Our
Frequently Asked Questions section refers to United States-based
generally standard and accepted practices. As always, please check
with your healthcare provider to determine their practices, guidelines
and what they recommend for you.
Preparation for Surgery
Insurance Issues
Surgery
The Hospital Stay
Life After Surgery
Diet
General
What
are the routine tests before surgery?
Certain basic
tests are done prior to surgery: a Complete Blood Count (CBC),
Urinalysis, and a Chemistry Panel, which gives a readout of about
20 blood chemistry values. Often a Glucose Tolerance Test is done
to evaluate for diabetes, which is very common in overweight persons.
All patients but the very young get a chest X-ray and an electrocardiogram.
Women may have a vaginal ultrasound to look for abnormalities
of the ovaries or uterus. Many surgeons ask for a gallbladder
ultrasound to look for gallstones. Other tests, such as pulmonary
function testing, echocardiogram, sleep studies, GI evaluation,
cardiology evaluation, or psychiatric evaluation, may be requested
when indicated.
What
is the purpose of all these tests?
An accurate
assessment of your health is needed before surgery. The best way
to avoid complications is to never have them in the first place.
It is important to know if your thyroid function is adequate since
hypothyroidism can lead to sudden death post-operatively. If you
are diabetic, special steps must be taken to control your blood
sugar. Because surgery increases cardiac stress, your heart will
be thoroughly evaluated. These tests will determine if you have
liver malfunction, breathing difficulties, excess fluid in the
tissues, abnormalities of the salts or minerals in body fluids,
or abnormal blood fat levels.
Why
do I have to have a GI Evaluation?
Patients
who have significant gastrointestinal symptoms such as upper abdominal
pain, heartburn, belching sour fluid, etc., may have underlying
problems such as a hiatal hernia, gastroesophageal reflux or peptic
ulcer. For example, many patients have symptoms of reflux. Up
to 15% of these patients may show early changes in the lining
of the esophagus, which could predispose them to cancer of the
esophagus. It is important to identify these changes so a suitable
surveillance or treatment program can be planned.
Why
do I have to have a Sleep Study?
The sleep
study detects a tendency for abnormal stopping of breathing, usually
associated with airway blockage when the muscles relax during
sleep. This condition is associated with a high mortality rate.
After surgery, you will be sedated and will receive narcotics
for pain, which further depress normal breathing and reflexes.
Airway blockage becomes more dangerous at this time. It is important
to have a clear picture of what to expect and how to handle it.
Why
do I have to have a Psychiatric Evaluation?
The most
common reason a psychiatric evaluation is ordered is that your
insurance company may require it. Most psychiatrists will evaluate
your understanding and knowledge of the risks and complications
associated with weight loss surgery and your ability to follow
the basic recovery plan.
What
impact do my medical problems have on the decision for surgery,
and how do the medical problems affect risk?
Medical problems,
such as serious heart or lung problems, can increase the risk
of any surgery. On the other hand, if they are problems that are
related to the patient's weight, they also increase the need for
surgery. Severe medical problems may not dissuade the surgeon
from recommending gastric bypass surgery if it is otherwise appropriate,
but those conditions will make a patient's risk higher than average.
If
I want to undergo a gastric bypass, how long do I have to wait?
New evaluation
appointments are usually booked 4-8 months in advance. Once a
patient is seen, if the surgeon and patient agree it is appropriate,
the operation can usually be scheduled within 8 weeks. Why so
long? There is more need for weight loss surgery than there are
qualified bariatric surgeons.
What
can I do before the appointment to speed up the process of getting
ready for surgery?
- Select
a primary care physician if you don't already have one, and
establish a relationship with him or her. Work with your physician
to ensure that your routine health maintenance testing is current.
For example, women may have a pap smear, and if over 40 years
of age, a breast exam. And for men, this may include a prostate
specific antigen test (PSA).
- Make a
list of all the diets you have tried (a diet history) and bring
it to your doctor.
- Bring any
pertinent medical data to your appointment with the surgeon
- this would include reports of special tests (echocardiogram,
sleep study, etc.) or hospital discharge summary if you have
been in the hospital.
- Bring a
list of your medications with dose and schedule.
- Stop smoking.
Surgical patients who use tobacco products are at a higher surgical
risk.
