WLS FAQ

•   What is "morbid obesity"?  
Morbid obesity is defined loosely as being 100 lbs or more overweight.  However, more clinically defined, and by most insurance companies' standards, it is having a BMI of 40 or above -- or having a BMI of 35 or above plus CO-morbid factors.  The morbidly obese patient is considered to be at a higher risk for developing, among many things, cardiovascular disease, cardiac dysfunction, pulmonary problems, digestive diseases, and endocrine disorders as well as obstetric, orthopedic, and dermatologic complications.
•   What is BMI and how do I find mine?  
BMI means Body Mass Index.  It is a calculation of your body fat content rather than just your weight, and considered to be a more accurate indicator of obesity than just weight alone.  If your BMI is 40 or above, you are considered morbidly obese and at a high risk of developing complications that will likely lead to death.  You can calculate your BMI by using the BMI calculator at the www.obesityhelp.com site by clicking this link:
http://www.obesityhelp.com/bmi-start.phtml
•   Why not just diet?  
There are several critical success factors associated with WLS.... smaller stomach... fewer calories.. mal-absorption of sugar for some of us...  a high protein diet... all of these things work in conjunction together.  The new stomach and its smaller size, however, is a key *tool* for many WLS patients.  
The average morbidly obese person may have a stomach in excess of 20 ounces, while the "normal" size person may have one of 6 to 10 ounces.  Quite simply, the WLS candidate never gets full until they have consumed far to many calories.  
In my humble opinion, it's just not realistic to think a human being can stick to a diet over the period of *years* it would take to lose safely.  Its not realistic to think a person with a 20 oz stomach is going to subsist on a thousand calories a day, and sustain that kind of self-deprivation over an extended period of time without some sort of tool to help them.  
According to the ASBS (American Society for Bariatric Surgery), "Published scientific reports document that non-operative methods alone have not been effective in achieving a medically significant long term weight loss in morbidly obese adults.... Surgical treatment is medically necessary because it is the only proven method of achieving long term weight control for the morbidly obese."
•   What is WLS?  
WLS is an acronym for Weight Loss Surgery.  It encompasses all the various types of WLS that are out there today, of which there are many, and which we'll explore.  
In general, the WLS patient loses weight based upon lowered calorie intake, and mal-absorption of food that is taken in.  The patient loses rapidly for the first 8 months, then the loss slows to a greater degree.  The "window" of opportunity, or duration of weight loss, for a WLS patient is generally 2 years from the date of surgery.  After that time, the body adjusts to the loss of weight and slowing of metabolism.  The surgeon also tends to encourage an increase of calorie intake after that period of time, if the patient has sufficiently lost enough weight and/or the surgeons feels the patient should cease losing.  Most patients generally lose 80% of their excess weight within this 2-year "window of opportunity."
•   Who is a candidate for WLS?  
Again, according to the ASBS, "The option of surgical treatment should be offered to patients who are morbidly obese, well informed, motivated, and acceptable [of] operative risks. The patient should be able to participate in treatment and long term follow-up."
If you think you are a candidate for WLS, if you have exhausted all avenues of dieting, consult your physician and do more research with local WLS groups in your area.  If your BMI is 40 or above, or 35+ with other CO-morbid factors, you may be a WLS candidate.
•   What are the different kinds of WLS?  
There are various kinds of Weight Loss Surgery existing today.  Traditionally in the past, and to some extent even today, WLS is referred to as a Gastric Bypass or Stomach Stapling.  However, there are many types that do not involve stapes or bypass.  I'll attempt to describe some of them below to the best of my civilian ability. (Note:  These are only *my* opinions based upon my own researched.  I do not claim to be a medical authority.  Please consult your physician for advice.)
•   RNY - This is the traditional and most common procedure currently.  RNY stands for Roux En Y.  The procedure consists of "bypassing" a certain amount of the stomach, usually the portion that processes sugar, to create a new smaller stomach.  The effects of this are that the patient has a smaller stomach and no long tolerates sugar the way they normally did, creating a "dumping" effect (explained lower).  The surgery is performed either by full open incision (Open RNY) or laparoscipally (Lap RNY).  Variations on the RNY include the "Fobi Pouch" which may include vertical stitching (note:  This is not to be confused with the older VBG described below).  The amount of bypass can be either proximal or distal (explained lower as well).
•   Open RNY - This is the traditional (and most common currently performed) type of RNY.  It is formed by open surgical technique, which includes creating an incision, generally 6 to 12 inches long, depending upon the size of the patient.  Traditionally, the incision runs from navel to sternum, and is performed with traditional surgical instruments. Surgery lasts anywhere from 2 to 4 hours.  It usually involves a hospital stay of 4 days, with the first day being in ICU.  Recovery is generally 4 to  6 weeks.  An Open RNY may or may not be transected (see below) based upon the surgeon.
•   Lap RNY - Newer techniques allow for the RNY to be performed via laparoscopy.  This involves the use of smaller incisions made in the patient, generally two to four of 1 or 2 inches in length. The surgery itself is performed with the use of a microscopic camera inserted into one small incision, and the use of microscopic tools.  The typical hospital stay is 2 to 3 days with the surgery generally lasting 4 hours.  Recovery is generally one to two weeks.  Lap RNY use to not be transected due to the inability to perform this procedure with microscopic instruments.  However, with the invention of the GI Stapler, transections can now be performed via lap.  The surgery is becoming more popular, though it may be difficult to find someone trained in lap RNY in your area.  Shop around.
•   "Fobi" Pouch - This refers to a type of RNY that was developed by Dr. Fobi.  It involves creating a smaller pouch from the old stomach using vertical stitching and transection (described lower).  The bypassed section of stomach is reattached lower on the lower intestine, though it no longer serves a function, while still kept viable (alive).  It may be either a lap RNY or an open RNY.
•   Distal  - This refers to the amount of stomach bypassed.  A distal RNY means that over 150 cm of intestine is bypassed - the section that processes sugar.  Thus the distal RNY patient does not process sugar and has a greater mal-absorption of food and nutrients.  The result is a more rapid weight loss, but a need for closer watch of nutritional intake.  An RNY patient may refer to their surgery as a "Distal RNY Fobi" procedure, or a "Distal RNY".  Distal RNY is usually reserved for patients with a weight exceeding 400 to 450 lbs.
