Gastric Bypass FAQ

Gastric Bypass

• What to Expect

  In general, the sequence of events that occurs follows in a step-wise progression:

  Seminar
  All patients are required to attend an informational seminar.  The seminars are free and you may come as frequently as you desire.  Click to register for a free seminar. The seminars are designed to address different weight loss methods including diet and exercise, medications and different surgical options.  The different weight loss operations and their specific weight loss patterns and potential complications are discussed in detail. After attending the seminar, prospective patients will have the opportunity to schedule an appointment for a one-to-one consultation with the surgeon of their choosing. 
  
  Consultation
  The purpose of the consultation is for you to meet your surgeon to make sure that you are comfortable with him.  The surgeon will obtain a detailed medical and surgical history and perform a physical exam.  Any necessary medical evaluations will be tailored to your individual medical history and current state of health.  It will also be another opportunity to ask any questions that you have.
  You should bring the following information with you at the time of consultation:
  • list of current medications with their dosages
  • copies of any recent cardiac (heart) or pulmonary (lung) evaluations
  
  Medical Evaluations
  You may be required to undergo further medical evaluation.  The purpose is to help the medical/surgical staff optimize your health prior to the surgery.  Some of the more common medical referrals are to:            

  • Cardiology (Heart Specialist)
    -You may require a stress test or other imaging study.
  • Pulmonologist (Lung Specialist)
    -You may require a sleep study.
  • Psychiatry
    -Almost all insurance companies require a psychiatric evaluation.

  We are able to provide you assistance in arranging appointments to see a specialist if you choose.  However, many patients will choose to use a specialist that their primary care physician prefers and this is also fine.

  Insurance Approval
  

  After your medical evaluation is complete (assuming that there are no medical reasons that you should not undergo the operation) your chart will be submitted to your insurance company for "approval".  This is generally the time where patients have the most trouble.  Insurance approval can take anywhere from two weeks to three months for a decision to be made.

  In the event that your insurance denies you, our staff will assist you in appealing the decision.  Our clinical coordinators are very skilled in getting patients through the insurance process and we boast one of the highest approval ratings in the state.

  
  
  Scheduling "The Date"
  

  Once you have been approved, one of our clinical coordinators will contact you to schedule an operative date.  Patients can usually be scheduled within three weeks from the time we receive approval.  There may be some circumstances that require a longer waiting period.

• How the Gastric Bypass Works

  The gastric bypass is predicated on two concepts: restriction and malabsorption.  The concept of "restriction" is relatively straight forward.  The stomach is divided with specialized surgical staplers disconnecting the upper 5% from the lower 95% of stomach.  The small portion is now referred to as the "pouch"; the large portion is now referred to as the "remnant".  The remnant is not routinely removed and remains in the same anatomical position that you were born with.  The pouch that has been created now acts as the reservoir for ingested foods.  The amount of food that the stomach can now hold has been greatly reduced.  In other words, there is a restriction in the volume that your new pouch can accommodate.  The actual volume of the pouch varies from surgeon to surgeon.  On average, the pouch is described as being able to hold 30 cc or one ounce, approximately the size of a small egg or Dixie cup.  Consider trying to push a single slice of pizza into a Dixie cup.

  The concept of malabsorption is slightly more complicated.  The idea is explained by first grasping the basics of human gastrointestinal anatomy.  The weight loss attributed to the bypass portion of the procedure can then be understood.

  Normal Anatomy 
  When food is swallowed it traverses the esophagus before entering the stomach.  The stomach acts as a reservoir and churn, breaking the larger pieces up into smaller particles.  The food particles are then released from the stomach in small, controlled quantities into the first portion of the small intestine (duodenum).  The duodenum is the "business end" of the small intestines even though it only compromises a very small length of the total small intestine.  

  In the duodenum, enzymes (chemicals necessary for digestion)  are secreted by the pancreas and the gallbladder that are necessary to further breakdown food particles so that they can be absorbed as the food travels the length of the small intestine.  On average, the small bowel is 18-25 feet long (5-7meters).  Just like people have different length fingers and toes, we all have slightly longer or shorter small intestine than the next person. As food traverses the small intestine it is absorbed into the blood stream to be used as energy, building blocks, etc.  At this point the ingested food has been reduced to a liquid.  The large intestine (colon), 4-7 feet long, primarily acts as a sponge, reabsorbing 90-95% of the water that remains behind.  The end of line is the rectum/anus where all that cannot be used is passed out from the body.
   

