A Guide To Your Bariatric Surgery - WakeMed

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A Guide to Your Bariatric SurgeryPatient Handbook

Table of ContentsIntroduction to the program . . . . . . . . . . . . . . . . . . . . 3Health problems associated with obesity . . . . . . . . . .4What is bariatric surgery? . . . . . . . . . . . . . . . . . . . . . . .4Patient selection . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .5Are you a candidate for bariatric surgery? . . . . . . . . .6Bariatric proceduresGastric balloon . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .7Adjustable gastric banding (lap band) . . . . . . . . . . . .7Sleeve gastrectomy . . . . . . . . . . . . . . . . . . . . . . . . . . . .8Gastric bypass . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .9Duodenal switch . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .9Potential risks and complications of surgery . . . . . .10Patient information seminar . . . . . . . . . . . . . . . . . . .11Pre-operative visits . . . . . . . . . . . . . . . . . . . . . . . . . . .12Final pre-surgery visit . . . . . . . . . . . . . . . . . . . . . . . . .14Day of surgery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .14After surgery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .15Patients at home . . . . . . . . . . . . . . . . . . . . . . . . . . . . .15Post-operative appointments & follow-up care . . . .16Work, activity & exercise . . . . . . . . . . . . . . . . . . . . . .17Post-operative nutrition plan . . . . . . . . . . . . . . . . . . .17General rules to follow . . . . . . . . . . . . . . . . . . . . . . . .18Post-operative concerns . . . . . . . . . . . . . . . . . . . . . . .18Taking medications . . . . . . . . . . . . . . . . . . . . . . . . . . .20Vitamins & minerals . . . . . . . . . . . . . . . . . . . . . . . . . .20Hormones & pregnancy . . . . . . . . . . . . . . . . . . . . . . .21Emotional concerns . . . . . . . . . . . . . . . . . . . . . . . . . . .21Obesity & support group websites . . . . . . . . . . . . . . .21Benefits, expectations & outcomes . . . . . . . . . . . . . .22Achieveing success . . . . . . . . . . . . . . . . . . . . . . . . . . .22Insurance & financial information . . . . . . . . . . . . . .23Acknowledgement . . . . . . . . . . . . . . . . . . . . . . . . . . . .24

Welcome to WakeMedPlease bring this handbook to all of your bariatric appointments.This patient handbook explains the bariatric surgery program offered byWakeMed Bariatric Surgery & Medical Weight Loss. Our multi-disciplinaryteam of surgeons, advanced practice providers, nurses, dietitians, exercisespecialists and psychologists provides a comprehensive program, and we arehonored to be a part of your journey to better health. Our bariatric surgeryprogram meets and exceeds the American Society for Metabolic andBariatric Surgery (ASMBS) standards as a Center of Excellence with boardcertified bariatric surgeons.In this handbook, we provide detailed information about the bariatricsurgery process. We believe that educating patients and preparing them forbariatric surgery is the foundation of patient success and continued supportafter surgery is essential for long-term weight loss. Bariatric surgery is ajourney and we are here to help you along the way to a healthier you.Introduction to the programWakeMed Bariatric Surgery & Medical Weight Loss is a comprehensiveprogram that includes: Fitness Consulting Nutrition Counseling Support Group Services Psychological Evaluation Pre-operative Testing & Medical Clearance Specialized Inpatient Bariatric Care Post-Operative Lifelong Follow-up Medical Weight Loss Integration3

