Life After Surgery
What do I need to do to be successful after surgery?
The basic rules are simple and easy to follow. We provide you with no less than 6 classes in your first year. We pay for (free for you!) and encourage you to attend over 10 support groups, both on-line and in the region. And, we give you your own “procedure bible” to help guide you. You will be well instructed. We know you do not know what to do—so we teach you. You will be an expert.
Even before surgery, we will provide you with special dietary guidelines. You will need to follow these guidelines closely. We teach you how to advance your diet in a very particular way in order to make the transitions easy for you to understand and do successfully. We not only teach you what to eat… we teach you how to eat, how to chew, when to swallow, how to shop for food, etc., etc.! These are all things you thought you already knew. Right? But, we believe in changing it all to give you both success and control. There are variations, dependent on the procedure you have, that will be clearly explained to avoid any confusion.
Here are some essentials. We like you to eat 5-6 small meals per day to avoid every really getting hungry. And, in this way, you “trick” your body into giving up its fat stores. Protein in the form of lean meats (chicken, turkey, and fish) and other low-fat sources should be eaten first. These should comprise at least 70% of the volume of the meal eaten.

Foods should be cooked without fat and seasoned to taste. Avoid sauces, gravies, butter, margarine, mayonnaise and junk foods. Never eat between meals. Do not drink flavored beverages, even diet soda, between meals. Drink 60 ounces or more of water each day. Water must be consumed slowly, 1-2 mouthfuls at a time, due to the restrictive effect of the operations.
What’s so important about exercise?
When you have a weight loss surgery procedure, you lose weight because the amount of food energy (calories) you are able to eat is much less than your body needs to function. It has to make up the difference by burning reserves or unused tissues. Your body will tend to burn any unused muscle before it begins to burn the fat it has saved up. If you do not exercise daily, your body will consume your unused muscle, and you will lose muscle mass and strength. And, lost muscle will decrease your basal metabolic rate—the rate at which you burn calories just by existing. Obviously, we want to avoid this. Daily aerobic exercise for 30 minutes at least will communicate to your body that you want to use your muscles and force it to burn the fat instead. Also, weight resistance workouts will similarly help to increase this lean body mass. We give a lot of exercise instructions. But, we realize that many of you are new to (or “hate!”) exercise. We will help you to change that. We start easy and ritualistically. Then, we increase to get you to a good performance state. We want you to live a health, active life—unencumbered by activity limitations and deconditioning. We want you to participate—not observe. Life is to be lived. Not to be watched. This requires a certain amount of conditioning. We can help make this “do-able” and fun.
What is the right amount of exercise after weight loss surgery?
Many patients are hesitant about exercising after surgery, but exercise is an essential component of success after surgery. Exercise actually begins on the afternoon of surgery – you must be out of bed and walking. The goal is to walk further on the next day, and progressively further every day after that, including the first few weeks at home. 6 activity sessions per day is the absolute minimum. It is not negotiable. We remind you constantly. Patients are often released from medical restrictions and encouraged to begin exercising about two weeks after surgery, limited only by the level of discomfort. The type of exercise is dictated by the patient’s overall condition. Some patients who have severe knee problems can’t walk well, but may be able to swim or bicycle. Many patients begin with low stress forms of exercise and are encouraged to progress to more vigorous activity when they are able.
Can I get pregnant after weight loss surgery?
It is strongly recommended that women wait at least one year after the surgery before a pregnancy. Approximately one year post-operatively, your body will be fairly stable (from a weight and nutrition standpoint) and you should be able to carry a normally nourished fetus. Also, we want the first year to be all about you. And, if you are pregnant, the baby comes first. We want you to experience the control and success to ensure that you know your true potential before getting pregnant. Only then should pregnancy be an option. Invariably, this takes at least one year. You should consult us as you plan for pregnancy.
Often, women become more fertile after bariatric surgery. We get many referrals from infertility doctors in this regard. So, be careful! Even if you “have trouble getting pregnant.” I know many stories of this surprisingly becoming untrue after a notable weight-loss.
