- Once I have decided to have Bariatric Surgery, how do I get started?
- Do I qualify for bariatric surgery?
- If I want to have weight loss surgery, how long do I have to wait?
- How do I prepare ahead for Bariatric Surgery?
- Why do I need to lose weight before surgery?
- How do I cope with my fear of surgery?
- How do I find the support I need?
- What are some of the tests before bariatric surgery?
- Why do I need to have a GI evaluation
- Why do I need to have a sleep study?
- Why do I need to have a psychiatric evaluation?
- What is the purpose of various tests before surgery?
- What can I do before my appointment to speed up the process?
- What do I do on the day of surgery?
- How long does it take to recover from Bariatric Surgery?
- How do I adjust to new daily habits?
- How do I keep the weight off after surgery?
- How will I feel after Surgery?
- What is my diet after surgery?
- How much food and how often will I be able to eat following surgery?
- What could happen if I don’t follow one or more of the dietary guidelines?
- How soon will I be able to walk?
- How soon can I drive?
- When can I go back to my normal activity level?
- Should I use birth control after surgery?
- How do I maintain my excess weight loss?
- Why is exercise so important after surgery?
- How much exercise is needed after bariatric surgery?
- Why is it important to drink so much water?
- How can I find a support group?
- What changes in my lifestyle can I expect after surgery?
- How often are the follow up visits after surgery?
- Do I meet with a dietitian after surgery?
- What is the effect of bariatric surgery on obesity-related health problems?
- How does bariatric surgery affect type-2 Diabetes?
- How does bariatric surgery affect high blood pressure and heart Disease?
- How does bariatric surgery affect high cholesterol?
- How does bariatric surgery affect osteoarthritis of weight-bearing joints?
- How does bariatric surgery affect depression?
- How does bariatric surgery affect Sleep Apnea and Respiratory Problems?
- How does bariatric surgery affect Gastroesophageal Reflux Disease?
- How does bariatric surgery affect Urinary Stress Incontinence?
- How does bariatric surgery affect Asthma and other respiratory disorders?
- How does bariatric surgery affect the reproductive health?
- Will bariatric surgery extend my life expectancy?
- What is the long-term weight loss with bariatric surgery?
- How does Bariatric Surgery Work?
- What are the differences between laparoscopic and open surgery?
- Is it possible that I may undergo an open instead of a laparoscopic procedure?
- What are the potential risks and complications of Bariatric Surgery?
- What is Dumping Syndrome?
- Is there a difference in the results of Surgery between men and women?
- How do I know if I qualify for Insurance Coverage?
- How do I appeal a denial by my insurance company?
- What can I do if my employer does not offer Bariatric Surgery coverage?
- If my insurance company does not pay for bariatric surgery, what are my alternative financing options?
I. About the Period Before Surgery:
In 1991, the National Institutes of Health recommended bariatric surgery as a treatment option for severe obesity1, 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 35or 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 other, less risky weight loss therapies 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. All candidates need to be between ages of 18-70 and free of advanced or irreversible medical conditions, such as end stage liver disease, advanced cancer, etc.
Unlike other large institutional programs which typically have lengthy wait times, 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 the amount of time. They include the type of insurance plan you carry, your associated health conditions, fulfillment of the program requirements (consultation with dietitian, psychologist, and other specialists), and completing the pre-operative tests. Our goal is to make the process quick and pain free.
Weight loss surgery is like other major surgeries. You can best prepare by knowing the benefits and risks of surgery and by closely following your doctor’s instructions.
To mentally prepare yourself:
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.
Write down your reasons for having weight loss surgery, outlining your plans to maintain your weight loss 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.
To prepare yourself physically, follow the guidelines that we will give you. The guidelines will be based upon your procedure, your personal profile, and other factors. They will lay out the need for weight loss before surgery, and the diet, supplement, exercise, and behavioral requirements after surgery. You want to ensure your best outcome, and the guidelines will help you accomplish that.
We will often require our patients to lose small amount of weight before surgery. This is primarily done to decrease the size of the liver, and increase your chances of undergoing a safe laparoscopic procedure without a need to convert to a traditional open surgery. Studies have shown significant shrinkage of the left lobe of the liver with weight loss prior to surgery. We will provide you with an easy-to-follow 10-day plan to help you reach the target weight. Virtually all patients achieve their target weight without much difficulty.
