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Q: Who is eligible for weight loss surgery?
A: Weight loss surgery is for patients who are morbidly obese (100 lbs above their ideal body weight) with a BMI of >40, or > 35 with co-morbidities.
Q: Will this surgery mean I can eat anything and not exercise?
A: No! This surgery is the beginning of a process. There is a very special diet that MUST be followed after surgery, and you MUST commit to a program of excercise. This surgery provides a tool for weight loss and life style changes; it is not a quick fix. This surgery is the beginning of a new life. It will be easier for patients to lose weight after the surgery, because of the surgery.
Q: How much weight can one expect to lose?
A: Weight loss varies depending on the before-surgery weight, after-surgery choice of food and level of activity after surgery. Most patients lose one-third (1/3) of their original weight with in two (2) years after gastric bypass surgery. Weight loss is slower after lap-band surgery but there is data that suggests weight loss after lap-band can continue for years after surgery. Life style changes and exercise are even more important for weight loss after lap-band surgery.
Q: Does this surgery require a blood transfusion?
A: Rarely, but with any surgery there is a chance of having a transfusion if the need arises. This surgery has been done on many Jehovah's Witnesses.
Q: How long is the recovery?
A: Six (6) weeks of no strenuous activities. Most office and routine work can be resumed in three (3) weeks. The lap-band recovery is typically a week.
Q: How long does it take to recover completely?
A: Most patients completely recover in six (6) weeks to three months.
Q: When can I work out with weights?
A: Most patients can begin lifting over 15 pounds six weeks after surgery; if this is done before that time you risk the development of a hernia, which would require hernia repair surgery. After the lap-band® you may return to work in a week, sometimes less.
Q: When can I go back to work?
A: If you have a non-strenuous job, you can go back to work in three weeks with the approval of the Surgeon. If not, you need to be out of work for about six (6) weeks. After the lap-band you may return to work in a week, sometimes less.
Q: How long is the scar?
A: The scar is typically six inches for an open gastric bypass, although it can be longer. For the laparoscopic gastric bypass there are 6-7small port site incisions. The lap-band has five very small (keyhole) incisions.
Q: Is there anything I can do to reduce the appearance of the scar?
A: The scar changes over time. It will go from being thick and red to a much thinner line in a year. Some people find that Vitamin E works well on scars, and there are a number of other products that people use.
Q: Is there a waiting list to have surgery?
A: Yes. We are booked at least one to three (1-3) months in advance. We have a program which we put together which consists of several classes and a meeting with a nutritionist.
Q: How long does it take from the time I turn my paperwork to the scheduled date of surgery?
A: It depends on how long it takes for your insurance company to approve your surgery. Once they approve the treatment, it is just a matter of scheduling the pre-op work and scheduling the surgery. Please allow three weeks after submitting your papers before you call to check for the status.
Q: How long does the operation last?
A: The gastric bypass usually takes three to five (3-5) hours. If other procedures are done it could take more than four hours. The lap-band surgery takes 30 minutes to an hour.
Q: How soon can I have sex after surgery?
A: Typically in three weeks, or when you feel comfortable.
Q: What insurance companies cover the obesity surgery?
A: Most insurance companies cover it, and now HMO's are referring patients for surgery or providing the services themselves. Many insurance companies are becoming more strict in their preoperative requirements, often requiring that a patient have had physician-supervised weight loss program.
Q: How long does it take to get an approval from the insurance company?
A: It varies. Some give an approval on the phone on the first call and most take four to eight weeks.
Q: Do various health insurance cover surgical treatment of obesity?
A: Many health insurance, PPO and HMO cover obesity operations. However there are some health plans with exclusions for obesity operations.
Q: What is the mortality rate?
A: 0.5 – 1%. The most common cause is pulmonary embolism, a blood clot which travels to the lung. The second most common cause is a heart attack. The lap-band surgery has a lower mortality rate.
Q: Can this operation be done through a laparoscope?
