Frequently Asked Questions
Preparation for Surgery
Surgery
Life After Surgery
Insurance Issues
The Hospital Stay
Diet
General
What are the routine tests before surgery?
Certain basic tests are done prior to surgery: a Complete Blood Count (CBC),
and a Chemistry Panel, which gives a readout of about 20 blood chemistry values.'
All patients but the very young get a chest X-ray and an electrocardiogram.
Other tests, such as pulmonary function testing, echocardiogram, sleep studies,
GI evaluation, cardiology evaluation, or psychiatric evaluation, may be requested
when indicated.
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What is the purpose of all these tests?
An accurate assessment of your health is needed before surgery. The best way
to avoid complications is to never have them in the first place. It is important
to know if your thyroid function is adequate since hypothyroidism can lead to
sudden death post-operatively. If you are diabetic, special steps must be taken
to control your blood sugar. Because surgery increases cardiac stress, your
heart will be thoroughly evaluated. These tests will determine if you have liver
malfunction, breathing difficulties, excess fluid in the tissues, abnormalities
of the salts or minerals in body fluids, or abnormal blood fat levels.
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Why do I have to have a GI Evaluation?
Patients who have significant gastrointestinal symptoms such as upper abdominal
pain, heartburn, belching sour fluid, etc., may have underlying problems such
as a hiatal hernia, gastroesophageal reflux or peptic ulcer. For example, many
patients have symptoms of reflux. Up to 15% of these patients may show early
changes in the lining of the esophagus, which could predispose them to cancer
of the esophagus. It is important to identify these changes so a suitable surveillance
or treatment program can be planned.
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Why do I have to have a Sleep Study?
The sleep study detects a tendency for abnormal stopping of breathing, usually
associated with airway blockage when the muscles relax during sleep. This condition
is associated with a high mortality rate. After surgery, you will be sedated
and will receive narcotics for pain, which further depress normal breathing
and reflexes. Airway blockage becomes more dangerous at this time. It is important
to have a clear picture of what to expect and how to handle it.
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Why do I have to have a Psychiatric Evaluation?
The most common reason a psychiatric evaluation is ordered is that your insurance
company may require it. Most psychiatrists will evaluate your understanding
and knowledge of the risks and complications associated with weight loss surgery
and your ability to follow the basic recovery plan.
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What impact do my medical problems have on the decision
for surgery, and how do the medical problems affect risk?
Medical problems, such as serious heart or lung problems, can increase the risk
of any surgery. On the other hand, if they are problems that are related to
your weight, they also increase the need for surgery. Severe medical problems
may not dissuade Dr. Lambert from recommending gastric bypass surgery if it
is otherwise appropriate, but those conditions will make the risk higher than
average.
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If I want to undergo a gastric bypass, how long do I have
to wait?
New evaluation appointments are usually booked 2-4 weeks in advance. Once a
patient is seen, if the surgeon and patient agree it is appropriate, the operation
can usually be scheduled within 8 weeks. Why so long? There is more need for
weight loss surgery than there are qualified bariatric surgeons.
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What can I do before the appointment to speed up the process
of getting ready for surgery?
- Select a primary care physician if you don't already have one, and establish
a relationship with him or her. Work with your physician to ensure that your
routine health maintenance testing is current. For example, women may have
a pap smear, and if over 40 years of age, a breast exam. And for men, this
may include a prostate specific antigen test (PSA).
- Make a list of all the diets you have tried (a diet history) and bring it
with you to your consultant appointment.
- Bring any pertinent medical data to your appointment with Dr. Lambert -
this would include reports of special tests (echocardiogram, sleep study,
etc.) or hospital discharge summary if you have been in the hospital.
- Bring a list of your medications with dose and schedule.
- Stop smoking. Surgical patients who use tobacco products are at a higher
surgical risk.
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Does Laparoscopic Surgery decrease the risk?
No. Laparoscopic operations carry the same risk as the procedure performed as
an open operation. The benefits of laparoscopy are typically less discomfort,
shorter hospital stay, earlier return to work and reduced scarring.
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Various methods of pain control are available
Every attempt is made to control pain after surgery to make it possible for
you to move about quickly and become active. This helps avoid problems and speeds
recovery. Often several drugs are used together to help manage your post-surgery
pain.' Various methods of pain control, depending on your type of surgical
procedure, are available.
