the bariatric handbook - monarcmonarcwlss.weebly.com/uploads/1/7/3/7/17370745/handbook.pdf · the...

THE BARIATRIC CENTER

The Bariatric Handbook

®

1

2 Welcome

4 Introduction4 Our Staff5 Bryn Mawr Hospital and the

Bariatric Center

7 Morbid obesity as a disease

9 Treatments of morbid obesity9 Options for weight loss surgery11 Qualifications for surgery

12 Getting started12 Attend an information seminar12 Next step12 First visit: comprehensive bariatric

evaluation12 Evaluation process13 Selecting your procedure13 Pre-op meeting13 Risks and complications14 Preparation for surgery14 Items to bring to the hospital15 Nutrition and exercise15 Preparing for surgery

16 At the hospital16 Day of surgery16 Care after surgery16 Discharge from the hospital

18 Nutritional needs after surgery18 Stages of diet after surgery19 Dietary program19 Food groups21 Protein supplementation21 Vitamin and mineral supplementation21 Other items22 Healthy recipes

24 Recovery from surgery24 First two weeks after surgery24 Six weeks after surgery

25 After surgery: your new life25 Three months after surgery25 Six months after surgery25 One year after surgery and annual visits26 Tips for moving more

27 Frequently asked questions28 Questions about lap adjustable

gastric banding

29 Important documents29 Consent for gastric bypass and sleeve

gastrectomy surgery31 Consent for adjustable gastric banding

surgery

mainlinehealth.org/bariatrics

THE BARIATRIC CENTER

Bryn Mawr Hospital Medical Building North | Suite 300830 Old Lancaster RoadBryn Mawr, PA 19010610.527.1185mainlinehealth.org/bariatrics

Bariatric Surgery Center of Excellence®

Bryn Mawr Hospital and Dr. Ing have earned the ASMBS Bariatric Surgery Center of Excellence designation. The ASMBS Bariatric Surgery Center of Excellence program recognizes surgeons and facilities that demonstrate an unparalleled commitment and ability to consistently deliver safe, effective, evidence-based care.

Table of contents

Bariatric Surgery Center of Excellence® is a registered trademark of the American Society for Metabolic and Bariatric Surgery (ASMBS). Used by permission of ASMBS. All rights reserved.

3mainlinehealth.org/bariatrics2

Welcome Congratulations on taking the first step towards your new healthier life. The Bariatric Center at Bryn Mawr Hospital has created a comprehensive weight loss program designed to help you attain long-lasting weight reduction to improve overall health and increase your longevity. We offer the following to our prospective patients:

• expert coordinated care from our team of health care professionals and surgeons before and after surgery

• complete psychological evaluations by specialists specially trained in bariatric needs

• dietary evaluation pre-surgery by a registered dietitian

• detailed exercise evaluation and program development

• caring physicians who are closely and directly involved with your care throughout the entire pre-operative evaluation and operative experience

It is imperative for you to contact your insurance company to determine if this surgery is a covered benefit and to find out what is specifically required for your procedure to be covered by your insurance carrier. Some insurance plans require a 3-6 consecutive month, health provider supervised diet with specific documentation prior to approval. Some insurance companies will only cover bariatric services with a health care rider to your existing health insurance policy.

If your insurance plan does not cover this procedure, a self-pay package (using either cash or financing) is available with our hospital. Please contact us for further details.

You should do as much reading and research as possible before making a decision to proceed with surgery. Weight loss surgery is not for everyone who is overweight, but is recommended for those patients whose health is affected by obesity or have failed to lose weight by any other means. Surgical weight loss procedures are valuable tools to help you lose weight and become healthier, but these procedures must be combined with proper diet and exercise in order to succeed.

Ask your primary care physician for copies of office notes that pertain to weight loss and get copies of all records from specialists seen in the last year. Also get copies of any commercial diet or weight loss program undertaken in the past as well as any receipts from diets or programs that you participated in. Please bring copies of these and all health care history forms to your first appointment. Don’t forget to obtain a referral from your primary care physician if your insurance requires one.

Please record your current weight with a health care provider to document your maximum weight. Be honest and open about all eating habits, eating disorders, addictions and current level of exercise. These will have a direct impact upon your outcome and success.

Once you have made the decision to proceed with weight loss surgery, you should make an appointment to meet us in our center by calling 610.527.1185.

Please note: before your first visit, you must complete a comprehensive medical history packet, which can be found in your folder. The forms in this packet will be used by all of our specialists to avoid unnecessary duplication. A missing or incomplete packet will delay your first visit significantly and may result in the rescheduling of your first appointment. Please help us ensure that your first visit proceeds without delay by completing the packet in its entirety.

Prior to surgery the evaluation process for insurance approval includes the following:

• medical evaluation with one or more of our physicians on our staff

• psychological health evaluation with one of our clinicians

• nutrition evaluation

• physical therapy evaluation

• upper GI series X-ray and/or upper endoscopy

• lab work

• possible cardiac evaluation

• possible sleep study

• possible pulmonary function tests

• health provider supervised weight loss program (if required by your insurance company) with copies of all office notes

• pre-op weight loss (preferably 5-10% of current body weight)

Appointments with specialists can take a great deal of time and should be made as soon as possible. We have a list of specific providers we prefer our patients to see who focus their evaluations on our bariatric needs. Please contact us if you have any questions.

A separate fee will be required before surgery to pay for all non-covered expenses. This will include pre-operative meal replacements and any evaluations not covered by insurance. This fee typically costs between $150 and 400. A separate comprehensive self-pay package is available.

The Bariatric Center at Bryn Mawr Hospital is now an accredited Center of Excellence by the American Society for Metabolic and Bariatric Surgery. The ASMBS Bariatric Surgery Center of Excellence program recognizes surgeons and facilities that demonstrate an unparalleled commitment and ability to consistently deliver safe, effective, evidence-based care. Please let our team know if you have any questions.

Sincerely,

Richard D. Ing, MD, FACS, FASMBS

mainlinehealth.org/bariatrics

®

Bariatric Surgery Center of Excellence® is a registered trademark of the American Society for Metabolic and Bariatric Surgery (ASMBS). Used by permission of ASMBS. All rights reserved.

Welcome

4 5mainlinehealth.org/bariatrics mainlinehealth.org/bariatrics

Our staffRichard Ing, MD, FACS, FASMBS

Dr. Ing has been in practice in the Delaware Valley for over 10 years, performing bariatric and advanced minimally invasive procedures. He completed his residency in general surgery at Wayne State University in Detroit, MI and is board certified in General Surgery. He was among the first group of surgeons in the country to complete a fellowship in Advanced Minimally Invasive Surgery at Baptist Hospital in Miami, FL and brings his leadership in Minimally Invasive Bariatric Surgery to our area. He is a Fellow of the American Society for Metabolic and Bariatric Surgery, the leading national association of Bariatric Surgery and has been nationally recognized as a Center of Excellence Surgeon.

Bariatric Coordinator—Michele Radaszewski, RN, MS

Michele is a nursing leader with over 25 years’ experience coordinating surgical care at the Bryn Mawr Hospital. She facilitates all aspects of our bariatric patient care.

Bariatric Nutritionist—Christine Hurley, RD, LD, CDE

Chris has over 15 years’ experience in the nutritional needs associated with weight loss, diabetes, and cardiovascular disease.

Bariatric Physical Therapist—Donna Pelura, PT, DPT

As a physical therapist for over 15 years, Donna has won numerous awards for clinical excellence and has dedicated her career to improving her patients’ health and quality of life.

Bariatric Psychologist—Maria Coletta, PhD

Dr. Coletta is a licensed psychologist with specialized experience in treating eating issues and body image disorders. She works with each patient to build the confidence and motivation needed to successfully maintain a healthy lifestyle.

Certified Medical Assistant—Marisa Palermo, MA

As a medical assistant for more than 13 years, Marisa has experience in physician assisted office procedures, scheduling of diagnostic tests and obtaining patient information.

Pictured above from left: Christine Hurley, RD, LD, CDE; Donna Pelura, PT, DPT; Richard Ing, MD, FACS, FASMBS; Michele Radaszewski, RN, MS; Marisa Palermo, MA;, Maria Coletta, PhD. Main Line Health Center in Newtown Square.

