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A:

Obesity results from having an abnormally high proportion of body fat which exceeds the body’s skeletal and physical standards.  Obesity develops into morbid obesity when an individual is 100 pounds or more over their ideal bodyweight and has a BMI (Body Mass Index) of 40 or higher.  Morbid obesity affects an estimated 10 million Americans; a number that has nearly doubled in the last 30 years.  Morbid obesity includes one or more serious health conditions or diseases that are a direct result of the excess weight an individual is carrying.  These are known as co-morbidities.  Co-morbidities result in an individual experiencing some type of significant physical ailment, which in some cases can lead to death.  With over 10 million sufferers today, morbid obesity is becoming more than just a serious disease, it’s a national epidemic.

Let our bariatric team help you overcome your battle with obesity!  Remember, you do have options.  We want to see you succeed on your weight loss journey.
A:

A surgical procedure of any kind will always involve a certain degree of risk, and bariatric surgery is no exception. However, with the development of new procedures and advancements in technology, bariatric surgery is a relatively safe solution to morbid obesity.  Today, the overall risk of weight loss surgery is fairly low with most patients experiencing few, if any, complications.  This is not to minimize the fact that this is still a serious operation, which should only be considered after all other weight loss options have been exhausted.

Once a bariatric surgeon has determined that you are a candidate for weight loss surgery, it is very important that, as a patient, you reveal all pertinent medical information to your surgical team.  The bariatric surgeon will assess the risks involved with your particular surgery and take every precaution necessary to reduce the risk of complications and ensure your safety.

Regardless of the type of weight loss surgery, it is important that the decision to undergo surgery is carefully thought out.  It’s imperative to weigh the risks of surgery with the long-term risks of remaining obese.  Discuss any concerns you might have with your surgical team and your outside support system (family, friends).

A:
With over 6 million Americans suffering from morbid obesity, the need for weight loss surgery has become more apparent.  Morbid obesity brings with it a plethora of health issues that, if left untreated, will substantially shorten life expectancy.  In fact, morbidly obese adults (those individuals whose weight is twice the ideal amount) are twice as likely to have an early death compared to a non-obese adult.

Would you like to know if you are a candidate for weight loss surgery?  To determine if you are a candidate for surgery, it’s important to know what medically classifies an individual as “morbidly obese.”  The following criteria are characteristic of a morbidly obese individual and could qualify you for weight loss surgery:
  • 100 pounds or more over their ideal body weight
  • BMI (Body Mass Index) of over 40
  • A BMI of 35-40 accompanied by significant life threatening medical conditions such as Type II diabetes, high blood pressure, heart disease, and severe sleep apnea
  • Inability to maintain a healthy body weight after numerous attempts to achieve weight loss with diet, exercise, medication, hypnosis, therapy, or a combination of methods
  • Overweight for at least 5 years with many failed attempts at losing the excess weight

Weight loss surgery is often the only option for an obese individual to improve their health.  In fact, for many patients, the risk of death from not having weight loss surgery is much greater than the potential risks associated with the procedure itself.  It’s important that you discuss all of your concerns with our bariatric team. Remember, we’re in this with you, every step of the way.

It’s important to note that weight loss surgery is not the answer for everyone who suffers from obesity.  The operation is an elective procedure, so it’s imperative that you are well informed on the potential risks and benefits involved.  Also, the surgery is not a guarantee to produce and maintain long term weight loss.  It’s only the beginning of a lifelong commitment to healthy living that is essential if you are to succeed.  Following the operation, you will begin the process of making important lifestyle and behavior changes to increase your chances of experiencing lasting weight loss and continued good health.
A:

Laparoscopic surgery is still major surgery, but its benefits typically include less discomfort, shorter hospital stays, earlier return to work, and much reduced wound complications and scarring.
A:

Dr. von Rueden will perform the surgery on a patient as young as eighteen years, however, there needs to be a full understanding and commitment to the altered eating pattern which is necessary for success.
A:

Patients over sixty-five years of age require very strong clinical indications for surgery and must also meet stringent Medicare criteria.The risk of surgery in this age group is increased and, in many cases, this fact is an argument against the procedure. Surgery can be successful in patients over sixty-five based on individual circumstances.
A: Having health insurance does not guarantee you will be covered for weight loss surgery.  Since the cost of this procedure can be very expensive, most patients would not even consider it an option if it were not for insurance or low-interest financing. Although weight loss surgery is still considered an elective procedure, it may be covered by your insurance carrier.  For this reason, it’s important that you fully understand what is and is not covered by your insurance provider.
Before you attempt to get authorization, here are some helpful hints to assist you with the authorization process:
  • Read and understand your insurance provider’s "certificate of coverage."
  • Get a referral and copy of medical records from your primary care physician in order to substantiate your claim.
  • Keep accurate, detailed records of visits to healthcare providers. Also, save receipts for any exercise equipment, fitness programs, diet centers, weight loss drugs and anything else that can assist in the authorization process.

