If you wish to proceed after attending an initial consultation, the Coastal Obesity Surgeon will order laboratory tests to substantiate the need for surgery. Depending on your medical history, the surgeon may also want you to see a specialist. After you have completed the necessary tests, we will send a letter to your insurance company requesting authorization for surgery based on your individual medical conditions (diabetes, high blood pressure) that would most likely improve with bariatric surgery. Please note that receiving authorization for surgery from your insurance company does not obligate you to have surgery.

It usually takes from one to six weeks to hear from you insurance company. In rare cases, this process may take longer. Our patient coordinators will contact your insurance company weekly to get a status report. Once surgery is approved, our surgical coordinators will call to notify you. At this time we will set a surgery date and schedule any necessary pre-operative laboratory studies and physician appointments. Should you have questions about your surgery date or your pre-operative medical appointments, please contact one of our surgical coordinators.

After insurance authorization is confirmed, you will be seen a second time in our office. This time a physical examination will be performed and your surgery will be scheduled. You will also be asked to complete a true-false questionnaire related to bariatric surgery and to sign a disclosure statement regarding operative risks and blood transfusions. You will also be scheduled for a pre-operative class taught by our program nurse. This class is designed to give you an overview of your hospital experience, and give you specific information about pre-operative and post-operative hospital procedures.

As part of our thorough, comprehensive medical care, every pre-operative patient may need to see the following physicians for pre-operative clearance. (Each individual physician’s office will bill your insurance company directly.)

• Psychologist (for evaluation)
• Internist
• Anesthesiologist
• Specialists such as a Cardiologist, Pulmonologist or Endocrinologist, based on your individual medical history
• Assistant Surgeon (not seen pre-operatively, but present on all surgical cases)

All patients are encouraged to attend at least one support group meeting before having surgery. While you are waiting for insurance approval, try to attend as many support group meetings as possible. Support group schedules are available in our office, and on our web site at www.coastalobesity.com. Support group meeting transcripts are also posted on the web site.

Hospital admission is sometimes the day of surgery, and sometimes the day before surgery. There will be some routine lab tests repeated in the hospital to be sure that nothing about your medical condition (e.g. pregnancy) has changed.

An RN will prepare you for your surgery. During this preparation you will sign a surgical consent and have your vital signs checked. An intravenous line will be started, usually in the forearm, the back of the hand, or occasionally under the collarbone. You will meet with the anesthesiologist and discuss what to expect from anesthesia. You will be given antibiotics and other medications prior to surgery. An incentive spirometer will be brought to your bedside and you will be instructed in breathing exercises. You may also be instructed in the use of a machine to deliver pain medication. Local anesthesia is usually placed in the surgical incision to decrease post-operative discomfort.

Surgery by open incision usually takes an hour to an hour and a half, although because of necessary immediate perioperative activities, the time during which the patient is separated from his/her family is usually 3-4 hours. (Laparoscopic gastric bypass surgery may take longer.) After surgery you will awake in the recovery room. Here you will be carefully monitored while the anesthesia wears off. A tube will be placed in your bladder to prevent post-operative urinary retention and to help determine the amount of intravenous fluids you will need. Y ou may also notice that you are wearing leggings that rhythmically squeeze your legs. These were applied immediately prior to surgery to prevent blood clots and are worn until you feel like getting up and walking around; usually on the second or third post-operative day.

(Dr. Owens is a General Surgeon as well as a Bariatric surgeon, and is fully qualified to take care of your other operative needs such as gallbladder, hernia, appendix, etc.)

It is common to remain in the hospital for four days. After surgery you will be allowed small amounts of ice and water, and this is usually a welcome treat as a "dry mouth" feeling often occurs after anesthesia. Only ice chips will be allowed to prevent nausea until your GI tract opens up and you have a bowel movement. Once your intestinal tract is functioning normally you will be served sugar free, clear liquids and protein shakes. Early ambulation is recommended to help prevent respiratory complications and formation of blood clots. A physical therapist will visit you to help you ambulate for the first time and a respiratory therapist will also visit you to help you with breathing exercises to prevent pneumonia.

The bladder catheter is usually removed soon after surgery. Gastrointestinal activity usually recovers on the third or fourth post-operative day, and is indicated by mild intestinal cramping, the passage of gas, or a bowel movement. At this point, intravenous fluids are no longer necessary and you may go home. We request that you call our office on your first day home to schedule your first post-operative appointment. The office staff, nurse or surgeon can answer any questions or concerns you may have at this time. Please call, so we can help.

Your first meals after surgery will consist of liquid protein drinks carefully balanced to provide adequate vitamins and nutrients for proper surgical healing, while still permitting weight loss. It is unlikely that you will feel hungry; most patients must make an effort to drink the proper volume of liquid diet. Your surgery takes weeks to heal and it is desirable that you not stretch the pouch or opening with solid foods during this period of time.

