If you are morbidly obese, you should remember these important points:

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1 What is Morbid Obesity? Morbid obesity is a serious medical condition. If you are morbidly obese, it means that you are severely overweight, usually by at least 100 pounds. It also means that you have excessive amounts of body fat compared to healthy standards. Knowing whether you are morbidly obese is important. This condition puts you at very high risk for a host of serious medical problems, including high blood pressure, diabetes, and heart disease. Being morbidly obese may also hamper your ability to get around, expose you to possible discrimination or social stigma and may lower your self-esteem. If you are morbidly obese, you should remember these important points: Morbid obesity is not a sign of weakness, laziness, or gluttony. It is a serious medical condition with serious medical consequences. Current research suggests that many factors work together to influence your weight; these include genetics, eating habits as a child and an adult, hormones, and psychological factors. You are not alone. Approximately 67% of all American adults are considered overweight, approximately 33% are considered obese and about 5% are considered morbidly obese. There is hope. Resources are available to help you avoid the medical consequences of morbid obesity. How Do I Know if I am Morbidly Obese? A good way to assess your weight is to calculate your Body Mass Index (BMI). Your BMI estimates how much you should weigh based on your height. Here are the steps to calculate it: Multiply your weight in pounds by 703. Divide that answer by your height in inches. Divide that answer by your height in inches again. For example, a woman who weighs 270 pounds and is 68 inches tall has a BMI of Use the chart on the following page to see what category you fall into and whether you need to be concerned about your weight. 1

2 BMI Height (inches) Body Weight (pounds) BMI CATEGORY Below 18.5 Underweight Normal Overweight 30.0 and Above Obese More than 40 Morbidly Obese 2

3 Although your BMI is a simple way to evaluate whether your weight puts you at potential risk for health problems, a lot of other factors may also affect your health. These include: general health history level of physical activity diet waist measurement smoking history family health history blood pressure blood sugar blood cholesterol levels Your healthcare provider can help you to evaluate your BMI and these other factors to determine your overall health picture. What Risks Do I face if I m Morbidly Obese? If you are morbidly obese, you have a much greater risk of developing a variety of serious medical conditions compared to individuals who are not obese. You may develop health problems at a younger age. Some of these conditions may include: High blood pressure High cholesterol Type 2 diabetes Angina Congestive heart failure Stroke Arthritis Asthma and obstructive sleep apnea Back pain Pregnancy complications including diabetes, high blood pressure, preeclampsia and the need for a C-section delivery Menstrual irregularity and infertility in women Bladder problems Gallstones Kidney stones Liver disease Carpal tunnel syndrome Gout Poor heat tolerance Complications and infections after surgery Skin infections Depression and eating disorders Endometrial, breast, prostate, kidney, esophageal and colon cancers Premature death 3

4 If I am Morbidly Obese, What Actions Do I Take Now? Morbid obesity is a life-threatening medical condition. Gaining control over this serious health problem requires a commitment of your time, attention energy and efforts. Only after you have tried every possible method in your fight against obesity, including balanced nutrition, exercise and medical intervention, you and your doctor may consider weight loss surgery. Who is a Candidate for Weight Loss Surgery (Bariatric Surgery)? To be accepted for weight loss surgery (such as gastric bypass surgery), you need to meet certain criteria. You must: Be 18 years old and older Be either severely obese (100 pounds or more overweight, with a BMI of 40 or greater) OR obese (75 pounds or more overweight, with a BMI of 35 or greater, with at least one medical condition such as diabetes, high blood pressure, or heart disease) Have tried unsuccessfully to lose weight through a structured, medical weight loss program that included diet, exercise, and lifestyle changes Be experiencing personal or occupational problems due to obesity Undergo a psychological evaluation and counseling to determine that you are emotionally healthy enough to understand the ramifications of your decision Be willing and able to commit to long-term medical follow-up, as well as rigorous, lifelong changes in dietary, exercise and lifestyle habits that will be necessary to meet and maintain your weight loss and health goals after surgery 4

