• Questions to ask your Insurance Company
• The Health Care Team
• Contacting the Weight Loss Surgery Office
• Operative Procedures
  • Roux en Y Gastric Bypass
    • Complications Following Roux-en-Y Gastric Bypass at Duke WLS
    • Expected Weight Loss
  • LapBand
    • Expected Weight Loss
• Path to Surgery
  • The First Clinic Visit
  • The Second Clinic Visit
  • The Third Clinic Visit
• Preparation Instructions for Surgery
• Day of Surgery and Postoperative Stay
• Complications of Roux-en-Y Gastric Bypass Surgery
• Preoperative Diet Instruction Manual
• Postoperative Gastric Bypass Meal Planning Guide

Introduction

Thank you for your interest in the Duke University Health System Weight Loss Surgery Center. Let us begin by stating that serious obesity is a disease. It is not due to any weakness or laziness on your part. Medical research is showing that obesity is a genetic abnormality that is expressed to variable degrees - even between individuals of the same family. When the genetic abnormality is weakly expressed and obesity is only a mild problem, medical risks are minimal and the multitude of diet programs available are usually effective and satisfactory. When, however, the genetic abnormality is strongly expressed and weight increases in excess of 100 pounds above one's ideal weight, medical implications become very important with increased risk for cardiac and pulmonary diseases, diabetes mellitus, and most importantly, a 10- to 20-fold increased risk of early death. For this population of patients, structured dietary programs have universally been unsuccessful. Patients report whatever weight loss occurs to be only followed by weight regain and all efforts are associated with guilt feelings and depression. It is this population of seriously obese patients that weight loss surgery is intended to help. The currently applied surgical procedures of Roux-en-Y gastric bypass and LapBand have consistently resulted in 80 to 140 pound weight loss in properly selected patients. As you might expect, such significant weight reduction has a tremendous impact on all aspects of life. As you begin to lose weight, the way you feel about yourself, your family, and friends will all change.

Weight loss surgery, however, cannot accomplish or maintain the necessary weight loss without your cooperation. To accomplish and maintain weight loss after surgery, you must eat less food, change the types of food you eat, and increase your exercise. The operations will create a very small stomach. Although you might continue to get hungry, one or two bites will satisfy your appetite and make you feel full. You must accept this fact and overcome the urge (habit) to overeat. Once you have recovered from surgery, liquids will not be as effective in satisfying your appetite and you must avoid large amounts of liquid calories.

We currently offer two surgical approaches for the management of obesity: the laparoscopic Roux-en-Y gastric bypass procedure and the laparoscopic LapBand procedure. The Roux-en-Y gastric bypass is recognized as the “gold standard” surgical procedure and is the only procedure to have demonstrated long-term (124 year) maintenance of weight loss. The LapBand procedure results in less weight loss, requires more frequent office visits for adjustment, and has not yet had long-term follow up. The LapBand procedure, however, is a less invasive surgical procedure and is associated with fewer major complications. It is therefore very important for you to carefully consider the two surgical options and for us to conduct a complete evaluation before surgery to make sure surgery is right for you. This evaluation will include completion of the attached questionnaire, a physical exam, an evaluation by our eating disorder psychologist, and a nutritional evaluation.

It is important for you to read and understand the information in this website before you make an application to our Surgery Program. We also encourage you to have your family read this information.

Note: To qualify for insurance coverage, you must have a body mass index of 40 or more. You can calculate your body mass index by clicking HERE.

Questions to Ask Your Insurance Company

1. Is Morbid Obesity a covered benefit in your policy? Give them the ICD9 Code of 278.01. If morbid obesity is a covered benefit, check that the operative procedure you are considering is also covered. For the Roux-en-Y procedure give them the CPT Code of 43846 or 43644 and for the LapBand procedure give them the CPT Code of: 43659 (Note that many insurance companies do not yet approve the LapBand Procedure so check carefully with your company if this is your selection). Finally ask if Duke University Health System and Durham Regional Hospital are accepted by your insurance.

