Choosing a Doctor for Bariatric Surgery - What Questions Should You Ask?
Our goal is to provide a comprehensive directory that will make researching bariatric surgeons easy for patients. While considering cost and location is very important, it is most important that find a doctor that not only meets your medical needs, but your pre and post surgical physical and emotional needs as well. These questions hope to help you create an open dialog that most doctors should be very willing to have before you make your decision. The information below each question is there to both educate and guide you through the conversation.
Q1. What types of bariatric surgery do you perform?
There are two primary types of bariatric surgery plus the newer gastric banding surgery.
Bileopancreatic diversion bypass is the most extreme surgery and the least used. In this surgery, up to three-quarters of the stomach is removed, and a bypass is connected to the illium. This results in a large permanent scar and carries a high risk of nutritional deficiencies. This technique is used primarily in patients who are extremely heavy (BMI over 50.)
Roux-en-Y-gastric bypass can be performed either through a large incision or laparoscopically. No parts of the stomach are removed. Again, a portion of the small intestine is rerouted to bypass the duodenum. This is a less invasive surgery than the bileopancreatic diversion bypass, and the laparoscopic version of the surgery has a shorter recovery time than the others.
In both bariatric bypass surgeries, a small pouch is created by stapling a portion of the stomach. The small intestine is then attached to the stomach so that food bypasses the upper part of the small intestine (the duodenum). This results in significantly reduced food intake and the patient also feels full sooner. With both of these techniques, the patient loses most weight in the first year, and weight loss is usually complete by the end of the second year. Both procedures are permanent and cannot be reversed.
Gastric banding involves placement of a silicone band around the upper stomach to restrict food intake. This slows the passage of food to the lower stomach, resulting in the patient feeling full sooner. This band can be inflated or deflated to reduce or increase the size of the passage between the two stomachs. This surgery is done laparoscopically and has the least recovery time. In some cases, this surgery can be done on an outpatient basis.
While the two bypass surgeries may limit the foods the patient can tolerate, the banding procedure only limits quantity. Over time, patients who undergo gastric banding may be more likely to regain the weight lost.
Read our Bariatric Surgery Glossary for additional information.
Q2. If you prefer one bariatric procedure over the others, could you explain why? What are the factors you use in deciding which to perform?
The Roux-en-Y procedure is the most commonly performed bariatric procedure and produces good weight loss, usually up to 50 to 60 percent of excess weight in the first two years. It is less invasive than the bileopancreatic diversion surgery, can be done laparoscopically in some cases, and recovery time is usually quicker. It has a lower risk of complications and nutritional deficiencies.
In patients who have an extreme amount of weight to lose the bileopancreatic surgery has been shown to produce more weight loss. However, it has a higher risk of complications, including malnutrition, and may not be the right choice if you have heart failure, sleep apnea, or other serious health risks. It cannot be done laparoscopically and results in a large scar. The time for recovery is longer as well.
Laparoscopic banding (also known as lap band) is the least invasive but requires a great deal of patient compliance to achieve maximum weight loss. Gastric banding also requires frequent doctor follow-up at to adjust the band. It is reversible when weight loss is complete.
It is important to remember that you will need a local lap band post-operative care center for your adjustments. If you decide on medical travel (usually because of cost) instead of a local surgeon, be sure to discuss this post-operative care need with your doctor.
Q3. Are there any things that might disqualify me for the surgery?
- Active substance abuse
Active substance abuse is an immediate disqualifier. You must not be actively using any addictive substances, other than physician-prescribed medications, at the time of surgery. You must also be able to abstain from alcohol for a period of time before and after surgery. - Untreated mental illnesses
Personality disorders such as schizophrenia or depression, are also a cause for disqualification. You must be able to show that you understand the nature of the surgery and the lifestyle changes required, and that you are willing to comply. - Life threatening disease
If you have a life-threatening disease, such as cancer, that is not likely to improve with weight loss, you may not qualify for bariatric surgery. - Non-compliance with other medical treatments
A failure to address diabetes or other treatable conditions will also disqualify you.
Q4. What types of ongoing support do you provide for your patients? Do you have support groups at your clinic or do you refer patients somewhere specific?
As with other weight-loss programs, bariatric surgery requires significant lifestyle changes. A support group is important both before and after the surgery. There are support groups in the community, often offered by hospitals or clinics.
