Jesse Brown VAMC Bariatric Surgical Program Patient .

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Jesse Brown VAMCBariatric Surgical ProgramPatient Education PacketIntroduction:Welcome to the Jesse Brown VA Medical Center Bariatric Surgical Program. Thegoal of our program is to provide veterans with safe, effective surgical weight losswhile improving co-morbid conditions associated with obesity.The bariatric patient needs to be well-informed, motivated, willing to participate inlong-term follow-up care, permanently change dietary patterns and embrace arevised lifestyle.It must be understood that surgery is not the magic cure. It provides a tool to helplimit the amount of food eaten and to change how food calories are absorbed.You must learn to consistently make appropriate food choices and alter poorbehaviors for you to have a successful and healthy outcome for life. You mustcommit to adopting a new lifestyle, not just following a diet. A lifestyle indicates anatural and automatic system of making good food and activity choices.The Bariatric Packet outlines the requirements expected of each patient. Thispacket also provides you with education of the procedures performed and postoperative care after bariatric surgery. There are exercises throughout the packetthat are recommended to be practiced to help reinforce the information.

Program Requirements and Patient Selection:1. Weight/BMI (Body Mass Index) CriteriaBMI 40 but 60; orBMI 35 to 39.9 with an obesity related co-morbidity(Diabetes Mellitus – type 2, Hypertension or High BloodPressure, Sleep Apnea, Coronary artery disease,Hyperlipidemia or High Cholesterol, Osteoarthritis)2. Medical Weight Management (minimum 12 weeks) - you must completeand demonstrate compliance in the MOVE program. The MOVE programprovides a multi-disciplinary approach to weight management focusing onhealthy life-style changes through diet, physical activity and behaviorchange. The MOVE program consists of 8 weekly sessions at the JesseBrown VAMC or your local VAMC. You then graduate to monthly supportgroup sessions.You must attend regularlyYou must participate in assignmentsWhat does compliance mean? Accepting personal responsibility for lifestylechanges and maintaining those changes. How will this be measured?Demonstration of reasonable weight loss of 0.5 – 1 pound per weekthroughout MOVE program towards preparation for surgery.Maintenance of weight loss and avoidance of weight re-gain whilepreparing for surgery.For those who have inability to lose weight, the bariatric team willconsider candidates who maintain their weight by maintaining healthylifestyle habits.3. Bariatric Psychological Consultation - The evaluation will identify whetherthere is evidence of any barriers that may interfere with your safety andwith adjustment to the surgical procedure.Based on identification of risk factors, recommendations will be made toyou and the Bariatric Team that are aimed at facilitating the bestpossible outcomes. This may include counseling.4. Dietitian Evaluation and Education – The purpose is to evaluate yourweight loss history and eating behavior. The bariatric dietitian specialist willteach the principles of nutrition after bariatric surgery. During this nutritioncounseling session, you will learn about the post-op dietary progression,protein and fluid requirements, and lifelong vitamin and mineralsupplementation.

The specialist then makes recommendations regarding how you canchange your eating behavior and food selection practices to adjust tothe post-op diet.5. Medical Tests/Consultations – based on medical history some of thefollowing tests may be required.Sleep StudyPulmonary Function TestCardiac Stress TestLaboratory blood testsNon-Candidates:Age 65Current tobacco smokers or chew usersOxygen Dependent COPD or other lung diseasePatients with Cirrhosis or active Hepatitis BPatient with significant heart failure or pulmonary hypertensionPatients with major psychoses or issues with non-compliance withmedications and treatment plans.Patients who were active substance abusers within a period of 1 year priorto referral.Anticipated Costs:You will be responsible for copays for inpatient and outpatient services. Todetermine your level of copays for services, please visit the Blue Desk in theadmitting department.

What is Gastric Bypass with roux-en-y:This is a combined procedure allowing for restriction and malabsorption for optimal weight loss. Restriction is created bydividing the stomach, thus making the new ―pouch‖ about thesize of a golf ball (15-30 cc in size). Mal-absorption occurs bydividing the jejunum and reconnecting to the pouch. Food is nolonger digested in the large portion of stomach and is notabsorbed in the duodenum. This severely reduces the amountof caloric intake.Physiology of the gastric bypassThe gastric bypass reduces the size of the stomach by wellover 90%. A normal stomach can stretch, sometimes to the sizeof a deflated football. The Gastric Bypass pouch is usuallyformed from the part of the stomach which is least susceptibleto stretching. This will prevent any significant long-term changein pouch volume. What can change, over time, is the size of theconnection (anastomosis) between stomach and bowel, and theability of the small bowel to hold a greater volume of food.Therefore, it is essential that you continue to follow the neweating style to maintain your lower body weight over time.When you ingest just a small amount of food, the first responseis a stretching of the wall of the stomach pouch, stimulatingnerves which tell the brain that the stomach is full. You feel a