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How long do I have to stay in the hospital?
As long as it takes to be self-sufficient. Although it can vary, the hospital
stay (including the day of surgery) can be 2-3 days for a laparoscopic gastric
bypass, and 5-7 days for an open gastric bypass.
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Will the doctor leave a drain in after surgery?
Rarely patients will have a small tube to allow drainage of any accumulated
fluids from the abdomen. This is a safety measure, and it is usually removed
a few days after the surgery. Generally, it produces no more than minor discomfort.
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If I have surgery, what can I expect when I wake up in
the recovery room?
When you awaken in the recovery room, your nurse will be monitoring your vital
signs (blood pressure, pulse and respiratory rates) every few minutes, as well
as checking your surgical incisions, monitoring your level of consciousness
and your return to wakefulness from the anesthesia. You will have several, small
light dressings covering your incisions as well as an elastic abdominal binder
covering your abdomen. In addition, you will be wearing sequential compressions
devices (SCDs) on your lower legs to help prevent blood pooling in your extremities.
You will remain in the recovery room until your condition stabilizes, when you
will be moved to a room in the Progressive Care Unit (PCU).
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How soon will I be able to walk?
Almost immediately after surgery Dr. Lambert will require you to get up and
move about. Patients are asked to walk or stand at the bedside on the night
of surgery, walk to the bathroom with assistance and take several walks the
next day and thereafter. On leaving the hospital, you may be able to care for
all your personal needs, but will need help with shopping, lifting and with
transportation.
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How soon can I drive?
For your own safety, you should not drive until you have stopped taking narcotic
medications and can move quickly and alertly to stop your car, especially in
an emergency. Usually this takes 7-14 days after surgery.
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What do I need to do to be successful after surgery?
The basic rules are simple and easy to follow:
- Immediately after surgery, our staff will be provide with special dietary
guidelines. You will need to follow these guidelines closely. You will begin
with a clear liquid diet, moving to semi-solid foods and later solid foods
can be tolerated without risk to the surgical procedure performed. Allowing
time for proper healing of your new stomach pouch is necessary and important.
- When able to eat solids, eat 5 - 6 small meals per day. Protein in the form
of lean meats (chicken, turkey, fish) and other low-fat' sources should
be eaten first. These should comprise at least half the volume of the meal
eaten. Foods should be cooked without fat and seasoned to taste. Avoid sauces,
gravies, butter, margarine, mayonnaise and junk foods.
- Never eat between meals. Do not drink flavored beverages, even diet soda,
between meals.
- Drink 2-3 quarts or more of water each day. Water must be consumed slowly,
1-2 mouthfuls at a time, due to the restrictive effect of the operation.
- Exercise aerobically every day for at least 20 minutes (one-mile brisk walk,
bike riding, stair climbing, etc.). Weight/resistance exercise can be added
3-4 days per week, when Dr. Lambert tells you that your incision and pouch
have healed sufficiently.
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What's so important about exercise?
When you have a weight loss surgery procedure, you lose weight because the amount
of food energy (calories) you are able to eat is much less than your body needs
to operate. It has to make up the difference by burning reserves or unused tissues.
Your body will tend to burn any unused muscle before it begins to burn the fat
it has saved up. 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 use your muscles and
force it to burn the fat instead.
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What is the right amount of exercise after weight loss
surgery?
Many patients are hesitant about exercising after surgery, but exercise is an
essential component of success after surgery. Exercise actually begins on the
afternoon of surgery - you will be out of bed and walking. The goal is to walk
further on the next day, and progressively further every day after that, including
the first few weeks at home. Patients are often released from medical restrictions
and encouraged to begin exercising about two weeks after surgery, limited only
by the level of wound discomfort. The type of exercise is dictated by the patient's
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 are encouraged to progress to more vigorous activity when they
are able.
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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 Dr. Lambert as
you plan for pregnancy.
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What if I have had a previous weight loss surgical procedure
and I'm now having problems?
Contact your original surgeon - he or she is most familiar with your medical
history and can make recommendations based on knowledge of your surgical procedure
and body.
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What happens to the lower part of the stomach that is bypassed?
In the procedure performed by Dr. Lambert, 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.
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How big will my stomach pouch really be in the long run?