A: The surgery can be done through a laparoscope if you meet certain criteria. In a small number of patients laparoscopic surgery may be converted to an open procedure. Laparoscopic surgery does have certain advantages, smaller incisions, decreased pain, better visualization, and lower risk of ventral hernia, but it may not be possible in some individuals. If you desire laparoscopic surgery, and are considered a candidate for it, we will go through these risks with you.
Q: Do patients need additional surgeries after this procedure?
A: Revision operations are due to outlet problems, fistulas, too much weight loss, and not enough weight. About 3% of patients a year will need revision operations. Some patients will need operations after surgery if they develop a leak.
Q: After I lose the weight will my skin sag and should I have a tummy tuck at the same time as surgery?
A: We do not recommend a tummy tuck at the same time as surgery, because often you will not need it. Once you lose weight your skin may return to its normal position. Further, insurance companies often do not cover the cost of this surgery. Decision to consider Tummy tuck or other reconstructive skin surgery should be made 12 – 18 months after weight loss surgery.
Q: What are some of the risks of this surgery?
A: Many are the same risks as other abdominal surgeries and may include...
- Anastomotic Leak
The risk of developing a leak at the staple line (where we make the new connections) is 1.5%. This may result in more surgeries, revisions, and prolonged hospitalization with rehabilitation.
- Heart and Lung Complications
Patients with significant heart disease, lung disease, or very severe obesity are at greater risk of developing complications such as heart attack or lung failure after the surgery. Such complications could require a breathing tube to be placed in the lungs leading to an extended stay in the ICU while on a ventilator. Patients who have had prior heart attacks or heart symptoms like angina are referred to their primary care doctor or a cardiologist for further evaluation prior to the operation. Patients who have had prior heart attacks, congestive heart failure, or who are severely deconditioned (bedridden or limited to minimal activity) are also at risk and would need clearance from the specialists. Many patients have sleep apnea and we ask you to bring your CPAP machine at the time of surgery. In addition, if during your evaluation, the surgeon feels that you have sleep apnea, you will be referred for a sleep study to determine if you need to be on CPAP machine prior to surgery. Pneumonia, atelectasis, or other problems with lungs happen about 10% of the time. This is why we encourage our patients to walk the day of surgery. Smoking increases the risk of lung infections and need for ventilator assistance. It is important to quit smoking for at least 6 weeks before surgery.
- Injury to the spleen
The spleen may be injured and require removal in 2 per cent of cases.
- Blood clots in the leg
This is why we place patients on blood thinners, (which increases risk of postoperative bleeding requiring reoperation) and have patients in stockings. Some of these blood clots will move to the lungs causing a pulmonary embolism, and possibly death.
- Post-surgical Infection
Infection can occur in the wound or in the abdominal cavity. Abdominal infection can be very serious and indicate a leakage of stomach contents from the point at which the small intestine is connected to the small stomach pouch. This can be a serious and life-threatening complication requiring reoperation, prolonged hospitalization, and long ICU stays. The chance of a leak occurring at this location is 1-5%. Infection can occur in the wound about 5% of the time. You are given antibiotics at the time of surgery to decrease this risk. If infection in the wound occurs, the skin and fatty layers of the wound need to be opened and the dressing changed. Healing usually occurs within 3 to 6 weeks.
- Hernia
Hernias are weaknesses in wounds and lead to a sometimes-painful bulge that tends to enlarge with time. This continues to be a problem when the gastric bypass is done using an incision. The risk of a wound hernia occurring is 10-20% greater with open surgery. If a wound hernia occurs, another operation is required to repair it. We typically wait 12 to 18 months until maximal weight loss has occurred before repair.
- Ulcers or strictures
The opening into the stomach may develop an ulcer (which is why our patients must be on life-long medication for this) or the opening may narrow requiring dilation from a gastroenterologist, or even reoperation. This risk is higher in patients who continue to smoke after gastric bypass surgery.
