Weight Loss Surgery
East Carolina University
Our Program: Before, During,
and After…
Goals and Objectives
Describe obesity and health effects of obesity
 Describe weight loss surgeries offered by East
Carolina University (ECU)
 Describe pre-operative work-up and postoperative care related to weight loss surgery
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Our Informational Materials
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This is not intended to persuade you to have surgery and should
NOT be considered medical advice
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Only you, your family, your medical doctor, and your surgeon
know if bariatric surgery is right for you
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Further information regarding the appropriate surgery for you
will be discussed in person with the surgeon at your first visit
Why have your surgery with ECU?
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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
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You or your doctor may choose a specific surgeon from our
practice to see.
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The surgeon that you select may require additional personal or
medical information in order to schedule an appointment.
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Once you have established a relationship with our surgeons, you
should then follow only their advice and educational materials
What is Morbid Obesity?
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Being 100 pounds over “ideal weight”
(your ideal body weight will be calculated during your first visit with your surgeon)
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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
What’s My BMI?
Using the Body Mass Index
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Used to determine if
you qualify for surgery
Measures obesity
based on weight
and height
Different Perceptions of Society
In the Past:
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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:
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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??
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Social Implications
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Unfortunately, still an acceptable form of social discrimination
Economic Implications
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Personal cost = $15,568 per year (diets, food, prescriptions)
National cost = $200 billion
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$93 billion in medical bills
$33 billion on weight-loss products/services
Medical and Health Implications
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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
Co-Morbidities with Obesity
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. Diet, Exercise, Behavioral Changes
-up to 10% loss of excess body weight
-ineffective long-term, less than 5% sustain
significant weight loss
2. Weight Loss Drugs
-minimal sustained weight loss
-side effects prevent long-term use
3. Weight-Loss Surgery
-55 to 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)
Overweight
(BMI 25 to 29.9)
BMI 18.5-24.9
BMI 25-29.9
Obese
(BMI 30 to 34.9)
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
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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
Gastric Bypass (GBP)
LAP-BAND System
Roux-en-Y Bypass
Restrictive and
malabsorptive
Restrictive
Roux-en-Y Gastric Bypass
Advantages
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Rapid initial weight loss
Laparoscopic approach is possible
Longer experience in USA
Takes 1-2 hours
Disadvantages
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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
What is Dumping Syndrome?
Stomach contents move too rapidly through the small intestines following surgery
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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
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Lowest mortality and complication rate
Least invasive surgical approach
No stapling, cutting, or intestinal
re-routing
Adjustable
Reversible
Low malnutrition risk
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Takes 1 hour/ outpatient surgery
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Disadvantages
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Slower initial weight loss than Gastric
Bypass
Regular follow-up critical for optimal
results: Need adjustments
Requires implanted medical device
Comparing Weight Loss
Source: O’Brien et al. Obesity is a Surgical Disease: Overview of Obesity and Bariatric Surgery, ANZ J
Surg, 2004; 74: 200-204.
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
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Remember: there are risks associated with
any surgery
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Your surgeon will discuss specific details
regarding each surgical option at your first
new patient appointment.
Gastric Bypass Potential Complications
Early Post-Operative Complications:
Death (.5 to 1.5%)
Pneumonia
Abdominal Infection
Heart Attack
Leak from the Bowel
Wound Infection
Spleen Injury
Bowel Obstruction
Bleeding
Anastomotic Narrowing
Pulmonary Embolus
Gastric Bypass Potential Complications
Late Complications:
Wound (Incisional) Hernia
Staple Line Breakdown
Bowel Obstruction
Weight Gain
Nutritional Problems
Ulcer at the Anastomosis
Band Potential Complications
Early Complications:
Gastric or esophageal perforation or injury
Death <0.1%
DVT/ pulmonary emboli
Bleeding
Splenic injury
Wound infection
Band Potential Complications
Late Complications:
Band Slippage
Band erosion
Port infection
Your Appointments With the Surgeon and the
Surgery Practice
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You will have three visits with your surgeon before your surgery.
Your first visit is called your “New Patient Visit”.
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At this visit, you will do the following:
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- 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 NICOTINE PRODUCTS!!! You must be nicotine- free 3
months prior to surgery, as well as after surgery!!!!
- 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:
 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
 Consult with
 Colonoscopy
pulmonologist
 Sleep Study
 Upper gastric endoscopy  Consult with vascular
doctor
 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
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Please do not miss your appointments!!
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Remember: rescheduling may mean prolonging your
process.
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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
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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 23 weeks before surgery.
Prescription Diet Before Surgery
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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
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After your “Decision Visit”, our office will begin
the approval process if you are an adequate
candidate for surgery.
We will mail or fax your evaluations, diet and
exercise history, letters of clearance, and personal
letter from our office to your specific insurance
company.
This approval process may take as long as 6-8
weeks.
Insurance Coverage Approved
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When we receive insurance approval, we will
contact you with your third appointment and
surgery date!
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Your third appointment is the “History and
Physical”.
History and Physical Appointment
Includes the following:
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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
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This is a weight-loss program! Any weight gain could
result in prolonging, rescheduling, or cancelling your
surgery.
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YOU MUST QUIT NICOTINE PRODUCTS! We may
require a nicotine test prior to having surgery in order to
ensure you have stopped.
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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
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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:
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This starts after surgery and lasts for 2 weeks
Two ounces (1/4 of a cup) of Bariatric Advantage in
place of meals
Between “meals” you may have two ounces of nonsweetened, 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
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Tips for Eating After Surgery
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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
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How Much Weight Can a Patient Expect to
Lose Following Surgery?
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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
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Must be compliant with follow-up!!!!!
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Plastic Surgery Consult Following Surgery
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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 (12-18 months usually)
- Your nutritional status is adequate
- Your surgeon will ultimately decide when this referral is appropriate
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-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
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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
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2 chewable multivitamins
daily (ex: Flinstones)
Calcium Citrate or Tums
1000 mg daily
Vitamin D 800 iu daily
Tips to Remember!
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After surgery, all vitamins and medications need
to be one of the following:
CRUSHED
CHEWABLE
LIQUID FORM
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Please speak with your primary care doctor and
pharmacist to help adjust these medications. Some
drugs are NOT safe to crush.
Pregnancy following Surgery
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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
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After the band surgery, it is best you maintain a stable weight loss
and plateau prior to becoming pregnant.
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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
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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!
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You will work up to doing exercise daily for 30 to 45
minutes per day
Exercise options can include:
-Walking
-Bike riding
-Aerobics
-Swimming
-Water aerobics
-Weight Training
-Jogging
Making An Appointment
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The next step in pursuing weight loss surgery is a visit
with a qualified bariatric surgeon.
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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!
Thank You!!