GASTRIC BYPASS ROUX-EN-Y PROCEDURE MEMORIAL HERMANN MEMORIAL CITY HOSPITAL, HOUSTON TEXAS Broadcast June 15, 2005

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1 GASTRIC BYPASS ROUX-EN-Y PROCEDURE MEMORIAL HERMANN MEMORIAL CITY HOSPITAL, HOUSTON TEXAS Broadcast June 15, 2005 NARRATOR Today, a bariatric surgical team from Memorial Hermann Memorial City Hospital in Houston, Texas, will demonstrate live a Roux-en-Y gastric bypass procedure to treat morbidly obese patients. This procedure combines the two main principles of bariatric surgery, restriction and malabsorption. The surgeon divides the stomach, creating a small pouch that greatly restricts the amount of food the patient can eat. The procedure also reroutes and shortens the small intestine, decreasing the amount of food energy absorbed by the body. The bypass stomach and intestine segments are re-attached below the pouch so the fluids and enzymes provided by those organs can drain into the intestines and facilitate digestion. Today s program is part of Memorial Hermann Memorial City Hospital s ongoing educational efforts to bring the latest information in healthcare to physicians and patients. During the program, you may send your questions to the OR surgeons at any time by clicking the MDirectAccess button on the screen. Good afternoon and welcome to Memorial Hermann Memorial City Hospital in Houston, TX, where this evening you will see a live gastric bypass Roux-en-Y procedure. We are live, this is not pre-recorded, so we are subject to some of the travails of live broadcasting. It is a live program here at Memorial Hermann Memorial City Hospital. I m Dr. David Mobley, I m a urologic surgeon here at the hospital. I will be your comoderator, along with Dr. Scott Duncan, anesthesiologist, who s sitting here next to me. Thank you, David. Performing the surgery this evening is Dr. Adam Naaman. He s a bariatric surgeon and Director of the Bariatric Center here at Memorial Hermann Memorial City Hospital. Dr. Naaman is recognized nationwide for his expertise in this area of surgery. During the broadcast today, we will take live s and I ll tell you how to do that in just a moment. If you want to us during the procedure, go to your computer MDirectAccess button, press on that and you will see how to send us an . We will do our best to answer as many of the questions as we can during today s broadcast, which will last about one hour.

2 You may continue to questions after the program and we will attempt to get answers to you through system. Also, don t forget to tell your friends and colleagues about this. This program will be kept indefinitely in an archived manner on Memorial Hermann s website. Innovation and quality are at the heart of everything we do here at Memorial Hermann Memorial City Hospital and what you ll see today is a minimally invasive laparoscopic technique for gastric bypass Roux-en-Y. At this point, I m going to turn you over to our surgeon, the esteemed Dr. Adam Naaman. Thank you, Dr. Mobley. I would like to introduce our team first. Our anesthesiologist is Dr. Lawrence Camp, my assistant is Dr. Absolam Samar, our instrument tech is Hedley Joseph, my cameraman is Julius Balog. We re going to look now at the abdomen. We already have inserted our trocars. We use three 12 mm trocars in this area and we use two 5 s. We already have inserted the liver retractor and the liver is already elevated. We ll be starting now. Our first step is to enter the lesser sac. We re going to elevate the stomach. What you see now is the back wall of the stomach. What you see here is the left gastric artery. A lot of people ask me what is the size of the gastric pouch. What we have found is if we start the gastric pouch in this area where the left gastric artery enters into the stomach, we end up with a pouch of about one ounce. The next thing that we ll be doing is actually transecting the stomach and making that pouch. We first transect this area of the lesser sac where there s some vessels and therefore those of you who can see there is this white Peri-strip that allows us to transect the vessels without any bleeding. While Dr. Naaman is constructing the pouch, we ll talk a little bit about who might be candidates for this type of surgery. We ll go to the definition of morbid obesity. Effectively that is people who have a weight greater than 100 pounds over their ideal weight. Most of the individuals who have this kind of surgery have weights of , 400 pounds more than their ideal weight. They have a body mass index of greater than 40. What I m doing now is continuing the transection of the pouch. The area that we want to aim for is what is called the angle of Hiss, which is the angle between the esophagus and the stomach itself.

