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Patient Information Book For Gastric Bypass Surgery FEBRUARY 2010

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Patient Information Book For Gastric Bypass Surgery FEBRUARY 2010 Powered By Docstoc
					Fremont Medical Center Bariatric Program

      Patient Information Book
     For Gastric Bypass Surgery




                Department for Bariatric Surgery
                  39400 Paseo Padre Parkway
                      Fremont, CA 94538


           Department main number      510-248-3335
           Wt. tracking line           510-248-3358
           Fax line                    510-248-3482
www.permanente.net/homepage/kaiser/pages/d18071-top.html

       FEBRUARY 2010 Edition
         Please bring this binder to every appointment
TABLE OF CONTENTS                                                             page

1. Introduction to the Kaiser Northern California Bariatric Programs

                 2. Overview of Obesity, Weight Loss, and Bariatric Surgery
What is Weight Loss?
How does surgery help with weight loss?
What is short term versus long term weight loss?
Conditions Improved with Weight Loss
3. Types of Weight Loss Surgery
    • The different types of Weight Loss Surgery
    • Open and Laparoscopic Procedures
    • Anatomy of the Stomach and Intestines
    • Roux en Y Gastric Bypass                                                pg. 4
             o Anatomy
             o Surgical Procedure and Hospital Stay
             o Weight Loss
             o Short Term Side Effects and Complications
             o Long Term Side Effects and Complications
    • Vertical Sleeve Gastrectomy                                             pg. 10
             o Anatomy
             o Surgical Procedure and Hospital Stay
             o Weight Loss
             o Short Term Side Effects and Complications
             o Long Term Side Effects and Complications
    • Adjustable Gastric Banding                                              pg. 13
             o Surgical Procedure and Hospital Stay
             o Weight Loss
             o Short Term Side Effects and Complications
             o Adjustments and Fills
             o The Green Zone
             o Long Term Side Effects and Complications
    • Comparison of the Different Operations                                  pg. 20
    • Goals and Preparation Before Surgery                                    pg. 22
             o Who is the ideal candidate for surgery?
             o Why do you need to lose weight BEFORE surgery?
             o How do you lose weight BEFORE surgery?
    • Hospitalization                                                         pg. 24
    • Life After Surgery                                                      pg. 25
    • Summary and Key Points                                                  pg. 29



4. Nutritional Guidelines

    •   Mindful Eating and Eating Behaviors                                   pg. 2

    •   The Components of Nutrition                                           pg. 9
    •   Pre-op Meal Plan (Before Surgery)                pg. 17
    •   Success Habits: Before and After Surgery         pg. 22
    •   Guidelines for Gastric Bypass and Sleeve         pg.24
    •   Vitamin chart                                    pg. 30
    •   Gastric Bypass/Sleeve Meal Guidelines & Stages   pg. 33
    •   Nutritional Problems after Bariatric Surgery     pg. 50
    •   Nutritional Guidelines for Lap-Band              pg. 56
    •   Additional Nutritional Resources                 pg. 60


5. Exercise

6. Emotional Health and Support
    • Support Group List

7. Members of the Fremont Bariatric Program


8. Appendix
    • Websites and References
    • BMI chart
    • Exercise and Wt Classes at Kaiser
    • Hayward-Fremont Resources
    • Cheat Sheet for Primary Care Doctors
•




              Section 1



     Introduction to the Kaiser
    Northern California Bariatric
             Programs
   Introduction to the Kaiser Northern California Bariatric Programs


Who Qualifies for Bariatric Surgery?
Weight loss operations are appropriate for adult members (over age 18) with:
• Failure of medical management to obtain sustainable weight loss.
• BMI greater than 40 (with or without other co-morbid conditions)
• BMI greater than 35 with a serious weight related condition.

The ideal candidate for surgery is the person who has seriously tried to lose weight in the
past, understands the risks and benefits of surgery, understands the lifelong changes in
lifestyle required for success, and has the support of family and friends to help him or her
through the process.

Evaluation by the Primary Care Provider (PCP)
Based on the criteria outlined at http://bariatrics.kaiser.org., the primary doctor must
determine eligibility, complete the appropriate referrals, and coordinate care at the local
facility. The primary care provider may suggest attending a health education class on
bariatric surgery prior to make a referral to a regional bariatric center.

Regional Bariatric Centers.
Surgical centers that perform a high number of weight loss operations are shown to
perform the operations with lower risk and lower complications. Centers with
multidisciplinary teams focused on weight loss education are shown to optimize long
term weight loss success. For this reason, regional bariatric centers were created to
maximize surgical and medical expertise and safety.
As of 2010, Kaiser Northern California Bariatric centers are located in:

   •   Fremont
   •   Fresno
   •   Richmond
   •   South San Francisco

All of the centers above have obtained or in the process of obtaining national
accreditation as “centers of excellence.” Outcomes data are tracked regularly, and
mortality and complication rates remain consistently better than the national averages.
Each of the centers has a multidisciplinary team consisting of surgeons, nutritionists,
psychologists, nurses, case managers, and sometimes medical internists, all specializing
in bariatric surgery.
The Fremont Bariatric Program


The Kaiser Fremont Bariatric Surgery Program offers a multidisciplinary
team oriented approach to the management of obesity. Although the surgical
operation is an important part of the program, it is only a tool to help
patients achieve the long term goal of gaining health through sustainable
weight loss. Our team is committed to a partnership with each candidate for
gastric bypass with the goal of maximizing your chances for success while
minimizing your risks. The program is designed to provide educational
information and resources to adjust to the lifestyle changes that will be
required after surgery to maintain a healthy weight. Only you can enact this
plan and utilize our team and its resources for your success.


Success of gastric bypass surgery requires commitment to long term lifestyle
changes, which include decreased caloric intake, nutrition focused eating,
regular exercise, and psychosocial support. This booklet is also designed to
provide guidance through the pre-operative and immediate post-operative
portions of the program. It is not a recipe to obtain an operation, but a guide
to the changes important for success. You are asked to read the material,
educate yourself about the procedure, and commit to a plan of action. Within
this booklet, information and guidance is given toward both the mental and
physical preparation for the changes required. Mental preparation includes
attending informational classes and regularly participating in an organized
support group. It also includes self-evaluation to understand how we use
food in our lives and if obesity offers us any advantages. Physical
preparation involves integrating the nutritional material you are learning into
your daily life and increasing your activity level, thereby, preparing your
body for a much more healthy future.
                  Section 2

      Overview of Obesity, Weight
      Loss, and Bariatric Surgery
What is Weight Loss?
How does surgery help with weight loss?
Short term versus long term weight loss?
Conditions Improved with Weight Loss
          Overview of Obesity, Weight Loss, and
                    Bariatric Surgery
Obesity in the United States

In the United States today, the epidemic of obesity is a major health concern. Experts estimate that over
300,000 deaths are attributed to obesity and obesity-related complications each year and that over 9.1% of
the National healthcare expenditures in the United States are directly related to obesity and physical
inactivity (2002 data).

Body Mass Index (BMI) is a uniform means of determining an individual’s weight classification and
measuring obesity. BMI is calculated by dividing a person’s weight (in kilograms) by the square of their
height (in meters) (kilograms/meters squared). According to the weight classification system, in the United
States 66% of the adult population is overweight and 34% of the population is obese (2005-2006 data).

% of U.S. population                     Term                                     BMI
 66 percent                              Overweight                               BMI 25 or higher
 34 percent                              Obese                                    BMI 30 or higher
5 percent                                Morbidly obese                           BMI 40 or higher


The reasons for obesity are very complex and not yet fully understood. Although diet and lifestyle choices
contribute to obesity, there are some individuals with similar habits who are not morbidly obese, and there
are some morbidly obese people who manage to change their lifestyle but lose very little weight. Thus,
genetics and heredity, differences in metabolism, and the increased availability of high calorie foods all
play a role in the development of obesity.