Protein shakes are your sole source of nutrition for five weeks following surgery. It is required that you purchase at least a two-week supply of protein shakes at the time of your pre-operative physical. This is a dietary supplementation cost that is not covered by your insurance company. All surgical patients should plan to purchase a five-week supply, at an approximate cost of $52.00 per week.

When you stop the liquid protein diet, it is replaced with a soft food diet which does not require chewing for a week or two before beginning to eat regular meals. Good foods to eat during this period include scrambled egg whites, oatmeal with nonfat milk, cream of wheat with nonfat milk, fat free yogurt (Dannon makes a great yogurt), broth soups, tomato soup, split pea soup, baby food meats like chicken or turkey, pureed vegetables, nonfat cottage cheese, bananas, mashed potato (made with broth or nonfat milk), and unsweetened applesauce. The recommended daily intake of protein from your soft meals is 60-70 grams. Keep in mind the following tips when eating:

1. Eat slowly and chew well.
2. Do not drink fluids with meals and within one hour after each meal.
3. Sit when you eat.
4. Don't snack.
5. Avoid concentrated sugars and fats.
6. Don't overeat. Your new stomach can only hold a few ounces, so you will fill up very quickly.
7. Each meal should contain protein.

When not eating, drink plenty of water. (As noted above, do not drink during a meal or within one hour after.)

In addition to eating soft foods, you should take BI2 and iron daily (Ferotrinsic is best). Also take 1500 mg of calcium, and multivitamins with antioxidant, daily. Most vitamins are available in our office. We try to be less expensive than drugstores.

Dietary habits are hard to change, but the effects of surgery and the post-operative liquid diet make it easier to begin new habits. You will be scheduled to attend a nutrition class at the fourth post-operative week to help teach you the best nutrition following surgery.

The following dietary rules should be followed.

1. Eat 3 meals a day no more than 5 hours apart.
2. Get at least 60 grams of protein a day, while not exceeding 20 grams of fat per day.
3. Eat protein first. Then a vegetable. Then a fruit.
4. Do not drink fluids with your meal or within one hour after your meal.
5. Wait one hour after a meal, drink plenty of water, eight glasses per day, if possible. Start drinking water 1 hour after eating.
6. No snacking between meals.
7. Eat slowly and chew all foods well to avoid stomach distress.
8. Sit while eating
9. Take daily: Multivitamin, B12 and iron (Ferotrinsic or Trinsicon), and Calcium (1200-1500mg)

Note that milk (lactose) intolerance is not unusual after surgery and may be signaled by bloating, cramps, nausea and diarrhea. This may be corrected with lactase drops to aid digestion or by the avoidance of milk products.

Lean meats, vegetables, and fruits should become your dietary mainstays. Fats, concentrated sugars, and snacking are to be avoided. Meals are necessarily small and food should be well chewed.

Here are some additional food tips.

• Bake, broil, or BBQ meats - do not fry foods!!! Avoid foods that are greasy or fried.
• Read labels. Some foods are surprisingly high in sugar and fat; for example, baked beans, BBQ sauce, salad dressings, mayonnaise, butter and spaghetti sauce.
• Spice to taste. Salsa is a great taste to add to eggs, potatoes, salad, and chicken.
• Use nonfat dressings and spreads. Use Equal or Sweet & Low. Avoid sugar.

Lean Protein Sources Remember to eat enough protein. Our bodies need the amino acids and other building nutrients found in protein foods. Protein builds and repairs muscle, and is an energy fuel. Patients should attempt to get at least 60 grams of protein a day.

Exercising on a regular basis is a necessary lifestyle change after surgery. Exercising induces a sense of well being, increases overall energy, maximizes fatty tissue weight loss, and minimizes muscle breakdown. Our Physical Exercise page describes an exercise program which you can use.

Postoperative visits with Dr. Owens will be frequent during the first three months after surgery, and ongoing after that. It is very important that you commit to attending all of your scheduled office visits.

Information obtained through regular attendance at support group meetings will help you with post-operative adjustments. Patients who attend support group meetings on a regular basis seem to lose weight more successfully than those who do not. No better opportunity exists to discuss the surgical experience with other patients than at the support group meetings, and the multi-disciplinary educational format offers a variety of topics to guide you toward healthy lifestyle. Check our schedule. Support group meeting transcripts are also available.

Even years after surgery we would like to keep in contact with you on a regular, annual basis. We would hope to do this even if you have neither medical insurance nor the financial means to pay for an office visit – in short, we will see you for free, forever, if necessary. By maintaining contact we expect to be able to offer you the latest information in the treatment of obesity as well as counsel you in using your surgery to the greatest benefit. Information on how you are doing also helps us in the management of other patients.

We are always available to answer questions, address your concerns, and provide additional information. Please contact us at 888-527-5222.