Bryn Mawr Hospital and the Bariatric CenterThe Bariatric Center at Bryn Mawr Hospital is located within the Medical Office Building North at Bryn Mawr Hospital, Suite 300. Hours are available by appointment.

The FREE information sessions and support groups are held at the Main Line Health Center in Newtown Square, located at 3855 West Chester Pike, Newtown Square, PA.

All bariatric surgery will be performed in the operating suites of Bryn Mawr Hospital by board certified and fellowship trained physicians. Procedures are performed using the latest minimally invasive instrumentation and high definition fiberoptic video technology, enabling our surgeons to carry out surgery with the highest degree of care and safety for our patients.

Bryn Mawr Hospital is nationally recognized for its clinical excellence and commitment to patient care. It has received numerous awards and commendations for quality and nursing care including recognition as a Top 100 Hospital by Thomson Reuters and Magnet designation, nursing’s highest honor, by the American Nurses Credentialing Center.

To schedule an appointment at our Bariatric Center, call 1.866.CALL.MLH (1.866.225.5654) or 610.527.1185. For additional information, please visit us on the web at mainlinehealth.org/bariatrics.

Directions to Bryn Mawr Hospital

130 South Bryn Mawr Avenue Bryn Mawr, PA 19010 484.337.3000

From the North Take I-95 South. In Philadelphia, exit I-95 onto I-676/76 West. Stay on I-676/76 to I-476 South to Exit 13 (Villanova/St. Davids). At light, take 30 East (Lancaster Avenue) for 2.25 miles. Make a right on Bryn Mawr Avenue and continue through one intersection. The hospital will be on your right.

From the South Take I-95 North to I-476 North (Blue Route). Travel to Exit 13 (Villanova/St. Davids). At light take 30 East (Lancaster Avenue) for 2.25 miles. Make a right on Bryn Mawr Avenue and continue through one intersection. The hospital will be on your right.

From the East/West Take the Pennsylvania Turnpike to the Valley Forge Interchange (Exit 326). Take I-76 East to I-476 South. Exit I-476 at Exit 13 (Villanova/St. Davids). At light take 30 East (Lancaster Avenue) for 2.25 miles. Make a right on Bryn Mawr Avenue. Remain on Bryn Mawr Avenue and continue through one intersection. The hospital will be on your right.

Public transportation

To map your trip or to find out about possible delays, visit the SEPTA (Southeastern Pennsylvania Transportation Authority) site at septa.org.

From Center City Philadelphia and West to Paoli By train: From Philadelphia’s 30th Street or Suburban Station, take SEPTA’s R5 “Paoli Local” to Bryn Mawr. From the station, it is a 5-minute walk across Lancaster Avenue and two blocks on South Bryn Mawr Avenue to the Hospital. From stops along the length of US Route 30 from Philadelphia to Paoli, it is possible to catch the 105 bus; ask a SEPTA official or look for the sign marking the stop.

By subway and bus: Take the Market-Frankford Elevated line to the 69th Street terminal, and transfer to the 105 bus to Bryn Mawr. The 105 bus travels along Lancaster Avenue (US Route 30) from Paoli to Center City.

From the airport: A SEPTA train runs from the Philadelphia International Airport to 30th Street Station, where you can take the R5 “Paoli Local” SEPTA commuter train.

Parking

Bryn Mawr Hospital offers parking at the following locations. To download a map of locations, visit mainlinehealth.org/brynmawr and click on Patient & Visitor Info.

• 101 South Bryn Mawr Avenue Parking Garage For visitors and patients of the 101 Medical Office

Building

• Old Lancaster Road Parking Garage For visitors and patients of Bryn Mawr Hospital or

the North and South Medical Office Buildings

• Metered parking lots For visitors and patients who need parking for two

hours or less. Rate: fifteen minutes for 25¢.

Introduction

Introduction


Directions to the Main Line Health Center in Newtown Square

3855 West Chester Pike Newtown Square, PA 19073

From the East via Rt. 3 (West Chester Pike) As you travel west on Rt. 3 (West Chester Pike), cross Rt. 252 in Newtown Square. Continue to the second stop light. Turn right onto Medical Drive. Main Line Health Center in Newtown Square, a brick and glass structure with a large parking lot, will be on your left.

From the West via Rt. 3 (West Chester Pike) As you travel east on Rt. 3 (West Chester Pike) from the West Chester area, cross Providence Road. Continue to the fifth stop light after Providence Road, passing the Edgemont Square Shopping Center and the entrance to SAP America on your left. Turn left onto Medical Drive. Main Line Health Center in Newtown Square, a brick and glass structure with a large parking lot, will be on your left.

From the North via Rt. 252 As you travel south on Rt. 252, cross Goshen Road and get into the right lane. Turn right at the next light (there’s a right-hand turn lane) into the entrance to the Ellis Preserve. After you pass the guard house, turn left at the first intersection, and continue to the first stop sign. Turn left and continue to the next stop sign. Turn left again and follow the road to the right to the entrance of the Main Line Health Center in Newtown Square parking lot.

From the South via Rt. 252 As you travel north on Rt. 252, turn left onto Rt. 3 (West Chester Pike). Continue to the second stop light, and turn right onto Medical Drive. Main Line Health Center in Newtown Square, a brick and glass structure with a large parking lot, will be on your left.

From Center City Philadelphia Take I-95 South. Merge onto I-476 North via Exit 7 towards Plymouth Meeting. Take Exit 9 towards Broomall (Rt. 3 West/West Chester Pike). Turn onto West Chester Pike West. Follow "From the East via Rt. 3" directions above.

From King of Prussia Take Rt. 202 South. Take the PA-252 South exit towards Paoli. Take Rt. 252 South. Follow "From the North via Rt. 252" directions above.

From West Chester Take Rt. 3/West Chester Pike going East. Follow "From the West via Rt. 3" directions above.

From Bryn Mawr Hospital Take South Bryn Mawr Avenue. Turn Right on Rt. 3/West Chester Pike going West. Follow "From the East via Rt. 3" directions above.

Obesity is the excessive accumulation of fat that exceeds the body’s skeletal and physical standards. Morbid obesity is defined as: a) greater than 200% of ideal body weight, b) over 100 pounds above ideal body weight, or c) a body mass index (BMI) of greater than or equal to 40.

The American Society for Metabolic and Bariatric Surgery (ASMBS) defines obesity as “a life-long progressive, life-threatening, costly, genetically-related, multi-factorial disease of excess fat storage.”

The ASMBS also states, “The biological basis for morbid obesity is unknown, though recent work has demonstrated a genetic component of between 25-50%, and several studies confirm the influence of genetically determined proteins produced by the fat cell which have a place in the control of satiety. This confirms that morbid obesity is a disease, not a disorder of will power, as is sometimes implied. The physiologic, biochemical and genetic evidence is overwhelming that clinically morbid obesity in a complex disorder. Contributing causes are inheritance, environmental, cultural, socioeconomic and psychological.”

Obesity is the #2 cause of preventable death. About 3 in 5 Americans are considered overweight. There are about 400,000 deaths each year related to obesity. People with morbid obesity tend to die 10-15 years earlier than non-obese people.

Health risks associated with obesity and excess weight (co-morbid conditions)

Obesity is directly associated with a number of health risks that adversely affect a patient’s life. Some of the more serious health problems related to excess weight include:

• Joint disorders • Cancer • Cardiac disease • Stroke • Diabetes • Hypertension

• Asthma • Sleep apnea • Liver disease • Infertility • Depression

Recent studies have shown that weight loss can result in significant and dramatic reversal of many of these disease processes including either reducing or even obviating the need for many of the medications and machines required to treat these illnesses.

World Health Organization classification: body mass index (BMI)

• 19-24 BMI ideal weight • 25-29 BMI overweight • 30-34 BMI moderate obesity • 35-39 BMI severe obesity • 40-49 BMI morbid obesity • >50 BMI super morbid obesity

(See BMI chart on page 8)

Introduction

Morbid obesity as a disease


Body Mass Index (BMI) Table

Weight loss is beneficial for individuals with severe obesity to become healthier, live longer and prevent the onset of new obesity related health problems. Healthy weight loss can be achieved by two methods: medical weight loss and surgical weight loss.

Medical weight loss encompasses a multitude of treatments designed to help patients lose weight by control of their appetite, reducing their calorie intake and increasing their energy expenditure. Traditionally this has included a variety of diets, nutritional replacements or supplements, and exercise. There have been a number of medications previously used to stimulate metabolism meeting varying degrees of success. Several holistic and behavioral therapies are being developed to assist with weight loss. However the mainstays of treatment remain proper diet and regular exercise.

Weight loss surgery is not for all patients who are overweight. It should be reserved for those individuals who have failed to lose weight with dieting and exercise. A patient considering weight loss surgery must be committed to making lifelong changes to their lifestyle and eating habits, including increasing their amount of daily exercise.

All bariatric procedures are tools to help patients lose weight by limiting their app etite and reducing calorie intake. Weight loss will not occur after surgery unless patients actively use this tool in combination with eating the proper foods and portion size and regular aerobic exercise. Unfortunately, continuing old habits and routines will result in little or no weight loss or regaining weight once it has been lost. The benefits of these procedures will be wasted without correct

patient compliance, follow-up and participation with the established support mechanisms.

Some patients are under the mistaken impression that a bariatric procedure allows them to eat whatever they wish or follow any lifestyle they choose. These patients are the individuals who frequently fail to lose weight or regain the weight they had previously lost.

Options for weight loss surgery

Digestive anatomy

In a normal, unchanged digestive tract, food that is swallowed passes from the mouth down into the esophagus. The esophagus is a long muscular tube that pushes food down into the stomach. The diaphragm is the muscle used for breathing, which separates the lungs from the abdomen. The opening in the diaphragm where the esophagus passes into the abdomen is called the hiatus and enlargement of this opening is called a hiatal hernia which is associated with heartburn.

The stomach holds about 1,000 ml of food in a single meal. In the stomach, food is mixed with acid and enzymes that assist in digestion. The stomach also helps to mechanically churn or grind up food. At the bottom of the stomach is a small muscle called the pylorus which helps to keep undigested food in the stomach for further digestion before passing into the small intestine.

The small intestine is about 20–25 feet long and is where most of the absorption of nutrients occurs. It is made up of three different segments called

Morbid obesity as a disease

Treatments of morbid obesity

10 mainlinehealth.org/bariatrics

the duodenum, the jejunum, and the ileum. In the duodenum, food is mixed with bile and other digestive juices to further break down food and is where iron and calcium are absorbed. The ileum is where vitamins A, D, E, K as well as other nutrients are absorbed.

After the small intestines, unabsorbed food passes into the colon where fluid is reabsorbed and this waste is transformed into stool which is prepared for elimination.

Success with weight loss surgery

Weight loss surgery is the only treatment for morbid obesity that helps patients to lose weight long-term, become healthier and reverse the course of many of their disease processes. Surgery is not for everyone. Patients need to be committed to life-long changes in their diet and lifestyle that they must follow in order for these surgical procedures to be successful.

All bariatric procedures help people to control their appetite but will not help them to make proper food selections, reduce their calorie intake or motivate them to continue with an exercise program. Patients must use these procedures properly as a tool to help them reach their own goals. Weight loss surgery does not give patients a license to eat whatever they want.

Bariatric surgery was first performed in the 1960’s originally through large, open incisions as with traditional surgical procedures. Recently, advances in surgery have led to refinements in the techniques, permitting these same bariatric operations to be performed as minimally invasive procedures through smaller incisions using fiber optic cameras. These new surgical techniques have been shown to greatly benefit patients by allowing a faster recovery, with less pain, fewer complications and a shorter hospital stay.

There are three types of bariatric procedures performed by Main Line Bariatrics for weight loss: the laparoscopic adjustable gastric band, the laparoscopic (Roux-en-Y) gastric bypass (Lap RYGB) and the laparoscopic sleeve gastrectomy. Each procedure has distinct advantages and disadvantages.

Laparoscopic adjustable gastric band

The laparoscopic adjustable gastric band is a silicone band that is wrapped around the upper portion of the stomach to create a small pouch (about 15-30 ml). No part of the GI tract is cut or divided and the band is placed into the abdomen through small incisions with the aid of a laparoscope. The band is filled through a small port implanted into the abdominal wall beneath the skin. Sequential fillings of the band over time restrict the passage of food into the rest of the intestinal tract which helps patients to lose weight.

Laparoscopic (Roux-en-Y) gastric bypass (Lap RYGB)

The laparoscopic gastric bypass has become the “gold standard” of all bariatric operations to which other procedures are compared. This procedure results in weight loss by two different mechanisms. The first part of the procedure is to create a very small “new” stomach (about 15 ml or ½ oz) and separate it from the old stomach (restriction). Next, the remaining stomach and a portion of the intestines are bypassed so food will not be absorbed by these sections of the GI tract (malabsorption). The new tiny stomach pouch creates the sensation of becoming satiated with a very small portion of food. The bypassed intestine reduces the amount of food that is absorbed and therefore lowers calorie intake. The combination of limiting the amount of food taken in and reducing the absorption of food greatly reduces food consumed.

Laparoscopic vertical (sleeve) gastrectomy

This is a new bariatric procedure and is simply the first part of a more complex bariatric procedure called the duodenal switch. This is primarily a restrictive procedure and does not require adjustments as with the band. It is not reversible. As a new procedure, limited information is available regarding success with long-term weight loss. Not all insurances will cover this procedure. Early data shows acceptable weight loss between the band and the RYGB.

Qualifications for surgery

Who is a proper candidate for surgery?

Surgery for weight reduction is not for every person who needs to lose weight. Proper diet and exercise are the mainstays of any program designed to lose weight and become healthier including weight loss with bariatric surgery. Weight loss surgery should be reserved for those patients who are unable to lose weight by any other means.

Weight reduction surgery is for those patients with: • Body Mass Index (BMI) >40 • BMI 35-40 with co-morbid conditions (listed before) • A clear understanding of the risks and benefits

of weight reduction surgery• A strong commitment to the post-operative patient

obligations such as follow-up, diet and exercise

Women of childbearing age should avoid pregnancy for at least 12 months following the procedure.

Insurance requirements

Each patient should call his or her insurance carrier to determine their policy’s coverage for bariatric procedures. Some carriers exclude bariatric procedures or require an extra rider.

Many insurance carriers require documentation of medically supervised weight loss for 3–6 months. If you carrier requires this be prepared to provide this or begin such a program. Our practice can help fulfill

requirements for medically supervised weight loss. We have developed a program that can shorten the time period most insurers require from six months to only three months.

Our practice accepts most insurance carriers; please check with the office for an updated list.

The Bariatric Center at Bryn Mawr Hospital is now an accredited Center of Excellence designated by the American Society for Metabolic and Bariatric Surgery.

Treatments of morbid obesity Treatments of morbid obesity

mainlinehealth.org/bariatrics 11


Attend an information seminarThe best way for any interested patient to begin the process of pursuing bariatric surgery is to attend a free informational seminar at the Main Line Health Center in Newtown Square, held regularly throughout the year. A detailed overview of weight loss surgery is presented to all persons who wish to attend. This meeting provides an opportunity for patients to meet the physicians and practitioners of our program in a spacious, comfortable environment. Space is limited so we encourage making a reservation by calling 1.866.CALL.MLH (1.866.225.5654) now or sign up on our web site at mainlinehealth.org/bariatrics.

At the seminar, patients will receive a detailed information folder as well as a medical history packet that must be completed before your first appointment. Included in the folder will be a contact card requesting more information or expressing an interest in proceeding further. This should be returned to one of our coordinators. Patients may also schedule an appointment by contacting our office.

Next stepAfter attending an information seminar at the Main Line Health Center in Newtown Square, patients may contact our Bariatric Coordinator, Michele Radaszewski, at 610.527.1185 or if you have filled out a contact card, then our Center will contact you within 48 hours. At that time we will review some preliminary health and insurance information with you to determine your eligibility and degree of interest.

Clinical criteria for eligibility are listed in our previous

section within this handbook. Patients are encouraged to verify their own health insurance eligibility policies.

First visit: comprehensive bariatric evaluationPatients who are interested in pursuing eligibility for surgery can schedule their first visit with our bariatric team for a comprehensive evaluation. It is necessary for you to complete the pre-admission assessment form prior to this appointment and to bring the completed form with you. If you forget it, you will be asked to complete another one. If you have not received this form, you can print one from our web site (mainlinehealth.org/bariatrics). Patients will meet the bariatric coordinator and their bariatric surgeon at this first visit. The initial appointment will last approximately 60 minutes and will begin a comprehensive evaluation and preparation process.

Evaluation processPatients will continue their pre-op nutritional and exercise education, which is necessary for long-term success following the surgical procedure.

The nutritionist will assess each patient’s individual nutritional needs and food intake history, review proper nutrition and discuss protein, vitamin and mineral supplementation needs after surgery.

The exercise physical therapist will evaluate each patient’s physical needs and restrictions to implement a healthy, sustainable pre-operative and post-operative exercise regimen.

In addition to the nutrition and exercise specialists, patients will be asked to obtain a medical evaluation and a pulmonary evaluation with one of our specialists who will assist in the care of our patients during and following surgery. Documentation from medical evaluations of other physicians from outside of our facility is welcome, but unfortunately cannot substitute for their involvement.

Patients may also require gastrointestinal, endocrine or cardiac physician evaluations before surgery depending on their insurance and health history.

Patients will undergo a psychological evaluation before surgery to assess understanding of the procedures, informed consent and to ensure no addictions or eating disorders.

As patients begin this evaluation process they will be expected to begin a proper diet and exercise regimen that they will continue after surgery.

Pre-op weight loss

All patients are asked to lose weight prior to surgery (about 5-10% of your body weight, i.e. if you weigh 300 lbs, you would need to lose 15-30 lbs). The purpose of this weight loss is to reduce your risk of operative complications at the time of your operation. This weight reduction before surgery will significantly shrink your internal organs, allowing easier access to perform the complex surgery. Our office can assist patients with this weight loss using meal replacement supplements if patients are not able to achieve this on their own.

Patients will need pre-operative tests that may include: baseline blood tests, upper GI series, upper endoscopy, chest X-ray, stress tests, EKG and ultrasounds.

A current list of specialists that patients are required to see is available from our office.

Selecting your procedureSelection of the surgical procedure is a decision process that occurs between a patient and surgeon. Every attempt is made to individualize each patient’s needs with the best procedure for him or her. There are many factors that enter into the selection process including eating habits, medical history, previous surgery, patient compliance and the patient’s wishes.

There is no one right procedure for all patients despite what other physicians, health care professionals, the media or internet may state. While there may be alternate procedures available nationally, our center performs those procedures that are nationally accepted and recognized as standard bariatric procedures by all insurance carriers, and that we feel are safest for our patients. These procedures are recognized by the American Society for Metabolic and Bariatric Surgery.

Proper education and explanation of all surgical options will be presented to each patient along with a recommendation for a particular procedure specific for each patient. Patients are strongly encouraged to investigate all options and discuss these with as many family members, physicians, former patients and friends as possible.

Pre-operative meetingOnce a patient has completed the evaluation process and been approved for surgery by their insurance company, a pre-operative meeting is set. Usually this will be at least two weeks before surgery. At this meeting the patient will see the bariatric surgeon and the program coordinator in preparation for their upcoming surgery and review all materials.

The surgeon will discuss the upcoming procedure in detail as well as review potential risks and complications. The inpatient course and post-operative expectations will also be presented to each patient.

The nutritionist will review dietary restrictions prior to surgery including a two week course of a meal replacement regimen leading up to surgery. The purpose of this course will be to help the patient lose the remaining weight needed before surgery as well as to prepare the internal organs for successful laparoscopic or minimally invasive surgery. In addition the nutritionist will review the gradual staged diet protocol during the few weeks immediately after surgery.

Risks and complicationsPatients who suffer from obesity are in a category of patients who are at higher risk for developing potential risks and complications than the average

Getting started

Getting started


patient. Bariatric surgery is considered major surgery and is associated with a higher degree of risks than other abdominal procedures.

Patients with a BMI above 50 are at a higher risk undergoing a bariatric procedure than those patients with a BMI less than 50. These patients have larger internal organs, thicker tissues and have a reduced capacity to undergo treatment and testing after surgery because of their excess weight (i.e. more difficult to place I.V.’s, reduced visibility with X-rays and weight limitations for equipment). This has the potential to adversely affect these patients’ outcomes.

Patients undergoing bariatric surgery are at risk for the same complications as patients who undergo any other surgery as well as risks specific to their procedure. Some of the more common risks include bleeding, infection, leakage, obstruction, perforation, blood clots, and organ failure due to sepsis, including death as a result of severe complications. Birth control pills increase the risk of blood clots and should be stopped 3–4 weeks prior to surgery, and restarted 2–3 weeks after surgery as desired.

The average weight loss is dependent on the type of procedure performed and the commitment of the individual patient to following the proper diet and exercising regularly. There is no guaranteed amount of weight loss. Some individuals lose only a very small amount or even no weight. Some individuals regain some or all of their weight with time once they have lost it. Again this is very dependent on following the proper diet and exercise.

Long-term effects of the operation are not certain. It is essential to be committed to a long-term program of follow-up care so that any metabolic abnormalities can be identified and adequately treated. Patients are required to take vitamin, mineral and protein supplements for the remainder of their lives.

Short term problems can arise including thinning of hair, gallstone formation, anemia, and gout.

Despite all of these potential problems, most patients do well and receive tremendous benefits from their weight loss.

Your surgeon will discuss a more detailed explanation of the surgery, benefits, risks and complications associated with each procedure with you.

Preparation for surgery

Items to bring to the hospital

Patients who use CPAP or BPAP at home need to bring their equipment to the hospital the day of their surgery.

Previous patients have recommended the following to bring to the hospital:

• Knee length bathrobe (hospital does have robes for patient use)

• Non-slip pair of slippers to walk in (hospital provides)

• Hand lotion (hospital soap is drying)

• Comb and/or brush

• Lip balm (especially when you first wake up from surgery)

• Extra box of tissue (if you use a lot)

• Small writing tablet and pen (for notes and names)

• Toothbrush and toothpaste

• Women: supplies for menstruation (can begin day after surgery)

• Cell phone and charger

• Reading material

• Copy of living will, durable power of attorney and contact information for all next of kin you want to include on your medical record.

• For discharge bring one or two pairs of loose-fitting underwear and a loose fitting top and sweatpants.

• DON’T bring anything valuable. Please do not wear or bring any jewelry or body-piercings. Leave money with significant other or family.

Nutrition and exercise

Patients are instructed to only take their meal replacements for the two weeks just prior to surgery without other solid food or other liquids with the except of non-caloric beverages such as water, unsweetened iced tea, Crystal Light, etc. We do not recommend alcoholic drinks before surgery or carbonated beverages for two weeks before surgery.

Patients are encouraged to continue their exercise regimen before surgery.

Preparing for surgery

Patients are asked to avoid aspirin, NSAIDS (such as Motrin, Advil, Aleve, etc.) for three weeks prior to surgery. Patients may continue their other medications up to the day of surgery as directed by our medical and pulmonary specialists.

Patients are asked to bring their CPAP machines with them to the hospital on the day of their surgery.

Before surgery, patients are asked to ensure their post-surgical protein and vitamin supplementation needs.

Patients should arrange for someone to assist them with their daily needs for the first 1–2 weeks after surgery.

Patients are strongly encouraged to review all bariatric documentation before surgery to ensure as smooth a post-operative course as possible, particularly the post-operative dietary staged regimen.

Any pre-operative illnesses should be reported to the Center before surgery.

In general, laparoscopic banding patients stay in the hospital the day of surgery and go home the day of surgery; laparoscopic gastric bypass patients are in the hospital 2–3 days and laparoscopic sleeve patients go home the day after surgery.

A pre-operative assessment nurse from Bryn Mawr Hospital will contact you one to three days prior to your surgery. All of your pre-admission testing should be completed prior to this interview. The nurse will review your health history, medications and what to expect during your upcoming surgery and hospital stay.

All jewelry and personal belongings should be removed and left at home. All blood thinners should be stopped one to two weeks prior to surgery only in consultation with your medical physician and your surgeon.

All medications needed after surgery must be reviewed with the patient’s medical specialist, pulmonologist, or primary care physician so that a proper substitute may be identified during the first two weeks after surgery when the patient’s diet is restricted to a liquid diet. During this time, all medications must be in a liquid form, a chewable form, a capsule that can be opened or a very tiny tablet that can be taken. This must be done before surgery!

All surgical patients are asked to shower with an antibacterial soap (Hibiclens soap) the night before and morning of surgery to prevent infection. This soap can be purchased at your local pharmacy.

Getting started Getting started

The average weight loss is dependent on the type of procedure performed and the commitment of the individual patient to following the proper diet and exercising regularly.


Day of surgeryOn the day of surgery patients enter the hospital through the Warden Lobby entrance and check in at the registration desk. They are then taken to the holding area on the third floor. Patients will meet with the operating team and an anesthesiologist who will discuss going to sleep using a breathing tube and anesthesia for the procedure.

Once the patient is ready for surgery, he or she will be taken to the operating room and family members will go to the waiting area called the Green Room. After surgery, Dr. Ing will speak to the family about the outcome of the surgery.

Care after surgeryAfter surgery, patients will first go to the PACU (Post-Anesthesia Care Unit) and then to the Bariatric Unit (5A). Patients are expected to cough and take deep breaths beginning immediately after surgery. Patients are also expected to get out of bed and into a chair beginning the night of surgery, as well as walk in the halls with help.

The hospital stay varies depending on the type of procedure performed and how motivated each individual patient is to recover; usually this varies from one to three days.

Patients will undergo an upper GI X-ray study to confirm the proper flow of nutrients, after which patients are started on liquids. Usually patients are allowed to go home once they are able to tolerate liquids.

Some patients will have tubes placed in their bodies at the time of surgery; these are usually removed before the patient leaves the hospital. The hospital will provide gowns that fit over the intravenous lines.

In general, laparoscopic banding patients go home the day of surgery; laparoscopic gastric bypass patients are in the hospital 3–4 days and laparoscopic sleeve patients go home the day after surgery.

Discharge from the hospitalOnce the patient has tolerated their liquid diet and is stable, they will be allowed to go home.

Patients must follow their post-operative medication and dietary regimen as instructed.

Medications during the first two weeks must either be in a liquid form, capsules that can be opened, in a chewable form or tiny tablets that can be ingested. This should have been reviewed prior to surgery.

The patient is to stay on liquids for two weeks, followed by soft food for two weeks and then may progress to solid food after four weeks.

Patients may shower 48 hours after surgery but should not wash their incisions. They may get them wet.

Patients should not drive until their reaction time is back to normal and they are off all pain medications.

Patients should not lift over 15 pounds for 2–3 weeks after laparoscopic surgery and 4–6 weeks after open surgery. Patients may walk and climb stairs as much as they desire.

Return to work will depend on the type of work performed and after consultation with Dr. Ing.

In the event a patient is sent home with a drain, a visiting nurse will be arranged and the output from the drain must be recorded regularly. It will be removed after return to the center.

In rare instances, nausea can persist for a period of time after the surgery requiring supplemental nutrition via a separate tube in the stomach or arm called a feeding tube or PICC line. These tubes are temporary and are for temporary nutrition until the nausea subsides. Separate care and instructions for this will be given and arranged.

Patients are given prescription pain medication for after surgery in a small pill form. They should wean themselves off the pain medication as soon as the pain can be tolerated, as pain medication can have unwanted side effects such as constipation and nausea.

Patients are given medication to prevent ulcers and medication to prevent gallstone formation, to be taken for the first year. Patients without a gall bladder will not need the second medication.

At the hospital

At the hospital

Discharge notes:


Stages of diet after surgeryStage Diet WeeksStage I clear liquids 1 (begin in hospital)

Stage II full liquids 2 (from hospital until first office visit)

Stage III soft/pureed foods 3-5

Stage IV solid food over 5

Stage I: clear liquids

• Clear liquids are anything you can see through.

• Clear liquids should be sugar-free, non-carbonated and decaffeinated.

• Allowed: broth, bouillon, herbal teas, sugar-free popsicles, diet gelatin, diluted apple or grape juice (with 50% water)

• Try to get at least 64 oz of fluid each day. Do not gulp; just sip slowly

• Stop when you feel the slightest bit full

Stage II: full liquids

• Includes all foods from the last stage as well as all other liquids

• Full liquids include: blenderized foods made to a liquid consistency; milks should be taken carefully because sometimes lactose intolerance develops

after surgery; very thin oatmeal or cream of wheat or mashed potatoes; thinned low calorie yogurts or sugar-free puddings (2–3 g sugar/serving)

• Add protein drinks to your diet

• Avoid: orange juice, tomato juice, milkshakes, eggnog, chocolate milk, any liquid with a high sugar content, anything with over 2 g of sugar per serving

• Foods must be the consistency to flow through a straw

Stage III: soft/pureed foods

• Includes all foods of above stages

• May also eat: soft scrambled eggs, cottage cheese, cream cheese, pureed chicken, pureed tuna, pureed ham salad, applesauce, tofu, pureed water packed fruits or mashed fruit, pureed or mashed vegetables, potted meats, hummus, mashed potatoes, grits, cream of wheat, toast, crackers, smooth peanut butter, sugar-free jams and jellies

• Avoid: fruited yogurt, crunchy peanut butter, meats with tough connective tissues, fried foods, broccoli, asparagus, shellfish, nuts, seeds, popcorn, alcohol, honey, sugar

Stage IV: solid food

• Gradually add all other foods as tolerated

• Eat slowly and savor each bite

• Chew eat bite thoroughly before swallowing

• Eat protein first, then vegetables then starches

• Stop eating when you feel full

• Measure out food into a small ½ cup container or 2–3 teaspoon servings until you learn proper portion size

Dietary program1. Follow these eating methods after surgery:

• After surgery, you must make changes in the way you eat, not only to prevent pain and vomiting, but to achieve desired weight. More important is the development of appropriate eating habits to prevent disruption of staple line and stretching of the pouch.

• Eat slowly and chew food until it is a mushy consistency. Swallowing chunks of food may block the opening of the stoma and prevent passage of food.

• Set aside 30–45 minutes to eat each meal.

• Chew each bite 30 times. Actually count the number of times you chew each bite of food.

• Explain to family members why you must eat slowly so they will not urge you to eat faster.

• Eat small bites of food. You may want to eat from a small plate with a small fork and spoon.

• Learn to savor each bite, noticing its flavor texture and consistency.

• Separate solids and liquids during a meal by drinking fluids 30 minutes before or after each meal.

• Stop eating as soon as you are full. Extra food may cause you to vomit or stretch the new stomach pouch.

2. Indications of fullness may be a feeling of pressure in the center of the chest just below the rib cage or sensations of choking or pain.

• Do not try to go back to eating for at least 45 minutes.

• Set aside three meal times each day and eat solid foods only at these times.

3. Do not snack.

• Eating snacks throughout the day may result in not losing any weight because you are taking in enough calories to maintain your weight or even gain weight.

• Make sure you have proper foods available in your house. It is too easy to grab the wrong thing when you are hungry, frustrated or bored.

• Limit fats.

• NO high calorie foods or beverages (regular soda, chips, cakes, cookies, fried foods, ice cream, etc.)

4. Always consult your physician if you are having problems.

Food groupsThe following is a list of foods that are allowed and those to be avoided.

Milk and dairy products

Allowed: skim milk, low fat milk, low fat buttermilk or low fat yogurt

Avoid: whole milk, milkshakes, eggnog, chocolate milk, evaporated milk, fruited yogurt

Milk and dairy products are good sources of protein, calcium and vitamin D.

Protein group

Allowed: fish fillet, eggs, cottage cheese, low fat cheeses such as farmer’s or part skim mozzarella, regular fat cheeses such as cheddar, Swiss, cream style peanut butter, canned tuna or salmon, pureed chicken or meats; lean ground hamburger, chicken, or turkey

Avoid: meats with tough connective tissue, hamburger, bacon, scrapple, ham, beef, lamb, pork, turkey, chicken, crunchy peanut butter, fried meats, shellfish, and nuts

Foods from the meat group supply protein, B vitamins and iron. Cheese is a good source of calcium.

Nutritional needs after surgery

Nutritional needs after surgery


Cereal group

Allowed: Refined or whole grain cereals except those listed below, cooked or ready to eat, without nuts, raisins or other dried fruits

Avoid: Shredded wheat, raisin bran, sugar-coated cereals, natural cereals

Foods from the cereal group supply B vitamins, iron and some protein.

Bread and substitutes

Allowed: White or refined rye or wheat bread, rolls or crackers, dinner rolls, ½ piece whole wheat toast or ½ deli flat

Avoid: Any breads or crackers with seeds (such as caraway, sesame or poppy), nuts or dried fruit, sweet rolls, doughnuts, sweet or iced breads

Foods from the bread group supply B vitamins, iron and some protein.

Potatoes and substitutes

Allowed: Potato without skin, macaroni, noodles, spaghetti, white or brown rice, plain yams, sweet potatoes, ⅓ to ½ cup maximum

Avoid: Wild rice, popcorn, potato skins, candied yams or candied sweet potatoes

Foods from the potato group supply B vitamins, iron and some protein.

Vegetables

Allowed: Tomato juice, vegetable juice, vegetables cooked until very soft: carrots, winter squash, pumpkin, chopped spinach, tomato paste and puree, pureed or blenderized vegetables

Avoid: Any raw vegetables or vegetable salads, all other canned or frozen vegetables, soybeans, chick peas, green beans, lima beans

Vegetables are high in vitamin A. Tomato products are good sources of vitamin C.

Fruits and fruit juices

Allowed: Soft water-packed canned fruits such as peaches, pears, applesauce, peeled apricots, skinless cherries, unsweetened fruit juice, banana, unsweetened pureed fruit without seeds or skin

Avoid: All other fresh or canned fruit, all dried fruits (raisins, currants, apricots, prunes, dates, figs), melon, rhubarb, papaya, mango, berries, candied or glazed fruit, maraschino cherries

Try to include one citrus juice such as orange or grapefruit every day because they are high in vitamin C.

Fats

Allowed: Margarine, vegetable oils, butter, shortening, mayonnaise, salad dressing

Avoid: Cream, nuts

Fats supply calories or energy that you are trying to avoid. You should limit this group as much as possible.

Desserts and snack foods

Allowed: Artificially sweetened gelatin or pudding, allowed fruits

Avoid: Pie, cake, cookies, pastries, sherbet, ice cream, regular pudding or gelatin, popcorn, pretzels, potato chips, nuts

Desserts and snack foods contain few nutrients, are not required for good health and should be avoided.

Beverages

Allowed: Coffee/tea (preferably decaffeinated), calorie-free beverages (diet), mineral or spring waters

Avoid: Regular carbonated sodas, sugar sweetened soft drink mixes

Alcoholic beverages should only be consumed with your physician’s approval.

Miscellaneous

Allowed: Salt, pepper, herbs, vinegar, lemon juice, mustard, catsup, diet syrup, sugar-free gum

Avoid: Seed spices, preserves, jams, jelly, honey, sugar, molasses, pickles, relishes, candy

Protein supplementation **IMPORTANT**

• Ingest 3–5 shakes per day, 30 g each, drink within one hour and space shakes at least two hours apart

• Needed for growth and repair of all body organs

• The average patient needs 50-65 g of protein each day, but due to malabsorption after surgery, the gastric bypass patient will need 100 g each day in the form of protein supplements

• Lack of protein can result in growth failure, loss of muscle mass, decreased immunity, weakening of the heart and lungs and even death

Vitamin and mineral supplementation **IMPORTANT**

• For the first five weeks you should take vitamins in a liquid or chewable form which can then be switched over to pills

• Patients should ingest the following:

– 1500 mg of calcium in divided doses daily. Calcium citrate is better absorbed than calcium carbonate (i.e. Tums)

– Calcium also needs vitamin D and magnesium to work. Boron can be used to improve calcium absorption

– 5000 iu of vitamin D/day

– Two multi-vitamins each day, since patients only absorb 50% of each

– 1000 micrograms of vitamin B12 sublingual

– Iron (either ferrous fumerate or ferrous carbonyl, not ferrous sulfate). Iron should be taken with vitamin C and not with calcium. Copper can be used to improve iron absorption

– Vitamin A, D, E, K and zinc should be taken in dry tablets. Gel caps with oil or coated pills are not well absorbed

Other items• Have someone to share the successes and problems

of your experience. Find someone who is supportive and can help you get through the hard times. Try to attend the support group regularly

• Exercise daily. Cardiovascular activity causes muscle growth which increases metabolism and burns more calories. Exercise also releases endorphins which give a sense of well-being. Make exercise fun by involving activities you enjoy. Exercise is what burns off excess and old calories.

• Give your body what it needs to survive.

– 3-5 protein drinks each day

– Plenty of water (64 oz) each day

– Minimize carbohydrates, eat mostly protein foods

– Stop snacking

– Take your vitamins regularly

– Keep a positive attitude

• Laparoscopic adjustable gastric nanding patients need to have their band filled regularly following surgery. As this is a restrictive procedure, patients may have difficulty eating thicker breads or heavy meats. Food should be eaten in small bites that are well chewed before swallowing. Meals should be eaten slowly and methodically. Liquids should be taken either 30 minutes before or 30 minutes after each meal.

• The surgeon of our practice runs our support group and all patients are expected to actively participate and attend regularly. Patients who belong to a support group are most likely to succeed in their weight loss regimen and maintain their weight loss long-term

• Patients who undergo bariatric surgery need life-long follow-up with their surgeon or bariatric specialist to help them monitor their long-term nutritional and health care needs. We recommend our post-operative patients see us annually to help them reach their goals.

Nutritional needs after surgeryNutritional needs after surgery


Healthy recipesEating right is an important part of staying healthy. The Main Line Health Web site offers delicious recipes to inspire healthy habits.

• Women’s Health Source recipes • Health eRecipes • BariatricEating.com – Protein Shakes

Chicken Marengo

Diabetic, heart healthy recipe

Looking for an easy chicken dinner? This savory Italian dish takes less than 45 minutes to prepare and uses just one pot. Each serving is just 215 calories and has loads of protein.

Yield: 6 servings

Portion size: 1 cup

• 6 boneless skinless chicken breasts (4 oz each) • 1 Tbsp garlic, minced • ½ tsp marjoram • ½ tsp thyme • ½ tsp freshly ground black pepper • 1 can diced tomatoes • ½ cup dry white wine (or low sodium chicken broth) • 1 medium onion, sliced • 1 cup barley • ¼ cup green olives, sliced

Rub chicken breasts with seasonings and set aside.

Drain tomatoes, reserving liquid. Combine tomato liquid and white wine in a large pot and bring to a boil. Add onion and barley to pot and stir.

Arrange chicken over barley, and spread diced tomatoes over chicken. Cover and simmer for 20 to 30 minutes.

Remove from heat and let stand (covered) until all liquid is absorbed, about 5 minutes. Sprinkle with sliced olives. Serve warm.

Nutrition facts (per serving): Calories 215; Fat 4 g; Saturated Fat 1 g; Cholesterol 66 mg; Sodium 485 mg; Carbohydrate 13 g; Fiber 3; Protein 28 g

Creamy Raspberry Protein Shake

• 1 to 1 ½ cups vanilla protein shake (made from powder and water)

• 3 tablespoons cool whip (you may try “light” or “non-fat” cool whip in place of regular)

• 4 tablespoons sugar-free raspberry syrup • 6 ice cubes • Fresh raspberries for garnish ( approx. ¼ cup)

Place ingredients into blender or food processor. Pulse until thick and smooth.

Place fresh fruit as garnish and serve.

A variation: substitute strawberry for the syrup and garnish.

Tomato Chicken Italiano

• 2 teaspoons olive oil • 1 ½ pounds chicken thighs—boneless, skinless • 26 ounce jar of tomato sauce (choose your favorite) • Grated parmesan cheese

Place olive oil in large skillet, add chicken and cover. Cook at medium heat. Drain any excess fat remaining in pan.

Add tomato sauce, bring it to a boil, cover, simmer and reduced heat until tender (about 35 to 40 minutes). Sprinkle parmesan cheese on top when ready to serve.

Nutrition facts (per serving): Calories (4 oz portion): 212; Fat: 8 g; Carbs: 5 g; Protien: 28 g

Healthy Baked Potato Soup

Diabetic, heart healthy, gluten free recipe

Serve this rich and creamy potato soup as an appetizer to a winter dinner party or alongside a big salad for lunch. It is full of flavor but light on calories with only 102 calories per cup.

Yield: 10 (1 cup) servings

• 5 cloves garlic, minced • 1 ½ cups celery, chopped • 1 cup of leeks, sliced • 4 ½ cups low sodium chicken broth • 6 large baking potatoes, chopped • Freshly ground black pepper • Reduced fat cheddar cheese (optional)

Sauté garlic, celery and leeks together in a large pot coated with cooking spray. Add in chicken broth and potatoes, and cook until potatoes are soft. Puree mixture in a food processor or blender. Ladle into bowls and top with reduced fat cheddar cheese if desired.

Nutrition facts (per serving): Calories: 102; Fat: 0; Sat Fat 0; Cholesterol: 0; Sodium: 268mg; Carbohydrate: 22g; Fiber: 2g; Protein: 4g

Nutritional needs after surgeryNutritional needs after surgery


First two weeks after surgeryDuring the first two weeks after surgery, patients should stay on the dietary regimen listed in the previous pages. By the end of the second week patients may progress to a soft diet.

Patients should be off their pain medications by this phase.

Patients will follow up with Dr. Ing two weeks after discharge at the Bariatric Center at Bryn Mawr Hospital:

Bryn Mawr Medical Building North 830 Old Lancaster Road | Suite 300 Bryn Mawr, PA 19010

Patients are also encouraged to follow up with their medical specialists or primary care physicians to have them coordinate medication adjustments. It is not uncommon for some medication doses to be altered in the immediate post-operative period, including being removed from some of these medications altogether. Any change in medication dosage or stopping medications should be done under the guidance of a physician.

Protein and vitamin supplementation should begin during this time.

Patients are given medication during the post-operative phase to prevent ulcer formation and gallstone formation that should continue during the first year.

Drinking enough fluid during this time is important to prevent dehydration. Patients are asked to consume between 48 and 64 ounces of fluid daily in small quantities throughout the day. Many patients have a

bottle of water or liquid with them throughout the day that they sip on.

Band patients will set up their first band fill under X-ray guidance at six weeks.

Plan to attend the support group meetings held regularly at the Bariatric Center at Newtown Square.

Any concerns or problems should be reported to Dr. Ing immediately.

Six weeks after surgeryFollow-up laboratory studies should be obtained through Dr. Ing before the six week visit.

Patients are encouraged to keep a food journal.

Patients should return for a follow up visit with Dr. Ing at the Bariatric Center.

Patients should follow up with their medical specialists.

Protein and vitamin supplementation should continue.

Post-operative visits with the nutritionist and physical therapist are available if needed.

Problems with hair loss are temporary and can best be mitigated by taking adequate amounts of protein, biotin and zinc supplements.

Band patients will have their first band fill under X-ray guidance. All subsequent fills will be done in the office every four weeks or as needed.

Any concerns or problems should be reported to Dr. Ing immediately.

Strict adherence to a proper diet and exercise regimen is paramount.

Patients should continue their protein and vitamin supplements daily.

Excess skin is common after loss of significant amounts of weight. Regular exercise can help with body tone. However, evaluation by a plastic surgeon for body contouring is possible once a patient reaches a steady weight. This can occur after 9 months to 2 years. Requesting insurance coverage for this can be an extensive process needing prolonged planning.

Many patients are able to get off many of their medications and treatments. Please notify the Bariatric Center when your medications and medical history changes.

Your monthly weight and medical history should be recorded on our website.

Any concerns or problems should be reported to Dr. Ing.

Three months after surgery• Patients should obtain laboratory studies before

their visit at three months

• Patients are encouraged to keep a food journal

• Patients will follow up with Dr. Ing at the Bariatric Center

• Patients should follow up with their medical specialist or primary care physician for medication adjustments

• Strict adherence to a proper diet and exercise

regimen is paramount

• Patients should continue their protein and vitamin supplements daily

Six months after surgery• Patients should obtain laboratory studies before

their visit at six months



• Patients will see the nutritionist and the physical therapist at this visit


• Strict adherence to a proper diet and exercise regimen is paramount


• Retake photo

One year after surgery and annual visits• Patients should obtain laboratory studies before

each visit



Recovery from surgery After surgery: your new life

27mainlinehealth.org/bariatrics26

• Patients will see the nutritionist and the physical therapist at this visit


• Strict adherence to a proper diet and exercise regimen is paramount


• Retake photo

Tips for moving moreTry to do at least 30 minutes of moderate intensity physical activity (like brisk walking) on most days of the week. You can “sneak” it into your day, a few minutes at a time.

“I don’t have time for physical activity”

• Get off the bus or subway early and walk the rest of the way (be sure the area is safe)

• Park the car farther away from entrances to stores, movie theaters or your home

• Take the stairs instead of the elevator (be sure the stairs are well lit)

• Walk and talk with a friend at lunch

• Rake the leaves or wash the car

• Take a walk after dinner instead of watching TV

“It’s too expensive”

• Find a local park or school track where you can walk or run

• Walk around a mall

• Work out with videos in your home. You can find workout videos at bookstores or your local library

• Join a recreation or fitness center at work or near your home

• Walk your dog. If you do not have a dog, pretend that you do

“Physical activity is a chore”

• Do things you enjoy, like walking, dancing, swimming or playing sports

• Walk or take an exercise class with a friend or a group—that way, you can cheer each other on, have company and feel safer when you are outdoors

• Be active with your kids—ride bikes, jump rope, toss a softball, play tag or do jumping jacks. Physical activity is good for them too

• Break it up into short blocks of time—taking three 10-minute walks during your day may be easier than taking one 30-minute walk

• Use your daily workouts as time just for yourself Should I expect any vomiting?

You should not have any vomiting. If you are vomiting then you should contact your doctor immediately and review your dietary restrictions. Vomiting after surgery can result in displacement of the gastric band and may compromise the results of surgery.

Will I be constipated?

Initially after surgery there can be a period of time where constipation can occur as a result of surgery and as a side effect of any pain medication. In the future as less food is eaten, less fiber will be taken in and constipation can be problematic. It is recommended to take as much fiber in your diet as can be tolerated in small portions. Bulk forming laxative supplements such as Metamucil should be taken with plenty of liquids.

Will I need any additional supplements?

We recommend eating foods with a high protein content and taking protein supplements after surgery to avoid protein malnutrition. We would like to see you taking about 100 g of protein in divided amounts each day. We would also like you to take a multivitamin each day to prevent other nutritional deficiencies such as Vitamin B12 deficiency or folate deficiency. For women who are menstruating it is important to take iron supplements and for mature women, calcium supplements.

Can I take my other pills and medications after surgery?

You should continue to take your other medications as prescribed. During the first two weeks after surgery you should crush your medications or take them in a liquid form. Do not swallow large pills during the first two weeks after surgery.

What should I do when eating out?

You should limit your meal to about the size of an appetizer. Eat more slowly while others are eating two to three courses. Inform your host/hostess that you can only eat a small portion to avoid any embarrassment.

Can I drink alcoholic beverages?

Alcohol contains a large number of calories in a liquid form and should be avoided in excess. An occasional glass of wine should not greatly affect your diet and may provide some health benefits. However, regular alcohol consumption should be avoided to minimize calorie intake.

Is this cosmetic surgery?

No. This is not cosmetic or plastic surgery. This operation actually restricts the amount of solid food that can be ingested. The purpose of this procedure is to correct the health problems associated with obesity. The amount of weight loss will depend on each individual patient and their commitment to eating the proper foods and pursuing regular exercise.

Frequently asked questions

After surgery: your new life

28 mainlinehealth.org/bariatrics 29

Questions about lap adjustable gastric banding

What happens if I become pregnant?

Bariatric surgery itself will not interfere with pregnancy. With weight loss your menstrual cycle will become more regular and the likelihood of becoming pregnant will be higher. You should contact us once you become pregnant so we can adjust the amount of fluid in the band to optimize nutritional intake for you and the baby.

What would happen if I develop an illness?

Because the band is adjustable the restricted food intake can be reversed if another illness should necessitate this, simply by removing the fluid within the band. At that point there would be little restriction to food intake. Once you have recovered from the illness then fluid can be added back to the band and the original diet resumed.

Is the silicone in the gastric band dangerous? How long will it last?

