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Tag Archives: top weight loss surgeon

What You Need to Know About the Gastric Sleeve

Posted on November 20, 2019 by

The gastric sleeve, or sleeve gastrectomy, is the new kid on the block so to speak. It’s not a new operation. We used to do the surgeries for other reasons not including weight loss. About 15 years ago a hormone was discovered called ghrelin. It’s a hormone made by part of the stomach that makes you feel hungry. We thought if we took that part of the stomach out, we’ve actually done two things. First we’ve made you a smaller stomach so you can’t eat very much. Secondly, when you take that part of the stomach out, ghrelin levels go way down. Since ghrelin makes you feel hungry, hunger levels go way down in its absence. If you think about it, one of the potential downfalls of every single weight loss plan in the world is hunger. If we can control hunger it’s a lot easier to lose weight and keep the weight off. Sleeve gastrectomy is the fastest growing option out there. It is the most common operation for weight loss right now. Last year about 2/3 of all operations done for weight loss were sleeve gastrectomy in the US. It’s close to 95% of what I do these days because it works so well and we see a quick recovery with very low risk. It keeps your anatomy normal.

In the sleeve gastrectomy, we remove the greater curve of the stomach (stretchy part). If you eat a large meal the stomach fills and stretches way out as you eat. That’s how it can hold so much. When we remove the stretchy part it leaves you with a tubular part (or sleeve). Sometimes when people hear the term sleeve gastrectomy they mistakenly think we’re placing something around the stomach. We’re not placing anything around the stomach. It’s referred to as a sleeve gastrectomy because we’re changing the shape. Like the sleeve on a shirt, it’s tubular shaped. We’re making it into a tubular shape. Nothing is bypassed so there is no malabsorption.  Your anatomy remains normal. Food is going to enter the stomach and empty into the small intestine the same way it did before. The size of the stomach is about the size and shape of a medium banana. The part of the stomach that’s removed is the part that makes the hormone ghrelin. Ghrelin is decreased so hunger decreases. This doesn’t mean that you won’t get hungry. There are still good reasons to get hungry. Your hunger is just much easier to control. This surgery is increasingly popular and the fastest growing option out there. It’s literally close to 95% of what I do nowadays.

The surgery doesn’t take that long. It generally lasts about 45 minutes. 95% of the surgeries we do are outpatient. It’s pretty rare that someone needs to spend the night. Full recovery isn’t as fast as the adjustable bands but it’s a lot faster than gastric bypass. Most people are comfortable driving about 3-4 days after surgery. Generally in 2 weeks people can do most things. In a month you can do anything you want. Recovery tends to be really quick.

What are the risks?  The first 30 days is the same as the other surgeries. It’s just slightly different numbers. In theory the death rate and leak rate should be the same as gastric bypass. But we’re not seeing that. What we’re seeing is about 1:1000 for deaths and less than half a percent for leaks. Wound infections, DVT’s, PE’s and dehydration have fewer risks than gastric bypass because the surgery doesn’t last as long. But it’s not impossible for any of those things. One of the things I really like about this operation is that we’ve gotten rid a lot of the long term risks. You’ve got normal anatomy so once you’re healed, you’re healed. The thing we have to keep in mind is stenosis.   Stenosis means narrowing. Anywhere along the tubular stomach could get scarring and become too narrow. If that happened you would go see a gastroenterologist. They can look in there and take care of it. It would be very rare to need another surgery after the sleeve. In theory stenosis should be about 1%. I’ve done over 1600 of these surgeries. I’ve only seen 1 case of stenosis.

We basically see the same weight loss as we did with the gastric bypass. Average weight loss is 70% of what you were overweight. If you are 100 pounds overweight, your average weight loss will be 70 pounds. If you are 200 pounds overweight, your average weight loss will be 140 pounds. That’s average. Some will lose more and some will lose less. That is very good weight loss. Long-term we see about 10-20% regain most of their weight. With any of these operations you can gain your weight back. Your stomach is a little bigger than with the gastric bypass. So why do we see a similar result?  It’s because ghrelin levels go down. In the other operations, that part of the stomach is still there. We can control the hunger somewhat with appetite suppressants. But they’re not necessarily ideal. With the sleeve gastrectomy ghrelin levels go down and hunger is easier to control.