sensation of fullness, as if they had just eaten a large meal —but with just a thumbful of food. Most people do not stop eatingsimply in response to a feeling of fullness, but you will rapidlylearn that subsequent bites must be eaten very slowly andcarefully, to avoid increasing discomfort, or even vomiting.It is important that you eat only at mealtimes, 3 small mealsdaily, and avoid snacks and grazing between meals, which caneffectively "bypass the bypass". This requires a change ineating behavior, and alteration of long-acquired habits forfinding food. In almost every case where weight gain occurslate after surgery, capacity for a meal has not greatly increased.The cause of regaining weight is eating between meals, usuallyhigh-caloric snack foods. There is no known operation whichcan completely counteract the adverse effects of destructiveeating behavior.The Duodenum and MalabsorptionThe small intestine is the part ofthe gastrointestinal tract (gut) between the stomach and the largeintestine and comprises the duodenum, jejunum, and ileum. It iswhere the vast majority of digestion takes place. Nutrients diffusethrough the villi, projections sticking out of the walls of the smallintestine, into the blood.Duodenum 26 cm (9.84 in) in lengthJejunum 2.5 m (8.2 ft) in lengthIleum 3.5 m (11.5 ft) in lengthThe majority of the nutrients from the food you have eaten areabsorbed in the jejunum. However, the duodenum is known to absorbmost of the iron and calcium you ingest. After a gastric bypass, foodno longer passes through the duodenum (malabsorption); therefore,

you will no longer absorb adequate levels of iron and calcium. Toprevent vitamin and mineral deficiencies, gastric bypass patients arerequired to take supplements for life. The specific types of vitaminsand minerals will be discussed further on in the packet.How is Surgery Performed?Open Technique: A single cut about 4-6 inches is made toprovide access to the abdomen.Anesthesia: General anesthesia will be required to performsurgery. This is a treatment that puts you to sleep so you don'tfeel or remember anything that happens. General anesthesia iscommonly produced by intravenous drugs or inhaled gasses.Length of Surgery: Typically surgery is about 3 hours long butvaries case by case.Length of Stay in Hospital: Typically patients stay 3 overnightsbut this is reviewed on a case-by-case basis. Patients travelingfrom a greater distance will generally stay longer to assure noimmediate complications before returning home.Advantages of Gastric Bypass SurgeryWeight loss of 60-77% of excess body weight duringthe first 12-18 months after surgery. Research studieshave shown after 10-14 years, 60% of excess bodyweight loss has been maintained.Most Type 2 Diabetes will be cured70-80% of patients will be off or have reduced highblood pressure and cholesterol medications.There will be major improvements in a whole range ofweight associated conditions. These include: sleepapnea, asthma, joint pain, arthritis, reflux, fatigue andshortness of breath.Reports of less depression, improved self-esteem andconfidence and an overall increase in sense of wellbeing.

Risks of Gastric Bypass Surgery:With any surgery there is a risk of mortality (death) and morbidity(complications). Nationally, there is a 0.5% mortality or death rate forobesity surgery. This means that for every 200 patients operated on,one dies. Death is not usually due to the operation per se, but as aresult of chronic lung or heart problems. The complication rate for thissurgery nationally is about 10%. This means that one in ten patientswill experience a complication related to the surgery.Operative/Hospital Complications:BleedingBlood ClotLeak at the anastomosis (connections)Anastomotic stenosis or intestinal obstructionInfection to incision or other areasRespiratory problems due to anesthesiaReduction in operative risks of surgery is managed by closepatient monitoring. In addition:Blood thinners are administered to prevent blood clots.Compression devices will be worn around the calves tohelp circulate the blood.You will be expected to get out of bed and beginwalking soon after surgery.Nebulizers along with deep breathing and coughing willbe encouraged to keep lungs open.To prevent incision infection, antibiotics are infusedintravenously before incision made and also postoperatively.Long Term Complications:Ulcers along the staple lineDecreased absorption of iron, calcium and vitamin B12Incisional herniaDumping SyndromeNon-compliance with diet and exercise

Prevention of long term complications is accomplished by:patient educationfollowing prescribed diettaking prescribed vitamins and mineralslong term follow-up of patient

