Outline. 1. Bariatric program goals. 2. Going through the process-how it works. 3. Bariatric Team Members. 4. Preoperative requirements

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1 Outline 1. Bariatric program goals 2. Going through the process-how it works 3. Bariatric Team Members 4. Preoperative requirements 5. Gastric sleeve surgery 6. Post-operative requirements 7. Activity/exercise 8. Medications 9. Oral intake 10. Laxatives 11. Possible complications 12. Support Groups

2 Goals Dr. Crapse main focus of his bariatric program is to provide an avenue for the morbidly obese person to reach a body weight that improves their health and ability to perform daily activities through diet, surgery, activity, and life style modifications. The final outcome after gastric sleeve surgery is patient dependent. This means if you follow the intake and activity requirements and life style changes recommended by Dr. Crapse you will reach your weight goals in the safest manner possible and have the maximum health benefits from your gastric sleeve surgery. This also means if you do NOT follow the guide lines and life style changes recommended by Dr. Crapse you will not lose as much weight as you expected to and you will not obtain the maximum health benefits that you could have.

3 Bariatric Team Members Contact number Surgeon - Dr. Fred Crapse, DO x 105 Psychiatry - Dr. Susan Corkran, MD Internal Medicine Dr. Linda Hickman, MD Office nurse and manager Meredith Moore, LPN x 105 Dietitian Bonnie Johnson, RD CEO Jan Winter Clark, RN, MHA Financial Liaison Scott West CFO Chief Nursing Officer - Rebecca Benham, RN Operating Room Nurse Manager Carla Webb, RN

4 Preoperative Requirements 1. Demonstrate a complete understanding of Dr. Crapse bariatric program. This includes preoperative, postoperative requirements and risks. 2. Demonstrate a complete understanding of the risks and benefits of the gastric sleeve surgery. 3. Understand and agree to accept all risks and complications associated with gastric sleeve surgery. 4. Complete abstinence of all tobacco and nicotine products. Yes this includes e-cigarettes/vapor cigarettes and all the like. 5. Abstinence of all recreational or illegal drugs. Yes this includes alcohol. 6. Complete three weeks of the Mayo or Adkins diet. 7. Drink an minimum of 70 ounces of water a day 8. Abstinence of weight loss medications (like phentermine) for at least two weeks prior to surgery. 9. Discuss all your medications (over-the-counter and prescription) with Dr. Crapse at least two weeks prior to surgery. 10. Anyone over 50 must have or had a colonoscopy prior to surgery 11. Have initiated a daily walking program. 12. Have initiated a daily multi-supplement. 13. Abstinence of ALL carbonated beverages for at least one week prior to surgery. 14. Give in writing to Dr. Crapse a list of your goals from having the gastric sleeve surgery. This should include weight loss, medical benefits, activity, and any other goals you have associated with the gastric sleeve surgery.

5 The Gastric Sleeve Surgery itself Gastric sleeve surgery, or the sleeve, as it is commonly referred to is a major intrabdominal surgery. It can usually be done by a minimally invasive (laparoscopic) technique. Simply put the sleeve is the surgical creation of a small pouch of stomach from the very end of the stomach while removing the majority of the rest of the stomach. This small pouch of stomach gives a person the sensation of being full after eating or drinking a very small amount as well as greatly limits the volume that can be put into the stomach. See diagram below.

6 Postoperative requirements Dr. Crapse divides the postoperative periods into three (4) phases which are: 1. Early phase immediately after surgery until the 21 st day after surgery 2. Mid phase is from the third to the sixth week after surgery, or from the day 21 st until 42 nd day after surgery. 3. Late phase is from six weeks after surgery until six months after surgery, or from the 43 rd day until the 182 nd day after surgery 4. Final phase from the 183 rd day on. Medications In the early and mid-phases if at all possible liquid, sublingual, or transdermal medications should be. The next best method is crushed oral medications. In the late and final phases pill are acceptable and usually tolerated. If possible blood thinners, aspirin, and nonsteriodal anti-inflammatory medications should NOT be used for at least the first three days after surgery. Use of blood thinners is sometimes mandatory for other medical conditions so this should be discussed completely with Dr. Crapse preoperatively. Exposure to water You may shower starting the day following surgery. Remove all dressings shower then dry the incisions completely and cover with a sterile nonadhesive dressing. No tub baths, or submersion of incision (tub, pool, jaqueze, pond, ocean or lake) until you are at the end of the early-phase. Activity A. Walking For the first three weeks after surgery all walking should be on an unobstructed, level, nonslippery floor. Use a cain or walking device to maintain balance as needed.