Following surgery, the support group will provide you with tips as you learn new behaviors. It will also give you a place to find support for the physical and emotional changes you are going through from others who have also had the surgery.
It is important to remember that you will need a local lap band post-operative care center for your adjustments. If you decide on medical travel instead of a local surgeon, be sure to discuss this post-operative care need with your doctor.
Before surgery, you may have the opportunity to talk with patients who have undergone the surgery and hear honest accounts of their successes and challenges. This will help you decide if the surgery is right for you. Your doctor will have to have permission directly from those patients before releasing any information to new patients.
Q5. How long have you been performing bariatric surgery and how many of that specific type of surgery that you are recommending has the doctor performed?
Bariatric surgery is medical specialty that requires training and ongoing continuing education. Look for a doctor who has done many surgeries and donít be afraid to ask his success rate, including his complication and mortality rates.
Ask your doctor if he has done a residency or fellowship in weight-loss surgery.
Q6. What special training have you had in bariatric surgery? Have you updated your certificates or training recently?
Bariatric surgery, especially laparoscopic Roux-en-Y, has a sharp learning curve. Look for a doctor who has had specialized training and is up-to-date on the latest techniques.
The American Society for Metabolic and Bariatric Surgery (ASMBS) recommends that surgeons be able to perform more than one type of weight loss surgery and that they be the lead physician on a minimum of 50 out of 100 bariatric surgeries during residency.
Because bypass surgeries are more complicated than gastric banding, they recommend that the physician be either the principal or attending physician for at least 50 bypass surgeries. The key things to consider:
- Experience in the area of bariatric surgery, having done a significant number of cases each year. More experience equals fewer complications.
- Membership in (not just affiliate member) the ASBS, or American Society for Bariatric Surgeons.
- Board certification. You can go to the The American College of Surgeons web site (www.absurgery.org) to check for board certification. Board certification ensures that your surgeon has undergone rigorous training and testing.
- A policy of follow-up care and monitoring that lasts at least a year after surgery.
- Performs surgery at an accredited hospital with experienced staff that are experts in bariatric surgery (2).
Q7. What does the surgery cost and what does that cost include? Does the cost include post surgical support?
Bariatric surgeries, including laparoscopic banding, range from $17,000 to $35,000. This includes pre-operative tests, surgery, hospital costs, anesthesia, and post-operative care (from 90 days to one year.) It does not include plastic surgery following weight loss, mental health treatment if needed, support group expenses, or the cost of vitamins and supplements.
The wide range in cost is related to how much time you have to stay in the hospital following surgery. Geography also plays a role with surgery generally costing more on the East Coast and in large cities.
Q8. Do you take insurance? What does my insurance cover?
Most doctors take insurance, but you will have to check with your insurance to make sure the doctor you choose is covered under your plan. Some plans require the use of in-network doctors and should be able to provide you with the name of doctors who are part of their network.
Private insurance usually covers between 80% and 100% of the cost of the surgery. Since morbidly obese patients cost insurers more if they stay heavy, there is incentive for insurance providers to assist in weight loss. However, you may need to have your doctor document the need for surgery through letters to your insurer.
Medicare and Bariatric SurgeryMedicare also pays for bariatric surgery for patients meeting their criteria. Medicare requires that the surgery be done in a facility that does a high volume of the surgeries and has a low mortality rate.
If your insurance does not cover the surgery, you may be able to arrange financing through your doctorís office or find out how you can acquire a private (personal) medical loan directly from a bank (or financial institution). Many have lower rates for medical loans.
Q9. Can I talk to any patients you have treated about the surgery?
Your doctor may be able to ask some of her patients to contact you. Due to HIPAA laws, your doctor cannot give you names of patients. Attending a support group is your best way to get information about the surgery. If possible, you should start attending a support group before surgery to make sure that surgery is the best option for you. Many support groups are led by people who have had the surgery and been trained by physicians or nurses to lead the groups.
Q10. What do YOU consider a successful surgery? When do you like to start seeing results?
The success of bariatric surgery lies primarily with the patient. Major lifestyle changes are required and the patientís compliance with these changes will determine how successful the surgery is. While weight loss is the desired goal, success is better measured in how the patient feels about himself and his lifestyle following surgery. Itís important to understand your doctorís point of view on your case in particular, because they should have experience with others that match your lifestyle, current weight and personality.