2. What percent of the total bill will you be responsible for and is there a deductible that you will need to pay?

3. If your policy does not cover morbid obesity or the operative procedure, you have a couple of options:

* You have the option to obtain another insurance carrier, but you need to make sure that the new policy covers morbid obesity and the surgical procedure.

* You can continue to participate in medical programs designed to lose and maintain weight loss.

* In selected cases we will consider performing the surgery if you elect to self-pay. There is a considerable deposit required by the Hospital and you must fully understand all risks of financial burden. We will review this major decision with you extensively and will help in any way we can.

If you cannot understand the information given by your insurance company on coverage of obesity care, please feel free to contact our insurance specialist Ms. Brenda Fisher at (919) 660-2229 for an in-depth review of your policy.

Your Health Care Team

Ranjan Sudan, M.D. Surgeon
Eric DeMaria, M.D. Surgeon
Aurora Pryor, M.D. Surgeon
Dana Portenier, M.D. Surgeon
Alfonso Torquati, M.D. Surgeon
Hilary Blackwood, N.P. Nurse Practitioner
Deborah Brown, R.N., FNP-C Nurse Practitioner
Mary Whitman, R.N.
Frances Kovens, R.N., MSN, CNOR
Katherine Applegate, PhD Psychologist
Kelli Friedman, PhD Psychologist
Patrick MaHaney, R.D. Nutritionist
Elizabeth Keenan, R.D. Nutritionist
Jenny Cash, Nancy Linden, Kimberly Peterkin, Brenda Fisher, Cathy Goss, Katherine Payne, Administrative Staff

Contacting the Weight Loss Surgery Office
To contact the office:
Telephone: (919) 660-2229
Fax: (919) 660-2256
Internet: http://www.dukewls.org

The Surgical Procedures

Roux-en-Y Gastric Bypass:

The most common operative procedure we perform for weight loss is the Roux-en-Y Gastric Bypass. This is currently considered to be the "Gold Standard" weight loss surgical procedure. It results in weight loss mostly by reducing the size of your stomach, so you cannot eat as much, and partly by bypassing some of your small intestines so you absorb less fatty foods. This operation is accepted by obesity surgeons and the major obesity physician societies as being the most effective in weight reduction and maintenance of weight loss.

For your insurance company, the code for this operative procedure is: CPT 43644 and the ICD-9 code for the diagnosis of morbid obesity is 278.01

We prefer performing the surgery using laparoscopic techniques, avoiding a large incision in your abdomen, however an abdominal incision is sometimes necessary based on your weight, body shape, and previous surgery. The decision to proceed with laparoscopy versus open surgery will be made during your third clinic visit when you discuss options with your surgeon. See the picture below for an idea of the placement of incisions.

Laparoscopic or Open Roux en Y Gastric Bypass Procedure

The surgical procedure is only slightly different whether done with the laparoscope or as an open procedure (see figure below).

Several studies have shown that people who experience significant weight loss can develop gallstones. On the other hand, people who have, or who subsequently develop gallstones, often do not suffer any consequences or even know they have them. Due to the required location of the trocar sites to perform the weight reduction surgery, removal of the gallbladder at the time of a roux-en-Y gastric bypass is somewhat difficult. In many cases the risk of taking the gallbladder out at the same time may well exceed any potential benefit. For this reason, unless you currently have gallstones that are causing trouble, we do not routinely remove the gallbladder at the time of your weight loss surgery operation. If you are known to have gallstones, we will discuss the possible risks for removing it with you and use our best judgement with respect to its removal at the time of surgery.

Duke WLS Complications Following Roux-en-Y Gastric Bypass: The following table shows the incidence of complications we monitor following surgery. Where available, the reported incidence from other centers is given.

