Tulane Bariatric Handbook March 2016 · As with any major surgery, gastric bypass and other weight-loss surgeries pose potential health risks, both in the short term and long term.

Bariatric  Surgery  Handbook    

Dear  Prospective  Patient:  

Thank  you  for  considering  Tulane  in  your  effort  to  take  control  of  your  weight  and  your  health.  If  you  have  been  suffering  from  severe  obesity  and  health  related  conditions,  weight-­‐loss  surgery  may  be  the  solution  you  have  been  searching  for.    Studies  demonstrate  that  weight-­‐loss  surgery,  as  compared  to  non-­‐surgical  treatments,  yields  the  longest  period  of  sustained  weight  loss  in  patients  who  have  failed  other  therapies.  

For  best  results,  patients  need  to  actively  participate  in  a  multi-­‐disciplinary  weight-­‐loss  program  that  includes  nutritional,  emotional,  and  exercise  counseling.  Our  highly  trained  team  is  committed  to  providing  the  highest  level  of  patient  care  every  step  of  the  way.  

We  have  a  multidisciplinary  group  of  surgeons  who  are  dedicated  to  the  care  of  bariatric  patients.  We  offer  patients  laparoscopic  roux-­‐en-­‐Y  gastric  bypass,  sleeve  gastrectomy,  and  some  revisional  bariatric  surgery.  

Please  read  through  the  materials  provided  in  this  packet  carefully.  It  is  important  that  you  provide  us  with  as  much  detail  as  possible  so  that  we  will  be  able  to  assist  you  and  help  you  start  your  journey  towards  a  healthier,  happier  life.    

Please  note  that  this  is  not  an  overnight  process.  There  are  many  required  steps  that  involve  multiple  parties.  We  will  make  every  effort  to  expedite  this  process  for  you.  Please  remember  to  follow  the  preoperative  checklist  very  carefully;  this  will  allow  your  surgery  to  proceed  as  planned.  This  may  require  extensive  cooperation  from  you  primary  care  physician,  i.e.  referrals  for  the  various  clearances  and  testing.  

We  look  forward  to  helping  you  achieve  your  health  goals!  

Best  regards,  

The  Tulane  University  Bariatric  Team  

The  increase  in  weight  in  the  United  States  population    

BMI  REFERENCE  CHART  

Indications  for  Surgery    • BMI  >  40  • BMI  >  35  with  comorbidities    

o HTN,  DM,  OSA,  NAFLD,  Osteoarthritis,  Lipid  abnormalities,                        Heart  Disease,  or  other  Gastrointestinal  disorders  

• Failed  attempts  at  diet  and  exercise  • Motivated  and  well-­‐informed  • Free  of  Significant  pathology  or  psychologic  disease  • Substance  Free  

Contra-­‐Indications  for  Surgery  • Participation  in  illegal  drugs  • Addiction  to  alcohol  • Terminal  disease  • Less  than  18  years  of  age  or  older  then  65  • Weight  of  greater  than  400  lbs  

Sleeve  Gastrectomy    

Today  sleeve  gastrectomy  is  the  fastest-­‐growing  weight  loss  surgery  option  in  North  America.  

The  procedure  is  a  surgical  weight-­‐loss  operation  in  which  the  stomach  is  reduced  to  about  25%  of  its  original  size,  by  surgical  removal  of  a  large  portion  of  the  stomach  along  the  greater  curvature.  The  result  is  a  sleeve  or  tube  like  structure.  The  procedure  permanently  reduces  the  size  of  the  stomach.    The  procedure  is  generally  performed  laparoscopically.  

The  procedure  involves  a  longitudinal  resection  of  the  stomach  starting  from  the  antrum  at  the  point  5–6  cm      

Roux-­‐En-­‐Y  Gastric  Bypass  

Surgical  procedure  in  which  the  stomach  is  divided  into  a  small  upper  pouch  and  a  much  larger  lower  "remnant"  pouch  and  then  the  small  intestine  is  rearranged  to  connect  to  both.  Surgeons  have  developed  several  different  ways  to  reconnect  the  intestine,  thus  leading  to  several  different  gastric  bypass  (GBP)  procedures.  

The  most  commonly  employed  gastric  bypass  technique  re-­‐routes  the  small  intestine  which  is  normally  20–33  ft  in  length.    The  small  intestine  is  divided  approximately  45  cm  below  the  lower  stomach  outlet  and  is  re-­‐arranged  into  a  Y-­‐configuration,  enabling  outflow  of  food  from  the  small  upper  stomach  pouch  via  a  "Roux  limb".    The  Roux  limb  is  constructed  using  80–150  cm  (31–59  in)  of  the  small  intestine,  preserving  the  rest  (and  the  majority)  of  it  for  absorbing  nutrients.    

   The  patient  will  experience  very  rapid  onset  of  the  stomach  feeling  full,  followed  by  a  growing  satiety  (or  "indifference"  to  food)  shortly  after  the  start  of  a  meal.  

