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Frequently Asked Questions and Answers
1. Wha t can I expect if I decide to have the surgery?
Answer: After you leave here today, you will be expected to see a Gastroenterologist (GI Doctor) for your upper endoscopy (bypass only). This needs to be performed prior to Gastric Bypass surgery in order to ensure that you have no Active Ulcers, Gastritis or H. Pylori Bacteria in your stomach. If you have chosen the Lap Band, you will simply need a breath test to check for the H. Pylori Bacteria. In addition, you may need to see a Pulmonologist (a Lung Doctor) to ensure that your lungs are clear and that you are capable of handling the anesthesia. You will also need to see your Primary Care Physician (PCP) and get medical clearance for the surgery. You may also need to see a cardiologist for cardiac clearance prior to the surgery. He/She may require that you undergo a cardiac stress test.
Why Do I need all these tests? This is elective surgery. We want to ensure that you are in the best medical condition possible and that you will be able to handle both the surgery and the anesthesia without complication.
2. How do I get my insurance company to approve the surgery?
Answer: Most insurance companies approve the surgery; however, they frequently require that you do some work on your end. They require that you get a letter from your PCP stating that he/she has supervised your weight loss for at least two years (the more the better). In addition, most insurance companies require that you see a psychologist in order to ensure that you are psychologically prepared for the surgery. Once you get all of your letters together, bring or send them to the office. We will then put your letters together with your letter of medical necessity from this office and send the application for approval in to your insurance company on your behalf. Some insurance companies, such as Aetna and Cigna, require that you submit several years worth of office notes from your PCP. This is, presumably, to ensure that you have tried to lose weight under medical supervision for several years and have failed. After your office visit, your bariatric co-coordinator will help inform you as to which doctors you will need to see and what information your insurance company requires in order to get approval.
3. When can I have the surgery?
Answer: The surgery date is dependent upon your insurance company. Once we get approval from the insurance company, my office will call you and ask you for a date for the surgery. Please think about a 2-4 week recovery period after the gastric bypass surgery (2-4 days for gastric banding). You may not feel like you will need that much time. In fact, you will not be experiencing pain or discomfort in that period, however, you will be very tired and may feel washed out until you regain your strength.
4. You do not participate with my insurance company. What does this mean?
Answer: It means that I do not accept the “Standard Rate” that they reimburse for the operation. As a result, I accept “Out of Network Benefits.” This means that you may be required to pay the balance due for the operation beyond what your insurance company pays. It is important to check with your insurance company and see if you have “Out of Network Benefits.” Most PPO and POS plans have these benefits. Unfortunately, HMO plans rarely if ever have these extra benefits.
5. What do I need to do the day before the surgery?
Answer: You will be on a clear liquid diet for the day before the surgery. Some of you will need to be on a clear liquid diet for an entire week prior to the day of the surgery (you will be informed if this is the case) - this is to help decrease the size of an enlarged liver. In addition, if you are having a Gastric Bypass, you will need to take a Fleet’s Kit #3 the day prior to the surgery. After that is completed, you will need to take a single dose of antibiotics. Please start the Feet kit early in the day, so that you are cleaned out early on. You should take the antibiotic after you are cleaned out and not before the bowel prep. If you take the antibiotic prior to the bowel prep, you will flush the antibiotic out of you bowel prior to it being absorbed. Band patients need only be on clear liquids the day prior to surgery and take the antibiotic some time that day.
Why do I need to do this bowel prep?
Answer: Over the past 7 years of performing this surgery, I have found that patients, who have cleaned out their bowls prior to the surgery: have less risk of infection; there is less "spillage" of bowel contents since the bowel is empty; patients not only recover quicker but experience less pain and discomfort prior to their first post-op bowel movement. (Bypass only)
6. Are there any support group meetings?
Answer: Yes. The meetings are held at the ACC (Ambulatory Care Center of St. Barnabas). They are held every two weeks. The mid-month meeting is designed mostly for Pre-op patients. The meeting is held at 6 pm (please check the schedule to see which meeting fits your needs), and is designed mostly for post-op patients but pre-op patients are welcome to attend. As of January 07, a LapBand only support group was established.
7. This is my first operation ever or my first operation at St. Barnabas. What can I expect?
Answer: The night prior to the surgery you will be called by your anesthesiologist (so make sure they have a number where they can reach you- call 973-322-5130 and give them the number) and he/she will discuss the anesthesia with you. You will be expected to show up two hours prior to your scheduled OR time. Typically we are running ahead of schedule, so calling the Same Day Surgery (SDS) area at 973-322-5130 to check on how things are going is not a bad idea. Once in SDS, you will be “checked in.” They will ask you all those questions again and then get you to change into a hospital gown. They will then start an IV. As soon as the OR is ready, you will be called for and then sent over to the “Holding Area.” Your family member can stay with you up until the time that you go into the OR. Once in the operating room, you will be placed on the table and strapped into place. The table will be tilted so that you are nearly standing up for the operation. We do this while you are awake so that we can ask you if anything hurts (feet, legs, back, arms, etc.) this is to help prevent a parasthesia or nerve injury. When you wake up, you will not feel any of the incisions- they will be numbed up with a local anesthetic, which lasts 12-16 hrs. You will also have a PCA or patient controlled anesthesia at your side. This is a button that you can press that will give you pain medicine- most commonly Morphine. Most patients don’t need it or use it, but it is there for you just in case. After the fist 12-16 hours have past, the anesthesia should have cleared from your system and the nausea, if you have any, should pass. Following that, you should feel better and better every couple of hours.
8. Do you perform the surgery?
Answer: Yes I perform the surgery. I do not allow residents in training to perform parts of an operation that could result in a leak. As a result, I perform the operation in order to ensure quality and to prevent potential complications. I do, however, need an assistant to hold the camera and to perform simple tasks during the operation.
9. How long does the operation take?
Answer: Most of the time, the operation takes about 90 minutes for a gastric bypass and 30 minutes for a Lap-Band. If you have had previous surgery, you may have scar tissue (adhesions) on the inside that will require extra time to take down. This could add anywhere from 10-60 minutes to the operative time.
10. How long will I be in the hospital?
Answer: You can expect to be in the hospital for 2-3 nights for a bypass and same day or overnight for a band. This is based on how you are doing during your recovery period.
11. Where do I get the pain medicine when I go home?
Answer: Most patients never need or fill the pain medicine prescription. The medicine is Liquid Roxicet and can be taken every 4 hours as needed. You can’t get it filled at a Rite Aid, CVS or Walgreen’s. Most of these “chain stores” don’t carry this medicine. As a result, you will need to go to an “old fashioned” pharmacy.
12. What is my diet after the surgery?
Answer: You will be on a clear liquid diet from the time you leave the hospital until your first post-op visit. After that, you will be on a full liquid diet for the next week. By the third week, you will begin soft or puree foods. Four to six weeks out, you will be introducing regular foods but in small portions. Any time you try a new food for the first time, you need to only try a teaspoon full of that new food.
13. I take a lot of medication. What do I do about the pills that I take?
Answer: After the surgery, you are allowed to take any pill that is M&M size or smaller. Any other medications need to be crushed or given in a liquid form. As a result, I suggest that you speak with the physician that prescribed the medication and find out if you can crush it or if he/she can prescribe a liquid form for you to take. It is important to note that most patients are taken off the majority of their medications soon after the surgery. Once you are 4-6 weeks out from the surgery, you are permitted to take any pill that you need to. This is with the exception of any NSAID’s (Aspirin, Motrin, Ibuprofen, Vioxx, etc.).
14. I have heard that I can’t take certain medications ever again after the surgery. Is this true?
Answer: Yes. You will not be able to take any NSAID’s (Aspirin, Motrin, Ibuprofen, Vioxx, etc.). This is due to the fact that they are Acids that are being dumped into a tiny, fragile, little stomach. These acids can wear away the lining of your stomach and cause an ulcer. More importantly, they can empty rapidly from the stomach into the small intestine. The small intestine has a much thinner lining and, as a result, is more susceptible to an ulceration and possible perforation. Is this to say that you can never take any Ibuprofen ever again- No. You can occasionally take one with food; however, it is best to avoid taking any of these medications.
15. When can I shower after the surgery and what about these bandages?
Answer: The bandages are called steri-strips. You can take a shower two days after the surgery. You should not take a bath. In the shower, just let the water run down over the steri-strips but do not rub them. If they fall off, you can clean them with peroxide and place Neosporin and a band-aid over the wound. The same applies to the Derma-bond that has replaced suturing the skin.
16. What is the Follow up?
Answer: I or my partner will see you every day in the hospital after the surgery. You will then see me one week after the surgery for your post-op visit. You will then see me again 3 weeks after that visit for your one-month visit. After that, you will see me every 3-6 months until you have stopped losing weight. Then, you will graduate to every 6 months for two years. Beyond that, as long as all your vitamin levels and lab work are all normal, you will advance to annual visits.
17. Is it true that I need to see a Nutritionist after the surgery?
Answer: Yes it is true. I require that all my patients see a Board Certified Nutrition/Metabolism Physician as part of their postoperative follow up. I believe that this is very important. You are having a big operation to lose weight; I want you to loose weight the right way- under medical supervision. You can see anyone you like or someone I refer to, but you have to agree to see someone. During your post-operative period, you will need to get blood work every 3 months. This is to check your vitamin levels and your nutritional status. Beyond the weight loss period, it us up to you and the Metabolic Physician to come up with a long term follow up plan that works for you.
18. What are the most common risks and complications?
Answer: The most serious complication is a leak, which could lead to infection. Every precaution is taken to prevent this from happening. The goal is to detect the leak in the operating room prior to completing the operation. That way the leak, if it exists, can be fixed right then and there. The next most serious complication is a DVT (deep venous thrombosis) otherwise known as a leg clot. The danger here is that the leg clot could break free and go to your lungs (Pulmonary Embolism).