Weight loss surgery reshapes your stomach and changes the digestive process of your body in a positive way. It is major surgery, 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 you control how much you eat can be a great tool. For other people, the idea of surgery and anesthesia 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 this surgery, you may want to examine them. In this section, you’ll learn strategies for working through these fears.
The fear of surgery is not irrational or abnormal; in fact, it’s completely normal. If the idea of surgery or anesthesia scares you, counter the fear by improving your knowledge about modern medicine. Research the risks and benefits of surgery and anesthesia. Once you do that, you will be pleasantly surprised to learn how safe modern bariatric surgery truly is. In fact, at present time the 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 specifically in our practice, with well over a decade of experience and over 1000 bariatric procedures, we have never lost a patient to surgery! This is a rare distinction and we work very hard to make sure our pristine record remains as such. If you are still afraid of surgery, we encourage you to attend a hospital support group 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 told by individuals just like yourself. Finally, if needed, a psychologist or therapist can help you work through your fears and concerns.
For many people who have spent years suffering from morbid obesity, Sleeve gastrectomy and other weight loss operations sound like lifesavers. However, it’s important to be prepared for all aspects of the treatment. Studies have shown that after Sleeve Gastrectomy and Gastric Bypass surgery, hormone Ghrelin is reduced in the blood stream and your appetite is suppressed as a result. These are powerful tools, which when combined with restriction in amount of food intake, help patients achieve sustainable long-term weight loss.
After gastric sleeve or bypass surgery, the amount of food that you eat is less than what you could eat before surgery. At the same time, a feeling of satisfaction, or satiety, is achieved with small quantities of food.
Because your stomach will smaller than its original size, you will have the opportunity to lose excess weight. Dangerous co-morbidities, such as type 2 Diabetes, gastroesophageal reflux disease, and sleep apnea, are often resolved or improved within weeks. As you recover, you may find that clothes that fit a week ago or even a few days earlier suddenly are too large. You also may find that a walk in the park no longer leaves you breathless, that you do remember how to ride a bike, and that you can keep up with your kids.
Many successful gastric sleeve or gastric bypass patients say that their support network helped them immensely in maintaining their new healthy lifestyle changes. From family and friends to bariatric program support groups, there is a wealth of options available for people interested in weight loss surgery.
The first step in getting support is talking to your family and friends about bariatric surgery and your interest in it. You might find that they are completely supportive. While this is always ideal, you might find that some family members and friends are against your decision. Often, this is because your loved ones are concerned about you or have preconceived notions about gastric reduction surgery. Explaining the advantages, benefits, and reduced risks of weight loss surgery may open their minds to its importance.
If you find that they are unsupportive, it doesn’t mean you are alone. Many people have had bariatric surgery and have been very successful with the care they received from the healthcare professionals on their bariatric program team. Support groups are an excellent resource. You’ll find people who share your goals of health and wellness. A support group is a forum for celebrating successes, such as the improvement or resolution of co-morbidities. The support group is devoted to people who have common experiences, who can share their feelings in a safe environment, and develop relationships that can contribute to improved physical and emotional health.
Our bariatric program includes support groups for bariatric surgery patients both before and after surgery. Dana Schroeder, the bariatric coordinator at Good Samaritan Hospital, and Karen Thomas, the bariatric coordinator at El Camino Hospital, Mountain View, manage the support groups for our program. Admission is free for life for our patients. Please ask our office for further information. Our bariatric surgery program also includes psychologists, who can provide tips and techniques for dealing with unsupportive people and listens to your frustrations without judgment.
Support groups are a wonderful place to meet people and get perspective on bariatric surgery. You’ll hear about successes, frustrations, plateaus, and special moments, and have a chance to share your own experiences.
Certain basic tests are done before surgery: Complete Blood Count (CBC), Chemistry panel, and Urine analysis. Often, a blood glucose test is done for diabetes, which is very common in people suffering from obesity. Except for the very young, all patients receive an electrocardiogram. You may receive a gallbladder ultrasound to look for gallstones. Other tests include pulmonary function testing, echocardiogram, sleep studies, endoscopy, cardiology evaluation, and psychiatric evaluation.