5 What is Gastric Bypass Surgery? EthiconEndo, Inc. Bariatric Edge The Roux-en-Y gastric bypass surgery provides a combination of restriction and malabsorption as part of a long-term weight loss solution. During the surgery, the surgeon creates a smaller stomach pouch, approximately the size of an adult human thumb. The surgeon then attaches a Y-shaped section of the small intestine directly to the new pouch. This allows food to bypass a large portion of the small intestine, which normally absorbs calories and nutrients. The smaller stomach pouch enables patients to feel fuller sooner and eat less food. Therefore, bypassing the small intestine means the body will absorb fewer calories. Read Tips to Remember About Gastric Bypass Surgery, which explains the nutritional requirements regarding vitamin and protein intake after gastric bypass surgery. You will also find this important information in the Post-Operative Nutrition Guidelines section of this manual. 5

6 TIPS TO REMEMBER ABOUT GASTRIC BYPASS SURGERY Gastric bypass surgery is both a RESTRICTIVE and MALABSORPTIVE procedure. It works by restricting the amount of food that can be eaten at one time AND by decreasing the absorption of calories. Diligent, ongoing visits to your surgeon and nutritionist are vital to your success. Gastric bypass surgery is only a TOOL to help you lose weight, and not a CURE for obesity. You can expect to lose approximately 70% of your excess weight in the first 1-2 years after surgery. An exercise regimen, which includes 30 minutes of aerobic exercise, preferably 5 times per week, will help to boost weight loss. It is possible to regain the weight you lose; remember gastric bypass surgery is a weight loss tool! Complications from the surgery, such as vomiting, anastomotic leaks, and bowel obstructions may occur weeks to months after the surgery; frequent follow-up with your surgeon is vital to your health and weight loss success. Depression after weight loss surgery is common. Seek professional treatment if you feel persistently depressed. You should eat 4-6 small meals per day, starting as soon as you go home from the hospital after your surgery. You will leave the hospital on clear liquids (stage I) and will progress according to nutrition guidelines. It is most important that you consume your prescribed amount of protein daily. You should not drink 30 minutes before and after each meal. You will be expected to take vitamin supplements for a lifetime! You should not use straws once you have your surgery. Straws allow excess air into the stomach and bowel which causes abdominal pain. 6

7 I m Considering Gastric Bypass (Roux-en-Y) Surgery- What are the Risks and Benefits? Every time a patient undergoes a surgical procedure, a certain amount of risk is involved. The reality of weight loss surgery is that your life will never be the same again. You will be limited to eating smaller portions because of the small size of your stomach after the surgery. You also may have diarrhea and difficulty absorbing important nutrients. Aside from the small but still concerning risk of death associated with bariatric surgery (from 0.89 percent in 1998 to 0.19 percent in ) the risks of surgery include potentially serious infections in the abdomen, difficulty with wound healing, and hernias. Surgical risks related specifically to gastric bypass surgery include: (soon after surgery): Anastomotic/gastric leak (can be a surgical emergency) Bleeding internally Collapsed lung Chest pain Constipation/diarrhea Dehydration Deep vein thrombosis (blood clot in leg) Hematoma (blood bruise ) requiring placement of drain Pulmonary embolism (blood clot in lung) Anastomotic stricture (opening at bottom of pouch swells shut) Nausea and vomiting Stoma obstruction Wound infections Long-term complications: Hernia Gallstones requiring removal of gallbladder Stretching of pouch Fistula- old stomach and pouch reconnect; requires surgical repair Vitamin and mineral deficiencies 7

8 Note: Your weight, age and medical history play a significant role in determining your specific risks. Your surgeon can inform you about your specific risks for bariatric surgery 2. When you are considering undergoing gastric bypass surgery to help you permanently control your excess weight, you should consult your health care provider, who can perform a risk assessment. Is your current health endangered enough by your weight to make gastric bypass surgery an option for you? Significant health risks associated with obesity include: Hypertension (high blood pressure) Type 2 Diabetes Sleep apnea Hypercholesterolemia (high cholesterol) Gastro-Esophageal Reflux Disease (GERD) Osteoarthritis Impaired cardiac (heart) and pulmonary (lung) function The benefits of having gastric bypass surgery include improvement or total resolution of these serious health risks, often referred to as co-morbidities. Also, the rapid weight loss that is realized boosts not only the physical, but the emotional well-being of the patient. The definition of success in studies of bariatric surgery is weight loss of 50% of excess body fat 3, while most patients can potentially lose 40-80% of their excess weight within 1-2 years. In considering gastric bypass surgery as a weight loss tool, remember that it is a major surgical procedure that is not without significant risk. Your surgeon will take every precaution to minimize your surgical risk. You should also consider that the risk of death from not having the surgery and remaining morbidly obese is greater than the risk of having the procedure itself. Mortality among morbidly obese patients who defer surgical intervention is > 10 times the expected rate. ( EthiconEndo, Inc. Bariatric Edge 3 8