7 A. Walking continued The day of surgery and day 1 after surgery walk in your house at least 20 times. This can be just to the bath room, or room to room but you must get up and move. Early movement has many proven benefits including: 1. Faster healing 2. Faster resolution of pain 3. Faster return of bowel function 4. Less use of pain medications 5. Less chance of blood clots From day three until day seven after surgery continue moving around your house twenty times or more but now add short distance walks. Examples would be going out to the mail box or walking up and down the drive way. On day eight after surgery you should walk nonstop for at least eight minutes plus the moving around in your home. From day nine after surgery on add one minute to your continuous walking. Examples day nine walk for nine minutes day ten walk ten minutes so that by day thirty after surgery you are walking thirty minutes and day sixty you are walking an hour without stopping! B. Lifting and physical limitations Early phase - No lifting over fifteen pounds. No driving. No bending past 45 degrees. Wear an abdominal binder except when showering. Stay off any equipment that vibrates you. Examples are any lawn mower, tractor, motor cycles, heavy duty trucks and work equipment. No sex. Mid phase - No lifting over 20 pounds. Drive only if you are off all pain medications. Extremity exercises are acceptable now but not core exercise. Examples of core exercises would be sit ups or leg raises or any activity that makes you strongly contract your abdominal muscles. Late and Final phases no limitations

8 C. Oral intake eating and drinking Out of diet forever Carbonated drinks, bread rice and pasta, stringy meats like roast. Why should I not eat or drink these ever again after my gastric sleeve surgery? Because carbonation will stretch you pouch. Bread rice and pasta will both stretch and obstruct your pouch. Stringy meats will obstruct your pouch. Early phase clear liquid diet plus 80 ounces or water and liquid vitamin and medications. No alcohol or caffeine products. Mid phase you can eat anything that will pour through a tea strainer plus 80 ounces of water and liquid vitamins and medications. High protein low carbohydrate shakes should be added to diet now. No alcohol or caffeine products. Late phase you must chew all foods to an apple sauce consistency. Now 1-2 ounces of nonstringy meats can be added to your diet at each meal. Examples of acceptable meats are eggs, fish, baked or broiled turkey and chicken, ground hamburger meat, ground sausage. 1-2 ounces of vegetables per meal. 60 ounces of water daily. Continue daily vitamins Final phase up to 4 ounces of meat per meal. Up to 4 ounces of vegetables per meal. Continue 60 ounces of water and vitamin daily.

9 Laxatives If you had normal bowel function before surgery you should have normal bowel function after surgery when you are active and the anesthesia has been metabolized and you are off narcotics. If you used bowel stimulants before surgery chances are you will need them after surgery. This should be planned with Dr. Crapse before surgery when you discuss your medications. In the first few days after surgery it is common to have an ileus (delayed bowel function). While activity is the best treatment of an ileus sometimes medications are needed. The following is Dr. Crapse s order of use; 1. Take an ounce of milk of magnesia every hour for four hours or until you have had some movement. If no action repeat one time. 2. Drink an ounce of magnesium citrate every hour for four hour or until you have had some movement. 3. If no results with #1 and #2 notify Dr. Crapse office.

10 Possible complications While most people only experience short time postsurgical pain and minimal bruising at puncture sites. Gastric sleeve surgery can have devastating complications. Major complications include death, anastomotic break down, and gastric leaks. Bleeding, infection, obstruction, stricture, hernia, adhesions, injury to spleen, injury to bowel, injury to the pancreas, chronic nausea, gastroesophageal reflux, ileus, malnutrition, protein calorie malnutrition, anemia, B12 deficiency, change in taste, stroke, blood clot, deep vein thrombosis, pulmonary emboli, pneumonia, and heart attack are all potential complications during and after surgery. Support Groups 1. Bartlesville 2641Huntington Dr. 2 nd Wednesday of the month at 6pm 2. Cushing Cushing Hospital 3 rd Tuesday of the month at 7pm 3. Miami Ottawa County Courthouse Annex in Community room 4 th Thursday 7pm 4. Muskogee Muskogee Creek Nation Casino, Bingo Hall 3 rd Thursday 6:30 5. Owasso Bailey Med Center 2 nd Monday of the month at 6pm 6. Pryor Mayes Co Med Center 3 rd Monday of the month at 6:30 7. Coffeyville KS Coffeyville Hospital 4th Floor 1 st Thursday at 7pm