Is Surgery For You?
Laparoscopic Roux-y-gastric bypass (LRYGB)
Laparoscopic Adjustable Gastric Band (LAGB)
Laparoscopic Mini-gastric bypass (LMGB)
Laparoscopic Sleeve Gastrectomy (LSG)
Laparoscopic Greater Curvature Plication (LGCP)
Biliopancreatic Diversion (BPD)
Revisional Bariatric Surgery
Endoscopic Gastric Balloon
I am Diabetic, can I undergo surgery? Is it safe? Will it affect my Diabetes?
Absolutely! Studies have shown that Bariatric (Weight Loss) Surgery is very effective in treating and sometimes resolving Diabetes, provided it is associated with obesity (type II diabetes). The risk of weight loss surgery (WLS) is not higher in diabetic patients and the expected benefits are much higher than the risks. All bariatric operations can benefit patients with diabetes, but gastric bypass and biliopancreatic diversion in particular are more effective than other operations. The end result will depend on the stage and the duration of the disease. For example you are more likely to benefit from WLS if the diabetes was diagnosed recently and you only take pills. In that case we expect your blood sugar to return to normal without medications within few weeks of the operation. On the other hand if you had diabetes for more than 10 years and you already take insulin, then we expect that the blood sugar control will improve after WLS but you will continue to take some form of medication.
I have sleep apnea, Will surgery improve my condition?
Yes. Sleep apnea occurs when the airways collapse during sleep decreasing oxygen delivery and forcing the patient to wake up to restore proper breathing. The patient will not realize this but the effect of this disturbed sleep will show the next day as he/she will complain of sleepiness and fatigue. Sleep apnea is a dangerous problem because it will lead to high blood pressure and heart disease. If Sleep Apnea is associated with excess weight, weight loss will usually resolve it.
I have heart problems, can I undergo surgery?
In general, Cardiac (heart) problems are not a contraindication to surgery. Overweight leads to extra stress that the heart has to endure. Weight loss will certainly improve the heart condition. However, a careful pre-operative evaluation from a cardiologist will be needed to make sure that the patient can tolerate the surgery. This might mean having to undergo some laboratory tests, imaging and even cardiac catheterization sometimes.
I have reflux (acid) symptoms, can I undergo surgery?
Excess weight is usually associated with reflux symptoms (acidity). Weight loss will usually improve that. However, in Sleeve Gastrectomy, there is a risk that reflux symptoms will get worse. An Endoscopy (stomach imaging) might be needed to assess the extent of reflux or if there are other causes (example: Hiatal Hernia). This will help decide which operation should be done. Roux-Y-Gastric Bypass is considered an excellent treatment option for acid reflux.
What is the youngest age for which weight loss surgery is recommended?
Most patients undergoing weight loss surgery are 18 years of age and older. Surgery has been performed on children and adolescents if the obesity is excessive and causing serious medical problems. Sadly these days we are seeing diseases of the adults in children who are obese. Examples include type 2 diabetes, sleep apnea, and high blood pressure among others. In such cases weight loss surgery is appropriate. It is important that young patients undergoing weight loss surgery have a full understanding of the lifelong commitment to the dietary and lifestyle changes necessary for success. That is why we involve the entire family in the education and preparation for surgery along with a team of pediatricians, dietitians and psychologists.
What is the oldest patient for who weight loss surgery is recommended?
Patients over 65 can safely undergo weight loss surgery (WLS) but need careful pre-operative evaluation and assessment especially for heart disease. One of the common reasons for choosing weight loss surgery in patients who are older than 65 is advanced joint disease and difficulties with moving and walking. Patients over the age of 65 have to be in relatively good condition to be considered good candidates for WLS.
Is the operation covered by insurance?
Unfortunately, in Lebanon these types of operations are usually not covered by insurance. Despite the fact that these are not Cosmetic surgeries, some insurance companies still refuse to cover their costs. Nevertheless, unless clearly stated by the policy, some insurance might cover the cost or at least part of it. These operations are covered by the NSSF.
Preparation For Surgery
Do I need to lose weight before surgery?
Weight loss is strongly advised before surgery. This is mainly to ensure the ease of the operation. Anatomically, the liver lies on the stomach. Weight loss before surgery reduces the size of the liver, making it easier and safer for the surgeon to operate. In addition, weight loss before the operation will help patients tolerate the operation by reducing the stress on the heart and lungs.
What are the tests that I need to perform before surgery?
Evaluation before the operation usually consists of a set of blood tests that will evaluate the patient's sugar metabolism, lipid metabolism, overall blood, liver and kidney function as well as some vitamin deficiencies. Other tests ordered will depend on the patient’s general medical condition and will differ from one patient to the other. Examples of additional tests include endoscopy of the stomach, tests for heart and lung function.
When should I be admitted to the Hospital?
Admission to the hospital usually occurs on the same day of surgery. There is rarely a need to be admitted one day before surgery.
What should I eat the day before surgery?
