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The pathway to surgery and long term success requires an ongoing commitment from the patient. The steps leading up to and following surgery require the patient to be continually educated throughout the entire process.
If you are considering bariatric surgery, the first step of the process is to research your insurance policy to determine if surgical weight loss is covered. It is extremely important that you become informed of their requirements.
By understanding your insurance requirements, you can begin to prepare the necessary materials and records. This will expedite the insurance authorization process if you are a qualified candidate for
bariatric surgery.
NOTE: There are numerous insurance companies that require the candidate to have a documented six-month diet history before he or she can be authorized for surgery. Please be sure to begin this six-month process as soon as possible if it is one of your requirements. You can begin this process by
setting up an appointment with your primary care physician or by calling our office at 410.550.0409 to get
more information about our six-month diet and nutrition group.
There is a Maryland law covering obesity surgery, but if you have a plan that is self-insured, or your employer has under 50 employees, then the plan may fall under federal guidelines and you can be excluded. You can find more information at www.obesitylaw.com.
Begin to research the bariatric surgical procedure you're interested in having. Become informed on it and prepare questions for the surgeon and nurse practitioner. The consultation appointment with your surgeon is the best time to discuss your questions, thoughts, and concerns. Surgical Evaluation/Consultation
This is an office visit at which time you will meet the surgeon and have the opportunity to have questions answered about your chosen procedure. At this time, you will meet with the nurse practitioner who will gather your past medical history, explain the procedure and discuss the risks, benefits and complications. It is recommended that you bring your major support person with you to this visit. This is another key aspect to your success with surgical weight loss.
Please fill out the health history forms prior to your surgical appointment and bring them with you to your consultation. Please make sure that the forms are filled out completely and accurately, including all medications and dosing. The following evaluations are required for those patients who are qualified for bariatric surgery. Please set up both the nutritional and psychiatric evaluations; these are both requirements of the Johns Hopkins Center for Bariatric Surgery. Nutrition Evaluation
Each patient is required to meet with a registered dietitian at least once prior to surgery. We offer consulation at the Johns Hopkins Bayview Medical Center and at the Johns Hopkins Weight Management Center at Greenspring Station. At the Johns Hopkins Bayview Medical Center, you will be seen by a dietitian that is specially trained in adult weight management and the dietary needs of the obesity surgery patient. During this visit, the dietitian will discuss the pre- and post-operative dietary guidelines, behavioral changes and the supplements you will need following the surgery. It is important to check with your insurance company to see if this service will be covered. Please bring a referral to the appointment if your insurance company requires you to do so. To set up an appointment at Hopkins Bayview, call 410-550-7728. In addition to the comprehensive services offered at Hopkins Bayview, the Johns Hopkins Weight Management Center at Greenspring Station, a division of the department of clinical nutrition at Hopkins Bayview, provides a variety of pre- and post-operative services to meet the unique needs of the bariatric surgery patient. To set up an appointment at the Weight Management Center, call 410-583-2860. Please review and be aware of the nutritional guidelines you must follow after your procedure. Laparoscopic or Roux-en-Y Gastric Bypass Patients Lap Band Patients Duodenal Switch Patients Sleeve Gastrectomy
Psychiatric Evaluation
Bariatric surgery is a life-changing event for the patient and his or her family. The weight loss is relatively quick and significant, and can cause psychological, body image, and social disturbances. Therefore, it has become mandatory that a patient who intends to have bariatric surgery receive a psychiatric evaluation. The purpose is to ensure that the patient is aware of the risks and benefits of the surgery and is able to comply with the post-operative requirements. There are also other areas addressed, such as body image and sexuality, to improve the outcomes of surgery and the patient's quality of life. An initial psychiatric evaluation includes a diagnostic interview and the BES, NEO, BDI, DISF, and BAROS questionnaires. After the initial evaluation, the patient may be referred to the Cognitive Behavioral Therapy (CBT) Group if he or she has Binge Eating Disorder or practices emotional eating. CBT has been shown to reduce abnormal eating behaviors and assist in weight loss when combined with nutrition and exercise. The CBT group meets weekly for 12 weeks, with individual therapy if necessary. Some patients may need to take antidepressants for mood disorders or for reduction of their binge eating behavior. These patients will need medication management by a psychiatrist. Involvement of family members is encouraged and a meeting with a "support agent" is considered a requirement. This helps identify patient support systems that are so essential post-operatively. - Phase I CBT
- Establishing therapeutic relationship
- Implementing psycho-educational material
- Self-monitoring and record keeping of eating behavio
- Phase II CBT
- Identifying maladaptive cognitions regarding eating
- Using cognitive restructuring techniques
