Steps of the Laparoscopic Roux-en-Y Gastric Bypass: Steps of the Laparoscopic Gastric Sleeve:

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1 Welcome to our virtual seminar about bariatric surgery with our practice, William A. Graber, MD, PC. This seminar is about 25 minutes long, so it might be a good idea to grab a pen and paper to jot down?s as you go along. Watching this seminar all the way to end will count as your mandatory pre-consult educational requirement, if you decide to become a patient in our program. Did curiosity land you on this page? if so, we hope you find this information helpful. And please remember, feel free to contact us anytime with any questions you might have. We are excited to start this journey with you. Throughout this webinar we will discuss all aspects of the process of undergoing weight loss surgery, also known as bariatric surgery, with our practice. Our board certified surgeons specialize in minimally invasive, laparoscopic bariatric surgery. We are proud to perform surgery at 2 highly distinguished hospitals- St. Joseph s Hospital Health Center in Syracuse, NY and Mohawk Valley Health System in Utica, NY In 2002 Dr. Graber recognized the need for a bariatric program in Central NY and since then we have performed over 6000 bariatric surgeries. We are an experienced team of professionals dedicated to helping people change their lives and their health for the better. 1

2 According to the US Centers for Disease Control and Prevention, obesity affects 78 million people. Obesity is defined by using the Body Mass Index, or BMI, which is calculated using your height and weight. A BMI of 30 or above indicates obesity and severe or morbid obesity is indicated with a BMI of 35 or greater. Beyond just defining obesity, it is important to understand that this is a chronic condition. It can be difficult to treat with just diet and exercise alone. But it is not just about the presence of extra weight, it s how that weight can affect your health. On this slide you ll see that obesity can affect just about every organ system. People suffering from obesity have an increased risk of developing medical diseases and conditions including type 2 diabetes, high blood pressure, heart disease and stroke, liver disease, various types of cancer, gynecological abnormalities, obstructive sleep apnea, and arthritis just to name a few. Of growing concern is the increased prevalence of type 2 diabetes related to obesity, and this has been the topic of many studies in recent years. In addition, obesity and the comorbidities associated with obesity lead to an increase risk of overall mortality. And as BMI increase so too does mortality. So what can we do to combat this growing epidemic? There are numerous diet, exercise, and medication regimens out there and yes, you can lose weight using them. However, the weight loss is rarely sustained. Bariatric surgery is proven to provide a greater amount of weight loss, with long lasting results and improvement of comorbid conditions. 2

3 Listed here are some of those comorbid conditions associated with carrying excess body weight. The resolution or improvement of these diseases leads to an overall decrease in mortality. In fact, studies show bariatric surgery can reduce a person's risk of premature death by 30-40%. You might be thinking- well when is Bariatric Surgery medically necessary? Does my BMI have to be a certain number? To start with, we use the general guidelines from the National Institutes of Health. They state that bariatric surgery is indicated if you have a BMI of 40 or greater, or a bmi of at least 35 with associated medical conditions. You can calculate your BMI right on our website! We specialize in 2 of the most commonly performed weight loss surgery procedures, the Roux-en-Y Gastric Bypass and the Vertical Sleeve Gastrectomy, also known as the Gastric Sleeve. We also perform revisional surgeries for some patients who have had previous bariatric surgeries.. For example, the removal of a gastric band and conversion to a gastric sleeve or gastric bypass, or revisions of stomach stapling procedures. Some people ask us about the lap-band or other gastric band procedures. We currently do not perform this procedure. In recent years, studies have shown that the weight loss with this procedure is not as significant as other bariatric surgeries and so it has become less popular. However, we do still take care of patients who have had a previously placed gastric band. The RNY gastric bypass is a procedure that has been performed for many years. This procedure is regarded as the goldstandard of bariatric procedures. It provides significant weight loss of up to 80% of excess weight, generally achieved within 1-2 years following surgery. The gastric bypass works by restricting the amount of food that can be consumed in one sitting and also by altering gut hormones in a way that decreases appetite and increases feelings of fullness. 3

4 Steps of the Laparoscopic Roux-en-Y Gastric Bypass: 1) We gain access to the abdomen with ports for laparoscopic surgery 2) We make a new stomach pouch out of the top of your original (native) stomach 3) We divide the small bowel and rearrange it so the native stomach drains into the distal small bowel, and fashion a piece of bowel that will connect to the new stomach pouch that is created. This piece of bowel is now called the Roux limb 4) The Roux limb is connected to the new stomach pouch The gastric sleeve works similarly to the gastric bypass in that there is restriction of how much food the stomach can hold at one time. Also like the gastric bypass, this procedure causes hormonal changes that decrease appetite and increase feelings of fullness. The Gastric Sleeve leads to significant weight loss, though can be slightly less than the gastric bypass. Steps of the Laparoscopic Gastric Sleeve: 1) We gain access to the abdomen with ports for laparoscopic surgery 2) We disconnect the stomach from a piece of tissue called the greater omentum, and the spleen 3) We use a tube called a Bougie as a guide to size the new stomach 4) We remove the outer portion of the stomach, leaving the inner portion shaped as a tube Whichever operation is the best fit for you, it is important to be practical about weight loss goals after bariatric surgery. The example on this slide shows a realistic goal for weight loss w/i 1 to 1.5 years following a gastric bypass. In our program, you will have ample time to discuss weight loss goals with your surgeon and our staff. 4

