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Questions & Anwsers

What is "bariatric surgery?"
This is a surgical specialty that involves operative procedures used in the treatment of morbid obesity and the related health conditions.  All of the bariatric procedures are performed specifically to induce weight loss and work on the concepts of restriction (decreased food intake), malabsorption of calories and nutrients, or a combination of the two.  

How Does Surgery Promote Weight Loss?
The basic mechanisms that promote weight loss after bariatric surgery are restriction, malabsorption, and a combination of restriction and malabsorption.  Restrictive operations limit food intake but do not interfere with the normal digestive process.  Malabsorptive operations limit the number of calories and nutrients absorbed and to a lesser degree, the amount of food eaten.  A combined procedure involves both restriction and malabsorption.

An adjustable gastric band (LAP-BAND) is a purely restrictive operation.  The band is placed on the upper part of the stomach, creating a small outlet into the lower, larger part of the stomach.  The smaller upper stomach will only hold a small amount of food and the narrow outlet delays the emptying of food into the lower stomach, resulting in a longer lasting feeling of fullness or satiety.  Using saline through a tube that connects the band to an access port placed under the skin of the abdomen, the band can be tightened or loosened over time to change the size of the outlet between the upper and lower stomach. 

The Roux-en-Y Gastric Bypass operation is a combined restrictive/malabsorptive procedure.  The surgeon creates a small stomach pouch to restrict food intake. Next, the small intestine is divided and attached to the new stomach pouch.  This process allows food to bypass the remainder of the stomach and a portion of small intestine, reducing the amount of calories and nutrients the body is able to absorb.

The biliopancreatic diversion/duodenal switch (BPD/DS) is also a combined procedure, but is more complicated than the Roux-en-Y.  Instead of bypassing a portion of the stomach, approximately 75% of the stomach is removed.  Malabsorption occurs when the small intestine is divided and rearranged to keep food from mixing with digestive juices.  A portion of the intestine is brought up and connected just past the pylorus, the valve at the outlet of your stomach.  In the last step, the surgeon attaches the small intestines together down near the colon, creating a small area known as the "common channel" for digestive enzymes and food to combine and absorb nutrients.

 What are the advantages of the LAP-BAND?

  1. Adjustable gastric bands are easier to perform and have a much lower complication rate when compared to the Roux-en-Y or BPD/DS.
  2. The hospital stay is shorter - overnight in almost all patients. 
  3. This operation is considered completely reversible, if necessary. 
  4. There are few nutritional deficiencies seen in patients with an adjustable gastric band.

What are the disadvantages of the LAP-BAND?

  1. Weight loss is slower when compared to the Roux-en-Y or BPD/DS.
  2. The overall percentage of excess weight loss is lower.
  3. Long-term outcomes in the United States are unknown at this time.

What risks are involved with the LAP-BAND?
This is the safest bariatric procedure with complications seen in less than 1 percent of patients.  However, it is not risk-free.  The most frequently reported complication is vomiting. This happens if the patient attempts to eat too much or if the outlet into the lower portion of the stomach becomes blocked.  Slippage or wearing away of the band, and breaks or needle puncture in the tubing between the band and the access port may occur and require another operation to repair.  Although rare, death, infection, and/or bleeding may also occur.

What are the advantages of Roux-en-Y gastric bypass?

  1. Most patients lose weight quickly and continue to lose for 18 to 24 months after the procedure
  2. Many patients maintain a weight loss of 55 to 70 percent of their excess weight for 10 years
  3. Because of greater weight loss, the Roux-en-Y may also be more effective in improving obesity-related health problems such as type 2 diabetes, sleep apnea, high blood pressure, and osteoarthritis.

What are the disadvantages of Roux-en-Y gastric bypass?

The disadvantages of the Roux-en-Y and the BPD/DS are much the same.  Technically, they are more difficult to perform than a LAP-BAND. Of the three procedures, the BPD/DS is the most complicated; for that reason there are relatively few surgeons performing this operation.  Some of the most serious risks associated with these operations include:

  1. The risk of death is 0.5 to 2 percent of all cases. This rate is similar to other major operations such as hip replacement surgery.
  2. Leaking of stomach fluids from the stomach or intestine where a new connection (anastomosis) was made. If a leak is suspected, another operation is required to repair the leak. This occurs in about 1 percent of patients.
  3. Bleeding can occur in any area where surgical staples were placed. In many cases, the bleeding stops on its own, on occasion, another operation to find the bleeding area may be necessary. This occurs in about 2 percent of patients.
  4. An ulcer in the area where the new stomach pouch is connected to the small bowel occurs in about 2 percent of patients.
  5. Blood clots may form in the lungs (pulmonary emboli) or in the legs (deep vein thrombosis) and require treatment with blood thinners for several months.
  6. Overall, infections occur in about 1 percent of all patients. This includes wound infections, pneumonia, abdominal abscess, and urinary tract infection
  7. Due to the malabsorptive component of these procedures, there is a risk for long-term. In turn, nutritional deficiencies can cause complications such as anemia and osteoporosis. As a preventative measure, patients must take nutritional supplements every day for the rest of their lives.

Beyond the immediate postoperative period, complication can occur months and even years after bariatric surgery.  It is possible to develop hernias, bowel obstructions, nutritional deficiencies, ulcers, strictures (a narrowing at the anastomosis) gallbladder problems and other medical problems.  In addition to information given during our Bariatric Orientation sessions, our surgeons discuss the surgical risks and potential complications with each patient in detail during your surgical consultation.

Why isn't the BPD/DS more frequently?
Although this procedure results in the most weight loss (on average, 75 to 80 percent of excess weight), this procedure is the most technically difficult to perform and carries the highest risk for complications in the short-term as well as long-term. The risk of death is 2.5 to 5 percent. In addition to the same risks associated with the Roux-en-Y, patients often experience chronic diarrhea, abdominal bloating, foul-smelling stool and/or gas.  The BPD/DS cause the highest rates of malabsorption which results in a higher risk of developing nutritional deficiencies.  Additional supplements must be taken along with life-long use of special foods and medications.

What happens to the lower part of the stomach that is bypassed?
In some surgical procedures, the stomach is left in place with intact blood supply. In some cases it may shrink a bit and its lining (the mucosa) may atrophy, but for the most part it remains unchanged. The lower stomach still contributes to the function of the intestines even though it does not receive or process food - it makes intrinsic factor, necessary to absorb Vitamin B12 and contributes to hormone balance and motility of the intestines in ways that are not entirely known. In the BPD procedures, some portion of the stomach is completely removed.

How big will my stomach pouch really be in the long run?
This can vary by surgical procedure and bariatric surgeon but generally, the stomach pouch created in the Roux-en-Y gastric bypass is about one ounce in size (15-20cc).  The stomach pouch can expand over time and many patients end up with a meal capacity of 3-7 ounces.

Why do some people gain back the weight they lost?
Typically when patients gain back weight, it is because they have resumed old eating habits and stopped exercising.  It is possible to "eat around" a bariatric procedure by eating foods that are laden with fat and calories or by "grazing" (eating all day long).   Some patients never change their eating patterns or food types and don't lose much weight, if any, to begin with.  There is no bariatric operation that will do the work for you.  Each patient's level of success depends on their willingness and ability to adhere to a lifetime of healthy eating and regular physical activity.

What is dumping syndrome?
Dumping syndrome is a very unpleasant reaction that can occur after eating foods that are high in simple carbohydrates.  The sugars in these types of food move too quickly through the small intestine and are rapidly absorbed by the body.  This may cause the dumping syndrome symptoms: nausea, abdominal pain and/or bloating, feeling faint or very weak, sweating, and diarrhea.

What's the difference between Laparoscopic Bariatric Surgery and the traditional "open" approach?
Laparoscopic surgery requires mulitple small incisions to pass the required surgical  instruments into the abdomen. The open approach is a single, larger incision. 

Can laparoscopic surgery be performed on any patient requesting it?
No; our surgeons take many factors into account when deciding the best surgical approach.  Patients who have had previous abdominal operations or who weigh more than 350 pounds may be better off using the open approach.  The LAP-BAND is typically placed laparoscopically on all patients.  It is important to be aware that any laparoscopic operation may need to be converted to an open procedure.

How do I know if I qualify for Bariatric Surgery?
Most insurance companies adhere to the recommendations of the National Institutes of Health for bariatric surgery as treatment for obesity

  1. BMI of 35 -39 with one or more obesity-related health condition
  2. BMI of 40 or greater
  3. Age 18 or older

Other qualifying factors may include:

  1. Documented attempts at non-surgical weight loss
  2. Demonstrated willingness and ability to adhere to permanent changes in diet, exercise, and lifestyle.
  3. A commitment to adhere to regular and lifelong medical follow-up care

Each patient must complete a full bariatric evaluation which will include consultation with a nutritionist, psychologist, and other members of our bariatric team.  Our team will help you determine if bariatric surgery is right for you,  and if so, which procedure is best for you.  Our focus is to help you prepare for the changes and challenges that lie ahead.

How is obesity measured?
Body mass index, or BMI, is the measurement most frequently used in the medical field to measure obesity.  The BMI is figured using a mathematical formula that takes into account a person's height and weight: BMI=kg/m2  (weight in kilograms divided by height in meters squared. )  To easily determine your BMI, use the table below; the math and metric conversions are already done.

To use the table, find your height in the left-hand column. Move across the row to your current weight. The number at the top of the column is your BMI. 

What Causes Obesity?
Obesity is a complex disease that involves many factors.  Obesity tends to run in families, suggesting a genetic cause.   Lifestyle behaviors, such as what a person eats and level of physical activity, strongly influence obesity.  Some illnesses and medications may lead to obesity.  Usually, obesity results from a combination of these factors.  For most people, diet and exercise do not provide effective, long-term weight loss.  At Marshfield Clinic, we understand the obstacles you face and are available to help you.