Expected Weight Loss:

Most patients lose between 80 and 140 pounds. The exact amount of weight you lose will depend on your compliance with the dietary instructions and commitment to exercise. Most of the weight is lost during the first 8 months. You will need to watch your diet very carefully after your weight stabilizes as failure to continue to restrict your intake can result in some weight regain. The following charts depict the average weight lost by our patients based on their initial BMI:

LapBand Procedure:

For your insurance company, the code for this operative procedure is: CPT 43770 and the ICD-9 code for the diagnosis of morbid obesity is 278.01

Considerable experience has been obtained, mainly in Australia and Europe, with placement of an inflatable Silastic band around the top part of the stomach to create a small gastric pouch, without the need for any bowel anastomoses. This procedure is performed laparoscopically and is called the LapBand Procedure. The surgical incisions for the needed laparoscopic ports are similar to those for the roux-en-Y gastric bypass:

The device consists of a band, connection tubing, and a plastic access port. The band has a plastic ring lining the inside that can be filled with water to narrow the stomach opening, thus limiting the amount of food that can pass over time. The access port is used to add or remove water from the band, here shown with a needle and syringe placed for an adjustment.

An area is cleared at the top of the stomach for passage of the band and the band is secured about the stomach by an interlocking mechanism. After placement of the band, all instruments are removed from the abdomen and a small plastic access port is implanted just under the skin. The band has a plastic ring lining the inside that can be filled with water to narrow the stomach opening, thus limiting the amount of food that can pass over time. The amount of water in the plastic ring is adjusted by placing a needle into the plastic access port and adding or withdrawing fluid. Placement of the needle is minimally painful.

Expected Weight Loss:

Results of the LapBand procedure have been encouraging, however weight loss is less than for the Roux-en-Y gastric bypass and management requires more frequent clinic visits to adjust how the band narrows the stomach. Most patients will lose between 80 and 100 pounds. The exact amount of weight you lose will depend on your compliance with the dietary instructions and your tolerance to adjustments to the tightness of the band. Weight loss is slower with this procedure with most of the weight loss occurring after the first 3 months. You will need to watch your diet very carefully as the band is adjusted and continue long-term follow up to maintain weight loss.

Path to Surgery

Call your insurance company and ask them the following question: “I am considering having an operative procedure performed whose CPT code is 43644 (roux en Y), 43770 (LapBand). Is this procedure an exclusion on my GROUP policy?” If it is an exclusion then surgery for obesity is not, nor can it become, a covered benefit. At this time there is no procedure code for the LapBand procedure. The procedure is self-pay. If you would like a more information concerning the cost for the LapBand please call our office and ask to speak with Brandy Morris.

Note: Even if surgery for obesity is covered, to qualify you must:

• Have a body mass index of 40 or more, or a body mass index greater than 35, if you also have significant medical problems. You can calculate your body mass index on our web site by clicking HERE
  
• Be 18 years or older.
• Weigh less than 400 pounds.

Finally, STOP Smoking! The risks of anesthesia are greatly increased if you are actively smoking and it takes about a month for the lungs to recover. Stop NOW! If you do not quit, or cannont quit, your surgery will likely be cancelled.

The path to surgery typically takes 2 to 3 months AFTER your first clinic visit. Each individual is carefully evaluated for all related medical conditions. This often require special studies and occasionally consultations from medical specialists. Only after we are completely satisfied that weight loss surgery is right for you and that both you and we are fully aware of associated risks will we proceed with the scheduling of surgery.

The First Clinic Visit

Please obtain the following items to bring with you at your first clinic appointment:

• Documentation of your weight for the last 5 years from your primary care physician.
• Documentation of non-surgical weight loss attempts.
• A supporting letter from your primary care physician recommending surgery.

Your first visit to the Duke University Health System Weight Loss Surgery Clinic will include necessary laboratory studies, a medical examination, a psychological interview, and a nutritional evaluation. This visit will take about two - three hours. A full body photograph will be taken (FULLY CLOTHED) for your medical record.

Medical Evaluation: You will meet with one of our nurse practitioners, Hilary Blackwood, NP, or Deborah Brown, FNP-C, who have special knowledge and experience in the diagnosis and treatment of morbid obesity. They will perform an examination and evaluate any medical problems that have resulted from your obesity.

Psychological Interview: Psychological interview: As part of the evaluation for weight loss surgery, you will first complete a set of questionnaires. You will then be scheduled for a 45-minute interview with one of our health psychologists Katherine L. Applegate, PhD, or Kelli Friedman, PhD. n that interview, they will discuss behavioral and life-style issues that can impact on the adjustment to surgery. At the conclusion of their assessment, you will be provided feedback and given specific suggestions that may assist you both before and after bariatric surgery.

