Questions for Weight Loss Surgeons

Ask Your Doctor Discussion Guide
Best for: first office appointment with a weight loss surgeon

Weight loss surgery overview
Weight loss, or "bariatric," surgery is a common term used to describe a variety of operations for treating obesity. The operations vary in the type of physical changes made to the stomach and/or the small intestine, but all are designed to help you reduce your food intake. It is a proven method for long-term weight reduction and portion control for people who are exceedingly obese, but it should not be confused with cosmetic surgery.

The type of surgery you select should depend on several factors, such as your level of obesity, your overall health status, your ability and willingness to adopt lifestyle changes after surgery and your health insurance coverage. Your surgeon will recommend the surgery that is most suitable for you.

Most people who undergo bariatric surgery experience the following benefits:

• A significant amount of weight loss that is maintained long term (as opposed to people who solely try to lose weight through diet and exercise alone)
• Improvement or disappearance of obesity-related health conditions such as diabetes, high blood pressure, high cholesterol, sleep apnea or gastroesophageal reflux disease (GERD, or severe heartburn)
• Quality of life improvement as physical and behavioral changes occur, and improvements in social well-being

What types of weight loss surgeries are available, and how do they differ?
There are several types of weight loss surgeries, and they fall into two main categories: restrictive procedures and restrictive/malabsorptive procedures. Successful results depend on your willingness to adopt a long-term healthy eating and exercise plan.

Restrictive procedures
These surgeries significantly reduce the size of the stomach, making you feel satisfied after eating less food and you stay full longer. Adjustable gastric banding is a widely used restrictive procedure. There is also a new experimental procedure called sleeve gastrectomy, which involves stapling the stomach to create a small pouch and removing the rest of the stomach. However, it is only an experimental procedure not readily performed, and there are currently no long-term outcome data on weight loss effectiveness.

Adjustable gastric (stomach) banding, in which an adjustable band is placed around the top of the stomach and then filled with saline. This forms a small stomach pouch that is able to hold only a very small amount for food and a narrow passage to the rest of the stomach. This also slows down the digestive process and helps you feel fuller. The adjustable gastric band is reversible and can be removed if it becomes medically necessary. In comparison, other surgical procedures change the anatomy of the stomach and small intestine and are permanent.

Advantages of restrictive procedures:

• These procedures are simpler to perform and generally safer for patients. Adjustable gastric banding is the safest surgical weight-loss procedure to date, with lower rates of complications and death.
• These procedures require less time in the operating room, shorter hospital stays and less time for recovery.
• Weight loss is more gradual over time, with steady, healthy weight loss. After three to five years it is similar to patients undergoing restrictive/malabsorptive procedures (such as gastric bypass).
• Adjustable gastric banding has an added benefit of changing the level of restriction to fit each patient's individual needs without additional surgery.
• No dumping syndrome (the process of quickly passing food into the small intestine).

Disadvantages include:

• Less weight loss occurs than with gastric bypass in the first year to three years.

Risks commonly associated with restrictive bariatric surgery include:

• An adjustable gastric band can slip out of place, or part of the stomach can slip through the band, resulting in a revisional surgery to correct the placement.
• An adjustable gastric band may penetrate a hole in the stomach (erosion) and necessitate a corrective surgery.
• Infection.
• Eating too much or too quickly or eating certain kinds of food may cause nausea and vomiting. If not controlled, regular vomiting may continue for years after the surgery and may lead to malnutrition (as not enough vitamins and minerals are absorbed).