Why
does it take so long to get insurance approval?
After your
telephone interview consultation is completed, it usually takes
your doctor 1-2 days to send a letter to your insurance carrier
to start the approval process. The time it takes to get an answer
can vary from about 3-4 weeks or longer if you are not persistent
in your follow-up. Most treatment centers have insurance analysts
who will follow up regularly on approval requests. It may be helpful
for you to call the claims service of your insurance company about
a week after your letter is submitted and ask about the status
of your request.
How
can they deny insurance payment for a life-threatening disease?
Payment may
be denied because there may be a specific exclusion in your policy
for obesity surgery or "treatment of obesity." Such an exclusion
can often be appealed when the surgical treatment is recommended
by your surgeon or referring physician as the best therapy to
relieve life-threatening obesity-related health conditions, which
usually are covered.
Insurance
payment 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 - such as dieting, exercise,
behavior modification, and some medications - are considered to
be available. Medical necessity denials usually hinge on the insurance
company's request for some form of documentation, such as 1 to
5 years of physician-supervised dieting or a psychiatric evaluation,
illustrating that you have tried unsuccessfully to lose weight
by other methods.
What
can I do to help the process?
Gather all
the information (diet records, medical records, medical tests)
your insurance company may require. This reduces the likelihood
of a denial for failure to provide "necessary" information. Letters
from your personal physician and consultants attesting to the
"medical necessity" of treatment are particularly valuable. When
several physicians report the same findings, it may confirm a
medical necessity for surgery.
When the
letter is submitted, call your carrier regularly to ask about
the status of your request. Your employer or human relations/personnel
office may also be able to help you work through unreasonable
delays.
Does
Laparoscopic Surgery decrease the risk?
No. Laparoscopic
operations carry the same risk as the procedure performed as an
open operation. The benefits of laparoscopy are typically less
discomfort, shorter hospital stay, earlier return to work and
reduced scarring.
Will
I have a lot of pain?
Every attempt
is made to control pain after surgery to make it possible for
you to move about quickly and become active. This helps avoid
problems and speeds recovery. Often several drugs are used together
to help manage your post-surgery pain. While you are still in
the hospital, a Patient Controlled Analgesia (PCA), which allows
you to give yourself a dose of pain medicine on demand, may be
used by your physician. Various methods of pain control, depending
on your type of surgical procedure, are available. Ask your surgeon
about other pain management options.
How
long do I have to stay in the hospital?
As long as
it takes to be self-sufficient. Although it can vary, the hospital
stay (including the day of surgery) can be 1-2 days for a laparoscopic
band, 2-3 days for a laparoscopic gastric bypass, and 5-7 days
for an open gastric bypass.
Will
the doctor leave a drain in after surgery?
Most patients
will have a small tube to allow drainage of any accumulated fluids
from the abdomen. This is a safety measure, and it is usually
removed a few days after the surgery. Generally, it produces no
more than minor discomfort.
If
I have surgery, what can I expect when I wake up in the recovery
room?
Some doctors
will provide a Patient Controlled Analgesia (PCA) or a self-administered
pain management system, to help control pain. Others prefer to
use an infusion pump that provides a local anesthetic in the surgical
site to control pain without the side effects of narcotics. As
with any major surgery, you are in danger of death from a blood
clot or other surgical side effects. Statistically, the risk of
death during these procedures is less than 1 percent. Your doctors
will have assessed you for risks and prepared accordingly.
All abdominal
operations carry the risks of bleeding, infection in the incision,
thrombophlebitis of legs (blood clots), lung problems (pneumonia,
pulmonary embolisms), strokes or heart attacks, anesthetic complications,
and blockage or obstruction of the intestine. These risks are
greater in morbidly obese patients.
How
soon will I be able to walk?
Almost immediately
after surgery doctors will require you to get up and move about.
Patients are asked to walk or stand at the bedside on the night
of surgery, take several walks the next day and thereafter. On
leaving the hospital, you may be able to care for all your personal
needs, but will need help with shopping, lifting and with transportation.
How
soon can I drive?
For your
own safety, you should not drive until you have stopped taking
narcotic medications and can move quickly and alertly to stop
your car, especially in an emergency. Usually this takes 7-14
days after surgery.