Some patients will be recommended to participate in individual psychotherapy or to see a physician for a medication evaluation as part of their treatment plan. For some, surgery will need to be delayed until an identified psychological condition can be thoroughly addressed. Patients given substantial recommendations to complete prior to approval for surgery may be scheduled for a follow-up visit to assess progress. This session will be provided at no additional cost. Patients are required to comply with their treatment recommendations if they wish to have surgery with our program.

If approved for surgery, this initial assessment will be followed by a five session cognitive-behavioral group series facilitated by our psychologists. During these sessions, patients will learn behavioral and lifestyle changes that can enhance their long-term success with weight loss.

The cost for the pre-operative psychological assessment is $300, and the cost for the behavioral group series is an additional $250. Patients are required to pay these fees up front. The first installment will be due at the initial visit with the psychologist, and the second installment will be due just prior to surgery.

Insurance plans may or may not reimburse all or a portion of these fees. The psychologists do not participate in any insurance plans; thus, the out of network benefit may apply. We will provide you with the necessary documentation to submit to your insurance company to seek any available reimbursement (see below). The initial assessment will be billed as CPT code 90801, and the group sessions will be billed as CPT code 90853. Although they may represent an additional personal expense, it is well documented in the literature, and in our own experience, that behavioral interventions can enhance your eventual success with weight loss surgery.

The psychologists will provide insurance claim forms to patients on the day of their assessment to submit to the insurance company to determine if they are eligible for reimbursement for the assessment visit. Also, after each of the four group therapy sessions, patients will receive a claims form for $68 dollars to submit to the insurance company for possible reimbursement. Claim forms cannot be issued for sessions that have not yet occurred; they cannot be issued for sessions patients do not attend. Reimbursement for these expenses is not guaranteed.

Nutritional Evaluation: You will meet with one of our dieticians, Patrick Mahaney, R.D., or Elizabeth Keenan, R.D., to assess your current eating and exercise habits. The dietician will take measurements to determine your body mass index and total body fat (please do not apply body cream or oils to your feet before this first visit as it will interfere with this test). In addition, the number of calories you are burning each day will be measured from collection of the air you breathe out. Finally, he or she will evaluate your baseline respiratory and skeletal muscle function At the conclusion of the evaluation, he or she will share their findings and discuss recommended dietary changes to prepare for surgery. They will advise you on a low sugar, low fat, small portion meal program that you will need to follow until surgery.

Laboratory Studies: As part of the medical evaluation, you will need to complete several studies. There are two ways that this can be done:

• You can have your Primary Care Physician order the tests locally - give the explanatory letter and order form on the last page of this booklet to your physician. If you elect this option, please bring the results of these studies to your initial appointment, or have them sent to us (Fax 919 660-2256).
• If you would prefer to do the studies at Durham Regional Hospital, we can arrange for them to be done on a day separate from your first clinic visit.

The necessary studies include:

• Barium Swallow to evaluate your esophagus/swallowing
• Arterial Blood Gas to evaluate your oxygen levels
• EKG to look for any heart disease
• Pulmonary Function Test to evaluate your breathing
• Blood work - to be drawn while fasting :
  1. Comprehensive Chemistry Panel (to include an albumin level and liver function tests)
  2. HbA1c
  3. CBC with differential
  4. Ferritin level
  5. Thyroid Stimulating Hormone level
  6. Fasting Lipid Panel

In addition, if you have had any of the following studies or procedures, please bring copies or the reports to your initial appointment:

• Sleep Study
• Cardiac Studies – stress test, echocardiogram, cardiac catheterization
• Operations, in particular of any
  1. Stomach or intestinal surgery
  2. Hernia repair (hiatal hernia or abdominal wall hernia)
  3. Cancer surgery

After review of the above studies, we will determine if any special consultations are necessary, such as a cardiac or pulmonary consultation or sleep apnea test. If so, arrangements will be made for them to be done.

What’s Next: After all the above tests and examinations are performed, and if they are satisfactory, your chart will be given a final review by our surgeons. If they approve your application, our office will submit the accumulated medical information to your insurance company for their review and authorization for surgery.