Being overweight or obese does NOT guarantee that someone will develop serious health problems. Some
people can be obese and relatively healthy. But compared to a person of normal weight, the CHANCE of
developing a medical problem is higher. Some of these medical conditions include: diabetes mellitus,
hypertension, coronary heart disease, stroke, congestive heart failure, restrictive lung disease, sleep apnea,
degenerative arthritis, infertility, increased risk for cancer of the breast and uterus, psychological problems,
and gastroesophageal reflux disease.

In 1991, the National Institutes of Health (NIH) assembled a group of healthcare experts to make
recommendations on treatment options for obesity. These treatments ranged from dieting, to behavioral
modification, to drug therapy, to surgery. Surgery could be recommended for morbidly obese people who
failed to maintain the weight loss from other types of treatment.
Sustainable weight loss (losing the weight and keeping it off) is the goal of any treatment. This is what
results in the elimination of medical co-morbidity and improved health.

Patients may be considered for surgery when they meet the established National criteria, understand the
possible complications, and agree to comply with the post-operative regimen of dietary and physical
lifestyle changes.

                                What is Weight Loss?
Unused energy from food is stored in fat
Like all mammals, humans eat food to obtain energy. Energy is needed to live, breathe, work, walk, sleep,
talk, think, heat our bodies, and do every thing we do during our ordinary day. The digestive system breaks
food down for delivery into the blood stream, and for eventual energy use by the cells of the body.
Energy can be measured in calories. The average recommended American diet should provide 2000
calories per day. Most Americans consume far more than this. If the all the energy from food is not used
by the body, the extra energy is stored for future use in the form of fat.
Fat is like a savings account for calories (energy). In the future, if you cannot eat enough, you can obtain
the needed calories from fat. However, if you continue to eat more calories than you use, you will continue
to build fat.

Someone trying to lose weight is really trying to lose the weight related to the extra fat they don't need.
The ONLY way to lose fat is to burn more calories than you take in. You must “earn” fewer caloreis (eat
much less) and “spend” much more (exercise and be active). That is the only way one can hope to reduce
one's “savings account” (fat).

Every pound of fat contains about 3,500 calories.
If you eat 2,500 calories a day but only use 2,000 calories, you will store 500 calories each day. At the end
of 7 days you will GAIN 1 extra pound of fat.
If you eat 1,500 calories a day and use 2,000 calories, you will burn 500 calories from fat each day. At the
end of 7 days, you will LOSE 1 pound of fat.

         Calories from food         greater than       calories used with activity=      WEIGHT GAIN
         Calories from food         less than calories uses with activity =         WEIGHT LOSS




        How does surgery help with weight loss?
Losing 10 to 20% of ones total weight by dieting and exercise is a tremendous achievement, and is often
enough to improve associated health problems. A 300 pound person who can lose 30 pounds should feel
happy about their success. Unfortunately, this weight loss may not enough to completely eliminate the
associated health problems. In addition, a 10% loss in weight may not be obvious enough for friends,
family, and doctors to notice. Many cravings only increase with weight loss, making it extremely hard to
keep the weight off for a long time. Most people “rebound”, gaining more weight than they lost. This can
be very discouraging, making it even harder to stick to a diet and exercise program in the future. Despite
their best efforts, many people who are sincere about losing weight find themselves constantly trying to
lose weight and then gaining it back.

Surgery helps one to eat less, therefore making weight loss more likely.
Surgery can work by either by either limiting the capacity of food in the stomach (restrictive effect), by
shortening the amount of bowel that can absorb food (malabsorption effect), or by a combination of both
restriction and malabsorption. The operation may also work by affecting the balance of several hormones
related to eating, hunger, and taste. The operations seem to curb the feelings of hunger that seem to
sabotage many other types of weight loss programs.

 Researchers and drug companies are just beginning to understand the hormones that control obesity, but
are probably many years away from developing a medicine that could treat it.
              What is short term versus long term
                         weight loss?
Because of the mechanisms described above, most people some weight after weight loss surgery.Thus,
most people are successful with short term weight loss. Unfortunately, the appetite suppression and
restrictive effect may be pronounced in the first few years, but eventually diminishes over time.
This is enough time for motivated patients to break the cycle of obesity and keep the weight off for the
remainder of their lives. These people realize that by continued portion control, healthy food choices, and
an active lifestyle they can keep their weight down. These people are able to maintain long term weight
loss for 10 to 30 years, and enjoy all the health and social benefits of being a lower weight.
However, there are MANY people who regain much or all of their weight within several years. They often
do not count calories, do not practice portion control, snack frequently, or take too many liquid calories.
They are not active and able to burn off the extra calories they consume.
By only eating only 100 extra calories a day, it is possible to gain 1 pound each month. If not corrected,
this leads to 12 extra pounds in one year, 60 extra pounds in 5 years, and 120 extra pounds within 10 years.

Surgery is only a tool that allows patients to break the cycle of obesity.
It must be combined with healthy food choices and exercise.
Successful surgery, diet, and exercise shifts obesity from a disease that a person must battle to a
choice that a person can control.
                                           Weight Loss After Surgery
After an operation such as the roux en y gastric bypass or gastric sleeve, the vast majority of patients lose
50 to 80% of their excess weight in the first 12 months. With the lap band, the weight loss may take 3 to 4
years, and seems to be more variable.
After the first 2 years, there can be a regain in weight if changes in eating habits and exercise have not been
implemented. With the roux-en-y gastric bypass, most patients keep 50% to 70% of their excess weight off
after 10 years.
This means a person who is 300 pounds and has an ideal body weight of 150 pounds can expect to be
between 180 to 225 pounds at the end of ten years.



            Conditions Improved with Weight Loss

Many medical conditions seem to improve with significant weight loss. However complete improvement
or “cure” cannot be predicted, because many of the conditions are also related to genetics and aging. In
other words, there are many people of normal weight and size who may still develop these conditions.



Diabetes (Adult onset)
Over 50% of patients are able to reduce their diabetic medications with substantial weight loss. Diabetes
seems to improve most dramatically with the roux-en-y gastric bypass. Although much of the
improvement is related to the loss in weight, a significant portion of the improvement may be related to the
operation itself and the way it reroutes the stomach and intestines. After a roux en y gastric bypass, 95% of
younger patients (and 80% of all patients) are able to eliminate medications (oral and insulin) for diabetes.
For the sleeve gastrectomy and the lap band, the improvement in diabetes is proportional to the amount of
weight lost. Thus, for those patients who lose weight, there can be a 50 to 70% improvement in the need
for diabetic medications.

Acid Reflux
Acid reflux and heartburn often improve with a change in diet and lower abdominal pressure with weight
loss. It is important to realize that some operations such as the lap band and gastric sleeve may worsen
heartburn, while others such as the roux en y gastric bypass reduce heartburn by bypassing the acid
producing portion of the stomach.

Hypertension
About 70% of patients will have significant improvement in blood pressure. (Only about 30% can
eliminate all medications for blood pressure)


Sleep apnea
About 70% to 80% of patients will have minimal symptoms of apnea after surgery. About 50% will
eliminate the need for a CPAP machine.


Cardiopulmonary Failure
Improvements in cardiac function and heart muscle function have been studied, and often seem to
improve.

Elevated Cholesterol
Lowering of previously high cholesterol and lipid levels are common, possibly resulting in a decreased risk
of heart attack and cardiovascular disease.



Pseudo Tumor Cerebri
Headaches and visual changes seem to improve in many.


Infertility
Infertility seems to improve in many women with polycystic ovary disease or irregular periods.


Degenerative arthritis
Young patients who do not require NSAIDs for pain control usually report significant improvement in joint
stress and pain. However, patients who already have documented arthritis (inflammation and degeneration
of the joints) may continue to progress with arthritis. In addition, patients who depend on NSAIDs for pain
control may experience more pain after gastric bypass since NSAIDs are no longer allowed after the
operation.


Asthma
Most patients have mild to significant improvement, due to less restriction of the lungs (ability to take
deeper breaths).