Overall, for most people considering weight loss surgery, the sleeve gastrectomy is the better option. One of the reasons is we keep the anatomy normal. There’s a lower risk with the procedure, a fairly quick recovery and very good weight loss. We also get rid of any concerns about having anatomic abnormalities or nutritional abnormalities (malabsorption). There’s no mechanical device. Finally, you haven’t burned a bridge. That means if you don’t get out of it what you wanted out of it your anatomy is at least still normal. If your anatomy is still normal you could still have any of the other surgeries done. You could have a band placed on it or converted to a bypass. This is much more difficult after any other the other weight loss surgeries. We haven’t revised these things. We’ve seen really good results with them.

How does CFWLS compare to the national average? Obviously we’re doing this for weight loss to improve medical problems and improve your life.  We’re doing the same thing as everyone else in the world but we’re seeing better weight loss. We have a 15.8% better average weight loss at 2 years. We have good education and weight loss.  We give you a full year afterward. And with that better weight loss we also see better reduction in medical problems:  Diabetes 78.6% vs 62.3%, HTN 62.5% vs 46.9%, lipids 70.7% vs 45.3%, sleep apnea 69.4% vs 56.6%, and GERD 74.3% vs 16.6%.  Some people think weight loss surgery shouldn’t be done on patients with GERD. But we’ve seen it get much better, not worse. Again, it’s not the operation. It’s what you do with the operation. If you do the right things it can fix these medical problems.

Why is the education and support so important? We have Weight Management University for Weight Loss Surgery™.  It’s a 12-month post-op program. It includes all kinds of thing including the following:  pre-op and post-op text books, monthly support group, 12 Weight Management University courses, access to Members Only portal, fitness classes, personal training and more.

View the online surgical webinar and then schedule a call with Cat Williamson to go over any further questions you may have.  You’ll get a copy of my best-selling book, Less Weight…More Life!

What You Need to Know About a Gastric Bypass

Posted on November 11, 2019 by

gastric bypassLet’s start with a few facts about the gastric bypass. It’s been around the longest period of time. If you know anyone who’s had gastric bypass, they lose weight fairly quickly. People are often very concerned about the speed of the weight loss. Speed of weight loss doesn’t matter. It’s all tied to  body composition.. If you’re losing weight quickly and it’s all fatty tissue, than the faster the better. On the other hand, if you’re losing weight quickly but it’s lean body mass, that’s not so great. You’re going to get more and more tired and weaker and weaker. You’re slowing your metabolism down which will make it much harder to lose weight and easier to gain weight. No matter what, if you have gastric bypass, you’re going to lose weight fast. We refer to gastric bypass as being restrictive and malabsorptive. Restrictive means we’re making your stomach smaller. If we make you a smaller stomach, you can’t eat very much. You’re going to lose weight. The concept is simple. We make your stomach about the size of an egg. People often wonder if their stomach is going to stretch out. The answer is yes. We know it’s going to stretch out and we want it too. We don’t want your stomach the size of an egg. What we’re shooting for long term with all these operations is meal size, that being a small plate. That’s where we want to go. But, we’re working with stretchy material just like your skin is stretchy. If we make your stomach meal size small plate it would stretch way out. A normal size stomach can hold about 2-3 liters. We have to make your stomach tiny to begin with knowing that it’s going to stretch out.

The second part is the malabsorptive part. That’s where the bypass comes in. We’re going to bypass the part of the stomach called the excluded portion.  We go to the very beginning of the small intestine and divide it and pull it up and hook it into that tiny stomach so that we bypass the rest of the stomach. Whenever we bypass any portion of the intestinal tract, you’re not going to absorb things perfectly. You don’t absorb all the calories that you eat. But, you also don’t absorb some of the vitamins, minerals, and micronutrients quite as well either, which can be problematic. The surgery itself doesn’t take that long. It’s about 1 hour and 40 minutes. It can be done laparoscopically now. What we do is use long instruments and cameras and make little incisions on you. Recovery is pretty quick. Hospital stay is pretty quick. Recovery can take a while because this is a big operation. Whenever we start rearranging your anatomy, that’s a big operation. Recovery can take a good 4-6 weeks. Sometimes it can take up to 8 weeks to feel back to normal.