3 Dr. Duncan, while Dr. Naaman continues with the production of the pouch, would you spend a minute talking with our listeners and observers about the health benefits of this type of surgery? Or, we should say, some of the detriments of overweight and then the subsequent health benefits. That s right, David. We re basically looking at the pathophysiology associated with morbid obesity and they can be summarized very briefly as diabetes, which is very common, to have loss of blood sugar control in these patients. They tend to have high blood pressure, they have hypertension. They tend to have sleep apnea, which is a concern about soft tissue in their necks being excessively large, where they, at night, can t breathe in their sleep. They snore loudly and wake themselves up. They tend to have osteoarthritis, as the synovium in their joints, which normally acts as a cushion, gets worn down by the excessive weight and pressure on the joints. They also suffer from depression and reflux, or terrible heartburn. What we see is that this surgery results in reversal of almost all of these conditions in rather short order, I might add. One of the things we first see is a very rapid correction in blood sugar control. These patients often lose their diabetic problems within a few months of the surgery to a year. Their blood pressure improves drastically. Their sleep apnea also gets better and also one of the first things that we ve seen to improve is their lack of heartburn and reflux that often awoke them from sleep. There are some tremendous improvements that occur in rather short order after the bypass surgery results in some significant weight loss. Both improvements in quality of life and length of life as well. Yes, I think the average is about 6 to almost 7 years of length of life, which is really amazingly impressive. Dr. Naaman, what are we doing at this point? What we have done now is we almost have finished making our pouch and we know that we are now finished because we can see our stapler going right across the angle of Hiss right there and we re going behind the spleen. That s how we know that we are across the staple and we have now our pouch. What we have here is the pouch on this side and that s our new pouch right there and this is the old stomach right there. So now

4 that we have done that, we re going to look and make sure that the pouch is mobile, and indeed it is. We re going to lower our liver now just to make sure that it gets flow while we are working on the small bowel. Dr. Camp now is going to flatten the bed, which had been in a reverse Trendelenberg position, almost at a 45-degree angle. That flattening will allow the colon to go down, to go towards the head, and now we re going to pull the omentum towards us. That will bring the small bowel into view. We re going to begin answering some of our s. You can us now by going to your computer. Go to the MDirectAccess button, send us your s and we will do our best to answer them during the remainder of the program. We have a question here for you, Dr. Duncan. What is the recovery time for the surgery and is there a longer recovery if the gall bladder is removed? First, let s say that generally we don t remove the gall bladder during these surgeries, though it can happen, postoperatively, in the distant future, after the patient s had surgery. We generally don t have the gall bladder removed during the surgery itself. The average length of time postoperatively is about days, then the patients go home after that period of time. What we are doing now is we are measuring the small bowel. As you can tell, the small bowel really starts in this area, it s called the ligament of Treitz, and we start to measure our bowel. We always measure the length that we are going to do in relationship to the BMI. The BMI on this patient is 55. Let me just count now. As you can see, this is the fourth one and I count to this mark right here, that lets me have 40 cm. Then when I go to the fifth one, that will be 50, 60, 70 and 80. We re going to transect the bowel at this point. The criteria for gastric bypass is generally individuals with BMIs greater than 35 to 40. So your patient with a BMI of 55 is certainly an excellent candidate. I m assuming your patient has undergone some dietary evaluation and psychological evaluations, things of that nature? Exactly. All of the patients who undergo this surgery, obviously have to demonstrate that they have tried some form of diet. It has to be well-documented. We also like them to see a psychologist to resolve if there are any issues at hand. Also we like people to got to a seminar which explains what we do so that have, really, a fairly good notion of what

