The 10 Bariatric Surgery Steps to Long-Term Weight Loss
Reviewed by: John M. Rabkin, MD, FACS
The 10 essential bariatric surgery steps can be thought of as a timeline ranging from "How to Qualify" all the way through long-term weight loss and health improvement.
Click the links below to jump to any step or scroll down to review them all…
The National Institutes of Health (NIH) has determined that weight loss surgery is appropriate for people who:
- Have a body mass index (BMI) of 30 for the Gastric Balloon OR
- Have a BMI of 35 or higher and a serious obesity related health problem such as diabetes, sleep apnea, or heart problems
- Have a BMI of 40 or higher
The NIH may soon drop the minimum BMI from 35 to 30 for procedures other than just the balloon based on bundling research showing lower-BMI patients achieving similar weight loss and resolution of obesity-related health problems such as Type 2 diabetes.
Most insurance companies also require weight loss surgery patients to have completed a 3+ month medically supervised weight loss program, although many surgeons do not require this.
Use the BMI calculator below to figure out your body mass index…
Depending on the type of bariatric surgery you choose, your percentage of excess weight lost could be as high as 80% or more. While a BMI of 25 is possible, your initial goal should be to get your body mass index below 30 (click here to calculate your BMI and figure how much weight that equates to for you).
Bariatric surgery may be the best (or only) treatment to improve serious obesity-related health problems including Type 2 diabetes, sleep apnea, heart problems, depression and many other issues.
But it really comes down to this: According to one peer-reviewed study, morbidly obese patients who received bariatric surgery are 89% less likely to die over any 5 year period than morbidly obese individuals who didn’t have the surgery. (Source)
Risks & Complications
Just like any surgery, weight loss surgery does carry risks. The mortality rate (risk of dying) is about 0.135% (Source). The risk of complications both during and after surgery range from minor to severe. About 15% of bariatric surgery patients (1 in 7 patients) have some sort of complication, with the most common being nausea and vomiting. (Source)
Bariatric surgery may be the best tool to make you happier and healthier, but that’s all it is… a tool.
You will be the key to making it successful over the long-term, and there will be many challenges along the way such as a strict diet and exercise regimen, changing relationships as people react to your new weight and sagging skin resulting from the rapid weight loss.
To learn more about each of these areas, see the following links:
There are 4 established and generally accepted weight loss surgery procedures, each with its own set of positives and negatives:
- Gastric Bypass
- Gastric Banding (e.g., Lap-Band)
- Duodenal Switch
- Gastric Sleeve
Your individual situation will determine which type of bariatric surgery is best for you, but following is a general summary…
Gastric bypass surgery has a relatively low complication rate compared with its high levels of excess weight loss and significant improvement in co-morbidities. Its popularity also means that there are more surgeons out there with enough procedures under their belt to improve your chances for a good outcome.
However, gastric banding (e.g. Lap-Band) may be a better option for some mentalities. It has a lower risk of serious complications, and for those who are not 100% sure that they’re ready to permanently change their body, it is the only established procedure that is completely reversible; it can be relatively easily converted into a more elaborate procedure at a later date.
Unfortunately, lap band surgery has a very high variability in weight loss from patient to patient, and is associated with more minor and annoying complications. Most concerningly, lap band surgery is much more likely to require reoperation over the long-term as a result of permanent failure.
The duodenal switch is probably the most effective procedure for the super-obese. It has been proven to be successful (result in at least 50% of excess weight loss) for about 85% of patients after 3 years. It may also be the most effective procedure for treating obesity-related health problems. For example, in one study duodenal switch surgery cured 100% of diabetic patients (Source).
The amount of long-term weight loss after DS also appears to be better than any other procedure, but that comes with the highest rate of serious complications and the most intensive bariatric vitamin adherence requirements due to the level of malabsorption.
Gastric sleeve surgery is less complicated than gastric bypass and duodenal switch and leads to similar weight loss. While not reversible or easily adjustable like the lap band, it carries a much higher weight loss and much lower risk of reoperation.
Gastric sleeve surgery appears to be a bit safer than gastric bypass in terms of reoperation and complications, but gastric bypass seems to have a better effect on many obesity-related health problems.
Without insurance, the cost of weight surgery in the United States can range anywhere from $8,000 to $35,000 or more.