What
is done to minimize the risk of deep vein thrombosis/pulmonary
embolism or DVT/PE?
Because a
DVT originates on the operating table, therapy begins before a
patient goes to the operating room. Generally, patients are treated
with sequential leg compression stockings and given a blood thinner
prior to surgery. Both of these therapies continue throughout
your hospitalization. The third major preventive measure involves
getting the patient moving and out of bed as soon as possible
after the operation to restore normal blood flow in the legs.
What
should I bring with me to the hospital?
Basic toiletries
(comb, toothbrush, etc.) and clothing may be provided by the hospital,
but most people prefer to bring their own. Choose clothes for
your stay that are easy to put on and take off. Because of your
incision, your clothes may become stained by blood or other body
fluids. Other ideas:
- reading
and writing materials
- crossword
and other puzzles
- personal
toiletries
- bathrobe
What
do I need to do to be successful after surgery?
The basic
rules are simple and easy to follow:
- Immediately
after surgery, your doctor will provide you with special dietary
guidelines. You will need to follow these guidelines closely.
Many surgeons begin patients with liquid diets, moving to semi-solid
foods and later, sometimes weeks or months later, solid foods
can be tolerated without risk to the surgical procedure performed.
Allowing time for proper healing of your new stomach pouch is
necessary and important.
- When able
to eat solids, eat 2-3 meals per day, no more. Protein in the
form of lean meats (chicken, turkey, fish) and other low-fat
sources should be eaten first. These should comprise at least
half the volume of the meal eaten. Foods should be cooked without
fat and seasoned to taste. Avoid sauces, gravies, butter, margarine,
mayonnaise and junk foods.
- Never
eat between meals. Do not drink flavored beverages, even diet
soda, between meals.
- Drink 2-3
quarts or more of water each day. Water must be consumed slowly,
1-2 mouthfuls at a time, due to the restrictive effect of the
operation.
- Exercise
aerobically every day for at least 20 minutes (one-mile brisk
walk, bike riding, stair climbing, etc.). Weight/resistance
exercise can be added 3-4 days per week, as instructed by your
doctor.
What's
so important about exercise?
When you
have a weight loss surgery procedure, 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 tend to
burn any unused muscle before it begins to burn the fat it has
saved up. If you do not exercise daily, your body will consume
your unused muscle, and you will lose muscle mass and strength.
Daily aerobic exercise for 20 minutes will communicate to your
body that you want to use your muscles and force it to burn the
fat instead.
What
is the right amount of exercise after weight loss surgery?
Many patients
are hesitant about exercising after surgery, but exercise is an
essential component of success after surgery. Exercise actually
begins on the afternoon of surgery - the patient must be out of
bed and walking. The goal is to walk further on the next day,
and progressively further every day after that, including the
first few weeks at home. Patients are often released from medical
restrictions and encouraged to begin exercising about two weeks
after surgery, limited only by the level of wound discomfort.
The type of exercise is dictated by the patient's overall condition.
Some patients who have severe knee problems can't walk well, but
may be able to swim or bicycle. Many patients begin with low stress
forms of exercise and are encouraged to progress to more vigorous
activity when they are able.
Can
I get pregnant after weight loss surgery?
It is strongly
recommended that women wait at least one year after the surgery
before a pregnancy. Approximately one year post-operatively, your
body will be fairly stable (from a weight and nutrition standpoint)
and you should be able to carry a normally nourished fetus. You
should consult your surgeon as you plan for pregnancy.
What
if I have had a previous weight loss surgical procedure and I'm
now having problems?
Contact your
original surgeon - he or she is most familiar with your medical
history and can make recommendations based on knowledge of your
surgical procedure and body.
What
happens to the lower part of the stomach that is bypassed?
In some surgical
procedures, the stomach is left in place with intact blood supply.
In some cases it may shrink a bit and its lining (the mucosa)
may atrophy, but for the most part it remains unchanged. The lower
stomach still contributes to the function of the intestines even
though it does not receive or process food - it makes intrinsic
factor, necessary to absorb Vitamin B12 and contributes to hormone
balance and motility of the intestines in ways that are not entirely
known. In the BPD procedures, some portion of the stomach is completely
removed.