5 they re going to undergo and what kind of changes in lifestyle are necessary. What you re seeing here is that the small bowel has been transected. We like to make sure that we have this area here I ll clear some of the fat from the staple line Dr. Naaman, we have an . Since you re cutting there into the intestinal tract, we have an asking: does this surgery affect irritable bowel syndrome? The surgery generally doesn t. Most irritable bowel syndrome is in the colon and our experience is, if anything, you tend to help it a little bit. Dr. Duncan, as an anesthesiologist, which you are, we ve got an here. Does the loss of muscle which accompanies rapid weight loss weaken the heart? In this case, the answer is no. In fact, the rapid weight loss associated with this surgery, in fact, helps the heart out a bit because it decreases the work the heart has to do, both by correcting some of the hypertension that s associated with morbid obesity and decreasing the miles and miles of blood vessels associated with the excess fat tissue. So, in fact, in this case the heart doesn t lose any mass and the patient s health is generally improved, cardiovascularly. We also have an question here and you can us at MDirectAccess button on your computer we will do our best to answer as many of those as we can. Right to you, what type of general anesthesia does this type of procedure warrant? Actually, general anesthesia for the morbidly obese patient is quite a challenge. These patients do have to have a thorough preoperative evaluation done by our anesthesia team. We ve gotten quite adept at doing surgery and anesthesia for these patients. The surgery is done with a general anesthetic as the patient is put to sleep by giving medication through an intravenous line. Then an endotracheal tube, or breathing tube, is placed after they re asleep and it s kept in place until the surgery is over with and they re awakened. This helps protect their airway, especially in the morbidly obese patient, which often has problems with their airway. It can be very difficult. But, again, we ve got very used here at Memorial Hermann Memorial City Hospital at maintaining the patients very safely under a general anesthetic for the duration of the procedure.

6 Dr. Naaman, how are we doing? Good. We are dividing the mesentery here. We re going to do one more cut on the mesentery. You can see that on the upper part of the screen, we actually have one part of the bowel and we have the other one on the lower. We re going to divide just a little bit more and then we ll continue. Dr. Naaman, would you comment on the difference between the from either a surgeon s or a patient s perspective the difference between an open procedure and the laparoscopic approach you re using here today. We try to do them very much the same way, but what we have found over the years, the patients obviously like the laparoscopic procedures better mainly because they hurt less. The results are about the same and, obviously, the equipment that is necessary to do the laparoscopic surgery is a little more extensive. That kind of equipment is now certainly available. Here, we are measuring the Roux limb of the Roux-en-Y. We now measure 20 cm, we re going to go to 80 cm here. 40. We do have a Bariatric Center here at Memorial Hermann Memorial City Hospital. For those of you who can call the hospital and ask for the Bariatric Center, we do support groups and other activities that would be of interest to you. Dr. Naaman, we ve got an question here about how do if you re doing some bypasses of parts of the intestinal tract are there issues with regards to absorbing vitamins and adequate nutrients and things of that nature? Absolutely. As a matter of fact, we have found that patients who have this surgery have to be on, usually double the amount of vitamins than the normal person. They have to take these vitamins for life. We like to follow these vitamin levels at regular intervals and we ve found that such vitamins as B12, B6, B1, and folic acid especially need to be watched and if we find that these are too low then there has to be extra supplementation. We also like to follow the albumin and the protein level and the calcium. Not everybody needs it, but some people do.

7 What I m doing now is I m closing the mesentery defect between the two parts of the small bowel. While you re doing that, I want Dr. Duncan here to answer a question. We have a heart question from one of our s. Dr. Duncan? Yes I noticed the patient mentions that they have a supraventricular tachycardia, heart arrhythmia, with frequent PVCs. The patient mentions that otherwise, they re in good health. They do take medication for that particular problem and they wondered whether that would, in and of itself, stop them from having this surgery. Quite honestly, the answer would be no. The anesthesiologists here are quite adept at dealing with arrhythmias, we see it all the time and we re able to have them evaluated preoperatively, by cardiology if necessary, and then we ll follow them up in and through the entire operative procedure and postoperatively as well. So, no, that s not a barrier to having the surgery whatsoever. I m continuing to close the mesentery defect. Dr. Naaman, it would certainly appear to me and to, I think, all of the people watching this, that without some fantastic instrumentation, this procedure would be much more trying. Is that not true? Yeah, and what you re seeing here is I m using an instrument that seems almost to sew by itself and this device which I ll use next is called a Ti-Knot and actually that s what it does: tie knots. Here we sutured, then we tied and it makes sewing and tying in small areas a lot easier. This is the end of the mesentery defect and we re going to close that area. Some people like to close this area with a running suture. We tend to do it with an interrupted one. We ve done it both ways; we don t see any real difference. Dr. Naaman, we got the question that probably everyone out there thinking about this surgery is wondering and that is: what about postoperative pain?

8 Amazingly enough obviously, there s less of a postoperative pain with this kind surgery than if we do it open. And we give different kinds of medications to control the pain because, obviously, what we want is for people to walk the evening of the surgery. People don t like to walk when they have pain, so our first goal is to control the pain and make sure that they can tolerate the pain of the surgery and walk at the same time. Would you make a comment, Dr. Naaman, about the importance of exercise you mentioned walking the day of surgery walking afterwards, how important this is to their recovery. Well, it is essential. The number one risk of this kind of surgery is blood clots in the legs which then go in the lungs. We have a real interest in preventing them and the most important thing is to walk. What are you doing here? It looks like you re making a little hole. What I m doing now is I m connecting the bottom of the Roux-en-Y where the two loops of bowel, the small bowel are going to be reconnected. You remember we just separated them to make the Y. Once we do that, we need to reconnect them at the bottom of the Y to reestablish the continuity of the small bowel. And that s what we ll do now. We ve got a diagrammatic slide that shows the completed Roux-en-Y, we ll see if we can t get up on the screen here. While we re doing that, I want to know, too, Dr. Duncan, are there any particular difficulties with these individuals after surgery waking up, breathing on their own, things of that I mean, these people already have difficulty breathing, now they have added general anesthetic. Right, there are certain difficulties that can be associated with waking them up and that s why we watch them very carefully in the recovery room to make sure that they re wide awake and breathing smoothly before we leave them alone. They re monitored very carefully in the recovery room both for several reasons. We want them to be very comfortable when they wake up. We don t want them to wake up in a lot of pain. We want them to wake up and be able to take nice, big, deep breaths so that they can make sure that their lungs are fully expanded, they won t get pneumonia. We also want them to

9 be awake enough so that when we allow their airway to be unprotected, they ll breathe safely and won t have to worry about swallowing anything down the wrong tube, as it were. Good monitoring postoperatively and allow them to wake up and have good pulmonary toilet, to make sure their lungs are expanded well. Very important. As a reminder, you may us now or after the program this evening. You press the MDirectAccess button on your computer screen, it ll be very apparent how to send us an . Those questions that we can t get to today we will endeavor to get to at a future time. This program will also be archived. You can go to memorialhermann.org and find the program archived after tonight s program. Where do we stand now, Dr. Naaman? What we are doing now is we are actually making the lower anastomosis, which is another big word for the reconnection of the small bowel. As you can see, we re using a stapling device, it s called an endocutter. We made the cut one way, then we made it the other way and you re going to see in a second, we re going to make the third one. Here is the stapling device going one way, here is the stapling device going the other way and here we have this entry going into the bowel, which we are going to close now. This is what is called the lower anastomosis, the lower hookup of the small bowel. There s obviously a lot of hookups going on here. What is the risk, percentage-wise, of some of these giving you troubles in the postoperative period? The rate of a leak is just under 2% and we do several things to make sure that that doesn t happen. Obviously there are two areas that can leak. This one and the upper one. Our main concern is really the upper one. The liquid in this lower one is a lot less. Now we re going to finish the lower hookup. Dr. Naaman, one of our questions mentions: what happens to the part of the stomach that s no longer used after the bypass is completed? The er wants to know does it stay there or does it waste away? The stomach stays there. It still makes acid. Less acid than before, obviously, but it still makes acid. Here is the lower anastomosis, it is a good wide, patent anastomosis. The

10 stomach still makes acid and still works and actually it is the digestive enzymes from the stomach, the pancreas and the liver still meet with the food, but a lot lower down. They start to meet actually right here, so the absorption of food starts a lot lower down in the GI tract and this is a part of the malabsorptive aspect of this procedure. Aside from, Dr. Naaman, all the vitamins you mentioned and the nutritional importance in the postoperative period, what are the changes in their appetite and their eating habits? What changes for these individuals? Well, the small pouch which we made makes people feel fuller sooner, so they eat less. Then the food that gets through gets absorbed to a lesser extent. This is the same area that we have met earlier, the ligament of Treitz, which is where the small bowel starts and we re going to close this space so there won t be any hernia there. This area is called the space of Peterson and it s one of the areas where one can have an internal hernia after this surgery. We re going to close it now with this instrument I talked about earlier, called a Sew-Right. Makes here a nice suture, then it is tied. Dr. Duncan, we have a lot of questions about all that yellow stuff that we re seeing. Yes, we ve had a couple people us and ask what the yellow tissue is that they can see and in fact, it is fat. Your body is very adept at storing fat in different places. It was designed to survive famine. Unfortunately when we have a little excess food, we tend to store it in interesting spots and what you re seeing on the screen really is quite a bit of fat. One of the ers asked if that could be removed during the surgery and unfortunately not. :00 It s not a very good idea to remove the fat during this surgery. It s not the easy way to lose weight. Dr. Naaman, what has been your experience with insurance coverage for this type of surgery?

11 This is a very fluid kind of a situation. Some insurances pay and some not. Some of the largest, actually, in the nation right now are trying not to pay for that. It s always an issue. Hopefully, as more people become aware of the benefits of this surgery, there ll be more acceptance by the insurance companies of the need to cover this surgery. :00 I would think that from, even an expense standpoint, the amount of medical care most of these individuals will subsequently not require by losing two or three hundred pounds ought to more than pay for the expense of the procedure. Would that not frequently be the case? Yeah, you would think so, but unfortunately the insurance companies views all of a sudden, they asked why lots of people have this surgery and I believe they are faced with a fairly large expenditure and obviously they are trying to minimize it. I think they re also trying to make sure that the people who do this surgery are competent enough to do it and I think that s where we are at right now, where the insurances are trying to find out who can do it, who should not and also, I think that a lot of patients are asking more and more to have it done. You probably have some idea of the statistics as to the percentage of American people that might fit the diagnosis of morbid obesity. What is it, 2-3%, something like that? Right now the thinking is that 5% of Americans are morbidly obese. That s the way it looks. Why don t you tell us what you re doing at this point. What we re doing now is we made a small cut in the gastric pouch. We re going to make now a small cut in the Roux limb, which is going to bring the food to the lower gut. Then we re going to connect the Roux limb to the small gastric pouch, and thus reestablish the continuity of the bowel. Here we make the little hole in the small bowel and we re going to do the upper anastomosis, in other words, the upper hookup.

12 Dr. Naaman, you ve used that term, Roux limb, several times. Is there a reason it s called that, historically? Yes, this surgery was actually designed by a French surgeon called Rene Roux in the late 19 th century. Initially he did it for cancer of the stomach. Then a lot of people have noticed that people, after this kind of surgery, do die, but they don t die of the cancer of the stomach; they die because they lose weight. That s how they found out that some variety of this kind of a surgery can be used to lose weight, and, obviously, without the patient dying. What are we looking into right there? It looks like we re looking into part of the guts. What you re looking at now is the inside of the stomach, the small gastric pouch that we made and actually, here is the small bowel. So this is the area of the anastomosis. We re going to enlarge it a little bit and then we are going to combine As a surgeon, I ve got to comment on how little blood I see during this procedure. How do you accomplish that? Thank you David, you re a real gentleman. We accomplish that really by a lot of help from anesthesia. We do these surgeries with blood pressure running in the 90s. And so, Adam, keeping the blood pressure at a lower level will help you Keeping the blood pressure at the lower level makes it easier to lose very little blood. Dr. Naaman, we ve had a question from one of our ers that asks how long the open procedure takes versus the laparoscopic procedure.