The Second Clinic Visit

At this clinic visit you will meet one-on-one with your surgeon to review the results of all tests and to discuss the potential risks and benefits of surgery. This will be your chance to have any lingering questions concerning surgery addressed. At the end of the visit, you and your surgeon will decide if surgery is best for you. If it is elected to proceed, you will be scheduled to return for a final third visit.

The Third Clinic Visit

This visit begins at 7:45 am and takes about half a day. When you register, you will be required to pay a second psychology fee of $250 that will cover 4 group sessions with the psychologists (a preoperative session, one at 3 weeks, 3 months, and one at 6 months following surgery). Again, although we will provide you with the necessary documentation to submit to your insurance company to seek some reimbursement, insurance plans MAY or MAY NOT reimburse for all or a portion of these fees.

On this third visit, you will meet with Patrick Mahaney, R.D., or Elizabeth Keenan, R.D. to discuss dietary changes just before surgery and during the first three weeks after surgery; and with one of the surgeons in a group with other patients for an in-depth discussion of the operative procedure and associated risks. After the session you will sign a request form for the surgical procedure. You will also be given instructions to prepare for surgery (see next page) and an outline of your postoperative diet. After the above meetings, you will have a one-hour group session with the psychologists, discussing appetite cues and ways to plan for the variety of changes that may occur after surgery. All these meetings will give you the opportunity to meet others undergoing surgery at about the same time.

You will then be sent to Durham Regional Hospital to have an interview concerning administration of anesthesia and performance of final laboratory tests in preparation for surgery. All arrangements for your surgery and admission to the hospital will be completed after this third visit.

Preparation Instructions for Surgery

1. Beginning 1 MONTH before surgery, STOP SMOKING! If you do not stop smoking, your surgery will be delayed or cancelled.
2. Beginning 1 week before surgery, do not take any aspirin, herbal medications, or NSAIDS (Celebrex, Aleve, Mobic, Motrin, naproxen). Tylenol is safe for pain.
3. To get ready for your exercise program following surgery, look around for a gym or exercise facility that will allow you to walk on a track or treadmill, or drive your car to define a mile walking course. After you recover from surgery you will need to walk 1 to 2 miles two to three times a week. Use your pedometer and strive for 8,000 to 10,000 steps a day.
4. Sample and purchase a variety of high protein beverages – there are many possibilities, so taste and decide. Also get some sugar-free popsicles.
5. Beginning one week before surgery, change your diet to the one below. This diet will help shrink your liver and make surgery safer. It will also introduce you to what the typical postoperative diet is like:
• Eat more high protein, low fat foods: Lean meats, poultry, fish, seafood, eggs, low fat cheese, light yogurt, skim milk, cottage cheese, tofu, beans/lentils.
• Eat less than 4 servings per day of these high carbohydrate foods:
  (1 serving = ½ cup or 1 piece of fresh fruit or bread).
  Fruit/fruit juice, breads, pasta, crackers, cereal, rice, potatoes.
• Avoid: sugary foods and beverages, desserts and candy.
• Limit these high fat foods and condiments: Butter/margarine, oils, salad dressing, sour cream, mayonnaise, cream, gravy, cream cheese, chips, high fat meats, bacon, sausage, fried foods, desserts.
5. On the morning of the day before surgery, begin a clear liquid diet. Also drink one bottle of Magnesium Citrate (Citrate of Magnesia). This is a fairly strong laxative and will work within 4 to 8 hours.
6. On the night before surgery, take a long shower or bath and clean your abdomen 3 to 4 times with soap and water. Pay special attention to cleaning your belly button area – use a Q-tip.
7. Do not eat anything after midnight the evening before surgery. You may take those medications “Okayed” by anesthesia with sips of water as needed.
8. If you use a CPAP machine, bring it with you to the hospital. You will use it following surgery.
9. Pack a comfortable robe for use in the hospital.