Restrictive lung disesase
Decreased lung function can result from a combination of several factors. Lung function can be impaired
by obstructive disease (COPD, asthma), destruction of lung tissue (emphysema, pulmonary fibrosis), and
restriction (lung scarring, obesity). Obesity may limit one’s ability to take a deep breath and expand the
lungs. The extra weight also places more demand on the lungs and heart to supply oxygen. If this is a
major reason for poor lung function, then weight loss can result in significant improvement. However,
pulmonary function tests are required prior to the operation to help sort this out.




Stress incontinence
Incontinence is a complex problem that can be related to increased abdominal pressure and abnormal
anatomy. Mild cases of incontinence or increased frequency related to increased abdominal pressure may
improve with significant weight loss.


Hernias
Hernias (holes or tears in the abdominal wall allowing the bowels to bulge through) always require surgical
correction. Sometimes these can be corrected at the same time as weight loss surgery. Once the hernia is
fixed, the repair is probably more durable due to the lower weight and lower abdominal pressure.


Psychological Conditions
Psychological conditions can be very complex. Depression may seem to improve for a short time with
rapid weight loss, but usually persists in the long term. Some patients may face increased stress as their
self perception and relationships change. Others will no longer be able to use food as a source of comfort
during times of depression.
Medications for depression and other psychological conditions can still be taken immediately after the
operation. Occasionally dosages may have to be adjusted as weight is lost.


Unknown
Recent research has suggested that obesity may increase the risk of the conditions below. However, not
enough research has been done to determine whether significant weight loss can reverse or reduce the risk
of these conditions.
     Cancer risk (uterine and breast cancer)
     Deep venous thrombosis
     Pulmonary Emboli
     Heart Attack
     Stroke
     Immune Suppression
                               Section 3

    Types of Weight Loss Surgery
•   Types of Weight Loss Surgery
•   Open and Laparoscopic Procedures
•   Anatomy of the Stomach and Intestines
•   Roux en Y Gastric Bypass                                pg. 4
         o Anatomy
         o Surgical Procedure and Hospital Stay
         o Weight Loss
         o Short Term Side Effects and Complications
         o Long Term Side Effects and Complications
•   Vertical Sleeve Gastrectomy                             pg. 10
         o Anatomy
         o Surgical Procedure and Hospital Stay
         o Weight Loss
         o Short Term Side Effects and Complications
         o Long Term Side Effects and Complications
•   Adjustable Gastric Banding                              pg. 13
         o Surgical Procedure and Hospital Stay
         o Weight Loss
         o Short Term Side Effects and Complications
         o Adjustments and Fills
         o The Green Zone
         o Long Term Side Effects and Complications
•   Comparison of the Different Operations                  pg. 20
•   Goals and Preparation Before Surgery                    pg. 22
         o Who is the ideal candidate for surgery?
         o Why do you need to lose weight BEFORE surgery?
         o How do you lose weight BEFORE surgery?
•   Hospitalization                                         pg. 24
•   Life After Surgery                                      pg. 25
•   Summary and Key Points                                  pg. 29
                                   TYPES OF WEIGHT LOSS SURGERY


The different types of Weight Loss Surgery

Surgical procedures for the treatment of obesity can be divided into three general categories.

    1.   Malabsorptive procedures
    2.   Restrictive procedures
    3.   Combined malabsorptive/restrictive procedures

In the mid-1970’s malabsorptive procedures such as the jejuno-ileal bypass procedures were popularized
for the treatment of obesity. By 1983 it was recognized that complications associated with this bypass were
too frequent and too severe. The procedure was, therefore, abandoned and no longer recommended. A
modern variant called the biliopancreatic diversion and duodenal switch is currently being performed in
some centers for selected patients with very severe obesity. Restrictive procedures also have a history of
modifications and come in many variants today. Although these procedures have less metabolic
complications, it is still unclear if they are successful in creating sustainable long-term weight loss. This is
largely due to the nature of the stomach which is an expandable organ and adapts to any restriction placed
within it. Restrictive operations include the adjustable gastric band (lap band) and vertical sleeve
gastrectomy (gastric sleeve). The Roux-en-Y bypass is the most common weight loss operation performed
in the United States and worldwide. It can be regarded as a restrictive procedure; however, there is some
malabsorption component due to the bypassing of food around the duodenum and first portion of the
jejunum.
   Open and Laparoscopic Procedures
Many patients can have their surgery
performed laparoscopically (through
small incisions, cameras, and long
instruments). This usually involves 5 to 6
incisions measuring about one inch each.
Laparoscopic procedures can be limited
by high BMI, the size of the liver, the
anatomy within the abdomen, or the
technical limits of the instruments and
equipment. Thus, there may be instances
where a procedure is started
laparoscopically but must be completed
through an open incision.
Patients with prior abdominal
operations, large abdominal wall
hernias, cardiac disease or
high BMI’s may have their operation
performed through an open incision.
These
conditions may make laparoscopic
surgery technically challenging or
excessively long,
increasing the risk of organ injury,
blood clot, heart attack, and other
complications.
These incisions are vertical, usually 6
to 8 inches long in the upper part of
the abdomen.
There is no difference in weight loss
results between patients with
laparoscopic operations compared to
patients with open operations. Open
operations have a slightly higher rate
of wound problems (i.e. 5-10% chance
of wound infection or hernia) while
laparoscopic operations may have a
slightly higher risk of bleeding.
Anatomy of the Stomach and Intestines
This section provides a simple explanation of the structure and function of the parts of the gastrointestinal
(GI) tract involved in this surgery.

The esophagus (E) is muscular, hollow tube that connects the back of the mouth to the stomach. The
stomach (STOM) is a muscular organ which stores food and can stretch to the size of a football. The
stomach begins the process of digestion by secreting acid to help break food down and converting food to a
liquid state so that it can be pushed into the intestine for absorption. The stomach empties into the first
part of the small intestine called the duodenum. The duodenum comes from a Latin word meaning twelve
and in fact, it is 12 inches long in the average adult. It is here that secretions from the liver and pancreas
join the food coming from the stomach to enhance digestion. The next portion of the intestine is the
jejunum (jej), which is approximately 10 feet in length. Its roll is largely that of absorption of food which is
being broken down as the food moves through the intestine. The final portion of the small intestine, the
ileum, is approximately 9 feet in length. Its primary job is that of absorption. The total length of the small
intestine, therefore, is about 20 feet. It is in this area that most nutrients (iron, sugars, calcium, vitamins and
proteins) are absorbed. The small intestine empties into the colon or large intestine. It is approximately 6
feet in length and has a primary function of absorbing fluid and storing left over food material before it is
expelled as stool.

Normal Anatomy of the upper digestive system:
Food passes from the esophagus (E) to the stomach (Stom) and eventually into the small bowel (SB). The
liver and pancreas make juices which mix with the food in the early portion of the small bowel
(duodenum). The midportion of the small bowel is called the jejunum (jej).




                            ROUX EN Y GASTRIC BYPASS

                                                    Intro
The Roux-en-Y bypass is the most common weight loss operation performed in the United States and
worldwide. It can be regarded as a restrictive procedure; however, there is some malabsorption component
due to the bypassing of food around the duodenum and first portion of the jejunum. In addition, there may
be hormonal changes that help to suppress hunger.
The Roux-en-Y gastric bypass is considered the “gold standard” operation, because it has been around for
the past 30 years, and has the most extensive literature desribing its strengths and weaknesses. The vast
majority of long term (> 10 year) studies supporting the success of weight loss surgery are based on results
of the roux-en-Y gastric bypass.