With so many different insurance policies and types of plans among insurance providers, it’s important that you understand the authorization requirements for your individual policy. The insurance company will typically ask for the following information and documentation (Be prepared to provide these upon request.):
  • Current weight, height, and BMI.
  • Verification from a physician that the patient is 100 lbs or more over their ideal body weight.
  • The surgery recommended along with any post operative follow-up care, including nutritional and psychological support.
  • A detailed medical history including co-morbidities (i.e., the presence of one or more diseases in addition to a primary disease).
  • Six (6) months of medical records including a patient evaluation, treatments performed to date, and specific types of lab work done.
  • Six (6) months of a documented dieting and exercise routine (must include dates and results).
  • A psychological/psychiatric evaluation.

Once you have submitted your claim it’s a simple matter of waiting for your insurance provider to respond.  At times it can be a frustrating and discouraging process, but don’t give up. If your claim is denied you have the right to appeal the decision.  Being denied coverage for surgery happens to many patients, and this initial set back does not mean that you’ve reached the end of the road.  Some insurance providers may initially deny bariatric surgery claims automatically the first time they’re submitted, and can be more receptive to follow-up appeal letters.

If you have questions about the insurance process, please don’t hesitate to contact our office.  Let our experienced bariatric team help you with the authorization process.
A: Coverage may be denied because there are specific exclusions in your policy for obesity surgery, or “treatment of obesity.” Such exclusions can often be attacked by reasoning that the surgical treatment is recommended as the best therapy for the co-morbidities, which usually are covered. Coverage may also be denied for lack of “medical necessity.”  A therapy is deemed to be medically necessary when it is needed to treat a serious or life-threatening condition.  In the case of morbid obesity alternative treatments are considered to exist, according to conventional wisdom -- dieting, exercising, behavior modification, and some medications.  Usually, medical necessity denials hinge on the insurance company’s demand for some form of documentation, such as 1-5 years of physician-supervised dieting or psychiatric evaluation.  The best approach to these demands is to try and produce reasonable information to meet their needs.
A:

Some preliminary tests include, but are not limited to, blood tests: llipid profile, comprehensive metabolic profile, vitamin B12 & folate level, complete blood count with differential, thyroid panel, prothrombin time (PTT), iron (iron binding capacity); electrocardiogram; cardiac stress test; echocardiogram; pulmonary function tests; arterial blood gas; upper gastrointestinal series; ultrasound of abdomen and chest x-ray.  You will be required to have a psychiatric consult, and possibly consults with a cardiologist and pulmonologist.Each test ordered is to ensure the best possible treatment for the individual patient.
A:

We do not believe that patients with weight problems are crazy! The most common reason for a psychological evaluation is because your insurance may require it. If you are under a psychiatrist’s care, we would like a letter of approval/ disapproval for surgery.We are looking for confirmation that the patient understands the surgery, complications, and long-term care, and ensure their ability to follow the basic recovery plan. Very few people are disqualified by the psych evaluations.

A:

Surgery can usually be scheduled within 6 months of your comprehensive visit. Insurance approval is a pre-requisite for many patients, however, finance options are available should insurance not cover the entire cost of surgery. Once you decide to have the surgery, you will come in monthly for supervised weight loss. After you have met all criteria for insurance approval, we will submit your claim to your insurance carrier for approval. Once the approval is obtained you will be contacted and given a surgery date. All of your pre-op tests and evaluations need to be completed two weeks before surgery.
A:

First, help us to get all the information (diet records, medical records, medical tests) together so the carrier cannot deny for failure to provide “necessary” information.  Letters from your primary care physician and consultations attesting to the “medical necessity” of treatment are particularly valuable.

When one or several physicians corroborate the necessity of treatment, it will be hard for the carrier to contradict them.

