WELCOME To Einstein Bariatrics, The Comprehensive Weight Loss Specialty Center From Albert Einstein Health System

Einstein Bariatrics

Handbook for the Bariatric Surgery Patient

Ramsey Dallal, MD

Bariatric Surgeon

Alfred Trang, MD

Bariatric Surgeon

Ian Soriano, MD

Bariatric Surgeon

Call (215) 663-6422 or (484) 622-7700 for any emergency anytime!

Welcome to Einstein Bariatrics, the comprehensive weight loss specialty center from Einstein Healthcare. Einstein Bariatrics was created with quality in mind. The surgical team has performed thousands of weight loss procedures and has been involved in the care of many more. And although the surgeon is a primary force directing your care, a bariatric center, just like a transplant center, involves a team of expert people. Our registered dietitians, nurses and anesthesiologists all have an expertise in bariatric surgery. Einstein Healthcare has fully supported the development of the bariatric surgery program and is intimately involved in ensuring the nursing floors; operating rooms and all the ancillary staff are integrated into the program.

This educational handbook is designed to help answer many of the questions you may have about bariatric surgery performed at Einstein Bariatrics.

Our Website (www.einsteinbariatrics.com) is also a great resource with lots of educational materials.

Best Regards,

Ramsey Dallal, MD

Alfred Trang, MD

Ian Soriano, MD

TABLE OF CONTENTS

The obesity epidemic 4

Indications for Surgery 4

How do I select a Bariatric Surgeon? 5

Insurance 5

Minimally Invasive Surgery 5

The Roux en Y Gastric Bypass 7

Frequently Asked Questions about the Gastric Bypass 9

The Adjustable Gastric Band 13

Frequently Asked Questions about the Adjustable Gastric Band 14

Sleeve Gastrectomy 15

Frequently Asked Questions about the Sleeve Gastrectomy 16

LifeStyle Management Program 18

Pre-operative Tests 19

Minerals and Vitamins after Weight Loss Surgery – Gastric Bypass/Sleeve Gastrectomy 21

Pre-Operative Patient Instructions 23

The obesity epidemic

The rising problem of obesity has been in the news daily over the last several years. As new research becomes available, the devastation that obesity will have to individual lives, our health care system and to the national economy becomes more and more evident.

It has been estimated that if obesity were cured in America, more than 100,000 deaths each year would be prevented. A morbidly obese male has a life expectancy 13 years less than a non-obese individual! And yet, there is no national movement against obesity as there is against wars, environmental issues and pollution, which effect far fewer lives. There is a lack of empathy of the obese by the non-obese population because of the mistaken belief that a person can easily lose 100 or more pounds by simple will power. Unfortunately, this is not true. Although the cause of obesity is not understood, what is well documented is the complete failure of diet and exercise regimes in this population to have any lasting effect. Yes, the treatment is simple – eat less, exercise more. But, 95% of obese people will regain any weight lost through any weight-loss program.

Surgery is the only reliably proven long-term treatment for patients who have more than 100 pounds to lose.

Indications for Surgery

Patients are candidates if they meet the following criteria.

BMI range >40 OR BMI >35 with a significant weight related co-morbidity

A patient must have capacity to understand the procedure and life style changes

Age range 15 years – 74 years*

No active drug and/or alcohol abuse

Willingness to participate in long-term follow-up

Willingness to take vitamins and minerals as prescribed

To calculate your BMI – go to www.einsteinbariatric.com

*Teenagers must go through our specialized adolescent program

How do I select a Bariatric Surgeon?

One hour in the operating room and an overnight stay can “cure” a patient of diabetes, hypertension and sleep apnea. Quality of life dramatically improved and life expectancy is potentially increased. Too good to be true?

Unfortunately, the pressures placed on surgeons to perform these procedures has resulted in a large variation in complication and success rates with the operation. Laparoscopy has been a tremendous improvement in bariatric surgery. Even the most complex and sick patients can get back to work within a week or two. However, the techniques necessary to perform these operations laparoscopically are difficult to master. A number of studies have demonstrated that a minimal of 100 supervised cases are necessary to become simply proficient with the technique. Furthermore, a system must be in place for the long-term care of the patient’s psychological, nutritional and medical needs for successful outcomes after these procedures.

Insurance

Many insurance companies will pay for bariatric surgery when deemed medically necessary. Almost always that means having a minimum BMI of 40. Patients with a BMI between 35 and 40 who have significant weight-related medical illnesses such as diabetes may also be candidates. Einstein Bariatrics can help you obtain insurance authorization for surgery by determining medical necessity. The only way to know if your insurance company covers surgery is to get an explanation of benefits. If your contract with your insurance company has an exclusion to bariatric surgery – you will not be covered. If you insurance company covers surgery, you will want to know your deductible and co-pays. Some insurers require a medically supervised diet of varying lengths (6 months or longer). This means you must have weekly documented weights by a physician.

CALL OUR OFFICE and we can find out whether your insurance covers bariatric surgery services.

Minimally Invasive Surgery

Minimally invasive surgery, also called laparoscopic surgery, is where operations are performed using a narrow magnification camera, called a laparoscope, and narrow surgical instruments. Only small incisions are needed which helps to optimize patient comfort and outcomes. Gallbladder surgery was one of the first laparoscopic procedures developed because the skills involved are relatively basic to learn. Whereas gallbladder surgery is routine among most practicing surgeons, other procedures are much more advanced and require specialized training.

Study after study has documented the benefits of laparoscopic surgery. Most obviously, post-operative pain is markedly decreased. These incisions cut very little skin, muscle and nerve and thus cause much less pain than the large traditional incisions used for surgery. Patients can breathe, cough, and get out of bed to walk much easier without the typical pain from traditional open surgery. This translates into a decreased risk of certain complications such as pneumonia, blood clots and other problems seen after surgery. Because laparoscopic cameras magnify the images on a large TV screen, we can see the intestines and internal organs much better than through a traditional incision. This allows for an exactness and visual sensitivity that cannot be achieved with the unaided eye.

Minimally invasive surgery techniques have cut recovery times for many operations from weeks (or months) to days. The more cutting performed by the surgeon, the higher the stress on your body. With more stress there is an increase in heart and kidney problems as well as a decrease in immune function. Smaller incisions also result in a much smaller chance of developing significant infections. There is also a decreased formation of internal scar tissue, or adhesions.

Incredible advances have occurred over the past ten years in the techniques and skill of laparoscopic surgery specialists who now routinely perform many complex surgical procedures. To perform these procedures safely a surgeon must be an expert in the specialty of laparoscopic surgery. Laparoscopic surgery for obesity is one of the most complex intestinal surgeries being performed today. Therefore, laparoscopic weight loss surgery should only be performed by surgeons who have considerable skill in performing advanced laparoscopic surgery.

Advanced laparoscopic surgery is far too complex to learn during a weekend, or even a weeklong course and most general surgery training programs do not provide enough training for their graduates to perform the more advanced laparoscopic procedures.

These advanced laparoscopic surgery techniques required for bariatric surgery are difficult to learn and require extensive experience. You need to be certain that your surgeon is truly an expert before you agree to them performing this type of operation.

www.einsteinbariatrics.com

Einstein Bariatrics

The Roux en Y Gastric Bypass

The gastric bypass is the most commonly performed operation for weight loss in the United States. In the U.S, approximately 140,000 gastric bypass procedures will be performed in 2011, an amount dwarfing the number of adjustable gastric band, duodenal switch and sleeve gastrectomy procedures done. Furthermore, since the gastric bypass has been performed for almost 50 years, surgeons have become very comfortable with the understanding of the risks and benefits of the procedure. By shear volume of cases combined with the volume of scientific research, the gastric bypass has become the “gold standard” operation for weight loss in the U.S.

One of the biggest advancements in the gastric bypass operation has been the technique used to enter into the abdomen – the laparoscopic approach. Although the laparoscopic approach has a number of potential advantages over the traditional open operation, the training and expertise necessary to perform the laparoscopic approach safely is considerable.

Surgeons at Einstein Bariatrics have successfully performed more than 99% of gastric bypasses laparoscopically. The laparoscopic approach has a number of advantages.

a) Generally 5 tiny incisions are necessary. Four are about ½ “ long and one is 1” long. These incisions are too small for any significant infection to occur and the risk of developing a hernia is less than one percent. The risks of infection, wound problems and hernias are close to 30 percent with the traditional open procedure.

b) The operation, in expert hands, can be performed quicker than an open operation. In fact, average operating room times are close to one hour. Less time in the operating room means less anesthesia and anesthesia-related complications.

c) Less pain. Patients, although sore in the first few hours, need only Tylenol with Codeine the day after surgery. Many patients do not require any medications for pain by the time they go home.

d) Quicker return to work. Patient can often return to work in one week. We generally recommend two weeks off work to be on the safe side.

e) As patients are walking the day of surgery and discomfort is easily controlled, patients are at lower risk to develop blood clots, pneumonia, bed sores or other complications resulting from prolonged immobility.

The gastric bypass has been proven in numerous studies to have good long-term weight loss. The average weight loss often peaks at 18-24 months after surgery – but half of all the weight loss often occurs in the first six months. The gastric bypass, through multiple studies, has been shown to improve or cure diabetes, hypertension, arthritis, venous stasis disease, certain types of headaches, heartburn, sleep apnea and many other disorders. Most importantly, the gastric bypass has demonstrated significant improvements in quality of life.

Regardless of the entry technique (laparoscopic or open), most surgeons perform the operation in a very similar manner. The stomach is cut to form a small pouch (usually one ounce in size) and the remaining stomach and first 1-2 feet of small intestine are bypassed. In the standard gastric bypass, the amount of intestine bypassed is not enough to create malabsorption of proteins and other macronutrients. However, the bypassed portion of intestine is especially adept at absorbing calcium and iron – thus, anemia and osteoporosis are the most common long-term complications of the gastric bypass and must be prevented with lifelong mineral supplementation. Other clinically significant deficiencies have been identified such as thiamine and Vitamin B12. Lifelong follow-up with a bariatric program is mandatory to monitor and prevent nutritional complications. Most surgeons recommend specific supplements to prevent these long-term complications.

The mechanism in which the gastric bypass works is complex. After surgery, patients often experience significant changes in their behavior. Most state that they do not get hungry frequently and that their hunger is fleeting. Patients often state that they enjoy healthy foods and lose many of their food cravings. Rarely do people feel deprived of foods. These complex behavioral changes are partially due to poorly understood alterations in the hormones and neural signals produced in the GI track that communicates with the hunger centers in the brain. One interesting hormone that has recently been studies is ghrelin. Certainly the small size of the stomach pouch restricts the volume of food people eat as well. Thus, the decrease in hunger and the rapid feeling of fullness accounts for most of the weight loss after a gastric bypass.

Another mechanism of weight loss after the gastric bypass is called dumping syndrome. Dumping syndrome causes the intolerance to sweets after surgery. Dumping may result in lightheadedness, flushing, heart palpitations, diarrhea and other symptoms immediately after eating desserts. Some people are extremely sensitive to sweets for the rest of their lives; other patients lose some or all of their sweet sensitivity over time. The exact mechanism of dumping syndrome not entirely understood.

The mortality risk with the gastric bypass in expert centers appears to be less than 0.5%. Because of the increasing popularity of the procedures, some surgeons have been tempted to perform the operation without adequate training or an environment supporting long-term follow-up. Some studies have demonstrated that the mortality rate from hospitals with a low experience with the procedure is far higher than the 0.5% reported by expert centers. The most important questions to ask your surgeon: How many surgeries have you performed? Have you had any deaths?

The two most common causes of death after a gastric bypass are an anastomotic leak and a pulmonary embolism. An anastomotic leak can be rapidly deadly if not recognized and treated early. A “leak” occurs when intestinal fluids leak out freely into the abdomen. Symptoms of a leak may include, severe chest pain, shortness of breath, anxiety, heart palpitations and abdominal pain. Prompt treatment is critical. A pulmonary embolism is caused from a blood clot that forms in the leg that breaks off and gets lodged in the lungs. Prevention is the key to this complication. Blood thinners, leg compression devices and early walking are measures used to prevent blood clots.

Other complications include bowel obstruction, strictures, ulcers, bleeding and prolonged nausea. The open operation generally has a higher frequency of wound problems such as infections and wound hernias than the laparoscopic approach. Please see the written consent form for a more detailed written listing of complications. A frank discussion with your bariatric surgeon about the risks and benefits of surgery is critical to understanding the operation.