Despite the high price tag, you’re still likely to save money – a lot of money – over the long term. One prominent study found that as early as 13 months after surgery patients spend up to $900 per month less than if they hadn’t had surgery. The analysis showed that for those receiving laparoscopic bariatric surgery, patients "broke even" then started to come out ahead within 2 years (Source).
If you have insurance, you need to figure out:
- If weight loss surgery is covered by your plan
- The process required to get surgery approved
By far the easiest way to handle each of these is to seek the help of a top surgeon. Their office should be able to check your insurance for free and do all of the legwork to get you approved.
If you do not have insurance, there are several ways to make surgery more affordable. For example, many patients are able to get get monthly payments down to under $200 per month by working with their surgeon’s financial partner.
The most common ways patients without insurance are able to afford surgery include (click links for more information):
- Payment Plan Through a Qualified Bariatric Surgeon or their financial partner – This is probably your most realistic and affordable local non-insurance option
- Friends & Family
- Secured Loans (e.g., a home equity line of credit)
- Retirement Plan Loans
- Brokers, Direct Lenders and Credit Cards (Unsecured Loans)
- Medical travel (traveling outside the country where cost of care is less expensive)
Discounts and savings opportunities exist in many forms if you know where to look, including:
- Self-pay & other discounts
- Same surgeon, different hospital (the hospital chosen can have a huge effect on the price tag)
- Taxes (you may be able to write off the cost of surgery)
- Getting partial insurance coverage (even if your plan doesn’t explicitly cover weight loss surgery)
- Short term disability insurance during your procedure and recovery
Choosing an experienced surgeon tends to result in better patient outcomes including shorter hospital stays, lower complication rates and lower mortality rates (Source).
But you also want to work with a team that "just feels right," both on paper and in person. After all, the team you choose will be your go-to for any and all issues or questions, and it’s important to feel comfortable with them as people.
There are 4 steps to finding the right surgeon for you:
1. Create your list of surgeons
Click here to search the Bariatric Surgery Source surgeon directory of top surgeons around the country and world.
You can also ask your primary care physician or other trusted physician for a referral. If you have insurance, check to see which surgeons are included among their list of "in-network" physicians.
2. Verify credentials
Use the Administration in Medicine’s (AIM) DocFinder web site for your surgeon’s license status.
If any surgeons on your list have an outdated license, have public record actions listed against them or are not board certified, be on the safe side and remove them from your list.
3. Narrow your list
Your next step is to determine which surgeons on your list are worthy of face-to-face interviews.
To figure this out, call each surgeon’s office and sign up to attend their next free seminar.
Print out our Bariatric Surgeon Questionnaire (one for each surgeon on your list). While attending the seminar, take notes on the printed questionnaire, and be sure to ask any of the questions that are not covered
4. Choose your surgeon
To begin Step 4, attend each surgeon’s next patient support group and ask questions to learn other patients’ experience with your surgeon’s team (the surgeon won’t be present).
Then schedule a face-to-face consultation with the surgeon and ask any and all questions that come to mind. Good surgeons will be glad that you are doing your research and will be happy to provide answers.
After your interviews, go with your gut. Maybe one office was more relaxing and their staff more welcoming. Maybe one of their aftercare plans seemed more well-planned and thorough. Maybe one surgeon’s former patients seemed more pleased with their experience. Maybe one surgeon “just felt better.”
Regardless of which one you choose, you should now feel confident that you have chosen a great surgeon.
Click here for a more in depth review of each step in the surgeon selection process.
Effectively preparing for weight loss surgery will reduce stress, save money, minimize your risk of complications, increase the amount of weight you will lose and make you much more likely to keep the weight off over the long term.
For example, one study found that for every 1% of weight lost before surgery, patients can expect to lose 1.8% more weight at one year post-op. (Source) Another study found that the more weight patients lost before surgery, the less likely they were to experience complications. (Source)
The other big reason for preparing for weight loss surgery early is reversing poor habits. Habits take time to change, and if you go back to your old ways following surgery, you will gain the weight back and you will experience a relapse in your obesity-related health problems.