When the letter is submitted, call your carrier regularly (about once a week), to ask about your status. You may also be able to protest unreasonable delays through your employer or human relations/personnel office.
A:

Typically, gastric bypass requires a total operating room time of 2-4 hours - the operation itself takes 1-3 hours. If your family will be waiting, they should understand that the operation might not begin immediately. If the operation lasts longer, the doctor may be able to send a message to the waiting party. Gastric banding typically takes 1 hour.
A:

Our bariatric surgeon and staff will try very hard to control pain after surgery to make it possible for you to move about and become active. This helps to avoid problems and speeds recovery. There are various drugs that can be used via a system called Patient Controlled Analgesia (PCA). This is an intravenous medication dispensed through a pump, which allows you to push a button and give yourself pain medication on demand, whenever you need it. Most of the patients are pleasantly surprised at how little discomfort they experience after laparoscopic surgery.
A:

The quick answer is: as long as it takes to be self-sufficient. Typically, the hospital stay (including the day of surgery) is outpatient for the Lap-Band, and 1-2 days for laparoscopic gastric bypass.
A:

We do not typically insert a nastrogastric tube. You will have a Jackson Pratt drain, which is a small drain that has a bulb on the end to remove any accumulation of fluid. This will be removed at your first post-op appointment after surgery and may produce only minor discomfort, if any.
A:

Almost immediately after surgery. Patients walk or stand at the bedside on the night of surgery, and take several walks the next day and thereafter. On leaving the hospital, you will be able to care for all of your personal needs, however you will need help with shopping and transportation.
A:

It is recommended that you do not drive until you have stopped taking narcotic medications and can react quickly and alertly. This is for your safety and that of the others on the road. Usually this takes several days after surgery.
A:

Patients who come from outside the Baltimore, Maryland area for surgery may arrive the day of surgery. You can have one support person stay in the room with you post-operatively. Typically, you will be discharged on the evening of the second day and you will need transportation at that time. We will need to see you in the office within two weeks from surgery
A:

For the first six months post-operation, it is advised not to drink carbonated beverages.  Some patients try carbonation after six months and it still gives them discomfort. Some patients are able to drink sugar free carbonated beverages, but we don’t recommend drinking any beverages thirty minutes prior to, or after, eating a meal.
A:

You can eat red meat but it is best to avoid it for the first several months. Red meat contains a high level of meat fibers, or gristle, which holds the meat together and prevents you from separating it into small parts when you chew. It can plug the outlet of your stomach pouch and prevent anything from passing through, which is very uncomfortable.
A:

Dumping Syndrome is caused by eating foods with high sugar or carbohydrate content on an empty stomach. These substances produce a high osmotic load. Your body handles this by diluting the food particles with water, which reduces blood volume and causes a shock-like state. Sugar may also induce shock due to the altered physiology of your intestinal tract. The result is an unpleasant feeling causing you to break out into a sweat, turn pale, feel butterflies in your stomach and a pounding pulse. This may be followed by cramps and diarrhea. This state can last thirty to sixty minutes and is quite uncomfortable. Many people have to lie down until it goes away. Small amounts of sweets, such as fruit, are well tolerated at the end of a meal. Dumping Syndrome does not occur in patients that have the Lap-Band or gastric sleeve procedures because their intestines are not altered.
A:

Milk contains lactose, or milk sugar, which is not well digested. This sugar passes undigested until bacteria in the lower bowel act on it, which produces irritating byproducts as well as gas. Depending on individual tolerance, some people find even the smallest amount of milk or milk sugar will cause cramps, gas, and diarrhea. Patients with lactose intolerance can use Lactaid products or supplemental enzymes.
A:

The basic rules are simple and easy to follow:

  1. Eat three meals per day.  During those meals, eat your protein first.  The goal is to obtain at least 60 grams of protein per day.
  2. A mid-morning and/or afternoon high protein snack is acceptable.  
  3. Drink water. The goal is to drink two to three quarts of water a day.
  4. Exercise daily. Walking is a wonderful form of exercise, and while you may not be able to do much in the beginning, you will increase your endurance with time and practice.
  5. Take the recommended vitamins daily.
A:

One to two snacks per day is acceptable to increase your protein or fiber intake, but nibbling or grazing on usually high-calorie and high-fat foods can add hundreds of calories a day to your intake. This defeats the restrictive effect of your operation. Snacking on the wrong foods will definitely slow down your weight loss and can lead to regained weight. Snacking is a habit which is easier to avoid than break.
A:

When you are losing weight there is a heavy load of waste products to eliminate, mostly in 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 will also fill your stomach and will help to prolong and intensify your sense of satisfaction with food. If you feel a desire to eat in between meals it is because you did not drink enough water the hour before.
A:

When you have gastric bypass, you lose weight because the amount of food energy (calories) you are able to eat is much less than your body needs to operate. It has to make up the difference by burning reserves, or unused tissues. Your body will burn any unused muscle first before it begins to burn the precious fat it has saved up. Daily aerobic exercise for twenty minutes will communicate to your body that you want to use your muscles, forcing it to burn the fat instead.
A:

It is highly recommended that you attend the support group meetings. It is very helpful to listen to the experiences of other people in the same situation.Various emotions will accompany the changes experienced after weight loss, and it is important to process this as a group. For some people isolation was part of being morbidly obese and the support group will ensure no one is alone.
A:

Aside from the most obvious change that takes place with respect to diet, there are a number of other lifestyle changes that have to occur in order to experience success on your weight loss journey.

Eating Habits
  • Avoid alcoholic beverages.
  • Avoid high fat, high fiber foods.
  • Chew slowly during meals.
  • Don’t drink with meals (it makes you feel full too fast).
  • Keep snacking between meals to a minimum.
  • Omit desserts and sugary foods.

Home/Work Life

Your post surgery physical activity level will likely be determined by the type of procedure you have undergone.  Most patients can return to work within 1-3 weeks following laparoscopic surgery, while open surgical procedures may be slightly longer.  Exercise can typically resume within six weeks or less after surgery.

Follow-up Care

Long term follow-up care will be required annually and sometimes more frequently depending on post-surgical body functions.  There will be frequent testing to determine:

  • Nutritional levels (vitamin B-12, iron, and folate levels, etc.).
  • Is the patient anemic (i.e., low red blood cell count).

Support

Having the support of family and friends is important; however, equally important is for a person to surround themselves with other weight loss surgery patients who understand the intricacies of weight loss surgery.  Weight loss surgery is not a quick fix to repair the years of emotional pain caused by being morbidly obese.  The support groups are merely a way for patients to share their challenges and/or success’ with others who have been through similar challenges.  In fact, there is typically a big difference between the patients who are involved in a support group on a regular basis and those who attempt their weight loss journey alone.  Our surgical team will provide you with a list of support groups to fit your needs.

Pregnancy

For the first 18-24 months after weight loss surgery it’s important that women of childbearing age do not conceive.  Pregnancy can be taxing on the body and the potential for fetal damage increases.  During this waiting period, it’s important to give the body time to heal and recuperate.  For this reason, a surgeon will typically advise you to take every precaution necessary to reduce the chances of becoming pregnant.
A: Of course, we can’t predict exactly how your life will change after losing 100, 150 or 200+ pounds.  The old adage, “everyone is an individual” is wise and true!  We can ASSURE you that your life WILL change and the changes are very likely to be quite dramatic! Over the last 2 years that we have monitored our patients, we find some of the major changes to be:

Improved physical status (for example, blood pressure, blood sugar and respiratory regulation), more energy, less body aches and pains, improved sleeping, improved psychological status, including decreased depression, improved self-esteem, improved social skills, more confidence and realistic hope for the future, Changes in relationships, including family, love relationships, friends and co-workers.

In general these changes are positive and exciting.  They are also demanding.  In order to succeed in our program, patients must really put their own health care choices first.  This is often a dramatic change for our patients, since many have felt depressed and hopeless and have given their own lives the lowest priority.  Our patients have to learn to make assertive, healthy decisions for themselves, even when these decisions upset their loved ones.  For example, they may choose to go on their exercise walk instead of sitting down and eating with others, OR they may have to deal with their spouse’s jealousy or discomfort when they become increasingly attractive and independent.

Body Image: Patients undergo incredible changes in how they feel about and see their bodies.  Losing 100 or more pounds creates drastic changes in body size, appearance, and related areas such as dressing choices and feelings of being attractive and sexy.  Accepting normal body image is sometimes a major challenge for obesity surgery patients. Even though wearing a size 8 dress may be a lifetime goal, some patients require some adjustment time to accept this reality, sometimes still “feeling fat”, or worrying that they will gain back the weight.