How
big will my stomach pouch really be in the long run?
This can
vary by surgical procedure and surgeon. In the Roux-en-Y gastric
bypass, the stomach pouch is created at one ounce or less in size
(15-20cc). In the first few months it is rather stiff due to natural
surgical inflammation. About 6-12 months after surgery, the stomach
pouch can expand and will become more expandable as swelling subsides.
Many patients end up with a meal capacity of 3-7 ounces.
What
will the staples do inside my abdomen? Is it okay in the future
to have an MRI test? Will I set off metal detectors in airports?
The staples
used on the stomach and the intestines are very tiny in comparison
to the staples you will have in your skin or staples you use in
the office. Each staple is a tiny piece of stainless steel or
titanium so small it is hard to see other than as a tiny bright
spot. Because the metals used (titanium or stainless steel) are
inert in the body, most people are not allergic to staples and
they usually do not cause any problems in the long run. The staple
materials are also non-magnetic, which means that they will not
be affected by MRI. The staples will not set off airport metal
detectors.
What
if I'm not hungry after surgery?
It's normal
not to have an appetite for the first month or two after weight
loss surgery. If you are able to consume liquids reasonably well,
there is a level of confidence that your appetite will increase
with time.
Is
there any difficulty in taking medications?
Most pills
or capsules are small enough to pass through the new stomach pouch.
Initially, your doctor may suggest that medications be taken in
liquid form or crushed.
Will
I be able to take oral contraception after surgery?
Most patients
have no difficulty in swallowing these pills.
Is
sexual activity restricted?
Patients
can return to normal sexual intimacy when wound healing and discomfort
permit. Many patients experience a drop in desire for about 6
weeks.
Is
there a difference in the outcome of surgery between men and women?
Both men
and women generally respond well to this surgery. In general,
men lose weight slightly faster than women do.
Will
I be asked to stop smoking?
Patients
are encouraged to stop smoking at least one month before surgery.
If
I continue to smoke, what happens?
Smoking increases
the risk of lung problems after surgery, can reduce the rate of
healing, increases the rates of infection, and interferes with
blood supply to the healing tissues.
How
can I know that I won't just keep losing weight until I waste
away to nothing?
Patients
may begin to wonder about this early after the surgery when they
are losing 20-40 pounds per month, or maybe when they've lost
more than 100 pounds and they're still losing weight. Two things
happen to allow weight to stabilize. First, a patient's ongoing
metabolic needs (calories burned) decrease as the body sheds excess
pounds. Second, there is a natural progressive increase in calorie
and nutrient intake over the months following weight loss surgery.
The stomach pouch and attached small intestine learn to work together
better, and there is some expansion in pouch size over a period
of months. The bottom line is that, in the absence of a surgical
complication, patients are very unlikely to lose weight to the
point of malnutrition.
What
can I do to prevent lots of excess hanging skin?
Many people
heavy enough to meet the surgical criteria for weight loss surgery
have stretched their skin beyond the point from which it can "snap
back." Some patients will choose to have plastic surgery to remove
loose or excess skin after they have lost their excess weight.
Insurance generally does not pay for this type of surgery (often
seen as elective surgery). However, some do pay for certain types
of surgery to remove excess skin when complications arise from
these excess skin folds. Ask your surgeon about your need for
a skin removal procedure.
Will
exercise help with excess hanging skin?
Exercise
is good in so many other ways that a regular exercise program
is recommended. Unfortunately, most patients may still be left
with large flaps of loose skin.
Will
I be miserably hungry after weight loss surgery since I'm not
eating much?
Most patients
say no. In fact, for the first 4-6 weeks patients have almost
no appetite. Over the next several months the appetite returns,
but it tends not to be a ravenous "eat everything in the cupboard"
type of hunger.
What
if I am really hungry?
This is usually
caused by the types of food you may be consuming, especially starches
(rice, pasta, potatoes). Be absolutely sure not to drink liquid
with food since liquid washes food out of the pouch.
Will
I have to change my medications?