•   Proximal - A proximal RNY patient has less than 150 cm of intestine bypassed.  Most RNY's are proximal.  The Proximal patient still has a mal-absorption of food and sugar, though to a lesser extent than a Distal patient.  The result is still weight loss, though it may be considered that the patient has less of a worry about mal-absorption of nutrition.  
•   Transection - Transection refers to the separation of old stomach from new.  In an RNY, the new smaller stomach is created by sectioning a smaller portion from the old.  This is accomplished usually by the use of 4 rows of staples.  The stomach is mucous tissue on the inside.  Mucous tissue cannot heal onto itself.  Thus, the barrier between old and new stomach is the staples.  Some surgeons will transect or cut between the second and third row of staples.  This transection or cut allows the newly cut edges to heal together, forming a seal via the scarred edges.  One way to think of this is to imagine a welded pipe.  It is considered that a welded seam is the strongest portion of the pipe.  The number of rows of staples used may vary from surgeon to surgeon.
•   Dumping - Dumping is a reaction sometimes experienced by the RNY patient who consumes too much sugar.  It is often considered a desired side effect.  Many patients, like me, were sugar addicts.  With the resulting mal-absorption of sugar after an RNY, the sugar is "dumped" directly into the lower intestine and thus reaches the bloodstream much faster than pre-op.  No processing takes place to stimulate the production of insulin.  Thus, "dumping syndrome" occurs.  The effects are sweating, nausea, disorientation, and perhaps stomach cramping -- much like what a diabetic encounters who overindulges in sugar.  Effects of dumping can last anywhere from a few minutes to hours, and become a big deterrent to eating sugar.  
•   DS - The DS or Duodenal Switch is a newer surgical technique (more info to come as I learn more!  Many appear to be quite happy with this new technique).  It is also referred to as a BP/DS or Bilio-pancreatic Duodenal Switch.
•   VBG - The VBG or Vertical Banded Gastroplasty is an older technique that involves the use of silastic bands or rings placed via open procedure about the stomach or intestines.  Some of these rings may be filled with a saline solution and can then be expanded to "tighten" about the stomach.  While many patients have been happy with the result of this surgery, there is the risk of the rings or bands breaking down.  Several VGB patients have followed up the technique with a revision to RNY.  Consult several surgeons for the best technique for you.
•   VGB - The Vertical Gastric Bypass is not to be confused with the VBG -- though the acronym is too close for my taste.  The VGB is similar to the "Fobi Pouch" and uses vertical stitching.  (More info to come as I find it).
•   Mini-Gastric Bypass - (when I learn more I'll post it here)
•   What about the use of rings or bands?  
Bands are traditionally used in VBG.  However, some surgeons have implemented the technique of using them in an RNY.  A single silastic band (non-saline filled) is placed around the new "pouch" to prevent the pouch from stretching over time.
•   How big will my new stomach be?  
The RNY procedures generally create a new stomach or "pouch" of approximately 2 to 4 ounces.  The average person has a roughly 6 to 10 ounce stomach, while the morbidly obese person may have in excess of a 20 oz stomach.
•   Will my new stomach stretch out?  
It's not likely.  Overeating to the point of "stretching" the new stomach can be extremely painful for the WLS patient.  Some surgeons even use the extra precaution of adding a silastic band around the new "pouch", though it is not required.
•   What about hair loss?  
Many WLS patients do experience some hair loss, those most report that it is not noticeable.  Some experience none at all.  I experienced no hair loss at all, and attribute it to appropriate consumption of protein following WLS.  
The body uses protein for healing after any trauma to the body (yes, surgery is a trauma).  It also uses it whenever the body feels deprived.  You will be taking in less food and thus less nutrition.  Many physicians feel its important for the RNY patient to increase protein intake to maintain good health.  It is also thought that it can inhibit hair loss.
•   Will I have to follow a special diet?  
Yes and no...  
After surgery, your stomach is healing.  It has received trauma.  The natural reaction of any tissue to trauma is to swell and be tender.  You will have to go easy on your new stomach in the days following surgery.  
The amount of time you will need to follow restricted solid intake varies from surgery to surgery and from surgeon to surgeon.  Some want you on solid foods right away, others feel its better to allow the stomach to heal and restrict intake for a period of time to liquids or purees.  It can somewhat be likened to a newborn.  The stomach or pouch is new, and you are just learning what foods you can tolerate.  
After a period of time, you will be able to eat more normally, including many if not all of your old favorite foods, except in smaller quantity than before.  You may develop a lactose intolerance or intolerance to fatty foods.  RNY patients often cannot tolerate sugary foods without experiencing "dumping" (see above).  
Most assuredly your eating patterns become more normalized over time, although quantity of intake is forever reduced.  Many patients report that the "chain" of addiction to food is broken and cravings are reduced or eliminated.
•   What about exercise?
Diet or no diet, WLS or no WLS, exercise is  KEY contributor toward good health.  It promotes cardiovascular fitness, makes you feel better in general, and provides muscle tone.
•   What are my chances for success?  
The ASBS reports that roughly 14 years after surgery, in excess of 50% of patients maintain 50% or better of their weight loss.  
Bear in mind, this study includes much older procedures that are not as successful as today's surgeries.  I suspect in time, studies will show that the results are much higher than this for new surgeries.   NAAFA (The National Association for Advancement of Fat Acceptance), reports that traditional dieting methods however, only have a long term success rate among the morbidly obese of 2% or less!
•   How dangerous is it?  
The IBSR (International Bariatric Surgical Registry) published a ten-year study in 1997.  The study reported that roughly 93% of patients had no complications after 30 days.  It also reported a mortality rate of only .17% (NOT 17 percent.. but POINT seventeen percent).  This is less than one quarter of a percent.  
Remember that Morbid Obesity is a progressive and life threatening disease in and of itself, and they morbidly obese patient, depending upon the age and advancement of obesity, may already be at risk for any surgery.
•   How do I find out more about WLS in my area?