If you are at high risk for a DVT and PE, you may be required to have a “Filter” placed in the blood vessel returning blood from both of your legs. This filter helps prevent blood clots from moving to your lungs. Two options exist here: a permanent filter or a retrievable filter (which can be removed within 2 months of placement). It us up to you to decide if you want the filter removed in that period of time. After the two months has lapsed, the lining in the blood vessel of your body will grow around the filter and make it permanent.
19. What about the excess skin after I lose the weight?
Answer: Not everyone needs to or decides to have the skin removed. It is more common, however, for men to have hanging skin on their abdomen after they lose massive amounts of weight. The answer is that it is up to you and that we will have to cross that bridge when we come to it.
20. Can I gain the weight back?
Answer: We haven’t had any patients gain back all their weight; however, it is not impossible. If you eat the wrong foods, you will pay the price with dumping syndrome (pain, nausea, vomiting, and diarrhea). If you continue to experience dumping on a regular basis, you may become so insensitive to the symptoms that you begin to gain back the weight with daily pain and diarrhea. This is why the insurance companies require a psychological evaluation prior to the surgery. They do not want you to become one of these people.
21. What if I get nauseous and throw up after the surgery?
Answer: Don’t panic. If you eat the wrong foods or eat too quickly, you will throw up. Get the food out of your system and you will clear the blockage. You will either throw up the food obstructing the anastamosis (the hole at the bottom of the stomach) or flush it through with clear liquids. If the nausea and/or vomiting continue, you may need to see your GI doctor for an endoscopy to look inside your stomach. This is either to retrieve the food blocking the opening or to “Dilate” open the anastamosis that may have a “stricture” or scar tissue.
22. Will I need my gallbladder out?
Answer: You may and you may not ever need your gallbladder taken out. I do not routinely take out the gallbladder unless you are having problems. If you do, eventually, need your gallbladder out it is not a problem. Most of the time it can be performed as same day surgery and is done laparoscopically as well.
23. When will I stop losing weight?
Answer: The time period that it takes for you to lose weight is based on may factors: Initial weight, Target Ideal body weight, Exercise, Water intake, Watching what you eat. As far as your target weight, your body has set points for weight. This is similar to a "Thermostat." It is hard to predict those "set points" but we have an idea about where that should be. In general, you will always be 20-30 lbs. over your ideal body weight (refer to your booklet for your ideal body weight).
24. I need to speak with you after the surgery. What do I do?
Answer: Call my office. Let them know what is wrong. If I am not in the operating room, I will call you back as soon as possible. I operate every Tuesday, Thursday and Friday. In case of an emergency, they can call directly into the operating room and let me know what is going on.
Michael J. Nusbaum, MD, FACS
Patient Requirements for Weight Loss Surgery
What do I need to do after the office visit today?
- You must obtain a letter from your Medical Doctor that states that He/She has treated you for your obesity for at least two years (the longer the better). It must also state that you have been unable to loose weight through medical treatments and that He/She agrees that you would significantly benefit from Weight Loss Surgery.
- Many Insurance carriers require that you obtain a Psychiatric evaluation. A Psychiatrist, Psychologist or Therapist can perform this evaluation. It must state that that you would significantly benefit from Weight Loss Surgery. (Required by all carriers).
- All Insurance carries require that you obtain a TSH Level to rule out Hypothyroidism as a cause of you weight problem. This can be performed by your medical doctor- or may already have been performed and addressed.
- Nutritional evaluation if required by your Insurance carrier. (Aetna, Cigna, HealthNet, United)
- Once you have obtained the four items above, you must get them into the office so that your application to the insurance company can be completed. At this point, you need to follow up with your insurance carrier as to the status of your application. It is now out of our hands. (Frequently, the more you call them the more rapid the response from your insurance company).
- Medical Clearance must be obtained and may or may not also require Cardiac Clearance. If you are over 350 lbs or over age 40 or if you have any personal or family history of cardiac disease or if your medical doctor requires that you obtain a cardiac clearance prior to surgery.
- Stress Test and/or Echocardiogram. If your BMI is over 50 or you are over 350 lbs or over age 40 or if you have any personal or family history of cardiac disease or if your medical doctor requires it or if your cardiologist requires it prior to surgery.
- You must see a Pulmonologist (preferably a SBMC doctor) to provide pulmonary function tests and pulmonary clearance.
- Venous non-invasive studies must be performed to rule out any blood clots in your legs. This can be performed at any vascular laboratory or at SBMC as an outpatient.
- You must see a Gastroenterologist (preferably a SBMC doctor) to perform an endoscopy to rule out any active ulcer, gastritis or H. Pylori bacteria in your stomach. If you have H. Pylori, it needs to be treated with antibiotics before you can have the surgery (both bypass and banding).
- PAT's: EKG, CXR and Blood Work within 30 days prior to the procedure (this can be done at a local hospital but it is preferable that it be performed at SBMC) Required: H&H, CBC, CMP, PT/PTT, Urine pregnancy, EKG, CXR
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