Day of Surgery and Postoperative Stay

Surgical Admissions and Family Waiting: Bring your "Patient Education Booklet" with you to the hospital as it will be used to help discuss discharge instructions. Wear comfortable clothing to the hospital. Please do not wear fingernail polish or makeup, especially eye makeup which may cause irritation during surgery. Please leave all valuables at home, including jewelry, wigs, and contact lenses. The hospital cannot be responsible for valuables. Free parking is available in Durham Regional Hospital's Visitor's parking lots located near the front entrance.

Once you enter the front door to the hospital, have all but one of the people with you wait in the main lobby until your surgery is over. One family member or friend may accompany you until you go to surgery. As you will have already pre-registered when you were seen by anesthesiology, you should go directly to the left side of the Main Lobby (3rd Level), at the very back where you will find the receptionist desk for same day admission surgery. Check in with the receptionist. When it is time for you to get ready for surgery, she will call for you and escort you to your bed in the preoperative area. In this area you will put on a hospital gown, have and IV started, and receive any medications ordered by your surgeon. When in the preoperative area you can request medications to help with any anxiety, however the anesthesiologist will carefully evaluate you to be sure some sedation is safe based on your cardiac and pulmonary function. When it is time for you to go into the operating room, all family and friends should wait in the waiting room on the third floor just inside the main entrance. Surgery usually takes between 2 and 4 hours. The surgeons will not contact your family during the operation, but will visit with them immediately upon completion of the surgery. Let your family/friends know there is a cafeteria and snack room on the first floor.

Recovery Room: When your surgery is finished, you will be moved to the recovery room where you will wake up (if you have any respiratory or cardiac problems, you may be transferred to the intensive care unit instead). The nursing staff will be testing your breathing, blood pressure and pain control. It is important for you to be able to communicate how much pain you are having. We use a pain scale to communicate pain:

0    1    2    3    4    5    6    7    8    9    1 0

No Pain  Moderate Pain  Very Severe Pain

It will be helpful to give a number on this scale when you describe your pain to the nursing staff. If you do not feel comfortable using this scale, you may describe your pain with this verbal scale:

No Pain
Mild Pain
Moderate Pain
Severe Pain
Very Severe Pain

Hospital Course Following a Roux-en-Y Gastric Bypass:

After you are fully awake (2-4 hours), you will be transferred to a regular hospital room on our Bariatric Surgery floor. Most of the hospital rooms are private - you will most likely not have a roommate. Under certain circumstances, a family member may sleep in the room with you -- arrangements must be made with the Charge Nurse on the Ward. After arriving to your hospital room, you will be assisted out of bed the same evening to sit in a chair. This early activity will help prevent postoperative complications of pneumonia and deep vein thrombosis (blood clots in your legs). When in bed you will wear compression booties that act to pump blood through your legs even though you are not walking. There will be small devices placed on your chest and finger to monitor your electrocardiogram and breathing. You will have a catheter in your bladder so you won’t have to urinate, and there will be a small drain tube coming out of your abdomen. Finally, you will have an IV in place through which you will receive pain medication on demand (called a PCA). There is a small button you push whenever you have pain and pain medicine is automatically infused without having to call a nurse.

Post-Operative Day 1: The tube in your bladder will be removed. Your intravenous line will be left in place. You will be expected to walk in the hallway with help and sit in a chair during the day. It is very important for you to get out of bed to help prevent postoperative pneumonia or blood clots in your legs. Also this activity reduces the severity and duration of pain. On this first postoperative day you will have an x-ray test performed in the morning called an Upper Gastrointestinal Series or UGI Series. You go to radiology and they will ask you to swallow contrast material while they take pictures of your new stomach. This test will confirm that there are no leaks in the staple lines. If okay, you will be started on a liquid diet - one ounce of room temperature tap water each hour while you are awake.

Post-Operative Day 2: Most patients start to feel better! You will increase your activity - walking and sitting up in a chair will be the main goals for the day. Your diet will remain liquids only but increase to 2 ounces of full liquids, like Boost Plus or Instant Breakfast, every hour while awake; plus 1 ounce of low or no calorie, noncarbonated, non-caffeinated beverage every 15 minutes as desired. You will begin oral pain medications and be started on some of your home medications. If you have not had a bowel movement, you may be given a laxative or a suppository. If your pain is under control and you are drinking the liquids well, IV fluids will be stopped and the IV removed. If you have a small drainage tube in your right side, it will be removed.