- Late Staple Breakdown
The staple line partitioning the stomach may give way in 5 to 10 per cent of the patients. If this happens food can enter the lower stomach and weight gain can return. This will require reoperation to maintain weight loss.
- Vitamin and mineral deficiencies
This can be prevented by taking vitamins, minerals, and having careful follow up with your primary care physician and a nutritionist.
- Gallstones
More than one-third of obese patients who have gastric surgery develop gallstones. Gallstones are clumps of cholesterol and other matter that form
in the gallbladder. During rapid or substantial weight loss, the risk of developing gallstones increases. We advise patients to take Actigall (generic ursodeoxycholic acid) for the first 6 months after surgery to reduce this risk. If you happen to develop gall stones despite that medication you will need to have your gall bladder surgically removed.
- Hair loss
Twenty percent will have this. This usually happens 3-9 months after surgery. Most patients report that it returns fuller and thicker than before.
- Menstrual irregularities
Common with weight loss, but you should consult your gynecologist after three months.
- No weight loss
You can defeat this, and believe it or not, once a year we have patients who try hard to defeat what we have done. How can you defeat this --- milk shakes, chocolates, and carbonated beverages immediately after surgery. Now you would think that someone with the courage to make a healthy choice for surgery, with all its risks, would make the determination to not destroy the work. Most people will experience plateaus in weight loss - where they will lose ten pounds quickly, then plateau for a while and lose more. If you have reached these, we suggest you walk, and walk some more. But if you manage to stretch your upper pouch it is doubtful you will have another operation. You can overcome what we have done by continuous nibbling, or by excessive intake of high-calorie liquids. If you feel like you will test this procedure, by trying to overeat, nibble, or eating the wrong things please save yourself the trouble of the surgery.
- Death
For most patients, the risk of death from the surgery is less than 1%. It is higher in patients who have severe heart or lung disease or patients who are having revision of gastric bypass surgery. The most common causes of death after the surgery are infection and blood clots that travel to the lungs.
Q: What can I eat after surgery if I have a Roux-en-Y Gastric Bypass?
A: For the first three weeks after surgery the only thing you can eat must be able to fit through a straw - tacos don't fit through a straw. The first four weeks are critical to healing. Some patients cannot tolerate certain foods they ate before the operation. Each individual is different. After four weeks most patients graduate to pureed foods.
Q: How often do post Gastric bypass patients need to eat a day?
A: Three meals a day when you are on solids. Prior to that eat small quantities at least four to five times (4-5) times a day for the first six (6) weeks.
Q: What if I eat, or drink, too much during this time?
A: Two bad things can happen. The worst is that you can disrupt the surgery, which can cause a leak, which can be life threatening. The second is that you can cause the pouch to stretch. If the upper pouch stretches too much you will lose its effectiveness. Third, is that you will vomit. Vomiting is not fun. Vomiting can cause problems, but many of our patients have an irritated stomach the first weeks after surgery. We want you to measure the volume of food you put in your stomach.
Q: How much will I eat the first four weeks after surgery if I have a Roux-en-Y Gastric Bypass?
A: You will have 30 cc, or one ounce. You can have this several times a day, but only 30 cc at a time. Some can tolerate more than this without vomiting, but we recommend you be quite strict the first few weeks.
Q: Can I survive the first few weeks on just this little amount of food?
A: Yes. Most patients who are obese can, with water and vitamins, survive for six months.
Q: Am I really going to be able to eat only a tablespoon of food at a time forever if I have the Roux en Y?
A: No. After a while when you have learned to eat and chew properly, your typical meal will be approximately a quarter (25%) or less of what you could eat before the operation.
Q: What about pureed foods (Roux en Y patients only)?
A: This happens during the transition time. The transition time is typically between week four and six after surgery, although sometimes it is later. During this time you put foods into a blender or a food processor. This is when you can enjoy more. But you do this with the doctor's supervision. Some foods will still not be tolerated. During this time your food is more semi-solid. You still take in a limited volume of food.