  

  Gastric Bypass Anatomy 
  The Roux-en-Y changes the gastrointestinal anatomy.  The small intestine is divided one to three feet (40-90 cm) beyond the first portion of small intestine (duodenum).  The side that is downstream (distal segment) is measured out an additional 4-6 feet (100-200 cm).  This is called the "Roux limb" and is reconnected to the gastric pouch.  In other words, food will now travel from your esophagus into your gastric pouch and then into your Roux limb.  The upstream portion of small intestine is now referred to as the "biliopancreatic limb" because it carries the bile and pancreatic enzymes necessary for digestion.  The end of the biliopancreatic limb is connected to the end of the Roux limb reestablishing small bowel continuity.  The straight shot from the reconnected small intestine to the colon is now referred to as the "common channel".  That's because this segment of small intestine will be a common mixing site for the enzymes of digestion and the food that is ingested.  The end result is a "Y" shaped set of small intestinal connections.

  So what is the significance of the new plumbing?  The bottom line is the small intestine has been rerouted, and so has the road to be traveled by ingested food. The business center (the duodenum) continues to see the necessary enzymes secreted by the pancreas and gallbladder; however, these enzymes are not in contact with food until they reach the "common channel".  Only where the food and enzymes mix can absorption of nutrients (calories) take place.  This is the principle of "malabsorption"; the intestinal system has been short-circuited and therefore does not allow the complete absorption of all ingested nutrients and calories.  The end result is that there is incomplete absorption of the calories that you eat.

• Risk of Surgery

  Although relatively infrequent, severe complications after gastric bypass surgery can occur.  Not all complications are life threatening, however, some complications can be.  Complications occurring within the first 30 days after the procedure are considered "early" complications.  Those complications occuring after the first 30 days are considered "late" complications.  The following is a brief description of the most common complications after gastric bypass surgery, both early and late.  There may be other complications that can occur following this operation.
  
  Early Complications 
  Staple line leak:  One of the most feared complications after gastric bypass surgery is a leak at the connection between the pouch and the small intestine.  This staple line disruption can also occur at other sites where the stomach and small intestine have been divided.  The incidence of this complication is considered to be around 1% nationally.  In some instances you may have to undergo an additional surgical procedure(s) to correct this problem. 
  Deep Vein Thrombosis and Pulmonary Embolus:  This is a rare but dangerous complication.   A blood clot can form in your leg or in your pelvic veins (deep vein thrombosis) and can travel to your lungs (pulmonary embolism).  This can place a significant strain on your heart and lungs endangering your life. 
  Cardiac Problems (Heart Attack, Arrythmia, Congestive Heart Failure):   Severe cardiac problems can occur. We will make every effort to assess your cardiac condition prior to the surgical procedure.
  Lung Problems (Respiratory Insufficiency or Pneumonia):  Lung complications may occur after the surgery necessitating the use of a ventilator. This can lengthen your hospital stay and your recovery.
  Injuries to other Intra-Abdominal Organs:  As with all surgical procedures, injuries to other intra-abdominal organs can occur. Your surgeon will attend to them as needed. *Removal of the spleen is necessary in about 0.3% of patients to control operative bleeding.
  Hemorrhage:  Bleeding can occur from staple lines or blood vessels during the procedure or in the early post-operative period.  This may require the transfusion of blood products.  In some instances you may need an operative intervention to control the blood loss.
  Infections:  Infections can develop either at incision sites or within the abdominal cavity and may require further procedures or the possible need for another operation.  Infections of the urinary tract and intravenous line sites can also occur but are usually managed with oral antibiotics and discontinuing the IV or bladder catheter.
  Dehiscence:  is complete breakdown of the surgical incision (associated with open surgery only) and requires another operation to repair. 
  Complications due to Anesthesia and Medications:  Your surgeon and anesthesiologist will take a complete history to ensure there are no adverse reactions to medications as a result of a known allergy.  Despite this, there are rare occasions when a patient has an adverse reaction to an anesthetic or medication.
  Conversion to an "Open" Operation:  Although this is not a true complication, it is important for patients to understand that it may be necessary to convert to an open operation.  Common reasons for converting to an open operation are bleeding, dense scar tissue, difficulty working against a very thick abdominal wall or difficult anatomy.  Your surgeon will convert to an open operation to ensure that you get the best and safest operation possible.
  Death:  The risk of dying is less than 0.5%.  The most common cause of death is from a massive pulmonary embolism.  Other causes can be related to problems with the heart, lungs or kidneys.
  