13 Actually, they re about the same. There isn t that much of a difference. That s amazing. Our experience has been that for an open procedure the average length for the surgery is about an hour and fifteen minutes and for the laparoscopic procedures it s anywhere between 45 minutes and an hour. So it s about the same. Dr. Naaman, would you mind commenting on this is not the only, I ll say bypass procedure, for obesity. There s a couple of other wrinkles in this area. Could you comment on some of those and why you might use one over the other? What you re seeing now is, if you will, the classical Roux Y gastric bypass. And this, what you re seeing now is a proximal bypass. There are two kinds of bypasses which are distal. Distal bypass and also the duodenal switch. They re all designed for people who are a lot heavier than the patient that you re seeing here now. What I m using now is another one of these wonderful sewing devices. It s also a Sew-Right. That allows me to close this anastomosis with a running stitch. Is there such a thing, Dr. Naaman, as an average length of time for weight loss? Let s suppose an individual needed to lose 150 pounds to get down to a decent weight, is there an average time that kind of weight loss might take? We kind of looked at it and we do have different curves, but how much you lose depends a lot on how much you have started with. Obviously, somebody who starts at 600 pounds can lose about 300 pounds in one year. Somebody who starts at 300 will get to where they want in about a year and a half and they ll lose about 115 or 150 pounds. Does that give you some notion? Yes, thank you.

14 We have finished now the upper anastomosis, what is known as the gastrojejunostomy. Once we are done with that, the next thing that we re going to do is some checking to make sure that things are the way that they should. Here again, I m tying up the upper anastomosis with a Sew-Right. :00 Dr. Naaman, interesting question that I ll bet a lot of women are wondering and that is: what about pregnancy after a procedure like this? Ah, that s an excellent question. Lots of people ask me it. Actually, women become more fertile after this procedure so we advise all of our women patients to use two methods after the surgery. We don t like the patients to become pregnant the first year and a half. We would like them to stabilize and then become pregnant. We ve had quite a few women who had babies after this surgery and they do very well What I m going to do now is check the upper anastomosis and the way that we do it, we have a gastroscope inside of the mouth and we re going to look inside of the anastomosis which we have just made. As you can see, it is nice and wide. We re going to a picture. Yeah. So, Dr. Naaman, we re actually looking inside the bowel now, after you ve reconnected everything? Right Now one would have to wonder, can you really tell what you re seeing? Yeah. See that? Uh-huh

15 This is the small bowel, right there and we re going now to lower the head of the bed and we are going to pour saline over the upper anastomosis to see if there are any air bubbles. I m blowing air through the gastroscope and we are looking and you can see the gastroscope here in the small bowel, see that light moving back and forth that s in the small bowel. You don t see any air bubbles. Now I m going to go back, you re going to see things a lot better when I come back. You can see the light inside and there s no bubbles coming up through that water. Right. Here are the small bowel. You re going to see now the anastomosis right there. You even see the staples of the anastomosis in the 6:00 position. That s how I know that I have a wide, patent anastomosis with no air leaks, which means it is an intact anastomosis. At this point, I m going to suck all the air out. The only thing left for us to do is to put a drain. We always put a drain in that area because we want to know if there is any leak and this is a nice way of knowing if there is a leak. How long will you leave that drain in? The drain will stay for a whole week. If the patient, or us, if we re concerned there is a leak, we ll just ask him to drink some blue Gatorade. Obviously if there s blue coming out of the drain, there s a leak. The aim of the drain also is a lot of these leaks are very, very small and they can be handled without any surgery and the drain will then let all the leaking material out and the antibiotics will take care of the leak. We ve had a number of s regarding emotional support and support after this type of surgery. I want to mention that here at Memorial Hermann Memorial City Hospital we have a very strong support group. I know you participate, Dr. Naaman, in that certainly some of the time. I want our viewers to know that they can go to memorialhermann.org or our shortcut web address, mhhs.org and click on Memorial City Hospital, Memorial Hermann Memorial City, then you ll go to the Bariatric Center and you can get a lot of information about what we have been watching here today. So here, at least, at Memorial Hermann Memorial City we do have a very strong support system for individuals who are considering or have had this type of surgery. In fact, you ll have the opportunity to visit with people who ve undergone this type of surgery.