Patients who have 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. For example, many patients have symptoms of reflux. Some of these patients may show early changes in the lining of the esophagus, which could be an early sign of esophageal cancer. It is important to identify these changes so that a treatment program can be planned.
If you snore at night, and feel excessively tired and fall asleep frequently during the day, you may be suffering from Obstructive Sleep Apnea. To test for that, the sleep study looks for abnormal stopping of breathing because of the airway being blocked when the muscles relax during sleep, which is linked to a high mortality rate. After surgery, you will be given pain-killing drugs, which affect normal breathing and reflexes. Airway blockage becomes more dangerous at this time. It is important to have a clear picture of whether you have Obstructive Sleep Apnea and start treatment with CPAP (Continuous Positive Airway Pressure) ahead of surgery.
Bariatric surgery will affect you for the rest of your life, so this is a decision that requires a lot of serious thought. For many people, the results are positive, but successful treatment takes dedication and commitment to a lifelong lifestyle change. Most psychiatrists will look at your understanding of the risks and complications of bariatric surgery and your desire to follow the basic recovery plan to see if bariatric surgery is right for you.
A clear picture of your health is needed before surgery. It is important to test your thyroid function because hypothyroidism can lead to sudden death after surgery. If you are diabetic, special steps must be taken to control your blood sugar. Because surgery increases cardiac stress, your heart may be tested. Other tests will show if you have liver malfunction, breathing difficulties, excess fluid in the tissue, abnormalities of the salts or minerals in body fluids, or abnormal blood fat levels.
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 or CPT-43644 for gastric bypass) 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.
Gather all of the information your insurance company may require. This may include diet records, medical records, medical tests going back at least 2-5 years depending on the insurance company. This reduces the chance of being turned down because you failed 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.
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 type 2 diabetes and high cholesterol can be necessary for documentation of medical necessity.
Make a list of all the diets you have tried (a diet history) and take it to your doctor.
Bring any relevant medical data to your first office visit, including reports of special tests (echocardiogram, sleep study, etc.), or a 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.
Quit smoking. Surgical patients who use tobacco products are at a greater surgical risk. Talk to a doctor for help with this.
When you send your letter, call your insurance carrier regularly to ask about the status of your request. Your employer or human relations office also may be able to help you work through any issues. Be sure to write down dates and the names of people you speak with and keep notes about the conversations. When possible, get them to fax you copies of the policies they are quoting.
Make sure your primary care physician is documenting your weight loss efforts and your weight in your medical records at every visit.
For many bariatric surgery patients, the long-anticipated day of surgery is an exciting end to a long wait. It’s often referred by patients who have gone through surgery as their “birthday,” because of the life-changing transformation of health they’ve achieved.
Preparing for the day of bariatric surgery is like preparing for many other surgeries: We will give you specific instructions for you to follow. A few of the more frequently given instructions include:
Do not drink or eat anything prior to surgery, beginning the midnight before the day of surgery.
Most medicines can be taken the day of surgery, just with small sips of water (however, your doctor will have instructions regarding specific medications).
Bring all of your medications with you to the hospital.
Bring your CPAP machine, if you have one, for use in the hospital.
Arrive early; you are usually required to be two hours early.
When you arrive, you will undergo a few preoperative steps. You will change out of your clothes. You will see your nurses, and you will see your bariatric surgeon as well as 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.
If you are not already under anesthesia before you get to the operating room, you will be once there. Then, you will be intubated and your surgeon will perform the operation. Bariatric procedures, whether they are minimally invasive or open, usually last between 70-180 minutes.
After surgery, your healthcare team will make sure your vital signs are acceptable and arrange for you to be taken to a recovery room.
II. About the Period After Surgery:
Bariatric surgery is major surgery and recovery doesn’t happen overnight. Therefore, it’s important to follow your surgeon’s postoperative recovery instructions.
Postoperative pain and discomfort: Many people think that bariatric surgery will be followed by a long and painful recovery period. However, patients usually do not have that experience. In fact, many patients speak of discomfort and soreness rather than pain. Recovery does, however, vary from patient to patient. You may want to speak with your surgeon if you are very concerned about postoperative pain.