What if I have had a previous weight loss surgical procedure and I’m now having problems?
Contact your original surgeon – he or she is most familiar with your medical history and can make recommendations based on knowledge of your surgical procedure and body. Revisions are a difficult undertaking. We consider them selectively. However, often the procedure is intact and the patient’s use of it is not. We do a lot of re-teaching those who have failed their procedure from other doctors. Often, education is the answer to success. Ask us about specifics.
In a gastric bypass procedure, what happens to the lower part of the stomach that is bypassed?
The remnant stomach is left in place with intact blood supply. In some cases it may shrink a bit and its lining (the mucosa) may atrophy. But, for the most part, it remains unchanged. The remnant stomach still contributes to the function of the intestines even though it does not receive or process food – it makes intrinsic factor, necessary to absorb Vitamin B12 and contributes to hormone balance and motility of the intestines in ways that are not entirely known. It still functions in many of the parts of digestion that do not involve food passing through it. In the Sleeve procedure, a large portion of the stomach is completely removed.
How big will my stomach pouch really be in the long run?
This can vary based on your individual anatomy and surgical considerations. But, in general, in the gastric bypass the stomach pouch is created is 1-2 ounces in size. We say it is roughly the size of an egg. In the first few months it is rather stiff due to natural surgical inflammation. About 6-12 months after surgery, the stomach pouch can expand and will become more expandable as swelling subsides. Many patients end up with a meal capacity of 4-8 ounces.
In the Band procedures, the pouch above the Band is made about the same size as in the bypass. Over time, the ideal meal volume tolerated for satiety is 4 ounces of protein.
In the Sleeve, the actual volume of the stomach created is about 10-20% of your present stomach volume (the tube made is about 150ml in volume). But, it is created from the relatively less “stretchable,” left side of your stomach—so it does not expand as much as your present stomach. A great ultimate meal volume after the Sleeve is about 6-8 ounces.
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 stainless steel or titanium so small it is hard to see other than as a tiny bright spot. Because the metals used (titanium or stainless steel) 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.
What if I’m not hungry after surgery?
It’s normal not to have an appetite for the first month or two after Band and Sleeve surgery, and for up to 6b months after Bypass. Eating to us is like taking your medicine. It just has to be done. You plan you meal content, volume, and times always. But, especially during these non-hunger intervals post-operatively, eating becomes a way of just “feeding the machine.” It will make you do better, feel better, and lose weight better. This is not the time to diet. (And, dieting never worked for you in the long run anyway. Why continue to do it?)
Is there any difficulty in taking medications?
Most pills or capsules are small enough to pass through the new stomach to bowel connection or through the Band. Initially, we may suggest that medications be taken in liquid form or crushed. We will discuss this in detail and in specific with you as you get closer to surgery.
Will I be able to take oral contraception after surgery?
Most patients have no difficulty in swallowing these pills. We like you to be off of them for 4 weeks pre- and 6 weeks post-operatively. This decreases blood clots. Use another, non-hormonal, birth control regimen during this interval. Getting pregnant will seriously delay your surgery for at least 9 months!
Is sexual activity restricted?
Patients can return to normal sexual intimacy when they feel like it—when wound healing and discomfort permit. Many patients experience a drop in desire for about 6 weeks. That is normal.
Is there a difference in the outcome of surgery between men and women?
Both men and women generally respond well to bariatric surgery. In general, men lose weight slightly faster than women do. We believe that this has a lot to do with their generally higher lean body mass, and therefore their basal metabolic rate. Women DO catch up.
Will I be asked to stop smoking?
Patients must stop smoking at least one month before surgery. This is non-negotiable. Smoking more than doubles all major complications. And, it is an addiction and an unhealthy activity that will undermine the health and control you will be gaining after surgery. To continue to smoke would be to actively work against all that you and we are doing to improve your life and health. We will help you stop.
How can I know that I won’t just keep losing weight until I waste away to nothing?