Risks  of  these  surgical  procedures    

As with any major surgery, gastric bypass and other weight-loss surgeries pose potential health risks, both in the short term and long term.

Risks associated with the surgical procedure can include:

• Excessive bleeding • Infection • Adverse reactions to anesthesia • Blood clots • Lung or breathing problems • Leaks in your gastrointestinal system • Death (rare)

Longer term risks and complications of weight-loss surgery vary depending on the type of surgery. They can include:

• Bowel obstruction • Dumping syndrome, causing diarrhea, nausea or vomiting • Gallstones • Hernias • Low blood sugar (hypoglycemia) • Malnutrition • Stomach perforation • Ulcers • Vomiting • Death (rare)

Expected  outcomes  from  each  procedure    

Resolution  of  Co-­‐morbidities  after  Bariatric  Surgery

 Hospital  stay  

   You  should  expect  to  spend  1-­‐3  days  in  the  hospital  depending  on  your  individual  condition  and  type  of  surgery.  Every  attempt  is  made  for  you  to  have  a  smooth  and  comfortable  hospital  stay.      Tulane  University  is  dedicated  to  the  quality  of  your  care.  This  means  at  the  hospital  and  staff  are  fully  trained  to  care  for  a  bariatric  patient.  Routine  visits  from  the  bariatric  program  coordinator  and  your  surgeon  will  also  take  place  through  the  days  you  are  staying  with  us.        Things  to  bring  with  you:  

• Comfortable  loose-­‐fitting  clothing  • Walking  shoes  and  socks    • Chapstick  or  Vaseline  • CPAP  machine  and  all  the  parts  if  you  use  it  at  home  • Toothbrush  and  toothpaste  • Deodorant  • Pajamas,  robe  and  slippers  if  you  prefer  • Container  for  glasses  or  contacts,  if  applicable  

Please  do  not  bring  medications  from  home  except  for  inhalers  

*Do  not  bring  any  jewelry  or  other  valuables  to  the  hospital  

Bariatric  surgery  patient  contract      

Having  elected  to  undergo  bariatric  surgery  for  my  morbid  obesity,  I  agree  to  the  following:    

1.  I  have  been  informed  of  my  personal  medical  problems,  the  dangers  of  morbid  obesity,  and  the  operations  available  to  me.    2.  The  dangers  and  complications  of  surgery  have  been  completely  explained  to  my  satisfaction,  including  the  possibility  of  dying.    3.  I  am  voluntarily  electing  to  have  this  surgery  without  coercion  or  deception  on  the  part  of  the  surgeon  or  staff.    4.  I  realize  the  importance  of  lifelong,  regular,  postoperative  follow-­‐up  and  will  keep  all  scheduled  appointments.    5.  Specific  vitamins  and  minerals  supplements  will  be  required  after  surgery.  I  will  purchase  and  be  committed  to  taking  the  supplements  daily  for  the  rest  of  my  life.    6.  I  realize  the  importance  of  attending  support  group  meetings  and  understand  that  they  are  crucial  to  my  success,  especially  in  the  first  year.    7.  I  am  aware  that  behavior  modification  is  primarily  learned  through  support  group  meetings  and  is  made  easier  as  a  result  of  my  surgery.  Behavior  modification  is  an  important  part  of  bariatric  surgery  and  will  enhance  the  success  of  my  weight  loss.  I  understand  that  it  involves  exercise,  changes  in  the  types  of  food  I  eats,  liquids  I  drink,  the  number  of  meals  I  eat  each  day  and  how  thoroughly  I  chew  my  food.    8.  I  realized  that  my  liver  may  be  sensitive  after  this  surgery  and  I  should  stay  away  from  alcohol  and  any  drugs  that  may  cause  liver  damage.    9.  I  will  immediately  give  all  tobacco  products  and  will  work  with  my  health  providers  on  smoking  cessation.  I  understand  that  if  I  continue  to  smoke,  I  will  not  be  eligible  for  surgery.    10.  I  am  committed  to  contact  the  surgeon  and  staff  should  I  have  a  surgically  related  medical  complication.  

 I  have  read  and  understood  the  bariatric  surgery  guide  given  to  me  and  I  plan  to  adhere  to  the  guidelines  as  written.  I  have  read  the  above  contract,  understand  and  agree  to  abide  by  the  terms.    Patient  signature_____________________________________Date:_____________________  

Bariatric  Patient  Testing  Checklist      The  following  are  testing  or  requirements  which  your  surgeon  has  deemed  necessary  in  order  for  you  to  have  surgery.      Description   Required   Received   Findings  

Immediate  smoking  cessation      

Nutritional  evaluation        

Psychological  consultation        

Medical  clearance        

EKG        

Lab  work  (CBC,  lipids,  LFTs,  CMP,  PT,  PTT,  TSH,  T3,  T4,  H  pylori)  

Chest  x-­‐ray        

Ultrasound        

Sleep  study        

Upper  GI        

Echo        

Cardiology  clearance        

Pulmonary  clearance        

GI  consultation        

Colonoscopy        

Endocrinology  consultation        

Hematology  consultation        

Other: