Transcript Who Qualifies for Weight-Loss Surgery?

Weight Loss Surgery
at
East Carolina University
An Introduction to Our Program:
Before, During, and After!
Goals and Objectives
• Describe obesity and health effects of
obesity
• Describe weight loss programs offered by
East Carolina University (ECU)
• Describe pre-operative work-up and postoperative care related to weight loss surgery
Our Informational Materials
• This is not intended to persuade you to have surgery and
should NOT be considered medical advice
• Only you, your family, your medical doctor, and your
surgeon know if bariatric surgery is right for you
• If you are interested in exploring weight loss surgical
options further, you will need to talk with a bariatric
surgeon
Why have your surgery with ECU?
• Our surgeons are highly qualified experts
• We are involved in research
• We have an array of services aimed at providing
care to morbidly obese clients and their families
• We genuinely want to help you reach your goals
Choosing a Surgeon
• You or your doctor may choose a specific surgeon from
our practice to see.
• The surgeon that you select may require additional
personal or medical information in order to schedule an
appointment.
• Once you have established a relationship with our
surgeons, you should then follow only their advice and
educational materials
What is Morbid Obesity?
Being 100 pounds over “ideal weight”
(your ideal body weight will be calculated during your first visit with
your surgeon)
Using the Body Mass Index (BMI)
Morbid Obesity is defined as a person:
-BMI of 40 or higher
OR
-BMI of 35 or higher with co-morbidities related to
morbid obesity
Sizing Up Your Level of Body Fat
Using the Body Mass Index
(BMI)
– Used to determine if
you qualify for surgery
– Measures obesity
based on weight
and height
Changing Perceptions of
the Seriously Overweight
In the Past:
• Obesity was seen as a weakness or failure of individual
• Diet and exercise were prescribed treatments
• Weight loss surgery was viewed as dangerous and extreme
Now in the Present:
• Obesity is considered a disease and the cause of many
serious health conditions
• Surgery has gained acceptance as the only proven method
to treat this disease
What are the impacts of Obesity??
• Social Implications
– Unfortunately, still an acceptable form of social discrimination
• Economic Implications
– Personal cost = $15,568 per year (diets, food, prescriptions)
– National cost = $200 billion
• $93 billion in medical bills
• $33 billion on weight-loss products/services
• Medical and Health Implications
– With BMI > 30
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70% increase in coronary artery disease
75% increase in stroke
400% increase in diabetes
55% increase in mortality
Health Conditions Associated with
Morbid Obesity (Co-morbidities)
High Blood Pressure
Congestive Heart Failure
Diabetes
Degenerative Joint Disease
Shortness of Breath
Stress Incontinence
Irregular Menstrual Cycles
Gallbladder Disease
Heart Disease
Swelling (legs, feet)
Sleep Apnea
DVT (Blood Clots)
Acid Reflux
Depression
What are your options??
1. Diets, exercise, and behavioral change
– Up to 10% loss of excess body weight
– Ineffective long-term: less than 5% sustain any significant weight
loss
2. Weight Loss Drugs
– Minimal sustained weight loss
– Side effects prevent long term use
3. Weight Loss Surgery
– Average 55-75% loss of excess body weight
Source: Adkinson, Am J. Clinical Nutrition, 1994
Who Qualifies for Weight-Loss Surgery?
Clinical Terms Used to Describe Various Levels of Body Fat
Normal Weight
(BMI 18.5 to 24.9)
BMI 18.5-24.9
Overweight
(BMI 25 to 29.9)
Obese
(BMI 30 to 34.9)
BMI 25-29.9
BMI 30-34.9
Severely Obese
(BMI 35 to 39.9 )
BMI 35-39.9
Morbidly Obese
(BMI 40 or more)
BMI>40
Characteristics of Potential Candidates
100 pounds above your Ideal Body Weight
Body Mass Index:
-40 or greater with no co-morbidities
-35 or greater with co-morbidities
Age of 18 to 65+ (assessed on individual basis)
Failed attempts at weight loss
Health complications related to obesity
No psychological contraindications
Understanding of the surgery/risks
Compliance with diet/exercise requirements
Most Common Surgical Options
Roux-en-Y Bypass
LAP BAND
Restrictive and
malabsorptive
Restrictive
Gastric Bypass
Advantages
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Rapid initial weight loss
Laparoscopic approach is possible
Longer experience in USA
Takes 1-2 hours
Disadvantages
• Stomach cutting, stapling and
intestinal re-routing required
• Portion of digestive tract is bypassed,
resulting in nutritional deficiencies
• “Dumping syndrome” can occur
• Non-adjustable
• Extremely difficult to reverse
Dumping Syndrome
-Stomach contents move too rapidly through the
small intestines following surgery
- Does not happen with the band.
- Avoid by following prescribed diet
-Symptoms:
-Rapid heart beat
-Headache
-Sweating
-Nausea
-Dizziness
-Diarrhea
-Lightheadedness
-Stomach cramping
-Sleepiness
The LAP-BAND System
Advantages
• Lowest mortality and complication
rate
• Least invasive surgical approach
• No stapling, cutting, or intestinal
re-routing
• Adjustable
• Reversible
• Low malnutrition risk
• Takes 1 hour/ outpatient surgery
Disadvantages
• Slower initial weight loss than Gastric
Bypass
• Regular follow-up critical for optimal
results: Need adjustments
• Requires implanted medical device
What Surgery is Right for Me?
REMEMBER…..
• All surgery has risks
• Not all patients are candidates for surgery
• Discuss your options with your surgeon
Possible Risks and Complications
• Remember: there are risks associated with
any surgery
• Your surgeon will discuss specific details
regarding each surgical option at your first
new patient appointment.
Comparing Weight-Loss Results
Gastric Bypass
LAP-BAND
Source: O’Brien et al. Obesity is a Surgical Disease: Overview of Obesity and
Bariatric Surgery, ANZ J Surg, 2004; 74: 200-204.
Your Appointments With the Surgeon and
the Surgery Practice
• You will have three visits with your surgeon before your surgery.
• Your first visit is called your “New Patient Visit”. At this visit, you will
do the following:
- Talk with the surgeon about the procedure
- Explore financial and insurance requirements
- Have a brief physical exam
- Determine preoperative evaluations you may need
- We will remind you to STOP SMOKING!!! You must be
smoke-free for 3 months prior to surgery and should not
smoke after surgery as well!
- Have an opportunity to complete a few tests before going
home.
After the “New Patient” Visit
You will receive a letter a few weeks later with appointments you must keep
before your second visit. These will include:
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Psychological evaluation
Nutrition evaluation
Upper Gastric Exam
Blood testing (lab work)
Anesthesia Consult
Also, if not done at your “new patient” visit:
• Chest X-Ray
• EKG
• ABG
Possible Pre-Operative Evaluations
(you may need these additional tests before your second visit
if your surgeon feels it is necessary)
• Other Lab Work
• Consult with cardiologist
• Colonoscopy
• Consult with pulmonologist
• Sleep Study
• Consult with vascular doctor
• Upper gastric endoscopy • Ultrasound of the abdomen
6 Month Program
Depending on your insurance company, you may
have to complete a six month diet and exercise
program. Please refer to the example progress note
in your introductory handout. When you contact
our office, we will inform you if this is your
insurance requirement. If you do require a
program, you will need to complete 4 months
prior to being scheduled for your first visit with
the surgeon.
Scheduling your appointments
• Please do not miss your appointments!!
• Remember: rescheduling may mean prolonging
your process.
• If you repeatedly miss an appointment or fail to
show up for an appointment without notice, you
may be dismissed from the program. This surgery
is a lifestyle change, and we want you to be
successful in your weight loss journey!
Making The Decision
Once your consults and tests are completed, you will
have your second visit, called the “Decision Visit”
-You will be seen in the clinic by your surgeon
-Tests results are reviewed
-All questions about the surgery are answered
-The risks and benefits of the surgery are reviewed with you
-Research opportunities will be discussed with you
-You will receive a prescription for a diet that we will instruct
you to begin 2-3 weeks before surgery.
Prescription Diet Before Surgery
We will give you the prescription for Optifast,
which will be in the form of shakes (and the
choice of one soup if you like) in place of meals.
This prescription is not usually covered by
insurance. It is approximately 71$ per week.
This diet will allow you to jumpstart your weight
loss journey.
At your first appointment, we will go into further
detail regarding your pre-operative diet.
Insurance Approval Process
After your “Decision Visit”, our office will
begin the approval process if you are an
adequate candidate for surgery.
We will mail or fax your evaluations, diet
and exercise history, letters of clearance,
and personal letter from our office to your
specific insurance company.
This approval process may take as long as 68 weeks.
Insurance Coverage Approved
When we receive insurance approval, we will
contact you with your third appointment
and surgery date!
Your third appointment is the “History and
Physical”.
History and Physical Appointment
Includes the following:
 Brief physical exam
Discussion of surgery, risks and benefits
Consent forms signed
Update lab work and tests if necessary
Must have support person present or your surgery
may be cancelled!!
Insurance Tips to Remember
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You MUST meet the requirements of all the insurances that you have
prior to submitting for approval
Depending on your insurance company, the approval process may be
lengthy (6-8 weeks)
You must check your SPECIFIC policy (or policies) to make sure
weight loss surgery is a covered benefit!!!
If your insurance company denies your request for surgery, the appeal
process may be started. This can be quite lengthy and involved, so it is
important to know from the beginning your specific insurance
company’s criteria. We will help you to the best of our ability to meet these
requirements, but it is ultimately your responsibility to be familiar with your
individual insurance policy.
Helpful Hints Prior to Surgery
- This is a weight-loss program! Any weight gain
could result in prolonging, rescheduling, or
cancelling your surgery.
- You must quit smoking! We may require a
nicotine test prior to having surgery in order to
ensure you have stopped.
- Multiple cancellations, skipped appointments, or
just not showing up for appointments can result in
prolonging the pre-operative process and possibly
dismissal from the program.
Day of Surgery
(you have been approved and completed your third visit which is your
History & Physical)
-You will be admitted to our Ambulatory Surgery
Unit (ASU)
-An IV will be started
-You will be given an antibiotic and additional
teaching by the nurse
-After you have been prepared for surgery, you will
go to the operating holding area
-Your family may wait in the family waiting area
and will be contacted after the operation
Recovery
Hospital Stay: Open surgery (3 to 4 days)
Laparoscopic (2 to 3 days)
Lap Band (1-2days)
Out of Work: Open surgery (4 to 6 weeks)
Laparoscopic (2 to 4 weeks)
Lap Band (1 to 2 weeks)
-No driving for 1-2 weeks following surgery
-No heavy lifting anything over 10 pounds for one
month after surgery
Gastric Obesity Procedure (GOP)
Diet Following Surgery
GOP Level I Diet:
- This starts after surgery and lasts for 2 weeks
-Two ounces (1/4 of a cup) of Optisource in
place of meals
-Between “meals” you may have two ounces
of non-sweetened, non-carbonated beverages.
- You MUST SIP WATER all day long
-No carbonated beverages
Home Diet Following Surgery
We will give you specific details
about your diet following weight loss
surgery. Generally this consist of:
• Drastically limiting volume
• Limiting the consistency of food
• Limiting the types of food
Tips for Eating After
Weight Loss Surgery
-Do not drink liquids with meals, either drink 30
minutes before or 30 minutes after
-Chew food well
-Take small bites of food
-Eat meals over a 30 to 45 minute time span
-Eat meals on small plate, use baby spoon
Eating after LAP BAND
• Small volumes 2-3 oz. of healthy foods
• Similar restrictions as the gastric bypass
• When you are not “filling up” than
adjustment needs to be done.
• Band may need to be adjusted 3-4 times in
first year.
• Diet modified after each adjustment
How Much Weight Can a Patient Expect to
Lose Following Surgery?
• Depends on the surgery and the follow-up
• 75% of excess weight -with Gastric bypass at the
end of one year
• 45% of excess weight with Band but increases to
65% at 2-3 year follow up with adjustments
• Amount of weight loss varies from person to
person
• Must be compliant with follow-up!!!!!
Plastic Surgery Consult Following
Surgery
-There may be excess skin on the chest, abdomen
and arms and legs
-We can refer you to a plastic surgeon when the
following criteria is met:
-After you Have Maintained a Stable Weight (this may be 12-18
months or longer)
- Your nutritional status is adequate
- Your surgeon will ultimately decide when this referral is appropriate
-Insurance rarely covers these procedures. Document
issues with your primary care now and after surgery.
Vitamins and Medications after Surgery
(REQUIRED for LIFE)
Gastric Bypass
-2 chewable multivitamins
daily (ex: Flinstones)
-Calcium Citrate or Tums
1000 mg daily
-Vitamin D 800 iu daily
-Vitamin B 12 250 mcg
daily
-Ferrous Sulfate elixir 325
mg daily (menstruating
women only)
Band
-2 chewable multivitamins
daily (ex: Flinstones)
In addition, women take:
-Calcium Citrate or Tums
1000 mg daily
-Vitamin D 800 iu daily
Vitamins and Medications
Tips to Remember!
- After surgery, all vitamins and medications
need to be one of the following:
CRUSHED
CHEWABLE
LIQUID FORM
- Please speak with your primary care doctor
and pharmacist to help adjust these
medications. Some drugs are NOT safe to crush.
Pregnancy following Surgery
-Females should not become pregnant for at least 12 to 18
months following Gastric Bypass. Pregnancy prior to this
could result in fetal demise or neural tube defects
- After the band surgery, it is best you maintain a stable
weight loss and plateau prior to becoming pregnant.
- You must follow what your surgeon tells you is best, and
please inform them if you plan on having children in the
future after weight loss surgery.
Follow-Up After Surgery
Gastric Bypass
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Lifelong commitment
Every 2 weeks for first month after surgery
Every 3 months for the first year after surgery
Yearly for a lifetime
Lab work is checked at every visit
Lap Band
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Life long commitment
2 weeks and 6 weeks after surgery
At 6 weeks, you may have your first adjustment
Monthly for first year
After first year, surgeon will decide how often to see you
Lab work checked every 3 months
Support Groups
We encourage you to join a support group prior to
surgery and maintain participation with the
support group after surgery.
Ideally, you should attend the support group offered
by your surgical practice.
Our Support Group is the 3rd Tuesday of each month at 6pm. Enter
through the Brody Outpatient Center Lobby and follow the signs!
Exercise
- Exercise is an important part of your weight
loss journey. Remember, surgery is a tool to help you
reach your goals. You must do your part as well!
- You will work up to doing exercise daily for 30 to
45 minutes per day
- Exercise options can include:
-Walking with hand weights
-Bike riding
-Weight Training
-Aerobics
-Jogging
-Swimming
-Water aerobics
Making An Appointment
• The next step in pursuing weight loss surgery is a
visit with a qualified bariatric surgeon.
• If you already have an appointment with a weight
loss surgeon, please keep the appointment, or if
you are no longer interested, please contact their
office to cancel your appointment.
Conclusion
Thank you for reviewing our informational material! We
look forward to working with you in the future, and we are
available to answer any questions you may have.
Please type in the following web address in your internet
browser to receive your certificate,
http://www.ecu.edu/weightlosssurgery/certificate.cfm
Please print out the following certificate and sign. This
certificate is proof that you have completed our online
orientation. Please write down any questions you may have
on the space provided. You must bring this form with you
to your first appointment with the surgeon, as this is a
requirement for our program. We look forward to seeing
you soon!