Return to normal activity: As with any major surgery, there will be a recovery period when you’ll have to take it easy. Remember that this is a necessary step, and the better care you take during recovery, the more likely and quickly you’ll return to normal activity. Recovery time varies from patient to patient and also is based on the type of surgery you have.
You can expect to be up and moving within hours of your surgery. While you may move slowly at first, many patients have found that each day often brings improvements. Many patients return to normal activities, such as driving, cooking, and caring for children, two to four weeks after surgery. You may also return to work within this time frame. You will be required to avoid lifting heavy objects (heavier than 20 lbs) or doing strenuous activities for six to eight weeks after surgery.
Whether it’s family, friends, or coworkers, build a support network for all aspects of your life. 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.
The recovery period varies among patients and is dependent on many different factors. For example, many patients choose to have laparoscopic, or minimally invasive, bariatric surgery because the recovery period generally is shorter than with open surgery. In some patients, the laparoscopic, or minimally invasive, approach to surgery cannot be used. The decision to perform the open procedure is a judgment made by your surgeon either before or during the actual operation, and is based on patient safety.
Other factors for recovery time include pain tolerance, preoperative health, preoperative BMI, any complications that may occur, and even the patient’s level of compliance to the surgeon’s recovery instructions.
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. Many of these changes will be discussed before surgery and should come as no surprise following surgery. 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.
For people suffering from the lifelong disease of morbid obesity, bariatric surgery can be a powerful tool that allows them the ability to manage their condition. Of course, bariatric surgery is a tool, not a cure. For the surgery to be effective long term, it must be used properly. Through lifestyle changes such as regular exercise and a healthy food plan, many patients are able to make a long-term change for better health.
While most bariatric surgery patients are able to lose excess body weight and improve or resolve their co-morbidities, they still must use the tools given to them effectively in order to achieve long term weight loss.They should follow a healthy and balanced food plan with additional nutritional supplements, as well as regular physical activity. These lifestyle changes contribute to patients’ overall health and can be embraced before surgery, with your doctor’s approval, to prepare you for the changes ahead.
Bariatric surgery is not a quick fix. It’s an ongoing journey toward weight loss through lifestyle changes. After surgery, the difference in your body makes it physically easier to adjust your eating and lifestyle habits. Fortunately, you will not have to go through the process alone. A team of professionals will be there to support your efforts. Positive changes in your body, your weight, and your health will occur, but you will need to be patient through the recovery process.
Hear patients and healthcare professionals including a dietitian speak from experience about the realities of bariatric surgery.
In the early days after surgery, you may not feel much different. Even though you’ve taken a big step, you may find yourself asking what has changed. In the recovery room, you can expect to have some discomfort and feel the effects of the surgery (this can last for several days). Unfortunately, you may feel worse before you feel better.
We will provide you with a Patient Controlled Analgesia (PCA), or a self-administered pain management system, to help control pain.
The changes made to your gastrointestinal tract will require permanent changes in your eating habits that must be followed for successful weight loss. It is important that you follow your guidelines very carefully after surgery. We will provide you with a very detailed guideline when you come for your first office visit. This will also include the dietary supplements you will be taking after surgery. The following is a very brief example of some of the dietary guidelines you will be provided with.
When you start eating solid food, it is important to chew your food thoroughly and eat very slowly. It is important to wait two to three minutes after swallowing before putting the next bite of food in your mouth. You will not be able to digest steaks or similar types of meat if they are not ground or chewed thoroughly.
Don’t drink fluids while eating. They will make you feel full before you have eaten enough food. Fluids consumed with meals can cause vomiting and dumping syndrome, and can lead to feeling hungry sooner after a meal.
Don’t eat desserts and other items with sugar if they have more than 8 gms of carbohydrates per 100 calories.
Avoid carbonated drinks, high-calorie nutritional supplements, milk shakes, foods high in fat, and foods that have no nutritional value.
Limit snacking between meals.
Most patients are instructed to eat ¼ to ½ cup (2-4 ounces) of food each time, in the beginning. As time goes on, you can eat 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 all right.