        Anatomy after the Roux-en-Y Gastric Bypass
The beginning portion of the stomach is used to make a new stomach the size of an egg. Food now passes
from the esophagus to a smaller stomach (gastric pouch), which can only hold small portions of food
before feeling full (restrictive effect). The food then passes through a small, surgically created opening
(GJ, gastro-jejunostomy) into the jejunum. Because this opening is small, it takes time for food to travel
through it, although liquids can pass through easily. NSAIDs (Advil, Motrin, etc.) and alcohol can irritate
this opening, causing it to swell shut. The digestive juices of the remaining stomach (remnant), liver, and
pancreas, travel down the duodenum and eventually mix with the food in the jejunum. The juices must
travel through another surgically created opening (JJ, jejuno-jejunostomy). Food travels for about 100cm
(3 feet) from the gastro-jejunostomy to the jejuno-jejunostomy, before being mixed with digestive juices.
Thus, there is poor absorption of nutrients and vitamins for the first three feet (malabsorptive effect).
Anatomy of the Roux Y Gastric Bypass:
Food now passes from the esophagus to a smaller stomach (gastric pouch). The food then passes through
a surgically created opening (GJ, gastro-jejunostomy) into the jejunum. The digestive juices of the
remaining stomach (remnant), liver, and pancreas, travel down the small bowel and eventually mix with
the food in the jejunum. The juices must travel through another surgically created opening (JJ, jejuno-
jejunostomy).




          Variations in Anatomy:
          The limb of small bowel (Roux limb) can
          travel through several pathways depending on
          the technique used by the surgeon and
          findings during surgery. The limb can travel
          either in front of or behind the colon, and in
          front of or behind the remaining stomach.
          Notice how the route of the small bowel makes
          a Y shape (thus, roux-en-Y).
    Antecolic Antegastric    Retrocolic Antegastric Retrocolic Retrogastric

The variations in roux limb anatomy will have no effect on weight loss or how you process food. They are
only important for a surgeon to know in case you ever need another operation involving your intestines.
   Before your surgery your stomach is
about the size of a football. After surgery
 your working stomach (gastric pouch) is
  about the size of a small egg. The small
 pouch of stomach can hold about 1/3 cup
  of food. After this, it begins to stretch,
      giving you the feeling of fullness.
   Although in most people it will give a
   feeling of fullness, in some people the
       stretching may give a feeling of
discomfort. The small stomach pouch will
  need time to digest the food and push it
    through the GJ (gastrojejunostomy)
  opening into the small bowel. If you do
 not give enough time to do this, you may
     start vomiting. Because the healing
process around the pouch takes time, it is
very important not to stress the pouch for
     the first two weeks after surgery.
Surgical Procedure and Hospital Stay
Over 98% of RYGB's are performed laparoscopically, with an average of 6 small incisions. They all
require full general anesthesia and about 2 hours of surgical time. Most patients stay one or possibly two
nights in the hospital.

Weight Loss
The vast majority of patients lose 50 to 80% of their excess weight in the first 12 months.
With the roux-en-y gastric bypass, most patients keep 50% to 70% of their excess weight off after 10 years.
However, some patients can regain some or much of their original weight.
This means a person who is 300 pounds and has an ideal body weight of 150 pounds can expect to be
between 180 to 225 pounds at the end of ten years.

After the first 2 years, there is a very slow weight loss depending on the eating habits and exercise
commitment of the patient. If you successfully use the preoperative period to adapt your lifestyle and train
yourself to eat differently, this small pouch helps to remind us to eat less food. Thus, the intake of food is
dramatically limited and enables us to lose weight, and keep the weight off lifelong. Although there is some
malabsorption of certain types of minerals and vitamins as described above, the food that is eaten will be
well digested and nearly completely absorbed. This enables us to maintain good nutritional status and
remain healthy with proper eating.

There can be a regain in weight if changes in eating habits and exercise have not been implemented. This
occurs because it is possible to outsmart or overeat these bypass operations. For example, liquids move
quickly through the pouch and are absorbed almost entirely in the intestine. If a person with a bypass eats
and drinks high calorie liquids or solids, or eats between meals, the weight will not be lost. This again
emphasizes that the surgical procedure is a tool which allows us the possibility of losing and controlling our
weight. We must still work hard and remain committed to changing our lifestyle both with regard to
exercise and with regard to the types and quantities of food that we eat.

Short Term Side Effects and Complications

The following complications can occur within the first few weeks of the operation:

    •    gastric pouch or bowel leakage (1 in 400 in the Fremont program)
    •    bowel obstruction (blockage) (less than 1%)
    •    respiratory arrest, usually caused by pulmonary embolus or apnea.
    •    cardiac arrest (heart attack).
    •    physical injury
    •    organ injury (liver, spleen, intestines)
    •    bleeding and need for blood transfusion or reoperation (1%)
    •    wound infection (5% in open operations, less than 0.5% in laparoscopic)
    •    death


Any of the complications above may result in a longer hospital stay and a prolonged recovery.
Across the nation, the overall rate of death (mortality) or serious disability after this operation is
about 1 in 400 (0.25%). Within the Northern California Kaiser Bariatric Programs, the death rate
has been much lower.

The most common reason or death is either a pulmonary embolus (a blood clot in the leg travels to the
lungs), a respiratory arrest due to swelling of the airways, a significant heart attack, or an overwhelming
infection. Men, patients over age 50, patients with the highest BMI's (greater than 60), and patients with
multiple comorbid diseases (sleep apnea, diabetes, etc.) have a slightly higher risk for complications.
However, it is important to remember that across the country deaths have occurred even in young women
with BMI’s of 40 to 50.

Long Term Side Effects and Complications

Vitamins:
 Because the anatomy of the stomach and intestines is altered, absorption of certain vitamins (iron, calcium,
vitamin B12, folate) are impaired. Patients need to take multivitamins daily. Even with multivitamins, a
few patients may develop deficiencies of B12 or iron and may need extra supplementation (sometimes
shots). Blood tests should be performed at least yearly.
Most patients will need to continue a lifelong regimen of:
    • multivitamins
    • calcium with vitamin D
    • sublingual vitamin B12
    • B1
    • Iron (for menstruating women)




Incisional hernia
Hernias are openings in the deep (fascial) layer of the incision and can present at any time. They may
occur in 5 to 10% of patients after open operations. Hernias are usually fixed after 12 to 18 months (the
time of maximum weight loss) and the repair can be combined with cosmetic procedures (i.e. “tummy
tuck”). Although the cost of hernia surgery will be covered by insurance, additional cosmetic procedures
will not. Hernias can also occur at laparoscopic incisions, but are smaller and less frequently bothersome.
Nevertheless, new pain at an old laparoscopic incision should raise the suspicion of a small hernia.

Obstruction and internal hernia
The operation creates new connections between the intestines, and several windows (or pockets) between
the segments of intestine must be created and re-closed. In addition, adhesions and scars may form within
the abdomen over time. These adhesions and pockets may often block portions of bowel (obstruction) or
intermittently trap them and choke them off (internal hernia). These complications occur in 1 to 2 % of
patients.
Patients with obstruction may present with inability to pass gas and persistent vomiting. Sometimes this
can be treated in the hospital with watchful waiting, while other times it may require another operation.
The diagnosis of an internal hernia can be difficult to make, but should be suspected any time a patient has
recurrent intermittent or crampy pain.

Anastomotic ulcer
Although, the roux-en-y gastric bypass helps acid reflux, the small pouch of stomach is very sensitive to
agents that irritate the lining of the stomach. 3 to 4% of patients may develop a gastric ulcer requiring
treatment. Ulcer causing agents include NSAIDs (motrin, advil, etc.), cigarrette smoking, and alcohol.
Most ulcers present with pain, and are diagnosed by endoscopy. Almost all ulcers can be treated effectively
with anti-ulcer medications, but may take 6 to 12 weeks to heal completely.Occassionally ulcers can
present with life threatening perforation (hole in the pouch) or bleeding, requiring urgent endoscopy or
reoperation. Very rarely, ulcers than do not respond to medical treatment may require surgical removal.

Medicines and agents that can cause ulcers:
   • NSAIDs: advil, motrin, ibuprofen, naprosyn, relafen (nabumetone), celebrex, vioxx
   • Oral steroids (oral prednisone)
   • Immunosuppressive medications for organ transplant patients and autoimmune diseases.
   • Cigarrettes, cigars, chewing tobacco
   • Alcohol


Pain medications such as tylenol, codeine, vicoden, percocet are completely safe for treatment of pain, and
DO NOT cause ulcers.