There are risks with every operation in the world. This is a bigger operation so the risks are bigger. When I talk about risk, I divide it into two time-frames. This is not something I made up. This is a medical standard which is basically right around surgery (peri-operative). By medical definition this means the first 30 days. The second time-frame is long-term which, by medical definition, means longer than 30 days. What’s the worst thing that could happen in that first 30 days? Could you die?  The answer is yes it could happen. The risk of death is real when we start dividing your intestinal tract. It wouldn’t matter if I was talking about taking your appendix out or taking your colon out. When you look at national statistics, the risk is about 1: 200.  What we see is about 1:500.  Bottom line is that it may be rare, but not impossible. The things we worry about the most are infections. Some things are easy to treat such as urinary tract infections. Other infections aren’t so easy to treat such as pneumonia. They occur about 2% of the time after any surgery where you have to go to sleep for. You have to go to sleep for all these surgeries. It’s somewhat related to how long did the surgery take? The biggest fear as far as infections go is a leak on the inside. What if the pieces we took apart during surgery and put back together leaked?  There are literally trillions of bacteria that live in the intestinal tract. When we start dividing the intestinal tract some of those bacteria could potentially get out. If they set up a rip-roaring infection, potentially you’d have to have another surgery to fix that. Wound infection means on the skin. They’re more of a nuisance than dangerous. They have to be treated with antibiotics. DVT is a deep venous thrombosis. PE is a pulmonary embolism. These are blood clots. You can get a blood clot without having surgery. You can get it from being dehydrated. One of the most common ways to get a blood clot is traveling on a long plane ride. You can also get it from having a general anesthetic. Again, it’s somewhat related to how long the surgery takes. The longer the surgery takes, the higher the risk is. We do all kinds of things to prevent that during surgery. The blood clot risk is 1-2%. If you got a blood clot you have to be on a blood thinner to dissolve that blood clot. The first thing that happens to that tiny stomach is the tissue swells up. Just like if you sprained your ankle. Your ankle would swell up. Stuff just trickles through the stomach initially. If you’re not able to stay hydrated you have to come back to the hospital to get IV fluids. You have to rest for a few days.

Long-term means 30 days until forever. The most common long term physical problem is peptic ulcer. You can get an ulcer without having gastric bypass. But when you have the anatomy of gastric bypass, the risk of getting an ulcer goes up. The people who tend to get ulcers are smokers and people who take anti-inflammatory meds. Ulcers just need to be treated. Something that could require another surgery is a bowel obstruction. Adhesion means scar tissue. If you’ve had any surgery on your abdomen you’re going to have scar tissue, not only on the outside, but also on the inside. That scar tissue can potentially kink the intestine. Just like a kind in a hose, nothing is going through there. You then have to go back to the operating room. Hernias are another risk. You can get them without having surgery. Any place we make an incision there is potentially a weaker spot. Stenosis means narrowing. What we’re talking about is right where we take the stomach and hook the small intestine to it. A scar could potentially form and cause a narrowing. If this happened, stuff wouldn’t go through very well. We would send you to a gastroenterologist. They would take a look down there and can stretch it out. Typically it doesn’t need any surgery but it does need to be evaluated and treated. Vitamin and nutrient malnutrition is relatively common. You won’t be able to absorb things perfectly. You’re going to have to take some things long term in addition to taking a battery of tests every 6-12 months to make sure those things are staying where they should. That’s a forever thing. That doesn’t go away.

We see great results with gastric bypass. You’ll lose about 70% of what you were overweight.  If you were 100 pounds overweight you’ll lose 70 pounds. If you’re 200 pounds overweight, you’ll lose about 140 pounds. That’s the average. Some people lose more, some people lose less. About 40% of people with gastric bypass regain most of their weight back. Overall the long term anatomical and nutritional problems, with relatively poor weight maintenance, make it difficult for me to recommend gastric bypass for most people.

What should you do? You need to decide what’s best for your unique situation. There is no right or wrong here.  What I encourage you to do is give us a call and set up a 1:1 consultation to discuss the options.  Let’s you and I sit down and go over your situation. Everybody’s situation is different.  Give us a call at (757) 873-1880 or email us at success@cfwls.com.

I have some final thoughts for you. Weight loss is the most important step you can make to improve your health!! There are so many medical problems that are directly related to weight loss. If we can control weight, we can control medical problems. If we can control all these medical problems it gives you the best chance of living a long, healthy life.

