, instead of going to court.

Litigation: This option is expensive and takes a lot of time but can be a last resort.

Self-finance: Because of the need to provide a cost-effective alternative to insurance-covered programs, our program in partnership with Good Samaritan Hospital is able to offer a cost-effective self-financed option worth exploring. The total cost of the procedure is nearly one half of the cost a decade earlier. Because of that, self-financing is not only within the reach of many individuals today, it provides a significantly shorter timeline to surgery as compared to all other options named above. Patients can receive surgery within 2-3 weeks of a decision to pursue this option.

Health insurance is one of the most common benefits offered by employers to their employees. A few insurance companies have made it a policy not to offer bariatric surgery coverage. However, it is often the case that larger employers decide what health services and procedures are covered under their benefit plan, not the insurance company that administers the health benefits.

If you find that your employer does not offer coverage for bariatric surgery as part of its benefits package, there are steps you can take. Find out why it’s not covered. It might be beneficial for you to provide your human resources representative information about benefits of bariatric surgery. Often, a quick meeting with the person will tell you how much your administrator knows about advantages of bariatric surgery, such as increased energy levels and a decrease in health problems.

You may find that a combination of your own story, your medical history, and peer-reviewed articles from reputable medical journals will help your benefits administrator understand that severe obesity is a chronic disease and that bariatric surgery is a medically accepted treatment of the disease. By finding statistics that detail the costs of obesity, including the costs of treating obesity and its co-morbidities, and lost productivity, you can create a powerful financial argument stated in dollars and cents. Using this information, the benefits administrator can share your story and the need for insurance coverage with others who will make the final decision.

Getting coverage approved by an employer can be a time-intensive process that may require several meetings. Educating coworkers about the surgery and its importance helps to fight society’s obesity bias, and you may find that other people are interested in bariatric surgery, too.

Self-finance: Because of the need to provide a cost-effective alternative to insurance-covered programs, our program in partnership with Good Samaritan Hospital is able to offer a cost-effective self-financed option worth exploring. The total cost of the procedure is nearly one half of the cost a decade earlier. Because of that, self-financing is not only within the reach of many individuals today, it provides a significantly shorter timeline to surgery as compared to all other options named above. Patients can receive surgery within 2-3 weeks of a decision to pursue this option. Visit the patient resource page to learn more about financing option.