Patients may begin to wonder about this early after the surgery when they are losing significant weight. Many see a loss of 20-40 pounds per month, some worry when they’ve lost more than 100 pounds and they’re still losing weight. Two things happen to allow weight to stabilize. First, a patient’s ongoing metabolic needs (calories burned) decrease as the body sheds excess pounds. Second, there is a natural progressive increase in calorie and nutrient intake over the months following weight loss surgery. With the Bypass, the stomach pouch and attached small intestine learn to work together better, and there is some expansion in pouch size over a period of months. With the Band, we orchestrate your increased intake too. The bottom line is that, in the absence of a surgical complication, patients are very unlikely to lose weight to the point of malnutrition. In fact, the last 10% or so of your target weight loss usually requires a little more focus and commitment on your part. That is built into the procedures and is a good thing. Working for it makes it all the more yours.
What can I do to prevent lots of excess hanging skin?
Many people heavy enough to meet the surgical criteria for weight loss surgery have stretched their skin beyond the point from which it can “snap back.” Some patients will choose to have plastic surgery to remove loose or excess skin after they have lost their excess weight. Insurance generally does not pay for this type of surgery (often seen as elective surgery). However, some do pay for certain types of surgery to remove excess skin when complications arise from these excess skin folds. Ask your surgeon about your need for a skin removal procedure. We work closely with a number of plastic surgeons who are experts and belong in this process, if you are interested. For the vast majority of patients, it is either not a problem or not a big enough deal to do anything about.
What will help with excess hanging skin?
The cornerstones of minimizing excess skin are: good (high protein) nutrition, hydration, exercise, vitamin supplementation, sun block, and good genetics!
Will I be miserably hungry after weight loss surgery since I’m not eating much?
Most patients say no. In fact, for the first 4-6 weeks patients have almost no appetite. Over the next several months the appetite returns, but it tends not to be a ravenous “eat everything in the cupboard” type of hunger. If you eat as we recommend—5 to 6 small, high protein, meals per day—then when do you have time to get hungry? Impulse and starvation fade. You are in control.
What if I am really hungry?
This is often caused by the types of food you may be consuming, especially starches (rice, pasta, potatoes) that cause insulin surges. Be absolutely sure not to drink liquid with food since liquid washes food out of the pouch or through the Band. And, we want you to eat often. Just to be careful with what your diet consists of. We teach this again and again. It will not be a mystery.
Will I have to change my medications?
Your doctor will determine whether medications for blood pressure, diabetes, etc., can be stopped when the conditions for which they are taken improve or resolve after weight loss surgery. For meds that need to be continued, the vast majority can be swallowed, absorbed and work the same as before weight loss surgery. Usually no change in dose is required. Two classes of medications that should be used only in consultation with your surgeon are diuretics (fluid pills) and NSAIDs (most over-the-counter pain medicines). NSAIDs (ibuprofen, naproxen, etc.) may create ulcers in the bypass pouch or the attached bowel. Most diuretic medicines make the kidneys lose potassium. With the dramatically reduced intake experienced by most weight loss surgery patients, they are sometimes not able to take in enough potassium from food to compensate. When potassium levels get too low, it can be a problem.
What is a hernia and what is the probability of an abdominal hernia after surgery?
A hernia is a weakness in the muscle wall through which bowel can pass and possibly get caught. With the laparoscopic approach, it is relatively rare. But, it does happen. It is usually relatively easy to diagnose and fix.
Is blood transfusion required?
Patients rarely need a transfusion after Bypass. It is almost always a delayed issue to need blood—which is usually caused by a delayed bleed from a staple line. Almost never does this require an operation. Usually, in the rare instances blood is given, a simple transfusion is all that is needed. In the Band and Sleeve procedures, transfusions are almost unheard of.
What is a blood clot (also called DVT or Deep vein thrombosis) and is it preventable?
Undesired blood clotting in veins, especially of the calf and pelvis is a big deal and very dangerous. It can break off, go to your lungs, and cause death. It is not completely preventable, but preventive measures will be taken, including: early and frequent ambulation, blood thinners, pulsatile ‘squeeze” stockings (SCD’s), short OR times, and close vigilance. Fortunately, our DVT rate is very low. We take all precautions.

