• Have a body mass index of > 40, for at least 5 years or > 35 with significant medical complications of obesity.
• Be between the ages of 21 and 65. Over 65 years of age requires individual consideration.
• Verify a documented attempt to lose weight by a medically supervised program.
• Have no restrictions or limitations to possible transfusion of blood or blood products, if needed, during or following the operative procedure.

Before you consider weight loss surgery as an option in management of your obesity, we suggest you contact your insurance company to verify that weight loss surgery is covered by your policy and that Durham Regional Hospital and the physicians of the Private Diagnostic Clinic at Duke University Medical Center are part of your coverage. Some policies exclude all types of weight loss surgery.

Questions to Ask Your Insurance Company

1. Is Morbid Obesity a covered benefit in your policy or is it an EXCLUSION? Give them the diagnostic ICD9 Code of 278.01. If morbid obesity is a covered benefit, check that the operative procedure you are considering is also covered. For the Roux-en-Y procedure give them the CPT Code of 43846 or 43644 and for the LapBand procedure give them the CPT Code of: 43643 (Note that many insurance companies do not yet approve the LapBand Procedure so check carefully with your company if this is your selection). Finally ask if Duke University Health System and Durham Regional Hospital are accepted by your insurance.

2. What percent of the total bill will you be responsible for and is there a deductible that you will need to pay?

3. If your policy does not cover morbid obesity or the operative procedure, you have a couple of options:

* You have the option to obtain another insurance carrier, but you need to make sure that the new policy covers morbid obesity and the surgical procedure.

*You can continue to participate in medical programs designed to lose and maintain weight loss.

*In selected cases we will consider performing the surgery if you elect to self-pay. There is a considerable deposit required by the Hospital and you must fully understand all risks of financial burden. We will review this major decision with you extensively and will help in any way we can.

If you cannot understand the information given by your insurance company on coverage of obesity care, please feel free to contact our insurance specialist Mrs. Beth Millard at the following e-mail address: obesitysurgery@mc.duke.edu, or if you do not have access to e-mail, you can call (919) 660-2229 for an in-depth review of your policy.

There are multiple reasons to stop smoking before having weight loss surgery. Long-term outcome data document that patients lose more weight and have fewer complications if they no longer smoke. In particular vascular complications are considerably less common.

In addition, smoking injures the lungs and bronchi resulting in higher anesthetic risks during and immediately following surgery. It takes about a month before the lungs and bronchi repair themselves after smoking cessation - so stop now!

Finally, the goal of weight loss surgery is to improve both the quality and quantity of your life. Smoking contradicts both of these goals. We want you to do everything possible to get the most out of this life changing surgery.

For both operative procedures, weight loss depends on you and how well you use your new surgical tool. You must follow the prescribed diet and practice an active exercise program.

Roux-en-Y Gastric Bypass:

Patients lose between 100 and 180 pounds. Most of the weight is lost during the first 14 months, although some aditional weight can be lost up for up to two years.The exact amount of weight you will lose depends on your preoperative body mass index (heavier people lose more weight) and your compliance with the dietary instructions. The charts below demonstrate our patient's experiences to date based on their initial body mass index and can be used to estimate your posssible weight loss. You will need to watch your diet very carefully after your weight stabilizes as failure to continue to restrict your intake can result in some weight regain.

Average Weight Losses of Our 1465 Patients as of 2/25/06

Results of the LapBand procedure have been encouraging, however weight loss is slightly less than for the Roux-en-Y gastric bypass and management requires more frequent clinic visits to adjust how the band narrows the stomach. Most patients will lose between 60 and 100 pounds. The exact amount of weight you lose will depend on your compliance with the dietary instructions and your tolerance to adjustments to the tightness of the band. Weight loss is slower with this procedure progressing over 3 t0 4 years. You will need to watch your diet very carefully as the band is adjusted and continue long-term follow up to achieve and maintain satisfactory weight loss.

The following graph depicts the weight loss achieved by our 47 patients as of 2/24/06.