The guidelines are designed to improve the chance of long-term success in weight loss. If you don’t follow the guidelines, you may not lose or maintain the loss of the estimated 70 to 90 percent of excess weight.
Soon after surgery, within 2-3 hours, we will require you to get up and move around. Patients are asked to walk at the bedside the evening of surgery and take several walks the next day and soon after. Upon leaving the hospital, you may be able to care for all your personal needs, but you will need help with shopping and lifting, and with transportation.
You should not drive until you have stopped taking medications (associated with surgery) and can move quickly and alertly. 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 to 24 months after bariatric 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.
Bariatric surgery is meant to help you keep off excess body weight for life. It does not guarantee the weight loss. Maintaining weight loss means a dedicated lifestyle-finding new ways to deal with food, get exercise, and even relate to other people.
Bariatric surgery is not an immediate fix. It’s a positive, ongoing process of change. Following surgery, your body will give you signals to stop eating before you take in extra calories that would return your excess body weight. It’s what you do with these signals that counts. When you take on new habits and truly stick to them, you can achieve lasting weight loss without dangerous weight loss/weight gain cycles. At least two-thirds of patients who have sleeve gastrectomy are able to keep off at least 60 percent of their excess weight for 10 years or longer.
Your bariatric surgeon, nutritionist, and psychologist are each involved in providing you with ongoing support. Also, you are required to take part in support groups with other patients, where you can share experiences, insights, and concerns. The goal is to adopt lifestyle changes, lose fat, gain muscle, and keep off the weight for good.
Here are some questions patients have asked about maintaining excess weight loss:
When you have bariatric surgery, you lose weight as the amount of food energy (calories) you can eat becomes much less than your body needs. 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 it has saved up. Without daily exercise, your body will burn unused muscle, and you will lose muscle mass and strength. Daily aerobic exercise for 20 minutes will tell your body to use your muscles and force it to burn the fat.
Exercise is an important part of success after surgery. Exercise actually begins on the afternoon of bariatric surgery–the patient must be out of bed and walking. The goal is to walk further every day after that, including the first few weeks at home. You may be encouraged to begin exercising, limited only by discomfort, about two weeks after surgery. The type of exercise depends on your 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 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. A high water intake protects you and helps your body rid itself of waste efficiently, promoting better weight loss. 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.
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 well being. 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 personal ways. Some benefits are common among patients; others are unique to each individual patient.
Here are some of the surgery benefits patients have described:
Improved job or career prospects
Reduced shortness of breath
Increased energy level
Regularly get a good night of sleep
Improved dating life
Greater variety in choice of clothes
Exercise is more rewarding
Here are a few activities and changed behaviors patients have enjoyed:
I put on a bathing suit for the first time in 22 years.
It’s more enjoyable to be outdoors.
I walk farther than I used to.
Now I ride my bike, walk, and go hunting and fishing.
I’m able to ride roller coasters with my daughter.
It’s easier to play and be active with the family.
Traveling is more enjoyable.
To ensure success, we require that you make 4 visits within the first year and then a yearly visit for life. Frequent follow up visits have been shown in many studies to improve surgical outcomes after bariatric surgery. During your visits, you will have physicals, and three times during the first year and yearly thereafter, you will have blood tests to look for anemia (low red blood cell count) and to check levels of various vitamins and essential nutrients.
Personal dietary counseling after surgery is extremely important as you toy with your new diet and lifestyle. At our practice, we have made available to you a number of registered dietitians with experience and expertise. These will be able to meet with you and guide you through the process. Our office will make the necessary appointments for you.
III. About the 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
Sleep apnea/respiratory problems
Urinary stress incontinence
Swollen legs/skin ulcers
A sample of scientific evidence on the effects of bariatric surgery is included below:
A 2004 meta-analysis of more than 22,000 patients showed that those who underwent a bariatric surgical procedure experienced complete resolution or improvement of their co-morbid conditions including diabetes, hyperlipidemia, hypertension, and obstructive sleep apnea.
- A study of 20,000 individuals, half of whom had undergone gastric bypass 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 the 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.
96.9 percent of hyperlipidemia cases were resolved.
75.4 percent of hypertension cases were resolved; 87.1 percent were resolved or improved.