Your doctor
will determine whether medications for blood pressure, diabetes,
etc., can be stopped when the conditions for which they are taken
improve or resolve after weight loss surgery. For meds that need
to be continued, the vast majority can be swallowed, absorbed
and work the same as before weight loss surgery. Usually no change
in dose is required. Two classes of medications that should be
used only in consultation with your surgeon are diuretics (fluid
pills) and NSAIDs (most over-the-counter pain medicines). NSAIDs
(ibuprofen, naproxen, etc.) may create ulcers in the small pouch
or the attached bowel. Most diuretic medicines make the kidneys
lose potassium. With the dramatically reduced intake experienced
by most weight loss surgery patients, they are not able to take
in enough potassium from food to compensate. When potassium levels
get too low, it can lead to fatal heart problems.
What
is a hernia and what is the probability of an abdominal hernia
after surgery?
A hernia
is a weakness in the muscle wall through which an organ (usually
small bowel) can advance. Approximately 20% of patients develop
a hernia. Most of these patients require a repair of the herniated
tissue. The use of a reinforcing mesh to support the repair is
common.
Is
blood transfusion required?
Infrequently:
If needed, it is usually given after surgery to promote healing.
What
is phlebitis and is it preventable?
Undesired
blood clotting in veins, especially of the calf and pelvis. It
is not completely preventable, but preventive measures will be
taken, including:
- Early ambulation
- Special
stockings
- Blood thinners
- Pulsatile
boots
Will
I lose hair after surgery? How can I prevent it?
Many patients
experience some hair loss or thinning after surgery. This usually
occurs between the fourth and the eighth month after surgery.
Consistent intake of protein at mealtime is the most important
prevention method. Also recommended are a daily zinc supplement
and a good daily volume of fluid intake.
Does
hair growth recover?
Most patients
experience natural hair regrowth after the initial period of loss.
What
are adhesions and do they form after this surgery?
Adhesions
are scar tissues formed inside the abdomen after surgery or injury.
Adhesions can form with any surgery in the abdomen. For most patients,
these are not extensive enough to cause problems.
What
is the "Candida Syndrome?"
Some patients
have a type of yeast present on the surface of their skin, intestine
or vagina at the time of surgery. This leads to overgrowth in
certain circumstances. A whitish coating may occur on the tongue
or throat. This syndrome is associated with a frothy mucous, nausea,
difficulty swallowing, sore throat, loss of taste and appetite,
and occasionally abdominal bloating and diarrhea.
What
causes it to appear?
It is promoted
by the use of most antibiotics and some other medications, by
stress, by reduced immune response, and by diabetes.
Can
it be cured?
There are
several effective medications now available for treating the overgrowth
of Candida.
What
is sleep apnea (SA)?
It is the
interruption of the normal sleep pattern associated with repeated
delays in breathing. Sleep apnea often shows rapid improvement
after surgery. In most patients, there is a complete resolution
of symptoms by six months following surgery.
How
long will I be off of solid foods after surgery?
Most surgeons
recommend a period of four weeks or more without solid foods after
surgery. A liquid diet, followed by semi-solid foods or pureed
foods, may be recommended for a period of time until adequate
healing has occurred. Your surgeon will provide you with specific
dietary guidelines for the best post-surgical outcome.
What
are the best choices of protein?
Eggs, low-fat
cheese, low-fat cottage cheese, tofu, fish, other seafood, chicken
(dark meat), turkey (dark meat).
Why
drink so much water?
When you
are losing weight, there are many waste products to eliminate,
mostly in the 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 also fills your stomach and
helps to prolong and intensify your sense of satisfaction with
food. If you feel a desire to eat between meals, it may be because
you did not drink enough water in the hour before.
What
is Dumping Syndrome?
Eating sugars
or other foods containing many small particles when you have an
empty stomach can cause dumping syndrome in patients who have
had a gastric bypass or BPD where the stomach pylorus is removed.
Your body handles these small particles by diluting them with
water, which reduces blood volume and causes a shock-like state.
Sugar may also induce insulin shock due to the altered physiology
of your intestinal tract. The result is a very unpleasant feeling:
you break out in a cold clammy sweat, turn pale, feel "butterflies"
in your stomach, and have a pounding pulse. Cramps and diarrhea
may follow. This state can last for 30-60 minutes and can be quite
uncomfortable - you may have to lie down until it goes away. This
syndrome can be avoided by not eating the foods that cause it,
especially on an empty stomach. A small amount of sweets, such
as fruit, can sometimes be well tolerated at the end of a meal.