It is strongly advised to have a light lunch the day before surgery consisting mainly of vegetables and a piece of grilled meat or chicken followed by a liquid diet (soups, water…) for the rest of the day. It is crucial not to eat anything after midnight, even fluids.
Can I take my medications before the surgery? Is there any specific medication that I need to take?
Your anesthesiologist (sedation doctor) will give you instructions on how to manage your medication for surgery. It is therefore preferable to meet with him/her a couple of days before surgery so that you are comfortable on the day of surgery. Patients are usually given a blood thinner the eve of the surgery to decrease the risk of blood clots. These can usually be taken at any local pharmacy.
Questions about the Surgery
How are the operations done? Does it hurt?
All operations are done Laparoscopically and under general anesthesia. This means that the patient will be asleep and unaware and the surgeon will only need to make 4-5 small incisions (1 cm each) so that he can introduce small ports which will give him access to the inside of your abdomen. This technique significantly reduces surgery complications, post-operative pain and recovery. Nevertheless, pain will still occur but is usually very tolerable and patients rarely need strong analgesics (pain medication) and will do fine with mild ones (ex: paracetamol).
How long does the operation take?
The duration of the operation depends on the type of operation but usually ranges between 1 hour and 3 hours.
Is the surgery reversible?
Obesity is a chronic disease and itself is not reversible, so when a decision is made to undergo an operation, the reversibility of the operation should not be an issue. However, technically all operations are reversible except for the Sleeve Gastrectomy since part of the stomach will be removed from the body and later on discarded.
Will I need blood transfusions?
Blood loss in these operations are minimal, rarely exceeding 20 ml. Blood transfusion is rarely needed and there is no need to prepare blood before the operation.
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 titanium so small it is hard to see other than as a tiny bright spot. Because the metals used (titanium) 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.
In Sleeve Gastrectomy, What happens to the stapled stomach?
After the operation, the stomach is reduced by almost 70% of its normal size. The part that is separated and stapled will be removed from the abdomen through the belly-button incision and then sent to pathology for examination. It will then be discarded. It is unsafe to leave that part of the stomach inside the abdomen.
In Roux-Y-Gastric Bypass, what happens to the remaining stomach?
The stomach that will remain in use is reduced to a volume of 30 ml (almost an egg size). The remaining stomach still receives adequate blood supply and remains in the abdomen but will not receive any food.
In Gastric Banding, Where is the adjustment reservoir located?
Gastric banding is the only operation that can be later adjusted according to patient preferences. For that, the surgeon uses a reservoir into which he can inject or remove water to tighten or loosen the band. The reservoir is placed under the skin through a small incision in a place where the surgeon can easily access it (usually under the chest bone, or sternum). The reservoir is completely covered by skin and will not be visible.
What should I bring with me to the hospital?
Basic toiletries (comb, toothbrush, etc.) and clothing may 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. Do not forget to bring your medications and/or any relevant medical history information that your doctors might need. If you use a CPAP or BiPAP machine bring it to the hospital as you might need it after the operation.
How long do I have to stay in the hospital?
Most patients will usually need one or two days in the hospital for recovery after which they can be go home.
When will I be able to walk?
It is strongly advised to start walking as soon as possible to avoid blood clots from forming (usually in the legs). Patients can usually walk almost 6 hours after the surgery. Assistance will be provided initially to avoid any accidents.
After the operation, when will I be able to go back to my regular activity (walking, driving…)?
Patients will be able to walk immediately after surgery. Regular activity can be resumed gradually and is usually restored within 10 days. It is advised that the patients avoid lifting heavy weights (>5 kgs) before 3 weeks for fear of any injury. Light exercise can restart within 10 days of surgery, as well as sexual intercourse.
Will I have to take any supplements after the surgery?
Most patients will be required to take some vitamin supplements for life (especially Vitamin B12). However, a lot of our patients are found to be already deficient in these vitamins even pre-operatively. Levels will be measured routinely (usually every 6 months, or every year) and recommendations will be adjusted accordingly.
Do I need to go on a diet after the surgery?
It is strongly advised that the patient adopts a healthy lifestyle after the surgery. Choosing healthy food and avoiding junk foods and sweets is crucial to the success of any operation. These operations are a helping tool that when used properly will give great results. Effort and commitment will always be required from the patient.
Do I need to exercise after surgery?
Yes! Exercise is strongly advised. Not only will it help with the weight loss, but will also improve the patient’s overall medical condition, help to establish a healthy life style and maintain good results for years to come. An average of 2-3 hours per week is what the patient should aspire for by the end of the first year.
When Can I get pregnant after surgery?
For female patients, it is advised to avoid pregnancy at least one year after surgery. The reason is that patients will need time to adapt to their new eating habits. Pregnancy itself will add stress to the patient and will require an extra effort to accommodate for the growing nutritional needs of the baby. However, in case it occurs it is crucial that the patient follows up regularly with her treating physician to make sure that no nutritional deficiencies are occurring.
If I undergo surgery, will that reduce my chances of getting pregnant?