Stricture
Progressive scarring at the junction of the stomach and small bowel may lead to an inability to keep food
down in 2 to 5% of patients. Some patients may have difficulty even keeping liquids down. After the
diagnosis is confirmed by an X-ray swallow study, the stricture may be widened with endoscopy. The need
for another surgery is very rare.
Most strictures occur within the first few months of surgery.

Gallstones
With rapid weight loss, some patients (less than 10%) may develop gallstones in the gallbladder, resulting
in episodes of pain. This usually presents as pain on the right side of the abdomen, under the ribcage. The
treatment is an operation to remove the entire gallbladder with the stones (laparoscopic cholecystectomy)

Dumping Syndrome
When a large dose of sugar is released rapidly into the small intestine, the patient may experience sudden
nausea, cramps, diarrhea, perspiration, weakness, and lightheadedness. The symptoms will resolve over 30
minutes to 2 hours, and help prevent patients from eating high calorie high sugar foods that lead to weight
gain. Not everyone will experience dumping syndrome, but it is still very important for all patients to
avoid high sugar foods.

Side effects
There are many minor side effects that some patients experience, usually during the first year. These
include hair loss, bad breath, flatulance, feeling cold, hormonal changes, and mood swings. Almost all of
these symptoms seem to occur in the first year during rapid weight loss, and improve afterwards.

Cosmetic effects of weight loss:
Quite often, as the fat is absorbed from the belly, buttocks, thighs, upper arms, and
neck, the patient may be left with unattractive folds of skin. This excess skin can be
removed surgically. Most plastic surgeons recommend waiting until 18 months
after your bypass surgery. It is difficult to predict who will have excess skin.
It is important to remember that such operations are considered cosmetic, and will
usually not be covered by Kaiser or other health insurances.
                     VERTICAL SLEEVE GASTRECTOMY
                                                  Intro
The Vertical Sleeve Gastrectomy (VSG) or Laparoscopic Sleeve Gastrectomy (LSG) is an emerging weight
loss procedure. It involves reducing the size of the stomach only, without any intestinal bypass or artificial
device.
The procedure was first presented in 2002 as a “Staged Procedure” for the Super-Super morbidly obese
patients (BMI >60), with the aim to decrease operative time and effectively "downstage" a high risk patient
to a lower risk group. Patients would lose 100-150 lbs and return to surgery 12-18 months later for
intestinal bypass (stage II). Because there was substantial weight loss after the sleeve alone, it was
eventually offered as a primary (stand alone) weight loss procedure.


      Anatomy after the Vertical Sleeve Gastrectomy
Blood vessels along the greater curvature of the stomach are divided and a new stomach is tailored along
the lesser curvature with staples that seal and cut. About 80% of stomach is removed, leaving the
remaining stomach shaped like a banana. It is purely a restrictive procedure. Compared to the gastric
bypass, the volume of the stomach is larger, but there is no intestinal malabsorption. Like the bypass, there
may be a hormonal effect that reduces sense of hunger.




Surgical Procedure and Hospital Stay
Over 98% of sleeve gastrectomies are performed laparoscopically, with an average of 5 small incisions.
They all require full general anesthesia and about 1 to 1 ½ hours of surgical time. Most patients stay one
or possibly two nights in the hospital.

Weight Loss
The initial weight loss is similar to the gastric bypass. The vast majority of patients lose 50 to 80% of their
excess weight in the first 12 months.
With the roux-en-y gastric bypass, most patients keep 50% to 70% of their excess weight off after 10 years.
However, some patients can regain some or much of their original weight.
This means a person who is 300 pounds and has an ideal body weight of 150 pounds can expect to be
between 180 to 225 pounds at the end of ten years.

As of 2009, the 3 year weight loss results of the gastric sleeve seem similar to the gastric bypass. However,
in the past, purely restrictive operations have led to LESS long term weight loss than the gastric bypass.
Thus, at this time it is unclear if patients will maintain the same long term weight loss after 10 years that
has been observed with the gastric bypass. For this reason, despite its increasing popularity, it cannot be
considered the gold standard for weight loss operations.

Like the gastric bypass, it is easily possible to regain all the weight if changes in eating habits and exercise
have not been implemented.

Short Term Side Effects and Complications

The short term complications are similar to the gastric bypass, and can include all of the following within
the first few weeks of the operation:

    •    gastric leakage (about 1 in 100 reported nationally)
    •    respiratory arrest, usually caused by pulmonary embolus or apnea.
    •    cardiac arrest (heart attack).
    •    physical injury
    •    organ injury (liver, spleen, intestines)
    •    bleeding and need for blood transfusion or reoperation (1%)
    •    wound infection (5% in open operations, less than 0.5% in laparoscopic)
    •    death




Long Term Side Effects and Complications

Vitamins:
Although not malabsorptive, the stomach is also responsible for absorbing certain vitamins, and removal of
80% can result in some vitamin malabsorption. Thus, it is still strongly recommended that all patients
continue a lifelong regimen of:
    • multivitamins
    • calcium with vitamin D
    • sublingual vitamin B12
    • Iron (for menstruating women)

GERD: Heartburn and Reflux
Acid reflux and heartburn symptoms may INCREASE after sleeve gastrectomy due to the new anatomy.
This may occur in about 6% of patients, and will require lifelong medications (pepcid, prilosec, protonix,
etc.) or conversion to gastric bypass.

Anastomotic ulcer
The incidence of anastomotic ulcer is thought to be lower than that of the gastric bypass, although long
term results are still unknown. For this reason cigarrette smoking and regular alcohol use are still
prohibited. However NSAIDs, steroids, aspirin, and immunosuppressive medications can be tolerated if
required for other medical conditions.

Difficulty Swallowing
Some patients may have difficulty even keeping liquids down, usually within the first few weeks of
surgery. Unlike the bypass, the sleeve cannot be dilated, and may require several weeks to improve as the
swelling lessens and the scar tissue softens.

Gallstones
Like the gastric bypass, some patients may develop gallstone related symptoms with weight loss.

Side effects
Side effects are similar to the gastric bypass. These include hair loss, bad breath, feeling cold, hormonal
changes, and mood swings. Almost all of these symptoms seem to occur in the first year during rapid
weight loss, and improve afterwards.

Cosmetic effects of weight loss:
The cosmetic effects are identical to those of the gastric bypass.
   ADJUSTABLE GASTRIC BANDING (LAP-BAND)
                                                  Intro
While the Lap-Band differs in many ways from gastric bypass surgery the need for LIFE LONG
COMMITMENT to a new healthy lifestyle remains the same.
Just like gastric bypass you must use this “tool” EVERYDAY for the REST OF YOUR LIFE to be
successful with your continued weight loss and weight loss maintenance.




The Band is a silicone hollow ring placed around the upper part of the stomach, creating a pouch above the
band about the size of an egg. The inner surface of the Band (or “balloon”) is adjustable by adding or
removing saline. By adjusting the amount of saline in the band you can reduce the flow of food from this
pouch into the lower part of your stomach. The band lets you feel full after eating a smaller amount of food
and makes you less hungry between meals. The Band is connected by a tube to a port placed underneath the
abdominal skin during surgery. The amount of saline in the band is controlled by piercing this port through
the skin with a special needle.



                    Anatomy and Surgical Procedure
Almost 100% of gastric bands are placed laparoscopically, with an average of 5 small incisions. They all
require full general anesthesia and about 1 hour of surgical time. Most patients stay one night in the
hospital.

Although most pictures you will see do not show it, the band is kept in place by securing it in a flap of
stomach with 3-4 sutures. Should the band be removed, this flap is left in place. Due to the natural scarring
that occurs in the body, reversal of this flap would be very difficult. Even with removal of the band, the
stomach is left scarred and altered. Thus, the band is REMOVABLE, but not everything is reversible.
Short Term Side Effects and Complications

The following complications can occur within the first few weeks of the operation:

    •    respiratory arrest, usually caused by pulmonary embolus or apnea.
    •    cardiac arrest (heart attack).
    •    physical injury
    •    organ injury (liver, spleen, intestines)
    •    bleeding and need for blood transfusion or reoperation (less than 1%)
    •    wound infection, port site infection.
    •    death

Weight Loss

The weight loss with the lap band is slower and more variable than with the gastric
bypass or gastric sleeve. Patients may lose ZERO to 80% of their excess weight over 1 to 5 years.
Compared to the gastric bypass and gastric sleeve, the calorie restrictions and hunger suppression is less.
Because it is a “smaller tool”, it requires even greater diligence, understanding, and motivation to make
weight loss successful.