9 What is Vertical Sleeve Gastrectomy? The sleeve gastrectomy originated as the restrictive part of the duodenal switch operation. In the last several years, though, it has been used by some surgeons as a staging procedure prior to a gastric bypass or duodenal switch in very high risk patients. It has also been used as a primary, stand-alone procedure for morbidly obese patients with a BMI of 35 and above. Sleeve gastrectomy is a restrictive procedure. It greatly reduces the size of the stomach and limits the amount of food that can be eaten at one time. It does not cause decreased absorption of nutrients or bypass the intestines. After this surgery, patients feel full after eating very small amounts of food. Sleeve gastrectomy may also cause a decrease in appetite. In addition to reducing the size of the stomach, the procedure reduces the amount of the hunger hormone, ghrelin, produced by the stomach. The duration of this effect is not clear yet, but most patients have significantly decreased hunger after the operation. How is Sleeve Gastrectomy Performed? The majority of sleeve gastrectomies performed today are completed laparoscopically. This involves making five or six small incisions in the abdomen and performing the procedure using a video camera (laparoscope) and long instruments that are placed through these small incisions. During the sleeve gastrectomy, about 75 percent of the stomach is removed leaving a narrow gastric tube or sleeve. No intestines are bypassed or removed. This procedure takes one to two hours to complete. This short operative time is an important advantage for patients with severe heart or lung disease. 9

10 I m Considering Vertical Sleeve Gastrectomy Surgery- What are the Risks and Benefits? The risk of major post-operative complications after vertical sleeve gastrectomy is 5-10 percent, which is less than the risk associated with gastric bypass or malabsorptive procedures such as duodenal switch. This is primarily because the small intestine is not divided and reconnected during VSG as it is during the bypass procedures. This lower risk and shorter operative time is the main reason it can be used as a staging procedure for high-risk patients. Complications that can occur after VSG include: (soon after surgery): Gastric sleeve leak (can be a surgical emergency) Bleeding internally Collapsed lung Chest pain Constipation/diarrhea Dehydration Deep vein thrombosis (blood clot in leg) Hematoma (blood bruise ) requiring placement of drain Pulmonary embolism (blood clot in lung) sleeve stricture (opening at bottom of pouch swells shut) Nausea and vomiting Wound infections Long-term complications: Hernia Gallstones requiring removal of gallbladder Stretching of sleeve Vitamin and mineral deficiencies Major complications requiring re-operation are uncommon after vertical sleeve gastrectomy and occur in less than 5 percent of patients. How Much Weight-loss Occurs after Vertical Sleeve Gastrectomy (VSG)? Several studies have documented excellent weight-loss up to three years after VSG. In higher BMI patients who undergo VSG as a first stage procedure, the average patient will lose percent of their excess weight in the first two years after the procedure. This typically equates to about 125 pounds of weight-loss for patients with a BMI greater than 60. Patients with lower BMIs who undergo VSG will lose a larger proportion of their excess weight (60 80 percent) within three years of the surgery. Short-term studies show that the sleeve is as effective as the Roux-En-Y gastric bypass in terms of weight loss and improvement or remission of diabetes. There is also evidence to suggest the sleeve, similar to the gastric bypass, is effective in improving type II diabetes independent of the weight loss. Additionally, more than 75 percent of patients will have significant improvement or resolution of major obesity-related co-morbidities. 10

11 Advantages and Disadvantages of Vertical Sleeve Gastrectomy Vertical Sleeve Gastrectomy Advantages Reduces stomach capacity but tends to allow the stomach to function normally so most food items can be consumed, albeit in small amounts. Eliminates the portion of the stomach that produces the hormone that stimulates hunger (Ghrelin). Dumping syndrome is avoided or minimized because the pylorus (bottom part of stomach connected to the duodenum, the beginning of the small intestine) is preserved. Minimizes the chance of an ulcer occurring. By avoiding the intestinal bypass, almost eliminates the chance of intestinal obstruction (blockage), marginal ulcers, anemia, osteoporosis, protein deficiency and vitamin deficiency. Very effective as a first stage procedure for high BMI patients (BMI > 55 kg/m 2 ). Limited results appear promising as a single stage procedure for low BMI patients (BMI kg/m 2 ). Appealing option for people who are concerned about the complications of intestinal bypass procedures or who have existing anemia, Crohn s disease and numerous other conditions that make them too high risk for intestinal bypass procedures. Can be done laparoscopically in patients weighing over 500 pounds, thereby providing all the advantages of minimally invasive surgery: fewer wound and lung problems, less pain, and faster recovery. 11