What is the Vertical Sleeve Gastrectomy?This procedure produces weight loss by creating restriction andlimiting the amount of food you can eat. The stomach is dividedvertically, and then about 85% of the stomach is removed.How the Vertical Sleeve Gastrectomy Works:First, the vertical sleeve gastrectomy reduces the size of thestomach about 85%. A normal stomach can stretch,sometimes to the size of a deflated football. After the sleevegastrectomy procedure, your stomach that remains is shapedlike a very slim banana and holds about 1 to 5 ounces (30150cc) of food, depending on the surgeon performing theprocedure.Next, the stomach is responsible for producing a hormonecalled ―Ghrelin‖. This hormone is associated with appetite andhunger leading to increased food intake. By removing asignificant portion of the stomach, the level of ghrelin isdecreased, which causes loss of or a reduction in appetite.

How is Surgery Performed?Laparoscopic Technique: Several small incisions are made toallow long-thin instruments through.Anesthesia: General anesthesia will be required to performsurgery. This is a treatment that puts you to sleep so you don'tfeel or remember anything that happens. General anesthesia iscommonly produced by intravenous drugs or inhaled gasses.Length of Surgery: Typically surgery lasts about 1 ½ - 2 hourbut varies case by case.Length of Hospital Stay: Typically 2 overnights is the averagebut reviewed each day on a case-by-case basis. Patientstraveling a great distance will probably have longer stay toensure no immediate complications before being sent home.Risks of Sleeve Gastrectomy:With any surgery there is a risk of mortality (death) andmorbidity (complications). Nationally, there is a 0.1% mortalityor death rate for this surgery. This means that for every 1000patients operated on, one dies. Death is not usually due to theoperation per se, but as a result of chronic lung or heartproblems. The complication rate for this surgery nationally isabout 1-2%. This means that one in 50 to 100 patients willexperience a complication related to the surgery. This can be ahospital/surgical complication or a long-term complication.Surgical Risks:Operative/Hospital ComplicationsBleedingBlood ClotLeak at the staple line- This rate varies by surgical group.Infection to incision or other areasRespiratory problems due to anesthesia.

Long-term Chronic Risks/Complications:Strictures – a narrowing of the passageway caused byscar tissue.GERD (Gastro-esophageal Reflux Disease) - due to highpressure in the stomach, contents may back up intoesophagus.Weight re-gainAdvantages of Vertical Sleeve Gastrectomy:Estimated weight loss of 30-50% of your Excess Body WeightImprovement of obesity related conditions such as: DiabetesMellitus, Obstructed Sleep Apnea, Hypertension, and joint pain.Reduces stomach capacity but tends to allow the stomach tofunction normally so most food items can beconsumed.Dumping Syndrome is avoided or minimized as the pyloricvalve is preserved.Risk of ulcers is significantly reduced.By eliminating the intestinal bypass, reduces chance ofdeveloping intestinal blockage, vitamin and mineral deficienciesand protein deficiencies.Disadvantages of Vertical Sleeve GastrectomyPart of the procedure is not reversible.No long term results to report. Do not know if the procedure willhave lasting results.Weight failure can occur with frequent snacking, intake of highcaloric foods, and/or lack of exercise/activity.Reduction in operative risks of surgery is managed by close patientmonitoring. In addition:Blood thinners are administered to prevent blood clots.Compression devices will be worn around the calves tohelp circulate the blood.You will be expected to get out of bed and beginwalking soon after surgery.Nebulizers along with deep breathing and coughing willbe encouraged to keep lungs open.

To prevent incision infection, antibiotics are infusedintravenously before incision made and also postoperatively.Prevention of long term complications is accomplished by:Patient educationFollow the prescribed diet – learning to eat slowly, notto overeat and to select healthy foods.Taking prescribed vitamins and mineralsLong term follow-up with healthcare providers

