What is the youngest patient on whom you will perform gastric bypass surgery?
We can perform surgery on patients as young as 18 years of age. We believe at this age patients are better prepared to make solid choices that will affect them for the rest of their adult life. Patients younger than 18 years are considered on an individual basis. We want our patients to be able to make an informed decision for themselves, and have a solid understanding and willingness to commit to the life-long dietary restrictions they will face following surgery. We believe most individuals are physically and emotionally ready to make such a decision after they have completed their adolescent and teenage years.

What is the oldest patient on whom you will perform gastric bypass surgery?
Patients over 65 require strong indications for surgery and must meet strict criteria in order to be considered for surgery. The risk of surgery in this age group significantly increases along with mortality (Death).

What are the routine tests before surgery?
outine tests performed include a Complete Blood Count (CBC) and a Chemistry Panel, Lipid profile, Thyroid function tests, Iron and vitamin levels, Liver function tests, clotting profile, urine analysis etc. A Chest X-Ray and Pulmonary Function Test will be ordered to determine the health status of your lungs, as well as an Electrocardiogram to determine if your heart is strong and prepared to handle the stresses associated with surgery.  A psychological evaluation, nutritional consult and exercise evaluations are also performed. Ultrasound may be performed in some patients. Selective patients may require sleep study, specialist evaluations and endoscopy.

What is the purpose of all these tests?
An accurate assessment of your health is required before undertaking any surgery. The best way to avoid a complication during and after surgery is to know your state of health prior to having the surgery and optimizing your health to the best state possible prior to the surgery.

We will evaluate and determine if your thyroid function is adequate because hypothyroidism can lead to sudden death following surgery. We also look for signs of diabetes, liver malfunction, breathing difficulties, excess fluid in the tissues, abnormalities of the salts and minerals in body fluids, and abnormal blood fat levels. Some of these laboratory and diagnostic tests will help validate co-morbidities that increase your chances to gain insurance coverage approval.

Why might I need a GI Evaluation?
Not all patients will be required to have a GI evaluation but when it is determined necessary it must be performed prior to having your surgery.  Patients who have significant gastrointestinal (GI) symptoms such as upper abdominal pain, heartburn, belching sour fluid may have serious underlying problems, such as a hiatus hernia, gastro esophageal reflux, or a peptic ulcer. Patients having symptoms of gastric reflux may have early changes in the lining of the esophagus that could predispose them to cancer. It is important to identify these changes so that a suitable surveillance program can be planned for the future.
           
Why might I need a Sleep Study?
Some patients experience signs and symptoms of sleep disorders and are not aware that a problem may exist. The sleep study detects a tendency for abnormal cessation of breathing associated with airway obstruction when the muscles relax during sleep. This condition is referred to as Sleep Apnea. After surgery you will receive sedatives and medications that will help control your pain. Pain medication can depress your normal respiratory drive and protective reflexes, therefore increasing the possibility of an airway obstruction. Sleep Apnea can make this situation life threatening. We need to have a clear picture of what to expect prior to your surgery in order to prevent, or better handle a complication if it should arise. Our office can assist you with arrangements to have the sleep study performed quickly.

Why do I need a Psychological Evaluation?
We do not believe that people with weight problems are crazy!  The psychological evaluation helps determine your understanding and knowledge of the surgery, and ability to follow the basic post-operative weight loss plan. Many insurance companies require the evaluation prior to giving approval for surgery.  Most importantly, you will find that the psychologist may be helpful in defining your personal goals and expectations.

How long does it take to schedule surgery?
Ordinarily, surgery is scheduled within about 2 to 3 weeks once insurance approval is received and financial arrangements are made. Insurance approval is a prerequisite for many people requesting weight loss surgery. You will receive a telephone call from our pre-certification nurse informing you that insurance approval was received. She will provide you with available dates for surgery and you will be asked to select the surgery date that best meets your schedule (we recommend that you do not wait more than about 90 days to have your surgery following approval, or re-approval may be necessary). Once a surgery date is selected, you will be prepared for surgery with preoperative testing and preoperative education.

Why does it take so long to get insurance approval?
Ten to fourteen days following your initial surgical consultation, a letter will be sent to your insurance carrier initiating the approval process. The time it takes to get an answer can vary from about 3-4 weeks or as long as they can dawdle without being asked. Our pre-certification nurse will regularly follow-up on the approval requests. It is extremely helpful when you get behind the process and call your carrier frequently to inquire about the status of your request. Eventually, they get the picture that you are serious and eager to get a response.

How can insurance coverage be denied for a life threatening disease?
Coverage may be denied because there is a specific exclusion in your policy for obesity surgery, or the "Treatment of Obesity". A policy exclusion means that you have no coverage for weight loss surgery. Insurance carriers may state that they do not cover treatment for obesity. It is important for them to understand that we are not treating “obesity”; we are treating an entirely different disease known as “morbid obesity”.
Coverage may also be denied for lack of "medical necessity". A therapy is deemed to be medically necessary when it is needed to treat a serious or life threatening condition. Morbid Obesity has alterative treatments such as dieting, exercise, behavior modification, and some medications that insurance carriers require candidates to have tried prior to seeking surgery as an option for treatment. Medical necessity denials frequently hinge on the insurance company's demand for some form of documentation of such previous dieting attempts. The best approach to these demands is to try to produce as much documentation as possible and submit along with the letter. Once you have successfully jumped over all obstacles, it is more difficult for you to be denied.

What can I do to help speed-up the approval process?
First, provide us with all the information (diet records, medical records, medical tests) necessary to prepare your request for coverage. Letters from your personal physician and consultants attesting to the "medical necessity" of surgical weight loss treatment is particularly valuable in persuading your insurance carrier to cover your surgery. Also obtain all medical records from your physician for the past five years. Insurance company needs your records documenting your height, weight as well as any physician supervised weight loss records. When one or several physicians corroborate the necessity of treatment it is more difficult for the carrier to contradict them. The best chance of approval is when we submit a complete package with all the information the insurance company is looking for. The sooner you provide us with all the necessary documents the sooner we can submit and get the approval.

Secondly, about two weeks after the letter of medical necessity is submitted to your carrier, call them regularly (once a week) to ask about your status.

Does Laparoscopic Surgery decrease the risk?
No. Laparoscopic surgery carries the same risks as the same procedure performed utilizing the open technique. The benefits of laparoscopy are less discomfort, shorter hospital stay, earlier return to work, and reduced post-operative scarring. The complications related to the incision such, as infections in wound and hernia in the incision are much less with the laparoscopy.

How long does the surgery last?
Typically, the gastric bypass requires a total time in the operating room of 3-31/2 hours. The operation itself takes 2 - 3 hours. If your family will be waiting they should understand that the operation might not begin immediately, so they should not watch the clock. If the operation is lasting longer than anticipated, the surgeon will send word on your progress and reasons for the delay.

Will I have a lot of pain?
Every attempt is made to control pain after surgery and make it possible for you to move about quickly. This will help prevent post-operative problems and speed the recovery process. There are several post-operative pain management strategies you and your surgeon will discuss during your pre-operative consultation that will help manage your pain after surgery.  Most of our patients are pleasantly surprised at how little discomfort they experience after surgery.

How long do I have to stay in the hospital?
Typically, the hospital stay (including the day of surgery) is 2-3 days for a Laparoscopic Gastric Bypass and 5-6 days for an Open Gastric Bypass. Most Lap-bands are performed as an outpatient.

Will I have a drain?
Most patients will have a small tube-like drain inserted into the abdominal cavity, which allows accumulated fluids from the abdomen to flow out into a small reservoir. It may produce minor discomfort that can be lessened by applying warm compresses to the drain site. The drain is usually removed 2-7 days following your surgery.

Some patients may require the need for a gastrostomy tube. This is inserted during surgery into the detached stomach. The tube will help keep the detached stomach from expanding and stretching out the new staple lines following surgery. Patients who suffer from sleep apnea and use a device called CPAP may occasionally have this tube in place after surgery. This tube is usually removed the second post-operative week once the staple lines have had a chance to begin the healing process.

How soon will I be able to walk?
Patients are asked to walk or stand at the bedside on the night of surgery and take several walks the next day and thereafter. On discharge from the hospital you will be able to care for all your personal needs, but will need help with shopping and transportation.

How soon can I drive?
We recommend that you do not drive until you have stopped taking prescribed narcotic pain medications and can move quickly to stop your car in an emergency. This is for your own safety and the safety of others on the road. Expect not to drive for 7 14 days after surgery.

Can I drink carbonated beverages after surgery?
Many patients find that when they drink carbonated beverages they are uncomfortable from the gas that the drink produces. Carbonated beverages may stretch your pouch. However if you are following the post-operative guidelines you will find that any flavored drinks between meals are to be avoided. This includes carbonated sodas. Drinking flavored sodas may activate your hunger mechanism and cause you to snack. They also hamper the water intake necessary to hydrate your body.

Why can't I eat red meat after surgery?
We recommend that you avoid it for the first several months because red meats contain a high level of meat fibers or gristle that hold the piece of meat together, and prevents you from separating it into small parts when you chew. It can plug the outlet of your stomach pouch and prevent anything from passing through. This can be very uncomfortable and cause nausea and vomiting. We advise patients to avoid red meats until their stomach is functioning very well, usually after at least 4-6 months following surgery.

What is Dumping Syndrome?
Refined sugars and candy consist of many small molecules that tend to draw fluid into the intestine. After the gastric bypass a condition called "dumping syndrome" may occur. This happens when sugar is taken on an empty stomach, passes rapidly through the stomach into the intestine, and draws a large amount of fluid into the bowel. The physiology is complicated, but the result is a condition much like shock: one turns ghostly pale, breaks out into a profuse sweat, feels butterflies in the stomach, a rapid pulse, and a feeling of prostration. Nausea and vomiting, cramps and diarrhea may follow. Most people who have this reaction never try to sneak another candy bar. We believe that this occurrence is not a bad effect when you're trying to lose weight. Negative reinforcement can go a long way in teaching you to pay attention to what’s best for your body and health. The problem of dumping is avoided by avoiding sweets, candies, and fruit juices on an empty stomach. Certain dressings, barbecue sauce, and mayonnaise may also cause problems and need to be avoided.

What is the problem with milk products?
To digest milk sugar (lactose) our bodies need an enzyme called lactase that may be in short supply in the lower small intestine. Milk and milk products are more difficult to fully digest after gastric bypass. As they move through the digestive tract and settle into the lower segments of the colon bacteria causes milk sugars to ferment. The fermentation process will cause a build up of gas, cramping, and diarrhea that may be quite uncomfortable. Milk can be treated to make it more tolerable, however it's best to try to avoid it all together. Many prepared foods such as those products found in boxes or frozen entrees contain milk sugar as an additive. It is important to learn to be a label reader so you can avoid foods that could potentially cause you discomfort.

What can I do to use the Gastric Bypass "tool" successfully?
The basic principles or the keys to success are quite simple and easy to follow. As long as you follow the guidelines you have done your best.
Eat no more than 3 meals per day.
Eat protein first, every meal.
Drink water - 64-oz./day minimum.
Avoid all liquids with calories except recommended protein shakes.
Do not drink 30 minutes before and 60 minutes after a meal
Exercise regularly.
Absolutely no snacking.

Why drink so much water?
When you are losing weight there is a heavy load of waste products to eliminate. These waste products are excreted mostly in the urine. Some of these substances tend to form crystals, which can cause kidney stones. A high water intake protects you and helps your body to rid itself of waste products efficiently. In addition, water fills your stomach and helps prolong and intensify your sense of satisfaction with food. If you feel a desire to eat between meals, it is because you did not drink enough water in the hours before. 

Why must I exercise on a regular basis?

Following Gastric Bypass surgery weight loss occurs because the amount of food energy (calories) that you are able to eat is much less than what is needed for your body to operate. Your body will make up the difference by burning your reserves or unused tissues. There are two sources of energy it will choose to take from. First, your body will seek unused muscle for its source of energy followed by your fat stores. Your body recognizes your fat store as a precious resource and will only take from those areas if faced with no other choice. If, you do not exercise daily your body will consume your unused muscle, and you will lose muscle mass and strength. Daily aerobic exercise for 20 minutes will communicate to your body that you want to keep your muscles and force it to burn the fat instead.