- Identifying triggers for binge eating
- Continuing focus on normalizing eating pattern
- Addressing emotional changes in post-bariatric surgery patterns with special attention to body image and relationship
- Phase III CBT
- Maintaining change
- Identifying high risk situations
- Developing a relapse plan
Both the patient and the professionals will work together to establish goals during the 12-week period. The goals include a target weight and a reduction in binge eating behavior. At the end of the 12-week period, the patient's participation and motivation can be accurately assessed to predict the patient's likelihood
of compliance post-operatively. Bariatric surgery requires careful patient selection pre-operatively to ensure success. Increasing numbers of obese patients seeking bariatric surgery tend to have binge eating disorder or practice emotional eating. These behaviors increase the tendency for weight gain 2 years post-operatively. To enhance the predictibility of patient compliance and ensure success of bariatric surgery, the patient's obesity is managed in a holistic way with psychiatry, nutrition, and exercise, setting goals for weight loss as well as a reduction in abnormal eating behaviors. To schedule an appointment with Varsha Vaidya, M.D., at the Johns Hopkins Bayview Medical Center, call 410-550-0064. Please contact your insurance company to ensure that this visit will be covered. You may wish to see a psychologist or psychiatrist that is included in your plan who specializes in obesity surgery counseling. Pre-operative Evaluation
Approximately 1 to 6 weeks prior to your scheduled surgery, you will be scheduled for a visit to the pre-evaluation center at Hopkins Bayview. This session will last about 40-45 minutes. You will meet with a nurse, who will perform an anesthesia screening to determine if you have any special needs in this aspect. The nurse will conduct a brief physical assessment to evaluate your heart and lungs. The nurse will also provide pre- and post-operative teaching to better prepare you and your family for the upcoming surgery. Other Evaluations
Often, based on your past medical history, you are requested to have additional evaluations prior to surgery, such as a sleep study for sleep apnea, a cardiac assessment for history of cardiac problems or pulmonary function tests in the presence of respiratory problems.
What to Bring to the Hospital - Small overnight bag with toiletries (toothbrush, glasses, etc)
- List of current medications and doses
- Insurance cards
- CPAP machine (if you have sleep apnea)
You can expect to be in the hospital for 2 to 3 days for a laporascopic procedure, or 3 to 5 days for an open procedure, one involving making an incision in the abdomen. *Please remember that your hospital stay is dependent on many factors and may not be the same for every patient. Path of Care
On the day of your scheduled surgery, you will arrive in the pre-operative area (ASU) where you will prepare for sugery. You will be transferred to the operating room (OR), then to the recovery area (PACU) where you will spend approximately one hour. From there, you will be admitted to the surgical intensive care unit (SICU) or to a regular room on the 6th floor, depending on the type of surgery conducted. What to Expect After Surgery - Post-operative Tubes/Drains
When you wake up from anesthesia, you will be aware of many pieces of medical equipment that are routinely used after surgery, including a/an: - Oxygen mask to provide oxygen. The breathing tube used during general anesthesia will likely be removed at the end of the operation.
- Catheter, placed in your bladder, which is used for 24 to 48 hours. Urine from the bladder is collected into a bag and is measured regularly by the nursing staff.
- Naso-gastric tube, placed through your nose into your stomach, will be removed the day after your surgery. Your throat may be sore for a few days after the tube is removed.
- Gastrostomy tube (G-tube), which may be placed, by the surgeon, into the bottom part of your stomach
- Surgical drain, placed during the operation if you have had an open procedure. The drain will be removed in 48 to 72 hours, or when drainage is minimal
- Post-operative Activity
- Early ambulation is very important to prevent blood clots, pnemonia, and to enhance your overall recovery process. With the assistance of the nurses and physical therapists, you will be getting out of bed on the day of your surgery. The goal is that you spend more time out of bed than in bed. Of course, you will be tired after surgery, so rest periods also are important
- To prevent blood clots, compression stockings are placed around your legs. A pump, attached to the stockings, inflates from time to time to provide gentle pressure on the legs to help circulation. It also is important to move your legs and do ankle twists when you are in bed, or sitting in the chair
- Breathing Exercises
- After you are awake in your room, the nurses will give you an incentive spirometer, a device to help you take deep breaths. Deep breathing exercises are very important to prevent congestion and pneumonia. It will help to hug a pillow when you are deep breathing and coughing. Also, use your pain medication before coughing.
- Before you come to the hospital, you should do deep breathing exercises. Take 8 to 10 very deep breaths and hold for a few seconds. Do this several times a day to help the small airways in your lungs to be to open and in good condition before surgery
- If you use CPAP, bring your machine with you to the Medical Center. Make sure you mark the machine with your name and phone number
- Pain Control
- We are committed to making you as comfortable as possible after surgery. We know that pain may interfere with activities necessary for recovery. It is difficult to get out of bed, walk, deep breathe and cough if you are having pain.