Health problems associated with obesityObesity is the most common medical disorder in theUnited States. More than two thirds of U.S. adults areoverweight or obese and the rate has steadily increasedsince 1960. Obesity in America has doubled in fewerthan 20 years. It is a leading cause of preventable deathamong American adults.Obesity is associated with several of health problems.People with obesity have a significant increase in heartdisease and early death due to high blood pressure, highblood cholesterol and type 2 diabetes. Other commonproblems that people with obesity face include sleepapnea, respiratory insufficiency (shallow breathing),heartburn or reflux disease (GERD), fatty liver disease,asthma, hernias, gallbladder disease, stress urinaryincontinence, knee and back pain, infertility and somecancers.Daily life for those who are obese is affected in manyways. Carrying extra weight is painful and debilitating.Often times size alone will limit access or comfort insociety. Most people who struggle with obesity havetried dozens of weight loss methods including diets andmedications, but are unable to lose weight and keep itoff. For many, chronic dieting has led to biochemicalchanges causing resistance to weight loss. Scientificstudies show that a minority of very obese people getpermanent weight loss using the usual methods, such asdiet, exercise and behavior modification.Obesity is very difficult to treat. When other medicallysupervised methods have failed, bariatric surgery canoffer a good option for weight loss. The long-termsuccess of the surgery depends in large part on yourmotivation and willingness to make lifestyle changes.What is bariatric surgery?Bariatric surgery is the area of surgery that is devoted toweight loss. The term “bariatric” comes from the Greekword “baros” for weight. The field of bariatric surgery isa specialty that offers surgical treatment for people whoare suffering from health problems as a direct result oftoo much weight when other measures have not been4successful. Surgery and procedures for morbid obesityinvolve changes to the stomach, or to the stomach andsmall bowel. These procedures reduce your stomach sizeand some also change the hormones linked to foodintake and hunger, thus helping you with weight loss.There are several operations or procedures available formorbid obesity: intragastric balloon, gastric band,Roux-en-Y gastric bypass, sleeve gastrectomy and singleanastomosis and traditional duodenal switch. Eachbariatric procedure or surgery has its own benefits andrisks. Our providers will help you decide whichprocedure best meets your needs and goals.If you are thinking about bariatric surgery, it isimportant to understand that these operations are notplastic or cosmetic surgery. As with all surgicalprocedures, there are real risks that come with weightloss surgery. For this reason, surgery is only offered tothose who meet the criteria of morbid obesity (see page8) – when the medical risk of continued obesityoutweighs the risk of the surgery itself.All of our bariatric procedures are done endoscopicallyor with laparoscopic instruments through several smallincisions. Endoscopy involves placing a flexible scopethrough the mouth and inflating the stomach withoutany incisions on the abdomen. Devices can then beplaced in the stomach or removed through the scope.Laparoscopy involves inserting a video telescope intothe abdomen through one incision. Additional incisionsare placed in the upper abdomen. The operation is thencarried out using specialized instruments. Thisapproach has the advantage of smaller incisions, lesspain, quicker recovery, fewer wound problems, earlierdischarge from the hospital and less scarring whileproviding the same weight reduction as the traditionalopen approach. The typical stay in the hospital is onenight.In the rare situations where bariatric surgery cannot besafely completed with the laparoscope, an incision fromthe breastbone to just above the umbilicus (navel, bellybutton) is used.

Patient selectionA successful surgery is gauged not only by weight loss,but also by the improvement of your medical issues.Before surgery, we will evaluate your medical issues andcalculate your excess body weight. Excess body weight isthe weight over what a person of your height shouldideally weigh. We consider weight loss of more than50% of pre-operative excess body weight a good result.We expect 85 to 90% of patients to achieve a good toexcellent result.The average patient loses 50% to 70% of excess bodyweight with sleeve gastrectomy 50% to 75% of excessweight with gastric bypass and 60% to 85% withduodenal switch, but there is a great deal of variationwith some patients losing more and some losing less.With that weight loss, patients have a high likelihoodthat many of their medical issues will improve or goaway completely. In addition, you can see improvementof some medical issues even before weight loss occurs.For example, persons with diabetes can seeimprovement or remission of their diabetes within a fewweeks of surgery.Bariatric surgery may be right for you if: You are at least 18 years old. You have a body mass index (BMI) of 30* or greaterwith comorbidities (health problems), OR you have aBMI of 40 or greater without comorbidities. You have physical problems and/or diseases related toobesity including, but not limited to: diabetes, highblood pressure, elevated blood fats, heart problems,sleep apnea, chronic back or knee pain ordegenerative arthritis. You have been overweight for more than 5 years. Your serious attempts to lose weight have had onlyshort-term success. You are prepared to make major changes in youreating habits and lifestyle. You are willing to continue working with our bariatricteam for lifetime follow-up care.Bariatric surgery may not be right for you if: You have medical conditions that make the surgerytoo risky. You currently have a problem with drug, alcohol ortobacco abuse. You have an unstable psychiatric condition such asschizophrenia. You have an uncontrolled eating disorder. You are not ready to make dietary changes and makephysical activity a part of your life. You are not committed to lifelong follow-up.* The American Society for Metabolic and Bariatric Surgery (ASMBS) recognizes a patient with a BMI over 30 with comorbidities should beconsidered for bariatric surgery. However, insurance providers currently only recognize patients with a BMI over 35 with comorbidities to becandidates for bariatric surgery. In the case that insurance won't cover the procedure, we do have self-pay options for patients concerned enoughabout their health to proceed with surgery outside of insurance.5