Most of the 10 year results for the band have been based on patients from Europe and Australia. In the
United States, the long term weight loss results have been less successful. Some surgeons feel that it is
extremely difficult to lose more than 100 pounds with the band, and do not recommend it for anyone with a
BMI of 50 or above.

Adjustments and Fills

Band adjustments are done in the clinic in the doctor’s office. The skin over the port site is sterilized. To
adjust the band your doctor will inject or remove a small amount of saline from the port located under the
skin of your abdomen. This procedure is generally very well tolerated and local anesthetic is not needed.
Most patients say it is nearly painless.

Only a trained clinician can adjust your band. Never let an untrained clinician do it.
A special needle provided by the makers of the Band MUST be used otherwise the port may be damaged
and leak saline.
Generally it can take 3-5 fills before reaching your Green zone. You must wait at least a month between
fills to allow your stomach to adjust to the tighter band and to allow you to continue to adjust your dietary
habits. Afterwards you may need 1-2 fills a year life long to maintain the band tightness. This is because
the saline slowly leeches out of the band, causing it to loosen over time

The algorithms to determine the appropriate adjustments may be complex. Often, it is not clear whether
failure to lose weight is due to poor lifestyle with liquid or soft calories, lack of exercise, a complication
(i.e. Band slippage or erosion) or improper filling. It is important to understand that the band can only help
with weight loss if the patient and the bariatric team have an honest and clear understanding of what the
patient is experiencing. The patient must be able to clearly communicate what they have experienced over
several weeks in order for the bariatric team to make the appropriate adjustments. Adjustments must be
made in small increments, and it is only through frequent visits and adjustments that the best weight loss
can be achieved.


It is important to note that fills are not always covered by insurance plans and outside of Kaiser, can cost
$300-$600 each fill.



When the band is first placed, it is usually left empty or with minimal fluid in it.
The first time the Band is adjusted is at your 6 wk appointment. To determine if a fill is
appropriate, at each appointment your doctor will consider:

    1. Your weight loss.
    The goal is 1-2 lbs weight loss a week. Do not expect more.

    2. Your total calorie intake in a day.
    The ideal is approximately 1200-1500 calorie a day diet divided over 3 meals. If the Band is correctly
    adjusted you should not feel hungry on this diet.
    Initially you will need to count calories every day until you become very familiar with the calories in
    various foods. Long term it is advisable to do a calorie count a few times a mouth to make sure you are
    not inadvertently taking in extra calories.
    Please review the “Mindful Eating” section earlier in the Nutrition chapter.

    3. The TYPE of food you can comfortably eat.
    The Band will NEVER work if you are eating liquid or soft calories. If the Band is so tight that these
    are the only types of food you can tolerate, the best thing to do is remove some fluid from the band.
    Remember more fluid is not necessarily a good thing and may actually slow your weight loss if added
    inappropriately.

    4. Your exercise routine.
    For ANY type of weight loss surgery to be successful you MUST exercise (do something you enjoy!)
    at least 5 days a wk for 45mins each time.

    5. How much fluid is already in your band.
    After the first few fills the maximum amount added at each fill is reduced. As you get closer to the
    ideal amount of fluid in the band (the GREEN ZONE) it may only take tiny amounts of saline to adjust
    the band to the correct size. Too much fluid at this stage may over tighten the band requiring fluid to
    be removed

    There will be times when you make an appointment for a fill, but your doctor decides it is not
    appropriate based on the above assessments. Don’t be in a hurry to have a fill before you are ready.
    The Band is designed to offer steady, gradual weight loss. There is no race to any finish line! Too
    much can very easily get you into trouble and you end up further behind than if you had gone slower
    with the fills.
6. After every fill you will be on a liquid diet for the first 24 hours. You can then quickly advance
to a regular Band diet.
The Green Zone

         This is the ideal band fill volume which allows you to achieve optimal weight loss. Everyone
         requires a different restriction volume and adjustment schedule to reach their Green Zone.
         Ideally, once the band is adjusted to the green zone, the patient should tolerate a 1200calorie a day
         diet without significant hunger between meals.

         When patients are not in the green zone, they will often experience the following symptoms:
            • Well chewed food getting stuck
            • Frequent heartburn
            • Regurgitation
            • Waking up at night coughing or vomiting.
            • Maladaptive eating (liquid or soft foods are the only foods you comfortably eat).




Long Term Side Effects and Complications
The overall reoperation rate for lap bands may be as high as 1 in 6 over ten years. Because it is a silicone
foreign body place around a soft organ, there is a significant rate of slippage, erosion, and infection often
requiring complete removal. Most patients will regain their weight once the band has been removed.

Vitamins
With the Band there is no vitamin or nutrient malabsorption. However because your food
intake is significantly reduced you will need to take the following for as long as the band
is in place and functional. Chewable vitamins may be better tolerated.
     • Multivitamin
     • Calcium PLUS vitamin D

Slippage
This is also known as prolapse and occurs in approximately 2-15% of people an average of 10mths after
surgery. The exact cause is unknown but it may be related to significant vomiting after surgery. Encasing
the band in a sleeve of stomach as shown in the diagram page 1, helps reduce the occurrence of prolapse.
Symptoms typically include new onset reflux and difficulty swallowing foods you previously tolerated.
Pain is rare. The diagnosis is confirmed with an x-ray known as a barium swallow. Surgery is necessary to
remove the band.

Erosion
Band erosions into the stomach occur in up to 5% of patients. Non steroidal anti-inflammatory medications
such as Motrin™ may increase his risk. Erosion generally present with failure of weight loss despite
adjustments and good lifestyle habits. Endoscopy confirms the diagnosis and surgical correction is
warranted.

Dilatation of the Esophagus
Rapid and aggressive adjustments will lead to over-tightening and subsequent difficulty swallowing with
possible dilatation of the esophagus. His can occur in up to 10% of patients. This is more likely to occur
with band adjustments performed on the basis of radiological stoma size under fluoroscopy rather than on
subjective patient satiety. Symptoms may include heartburn, lack of weight loss and loss of satiety.

Tubing and Port Complications
These include tubing breaks, leaks, kinks and disconnections. Port site infections and port site pain can also
occur. Generally these are correctable with laproscopic surgery. Avoiding heavy exertion for 6 wks after
surgery will allow adequate healing and fixation of the access port to the stomach muscle sheath.
Other Issues

Pregnancy
If you need to eat more during pregnancy the band can be loosened and tightened again after pregnancy.
There may be an increased risk of slippage as the stomach is compressed by the pregnancy.

