Questions to Ask Before Having Bariatric Surgery, Part 2

“How Much Weight Should I Expect to Lose and What Are Other Benefits?”

Weight loss after bariatric surgery is calculated by experts in an unusual way. Of course, we can look at your actual weight loss in pounds, but to average weight loss between different patients (men and women, of different heights and builds, and can expect different overall weight loss) we look at ideal body weights based on height, and then calculate the amount above that number that each patient has. This number is called the excess body weight.

When surgeons mention percentages of excess weight loss (%EWL), they mean the percentage of the excess weight each person has before surgery that is lost overall. This weight loss usually occurs over the course of a year or 18 months, but the majority of it can often happen in 6 months or less, depending on where people start.

The two most common procedures in the U.S., the gastric bypass (RNY) and sleeve gastrectomy (VSG) have averages of 70% EWL and 60% EWL respectively. More malabsorptive operations like the duodenal switch (which is performed less often) can average almost 80% EWL but can be associated with rare problems with excess weight loss or vitamin deficiencies.

Other benefits that many weight loss operations provide (especially the gastric bypass) is relief from heartburn or GERD, and improvement in blood sugar control. None of these procedures “cure” medical problems related to weight, but they can often set the clock back ten years for diseases, or reduce the need for medication to control them.

“Will I Have a Special Diet After Surgery?”

For my patients, during the initial one-month recovery period we recommend a diet that is initially liquid only (about one week), then we have patients move onto a pureed (baby-food consistency) for another 20 days. This allows some of the initial swelling from the surgery to subside, avoiding problems with nausea or vomiting. Many patients feel they may tear the stomach pouch or injure themselves with food after surgery, but this is not the case.

After one month, we allow our patients to try solid foods and find protein sources that work well for them. Ultimately bariatric patients can eat a wide variety of healthy foods, but of course, the meal size is the smaller and will remain so. We urge our patients to avoid foods that are high in sugar or carbohydrates (like junk food or soda) and seek foods high in protein.

You may have heard of “dumping syndrome,” the gastric bypass can cause unpleasant sensations when patients consume food high in carbs. It is not dangerous but can help patients eliminate these foods from their diets. Many patients also have heard that they need to eat small meals throughout the day, but we try to get our patients to eat the normal three meals a day (it is important not to skip breakfast, it is hard to catch up) with snacks in-between only if they are hungry.

“What Will My Recovery Be Like?”

I tell patients to expect about two days in the hospital and about two weeks off from work. Of course, everybody responds to surgery differently, but most patients are pleasantly surprised that the laparoscopic (keyhole) incisions aren’t too painful; and, many tell me they just have soreness rather than exquisite pain the day after surgery.

We often let patients leave after just one night after the sleeve gastrectomy procedure, and about half choose that option. Most patients have no pain after a few days and are off pain medication as well. About half of our patients do not have a drain in place. Those that have one are usually for one week (there is some discomfort, but it is removed easily in our clinic).

We do have lifting restrictions for the first few weeks, but we urge gentle aerobic exercise (walking), and steps and daily activities are okay right away. I also tell patients that to varying degrees fatigue is normal for up to 4-6 weeks after bariatric surgery, so plan accordingly!

“Will I Need Plastic Surgery for Excess Skin After My Weight Loss?”

These questions are understandably among the most common, patients are looking forward to good results! The advice I give patients is that any strength training can build muscle and help reduce loose skin on the arms and legs, and is helpful for overall weight loss as well. Think of the athletes that can eat thousands of calories per day and stay lean- muscle tends to burn more calories overall, even when you aren’t exercising.

Of course, there are many patients who carry much of their weight on the abdomen, having excess skin is quite common and often unavoidable with successful weight loss. These patients may often have rashes at skin folds and can have trouble with clothing fitting properly. At the advice of our plastic surgery colleagues, we generally wait about 18 months to refer patients for excess skin removal (panniculectomy or abdominoplasty). This time allows patients to comfortably reach a low weight, allowing the best cosmetic result.

“Are the Procedures Reversible?”

This question is very common, and the answer is different based on the type of surgery you choose. Keep in mind that the intention of every bariatric surgery is for the operation to be permanent. Even patients with the laparoscopic band (the easiest to reverse or remove), the idea is that the device is kept in place unless weight loss is insufficient or causing problems.

Of the more common procedures, the gastric bypass again is a permanent procedure but can be reversed on rare occasions. About 1/1000 patients have a bypass or malabsorptive procedure reversed, usually due to rare problems with low blood sugars.

The other malabsorptive procedures (duodenal switch) have slightly higher rates of reversal, usually due to trouble maintaining weight or vitamin levels. The sleeve gastrectomy is not technically reversible (remember that much of the stomach is removed), but about 5% of patients undergo revision where a surgeon can covert the sleeve operation to a gastric bypass or other procedure. These revisions can be necessary if patients have unsuccessful weight loss or heartburn that is uncontrolled.