Will I lose hair after surgery? How can I prevent it?
Many patients experience some hair loss or thinning after Bypass surgery. This usually occurs between the fourth and the eighth month after surgery. Consistent intake of protein at mealtime is the most important prevention method. Also recommended are a daily multivitamin supplement and a good daily volume of fluid intake. Some people recommend biotin supplementation. It almost always returns to just about normal at the one year anniversary. In very few patients is this a “deal breaker.” And, in most, it is not evident to anyone but the patient and their shower drain. When seen, it is usually with the Bypass. Rarely is this seen with the Band.
What are adhesions and do they form after this surgery?
Adhesions are scar tissues formed inside the abdomen after surgery or injury. Adhesions can form with any surgery in the abdomen. For most patients, these are not extensive enough to cause problems. And, they are notably less significant after laparoscopic surgery than with the old-fashioned, open procedures.
What is sleep apnea (SA)?
It is the interruption of the normal sleep pattern associated with repeated delays in breathing. Sleep apnea often shows rapid improvement after surgery. In most patients, there is a complete resolution of symptoms by six months following surgery.

Diet
How long will I be off of solid foods after surgery?
For the Band, bypass, and Sleeve, we provide you with detailed dietary instructions. All involve a progression from liquids with protein supplementation, to soft/pureed foods, to “regular” food. The timing is different with the different procedures. We will provide you with specific dietary guidelines for the best post-surgical outcome.
What are the best choices of protein?
Eggs, red meat, chicken, fish, tofu, soy, cottage cheese, yogurt, and many others that are more subtle. We also teach this.
Why drink so much water?
When you are losing weight, there are many waste products to eliminate, mostly in the urine. Some of these substances tend to form crystals, which can cause kidney stones. A high water intake protects you and helps your body to rid itself of waste products efficiently, promoting better weight-loss. Water also fills your stomach and helps to prolong and intensify your sense of satisfaction with food. If you feel a desire to eat between meals, it may be because you did not drink enough water in the hour before.
What is Dumping Syndrome?
Eating sugars or other carbohydrate-rich foods can cause dumping syndrome in patients who have had a Bypass. Your body handles these small particles by diluting them with water, which reduces blood volume and causes a “shock-like” state. The result is a very unpleasant feeling: you break out in a cold clammy sweat, turn pale, feel “butterflies” in your stomach, and have a pounding pulse. Cramps and diarrhea may follow. This state can last for 30-60 minutes and can be quite uncomfortable – you may have to lie down until it goes away. This syndrome can be avoided by not eating the foods that cause it, especially on an empty stomach. A small amount of sweets, such as fruit, can sometimes be well tolerated at the end of a meal. You will learn your limits. It is not a feeling you will court more than a time or two. Not everyone has dumping and it can also fade away. Many patients “want” to have these intolerances to limit them.
Is there a problem with consuming milk products?
Milk contains lactose (milk sugar), which is sometimes not well digested in bypass patients. This sugar passes through undigested until bacteria in the lower bowel act on it, producing irritating byproducts as well as gas. Whether you have this intolerance or not often it depends on the form of the milk product, the volume eaten, and your particular constitution and tolerances.
Why can’t I snack between meals?
Snacking, nibbling or grazing on foods, usually high-calorie and high-fat foods, can add hundreds of calories a day to your intake, defeating the restrictive effect of your operation. Snacking will slow down your weight loss and can lead to regain of weight. And, with 6 meals per day, when are you going to find the time to snack. We like meals—what you plan to eat. Not snacks—what you “happen to grab.”
Why can’t I eat red meat after surgery?
You can, but you will need to be very careful, and we recommend that you avoid it for the first 6 weeks. Red meats contain a high level of meat fibers which hold the piece of meat together, preventing you from separating it into small parts when you chew. The fibers can plug the outlet of your stomach pouch or your Band and prevent anything from passing through. This is a condition that is very uncomfortable. We teach you how to cut up and eat meat properly to minimize this potential problem.