• Because of the small gastric pouch, eating as little as 2 to 3 ounces at one time produces a full feeling, allowing one to easily stop eating without overeating, fully satisfied. The muscle fibers of the stomach right next to the esophagus, where the small gastric pouch is created, do not stretch over time so the pouch stays the same size, contrary to other operations that have been done where the stomach remnant stretches allowing more intake over time. In addition, this part of the stomach has most of the nerve fibers that relay "fullness" to the brain. Therefore, eating just a small amount, barely distending the pouch, results in the full feeling usually only felt after overeating.
• The new diet rule is to eat whenever hungry but to eat only until full. Having even 7 or 8 "meals" a day results in only about 800 total calories. One loses weight without a feeling of starvation or deprivation.
• Intentional overeating is associated with heartburn, nausea and vomiting of excess food. It is really difficult to cheat!
• Most patients express loss of appetite - often saying they no longer crave food and even have to be told to eat. This loss of appetite may be related to changes in production of Ghrelin - a peptide hormone usually secreted by the stomach. This hormone is known to be associated with hunger. Normally, the blood concentrations of Ghrelin increase just before breakfast, lunch, and dinner and decrease after eating. When one diets, Ghrelin levels dramatically increase - making compliance with the diet quite difficult - a problem you all recognize. After a Roux-en-Y gastric bypass Ghrelin levels in the blood are barely measurable, possibly accounting for the decreased sensation of hunger. The fall in Ghrelin levels has only been shown to occur so far following the Roux-en-Y gastric bypass procedure.

You will be called the day before your surgery to be given a time to arrive at the hospital the day of your surgery.

You will have already pre-registered, so you need only go to the Main Lobby (3 rd Level). Go to the left side of the lobby, at the very back and you will arrive at the receptionist desk for same day admission surgery. Check in with the receptionist and when it is time she will call for you and escort you to your bed in the preoperative area. You will be given a gown and slipper socks and the nurse will take your blood pressure, pulse and temperature.

Give all of your valuables to your family or the responsible person with you.

When it is time for you to go into the operating room, your family member should go to the main waiting room on the third floor just inside the main entrance.

Several studies have shown that people who experience significant weight loss can develop gallstones. On the other hand, people who have, or who subsequently develop gallstones, often do not suffer any consequences or even know they have them. Due to the required location of the trocar sites to perform the weight reduction surgery, removal of the gallbladder at the time of a roux-en-Y gastric bypass is somewhat difficult. In many cases the risk of taking the gallbladder out at the same time may well exceed any potential benefit. For this reason, unless you currently have gallstones that are causing trouble, we do not routinely remove the gallbladder at the time of your weight loss surgery operation. If you are known to have gallstones, we will discuss the possible risks for removing it with you and use our best judgement with respect to its removal at the time of surgery.

Most patients will not experience any significant complication of their surgery. Nonetheless, Roux-en-Y Gastric Bypass must be considered a major operative procedure and the complications associated with any major procedure, as well as with general anesthesia, can occur.

About 1 in 5 patients will have some type of complication after surgery. Most complications are minor such as drainage from a skin incision, a urinary tract infection, mild to moderate temporary loss of hair, nausea, or abdominal wall muscle spasms with pain. Rarely, complications can be major, such as a serious wound infection, intra-abdominal bleeding, infections within the abdomen, and hernias. Very rarely, life threatening complications can occur including heart attacks, strokes, leakage from a suture line, and blood clots in the deep veins of the legs which can break off and travel up to the lungs (pulmonary embolism). Although even these serious complications can usually be treated successfully, they can result in permanent disability and even death.

The following table shows the incidence of complications we monitor following surgery. Where available, the reported incidence from other centers is given.

Most patients develop some loose, flabby skin on their arms, breasts, ankles, and legs after weight loss with less obvious changes on the face and neck. In our patients, only 2.8 percent have subsequently undergone plastic surgery. You should contact your insurance carrier to see if they cover such procedures - many consider them to be cosmetic surgery and do not cover the expense. We can refer you to our plastic surgery specialist if you wish a consultation. Plastic surgery is not considered until at least one year after your surgery and only when you reach a stable weight. Although not proven, it is felt that the more you exercise, the less likely you will need plastic surgery.

Roux-en-Y Gastric Bypass Surgery: On the morning of the first postoperative day, you will be asked to swallow contrast liquid in Radiology to determine if you have any leaks at the intestinal suture lines. When this test is shown to be normal, you will be started on one ounce of tap water to be taken every hour while awake. If this is tolerated, your diet will be advanced the next day to two ounces of full liquids each hour while awake. A full liquid diet is any fluid you can pour that does not contain any solid or excessively thick material. When you are discharged from the hospital, you will be instructed to continue on a full liquid diet for the next three weeks. At home you will need to drink 2 ounces of a protein produce every hour while awake but may also take another 2 ounces of any liquid every 15 minutes between the hours. This will amount to about a "glass of liquids" every hour so you should NOT become dehydrated. You will be scheduled to return to the Weight Loss Surgery Clinic around 3 weeks following surgery at which time you will be instructed on proper methods to progress to soft and solid foods.