There is little knowledge to date of any danger from this. There have been concerns of liquid silicone from breast implants but this has not been proven from numerous studies. The band is made of solid silicone and cannot leak into tissues. Therefore we do not expect that this would be problematic. If any new information becomes available, you will be contacted.

The lifespan of the band is not known. Similar products have been in use for at least ten years without signs of failure. It is unrealistic to expect the band to last for 40-50 years. Some maintenance of the band can be expect in the future.

How are adjustments made to the band?

Tightening or filling of the band does not start until 5–6 weeks after the surgery. The band is filled by placing a small needle through the skin into the reservoir. The band is then filled with fluid or fluid is withdrawn according to the patient’s needs. The band is then adjusted every 4–6 weeks as needed until the weight loss goal is reached. At that point we would leave the band at that setting to maintain your weight at the desired level.

Are the adjustments painful?

The actual tightening or loosening of the band internally is not something that patients are even aware of while it is occurring. It is NOT painful.

Can the gastric band be removed?

Yes, the band can be removed and the anatomy of the stomach will remain intact. We do not place bands expecting to remove them, but it can be accomplished if it becomes necessary. After a band is removed the stomach would resume its normal configuration and one could expect weight gain.

Frequently asked questions

Consent for Gastric Bypass & Sleeve Gastrectomy Surgery

Name:

Surgeon:

The purpose of this form is to provide me with certain information so that I may make an informed decision as to whether or not I should undergo obesity surgery. My physician has recommended gastric bypass surgery because I have been diagnosed with clinical morbid obesity.

Specific risks associated with gastric bypass surgery include but are not limited to the following:

1. Infection—including wounds and the intravenous line sites.2. Intra-abdominal infections or abscesses (inside the abdomen).3. Bleeding.4. Formation of ulcers, gastritis (stomach irritation) or heartburn.5. Failure to lose weight or regaining of weight lost.6. Injury to adjacent organs such as the esophagus, stomach, intestines, diaphragm, pancreas, spleen or liver.7. Port-site infections.8. Leaking from stomach or intestines, or development of fistulas.9. Problems with intubation or anesthesia (a more detailed description of the risks associated with anesthesia will be

provided by the anesthesiologist).10. Hernias of the wounds or internal organs requiring operative repair.11. Formation of adhesions or scar tissue inside the abdomen or possible stricture formation.12. Damage to nerves of the stomach or in the skin near the incisions.13. Pneumonia and respiratory failure requiring mechanical ventilation.14. Transfusion of blood and blood products if needed and the attendant risks of transfusion of blood products.15. Development of deep vein thrombosis or clots (DVT) resulting in pulmonary embolism (blood clots moving to the

lungs) requiring anticoagulant treatment. Diagnosis of DVT is difficult in morbidly obese patients due to unreliable venous dopplers and absence of clinical signs.

16. Pulmonary embolism.17. Depression due to restraints in eating habits, types and amounts of food consumed.18. Re-operation for any unforeseen complications not yet listed.19. Unexpected medical catastrophe such as heart attack, stroke or other disabling condition.20. Death.21. While the majority of patients with this operation lead a normal life, there are some who find that the restriction of

eating small meals creates a lifestyle that is intolerable.22. Body Mass Index above 50: patients have greater risks for surgery, including but not limited to, difficult exposure,

greater risk of injuring internal organs, difficulty with I.V. access, difficulty performing and interpreting X-ray studies, higher risk of leaks or fistulas, higher risks for infections and DVT.

The alternatives to obesity surgery include: further attempts at non-operative approaches to weight loss such as diet, exercise and behavior modification. The benefits of such alternatives include: weight loss without the risks of surgery. The risks associated with those alternatives include: failed attempts, worsening of co-morbid conditions, further weight gain and increased mortality.

No guarantees have been made to me that this surgery will improve my condition or result in weight loss.

I have read and understand (1) risks associated with obesity surgery, (2) the alternatives to obesity surgery, and (3) the benefits and risks associated with the alternatives to obesity surgery. Anything I may not have understood was explained to me to my satisfaction, and any questions I may have had were answered to my satisfaction.

I hereby authorize , and such other qualified medical persons as are needed, to perform gastric bypass surgery on me.

Date: Signature:

Time: Witness:

Surgeon:

31

Consent for Adjustable Gastric Banding SurgeryName:

Surgeon:

The purpose of this form is to provide me with certain information so that I may make an informed decision as to whether or not I should undergo obesity surgery. My physician has recommended adjustable gastric banding surgery because I have been diagnosed with clinical morbid obesity.

Specific risks associated with adjustable gastric banding surgery include but are not limited to the following:

1. Infection—including wounds and the intravenous line sites.2. Intra-abdominal infections or abscesses (inside the abdomen).3. Bleeding.4. Formation of ulcers, gastritis (stomach irritation) or heartburn.5. Failure to lose weight or regaining of weight lost.6. Injury to adjacent organs such as the esophagus, stomach, intestines, spleen, pancreas, diaphragm or liver.7. Port-site infections.8. Malfunction of the device requiring repair, replacement or removal of the device such as leakage, breakage or other

problem with inflation or deflation.9. Enlargement of the stomach pouch, blockage of the stomach outlet, swelling of the stomach, improper placement of

the band or over-inflation of the band.10. Need for removal of the band due to port or tubing infection, malfunction or loss of muscular function of pouch.11. Erosion of the band into the stomach which may require re-operation.12. Migration of the band which may require re-operation.13. Problems with intubation or anesthesia (a more detailed description of the risks associated with anesthesia will be

provided by the anesthesiologist).14. Hernias of the wounds requiring operative repair.15. Formation of adhesions or scar tissue inside the abdomen.16. Damage to nerves of the stomach or in the skin near the incisions.17. Pneumonia and respiratory failure requiring mechanical ventilation.18. Transfusion of blood and blood products if needed and the attendant risks of transfusion of blood products.19. Development of deep vein thrombosis or clots (DVT) resulting in pulmonary embolism (blood clots moving to the

lungs) requiring anticoagulant treatment. Diagnosis of DVT is difficult in morbidly obese patients due to unreliable venous dopplers and absence of clinical signs.

20. Pulmonary embolism.21. Depression due to restraints in eating habits, types and amounts of food consumed.22. Re-operation for any unforeseen complications not yet listed.23. Unexpected medical catastrophe such as heart attack, stroke or other disabling condition.24. Death.25. While the majority of patients with this operation lead a normal life, there are some who find that the restriction of

eating small meals creates a lifestyle that is intolerable.26. Body Mass Index above 50: patients have greater risks for surgery, including but not limited to, difficult exposure,

greater risk of injuring internal organs, difficulty with I.V. access, difficulty performing and interpreting X-ray studies, higher risk of leaks or fistulas, higher risks for infections and DVT.

While gastric banding surgery is reversible/removable, I understand that there are significant risks associated with the reversal/removal, and that such risks may be life-threatening. I also understand that reversal/removal of a gastric band may have an adverse effect on future surgery in this area of the stomach.

The alternatives to obesity surgery include: further attempts at non-operative approaches to weight loss such as diet, exercise and behavior modification. The benefits of such alternatives include: weight loss without the risks of surgery. The risks associated with those alternatives include: failed attempts, worsening of co-morbid conditions, further weight gain and increased mortality.

No guarantees have been made to me that this surgery will improve my condition or result in weight loss.

I have read and understand (1) risks associated with obesity surgery, (2) the alternatives to obesity surgery, and (3) the benefits and risks associated with the alternatives to obesity surgery. Anything I may not have understood was explained to me to my satisfaction, and any questions I may have had were answered to my satisfaction.

I hereby authorize , and such other qualified medical persons as are needed, to perform adjustable gastric banding surgery on me.

Date: Signature:

Time: Witness:

Surgeon:

This page intentionally left blank

Notes:

This page intentionally left blank

THE BARIATRIC CENTERBryn Mawr Hospital Medical Building North | Suite 300 830 Old Lancaster RoadBryn Mawr, PA 19010

Find out more today.

610.527.1185mainlinehealth.org/bariatrics

Follow us on Facebook: Bariatric Center at Bryn Mawr Hospital

Membership on the medical staff of Main Line Hospitals does not constitute an employment or agency relationship.

BM

H.9

/12.

AS

®

the bariatric handbook - monarcmonarcwlss.weebly.com/uploads/1/7/3/7/17370745/handbook.pdf · the...

Documents