Other medical issues
If you develop and illness that requires to eat more or that causes vomiting the band can be loosened. If the
band cannot be loosened enough, it may need to be removed.
   COMPARISON OF THE DIFFERENT OPERATIONS
BAND vs            Lap Band                        Lap RYGB                    Lap Sleeve
RYGB vs
Sleeve

Operation          5 incisions (4 x ½”, 1 x 2”)    6 incisions (1/2”)          5 incisions (4 x ½”, 1 x
                   1 ½ hours, general anesth.      2 hours, general anesth.    2”)
                   Overnight stay                  Overnight stay              1 ½ hours, general
                   Possibly 1/600 chance of        1/400 chance of death       anesth.
                   death                                                       Overnight stay
                                                                               1/400 chance of death
Post op recovery   2 weeks off from work,          4 weeks off from work,      4 weeks off from work,
                   primarily for incisional pain   primarily for tiredness     primarily for tiredness
                                                   and fatigue                 and fatigue

Follow up          5 – 10 adjustments (needle      4 visits in office/ 1st     4 visits in office/ 1st
                   injections) over 2 years,       year.                       year.
                   then 1 – 3 every year for       1 visit / year from years   1 visit / year from years
                   life. Adjustments only at       2 to 5, (can sometimes      2 to 5, (can sometimes
                   bariatric centers.              be done over the            be done over the
                   Kaiser Cost = $ copay,          phone).                     phone).
                   future increase in copays
                   unknown.
                   Private pay cost = $200-
                   $800/ injection

Vitamins           Vitamins strongly               Vitamins essential,         Vitamins strongly
                   recommended, deficiencies       deficiencies can take       recommended,
                   can be corrected quickly        long time to correct        deficiencies can be
                                                                               corrected quickly
NSAIDs (motrin,    Can be tolerated with           Even occasional use can     Can be tolerated with
advil, etc.)       occasional use                  lead to ulcers              occasional use
Smoking            Not recommended, but not        Can lead to significant     Can lead to significant
                   life threatening                ulcers and chronic pain     ulcers and chronic pain
Binge drinking     Not recommended, but not        Can lead to significant     Can lead to significant
                   life threatening                ulcers and chronic pain     ulcers and chronic pain
Heartburn          Heartburn (acid reflux)         Heartburn (acid reflux)     Heartburn (acid reflux)
                   symptoms can increase           symptoms decrease, but      symptoms can increase
                                                   ulcer symptoms may
                                                   increase.
Diabetes           50-70% improvement,             70-95% improvement,         50-70% improvement,
                   proportional to weight loss     due to weight loss AND      proportional to weight
                   if the weight is lost.          intestinal bypass.          loss.
BAND vs       Lap Band                        Lap RYGB                    Lap Sleeve
RYGB vs
Sleeve

Reoperation   1 in 6 over 5 years, 10 year    1 in 30 reoperation over    At 3 years,
              results unknown.                5 to 10 years, 30 year      reoperations due to
              Due to slippage, infection,     results may be higher.      leak (1%). Long term
              erosion, break or leak, port    Due to internal hernia,     reoperation rate
              site pain, heartburn, failure   bowel blockage, scar        unknown, but should
              to lose weight.                 tissue, adhesions,          be very low.
                                              ulcers, abdominal wall
                                              hernia.

Weight loss   Weight loss occurs over 2       Weight loss occurs over     Weight loss occurs
              to 5 years, and then            1 year, and then            over 1 year, and then
              stabilizes. On average, 40-     stabilizes. On average,     stabilizes. On average,
              70% excess weight is lost.      50-80% excess weight        50-80% excess weight
              Some patients do not lose       is lost. Wt loss and low    is lost.
              any weight.                     weight maintenance          Wt loss and low weight
              Wt loss and low weight          require daily lifelong      maintenance require
              maintenance require daily       mindful eating and          daily lifelong mindful
              lifelong mindful eating and     exercise.                   eating and exercise.
              exercise.                       70% of patients             Wt loss beyond 3 years
                                              maintain good weight        still unknown.
                                              loss over 10 to 30 years.
     GOALS AND PREPARATION BEFORE SURGERY

       Who is the ideal candidate for surgery?
The ideal candidate for surgery is the person who has seriously tried to lose weight in the past, understands
the risks and benefits of surgery, understands the lifelong changes in lifestyle required for success, and has
the support of family and friends to help him or her through the process. For the Fremont Bariatric
Program, we will ask each candidate to meet the following criteria prior to the actual surgery (not
necessarily prior to entry in the program):
• learn how to estimate the number of calories in different foods and learn how to count the total number
     of daily calories
• quit smoking for 3 months. Compared to surgery, quitting smoking is an easier and much less risky
     way to improve ones health. In addition, smokers have more chances of complications with surgery.
• attend a support group session to meet people who have undergone the surgery.
• start a regular exercise program
• demonstrate a 10% weight loss during the period approaching surgery
• understand the need to avoid pregnancy for the first two years (if you are a woman of child bearing
     age).


Why do you need to lose weight BEFORE surgery?

Surgery is only one step in the battle to lose weight. Patients who cannot change their eating habits and
start an exercise program will eventually gain all their weight back despite the surgery. This may occur
even if the pouch does not stretch to a larger size. It is believed that the hormones responsible for feelings
of fullness and appetite may start to adapt over time. Thus, many of the cravings and desires that seem to
disappear right after surgery start to return one or two years after surgery.

It does not make sense to accept the risk of surgery if it will not be helpful in the long
run.
Losing weight before surgery
    • allows you to learn the lifestyle that you must continue after the surgery and for the remainder of
        your life, making post operative adjustment much easier.
    • proves to yourself that you can change your lifestyle
    • improves control of pre-operative medical conditions
    • improves the safety of surgery by decreasing the complication rate




How do you you lose weight BEFORE surgery?

1.   RECORD YOUR WEIGHT NOW. Try to record your weight in the presence of a health or medical
     professional when possible. Try to check your weight every week at the same time of day. Some
     offices may not have the correct scales, but usually there is at least one place in each hospital or clinic
     where you can get an accurate weight. Sometimes it will be up to you to find a good scale and a
     medical professional willing to witness your measurements. Use a chart to keep track.

2.   Attend the nutrition and weight management classes offered by Kaiser or other organizations. Learn to
     eat slowly and without distractions. Studies show that people tend to eat more when watching
     television or participating in other passive activities. By choosing food wisely and enjoying it slowly,
     you can actually feel fuller with less food. Review all the recommendations in the Nutrition portion of
     the Patient Information Book

3.   Learn about calories. To lose weight you must burn or use up more calories than you eat. Once the
     energy from food is used up, additional energy must come from fat and other storage areas in your
     body. Learn about the amount of calories in common foods, both healthy and unhealthy. Try to
     figure out how many calories you have eaten by the end of the day. Also try to learn about which
     foods are higher in fat and which are higher in protein. Try to eat foods with a lower density of
     calories at each meal.

4. Start planning an exercise program. Exercising and activity help you burn calories.
   Even when not trying to lose weight, obese people who exercise tend to be much
   healthier and live longer than obese people who do not. In fact, some obese people
   who exercise are healthier and live longer than seemingly thin people who do not.
                                   HOSPITALIZATION
The expected hospital course is as follows:
1.   Be seen in the preoperative clinic prior to your operation. We will give you a time of arrival for the day
     of surgery.

2.   Arrive at Fremont Medical Center (main hospital) on the day of your operation.

3.   Meet with your surgeons, the anesthesiologist, and the operating room nurses just prior to your
     operation.

4.   Have your operation.

5.   A brief stay in the recovery room followed by admission to the nursing floor 2 south. Patients with
     some cardiac or lung conditions, difficulty during intubation, or prolonged operative time MAY
     require a breathing tube overnight. This will require an overnight stay in the ICU with sedation and a
     ventilator.

6.   One to two day stay in the hospital. Most patients will be allowed to drink liquids the night of the
     operation or the next morning. You will have an I.V. (intravenous line) to receive pain medications,
     and perhaps a Foley (bladder) catheter. No further tests will be required unless there is a suspicion of a
     complication. The main reasons for hospitalization after the operation is too help you with the pain of
     the incisions and to make sure you will be safe at home.

7.   You may have a drain placed during the operation. Sometimes this drain will be removed before you
     go home, but sometimes you may be taught how to care for it until it is removed on the first clinic
     visit.

Time off from work

Most patients require approximately 4 wks off from work, but there is a significant amount of variation.
The type of incision (open vs. laparoscopic) does not seem to make much of a difference. The most
limiting factors seem to be persistent nausea, fatigue, the need to drink frequently, and the type of work.
                                   LIFE AFTER SURGERY
Diet: You will receive instructions to slowly advance your diet through the following
        Stages.

Stage 1: Liquid Diet.
         Soon after surgery, patients are started on a liquid diet.

Stage 2: Blended Foods
         For the first two weeks after surgery, patients can have blended foods such as    strained soups,
cream of wheat, sugar free puddings, and plain yogurt.