Bariatric Surgery Diet and DietaryEducationYou will be receiving an individual consultation with the dietitian. Thedietitian will provide you specific handouts on the diet progressionand sample meal plans for after your weight loss surgery. Thissection is to educate you on the ―rules‖ of eating after any weight losssurgery and to provide further information why taking vitamin andmineral supplements everyday for life is essential.Bariatric Surgery Eating Rules – the way you eat will need tochange after bariatric surgery. By now, your eating style has becomea habit. Do you eat in front of the TV? Are you rushing and eating toofast? Do you skip meals and become overly hungry? Please reviewthe following eating recommendations and refer to Exercise I. Thisexercise asks you to begin practicing these new styles of eating.Constant repetition will help you develop new habits.1. Eat slowly, small bites and chew food thoroughly – eating too fastmay cause nausea from stretching the pouch and food entering the smallintestine too quickly after gastric bypass. Food must be chewed extremelywell to avoid blockage of the new opening to intestine. After a sleevegastrectomy, chewing well and slowly prevents blockages and preventsovereating which will cause reflux and vomiting.2. Eat proteins first, and then vegetable, then fruit or grains last –Without protein our body cannot function properly. Our body nerves,tissues, bones all are made up of proteins. So proteins become verynecessary for them to grow and repair. It also used to produce somehormones, antibodies and enzymes in our body. After surgery, your pouchwill hold only small amounts of food making it difficult to obtain enoughdaily protein. During the early times, you may need to supplement yourdiet with protein supplements. It is also recommended you eat your proteinfirst and include protein in every meal.

3. Avoid sugar, high carbohydrate and fatty foods – to avoidexperiencing dumping syndrome (associated with Gastric Bypass) it isrecommended to consume foods with less than 15 grams of sugar and lowin fat. Dumping syndrome occurs when a concentrated food quickly entersthe intestine. It will draw water into the intestine. The experience will causelight-headedness, sweatiness, and diarrhea. Avoidance of these willprevent intake of too many calories leading to weight re-gain.4. Do not drink liquids with meals – Drinking liquids at mealtime mayleave you feeling full and prevent you from eating enough nutrient-richfoods. Also, drinking with meals may lead to dumping syndrome or nauseaas the liquid will allow food to empty into the intestine too quickly. Youmust consume 48-64 oz of fluid per day. You must drink between mealsby sipping slowly every few minutes.5. No carbonated beverages – The gas from carbonated beveragesexpands leading to nausea and pain. Also, carbonation is irritating to thestomach wall and depletes the body of minerals (magnesium andcalcium). Drink water, crystal lite, iced tea, diluted Gatorade.6. Avoid coffee (decaf or regular) – all types of coffee stimulate acidproduction in the stomach which can increase your risk of stomach ulcers.7. Stop when full – after surgery your stomach holds about 1 ounce offood at a time. Over time, it will tolerate about ½ to 1 cup of food per meal.Eating slowly will help your brain receive the message you are full. If youcontinue to eat, you will feel nauseated, suffer abdominal pains andcramps and perhaps vomit or suffer reflux.

All about ProteinNext to water, protein is the most abundant substance in thehuman body. The word "protein" is derived from the Greek wordmeaning "of first importance." This is literally true for thebariatric surgery patient. Protein is undeniably the mostimportant nutrient in the bariatric diet.Weight loss surgery causes severe trauma to the body. Afterbariatric surgery or gastric bypass surgery, you must take insufficient protein every day to speed wound healing, preserveyour lean body mass, enhance your fat-burning metabolism andminimize hair loss. Foods that are high in protein should alwaysbe eaten first during meals. The recommended long term postsurgery protein intake may vary from 55 to over 100 grams perday, depending on your individual needs and the bariatric dietprovided by your surgeon or dietitian.It's very difficult to consume enough protein from foods aloneduring the first several months after weight loss surgery. Mostbariatric surgery patients integrate liquid protein supplementssuch as shakes, cold drinks, hot drinks, soups and puddingsinto their diet after surgery and many continue to use them as abalanced, convenient source of protein and nutrition for the restof their lives.Protein provides many important benefits:- Protein aids in proper wound healing after bariatric surgery.- Protein helps keep your hair, skin, bones and nails healthy.- Protein helps form hormones, enzymes and immune systemantibodies to help your body function properly.- Protein helps your body burn fat instead of muscle for ahealthier weight loss.- Protein curb's your hunger between meals.A good source of complete protein is animal protein whichincludes meat, fish, eggs and dairy products. Vegetable or plantprotein is incomplete protein. Exercise 2: Located in the back of thepacket is exercise #2. You will track the grams of protein contained in yourfood for the day. A large protein chart is provided to help you calculate thegrams.

Management at HomeManagement of Medications at

The Bariatric Packet outlines the requirements expected of each patient. This packet also provides you with education of the procedures performed and post-operative care after bariatric surgery. There are exercises throughout the packet that are recom

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at the Mercy Bariatric Center Office in Washington, MO. Our office will contact you by telephone for your initial consultation. If you have questions concerning the packet, please call our Mercy Bariatric Center Coordinator - Cathy Radford, RN at 636-861-7891. Good luck on your journey, The Mercy Bariatric Center Team Mercy Bariatric Center

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