Is
there a problem with consuming milk products?
Milk contains
lactose (milk sugar), which is not well digested. This sugar passes
through undigested until bacteria in the lower bowel act on it,
producing irritating byproducts as well as gas. Depending on individual
tolerance, some persons find even the smallest amount of milk
can cause cramps, gas and diarrhea.
Why
can't I snack between meals?
Snacking,
nibbling or grazing on foods, usually high-calorie and high-fat
foods, can add hundreds of calories a day to your intake, defeating
the restrictive effect of your operation. Snacking will slow down
your weight loss and can lead to regain of weight.
Why
can't I eat red meat after surgery?
You can,
but you will need to be very careful, and we recommend that you
avoid it for the first several months. Red meats contain a high
level of meat fibers (gristle) which hold the piece of meat together,
preventing you from separating it into small parts when you chew.
The gristle can plug the outlet of your stomach pouch and prevent
anything from passing through, a condition that is very uncomfortable.
How
can I be sure I am eating enough protein?
40 to 65
grams a day are generally sufficient. Check with your surgeon
to determine the right amount for your type of surgery.
Is
there any restriction of salt intake?
No, your
salt intake will be unchanged unless otherwise instructed by your
primary care physician.
Will
I be able to eat "spicy" foods or seasoned foods?
Most patients
are able to enjoy spices after the initial 6 months following
surgery.
Will
I be allowed to drink alcohol?
You will
find that even small amounts of alcohol will affect you quickly.
It is suggested that you drink no alcohol for the first year.
Thereafter, with your physician's approval, you may have a glass
of wine or a small cocktail.
Will
I need supplemental vitamins?
B12 injections
are sometimes suggested once a month for the first year and every
six months thereafter. B12 may also be taken orally or sublingually
(under the tongue) by many patients.
What
vitamins will I need to take after surgery?
Most surgeons
recommend a daily multivitamin for the rest of your life.
Is
it important to take calcium, iron, trace elements or female hormone
replacements?
Some patients
require these supplements, but your need for these can be determined
by your surgeon.
Do
I meet with a nutritionist before and after surgery?
Most surgeons
require patients to consult with a nutritionist before surgery.
Counseling after surgery is available on an individual basis as
needed or required by your physician.
Will
I get a copy of suggested eating patterns and food choices after
surgery?
Surgeons
provide patients with materials that clearly outline their expectations
regarding diet and compliance to guidelines for the best outcome
based on your surgical procedure. After surgery, health and weight
loss are highly dependent on patient compliance with these guidelines.
You must do your part by restricting high-calorie foods, by avoiding
sugar, snacks and fats, and by strictly following the guidelines
set by your surgeon.
What
is the youngest age for which weight loss surgery is recommended?
Generally
accepted guidelines from the American Society for Bariatric Surgery
and the National Institutes of Health indicate surgery only for
those 18 years of age and older. Surgery has been performed on
patients 16 and younger. There is a real concern that young patients
may not have reached full developmental or emotional maturity
to make this type of decision. It is important that young weight
loss surgery patients have a full understanding of the lifelong
commitment to the altered eating and lifestyle changes necessary
for success.
What
is the oldest patient for whom weight loss surgery is recommended?
Patients
over 65 require very strong indications for surgery and must also
meet stringent Medicare criteria. The risk of surgery in this
age group is increased, and the benefits, in terms of reduced
risk of mortality, are reduced.
Can
Weight Loss Surgery prolong my life?
There is
good evidence from scientific research that if you have Type 2
diabetes (or other serious obesity-related health conditions),
are at least 100 lbs. over ideal body weight, and are able to
comply with lifestyle changes (daily exercise and low-fat diet),
then weight loss surgery may significantly prolong your life.
Can
weight loss surgery help other physical conditions?
According
to current research, weight loss surgery can improve or resolve
associated health conditions.
| Condition |
Percentage
found in preoperative individuals |
Percentage
cured 2 years after surgery |
| Diabetes
or insulin resistance |
34% |
85% |
| High
blood pressure |
26% |
66% |
| High
triglycerides |
40% |
85% |
| Sleep
apnea |
22%
in males, 1% in females |
40% |