Substantial weight reduction occurred; 61.6 percent of excess weight was lost.
In 2000, 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.
2. How does bariatric surgery affect type-2 Diabetes?
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 gastric bypass surgery have lower insulin resistance. Their risk for metabolic syndrome, high blood pressure, and a high amount of fats in the blood is also decreased.5 In fact, a landmark study found that resolution of diabetes often occurred within days following gastric bypass surgery, even before marked weight loss was achieved. A large meta-analysis of more than 22,000 patients showed 76.8 percent of gastric bypass patients found complete resolution of type 2 diabetes, and 86 percent found improvement or resolution.3 Many gastric bypass surgery patients with type 2 diabetes have demonstrated little or no need for continuing medication.6
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.3
A recent meta-analysis showed hypertension was resolved or improved in 78.5 percent of patients.3 A study of 500 patients showed 92 percent resolution of hypertension.8
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.
Recent research on the impact of gastric bypass surgery found that hyperlipidemia and hypercholesterolemia were improved in more than 93 percent of patients.3
Osteoarthritis is one of the most common forms of arthritis. Known as the wear-and-tear kind of arthritis, osteoarthritis 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 rapid wear and tear, and pain caused by inflammation. 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.8
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.9 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. When you are morbidly obese, you are likely to have a greater buildup of fat deposits in the tongue and neck. While sleep apnea may occur regardless of someone’s age, gender, or body mass, the disease tends to be more severe in the obese.
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.10
Recent research found that obstructive sleep apnea was resolved in 85.7 percent of patients through gastric bypass surgery.3
Many people suffering from sleep apnea go undiagnosed. If you are obese and feel tired and fall asleep during the day, talk to your physician about sleep apnea.
Gastroesophageal Reflux Disease (GERD) is a disorder characterized by heartburn and regurgitation of food. It is a serious disease caused by reflux of stomach acid and ingested food into esophagus. It can be associated with esophagitis (injury to the esophagus caused be chronic exposure to stomach acid), Barrett’s esophagus (a pre-cancerous change in the lining of esophagus), and esophageal cancer. Occasional heartburn does not indicate GERD.
Excess body weight may weaken the valve at the top of the stomach, allowing acid to escape into the esophagus, and causing GERD. While GERD may occur regardless of someone’s age, gender, or body mass, the disease tends to be more severe in the obese.
A five- to 10-year follow-up study that included 16,191 participants showed that there is an independent relationship between obesity, nighttime GERD and habitual snoring, and the onset of asthma and respiratory symptoms in adults.11 A 130-patient study found that people who suffer from GERD experienced a worsening of symptoms as their weight increased.12
Obesity increases a person’s risk of GERD. Bariatric surgery improves GERD by reducing the amount of stomach acid produced, and by reducing the pressure inside the abdomen.
A 2000 study of 500 patients showed complete resolution of GERD in 98 percent of patients.8 While there is anti-reflux surgery, it fails more often in people with morbid obesity and only addresses one co-morbidity.13 Another study found that all participants who had gastric bypass surgery reported an improvement in or no symptoms of GERD.13
Among women, morbid 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 morbid 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 gastric bypass surgery.8
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.14
Reproductive health can be a concern for women struggling with morbid obesity. Issues such as infertility (the inability or reduced ability to produce children) and menstrual irregularities may occur due to morbid 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 morbid obesity worldwide. Most importantly, bariatric surgery saves lives. Recent studies show that bariatric surgery patients are living longer lives than morbidly obese individuals. You also can see the benefits of bariatric surgery when you look back on how individual lives have improved. Although there are benefits, this surgery is not without risks. It’s important to consider each risk in making your decision.
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.19 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.7
The amount of weight a patient will lose after the procedure depends upon several factors. These include:
Weight before surgery
Overall condition of the patient’s health
Ability to exercise
Commitment to maintaining dietary guidelines and other follow-up care
Motivation of patient and help from family, friends, and associates
Surgical treatment, although not without risk, is the most effective long-term treatment for extreme obesity and is likely to be used more widely given that the number of Americans with a BMI > 40 has nearly tripled in the last decade.20 In 2004, approximately 140,600 bariatric surgeries were performed in order to treat morbid obesity.20
There are at least three basic mechanisms by which bariatric surgery helps patients lose weight and improve or resolve their co-morbidities: malabsorption, restriction, and satiety. The most common bariatric surgery performed today, Roux-en-Y gastric bypass surgery, uses all the three mechanisms.