  Late Complications 
  Gastroenterostomy stenosis:  The connection between the stomach pouch and the small intestine is made a certain size to restrict the rapid emptying of your new stomach. In some patients, excessive scarring can occur at this site and will shrink this opening further. The patient usually complains of inability to tolerate solid foods and may have retching or vomiting. This complication is managed by performing an endoscopic dilation (enlarging the opening via a camera placed through the mouth). It may require multiple dilatations at different times to manage the problem. 
  Marginal ulcers:  Marginal ulcers are erosions that develop at the connection between the small intestine and stomach pouch. Patients usually complain of pain, nausea and occasional vomiting blood. Treatment usually consists of antacid medications, however, refractory cases may require re-operation and reconstruction of the connection between the stomach and small intestine. 
  Internal Hernias:  These complications are decreasing as bariatric surgeons have modified the surgical techniques accordingly.  Patients usually complain of diffuse crampy, abdominal pain after meals that may or may not improve with vomiting. If they do occur, you will require a surgical intervention to correct it.
  Small Bowel Obstruction:  After any type of surgery adhesions will develop.  Adhesions are scar tissue that forms inside the abdominal cavity.  Adhesions are the most common cause of small bowel obstruction.  The risk of developing dense adhesions is substantially higher if the procedure is performed "open".
  Malnutrition:  This procedure causes malabsorption of the food and nutrients you eat. Certain vitamins (B1, B12, calcium, iron, folate, etc.) may not be absorbed well enough for you to meet the recommended US daily requirements. For this reason, we recommend you take a multivitamin, calcium, vitamin B12 and possibly iron for the rest of your life.  You will be required to undergo annual blood work to evaluate for possible nutritional deficiencies. 
  Dumping Syndrome:   Although dumping is not dangerous, it is frightening to the uneducated patient. Short periods of dizziness, sweating, nausea, vomiting, diarrhea and palpitations can occur.  This phenomenon is almost always caused by eating food or drink high in sugar.  Changes in dietary habits are usually all that is needed to prevent this from happening. 
  Diarrhea:  Diarrhea can occur immediately after surgery but usually subsides. Chronic diarrhea is not a common side effect of this procedure. 
  Kidney/Bladder Stones: Kidney stones and bladder stones can develop after gastric bypass surgery. It is extremely important to maintain good hydration by drinking plenty of fluids.
  Hair Loss:  Some patients report some form of temporary hair loss, which is believed to be due to a reduced and insufficient post-operative intake of protein. Again, patients need to follow post-operative instructions meticulously.   The hair loss almost always returns within one year.

• Do I Qualify

  Insurance companies differ in their requirements for approval of weight loss surgery. Furthermore, any given insurance company may have different requirements depending on the individual policy the patient has. For example, Blue Cross Blue Shield may have different requirements from one policy to another.
  
  The general guidelines used come from National Institute of Health criteria for weight loss surgery:

  • BMI > 40
  • BMI 35 or greater with existing medical conditions that are the result of obesity.
  • Patients must have demonstrated that previous attempts of weight loss have failed.
  • Age must be older than 18.

  Most insurance companies require evaluation by a psychiatrist or psychologist prior to approval. Some insurance companies may require evaluation by a dietician or nutritionist as well. Your surgeon will determine whether you need further medical evaluation by medical specialists such as a Cardiologist, etc.

  All patients are required to attend an informational seminar, followed by a consultation with the surgeon

• The Hospital Stay

  After the operation you will be transferred to our bariatric floor.  The nurses on this floor are specifically trained to meet the needs of our patients.  Most patients stay in the hospital approximately two to three days after the laparoscopic procedure and three to five days after an open procedure.
  
  Depending on your medical condition, there is the possibility of being placed in the intensive care unit to closely monitor your heart and lungs. Patients who use Continuous Positive Airway Pressure (CPAP) or Bi-level Positive Airway Pressure (BiPAP) for sleep apnea may be asked to bring their machines with them for use immediately after the operation.
  