3 to 6 Months Before Surgery – 2 Essential Checklists
1. Medical, Payment & Logistics Checklist
- Attend your surgeon’s next free seminar to learn your options and better understand what to expect
- Understand payment options and savings opportunities
- Schedule pre-surgery tests and consultations/physicals to confirm that you are a good candidate for surgery
- Arrange and begin your physician-supervised diet program (if required by your insurance company or surgeon)
- Schedule your initial consultation with your surgeon and find out what paperwork and medical history you’ll need to move forward
- Ensure that surgeon has obtained pre-authorization from your insurance company (if applicable)
- Join an in-person weight loss surgery support group (your surgeon can recommend one). In addition learning what to expect first-hand and building relationships that will make the tough times easier, regular support group participation has also been proven to result in significantly more weight loss and a lower body mass index. Click here to learn more about support groups.
- Participate in other preparatory steps or educational meetings as advised by your surgeon’s team
2. Lifestyle Changes Checklist
For long-term weight loss and health improvement following surgery, you must start living as if you’ve had the surgery at least 3 months in advance:
- Begin eating for health and not just flavor and pleasure
- Eat protein, LOTS of protein
- Eat slow, chew each bite and watch the portion sizes
- Start taking a multivitamin
- Don’t drink anything with your meals
- Ditch the sugared beverages and drink more water
- Careful with the coffee
- Stop drinking alcohol
- Exercise just a little bit more
- Stop smoking
- Start attending in-person support group meetings
Click here for more information about each of the 3 to 6 month to-do’s.
2 Weeks Before Surgery – Your Essential Checklist
- Plan for time off from work – at least 4 to 6 weeks is best
- Have your child care worked out
- Have someone to take you to and pick you up from the hospital
- You’ll need someone to be with you for at least the first week of your recovery. That person should be there to help you 24/7 if needed, so be sure they’ve requested the time off work as well.
- Prepare the food and vitamins that you will eat after surgery
- Set up a comfortable sleeping arrangement for when you get home
- Prepare comfort items to take to the hospital
It’s normal to be nervous before the big day. But you have chosen your team of doctors and hospital well and you have everything in place, so please try to relax.
Here’s a high level overview of what to expect…1. Pre-Op
At least 2 hours prior to surgery, your team of nurses will prepare you to go to the operating room. You will meet with the anesthesiologist and your surgeon before surgery. The nursing staff will talk with you and let you know what to expect and will check your vital signs.
2. Operating Room
The anesthesiologist will give you the anesthesia that will keep you fast asleep during surgery. Your surgery can last from 1 to 4 hours depending on your procedure and individual circumstances.
During your initial 2 to 3 hours of recovery, you will receive one-on-one attention to manage your pain and monitor your vital signs. You will likely not remember this part much, if at all.
Some procedures, like the gastric balloon, vBloc Therapy, and AspireAssist, can be performed on an outpatient basis. In other words, the procedure should take less than an hour and you should be home on the same day.
Other procedures like the gastric sleeve or duodenal switch will require some recovering time in the hospital. During your 1 to 3 nights hospital stay following surgery, you can expect to have some pain at your incision sites, and your muscles may be sore from lying on the operating table.
Your surgeon will prescribe pain medications through your IV and will probably order nothing to eat or drink for the first 24 hours. You can also expect to have antibiotics, IV fluids, plastic tubes that will deliver oxygen through your nose, a urinary catheter to drain your urine and an abdominal binder to help your incisions heal. Your nurses may have you wear compressive devices around your legs to help prevent blood clots.
You will have get up and walk after surgery, usually within the first 8 to 10 hours and then several times per day thereafter to prevent blood clots, wake your body up from anesthesia, get your intestines to start working again and improve breathing. Your nurses will also help you through other exercises to reduce the risk of complications such as breathing, coughing and leg exercises.
Your doctors will check in on you every day to make sure you are healing properly. As soon as you’re able to start sipping water, your IV will be removed. The day after surgery, many surgeons will order a “leak test” for you to make sure your digestive system is functioning well. Once you pass this test, you can begin drinking clear fluids.
Congratulations… you did it! You’re on the road to recovery and your new life.
Any pain will slowly diminish and you’ll start feeling a little better each day. Don’t forget to pick up your pain medications on the way home if you don’t already have them. If your ride home is a long one, stop at least once every 2 hours to get out and stretch.
Click here to learn more about what to expect during your hospital stay.