In the Roux-en-Y gastric bypass, the stomach pouch is created at one ounce or
less in size (15-20cc). In the first few months it is rather stiff due to natural
surgical inflammation. About 6-12 months after surgery, the stomach pouch can
expand and will become more expandable as swelling subsides. Many patients end
up with a meal capacity of 3-7 ounces.
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What will the staples do inside my abdomen? Is it okay
in the future to have an MRI test? Will I set off metal detectors in airports?
The staples used on the stomach and the intestines are very tiny in comparison
to the staples you will have in your skin or staples you use in the office.
Each staple is a tiny piece of stainless steel or titanium so small it is hard
to see other than as a tiny bright spot. Because the metals used (titanium or
stainless steel) are inert in the body, most people are not allergic to staples
and they usually do not cause any problems in the long run. The staple materials
are also non-magnetic, which means that they will not be affected by MRI. The
staples will not set off airport metal detectors.
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What if I'm not hungry after surgery?
It's normal not to have an appetite for the first month or two after weight
loss surgery. If you are able to consume liquids reasonably well, there is a
level of confidence that your appetite will increase with time.
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Is there any difficulty in taking medications?
Most pills or capsules are small enough to pass through the new stomach pouch.
Initially, medications cab be taken in liquid form or crushed.
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Will I be able to take oral contraception after surgery?
Most patients have no difficulty in swallowing these pills.
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Is sexual activity restricted?
You can return to normal sexual intimacy when wound healing and discomfort permit.
Many patients experience a drop in desire for about 6 weeks.
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Is there a difference in the outcome of surgery between
men and women?
Both men and women generally respond well to this surgery. In general, men lose
weight slightly faster than women do.
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Will I be asked to stop smoking?
You are encouraged to stop smoking at least one month before surgery.
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If I continue to smoke, what happens?
Smoking increases the risk of lung problems after surgery, can reduce the rate
of healing, increases the rates of infection, and interferes with blood supply
to the healing tissues.
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How can I know that I won't just keep losing weight until
I waste away to nothing?
Patients may begin to wonder about this early after the surgery when they are
losing 20-40 pounds per month, or maybe when they've lost more than 100 pounds
and they're still losing weight. Two things happen to allow weight to stabilize.
First, your body's ongoing metabolic needs (calories burned) decrease as the
body sheds excess pounds. Second, there is a natural progressive increase in
calorie and nutrient intake over the months following weight loss surgery. The
stomach pouch and attached small intestine learn to work together better, and
there is some expansion in pouch size over a period of months. The bottom line
is that, in the absence of a surgical complication, you are very unlikely to
lose weight to the point of malnutrition.
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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' 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.' If you have further questions about plastic
surgery a referral may be made for you.
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.
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Will I be miserably hungry after weight loss surgery since
I'm not eating much?
Most patients say no. In fact, for the first 4-6 weeks you have almost no appetite.
Over the next several months the appetite returns, but it tends not to be a
ravenous "eat everything in the cupboard" type of hunger.
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What if I am really hungry?
This is usually caused by the types of food you may be consuming, especially
starches (rice, pasta, potatoes). Be absolutely sure not to drink liquid with
food since liquid washes food out of the pouch.
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Will I have to change my medications?
Dr. Lambert 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 medication 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 Dr. Lambert 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.
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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 (usually
after open procedure). Most of these patients require a repair of the herniated
tissue. The use of a reinforcing mesh to support the repair is common.
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Is blood transfusion required?
Infrequently: If needed, it is usually given after surgery to promote healing.
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What is phlebitis and is it preventable?
Undesired blood clotting in veins, especially of the calf and pelvis, are not
completely preventable, but preventive measures will be taken, including:
- Early ambulation'
- Blood thinners
- Sequential Compression Devices (intermittently pulsing leggings)
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Will I lose hair after surgery? How can I prevent it?
Many patients experience some hair loss or thinning after surgery. This usually
occurs between the fourth and the eighth month after surgery. Consistent intake
of protein at mealtime is the most important prevention method. A daily zinc
supplement and a good daily volume of fluid intake may also help prevent hair
thinning and loss.
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Does hair growth recover?
Most patients experience natural hair re growth after the initial period of
loss.
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What are adhesions and do they form after this surgery?
Adhesions are scar tissues formed inside the abdomen after surgery or injury.
Adhesions can form with any surgery in the abdomen. For most people, these are
not extensive enough to cause problems.