Stage 3: Soft Solid Foods
         After being seen in the clinic at two weeks, patients may be able to start eating more solid foods.

 After roughly ¾ to 1 cup of food, patients will experience a feeling of fullness. Because of the narrowing
of the stomach, patients may not be able to tolerate dry breads and chewy meats. Most patients should be
able to tolerate soft foods such as eggs, deli meats, fish, soft vegetables, and cheese. Some patients may
not be able to tolerate solids for the first several weeks.

Patients must focus on getting enough water and protein each day. This will require a purposeful plan
to sip liquids every 10 minutes for the first two weeks post–op. You will also have to use protein
supplements until you are tolerating a Stage 3 diet.
You must eat your three meals per day and at all cost avoid snaking!

Patients must learn about which foods are low in calories and fat, and which foods are higher in protein.
Lack of protein can sometimes lead to poorly healing incisions and hair loss. Patients must avoid high
calorie drinks and alcoholic beverages.

In a few patients, high sugar foods will cause weakness, sweats, or cramps and will need to be avoided. A
few patients may develop lactose intolerance and will need to avoid milk, cheese, and other dairy products.

Exercise:

 Once the incisions have healed (usually 2 weeks), patients should start a regular exercise program 3 to 5
times a week. The specific exercise (i.e. swimming, walking, running) needs to be tailored to each
individual. As mentioned before, regular exercise is essential to keeping the weight off, becoming healthier
and living longer.




Medicatiion changes with weight loss:
As the weight improves, patients can reduce or eliminate diabetic and blood pressure medications, have less
pain from arthritis, and less problems with sleep apnea.

    •    With the gastric bypass, patients are able to reduce their medications for diabetes even before they
         lose much weight. After gastric bypass, almost 100% of young patients with adult onset diabetes
         will eventually be off all diabetic medications (and about 80% of older patients) within one year.
    •    About 70% of patients will be able to eliminate or significantly reduce their use of blood pressure
         medications over the first year.
    •    About 50 to 70% of patients have fewer episodes of sleep apnea and may eliminate the use of their
         CPAP machine after one year.
    •    Many patients will be able to stop their medications for high triglycerides.



Medication Restrictions:

•   Medications for high blood pressure and diabetes must be managed carefully as these conditions
    improve over the first year.
•   Patients who still have their gallbladder will be required to take ursodiol (actigall) twice a day for three
    to six months in order to prevent gallstone formation during rapid weight loss.
•   Patients cannot take non steroidal anti-inflammatory (NSAIDs) medications (Motrin, Advil, Naprosyn,
    Aleve, Feldene, Indocin, Lodine, Relafen, Votaren etc.) for the remainder of their lives because these
    medications can erode or destroy the small stomach pouch.
•   Patients who must take aspirin for heart disease or NSAIDs for arthritis may need to take a daily
    stomach protective medication (proton pump inhibitor) as well.
•   Most other medications (anti-depressants, thyroid medications, etc.) are continued at the regular dose.
    When taken with water, most medications (even large ones) can be swallowed and WILL NOT get
    stuck.


Birth Control and Pregnancy after Gastric Bypass and
                      Gastric Sleeve
Patients are advised to avoid pregnancy for the first two years after surgery because many post surgical
complications may make the management of pregnancy difficult. In addition, the major period of weight
loss occurs in the first 18 months after weight loss. Patients burning body stores of fat, which may make
management of the pregnancy difficult. In addition, patients will lose the benefit of maximal weight loss
in the first two years if it is interrupted by the natural weight gain of pregnancy.

After the first 18 to 24 months, patients have reached a stable weight, and pregnancy is safe. There are no
special considerations for most pregnant patients who have had bypass surgery. They should keep close
track of the weight gained during pregnancy, maintain healthy eating habits, and be very strict about
vitamin, iron, and folate supplementation.

Because of the issues related to pregnancy, we strongly urge all women of child bearing age to use a
reliable method of birth control.

After this period, it is perfectly safe for both the mother and baby to have a pregnancy. However, the
mother must not to forget to take the recommended vitamins, and must minimize the amount of weight
gained during the pregnancy (15 pounds maximum).




Primary Care Provider
Patients who undergo gastric bypass surgery will
  require follow up with a primary care provider for the
  rest of their life. For this reason, they should choose
  a primary care physician who is sensitive to the
  special needs associated with obesity and patients
  undergoing the surgery.
We will communicate a treatment plan to your primary care provider and be available to answer questions
should they arise.

With each visit, the following issues should be addressed:
1. Measurement of weight.
2. Documentation of average caloric intake
3. Management/ alteration of medications for diabetes, hypertension, etc.
4. Determine the need for continued CPAP
5. Checking for vitamin and protein deficiencies and ordering labs.
        Labs: Iron, folate, B12, Calcium, Magnesium, electrolytes, CBC, albumin
6. Recognition of any surgical complications requiring consultation with the surgeon



Fremont Surgeon or Bariatric Internist:
After gastric bypass and gastric sleeve, we will schedule visits at 2 weeks, 6 weeks, 3 months, 6 months, 12
months, 18 months, 24 months, and once a year for 10 years. With the lap band, the visits will be based on
the need for fills, with a minimum of one visit a year.

With each visit, the following issues will be addressed:
1. Answering questions, problem solving, and feedback.
2. Measurement of weight.
3. Documentation of average caloric intake
4. Documentation of changes in medication or CPAP use
5. Documentation of an exercise program
6. Documentation of attending support groups
7. Recognition of any surgical complications
8. Agreement with the primary care physician’s management



Support Groups
There are a variety of support groups run by different hospitals and patient groups across the nation. Most
do not require fees, but some do. A starter list of specific groups (including the ones at Kaiser) will be
provided to the patient during the orientation process. Many can be found on the obesity health website.

Although many of these meetings may seem informal, attending these meetings on a monthly basis is
extremely important. When patients hit a bump in the road (i.e. “my cravings are coming back”, “I don’t
feel as good as I think I should”), patients who have been through the experience can often provide much
better solutions and support than medical staff . Studies across the country clearly demonstrate that patients
who attend support groups regularly manage to keep more weight off for the rest of their lives.
YOU, the Patient
Despite the growing popularity of this operation, most physicians in the United States do not understand
how the operation alters the anatomy and the special complications associated with it. Many emergency
room and urgent care doctors may not be able to recognize problems when they arise. Patients must try to
understand the operation and the complications themselves, and be able to educate the doctors who do not
understand them when needed.

In addition to taking care of our patients, the staff at the Kaiser Fremont Bariatric Program is committed to
educating all the physicians and staff who take care of post surgical and obese patients. We are also
committed to aiding patients who undergo surgery at Kaiser Fremont achieve long term success. But
patients must know how to seek help when they need it, and which support services or doctors to seek help
from. This is the best protection against problems being overlooked and becoming serious.




                                          SUMMARY AND KEY POINTS

Despite their best efforts, most people who are sincere about losing weight
find themselves constantly trying to lose weight and then gaining it back.

Surgery is a tool that allows you to break the cycle of obesity. Successful
surgery, diet, and exercise shifts obesity from a disease that you must battle
to a choice that you can control.
As the weight improves, patients can reduce or eliminate many medications
and problems with sleep apnea.

Surgery provides only a short window of opportunity to make these changes
easier than before.
Eventually, some of the effects of surgery begin to wear off and it is the
permanent change in lifestyle, based on motivation and willpower, that
ensures long term success.

In the long run, the lifelong changes in diet and exercise, not surgery, result
in weight loss and better health. Motivated patients can keep 50% to 80% of
their excess weight off after 10 years.

All operations carry a small risk of death and well as complications and
reoperation.

It does not make sense to accept the small but real risk of death if you are
not committed to the lifelong changes which will result in sustainable weight
loss and improvement in your overall health.

Ultimately it is you who must make the choice, on a DAILY basis, to change
your lifestyle and change your life. It is the only way to make sure that the
small but very real risks of surgery are worth the benefits of better long term
health.

				
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