How can I be sure I am eating enough protein?
In general, 60 grams per day is your goal. We will help you decide what the right amount is for you.
Is there any restriction of salt intake or seasoning?
Your salt intake will be unchanged unless otherwise instructed by your primary care physician. We still want your food to taste good to you. Season away! The only limitation is to make sure that your condiments are not “over-carbing” you.
Will I be allowed to drink alcohol?
You will find that even small amounts of alcohol will affect you quickly. This is especially true with the Bypass. It is suggested that you drink no alcohol for the first 6-8 weeks. Thereafter, with your physician’s approval, you may have a glass of wine or a small cocktail. Be careful—the carbohydrates in many drinks can add up quickly.
Will I need supplemental vitamins?
Bypass patients need B-12 1000 mcg vitamins in sublingual form, daily for life. All bariatric patients need multivitamins for life to make up for the smaller amount of food you are eating. To make sure that you are on track, we will track your B-12, B-1, and foliate levels, as well as any other micronutrients that may need to be evaluated.
Do I meet with a nutritionist before and after surgery?
Some insurances require this type of evaluation. We provide extensive teaching at all of our classes as well, as in your many consultations with us. We have an in-house dietician. Counseling after surgery is available on an individual basis, as needed or required.
Will I get a copy of suggested eating patterns and food choices after surgery?
We provide patients with materials that clearly outline our expectations regarding diet and compliance to guidelines for the best outcome based on your surgical procedure. After surgery, health and weight loss are highly dependent on your compliance with these guidelines. You must do your part by restricting high-calorie foods, by avoiding sugar, snacks and fats, and by following the guidelines set.

General
What is the youngest age for which weight loss surgery is recommended?
Generally accepted guidelines from the American Society for Bariatric Surgery and the National Institutes of Health indicate surgery only for those 18 years of age and older. Surgery has been performed on patients 16 and younger. There is a real concern that young patients may not have reached full developmental or emotional maturity to make this type of decision. It is important that young weight loss surgery patients have a full understanding of the lifelong commitment to the altered eating and lifestyle changes necessary for success. My lower limit, in select cases, is 16 years of age.
What is the oldest patient for whom weight loss surgery is recommended?
I judge people by health age—not chronological age. I have turned down 30 year-olds and done procedures on 75 year-olds. It is all about understanding and managing risk/benefit rations. The risk of surgery in the elderly age group is increased, and the benefits, in terms of reduced risk of mortality, are reduced. But, quality of life in them is paramount. And, they are some of my star patients!
Can Weight Loss Surgery prolong my life?
A very important study was published in 2007 which definitively answered this question. It was al over the news. You probably saw it. The answer: YES!
Can weight loss surgery help other physical conditions?
According to current research and our database, weight loss surgery can improve or resolve associated health conditions. We are happy to share with you our amazing results in terms of: depression, diabetes, GERD, hypertension, lipid disorders, menstrual irregularities, urinary stress incontinence, joint pain, and sleep apnea… among others!
For the rest of my life, is the way that I experience fullness or satiety different than others?
Yes, it is different. Everyone in the world who has not had a stomach reduction procedure or Band placed achieves satiety by meeting his or her need for calories. The mechanism of your morbid obesity is that your appetite center may not be “set” properly to recognize satiety from calorie input until you have taken too many calories. You then store those extra calories as fat.

Following the Band, sleeve, and Bypass procedures, you now achieve satiety by stretching your pouch or sleeve stomach walls. If you do not stretch them (by missing meals), if they are not stretched sufficiently (by snacking), and/or if the stretch does not last long enough (by taking liquids with meals or by eating liquid foods), then the satiety does not last long enough to reach to the next meal. It is helpful if you always remember that your satiety comes from stretching the pouch walls, from the actual volume and type of food that you eat. The next logical step is to realize the importance of the caloric density of foods you eat, as I mentioned earlier. (For example, think of the difference between half a cube of butter and a large bowl of salad with light dressing—each may have the same calories, but their effect on your pouch and your appetite will be dramatically different).