Weight Loss Surgery East Carolina University A Description

Weight Loss Surgery East Carolina University A Description of Our Program: Before, During, and After…

Goals and Objectives Describe obesity and health effects of obesity v Describe weight loss surgeries offered by East Carolina University (ECU) v Describe pre-operative work-up and post-operative care related to weight loss surgery v

Our Informational Materials v This information is not intended to persuade you to have surgery and should NOT be considered medical advice. v Only you, your family, your medical doctor, and your surgeon know if bariatric surgery is right for you. v Further information regarding the appropriate surgery for you will be discussed in person with the surgeon if you come to the first visit.

Why have your surgery with ECU? v v We are involved in research. We have an array of services aimed at providing care to morbidly obese clients and their families. We genuinely want to help you reach your goals. Our surgeons are highly qualified experts.

Choosing a Surgeon v You or your primary care doctor may choose a specific surgeon from our practice. v The surgeon that you select may require additional personal or medical information in order to schedule an appointment. v Once you have established a relationship with our surgeons, you should then follow only their advice and educational materials.

What’s My Body Mass Index (BMI)? One factor used to determine if you qualify for surgery v Measures obesity based on weight and height v

Different Perceptions of Society In the Past: v Obesity was seen as a weakness or failure of individual. v Diet and exercise were prescribed treatments. v Weight loss surgery was viewed as dangerous and extreme. Now in the Present: v Obesity is considered a disease and the cause of many serious health conditions. v Surgery has gained acceptance as the only proven method to treat this disease.

What are the impacts of Obesity? v Social Implications: Unfortunately, this is still an acceptable form of social discrimination. v Economic Implications: • • v Personal cost = $15, 568 per year (diets, food, prescriptions) National cost = $200 billion • $93 billion in medical bills • $33 billion on weight-loss products/services Medical and Health Implications with BMI > 30 • • 70% increase in coronary artery disease 75% increase in stroke 400% increase in diabetes 55% increase in mortality

Co-Morbidities with Obesity ¡ ¡ ¡ ¡ Heart Disease High Blood Pressure Congestive Heart Failure Degenerative Joint Disease Stress Incontinence Gallbladder Disease Fluid retention (legs/feet) ¡ ¡ ¡ ¡ Diabetes Sleep Apnea Depression Shortness of Breath Irregular Menstrual Cycles Acid Reflux DVT (Blood Clots)

Clinical Terms to Describe Levels of Body Fat Who Qualifies for Weight-Loss Surgery? Normal Weight (BMI 18. 5 to 24. 9) Overweight (BMI 25 to 29. 9) Obese (BMI 30 to 34. 9) BMI 18. 5 -24. 9 BMI 25 -29. 9 BMI 30 -34. 9 Severely Obese (BMI 35 to 39. 9 ) BMI 35 -39. 9 Morbidly Obese (BMI 40 or more) BMI > 40

Characteristics of Potential Candidates v v v v 100 pounds above your Ideal Body Weight Body Mass Index: - 40 or greater with no co-morbidities - 35 or greater with co-morbidities Age of 18 to 65+ (assessed on an individual basis) Failed attempts at weight loss Health complications related to obesity No psychological contraindications Understanding the surgery/risks Compliance with diet/exercise requirements

What Surgery is Right for Me? REMEMBER…. . v All surgery has risks. v Not all patients are candidates for surgery. v Discuss your options with your surgeon at your first visit.

Most Common Surgical Options Gastric Bypass (GBP) Roux-en-Y Bypass Restrictive and malabsorptive LAP-BAND System LAP BAND Restrictive

Roux-en-Y Gastric Bypass Advantages v v Rapid initial weight loss Laparoscopic approach is possible Longer experience in USA Takes 1 -2 hours Disadvantages v v v Stomach cutting, stapling and intestinal re-routing required Portion of digestive tract is bypassed, resulting in nutritional deficiencies “Dumping syndrome” can occur Non-adjustable Extremely difficult to reverse

Early Post-Operative Gastric Bypass Potential Complications Death (. 5 to 1. 5%) q Pneumonia q Abdominal Infection q Heart Attack q Leak from the Bowel q Wound Infection q Spleen Injury q Bowel Obstruction q Anastomotic Narrowing q Bleeding q Pulmonary Embolus q

Late Post-Operative Gastric Bypass Potential Complications q q q Wound (Incisional) Hernia Staple Line Breakdown Bowel Obstruction Weight Gain Nutritional Problems Ulcer at the Anastomosis

Roux-en-Y Gastric Bypass ¡ ¡ ¡ It significantly restricts the amount of food that you can consume. You will have “dumping syndrome” if you eat sugar or fats. You should expect 70% of excess weight loss. Patients must consume 3 small high protein meals per day. Vitamin deficiency/Protein deficiency are usually preventable with adequate protein intake and vitamin supplements.