16 What you re seeing, what we ve done here is we ve lowered the liver, we have the drain in place where it should be. We re now going to remove the rest of the trocars and that will be it. Dr. Naaman, I m putting a little slide here on the screen. I know you have done revisions of people who have had problems with other types of surgery and so forth. Would you mention some of the reasons for doing a revision of this type of surgery or any kind of obesity surgery? Sure. The reality is that this is a man-made procedure, so sometimes one can have reasons to revise the What can happen is you can have patients who have narrowing of the upper anastomosis, you can have patients who have not lost enough weight, you can have patients with other kinds of surgeries like lap-band or vertical banded gastroplasty, who need a revision to a Roux Y. We do a lot of these revisional surgeries which help patients get to their ideal goal. We ve got innumerable questions about how long does this procedure take. I guess it sort of speaks for itself. I know you went a little bit slower than you usually do so I guess your average time is a half an hour, 40 minutes. Something like that. That s about right. It s not a question of how long does this take everybody. I guess the question here is how long does it take Dr. Naaman? Yes, I suppose so minutes, I guess. Patients are usually in the hospital a couple of days, is that right?

17 Yeah, patients on the average are in the hospital for just about a day and a half. Some people go home on the following day. Some stay for an extra day. We usually wait until there is some bowel action; that can vary from one to two days. Is there a difference between that admission time for an open versus a laparoscopic procedure, Dr. Naaman? Slightly, about half a day to three-quarters of a day longer. There are very few open procedures who go home on the following day. Usually they go home on the second postop day. I would say most go home on the second post-op day with some staying for a third day. Thanks. Got a couple of questions about anesthesia so I thought I d answer those. One is: during the surgery itself are you on a respirator or ventilator? And the answer is yes. In fact, we do relax all your muscles while you re deeply, deeply asleep and totally unaware of the process and we do breathe for you during the procedure. At the end of the surgery, we allow the anesthetic to wear off gradually and allow the patient to start breathing for themselves very comfortably and safely before we let them fully awaken so they re totally unaware of having been on the respirator. And that also is another question about how do they wake up after anesthesia. Do we give them a magic medication that wakes them up? And the answer is no, we allow the anesthetic to gradually wear off until they wake up comfortably in the recovery room. Do most of these patients, Scott, go back to a regular room or do some need to be in intensive care? Well, it depends upon their preoperative problems, or course, and anything that might happen in intraoperatively. But generally they do very, very well. We do watch their airway. Of course, we ve talked about some of their preoperative pathologies, but given the status that they come into the hospital with, they do very well and require really very little intensive care afterwards generally.

18 Dr. Naaman, we ve got a lot of questions that are sort of on the dietary realm. For example, I ve got one here, an how many times do you need to chew your food before you swallow? I think people are really intrigued by the idea of this small stomach and how it s going to change their eating habits. Can you comment on that a little bit? We have a regimen that kind of allows people to change how they view food and how they eat. We like to start with two weeks of clear liquids. That allows you, in those two weeks, to find which clear liquids work well for your new small stomach. We then go to four weeks of soups and that allows the patient to find which soups their new stomach likes. Then we have six weeks of soft foods for the same reason, to find out which new foods they can eat. A lot of our patients tell us there are lots of foods they liked in the past and now they just can t eat. Generally speaking, these are foods that have high fatty content. But nevertheless, there are patients who find now that for some reason they can t drink milk anymore or they cannot eat fish anymore. In other words, they develop likes and dislikes, just like everybody else. Speaking of food, we ve got a couple of s asking: what is the marshmallow test? Are you familiar with that? What is the marshmallow test? I have no idea, so I m curious how you re going to answer this one. The marshmallow test is an x-ray test that uses barium and marshmallows. You drink that to simulate small bites of food. Barium is a liquid so it ll pass through with ease, but the real issue is whether the marshmallows will pass through. That s kind of a slang way that we describe that test. Dr. Naaman, we ve had a couple of s from people saying that they ve been diagnosed as being morbidly obese and they re wondering what they can do preoperatively to decrease their risk for any postoperative complications. I think the most important thing, really, is to start walking. If one can start to walk just for 5 minutes, three times a day and then slowly increase the walking time to 10 minutes, three times a day or 15 minutes, two a day, I think just that will lower your risks considerably.