Q: Why can't patients eat and drink at the same time (Roux en Y only)?
A: If you gulp water you can wash food out of the pouch and into the small bowel and lessen your feeling of fullness. Therefore you should avoid liquids for ½ hour before and ½ hour after meals after gastric bypass surgery.
Q: Are there any foods that cannot be eaten after Roux en Y?
A: During the first four to six weeks you cannot eat solid foods. You can eat solid foods once you have permission from Dr. Ali. After six weeks some foods will be more difficult to tolerate. Steak can be difficult for some to tolerate.
Q: What about carbonated beverages?
A: We allow carbonated beverages for all surgeries after the first six weeks. Do not gulp these liquids, and please don't drink these beverages while eating food. Also, drink diet. Some of the lightly carbonated, sugar-free waters are helpful to keep hydrated after surgery, and we allow those.
Q: What about coffee, tea, and caffeinated beverages?
A: We advise patients to reduce caffeine intake before and after surgery. Most patients have difficulty consuming adequate amounts of liquids after gastric bypass surgery. If most of these liquids are caffeinated (coffee, tea, soda) they increase the risk of dehydration.
Q: What do I do if my pouch stretches (RNY only)?
A: The pouch normally stretches over time. Patients are able to lose weight, keep it off, and if they need to diet again they find it much easier than before. If a patient is non-compliant with the postoperative diet, it is unlikely that Dr. Ali would revise the pouch.
Q: How can I tell how large my pouch is (RNY only)?
A: Take a container of low fat cottage cheese. Measure out four-ounce portions, and eat slowly. Once you feel full you have reached an approximate pouch size. Most find their pouch has become about 5 to 9 oz after six months.
Q: What is the popcorn test (RNY only)?
A: Some patients think they are plugged up or the opening out of the pouch is too small thus causing them to regurgitate. To differentiate whether the vomiting or regurgitation is due to the patient eating or drinking too fast or the patient not chewing adequately before swallowing verses there being a mechanical problem with the operation, the patient is advised to eat some popcorn. If the patient eats the popcorn with no regurgitation or vomiting, then there is no mechanically obstructive problem with the operation. The patient is eating too fast, chewing inadequately or swallowing large quantities at a time. Popcorn can only be swallowed after chewing well and swallowing small quantities.
Q: How did the popcorn test come about (RNY only)?
A: When Dr. Fobi, a famous bariatric surgeon, was performing gastroplasty operations, he observed patients who would vomit after eating or drinking any type of food or liquid but not popcorn. These patients have radiologically and endoscopically normal stomas but presented with symptoms of outlet stenosis. These patients ate fast, did not chew the foods well, gulped their drinks or did not respond to the feeling of satiety during eating. These patients are best not treated surgically, but by counseling.
Q: What is dumping (RNY only)?
A: Dumping is when, after eating or drinking, you hear or feel your heart pounding, you feel clammy, you're sweaty, or shaky. You may also feel the urge to use the bathroom. Any combination of the above symptoms can occur either mildly or severely depending on what you ate. Some patients experience it after too much sugar usually in liquid form. Others can experience dumping from consuming large quantities of fat greasy food.
Q: What do I do when I have dumping (RNY only)?
A: Sit or lay down. It normally goes away in less than thirty (30) minutes. Make a note of what you just drank or ate. After several episodes of dumping you will be able to tell what foods or drinks to avoid.
Q: Is hypoglycemia a problem after obesity surgery (RNY only)?
A: The sensation may be similar to the dumping syndrome in that the person experiences the same queasy feeling. The person is nauseous, shaky, clammy and sweaty. The patient may experience a rapid and pounding heart beat. However, the cramps and the urge to have a bowel movement are not part of the reaction. The attack usually occurs between meals and is due to inadequate food intake or a long interval between meals. The best treatment is prevention by eating a balanced diet at regular intervals.
Q: Can you drink alcohol or smoke after surgery?