Watch the online seminar and give us a call (757-873-1880) and set up your 1:1 appointment. If weight is contributing to your health problems let us help you.  I hope to see you very shortly here in the office.

What Are the Options for Weight Loss Surgery?

Posted on November 04, 2019 by

What are the options for weight loss surgery?  The most common options done worldwide are: gastric bypass, Laparoscopic Adjustable Gastric Banding (LAGB), and sleeve gastrectomy. I’m going to give you the basics on all of these. You can also watch our complete online webinar on Weight Loss Surgery Options.

Gastric bypass has been around for a long period of time. The first gastric bypass was done in 1955. It’s been around for over 60 years. It’s a well-studied operation. We know what happens to people who have gastric bypass. We know the problems that arise and what to do about the problems. It’s a very well-studied operation.

 

Adjustable gastric bands have been around in the US since 2001. Worldwide they’ve been around since the early 1990’s. Why do you care how long an operation has been around? We talk about long-term problems and long term results. By medical definition, long-term means 10 years long. That wouldn’t matter if I was talking about brain surgery, heart surgery, or knee surgery. It doesn’t matter. With weight loss we’re going to be talking about things that literally can last 20, 30 or 40 years. If you’re fairly young it could be 50 or 60 years. Looking at the long-term issues is very important and how it impacts your health for your lifetime.

The sleeve gastrectomy is the new kid on the block. It’s not a new operation. We used to do the surgeries for other reasons not including weight loss. About 15 years ago a hormone was discovered called ghrelin. It’s a hormone made by part of the stomach that makes you feel hungry. We thought if we took that part of the stomach out, we’ve actually done two things. First we’ve made you a smaller stomach so you can’t eat very much. Secondly, when you take that part of the stomach out, ghrelin levels go way down. Since ghrelin makes you feel hungry, hunger levels go way down in its absence. If you think about it, one of the potential downfalls of every single weight loss plan in the world is hunger. If we can control hunger it’s a lot easier to lose weight and keep the weight off. Sleeve gastrectomy is the fastest growing option out there. It is the most common operation for weight loss right now. Last year about 2/3 of all operations done for weight loss were the sleeve gastrectomy in the US. It’s over 95% of what I do these days because it works so well and we see a quick recovery with very low risk. It keeps your anatomy normal.

How does CFWLS compare to the national average? Obviously we’re doing this for weight loss to improve medical problems and improve your life.  We’re doing the same thing as everyone else in the world but we’re seeing better weight loss. We have a 15.8% better average weight loss at 2 years. We have good education and weight loss.  We give you a full year afterward. And with that better weight loss we also see better reduction in medical problems:  Diabetes 78.6% vs 62.3%, HTN 62.5% vs 46.9%, lipids 70.7% vs 45.3%, sleep apnea 69.4% vs 56.6%, and GERD 74.3% vs 16.6%.  Some people think weight loss surgery shouldn’t be done on patients with GERD. But we’ve seen it get much better, not worse. Again, it’s not the operation. It’s what you do with the operation. If you do the right things it can fix these medical problems.

Why is the education and support so important? We have Weight Management University for Weight Loss Surgery™.  It’s a 12-month post-op program. It includes all kinds of thing including the following:  preop and postop text books, monthly support group, 12 WMU4WLS courses, access to a private membership site via CFWLS.com, “Losing Weight USA” (weekly live webinars with access to Dr. Clark), and a private Facebook support group.

What should you do? You need to decide what’s best for your unique situation. There is no right or wrong here.  What I encourage you to do is give us a call and set up a 1:1 consultation to discuss the options.  Let’s you and I sit down and go over your situation. Everybody’s situation is different.  Give us a call at (757) 873-1880 or email us at success@cfwls.com.

I have some final thoughts for you. Weight loss is the most important step you can make to improve your health!! There are so many medical problems that are directly related to weight loss. If we can control weight, we can control medical problems. If we can control all these medical problems it gives you the best chance of living a long, healthy life.

Watch the online seminar and give us a call (757-873-1880) and set up your 1:1 appointment. If weight is contributing to your health problems let us help you.  I hope to see you very shortly here in the office.

Phentermine – Could it Help You Lose Weight?