Ask your primary care physician or family doctor, or look for resources on the web.  You can write to the ASBS at:

            American Society for Bariatric Surgery
            140 NW 75th Drive, Suite C
            Gainesville, FL 32607 (USA)
            (352) 331-4900 (Phone)
            (352) 331-4975 (Fax)
            E-mail: info@asbs.org

or contact www.obesityhelp.com to find resources in your area.

•   How much does surgery cost?  
Having spoken with many WLS patients, I've found a large range of prices.  Factors include location, the hospital used, as well as whether other procedures are performed during the surgery.  The prices for a typical RNY appear to range anywhere from $17,000 to $28,000.  Do NOT base you surgery solely upon price.  This is your life!
•   Will insurance cover this?  
There are no guarantees.  Many insurance companies do cover the procedure in whole or in part.  Some do not.  Those that don't may exclude based upon general policy or by specific exclusion based upon your employers wishes.  Consult your policy, and BE diligent.  If your policy excludes WLS, try anyway.  Many patients have achieved success by fighting the exclusion and having it overturned.  Some states even now require that policies cover WLS.
•   What do I tell my family and friends?  
As much or as little as you want.  Close family can be reluctant to see you undergo what they perceive as a radical procedure.  There is a lot of misinformation generated about WLS.  It can seem drastic or dangerous.  
Remember that most of your loved ones' fears or reluctance may simply stem from concern for your well-being and safety.  Make sure they know the facts and not rumor.  Print the research you find to show them and inform them.  Be well versed and knowledgeable about WLS.  Above all, be patient with them.  If you decide to have WLS, do it for yourself and no one else.
•   What do I tell my boss and coworkers?  
Again, as much or as little as you wish.  They may have the same feelings for you as your family.  Be informed about what your company policy is regarding sick leave, disability and family/medical leave.  Obtain written copies of the documentation, and speak to your company's benefits representative.  Most companies' maintain a confidentiality policy regarding employees.
•   Will I need plastic surgery afterwards?
Some do and some don't.  Your age, the amount you need to lose, rapidity of weight loss, exercise regimen, and skin elasticity all play important roles in how your skin will react to WLS or any large weight loss or gain.