What is Dumping Syndrome? Stomach contents move too rapidly through the small intestines following surgery. v Does not happen with the band. v Avoid by following prescribed diet Symptoms: Rapid heart beat, headache, sweating, nausea, dizziness, diarrhea, sleepiness, lightheadedness, stomach cramping

The LAP BAND System Advantages v Lowest mortality and complication rate Least invasive surgical approach No stapling, cutting, or intestinal re-routing Adjustable Reversible Low malnutrition risk v Takes 1 hour in outpatient surgery v v v Disadvantages v v v Slower initial weight loss than Gastric Bypass Regular follow-up critical for optimal results: Need adjustments Requires implanted medical device

LAP BAND Potential Complications Early Complications: Gastric or esophageal perforation or injury Death < 0. 1% DVT/ pulmonary emboli Bleeding Splenic injury Wound infection

LAP BAND Potential Complications Late Complications: Band slippage Band erosion Port infection

L LAP BAND Procedure ¡ ¡ Moderately restricts the volume and type of foods able to be eaten. It is the only procedure that is adjustable. You should expect 40 -50% of excess weight loss. Requires the most effort of all procedures to be successful.

Sleeve Gastrectomy v v Removes 2/3 of the stomach Can be used as a single stage procedure Complications: v Typically less than 0. 5% Advantages: v There is no dumping syndrome. v There is no malabsorption. v Provides for early satiety (feeling of fullness)

Sleeve Gastrectomy ¡ ¡ ¡ It is a surgery on only the stomach, no rerouting of the intestines or anastomosis. The only insurance covering the sleeve is BCBS insurance at this time. Candidates are determined by the physician. This is the preferred surgery for kidney transplant and dialysis patients. You should expect 60 -70% excess weight loss at 2 years.

How to Maintain Your Success ¡ ¡ ¡ Surgery gives you the tool to assist with weight loss. Patients must be committed to making the emotional and physical changes necessary after weight loss surgery. The commitment will ensure successful weight loss and long-term weight maintenance. Lack of exercise, poorly balanced meals, constant grazing, eating processed carbohydrates and carbonated beverages are some causes of weight regain. Good habits of food intake and exercise will need to be practiced for the rest of the patient’s life.

Comparing Weight Loss Source: O’Brien et al. Obesity is a Surgical Disease: Overview of Obesity and Bariatric Surgery, ANZ J Surg, 2004; 74: 200 -204.

Your Appointments With the Surgeon and the Surgery Practice v v v You will have three visits with your surgeon before your surgery. Your first visit is called your “New Patient Visit”. At this visit, you will do the following: - Talk with the surgeon about the procedure. - Explore financial and insurance requirements. - Have a brief physical exam. - Determine preoperative evaluations you may need. - See the Referral Coordinator to have pre-op tests and consults arranged if your insurance does not require a waiting period. - We will remind you to STOP NICOTINE PRODUCTS! You must be nicotine-free 3 months prior to surgery, as well as after surgery! - Complete a few tests before going home.

At the “New Patient” Visit v v v v Psychological evaluation Nutrition evaluation Upper Gastric Exam Blood testing (lab work) Anesthesia Consult Chest X-Ray Electrocardiogram Arterial Blood Gas

Possible Pre-Operative Evaluations (Your surgeon may determine you need these additional tests before your second visit. ) v Other Lab Work v Colonoscopy v Sleep Study v Upper gastric endoscopy v Consult with cardiologist v Consult with pulmonologist v Consult with vascular doctor v Ultrasound of the abdomen

3 or 6 Month Program Depending on your insurance company, you may have to complete a six month diet and exercise program. Please refer to the example progress note in your purple folder. When you contact our office, we will inform you if this is your insurance requirement. If you do require a program, you will need to complete 4 months prior to being scheduled for your preoperative tests and consults.

