1	Surgical Management of Morbid Obesity A Team Approach Roy Cobean, MD Renee S. Wolff, MD Bariatric Surgery Program Maine Medical Center Portland, Maine
2	Outline What is morbid obesity? Steps of the evaluation process Gastric bypass vs. LAP-BAND Risks & results Follow-up care
3	Confidentiality We respect a patient’s right to privacy and ask that you do the same. If you see someone you know at the clinic or at support group, kindly keep this information to yourself. Many people do not tell their extended family and friends about their interest in this program.
4	Using the Body Mass Index (BMI)
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6	Conventional Therapies Diet Exercise Behavior Modification Anti-obesity drugs 10% weight loss = ineffective for morbid obesity
7	Obesity Health Risk
8	NIH Consensus Conference 1991 Surgery is an accepted and effective approach that provides consistent, permanent weight loss for morbidly obese patients Surgery indicated in patients with: BMI of 40 or over BMI of 35-40 with significant co-morbidity documented dietary attempts ineffective
9	Insurance Companies Get a copy of your policy and read it carefully. Some companies require special riders in order to cover weight-loss surgery. Some will pay for the evaluation but not the surgery. Some have requirements above and beyond what we normally require of you. Pre-approval for surgery starts at the completion of your evaluation, after getting a surgery date.
10	Program Steps Step 1 - Information Gathering Medical evaluation & referral letter from PCP Medical information review Stop Tobacco Use – nicotine test Step 2 - Team Assessments Initial assessments with Surgeon, Therapist and Dietitian Support Group
11	Program Steps Step Three – Tasks Medical tests Personal task list Dietary quiz Approval by Therapist & Dietitian
12	Program Steps Step 4 - Ready for Surgery Sign consent with surgeon Paperwork to Casco Bay Surgery for scheduling Insurance approval Possible Nurse visit (if delayed before surgery) Pre-op Anesthesiologist visit Pre-op Diet (2 weeks before surgery) Day of surgery Hospitalization Getting in the required amount of liquids
13	Program Steps Step 5 - First 90 days post-op Early focus on drinking 64 ozs of fluid per day Preventing constipation Taking your pulse Adding in protein requirements Soft/blended diet for one month Acid suppression for one month First visit 4-6 weeks after surgery Second visit 6-8 weeks later
14	Program Steps Step 6 - Long term Follow up Support groups Visits with Dietitian at the Bariatric Center 6, 12, 18, 24 months Annually forever (or at least 5 years) Lap-Band adjustment visits as needed
15	Requirements Before Surgery Separate evaluations by surgeon, dietitian, therapist Support group attendance Surgeon usually must meet spouse, support person Pass dietary quiz No tobacco use for 3 months - nicotine tests No weight gain between appointments Birth Control Plan if appropriate (gastric bypass only) Insurance approval or payment plan
16	Possible Diversions Before Surgery Therapy Sleep study - if sleep apnea suspected Cardiac, Pulmonary, or other specialists Tobacco cessation – No smoking policy Weight loss – sometimes required Diet attempts – occasionally better first approach than surgery
17	Support Group 1^st & 3^rd Tuesdays 6:30–7:45 p.m. Family & support people welcome Facilitated by Nurse & Dietitian Surgeon attends Attendance required for surgery Group discussions + Q&A
18	A Key to Long-Term Success Exercise 1 pound = 3500 calories 100 pounds = 350,000 calories Strenuous exercise = 10 calories per minute 30 min. exercise = 300 calories burned Calorie restriction causes weight loss Exercise maintains weight loss Begin an exercise program before surgery and stick to it after surgery
19	Your handbook Read it before your next appointment. Read it before your surgery. Read it when you get home. Have your family read it. Read it before you come back at 3 months. Then read it again.
20	Surgical Options
21	Which operation is right for you? Gastric Bypass Restrictive & malabsorbtive Anatomy changes, cutting, stitches, staples required Rapid weight loss Nutrition knowledge very important Higher surgical risk Lap- Band Restrictive only – no dumping No cutting required, no change in anatomy Gradual weight loss Nutrition knowledge less important Lower surgical risk
22	Hospital Course Gastric Bypass Operation 1.5-3 hours Hospital stay 1-2 nights Blended diet Walk same day Shower next day Lap Band Operation 1-1.5 hours Hospital stay 0-1 nights Blended diet Walk same day Shower next day
23	Complications Gastric Bypass Stricture 15% Blood transfusion <5% Leak 0.5% Blood clot Ulcer 10% Wound infection Vitamin deficiency Internal hernia 2% Death 0.5% Lap-Band Slippage 1-2% Band erosion 1-2% Problems with Port: infection, twisting, tube defect Occlusion of stoma 1-2% Failure 1-2% Wound infection Death 0.1%
24	The Unseen Team OR Technologist Circulating nurses Anesthesiology team Surgical Floor Nurses Aides Surgical residents
25	After Going Home Plenty of liquids – always sipping Need to urinate normally Acid suppression for one month No aspirin or NSAIDS for one month CALL for any problems Exercise !
26	Comparing Weight-Loss Results
27	Medical Co-Morbidities Resolved
28	Early Post-Op Issues Gastric Bypass > Lap-Band Nausea Dehydration, Dehydration, Dehydration Depression Fatigue Wound Issues : Soreness, Drainage
29	Late Post-Op Issues Therapists’ Support Groups Depression Changes in social interactions Changes in body image Two post-op support groups Early: 3-24 months after surgery Late: 24+ months after surgery Exercise !
30	Late Post-Op Issues Dietitian & Nurse Follow-Up Reaching weight-loss goals 1-2 years for gastric bypass longer for Lap-Band Hunger, old bad habits Weight re-gain Follow-up appointments for 5 years minimum, hopefully forever Exercise !
31	Failure to Keep Weight Off Achilles Heels Gastric Bypass CALORIES Grazing Fried foods Alcohol Sugars- some will get dumping syndrome Lap–Band CALORIES Grazing Fried foods Alcohol Sugars- no dumping syndrome
32	Long-Term Success Morbid obesity is a chronic illness – it will return if given a chance. Keep your handbook – read it again Keep your appointments with us Come to some support groups Work as hard in 10 years as you do during the first year EXERCISE !
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