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Pathway to Surgery

bariatric coupleNow that you've given careful thought to benefits and risks of weight loss surgery (also called bariatric surgery) and have decided it may be right for you, it's time to take the initial steps on your journey toward a new, healthier lifestyle. These include:

  • Patient Information Seminar - This required seminar, conducted by an expert board-certified bariatric surgeon, covers a variety of topics for you and your family and provides a great opportunity to ask questions, learn about surgical options, benefits and risks, etc.
  • Initial Office Consultation - This appointment will help determine whether you meet requirements for surgery and covers topics such as recovery time, support groups, and required physical and psychological consultations needed prior to surgery.
  • Surgeon Consultation - This is your opportunity to meet with our surgeon for a physical exam and discussion of benefits and expected outcomes of surgery.
  • Pre-Operative Testing and Visits - A variety of appointments will be required prior to surgery, including Fitness and Wellness appointments, lab tests, physical exams, etc.
  • Surgery - All procedures are performed at WakeMed Cary Hospital. Depending on the type of surgery, you may be released the same day or require an overnight hospital stay.

Patient Information Seminar

When you call WakeMed Physician Practices - General Surgery to make your first appointment, you will be told about the next Patient Information Seminar (also called "Info Session"), which is required before your appointment with a surgeon.  The information seminar covers a variety of topics on the weight loss surgery program, including:

  • The anatomy and physiology of the surgeries for weight loss.
  • Short-term and long-term patient results and outcomes, data and statistics.
  • Risks and complications.
  • Insurance and timelines for how soon you can expect to have surgery.
  • Comparing and contrasting the adjustable gastric banding with the gastric bypass procedure.
  • Pre-operative vitamin, mineral, nutrition and exercise programs to help get your body in the best possible shape for surgery.

Patients are invited to bring relatives and friends to seminar. You will be given a packet of materials that provides a wealth of valuable information about the surgery and what to expect. It is very helpful to review this handbook prior to your first appointment so you can be well-informed and prepared with any questions that you may have.  There is also a "patient true/false" quiz in the back of the handbook; please bring that along with the other completed forms to the office for your first appointment.

Counseling: Behavior problems such as binge eating, and other issues such as depression and anxiety are not cured by surgery. In fact, these conditions can actually worsen after surgery, so all patients are required to obtain counseling before they have surgery in order to ensure success after surgery. The Bariatric Program coordinator will provide a list of psychological providers that are available to help you.

Exercise and Diet: Unless you are physically unable, we will ask that you begin a walking or other aerobic exercise activity in the weeks prior to your surgery. You also will be required to reduce calories and follow a diet of low fat foods, as well as a vitamin and mineral supplements. During your appointment with the dietician, you will discuss your pre-op diet as well as the post-op recommendations. Making healthy lifestyle changes such as increasing activity, taking vitamins, and eating a healthy diet before surgery will put you in the best possible shape for major surgery and general anesthesia.

Smoking: If you smoke cigarettes or use other tobacco products, your surgeon will ask you to stop prior to the surgery. Smoking reduces lung capacity and stamina, and nicotine causes wounds to heal more slowly. It also can cause ulcers, bleeding, and leakage from the connections made during gastric bypass. Patients must be tobacco/nicotine-free for a minimum of one month prior to surgery. Pre-op blood work may be drawn to measure nicotine levels; if level are positive, your surgery will be postponed. We offer assistance to help you quit.

Surgical Consultation

At the time of your consultation with a surgeon, he or she will make sure that you meet the National Institutes of Health criteria required to quality for weight loss surgery.  NIH requires a BMI of 40 (or 35-39 with serious health problems).

During your consultation, your surgeon will discuss and clarify your medical history, conduct a complete physical examination, and determine from a surgical standpoint if you are a good candidate for weight loss surgery. If you are a candidate, he will discuss the benefits, expected outcomes, risks, complications, and contraindications for the different procedures.  You will have an opportunity to have all of your questions answered.  You and your surgeon will decide together which procedure may be best for you.

He will then ask that you lose 10 percent of your excess weight before surgery. For example, if you are 100 pounds above your "ideal body weight" you will be asked to lose approximately 10 pounds. Research indicates that patients who lose a small amount of weight before surgery have shorter anesthesia times and better recovery. Pre-operative weight loss also decreases the amount of fat around the abdomen and can decrease liver size, which gives the surgeon better dexterity and visibility in the abdominal area. This shortens operation time and increases your safety as a patient. Your surgeon may postpone your surgery if you do not lose the requested amount of weight or if you gain weight before your operation.

Moving forward: Once you make the decision to move forward with surgery, the process of getting insurance approval and scheduling additional medical appointments and evaluations begins.

Our office will prepare and send a request for pre-approval to your insurance company within approximately two weeks of your consultation with the bariatric surgeon. We will give you instructions on how to arrange for your psychological consultation, which is required prior to surgery by insurance providers.  The cost of the service should be covered by your insurance provider, and is designed to help ensure you are prepared mentally for the lifestyle change that comes with weight loss surgery. In addition, your surgeon will require (and your insurance company may require) that you complete a nutrition evaluation. We will assist you with setting up an appointment with our dietitian.

If at any point you choose to delay your surgery, you may call us regarding your decision at a later time.

Pre-Operative: Fitness and Wellness Component

All patients, including self-pay patients, will be required to select a Fitness and Wellness package option. Some insurance companies require patients to complete a "medically supervised weight loss program" before they will even consider payment for weight loss surgery. If this is true for you, we will assist you with the required documentation.

At minimum, each Fitness and Wellness package option will address exercise, wellness, nutrition, and support group. Each patient will be required to attend at least one nutrition visit and at least one fitness visit before surgery. The visits will be scheduled at WakeMed Raleigh Campus, WakeMed Cary Hospital, or WakeMed North.

You are invited to bring a support person such as a spouse or significant other, a parent, adult child (young children are not allowed for safety reasons), or other friend or family member with you to the classes. Attendance is required for surgery to go forward.

The fitness consult includes a review of pre- and post-operative exercise including:

  • Aerobic fitness
  • Resistance training
  • Flexibility
  • Resources for incorporating exercise at home
  • Demonstration of leg exercises to prevent blood clots

The nutrition consult includes:

  • Thorough review of the "Adjustable Gastric Band (AGB) and Gastric Bypass Nutrition Handbook"
  • In-hospital and home-from-the-hospital diet progression
  • Sample menus
  • Do's and Don'ts
  • Selecting and preparing liquid, pureed, and soft foods
  • Reading food labels
  • Vitamin and mineral supplementation
  • Prevention of vomiting
  • Eating methods for long-term success
  • Support resources and aftercare classes

Scheduling for Surgery and Pre-Op Testing

Once we obtain approval for surgery from your insurance or arranged payment decision, our office will arrange for your pre-operative visit in the office. All pre-op testing is completed at WakeMed Raleigh Campus, WakeMed Cary Hospital or WakeMed North, or at a facility close to your home.

If you have gallstones and are experiencing gallbladder-related pain, your surgeon will advise you to have your gallbladder removed several weeks or more before your AGB procedure. He will not perform the AGB placement at the same time as a gallbladder removal due to the increased risk of infection. Please note that not all patients need to have their gallbladder removed; your surgeon will discuss this with you.
Pre-Op Surgery Visits
During your first pre-operative surgery appointment, your surgeon will give you a complete physical exam. This visit allows you to ask questions and clarify any additional concerns you may have. Appropriate consults, labs tests, and referrals will be arranged based on your medical history. Appointments with our fitness and nutrition consultants will be arranged.

At your second pre-operative visit, results from your pre-operative lab work and studies will be reviewed. When you feel that you fully understand everything about the surgery, you will be asked to sign your consent forms. Your surgeon will not operate on you if you have failed to be compliant with any course of treatment.

You will be provided with written instructions on what to eat and drink for the two days prior to surgery. On the day before your surgery, and it is advised that you do not plan to work or travel on this day. Your surgery will be performed at WakeMed Cary Hospital. If you are from out of town, you may need to make arrangements to stay overnight in the Raleigh area before your surgery. We can give you a list of local hotels.

Before surgery, one of the nurses from Day Surgery will contact you to obtain a medical history and to provide additional information on arrival time, where to go, eating/drinking instructions, and to answer any questions you may have. Based on your medical history, you will likely meet with an anesthesiologist several weeks prior to your procedure; an anesthesiologist will reevaluate you for general anesthesia the morning of your surgery.

Hospital Stay

Some patients electing to have adjustable gastric banding surgery are eligible for discharge on the same day as surgery. In some cases, a patient who is scheduled to go home the day of surgery may remain in the hospital if there is a need for closer observation.

Note for Patients with Sleep Apnea

Surgery patients requiring an overnight stay should bring their sleep apnea equipment (such as CPAP machines) to the hospital.

Family members (or significant others) may accompany you to Day Surgery. There, you will be prepared for surgery, an IV will be started, and you will be given medication to reduce the incidence of nausea and vomiting. You may also be given IV medication to relax you. To decrease the chance of developing blood clots, antiembolism stockings and sequential compression devices will be placed on your legs, and blood-thinning medication may be given.

While you are in surgery, your family will be asked to wait in the waiting area near the operating room. Immediately after your surgery is completed, your surgeon will go to the day surgery waiting area to give your family a progress report. The surgery itself usually takes 30-60 minutes; however, total time from Day Surgery to Recovery Room (also known as the Post Anesthesia Care Unit or PACU) can take as long as two hours or more. After surgery, you will go to the PACU for approximately one hour. You will then be transferred back to Day Surgery to recover until you are discharged home.

Occasionally, a patient might need a urinary catheter or a NG tube (a tube that is placed in through the nose and goes down to the stomach) placed during surgery. Pain control is managed by the use of IV and oral pain medication. Your nurse will make sure that your pain is under control.

Pressure devices such as antiembolism stockings and SCDs will remain on your legs to prevent blood clots. These function independently, do not cause discomfort, and are effective in reducing the incidence of blood clot formation in the legs. The single most effective way to prevent blood clots and pneumonia (the two most common complications after surgery) at this critical post-op period is to get out of bed and walk. Once you have been evaluated by the nurse, you will be getting out of bed to a chair and will be walking with assistance down the hall.

As a precaution, oxygen will be provided to you via a nasal cannula on a continuous basis after surgery. If oxygen is ordered, an oxygen saturation monitor will be placed on your finger to ensure that you are breathing adequately. This monitor is a loose clamp that fits over your finger. If necessary, a respiratory therapist will conduct a pulmonary evaluation. To prevent lung complications, you will be required to use the "incentive spirometer" (plastic breathing device) every hour while awake. You will be instructed on its use during the pre-operative visit. Intermittent deep breathing and coughing are encouraged every hour while awake for the next several days.

If you are tolerating liquids well, and your pain is controlled with oral pain medication, you will be discharged. A detailed discharge instruction sheet will be given to you before you leave with information about wound care, activity, showering, fever, pain, nausea/vomiting, medications and other instructions.

If you have diabetes, your blood sugar will be monitored while you are in the hospital. A tiny pinprick on a fingertip provides the drop of blood necessary for this test. Diabetic patients will receive insulin on a "sliding scale" basis as needed. At the time of discharge, your nurse will advise you on how to resume your diabetic medications once you get home. Most patients are discharged from day surgery within 4-6 hours of their surgery.

Overnight Hospital Stay

Some patients are required to stay overnight after their adjustable gastric banding procedure. Conditions that would require an overnight stay would be health problems such as severe sleep apnea, oxygen requirement, heart disease, Diabetes Type I or Type II, history of blood clots, high BMI and others. Occasionally, patients with pre-existing heart and lung problems, patients with a high BMI, or patients that have an open procedure, may go to the Intensive Care Unit (ICU) for closer monitoring.

If you are tolerating liquids well and your pain is controlled with oral pain medication, you will be discharged before 12 noon the day after surgery. A detailed discharge instruction sheet will be given to you in the hospital that contains information about wound care, activity, showering, fever, pain, nausea and vomiting, medications, and other instructions.

At Home

Once you are home, it is important for you to get up and walk many times each day. It is suggested that you not stay in one place longer than 30 minutes at a time unless you are sleeping, and when you are seated, you should keep your legs elevated. Allowing your legs to dangle over the edge of a chair or the edge of a bed for more than a few minutes will cause your circulation to slow and allow blood clots to form. Do your breathing exercises using the incentive spirometer (IS) device every hour while awake for several days after surgery.

You will have between six and 10 appointments for adjustments to the band in the office within the first year after your bariatric surgery. Your first appointment will be two weeks after weight loss surgery. Your second appointment (unless for any reason you need to come in sooner) will be in the fourth week after surgery, at which time most patients receive their first band adjustment.

Please see "Life After Surgery" for more information about diet, exercise and support.