Scheduling your appointments v Please do not miss your appointments. v Remember that rescheduling may mean prolonging your process. v If you repeatedly miss an appointment or fail to show up for an appointment without notice, you may be dismissed from the program. This surgery is a lifestyle change, and we want you to be successful in your weight loss journey!

Making The Decision v v v Once your consults and tests are completed, you will have your second visit, called the “Decision Visit. ” You will see your surgeon in the clinic and review test results. All questions about the surgery are answered. You will review the risks and benefits of the surgery with the surgeon, along with research opportunities. You will receive a prescription for a diet that we will discuss and expect you to begin 2 -3 weeks before surgery.

Prescription Diet Before Surgery v v We will give you the prescription for Optifast, which will be in the form of shakes (and the choice of one soup if you like) in place of meals. This prescription is not usually covered by insurance. It is approximately $71 per week. This diet will allow you to jumpstart your weight loss journey. At your next appointment, we will go into further detail regarding your pre-operative diet.

Insurance Approval Process v v v After your “Decision Visit”, our office will begin the approval process if you are an adequate candidate for surgery. We will mail or fax your evaluations, diet and exercise history, letters of clearance, and personal letter from our office to your specific insurance company. This approval process may take as long as 6 -8 weeks.

Insurance Tips to Remember You MUST meet the requirements of all the insurances that you have prior to submitting for approval. Depending on your insurance company, the approval process may be lengthy (6 -8 weeks). You must check your SPECIFIC policy (or policies) to make sure weight loss surgery is a covered benefit. If your insurance company denies your request for surgery, the appeal process may be started. This can be quite lengthy and involved, so it is important to know from the beginning your specific insurance company’s criteria. We will help you to the best of our ability to meet these requirements, but it is ultimately your responsibility to be familiar with your individual insurance policy.

Insurance Coverage Approval v When we receive insurance approval, we will contact you with your third appointment and surgery date! v Your third appointment is the “History and Physical”.

History and Physical Appointment Includes the following: v v v Brief physical exam Discussion of surgery, risks and benefits Consent forms signed Update lab work and tests if necessary Must have support person present or your surgery may be cancelled

Helpful Hints Prior to Surgery v This is a weight-loss program! Any weight gain could result in prolonging, rescheduling, or cancelling your surgery. v YOU MUST QUIT NICOTINE PRODUCTS! We may require a nicotine test prior to having surgery in order to ensure you have stopped. v Smoking raises the risks associated with surgery. Smokers who undergo surgery are more likely than non-smokers to experience anesthesia-related complications, infections, heart attack, stroke, pneumonia or death. They are also more likely to have a longer hospital stay. Taken from Consumer Guide to Bariatric Surgery website.

Day of Surgery Ø Ø Ø You will be admitted to the Ambulatory Surgery Unit (ASU). An IV will be started. You will be given an antibiotic and additional teaching by the nurse. After you have been prepared for surgery, you will go to the operating holding area. Your family may wait in the family waiting area and will be contacted after the operation.

Recovery v v Hospital Stay: Open surgery (3 to 4 days) Laparoscopic (2 to 3 days) LAP BAND (1 -2 days) Out of Work: Open surgery (4 to 6 weeks) Laparoscopic (2 to 4 weeks) LAP BAND (1 to 2 weeks) No driving for 1 -2 weeks following surgery No heavy lifting (anything over 10 pounds) for one month after surgery

Gastric Obesity Procedure (GOP) Diet Following Surgery Level I Diet: v v v This starts after surgery and lasts for 2 weeks. Two ounces (1/4 of a cup) of Bariatric Advantage in place of meals. Between “meals” you may have two ounces of non-sweetened, non-carbonated beverages. You MUST SIP WATER all day long. Carbonated or sugary drinks are not allowed.

Home Diet Following Surgery v v v We will give you specific details about your diet following weight loss surgery. Generally this consists of: Drastically limiting volume Limiting the consistency of food Limiting the types of food

Tips for Eating After Surgery v v v Do not drink liquids with meals, either drink 30 minutes before or 30 minutes after. Chew your food well. Take small bites of food. Eat meals over a 30 to 45 minute time span. Eat meals on a small plate and use a baby spoon.