Posted on February 21, 2019 by

I’d like to talk to you about Phentermine. Phentermine is an appetite suppressant. It’s been around for a long time. Appetite suppressants are really carefully regulated by the FDA, so there are some hoops to jump through for those people utilizing them, but it’s very doable.  Potentially it can be helpful from a weight perspective, but also from a hunger/craving perspective.  It works very well for cravings.

A lot of appetite suppressants have come and gone.  There have been a number of them over the last 20 years or so. They got approved by the FDA, were around for a few years, and then gone.  One of the reasons is because the drugs were causing other problems.  There are a couple of newer ones in the last few years.  None of them really work any better than phentermine.  The new ones can be really expensive.  Phentermine has been around for about 60 years now. It can be very helpful.  And it’s very safe. We’ll talk about the risks, which are something we do have to keep an eye on. It can help with any medical weight loss plan. You have to be doing the right things. Phentermine will not make up for a bad eating and exercise plan.  It’s very closely monitored by the FDA. Part of that is because back in the 90’s they had phen-phen. It was a combination medication of phentermine and also phenfluramine. They put two medications together and it worked wonderfully. Unfortunately, the phenfluramine ended up causing heart problems. It was taken off the market.  Because phentermine was associated with it, it’s very closely regulated. Overall, it’s a very safe medication.  It has stood the test of time.  It can actually be used long-term but it needs to be monitored.  There can be some potential side effects. You do have to watch blood pressure. It’s rare but not impossible.

The clinical indications for using phentermine are a BMI over 30 or BMI over 28 with medicals problems.  It’s similar to having weight loss surgery.  Generally what they’re talking about mostly are sleep apnea and diabetes.  Chemically, phentermine looks like amphetamine. Because amphetamine can cause all kinds of problems, and can be addicting, it was thought that phentermine was in the same class as amphetamine, and therefore just as dangerous. It was more regulated by the FDA. A lot of those theoretical problems really never panned out.

I’ve been utilizing phentermine in the patient population for about 15 years now. Just like surgery, it’s a good tool. It’s just another tool in the toolbox. There’s nothing magic about it. It can be a good additive tool along with the surgery. All it really does is takes the edge off hunger.  It really takes the edge off cravings. It won’t prevent you from eating. It can also help with carbohydrate withdrawal. Most of our patients are very sensitive to carbohydrates. If they fall off the wagon and start eating too many carbs and then try to cut them back again they’ll go through withdrawal. Carbohydrates are like a drug. The phentermine can help with the carbohydrate withdrawal symptoms.  We have found that phentermine can give you 8-12 pounds of extra weight loss. It’s the same with our surgical patients. If they feel like they’ve stalled out, the phentermine can give them some more weight loss.

If you are keeping your carbohydrates down while utilizing phentermine, you can lose a tremendous amount of weight. The weight loss from phentermine will vary from person-to-person depending on age, genetics, sex, and other health problems.

There are potential side effects. You absolutely need to have an EKG done prior to starting phentermine. You want to document that your heart is fine. It’s not going to cause a heart problem. But if you’ve already got a heart problem, it can worsen the problem.  Almost everyone starting phentermine gets a dry mouth. Make sure you’re drinking a lot of water. It can make you feel slightly jittery. It’s kind of like having a few cups of coffee. They typically fade away in about 7-14 days. It’s a side effect. It’s not how the medication works.  I tell people that if it makes you jittery and it bothers you, then quit taking it. The medication will be out of your system within 12 hours. One of the uncommon side effects of phentermine is insomnia. If you take it too late in the day you might have a hard time going to sleep. But that typically over time goes away. Other uncommon side effects are tremors, dizziness, and high blood pressure. It’s really rare for blood pressure to go up, but that’s one of the reasons why we have to monitor it. Theoretical potential problems (which are related back to the phen-phen) are heart problems and addiction/withdrawal. You can get used to the medication, but that’s not necessarily addiction. You can build up a tolerance to the medication where it stops working as well. But you can’t go through withdrawals.  You don’t have to wean off the medication. You can just stop taking it.

There are some real reasons to avoid phentermine. If you have an allergic reaction to it, obviously you shouldn’t take it. If you have a history of heart problems (no matter what it is), I would discourage you from taking it. You shouldn’t take it if you have high blood pressure that’s poorly controlled.  You can take it if your blood pressure is well controlled. Theoretically you should avoid phentermine if you’re taking antidepressants. Because of the chemical make up of phentermine, there was a thought that there would be a cross over, and some antidepressants would make this exacerbate heart problems. It would make antidepressants not work as well or the antidepressant would make it exacerbate heart problems. But it’s absolutely fine to take it with antidepressants. There is actually some antidepressant affect with phentermine.