- Initially, pain medication is given through the IV by way of a small pump, called a PCA (patient controlled analgesia) pump. The PCA pump allows you to have frequent, small doses of medication, which provides steady pain relief. The nurse in the recovery room will set up the pump and instruct you on how to use it. You will push a button to give a small dose of pain medication into your IV. The machine will not let you overdose yourself. It will not take away all of your pain, but will make you comfortable enough to do the things necessary to help your recovery. The first day after surgery, the doctor may switch to oral pain medications.
- You will be sore for the first few days, but with each day the soreness will decrease.
Discharge Instructions Written discharge instructions are given by the surgeon. The instructions outline what you can and cannot do when you go home, diet restrictions, medications, pain management, when to call the doctor, etc. A dietitian will also review the dietary guidelines with you before discharge from the Medical Center. You will also receive prescriptions for medications that you may need. A nurse will review these instructions with you to make sure you understand. A member of the team is always available by phone. Accessing help, and how to do so, will be discussed with you prior to discharge. We recommend the following: - Call 911, and go to the ER for issues that require urgent medical attention, such as:
- chest pain
- shortness of breath
- excessive abdominal pain
- Call the office, or the physician on call, for non-emergent issues, such as:
- nausea, vomiting, diarrhea, or fever
- redness, swelling, drainage or bleeding from the incision
Diet
Once you are home, be very careful to follow the instructions given for diet progression. The benefits of surgery can be undone by not following the guidelines. Our dietitian is readily available to answer questions and help you adjust. Exercise
It is key that you begin an exercise program as soon as possible. Not only does exercise prevent complications after surgery, it improves weight loss. Start by walking short distances. Increase your pace and distance each day. Do not attempt any abdominal exercises, weight lifting or swimming. Ask your doctor when you can return to these activities. Activity - Light housework, short shopping trips and climbing stairs are okay.
- You can shower with your back to the spray. Do not soak in a tub.
- Do not drive or lift heavier than 5 pounds until your first follow-up with your physician.
- Resume normal activities gradually.
- Use common sense! If you have pain, stop what you are doing.
Work
Typically, individuals with a sedentary job return to work within 2 to 3 weeks. Do not return to work until after your first follow-up visit with your physician. Wound Care
Before you go home, the drains placed during surgery are usually removed. The area is covered with a small dressing. Contact your team if you notice redness, welling, drainage or bleeding from the incision. Support
Having bariatric surgery is not easy. You can expect to experience a variety of emotions as you recover and maintain your weight loss. Support groups are an ideal way to share experiences, learn coping tips and praise successes. You are invited to attend our free, monthly support meeting at Hopkins Bayview. Members of our team also are available to talk with you and your family about the adjustment process.
Follow-up care is very important following bariatric surgery. After the procedure, you will need to return to see the surgeon at least: - 2 weeks after surgery
- every 3 months after surgery for the first year
- every 6 months for the following year,
- and then annually
Your 2-week follow-up appointment will be made prior to leaving the Medical Center after your surgery. If an appointment was not made, please call 410.550.0409 to set up your appointment. Each additional appointment will be made at the Outpatient Clinic during the visit. Changing your lifestyle habits is a big challenge. That is why it also is important to continue following up with your registered dietitian and psychologist or psychiatrist. These medical professionals will provide you with the necessary guidance and support to help you and your family adjust to and maintain your new dietary, behavioral and lifestyle changes. How much weight will I lose?
Weight loss after obesity surgery varies from person to person. Typically, weight loss is rapid during the first few months, and then it may begin to slow down. It usually takes about 12 to 18 months for maximum weight loss to occur. The typical amount of weight loss is 60 to 70 percent of excess body weight. Some patients lose more or less depending on their dietary and lifestyle habits. You can expect some or all of your obesity-related medical problems to improve as you lose weight. Some patients are even able to discontinue their medications for diabetes and high blood pressure shortly after surgery. Successful Habits of Gastic Bypass Patients
It is always important to remember that this surgery is a tool, not a cure, for obesity. This surgery alone will not give you the results you want. You must be committed to a new lifestyle and the behavioral changes associated with it for the rest of your life. Exercise
A commitment to these lifestyle changes means exercising. It is important that you begin an exercise program as soon as possible. In addition to preventing complications after surgery, it will help you lose weight. Start by walking short distances and increase the length and speed every day. Do not perform any stomach exercises, weight lifting or swimming for at least 4 to 6 weeks. If you begin to have pain, stop what you are doing and rest. Walking may be hard for patients with osteoarthritis. Water aerobics is a great option for exercise that is not stressful on the joints. Find a local YMCA in your area that may offer water aerobics classes. You may be able to look into local colleges and universities to see if they offer these classes as well. Curves and Cuts are other great programs in which many patients participate.
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