Eating after LAP BAND Small volumes 2 -3 oz. of healthy foods v Similar restrictions as the gastric bypass v When you are not “filling up” then an adjustment needs to be done. v Band may need to be adjusted 3 -4 times in first year. v Diet is modified after each adjustment. v

How Much Weight Can a Patient Expect to Lose Following Surgery? v v v Depends on the surgery and the follow-up 75% of excess weight with Gastric bypass at the end of one year 45% of excess weight with Band but increases to 65% at 2 -3 year follow up with adjustments Amount of weight loss varies from person to person Must be compliant with follow-up

Plastic Surgery Consult Following Surgery v v v There may be excess skin on the chest, abdomen, arms and legs. We can refer you to a plastic surgeon when: -Your weight is stable (usually 12 -18 months). - Your nutritional status is adequate. Your surgeon will ultimately decide when this referral is appropriate. Insurance rarely covers these procedures. Document issues with your primary care doctor now and after surgery.

Tips to Remember! v v After surgery, all vitamins and medications need to be one of the following: CRUSHED CHEWABLE LIQUID FORM Please speak with your primary care doctor and pharmacist to help adjust these medications. Some drugs are NOT safe to crush.

Vitamins and Medications after Surgery (Required for Life) LAP BAND Gastric Bypass v v v 2 chewable multivitamins daily (ex: Flintstones) Calcium Citrate or Tums, 1000 mg daily Vitamin D 800 iu daily Vitamin B-12 250 mcg daily Ferrous Sulfate elixir 325 mg daily (menstruating women only) v v v 2 chewable multivitamins daily (ex: Flintstones) Calcium Citrate or Tums 1000 mg daily Vitamin D 800 iu daily

Protein and Vitamins after Weight Loss Surgery ¡ ¡ ¡ You must consume sufficient amounts of protein after surgery. Protein speeds wound healing, preserves lean body mass, and enhances fat burning. Always eat your protein first. Take 2 chewable multivitamins daily. Vitamin B-12 is needed to boost metabolism and enhance weight loss efforts. Calcium is important for bone health. Vitamin D aids in absorption of Calcium. Deficiency is linked to a host of chronic diseases. Anemia can occur in menstruating women after surgery and is due to iron deficiency.

Pregnancy following Surgery v v v Females should not become pregnant for at least 12 to 18 months following Gastric Bypass. Pregnancy prior to this could result in fetal demise or neural tube defects. After the band surgery, it is best to maintain a stable weight loss and plateau prior to becoming pregnant. You must follow what your surgeon tells you is best; inform the surgeon if you plan on having children after weight loss surgery.

Follow-Up After Gastric Bypass Surgery • • • Lifelong commitment Every 2 weeks for first month after surgery Every 3 months for the first year after surgery Yearly for a lifetime Lab work is checked at every visit.

Follow-Up After LAP BAND Surgery o o o Life long commitment 2 weeks and 6 weeks after surgery At 6 weeks, you may have your first adjustment. Monthly for first year After first year, surgeon will decide how often to see you. Lab work checked every 3 months.

Exercise v v v Exercise is an important part of your weight loss journey. Remember, surgery is a tool to help you reach your goals. You must do your part as well! You will work up to doing exercise daily for 30 to 45 minutes per day Exercise options can include: -Walking -Jogging -Bike riding -Weight Training -Aerobics -Water aerobics -Swimming

Support Groups ¡ We encourage you to join a support group prior to surgery and maintain participation with the support group after surgery. ¡ Ideally, you should attend the support group offered by your surgical practice. ¡ Our Support Group is the 3 rd Tuesday of each month at 6 pm. It is located at 517 Moye Blvd.

Making An Appointment v The next step in pursuing weight loss surgery is having a visit with a qualified bariatric surgeon. v If you already have an appointment with a weight loss surgeon, please keep the appointment, or if you are no longer interested, please contact the office to cancel your appointment.

Conclusion ü ü Thank you for reviewing our informational material. We look forward to working with you in the future, and we are available to answer any questions you may have. Please type in the following web address in your internet browser to receive your certificate, http: //www. ecu. edu/weightlosssurgery/certificate. cfm Please print out the following certificate and sign. This certificate is proof that you have completed our online orientation. Please write down any questions you may have on the space provided. You must bring this form with you to your first appointment with the surgeon, as this is a requirement for our program. We look forward to seeing you soon! Thank You!!