A successful, complication-free bariatric surgery recovery requires close adherence to your surgeon’s advice, a strict dietary regimen and proper incision care…
Diet During Recovery
In order to let your stomach heal, you won’t be able to eat for the first few days following bariatric surgery. Your doctor will start you on a liquid diet and have you slowly transition back to solid foods.
Following are key points to know about your recovery diet:
- Your calorie consumption will be about 1/4 of what it used to be
- Drink a lot of fluids… between 48 and 64 ounces per day
- Do not drink any liquids during your meals or within an hour afterwards
- From the 2nd through the 6th weeks your liquid meals will get thicker and thicker (but still completely pureed with no small bits remaining)
- Some time between the 4th and 8th week after surgery, your surgeon will slowly transition you to solid foods and on to your permanent long-term diet.
Caring for Your Incisions
A simple process of gently washing your incisions with soap and water (no scrubbing) then drying them gently but thoroughly is recommended. After the wounds have completely closed (usually takes about 2 weeks), you can start applying special lotions and sunscreen to minimize the scarring.
Slowly ease back into your normal routine, and don’t start any strenuous exercising until you have fully healed on the inside and out (talk with your surgeon to be sure).
Short-Term Difficulties and Side Effects
At first, you may experience discomfort in a number of areas which may sound unpleasant, but these side effects will usually pass with time or changed behavior…
- Nausea or vomiting
- Body aches
- Weak or tired feeling
- Feeling cold
- Diarrhea or loose stools
- Dumping syndrome
- Gurgling noises
- Thrush (yeast infection)
- Feeling more "emotional" than usual
- Skin changes
- Temporary hair loss
You likely won’t experience all of these issues, and – for those that you do experience – it typically takes anywhere from two to six weeks for them to start to wear off.
Click here for more information about recovering from surgery.
In order to maintain your weight loss and health improvement after weight loss surgery, you’ll need to develop proper long-term diet and exercise habits. Otherwise, you will gain your weight back.
Some procedures, like the duodenal switch, medically require significant changes in your diet, while others do not. However, no matter which procedure, if you do not make an effort to eat healthy you will gain back weight. So, regardless of which procedure you’ve had, you should work to adopt all of the following diet guidelines.
Long-Term Diet for Weight Loss Surgery Patients
Healthy eating for weight loss surgery patients has two angles… what you eat and how you eat.
As you can imagine, diet is a huge topic of conversation, so we’ll only touch on some key points here. Click here for detailed information.
In general, there are 7 food principles to live by:
- Eat healthy
- Protein first
- Keep your blood sugar stable
- Drink the right amount of water at the right times
- Don’t snack
- Be religious about taking your vitamins
- How you eat is as important as what you eat
Eating healthy means that your diet should consist primarily of FOG foods…
- Farm – The food is raised on a farm (i.e. chicken, turkey, eggs, dairy products)
- Ocean – It comes from the ocean (i.e. fish)
- Ground – It is grown in the ground (i.e. fruits, vegetables, nuts, whole grains)
When possible, avoid anything that was modified by humans in any way.
Regarding what NOT to eat, food intolerance affects different patients in different ways, and certain foods may upset your digestive system following surgery. Click here for the full list of foods that may give you problems.
How you prepare your food is as important as what you buy…
- When cooking, bake, grill, poach or broil…don’t fry.
- Use skim milk instead of whole milk.
- Use chicken or vegetable broth instead of oil.
- Replace oil in recipes with applesauce or yogurt.
- Add spices or lemon juice to add flavor instead of olive oil or butter.
Eat your protein first. Protein is one of the most important nutrients for your body, and you need a lot of it in order to stay healthy… up to 80 grams a day.
With your old stomach, this was no problem. But now that your stomach is down to the size of a golf ball, 80 grams is a big percentage of the available space.
Stable blood sugar leads to stable hunger and stable relationships (no mood swings). Avoid simple carbohydrates and eat "good" carbs in small portions.
Drink a lot of fluids… between 48 and 64 ounces per day. That’s equal to about 8 cups or 1/2 a gallon. This may be tough to do considering the size of your new stomach, but its extremely important to avoid problems.
Don’t snack… Snacking between meals is the quickest way to halt your weight loss progress and to gain your weight back after you hit the low point.