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What is the "Candida Syndrome?"
Some patients have a type of yeast present on the surface of their skin, intestine
or vagina at the time of surgery. This leads to overgrowth in certain circumstances.
A whitish coating may occur on the tongue or throat. This syndrome is associated
with a frothy mucous, nausea, difficulty swallowing, sore throat, loss of taste
and appetite, and occasionally abdominal bloating and diarrhea.
What causes it to appear?
It is promoted by the use of most antibiotics and some other medications, by
stress, by reduced immune response, and by diabetes.
Can it be cured?
There are several effective medications now available for treating the overgrowth
of Candida.
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What is sleep apnea (SA)?
It is the interruption of the normal sleep pattern associated with repeated
delays in breathing. Sleep apnea often shows rapid improvement after surgery.
In most patients, there is a complete resolution of symptoms by six months following
surgery.
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Why does it take so long to get insurance approval?
After your office consultation is completed, it usually takes your doctor 1-2
days to send a letter to your insurance carrier to start the approval process.
The time it takes to get an answer can vary from about 3-4 weeks or longer if
you are not persistent in your follow-up. Most treatment centers have insurance
analysts who will follow up regularly on approval requests. It may be helpful
for you to call the claims service of your insurance company about a week after
your letter is submitted and ask about the status of your request.
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How can they deny insurance payment for a life-threatening
disease?
Payment may be denied because there may be a specific exclusion in your policy
for obesity surgery or "treatment of obesity." Such an exclusion can
often be appealed when the surgical treatment is recommended by your surgeon
or referring physician as the best therapy to relieve life-threatening obesity-related
health conditions, which usually are covered.
Insurance payment 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. In the case of morbid obesity, alternative treatments
- such as dieting, exercise, behavior modification, and some medications - are
considered to be available. Medical necessity denials usually hinge on the insurance
company's request for some form of documentation, such as 1 to 5 years of physician-supervised
dieting or a psychiatric evaluation, illustrating that you have tried unsuccessfully
to lose weight by other methods.
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What can I do to help the process?
Gather all the information (diet records, medical records, medical tests) your
insurance company may require. This reduces the likelihood of a denial for failure
to provide "necessary" information. Letters from your personal physician
and consultants attesting to the "medical necessity" of treatment
are particularly valuable. When several physicians report the same findings,
it may confirm a medical necessity for surgery.
When the letter is submitted, call your carrier regularly to ask about the
status of your request. Your employer or human relations/personnel office may
also be able to help you work through unreasonable delays.
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The Hospital Stay
What is done to minimize the risk of deep vein thrombosis/pulmonary embolism
or DVT/PE?
Because a DVT originates on the operating table, therapy begins before a patient
goes to the operating room. Generally, you will be treated with sequential leg
compression stockings and given a blood thinner prior to surgery. Both of these
therapies continue throughout your hospitalization. The third major preventive
measure involves getting out of bed as soon as possible after the operation
to restore normal blood flow in the legs.
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What should I bring with me to the hospital?
Basic toiletries (comb, toothbrush, etc.) and clothing will be provided by the
hospital, but most people prefer to bring their own. Choose clothes for your
stay that are easy to put on and take off. Because of your incision, your clothes
may become stained by blood or other body fluids. Other ideas:
- reading and writing materials
- crossword and other puzzles
- personal toiletries
- bathrobe
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How long will I be off of solid foods after surgery?
A liquid diet, followed by semi-solid foods or pureed foods, may be recommended
for a period of time until adequate healing has occurred. Our staff will provide
you with specific dietary guidelines for the best post-surgical outcome.
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What are the best choices of protein?
Eggs, low-fat cheese, low-fat cottage cheese, tofu, fish, other seafood, chicken
(dark meat), turkey (dark meat).
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Why drink so much water?
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 to rid itself
of waste products efficiently, promoting better weight loss. Water also fills
your stomach and helps to prolong and intensify your sense of satisfaction with
food. If you feel a desire to eat between meals, it may be because you did not
drink enough water in the hour before.
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What is Dumping Syndrome?