LapBand Surgery: When you awaken from your surgery you will be given liquids to swallow. If the liquids pass satisfactorily, you will be instructed to drink liquids only for two weeks at home and then to gradually add soft, easily chewable, foods as tolerated. Upon discharge from the hospital there will be no restrictions on dietary intake except to avoid overeating and hard to digest foods, such as celery or other stringy foods. After the band is tightened at 6 weeks, the diet will be similar to the after 3-week diet for Roux-en-Y gastric bypass.

You will need to take three supplements for the rest of your life after you have the gastric bypass surgery. The first is a good adult multivitamin containing full complement of both water-soluble and fat-soluble vitamins, as well as iron and zinc. For the first three weeks the vitamin supplement should be chewable. After that a pill form is preferred.

The second necessary supplement is calcium. Dietary calcium and common calcium supplements require acidification in the stomach before they can be absorbed. Your new stomach will not make acid and without taking a special supplement you will become calcium deficient. Calcium deficiency can result in thinning of the bones and subsequent fractures with even small amounts of stress. The preferred calcium supplement is Calcium Citrate. Recommended daily intake is 1200 mg of calcium. We suggest you begin taking calcium citrate 3 weeks after your surgery.

The final necessary supplement is Vitamin B-12. For dietary Vitamin B-12 to be absorbed, it must combine with a protein called Intrinsic Factor that is made only in the part of the stomach we will bypass in your surgery. Vitamin B-12 deficiency is associated with progressive anemia but more importantly with spinal cord nerve function. Paralysis is possible if Vitamin B-12 deficiency becomes severe. We recommend that you get intramuscular shots of Vitamin B12, generally 1000 micrograms every 6 months. We begin these shots at your 6 month visit.

Otherwise you should drink plenty of water and emphasize protein in your daily meals.

Click HERE for a complete discussion of the postoperative diet program.

Following Roux-en-Y Gastric Bypass:

1. You will always eat more frequently than you do now. The actual number of "meals" varies between patients from 3 to 4 up to 6 to 8 small portions a day. Not only is there an adjustment to make about the frequency and quantity of food you can eat, you will also have to learn to eat slowly and chew your food thoroughly. The rule-of-thumb is to only eat when you are hungry and to stop eating when you are full. The "habit" of overeating must be broken and the surgery will help in this effort, along with the eating disorder psychologist if needed.
2. You will drink fluids 1/2 -1 hour after meals. Taking fluids before or at meal times may cause bloating, low food intake, vomiting, or dumping syndrome.
3. You should not eat sweets! This includes sweetened chewing gum, candy and sodas.
4. You must eat foods high in protein. Protein foods are very important for the healing of your pouch and staple line. Hair loss is one side effect of not eating enough protein. (Note: Any hair loss that is experienced does come back over time.)
5. You will eat foods low in fat.

We strongly advise against becoming pregnant as long as you are losing weight. Generally this means 1 to 1.5 years after weight loss surgery. The problem with early pregnancy is that the fetus may suffer injury due to your poor nutritional intake. To avoid such complications, we need to force high nutritional intake on the mother. Although this will protect the fetus from injury, the mother loses no further weight during the pregnancy, and usually no further weight after delivery, thereby losing the benefits of the weight loss surgery.

Be aware that during weight loss your hormonal profile will change significantly. Due to this change, you will likely become more furtile than ever before in you life. This makes you at high risk of becoming pregnant without appropriate protection. Talk to your gynecologist for advice on contraception techniques.

After your weight loss is over, pregnancy is perfectly safe. Indeed, many patients have since become pregnant and have had normal progress and delivery.

As of 2/25/06, 44 of our patients have become pregnant and had no complications due to the weight loss surgery.

We have had no patients that have gone completely bald after the operation. Virtually everyone has re-grown most, if not all, of their hair once their weight stabilizes and after they have eaten enough protein and taken their vitamin supplements.