12 Vertical Sleeve Gastrectomy Disadvantages Potential for inadequate weight loss or weight regain. While this is true for all procedures, it is theoretically more possible with procedures that do not have an intestinal bypass. Higher BMI patients will most likely need to have a second stage procedure later to help lose the rest of the weight. Remember, two stages may ultimately be safer and more effective than one operation for high BMI patients. This is an active point of discussion for bariatric surgeons. Soft calories such as ice cream, milk shakes, etc. can be absorbed and may slow weight loss. This procedure does involve stomach stapling and therefore leaks and other complications related to stapling may occur. Because the stomach is removed, it is not reversible. It can be converted to almost any other weight loss procedure. 12

13 TIPS TO REMEMBER ABOUT VERTICAL SLEEVE GASTRECTOMY Vertical sleeve gastrectomy (VSG) enhances weight loss efforts by restricting the amount of food that can be consumed and provides an early feeling of fullness. Ongoing medical care and follow-up with nutritionist is crucial to your success. The VSG is considered a RESTRICTIVE procedure only. It does not cause malabsorption since none of the intestines are re-routed during this procedure. On average, VSG patients lose 50-55% of excess weight within the first 2 years after surgery. Often, patients will lose much more than the average. VSG is a TOOL, not a CURE, which aids in weight loss in addition to a healthy diet and exercise program. Although the VSG is a powerful weight-loss tool, it is still important to exercise to enhance weight loss. It is possible to regain weight after VSG surgery. According to the National Weight Loss Registry, the most successful weight loss surgery patients exercise at least 30 minutes a day. In order to boost your weight loss, it is recommended to do an additional minutes of exercise 3 times per week. The most serious complication of VSG surgery, and any surgery where you undergo general anesthesia, is death. Most complications will occur well after the surgery, such as hernia, anemia, vitamin deficiency, and bowel obstruction. These complications are rarely seen in VSG patients. If you become depressed after VSG surgery, it is recommended to seek counseling/medical attention immediately. The amount of weight that is lost after VSG surgery is dependent upon regular exercise and following the prescribed eating plan. During Diet Phase 1, a meal consists of protein shake, broth, Crystal Light, sugar-free popsicle, or sugar-free Jello. It is recommended that you slowly sip 1 ounce (30 cc) of liquid every minutes. You should be consuming a meal somewhere between 6-8 times a day. When you get to Diet Stage 4, it is recommended that you consume 3 meals and 1 nutritious snack. You will be discharged on sugar-free clear liquids after your surgery. The most important nutrient in your diet is PROTEIN. You MUST consume grams of protein/day. 13

14 TIPS TO REMEMBER ABOUT VERTICAL SLEEVE GASTRECTOMY You should begin taking a multivitamin after discharge from the hospital. You will begin taking calcium citrate, feronyl iron (such as Bariatric Advantage or Celebrate brands), and B-12 sublingual 1 month after surgery. It is important not to drink from straws after VSG surgery. Straws introduce air into your smaller stomach, which displaces nutritious food and causes abdominal pain/bloating. It is recommended to drink at least 30 minutes before and after each meal, once you are on Diet Stage 3 (pureed foods). The VSG eliminates the portion of the stomach which produces ghrelin, or the hunger hormone. It is possible that after VSG surgery, you may not feel hungry for up to 2 years or more. 14

15 How Weight Loss Surgery Is Performed Open Procedure Laparoscopic Procedure Typically, the surgeon will perform your surgery laparoscopically. There may be circumstances that will prohibit laparoscopic surgery, such as adhesions, and the surgeon will have to convert to an open procedure. Until you are examined laparoscopically, there is no way to determine if there are factors that will prohibit the surgery from being performed using this technique. Every attempt will be made to perform your surgery using the laparoscopic technique. 15