Restrictive/malabsorptive procedures
These surgeries reduce the size of the stomach and shorten the small intestine, which permanently alters your anatomy. The smaller stomach also makes you feel satisfied and full after eating less food. However, a change to the intestine also reduces the amount of nutrients and calories the body can absorb. These operations include:

• Roux-en-Y gastric bypass (this is by far the most common type of bariatric surgery)
• Biliopancreatic diversion with duodenal switch

Advantages of restrictive/malabsorptive procedures:

• Faster and greater immediate weight loss in the first six months to 3 years compared to restrictive procedures

Disadvantages include:

• These procedures are more difficult to perform and carry higher risks during and after surgery.
• The surgery, the hospital stay and the recovery time are all considerably longer.
• During the first year after surgery, patients may experience dumping syndrome, a condition associated with sweating, weakness and low blood sugar levels. This condition mostly occurs after a meal containing too many high-fat and high-sugar foods is consumed.
• They carry higher risks for malnutrition and permanent dependency on supplements.
• This surgery also permanently alters anatomy.

Risks commonly associated with restrictive/malabsorptive procedures are:

• Leaks and bleeding may occur at the location where staples were used to repair the stomach or re-attach the small intestine. Serious bleeding may require blood transfusions. Leaks also result in failure of the procedures and subsequent weight regain.
• Infection.
• Eating too much or too quickly, or eating certain kinds of food, may cause nausea and vomiting.
• Vomiting and the lack of adequate absorption of vitamins and minerals from food passing through the altered small intestine too quickly may lead to malnutrition.
• Women who are premenopausal, especially those who experience heavy bleeding during their menstrual cycles, may become anemic from not absorbing adequate amounts of iron.
• Some patients may develop stomach or intestinal ulcers.
• After rapid weight loss, some patients may develop gallstones.

What other risks are associated with weight loss surgery?
Before your operation, your surgeon will carefully explain the risks that are unique to you and specific to the type of procedure you decide upon. Problems associated with bariatric surgery can range from minor to life-threatening. Complications may occur during, immediately after, or within weeks or several months after surgery. Additional surgery, re-admission to the hospital, medication or nutritional supplements may be required. Health insurance may not cover some or any of the costs related to these unanticipated circumstances.

Be sure to use this as a general guide to ask your surgeon any questions you may have about risks and benefits of weight loss surgery before undergoing your procedure.

What types of tests will my surgeon conduct prior to my surgery?
Before your operation, you will be scheduled to have the following types of tests:

• A complete medical examination. Your surgeon will ask you about your medical history, paying special attention to your current weight status, what attempts you have made to lose weight, and whether any weight loss strategies you tried were successful.
• You will be evaluated for any health problems that may have an impact on your surgery and recovery, your ability to lose weight, and your health status after surgery. This evaluation may also require you to have blood tests, X-rays or other diagnostic tests.
• You may also need to have a psychological and behavioral assessment. It is important that your surgeon be aware of any significant psychological issues (such as major depression, alcohol or drug abuse or bulimia) that may affect your ability to care for yourself after surgery. This assessment can also help you identify and make lifestyle adjustments before surgery and assist you in establishing realistic expectations about weight loss after surgery.
• Depending on your procedure, you may be required to undergo other laboratory tests, such as a complete blood cell workup, chest radiography or an electrocardiogram.

The presurgery medical and psychological evaluation may uncover concerns that may cause the surgeon to deem bariatric surgery too risky for you. If this occurs, you may be advised to postpone your surgery until these concerns are resolved. If the problem doesn't improve, you will be strongly discouraged from having the surgery.

How much will the weight loss surgery cost?
The cost of your surgery will depend on many factors: the type of procedure you have, where you have your surgery, your health status and whether any complications occur during or after surgery. In addition, your health insurance may or may not cover the costs of weight loss surgery, and your employer may or may not have weight loss surgery as a covered benefit. In general, the cost of surgery ranges from about $12,000 to $25,000 for an adjustable gastric band and up to $35,000 for gastric bypass.

Will my health insurance provider cover the costs of the surgery?
Many health insurance providers cover the cost of bariatric surgery. However, before committing to any surgery, you should review the "Exclusions of Coverage" section of your insurance policy contract.

Insurance regulations vary from state to state, and what one health insurance provider covers may not be covered by another. Over the course of your lifetime, however, there may be other unforeseen costs, especially if you experience complications related to your surgery. Your health insurance provider may not cover or reimburse you for some of these costs.

If you need special approval from your health insurance company, your weight loss surgeon's office can assist you. It is important to keep in mind that this approval may take several months. You will be responsible for completing a considerable amount of paperwork and investing time in communicating with your insurance company.

Here are some things to keep in mind:

• Primary care physician referral: Your primary care physician (PCP) may need to refer you for bariatric surgery. He or she should prepare a referral letter (called a "Letter of Medical Necessity," which is often required by insurance companies for weight loss surgery coverage) that includes information on any health concerns you have, a list of any medications you are taking, as well as your height, current weight status and your body mass index (BMI).
• Consent form: You may need to fill out a consent form in your doctor's office; this will allow your doctor to release information about your health status to your health insurance company.
• Weight loss history: You will need to show that you have been unable to successfully lose weight with diet and exercise alone. You will probably be asked to provide a complete list of your weight loss efforts over the past five years. You may need to provide written documentation, such as the letter of medical necessity, to confirm that you have made attempts in losing weight (for example, bills from WeightWatchers or nutritional counseling records).
• Medical history: If you have other pre-existing health conditions that are negatively impacted by or caused by your weight status, you should gather copies of your medical records, including your letter of medical necessity, to show you have these weight-related medical concerns. Health conditions related to obesity include type 2 diabetes, high blood pressure, sleep apnea, asthma and joint problems.
• Insurance payment: Keep in mind that even if your insurance provider covers bariatric surgery, your employer's plan may not provide it as a covered benefit. Obtain a copy of your health plan benefits contract and then contact the health plan administrator to review the specifics of your health plan coverage.

What if I am thinking about getting pregnant?
Getting pregnant is often easier after significant weight loss. However, pregnancy should be postponed for at least one year after surgery because you will experience significant physical and behavioral changes in the initial months—changes that could make pregnancy risky during the first year.

If you are a woman thinking about pregnancy or attempting to become pregnant, consult with your surgeon first to discuss certain adjustments that can be made. For example, the adjustable gastric band can be loosened during pregnancy for increased nutrition and then tightened again after childbirth.

What specific questions should I ask my weight loss surgeon?
During your appointment with the weight loss surgeon, be prepared to ask questions about his or her practice and experience. It is very important for you to feel comfortable with and confident in your surgeon. A few sample questions are listed here:

• Are you board certified in bariatric surgery?
• How much of your practice is devoted to bariatric surgery?
• How long have you been performing bariatric surgery?
• How many bariatric operations have you done?
• Are you experienced in all types of bariatric operations, or do you specialize in one in particular?
• How often do you currently perform bariatric surgery? (How many procedures per week or month in the last 12 months)
• Are your bariatric surgeries typically performed via open or laparoscopic (minimally invasive) procedures?
• Are most of your surgeries performed as outpatient procedures, or do they require a hospital stay?
• What are the average weight loss results for your patients? What about improvements in associated health conditions?
• Can you help me obtain insurance or discuss other payment options for surgery?
• Does your bariatric program address the specific needs of weight loss surgery patients: proper facilities, health professional team, post-op care and support?
• What type of support do you offer? Do you offer seminars, support groups, education for family and friends, psychological and nutrition counseling?
• How often do you see your patients after their surgery?
• What comments have your other patients made about their bariatric surgery experience? Can you connect me with other patients?

If you would like a second opinion from another surgeon prior to committing to weight loss surgery, ask your PCP to make another recommendation. The American Society for Metabolic and Bariatric Surgery (ASMBS) can assist you and your PCP in locating another surgeon. The ASMBS promotes the practice and improvement of bariatric surgery through research and education. A member of the ASMBS is board certified in weight loss surgery and has been the lead surgeon in at least 25 bariatric operations in the previous two years.

Supported through an educational grant from Allergan Inc.