Are you a candidate for bariatric surgery?Calculating Ideal Weight & BMIBody mass index (BMI) is a measurement calculated using your weight and height. We calculate ideal body weightusing BMI. A BMI of 25 is considered “ideal”. Ideal body weights based on BMI are often not a realistic goal weightfor our patients, but are a recognized standard of body weight measurement that we use to calculate your excessbody weight. You can identify your BMI using the table below using your weight in pounds and your height ininches.If your BMI falls into the purple range ( 40), your weight qualifies for bariatric surgery. If your BMI falls in thered or dark yellow range ( 30* but 40), you may qualify for bariatric surgery if you have other health problemsrelated to obesity such as diabetes, high blood pressure, elevated cholesterol and others.* The American Society for Metabolic and Bariatric Surgery (ASMBS) recognizes a patient with a BMI over 30 with comorbidities should beconsidered for bariatric surgery. However, insurance providers currently only recognize patients with a BMI over 35 with comorbidities to becandidates for bariatric surgery. In the case that insurance won't cover the procedure, we do have self-pay options for patients concerned enoughabout their health to proceed with surgery outside of insurance.6

The bariatric proceduresGastric balloonAdjustable gastric bandingPerformed in the endoscopy suite, Obalon BalloonSystem patients swallow a capsule that contains a smallballoon which travels to the stomach. The physicianinflates the balloon, which takes up space in thestomach and makes you feel full more quickly. Onceplaced, patients can drive and immediately resume dailynormal activity. Over the next several months, twoadditional balloons will be placed for a total of three –all of which are removed in the endoscopy center at thehospital at six months.Adjustable gastric banding (Lap Band) is the onlyadjustable weight loss surgery. It works by placing aninflatable silicone band around the top part of thestomach, which creates a small pouch and, in effect,makes the stomach smaller.On average, most Obalon patients lose around30 percent of their total body weight with appropriatedietary changes and exercise.Side effects are generally mild and include nausea andabdominal pain. Gastric perforation is a rare but seriouscomplication associated with the balloon.This pouch holds about a half-cup of food, rather thanthe roughly six cups that a normal stomach holds. It fillswith food quickly, which means patients won't be able toeat as much and will feel full faster, yet it also allowsthem to absorb nutrients from food normally.The band can be adjusted to meet your needs. Forinstance, it can be deflated if you become pregnant andit can be tightened if you are not losing enough weightto make a healthy difference.During the procedure, the surgeon uses laparoscopictechniques, making a small incision and usinginstruments to implant an inflatable silicone band intoyour abdomen. Like a belt, the band is fastened aroundthe upper stomach to create a new, tiny stomach pouchthat limits and controls the amount of food you can eat.It also creates a small outlet that slows the emptyingprocess into the stomach and the intestines.The band is connected by tubing to a reservoir, which isplaced under the skin during surgery. To change the sizeof the band, saline solution is injected into or withdrawnfrom the tubing with a fine needle, which inflates ordeflates the band's inner surface.7

ExcessStomachRemovedYou will have office visits to receive fluid adjustmentsthrough your port.While not common, excessive vomitin