19 Do you have to take and Dr. Duncan, maybe you can answer this, too are there special precautions you take to avoid deep vein thrombosis in these individuals? Yes, we do. We use what is called a thromboelastogram. It s a test which measures the hyper- or hypocoagulability of the patient. Based on that, we decide whether to give things like heparin or Thoradol or Lovenox. So we tailor the antithrombolic management based on tests. We have about 8 more minutes on tonight s broadcast and before we get too far to the end, I want to comment again that those of you who want to view this, this will be archived at memorialhermann.org or mhhs.org. So visit that, it s actually an awardwinning website, it s an outstanding website I ve visited many times. There s information about all of Memorial Hermann s facilities. There s also a virtual medical encyclopedia on this website. But also information about this and this particular broadcast will be archived if you want to tell your friends and colleagues about it to watch this at a later time. :00 We also want to encourage you to continue ing. Even if the broadcast finishes, we re more than happy to try to answer those questions for you later. Dr. Naaman, so many diets so many people are dieting and there s so much information about diets and the failure of diets, people who do this, that or the other diet. What about the 5-year, say, success rate? Somebody that gets down to an ideal weight, do they tend to stay there? Or what percentage stay there? With the diets or with the surgery? With the surgery, yes. Our experience has been that people who undergo either this surgery or other kinds of surgeries, by and large, have a very high rate of success at 5 years.

20 Suppose a person doesn t lose the weight they want? Can you say, Well, maybe we should have made whatever the pouch a little smaller? Or something like that. Can it be, shall we say, revised and changed? That s what we talked about earlier. Sometimes when we find people have not reached what we feel is an acceptable weight loss with either the lap, and other gastric bypass, we sometimes can revise it so they can lose more. Usually it is not that they haven t lost anything, usually that they have lost, let s say about 30 or 40% of the excess weight and they need to lose more. If we start at 400 pounds and somebody s at 250 or 300, usually there is a real reason to lose more weight. We ve had a couple other questions talking about preoperative conditions. One asks about a heart murmur. If they have a heart murmur, can they still have the surgery? That would depend on the murmur itself, of course. There are some murmurs that might make this difficult. At the same time, it s important to realize that obesity makes most murmurs worse, so that corrective surgery for their obesity might, in fact, help their heart murmur and improve their cardiovascular conditioning. Someone else has asked whether or not cigarette smoking is a big deal before the surgery. And the answer is yes. That morbidly obese people have problems with their lungs to begin with and that cigarette smoking will clearly worsen that and make it much more serious. So that would be a nice idea if you could quit smoking before your surgery, it would be great. Wonderful idea. We encourage everybody watching to stop smoking. Dr. Naaman, we ve had several interesting s about the emotional aspects of this surgery. Intuitively one would think, I think, that if you lost 200 pounds and were down to a normal weight, that you would feel so much better all the way around. But we have one that sort of looked at this in a different way. It says: has the surgeon noted female patients and I think this could apply to men, as well, but female patients experiencing depression post-surgery or wide hormonal swings and of course, relative to females only how about irregular menstrual cycles? Do you have any comments on that? By and large, after the surgery, the menstrual cycle improves. There is a period, the first six months especially, where people have to readjust to the new look, if you will. Many

21 times people will see them at work or on the street and they don t quite recognize them even. So there is a period of adjustment, which is why I think that a support group is very helpful, to see how other people have handled these social issues. We re about out of time and I want to remind you, you can go to memorialhermann.org or mhhs.org. This program brought to you at Memorial Hermann Memorial City Hospital in Houston. Dr. Naaman, we re down to about three minutes. Would you make a comment to somebody watching this program tonight who thinks, This sounds like something I would like to do. They ve made that decision. What is the time frame for getting the evaluation done that we mentioned earlier and perhaps moving on to surgery. Can this be done within a month or so or does it take longer? I think it depends a lot on the documentation. If people can show that they have done their diets and if they can come to the seminar and listen to all that. We have done some people in that period of time. But the average time can be, at times, about three months. Dr. Naaman, we re about at the end. Any closing comments you would like to make before Dr. Duncan and I sign off? Thank you for being here. It was really a lot of fun. Well, I thank you for allowing both of us to be the co-moderators on this. My thanks to Dr. Scott Duncan. I m Dr. David Mobley and we re signing off from Memorial Hermann Memorial City Hospital here in Houston, Texas. NARRATOR Thank you for watching the live Roux-en-Y gastric bypass procedure from Memorial Hermann Memorial City Hospital in Houston, Texas. To make a referral, make an appointment or request more information, please click the buttons on the screen.