5 Bariatric surgery is a lot safer than most people realize. The complication and mortality rates have decreased over the years due to advancements in surgical techniques and practice standardization. Both of our hospitals have met and maintained the highest standards for accreditation and we continue to strive to keep these procedures as safe and effective as possible. Overall mortality rate with bariatric surgery is around 0.1%. That is less than gallbladder, hip replacement, and heart bypass surgeries. And overall, the complication rate for bariatric surgery is low, around 4.3%. Many of these complications can be prevented by following post-operative instructions and being sure to keep in communication with us if you have any concerns at all. Some other concerns that patients have about bariatric surgery are as listed. The degree of these can be different from patient to patient...if you have questions regarding any of the post-op concerns or complications please let us know. You will have ample time to discuss all concerns with the surgeon when you come in for your initial consult, and our team is always available through our website and on the phone. 5

6 After surgery, patients are usually in the hospital for 1-2 nights. Most people experience minimal pain, often felt around the incision sites and as gas pains. This pain is managed with around the clock medications for the first 24hours, and then as needed after that. Our goal is to make you as comfortable as possible. You also do your part as well; There are 3 things we look for in determining if you are ready to leave the hospital after bariatric surgery. We will encourage you to get up and walk to help with post-op gas pains and prevent blood clots. We will start you on liquids right from the start to ensure you maintain adequate hydration. And lastly, we will show you how to use a device called an incentive spirometer to help you take nice big deep breaths to prevent pneumonia. All discharge instructions and medications needed will be thoroughly discussed with you before leaving the hospital. Some post-operative restrictions are listed. It is important to follow these instructions in order to have a smooth post-op course. Avoiding tobacco, anti-inflammatory medications, caffeine, and alcohol will allow your body to heal, and can reduce the risk of developing an ulcer after surgery. If quitting smoking is something you feel will be difficult for you, talk to us about the many resources available to help you quit. Let s talk for a moment about eating. Since we are talking about a surgery that alters how you eat, it can be beneficial to try and get into a few behaviors before surgery that we have noticed help people to be more successful long term after bariatric surgery. Therefore, right from your initial consult, we will encourage you to follow our preoperative diet, and many insurance companies require you to follow this program before they will approve surgery. Then, 3 full days before surgery we will require you to be on a clear liquid diet. Everyone will be meeting with our dietician prior to surgery, and the post-op diet and vitamins needed for life will be thoroughly explained to you. The basics are: you start with liquids and soft foods and move on to more solid/denser foods as time goes on. You should eventually be eating a diet of dense foods that fill you up quickly, and keep you fuller longer than they might have before bariatric surgery. Liquid calories should be avoided long term as well, and this includes protein shakes. We also recommend that patients incorporate exercise into their weight loss journey. Exercise can be useful for burning calories, but also as a way to cope with stress and increase energy levels. We understand that some people may have physical limitations to exercise, but even so much as walking 15 minutes a day can be beneficial, or any arm movements that you can do in a chair. 6

7 The biggest take home is that it is very important to follow our postop guidelines. Straying from the diet and behavior guidelines can put you at risk for causing complications and can slow down or even stop your weight loss progress. Whichever weight loss procedure is the right fit for you, it is important to think of your surgery as a "tool". Just as it would be difficult to build an entire house with only one tool, the same could be said about relying solely on your surgical tool for long term, lasting success on your weight loss journey. Through our years of experience, we've found that people do best with weight loss surgery when they include all the other "tools" in their toolbox diet vigilance, regular exercise, vitamin/mineral supplementation, support from family/friends/support groups, and of course, regular visits with their bariatric team. There are usually several steps to complete with any bariatric program before surgery can be performed and listed are the majority of steps in our program. Remember, the seminar you are watching right now will count towards your pre-consult mandatory education. Following that, an in person consultation with one of our surgeons will be scheduled. We take great care in guiding you through the process of appointments required by our program and your insurance company. Weight loss before surgery may be required either by your insurance company or your surgeon. Also, several insurance companies now require supervised monthly weight checks before they will approve bariatric surgery. These can be done in our office free of charge, or with your primary care if you live far away from our Syracuse or Utica locations. We are very experienced in the insurance approval process and will help guide you through all the requirements needed by our program and your insurance company. Caring for you and your success is our greatest pleasure. 7

8 Here is a copy of the quiz you answered online during the virtual seminar 1. The laparoscopic Roux-en-Y Gastric Bypass and the Gastric Sleeve are the most common weight loss procedures performed in the United States. 2. We perform weight loss surgery (bariatric surgery) through several small laparoscopic abdominal incisions. 3. There is no diet, exercise, or medication that is proven to work as effectively for weight management as bariatric surgery does. I will discuss realistic weight loss surgery goals with my surgeon. 4. Bariatric surgery may help lessen the severity of and even resolve many medical conditions associated with obesity, such as diabetes, high blood pressure, sleep apnea, and risk for certain types of cancers. 5. There are potential complications that can result from undergoing bariatric surgery, including death. 6. I will have to follow a diet after bariatric surgery that will start with liquids and soft foods and eventually lead to real, solid food not necessarily protein shakes and bars. 7. Tobacco use, anti-inflammatory medications, and alcohol should be avoided as these can cause ulcers. 8. After surgery I will likely have to use a blood thinner injected under the skin for a short amount of time as determined by my surgeon. I understand that this is to help prevent complications after surgery. 9. I will have to take vitamin and mineral supplements for the rest of my life after bariatric surgery and serious nutritional complications can occur if I do not take my vitamin and mineral supplements as directed after surgery. 10. Patients do best with weight loss surgery when they include all the other "tools" in their toolbox-- diet vigilance, regular exercise, vitamin/mineral supplementation as advised, support from family/friends/support groups, and regular visits with their bariatric team. 8