Why do I need to have a psychological evaluation?
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 changes.  Several areas are assessed such as your ability to understand the potential risks and benefits of surgery, whether your expectations about bariatric surgery are realistic, your support systems, your adherence to medical recommendations, and your plan for following the postoperative plan. 

What impact do my medical conditions have on the decision for bariatric surgery, and how can the medical problems affect risk?
Weight loss after bariatric surgery often results in significant improvements in some of the same medical conditions that increase the risk for surgical complications.  Our surgeons evaluate each patient and weigh the surgical risks and potential benefits on an individual basis. 

I don't want to try dieting; can't I just have bariatric surgery instead?
The decision to have bariatric surgery may be one of the biggest you will ever make.  Bariatric surgery should not be considered until you have tried other weight loss methods.  Long-term success of bariatric surgery requires a significant level of commitment that not every individual is ready or able to undertake.

Why Would I Have an Open Procedure?
In some patients, the laparoscopic or minimally invasive approach to surgery is not the best option. 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:

  1. Prior abdominal surgery that has caused dense scar tissue
  2. Inability to see organs
  3. Bleeding problems during the operation

The decision to perform the open procedure is a judgment call made by your surgeon either before or during the actual operation and is based on patient safety.

If I want to have bariatric surgery, how long do I have to wait?
The minimum amount of time needed for a full evaluation is approximately 6 months, depending on insurance requirements.

Can an insurance company deny coverage for bariatric surgery if I have a serious obesity-related medical problem?
Payment may be denied if there is a specific exclusion in your policy for weight loss surgery or "treatment of obesity." Such an exclusion may be appealed if your surgeon and primary care physician believe it is the best therapy for a life-threatening obesity-related health conditions.  However, filing an appeal does not mean the insurance company will reverse their decision.  Pre-authorization most often hinges on documentation showing you have met their qualifications for bariatric surgery.  These typically include a long history of morbid obesity, prior attempts at weight loss, or a psychiatric evaluation and clearance, nutritional counseling, and behavior modification.

Can I get pregnant after weight loss surgery?
It is strongly recommended that women wait at least one year after the surgery before a pregnancy. Approximately one year post-operatively, your body will be fairly stable (from a weight and nutrition standpoint) and you should be able to carry a normally nourished fetus. You should consult your surgeon as you plan for pregnancy.

What can I do to prevent lots of excess hanging skin?
Many people heavy enough to meet the surgical criteria for weight loss surgery have stretched their skin beyond the point from which it can "snap back." Some patients will choose to have plastic surgery to remove loose or excess skin after they have lost their excess weight. Insurance generally does not pay for this type of surgery (often seen as elective surgery). However, some do pay for certain types of surgery to remove excess skin when complications arise from these excess skin folds. Ask your surgeon about your need for a skin removal procedure.

Will exercise help with excess hanging skin?
Exercise is good in so many other ways that a regular exercise program is recommended. Unfortunately, most patients may still be left with large flaps of loose skin.

Will I have to change my medications?
Your doctor will determine whether medications for blood pressure, diabetes, etc., can be stopped when the conditions for which they are taken improve or resolve after weight loss surgery. For meds that need to be continued, the vast majority can be swallowed, absorbed and work the same as before weight loss surgery. Usually no change in dose is required. Two classes of medications that should be used only in consultation with your surgeon are diuretics (fluid pills) and NSAIDs (most over-the-counter pain medicines). NSAIDs (ibuprofen, naproxen, etc.) may create ulcers in the small pouch or the attached bowel. Most diuretic medicines make the kidneys lose potassium. With the dramatically reduced intake experienced by most weight loss surgery patients, they are not able to take in enough potassium from food to compensate. When potassium levels get too low, it can lead to fatal heart problems.

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

What is the youngest age for which bariatric surgery is recommended?
Guidelines from the American Society for Bariatric Surgery and the National Institutes of Health indicate surgery for those 18 years of age and older. Our surgeons have performed bariatric surgery on a limited number of patients 16 and younger. The patient's developmental stage, emotional maturity, and obesity-related medical conditions are strong considerations in the decision to perform bariatric surgery.  There is increasing evidence to support bariatric surgery in adolescent patients, but at this time, most insurance providers do not pay for surgery for those under 18 years of age.

What is the oldest patient for whom bariatric surgery is recommended?
The risk of complications from ANY major operation is generally increased in patients over 65 years of age; however, our surgeons do not have an age "cut off."  For each patient, several factors are considered to help determine whether the benefits of bariatric surgery are likely to outweigh the risks.         

Can bariatric surgery prolong my life?
If you have Type 2 diabetes (or other serious obesity-related health conditions), are at least 100 lbs. over ideal body weight, and are able to comply with lifestyle changes (daily exercise and low-fat diet), bariatric surgery may significantly  prolong your life.

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