Legally I have to have a discussion about the” art” of taking phentermine to a patient if they’re going to be taking it. I have to talk about the potential side effects as well as the” art” of using the medication. It tends to last for 10-12 hours. So, since most people don’t wake up starving, don’t take it first thing in the morning.  There’s no sense in taking it then.  Take it mid to late morning.  Play with the timing. If you find you’re having a hard time getting to sleep, then take it earlier. If you have a lot of hunger and cravings right before bed then you need to take it later.  It’s one of those medications that work if you take it.  It doesn’t work if you don’t take it. You don’t have to build up to it or wean off of it.  Therefore you can use it intermittently. It’s fine to use it certain days of the week. We typically write it as a daily dose but there’s no reason you need to take it every day.  Take it as you need it. It can be used long term. It originally was written in the PDR to be used for only 8-10 weeks. They originally said that because the original studies were only done for 8-10 weeks.  It was then approved by the FDA but never approved for long term use.  It has been used for long term use for many years the PDR has never been changed. So most physicians only prescribe it for a few months. It’s kind of silly to think we can fix something in a couple months. I’ve had people on phentermine for 10-12 years. It just has to be monitored. We’re making sure there aren’t any blood pressure problems, ensuring it’s still helping, and make sure there are not side effects bothering you. If it’s not helping, you shouldn’t be taking it anymore. There is evidence that if a person is taking it long term that if they stop it every few months for 7-10 days, and then it tends to work better.

There are some cautions about phentermine. Sometimes it may work so well that you don’t eat. We’ve talked about intermittent fasting and how that works.  The problem with skipping meals and intermittent fasting are two different things. If you’re just skipping means, then it was unintentional. Fasting is intentional. You don’t want to be skipping meals all the time. If you’re doing intermittent fasting for a day or two, you can take phentermine. It’s another tool in the tool box. Starvation has never been a good weight loss plan. Phentermine won’t stop you from eating. If you’re eating for many reasons (not hunger), then it’s not going to help you. You need to take a good look at the behavior side of things.  Why are you actually eating? Work on solving those problems. Without a good nutritional and exercise plan, any weight loss with the phentermine will likely be temporary.

In summary, phentermine has been around for a long time. It has stood the test of time. It can be very safe. It can be very helpful, especially for cravings. But it still needs to be used with a good diet and exercise plan. It doesn’t work to fix a poor life plan. You need to have a normal EKG. We have to monitor your blood pressure as well as side effects.

Come in and get your body composition done.  Make sure your losing body fat and not lean body mass.  Remember it’s your life! Make it a healthy one!  Take care everyone.

What If I Can’t Find a Qualified Bariatric Surgeon or Comprehensive Program in My Area?

Posted on July 16, 2018 by

2017-03-29_16.59.40_smallerIf you cannot find a qualified bariatric surgeon or comprehensive follow up program in your area, you will have to either compromise what you want/ need or continue your search until you find the surgeon/program that will meet and/or exceed your expectations.

A few experienced surgeons offer a travel program for surgery.  At the Center for Weight Loss Success, we offer such a program for appropriate surgical candidates.  Not only does the program include surgery with arguably the most experience bariatric surgeon in the United States who has performed over 5,000 weight loss procedures, but it also includes our comprehensive Weight Management University for Weight Loss Surgery™ program.  In addition, it is one of the most affordable options available in the United States.  You can learn more about it at www.cfwls.com

The bottom line is that you have to be comfortable with your choice.  We are fortunate to have many excellent bariatric surgeons in the United States.  Your long-term success is the most important thing under consideration here.  I hope this book has helped to inspire you, answer your questions and better prepare you for an amazing journey.  Only you know if this journey is something that is right for you.  If we can be of further assistance in any way, please let us know at success@cfwls.com.  If you desire additional information and would like to view helpful videos that address each of these questions, please visit our main website at www.cfwls.com or at www.myweightlosssurgerysuccess.com.

CFWLS-Rhonda-09-

Rhonda’s Opinion:  Travel to the surgeon/program of your choice – it’s all worth it!