A: In order to be a patient of Dr. Ali's you must agree to stop smoking. There are many calories in alcohol; however moderation is always a key.
Q: Do I have to take vitamins for the rest of my life?
A: Yes. Vitamins A, D, E, Calcium, Iron, B 1, B 12 because your intake is much less with a pouch compared to the regular stomach and because important parts of the stomach and small bowel for absorbing some of the vitamins have been bypassed. The first days after surgery we recommend Flintstones for patients who had the RNY because they are chewable, and the pouch cannot tolerate a large pill.
Q: What happens if I don't take vitamins?
A: You can have vitamin deficiencies. Preventing vitamin deficiencies is an easy thing to do, treating them is not as simple as taking a vitamin, and can put you at a significant health risk. These include anemia, neurological alterations, skin changes and other metabolic abnormalities. These are difficult to diagnose and may take time to correct. Vitamins, Calcium and Iron supplements should be taken life long after this operation.
Q: I normally take medicines. Should I crush them or stop taking them after surgery?
A: Some medicines need to be stopped before surgery, and we will go over these. Some medicines will need to be changed, so have a complete list of your medications available. We will work with your primary care doctor to determine when you should restart some medications and in what form. You probably will not need to restart medications for cholesterol or lipids after these surgeries, and we want these stopped at least a week before surgery (Lipitor, Pravachol, etc.).
Q: Is hair loss common?
A: Yes. Any time you go through rapid weight loss, you can experience hair loss. This is a temporary problem. It is usually during the third through the eleventh months (3-11) after the operation, the period of rapid weight loss. The hair typically comes back fuller and richer than before. Some advocate increasing protein, taking zinc, or biotin.
Q: Is there anything I can do to prevent hanging skin after weight lost?
A: Exercise can help, but if you lose an excessive amount of weight, more than likely you will have hanging skin. Often the skin returns, much as after pregnancy. We recommend exercise to help tone the muscles, and the skin. Some patients will want plastic surgery to help the problem areas, although we suggest patients wait for two years after weight loss surgery: first because there will be less skin to remove, and second, you might not need the plastic surgery.
Q: Will my sex drive change?
A: Yes. Most patients in the first two (2) years will have a decrease in their sex drive. A select few say their sex drive is higher.
Q: When can I resume sex after surgery?
A: Typically in three weeks, or when you feel comfortable.
Q: Can one get pregnant and have children after this surgery?
A: Yes, barring other fertility problems. It is recommended that women with the gastric bypass wait at least 18 months after the operation to get pregnant. Hormone based birth control methods (e.g. birth control pills, patches, or injections) are not very effective and reliable after weight loss surgery. Couples should use a barrier method (e.g. condom) during the first 18 months after weight loss surgery. Women become very fertile during rapid weight loss period after weight loss surgery and need to be very careful and avoid pregnancy for first 12 – 18 months after weight loss surgery.
Q: Are there any patients who have been dissatisfied with the Gastric bypass operation?
A: Yes, but they are few.
Q: Is the surgery reversible?
A: Yes and no. It is anatomically reversible, but not exactly as nature made it. With the RNY the stomach and bowel can be connected to allow eating as before the operation. Another operation is usually necessary for reversal. This is not a simple procedure to reverse the surgery, and the complications from this surgery are much higher. The Lap-Band® is the most reversible of all the surgeries. One should not entertain the idea of reversing this surgery unless there are complications as a result of the surgery, which interfere with your life.
Q: Will I ever regain my weight?
A: The operation is a tool to use to control your weight. If you do not use it correctly, you will regain some of the weight. More than that, the surgery is an opportunity to change lifestyle and eating habits. Having had the surgery will make it easier for you to lose weight in the future, should you need to.
Q: Does anybody not lose weight after the Gastric bypass?
A: Not yet, although some do not lose enough weight. Some patients can overcome the effects of surgery, as we have noted, but this is rare. There are always those patients who will try to out-eat the surgery. But by following our recommendations, they should easily loose weight. | 