Be religious about taking your vitamins – After surgery, you will be at much higher risk of serious vitamin deficiency if you don’t take your prescribed vitamins and supplements. Click here to learn which vitamins you’ll need and how to avoid problems.
How you eat versus what you eat – The right eating techniques can prevent complications and weight regain and ensure that your body gets the nutrients it needs. Follow these guidelines to stay on track…
- Consider preparing your own food to avoid harmful ingredients and help make your new diet taste good!
- Stop eating before you feel full to avoid vomiting, diarrhea, constipation and difficulty swallowing and to prevent stomach stretching and weight regain.
- Eat slowly and chew your food thoroughly
- Do not drink during meals or up to an hour afterwards
Exercise is often the first part of a patient’s long-term plan to get skipped following surgery. However, several studies have found regular exercise to be 2nd only to diet towards achieving and sustaining long-term weight loss and health improvement goals.
Long-term regular exercise after weight loss surgery has been shown to:
- Increase life expectancy
- Reduce abdominal fat
- Strengthen heart, muscles, bones and lungs
- Reduce risk of heart disease
- Lower blood pressure
- Reduce triglycerides
- Increase good cholesterol and reduce bad cholesterol
- Improve blood sugar control
- Improve insulin control
- Reduce risk of cancer
- Increase energy
- Improve balance
- Improve appearance
- Improve motivation and mental “sharpness”
- Improve libido
When Can You Start Exercising?
Check with your surgeon to be sure, but exercise can generally begin within three to six weeks following surgery…
- Immediately after returning from the hospital – Start walking slowly 20 to 30 minutes per day (not necessarily all at once), gradually increasing the speed at which you walk as your endurance improves
- 3 to 6 weeks after surgery: Build up to three 10 minute walks per day while walking at a relatively quick pace.
- 6+ weeks after surgery: Continue building strength, endurance and flexibility through regular exercise
A solid foundation for safe and effective exercise for weight loss surgery patients includes…
- Consistent exercise is more important that rigorous exercise.
- Start slowly and work your way up
- Prevent skin problems caused by sagging skin from rapid weight loss by applying lubricating gels and wearing supportive clothing
- Drink plenty of water while exercising
- Wear good shoes
- Warm up before exercising and do a cool-down routine afterwards
- Keep your heart rate within the proper range using a heart rate monitor or manually taking your pulse
- If you feel pain, stop immediately (but having sore muscles is okay!)
Which exercises are best?
There is not necessarily a "best" exercise routine as long as your routine focuses on all 3 essential elements:
- Endurance – Walking, marching, riding a stationary bike, hoola-hooping (yes, hoola-hooping) and swimming are all great options.
- Flexibility – Stretching and yoga (yoga is – by far – our favorite recommendation for improving mental strength, physical strength and flexibility – please trust us and try a beginners yoga class)
- Strength – Yoga, exercise balls, the Bodyblade and (light) weights are good beginner tools for building strength.
Congratulations on making it through all 10 Steps to a Successful Weight Loss Surgery Experience! We’ve covered a lot, and you should now feel confident in your knowledge of what it takes to succeed before, during and after weight loss surgery.
So where do you go from here?
Option 1: Attend a Free Online or In-Person Seminar with a Top Surgeon
Whether you’re confident that weight loss surgery is for you or if you’re still on the fence, the best thing you can do is:
- Contact a top surgeon
- Register to attend their next free online or in-person seminar
Most surgeons hold regular (weekly) seminars to talk about your options, introduce themselves and their staff and allow you to interact with others who are also considering surgery.
Be sure to ask about a free insurance check (most practices offer this), financial review and, if applicable to your situation, financing options.
Click here to find and connect with a top surgeon.
Option 2: Attend a Local Weight Loss Surgery Support Group Meeting
If you’re still on the fence, attending a local support group will give you a much better understanding of the benefits and challenges of weight loss surgery from actual patients.
Contact a local surgeon and ask if you can attend their next support group meeting.
Option 3: Send Us Your Questions
If you have any specific questions that you want to have answered before contacting a surgeon, please reach out. We’ve built a Question & Answer section at BariatricSurgerySource.com where you can interact with our team and receive specific feedback and advise.
Please click here to submit your questions.
We hope this email series has been helpful, and we look forward to staying in touch!