  A small drain may be placed around the stomach pouch and the bypassed stomach to drain body fluids after the surgery. These are usually removed in three to ten days. To help prevent blood clots, anti-embolism stockings or other compression devices will be placed on your legs, and your surgeon will require you to stand up and move around as soon as possible, usually within the first 24 hours. 
  
  On the day after your operation you will have a private consultation with one of our nutritionists.  The nutritionist will go over a post operative diet in detail with you.  You will also be provided written materials to take home with you should you have any questions when you return home.
  
  In general, you will begin to drink liquids the first day after your operation.  On the second day after your operation the amount that you are allowed to drink will be increased.  You will receive teaching on drain care, self-administering Lovenox (blood thinner) and wound care.
  You will be discharged home when you are able to:

  • Take enough liquids by mouth to prevent dehydration.
  • Have no fever, able to move about and urinating without difficulty.
  • Have adequate pain control with oral medication.
• Life After Surgery

  Going Back to Work
  Your ability to resume pre-surgery levels of activity will vary according to your physical condition, the nature of the activity and the type of weight loss surgery you had. Many patients return to full pre-surgery levels of activity within six weeks of their procedure. Patients who have had a minimally invasive laparoscopic procedure may be able to return to these activities within two to three weeks.
  
  Birth Control & Pregnancy
  It is strongly advised that women of childbearing age use the most effective forms of birth control during the first 24 months after weight loss surgery. The added demands pregnancy places on your body and the potential for fetal damage make this a most important requirement.
  
  Support Groups
  The widespread use of support groups has provided weight loss surgery patients an excellent opportunity to discuss their various personal and professional issues. Most learn, for example, that weight loss surgery will not immediately resolve existing emotional issues or heal the years of damage that morbid obesity might have inflicted on their emotional well-being. Harper University Hospital bariatric surgeons have support groups in place to assist you with short-term and long-term questions and needs. Ongoing post-surgical support helps produce the greatest level of success.

• Post-Operative Diet

  After the operation there is a stepwise advancement of your diet.  The diet has been designed to help reduce potential complications as a result of food getting stuck and causing episodes of vomiting or retching.  The change in your anatomy is major and it requires time to develop a sense of how much food or drink you can tolerate at any given time.
  
  One of our nutritionists will provide you with detailed information before you leave the hospital. The goal is to advance you to a "normal" diet by the 4th week after surgery.  Be mindful that as you progress through the different stages you may notice that you get full quicker or even have a little discomfort after you eat.  This is normal and is referred to as "the learning curve" after undergoing gastric bypass surgery.  Over time, you will learn how quickly you can drink, how much you need to chew and what items you just can't tolerate no matter what you do.  You will also realize that some of the foods that you once ate without difficulty may now become extremely difficult for you to tolerate.  No two gastric bypass patients have the same finger prints, and no two gastric bypass patients can tolerate every food item the same.
  
  We recommend that all gastric bypass patients take a daily multivitamin and a calcium supplement that contains vitamin D.  Blood work is required at least on an annual basis to evaluate your body's stores of essential vitamins and minerals.

• Insurance and other Payment Options

  The body weight criteria used by almost every insurance company is based off the National Institute of Health guidelines and recommendations for weight loss surgery.  A patient is considered an appropriate candidate for weight loss surgery if:
  
  Body Mass Index (BMI) is:
  Between 35-39 with medical conditions that are related to excessive weight
  or
  BMI > 40
  Calculate your BMI
  
  Despite this, many insurance companies require that patients be able to demonstrate that he or she has attempted less invasive methods to lose weight.  This is usually through documentation in medical records.  Some insurers require 6 months of documented weight loss attempts through their primary care physician.  Other insurers have required up to 12 consecutive months.  In addition, some insurance providers require that the documentation be within a certain time frame (i.e. within the last two years).  Most recently, some insurance companies have eased the requirements in patients who have extreme BMIs.  Every insurance provider has its own guidelines regarding weight loss history and these guidelines are constantly changing. 
  
  Insurance providers may also require their customers to undergo specific medical, psychological and nutritional evaluations prior to approval.  We recommend that every patient contact their insurance provider and find out what specific requirements must be met in order to receive pre-approval.
  
  If you have been denied by your insurance company there is still hope that you will be approved.  A bariatric coordinator will work with you to help you get through the appeal process.  We have a very high success rate in getting our patients approved both initially and through appeals.
  
  Other Payment Options
  Speak with your bariatric surgeon about other self payment options available.