No, in fact it will more likely increase chances of pregnancy! Many obese women have difficulties with either having regular periods, getting pregnant or with delivery. Pregnant women who are obese are more likely to develop high blood pressure and gestational diabetes during pregnancy. Weight loss surgery (WLS) is recommended for obese women who are having difficulties getting pregnant or those who had difficult pregnancies and past deliveries. However it is advisable to avoid pregnancy during the first year after WLS and in case it occurs it is crucial that the patient follows up regularly with her treating physician to make sure that no nutritional deficiencies occur.
How much weight will I lose after the operation? Will I reach my Ideal Body weight?
Studies have shown that patients will lose up to 70% of their Excess body weight (EBW) after bariatric surgery. The EBW is calculated as current weight – Ideal body weight (IBW). The IBW can be obtained from many sources including the Metropolitan Life Insurance Tables. Take for example a young woman who weighs 120 kgs and is 156 cm tall. The patient’s IBW is 55 kgs so her extra weight is 65 kgs. Therefore at one year, we expect her to lose 70% x 65 kgs or around 45 kgs so her weight at one year should be around 75 kgs. With time a some patients will gain weight so at long-term follow-up (beyond 5 years) the average %EBW loss drops to around 50-60%. Results however will vary depending on patients’ commitment and will to make significant lifestyle changes.
Will I have loose skin after surgery? How can I prevent it?
This will vary greatly between patients. Iit is very difficult to predict which patients will have it. However, it is well known that smoking and alcohol consumption negatively affect the skin and patients are strongly advised to avoid them. Exercise, although crucial in promoting healthy lifestyle and weight loss, has little impact on the end result when it comes to loose skin. Excess loose skin is best treated with surgery (example tummy tuck, arm lift, and breast lift).
Will I lose hair after surgery? How can I prevent it?
Hair loss is expected after surgery and is mainly due to the rapid weight loss. This might be troubling to most patients however this is all temporary. The hair follicles are still healthy and patients will regain the majority of their lost hair once the weight stabilizes. Using some hair products or supplements can be sometimes be helpful but is usually unnecessary since again this is all transient.
Do I need to follow up regularly with my physician?
Yes! Follow up is very important during the early stages after the operation to ensure good results and to tackle specific conditions that the patient might be facing. At first, follow up occurs at regular intervals, usually every three months, and then every 6 months or every year after the first year to ensure that all is well and that all vitamins and blood tests are ok.
What is Dumping Syndrome?
Dumping syndrome is a collection of symptoms that usually occurs after Bypass surgeries but can sometimes happen after Sleeve Gastrectomy. It usually occurs after consumption of sugars or carbohydrates and in some cases fatty meals. Patients will complain of a very unpleasant feeling: fatigue, sleepiness, cold clammy sweat, paleness, "butterflies" in their stomach, and have a pounding pulse. Cramps and diarrhea may follow. This state can last for 30 to 60 minutes and can be quite uncomfortable — patient may have to lie down until it goes away. This is usually caused by a state of low blood sugar because the pancreas has been “super” stimulated after eating something sweet so it release a large amount of insulin that drops the blood sugar. Dumping syndrome is better prevented than treated. So, it is best to avoid sugars, eating large amounts of carbohydrates quickly. Patients are tempted to eat sweets after they develop dumping syndrome to counter the effects of low blood sugar.. This unfortunately triggers a vicious cycle and might lead to more dumping and ultimately poor weight loss. The best way to treat it is to avoid eating sweets and carbohydrates in the first place.
What if I have abdominal (belly) pain after surgery? What should I do?
It is not uncommon for patients to complain of some mild belly pain after surgery. This can be easily managed with some light analgesics (pain medications, ex: paracetamol) and usually resolves after the first month. However, if the patient feels severe crampy abdominal pain, associated with nausea and vomiting, then the patient should contact his/her surgeon immediately. Even if the abdominal pain is felt years after surgery, the surgeon should be notified immediately. Examples of conditions causing abdominal pain even after many months or years include gall stones, pancreatitis related to gall stones and intestinal blockage and internal hernias after gastric bypass.
What is Gallstones? How can I prevent it?
Gallstone is a condition where small stones form in the gallbladder, a bile reserve situated under the liver. They usually occur in patients who experience significant weight loss in a short period of time. Gallstone can develop without symptoms and do not cause any problems. Occasionally, stones get stuck in the gallbladder outlet and cause pain. Patients will report dull pain lasting for hours in the upper part of the belly on the right side. The pain might refer to their right shoulder or back and can be associated with some nausea or vomiting. In this case, an ultrasound of the abdomen should be done to confirm the diagnosis, and if so the gallbladder needs to be removed by surgery. Sometimes a stone might slip out and obstruct the outlet of the bile duct or pancreas causing acute Pancreatitis, a dangerous condition that needs immediate medical attention. It is difficult to predict who will have gallstones. One medication, ursodeoxycholic acid (Actigall®, Ursofalk®) if taken regularly may reduce the risk of developing gallstone formation in the first 6 months after the operation; however its efficacy is not well established.