Restrictive procedures limit food intake:
Procedures that use restriction limit the amount of food patients can eat. This is accomplished surgically by creating a small stomach pouch. When eating, the pouch fills quickly and gives a feeling of fullness much sooner. Because patients feel satisfied and full sooner, they eat less.
Malabsorptive procedures alter digestion:
Procedures that use malabsorption change the body’s ability to absorb calories and nutrients from food. The surgeon changes the way food travels through the patient’s system. By rerouting food past a large part of the stomach and a portion of the small intestine, much of the calories and nutrients pass through without being absorbed.
Weight loss through satiety:
Procedures like Roux-en-Y Gastric Bypass and Sleeve Gastrectomy, in addition to restriction or malabsorption, also suppress the appetite and produce a sense of satiety. They suppress the blood levels of a newly discovered hormone called Ghrelin. Ghrelin, which normally stimulates the appetite, is permanently suppressed after Roux-en-Y Gastric Bypass and Sleeve Gastrectomy, allowing patients to limit their food intake without always feeling hungry.
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 long incision, or cut, opening up the patient. 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.24,25
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. In some cases, the open method is necessary due to some patient-specific risks.
Laparoscopic or Minimally Invasive Surgery: A laparoscopic operation involves making several small incisions for different medical devices to be used. There are, on average, four to six ports created. The devices, including a small video camera, are inserted through the ports. The surgeon uses a monitor to perform the procedure. Many patients are able to recover from the surgery in a shorter time than open procedures require. In fact, some return to work in 1-2 weeks, and many are able to quickly return to physical activity. Patients generally have very small scars. There is also a lower chance of wound complications such as infection and hernia.
In some patients, the laparoscopic, or minimally invasive, approach to surgery cannot be used. Here are reasons why you may have an open procedure, or that may lead your surgeon to switch during the procedure from laparoscopic to open:
Prior abdominal surgery that has caused dense scar tissue
Inability to see organs due to anatomy or excess weight
Bleeding problems during the operation
Abnormally large left lobe of liver
The decision to perform the open procedure is made by your surgeon either before or during the actual operation and is based on patient safety. The actual procedure itself is not different when performed through open approach.
IV. About the Side effects of Bariatric Surgery:
Complications due to anesthesia and medications
Deep vein thrombosis and pulmonary embolism
Dehiscence (separation of areas that are stitched or stapled together)
Leaks from staple lines
Ulcers in the stomach or small intestines
Stenosis (narrowing of a passage, such as a valve)
Need to avoid pregnancy for 18-24 months after surgery
Nausea, vomiting, bloating, diarrhea, excessive sweating, increased gas, and dizziness<
Need for additional operations or procedures
According to the American Society for Bariatric Surgery 2004 Consensus Statement, the operative morbidity (complications) associated with Roux-en-Y Gastric Bypass in the hands of a skilled surgeon is roughly 5 percent and the operative mortality (death) is roughly 0.5 percent.26 Long-term data for Sleeve Gastrectomy are unavailable, but operative mortality approaches 0.15% for this procedure.
Complications specific to Gastric Bypass:
Because the duodenum and other sections of the small intestine are bypassed, poor absorption of iron and calcium can cause low total body iron and a greater chance of having iron-deficiency anemia. Patients who experience chronic blood loss during excessive menstrual flow or bleeding hemorrhoids should be aware of the chance of iron-deficiency anemia. Women, already at risk for osteoporosis that can occur after menopause, should be aware of the possibility of increased bone calcium loss. By taking a multivitamin and calcium supplements, patients can maintain a healthy level of minerals and vitamins.
Bypassing the duodenum can cause metabolic bone disease in some patients, resulting in bone pain, loss of height, humped back, and fractures of the ribs and hipbones. Eating foods rich in nutrients and taking vitamins can help patients avoid this.