Eating sugars or other foods containing many small particles when you have an
empty stomach can cause dumping syndrome in patients who have had a gastric
bypass where the stomach pylorus is removed. Your body handles these small particles
by diluting them with water, which reduces blood volume and causes a shock-like
state. Sugar may also induce insulin shock due to the altered physiology of
your intestinal tract. The result is a very unpleasant feeling: you break out
in a cold clammy sweat, turn pale, feel "butterflies" in your stomach,
and have a pounding pulse. Cramps and diarrhea may follow. This state can last
for 30-60 minutes and can be quite uncomfortable - you may have to lie down
until it goes away. This syndrome can be avoided by not eating the foods that
cause it, especially on an empty stomach. A small amount of sweets, such as
fruit, can sometimes be well tolerated at the end of a meal.
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Is there a problem with consuming milk products?
Milk contains lactose (milk sugar), which is not well digested. This sugar passes
through undigested until bacteria in the lower bowel act on it, producing irritating
byproducts as well as gas. Depending on individual tolerance, some persons find
even the smallest amount of milk can cause cramps, gas and diarrhea.
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Why can't I snack between meals?
Snacking, nibbling or grazing on foods, usually high-calorie and high-fat foods,
can add hundreds of calories a day to your intake, defeating the restrictive
effect of your operation. Snacking will slow down your weight loss and can lead
to regain of weight.
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Why can't I eat red meat after surgery?
You can, but you will need to be very careful, and we recommend that you avoid
it for the first several months. Red meats contain a high level of meat fibers
(gristle) which hold the piece of meat together, preventing you from separating
it into small parts when you chew. The gristle can plug the outlet of your stomach
pouch and prevent anything from passing through, a condition that is very uncomfortable.
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How can I be sure I am eating enough protein?
40 to 65 grams a day are generally sufficient.
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Is there any restriction of salt intake?
No, your salt intake will be unchanged unless otherwise instructed by your primary
care physician.
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Will I be able to eat "spicy" foods or seasoned
foods?
Most patients are able to enjoy spices after the initial 6 months following
surgery.
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Will I be allowed to drink alcohol?
You will find that even small amounts of alcohol will affect you quickly. It
is suggested that you drink no alcohol for the first year. Thereafter, with
your physician's approval, you may have a glass of wine or a small cocktail.
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What vitamins will I need to take after surgery?
Most surgeons recommend a daily multivitamin for the rest of your life. Vitamin
B12 may also be taken, either orally, sublingually (under tongue), or by injection
if necessary. It is important to take 1200 mg to 1500 mg of calcium each
day. Iron supplements will be recommended.
Is it important to take calcium, iron, trace elements or female hormone replacements?
Some patients require these supplements, but your need for these can be determined
by your surgeon.
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Do I meet with a nutritionist before and after surgery?
We require patients to consult with a nutritionist before surgery. Counseling
after surgery is available on an individual basis as needed.
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Will I get a copy of suggested eating patterns and food
choices after surgery?
We will provide you with materials that clearly outline our expectations regarding
diet and compliance to guidelines for the best outcome based on your surgical
procedure. After surgery, health and weight loss are highly dependent on patient
compliance with these guidelines. You must do your part by restricting high-calorie
foods, by avoiding sugar, snacks and fats, and by strictly following the guidelines
provided.
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What is the youngest age for which weight loss surgery
is recommended?
Generally accepted guidelines from the American Society for Bariatric Surgery
and the National Institutes of Health indicate surgery only for those 18 years
of age and older. Surgery has been performed on patients 16 and younger. There
is a real concern that young patients may not have reached full developmental
or emotional maturity to make this type of decision. It is important that young
weight loss surgery patients have a full understanding of the lifelong commitment
to the altered eating and lifestyle changes necessary for success.
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What is the oldest patient for whom weight loss surgery
is recommended?
Patients over 65 require very strong indications for surgery and must also meet
stringent Medicare criteria. The risk of surgery in this age group is increased,
and the benefits, in terms of reduced risk of mortality, are reduced.
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Can Weight Loss Surgery prolong my life?
There is good evidence from scientific research that 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), then weight loss surgery may significantly prolong
your life.
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Can weight loss surgery help other physical conditions?
According to current research, weight loss surgery can improve or resolve associated
health conditions.
| Condition |
Percentage found in preoperative individuals |
Percentage cured 2 years after surgery |
| Diabetes or insulin resistance |
34% |
85% |
| High blood pressure |
26% |
66% |
| High triglycerides |
40% |
85% |
| Sleep apnea |
22% in males
1% in females |
40% |
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