Chronic anemia due to vitamin B12 deficiency may occur. The problem usually can be managed with vitamin B12 pills or injections.
A condition known as dumping syndrome can occur from eating too much sugar or large amounts of food. While it isn’t considered a serious health risk, the results can be very unpleasant. Symptoms can include vomiting, nausea, weakness, sweating, faintness, and, on occasion, diarrhea. Some patients are unable to eat sugary foods after surgery.
The bypassed portion of the stomach, duodenum, and parts of the small intestine cannot be seen easily using X-ray or endoscopy if there are problems such as ulcers, bleeding, or malignancy.
Eating simple sugars (such as sugar, honey, and corn syrup), high-fat foods, or other small-particle foods can cause dumping syndrome in patients who have had gastric bypass surgery. This occurs when these products, which have a small particle size, are “dumped” from the stomach into the intestine at a rapid rate. Water then is pulled into the intestine from the bloodstream to dilute the sugar load. This flush of water causes symptoms that can include diarrhea, rapid heart rate, hot flashes or sweating and clammy skin, dizziness, or the feeling of needing to lie down. Some individuals experience some or all of these symptoms after eating more than 3 to 5 grams of sugar, alcohol sugar, or greasy foods, while others can handle greater amounts.
Though the symptoms are unpleasant, dumping syndrome can be a helpful condition. Some patients will avoid sugar because of the very unpleasant symptoms it can cause. Dumping syndrome generally occurs 10 to 30 minutes after eating, and the symptoms can last for 30 minutes to two hours.
The best treatment is prevention by avoiding foods that cause dumping syndrome. If you have dumping syndrome, lie down for a short while to lessen the symptoms. Dumping syndrome is a positive side effect of the surgery; it helps you learn to eat healthy!
Both men and women generally respond well to this surgery. In general, men lose weight slightly faster than women do.
V. About Insurance Issues:
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 code CPT-43644 for gastric bypass and 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, many insurers require patients to have documentation of having been morbidly obese for 5 years as well as having a history of medically supervised weight loss efforts. To meet these two important criteria, you will need to gather all of the information your insurance company may require. This may include diet records, medical records, medical tests going back at least 2-5 years depending on the insurance company. This reduces the chance of being turned down because you failed 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.
Keep track of every visit you make to a healthcare professional for obesity-related issues or visits to supervised weight loss programs. Make note of other weight loss attempts made through diet centers and fitness club memberships. Keep good records, including receipts.
Once we recommend bariatric surgery, we will prepare a letter to obtain preauthorization from your insurance company. The goal of this letter is to establish the medical necessity of 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.
Simply describing your condition as morbid obesity is not enough. A full description of all your obesity-related health conditions, including records of treatment, a history of medications taken, and documentation of how these conditions affect your everyday life, is necessary.
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 your request within 30 days. You should schedule a follow-up if you have not heard from your insurance company in that amount of time.
If the insurance company turns down your request for gastric bypass 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. The 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, exactly, 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, and litigation.
Here is some more information about how these three options work:
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. Bariatric surgery is expensive, but patients’ decisions are based on their own resources and desire.
Health insurance is one of the most common benefits offered by employers to their employees. A few health 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 gastric bypass 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 benefits administrator or human resources representative with information about the many benefits of gastric bypass surgery. Often, a quick meeting with the person will tell you how much your administrator knows about the advantages of gastric bypass 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 morbid obesity is a chronic disease and that gastric bypass 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 gastric bypass surgery, too.
If you are considering gastric bypass surgery and need to find an alternative source of financing, the options are out there. Few people are able to pay cash up front for gastric bypass surgery. If you do not have health insurance coverage for gastric bypass surgery, but would like to have it, there are alternative financing options available to you. A popular option is a Medical loan from a financing company. If this is something you are interested, make sure to ask our office and we will provide you reliable information that will help you secure an affordable medical loan.
Important Information for Self-Pay Patients: Self-pay patients should consider the expense of complications. It’s a good idea to hope for the best and plan for the worst. If you do have health insurance (even if it does not cover gastric bypass surgery), be sure to read your policy. You may find that your insurance company will cover medical costs from complications due to the surgery. If not, we can recommend alternate ‘financing plans’ that would cover you in the event of complications.