If all is well, you will be discharged on this day, although a few patients are not ready to go home until the morning of day 3. You should plan to have someone drive you home and to leave the hospital no later than 5 pm.

When you go home you should be independent and need no special help. To be safe, you should not drive for at least 2 weeks and you should not lift anything heavy (so heavy that you have to hold your breath or grunt). You will be able to go up and down stairs and you should plan to walk a lot.

Hospital Course Following a LapBand Procedure:

You will be encouraged to begin walking as soon as you have recovered from the anesthesia. Depending on how you tolerate the operative procedure, and whether your surgery was done early or late in the day, you may recover satisfactorily to go home the same day as surgery. This decision will be made after your surgeon sees you in the afternoon. If the decision is made for you to stay overnight in the hospital, you will again be evaluated the next morning and most likely be discharged before 11 am.

Post Surgery Follow-up Care

Your "Patient Education Booklet For Weight Loss Surgery" contains full instructions for your use following surgery. Please hold on to it and refer to the relevant pages for the following:

• Diet instructions
• List of problems that you need to call the WLS Office about (and those you do not)
• Answers to common questions
• Follow up appointments (3 week, 3 month, and 6 month, and 12 month, and yearly thereafter)
  NOTE: Upon discharge YOU MUST call the office to arrange these appointments. As a reminder, enter the dates on page 33.

Potential Complications of Roux-en-Y Bypass Surgery

Most patients will not experience any complications of their surgery. Nonetheless, both the Roux-en-Y gastric bypass and the LapBand procedures are major operative procedures and complications associated with any major procedure, as well as general anesthesia, can occur. This operation is associated with a complication rate of about 20% (one in five). This means that about 1 in 5 patients will have some type of complication after surgery. Most complications are minor such as drainage from a skin incision, a urinary tract infection, nausea, or abdominal wall muscle spasms with pain. Occasionally, however, complications can be major (less than 1%), such as a serious wound infection, intra-abdominal bleeding, infections within the abdomen, and hernias. Very rarely, life-threatening complications can occur including heart attacks, strokes, leakage from a suture line, and blood clots in the deep veins of the legs which can break off and travel up to the lungs (pulmonary embolism). Although even these serious complications can usually be treated successfully, they can result in permanent disability and even death.

Many patients develop some loose, flabby skin on their arms, breasts, ankles, and legs after weight loss with less obvious changes on the face and neck. In some cases, patients want to have plastic surgery to fix this problem. You should contact your insurance carrier to see if they cover such procedures - many consider them to be cosmetic surgery and do not cover the expense. We can refer you to the Duke Center for Aesthetic Services if you wish a consultation. Plastic surgery is not considered until at least one year after your surgery and only when you reach a stable weight. The more you exercise, the less likely you will need plastic surgery.

EMOTIONAL CHANGES: Be prepared for emotional ups and downs after you go home from the hospital. Some patients feel like they are on an emotional roller coaster. These feelings are completely normal and usually go away after several weeks. If these feelings continue or get worse, we will arrange for you to get help from our eating disorder psychologist.

DUMPING SYNDROME: Occasionally, following the Roux-en-Y gastric bypass procedure, patients will have problems with food emptying from the stomach too quickly. A syndrome can develop which is characterized by bloating, cramps, nausea, vomiting, sweating, rapid heartbeat, occasional fainting, and diarrhea. The problem usually is mild and resolves over several weeks. When severe a special diet is needed to slow gastric emptying:

1. Avoid foods that are high in osmolarity (highly concentrated foods like sweets).
2. Protein and fat may be increased in this diet. High protein foods include milk, eggs, meat, fish, cheese, peanut butter, and dried beans. Fat is used in amounts that are tolerated.
3. Meals are divided into 6 small servings.
4. Liquids should not be given with meals. Liquids should be given 30 - 60 minutes before or after meals. Liquids are fluids or foods that are fluid at room temperature - such as Jello, ice cream, or sherbet. Do not drink very hot or very cold liquids.

Bariatric Surgery Diet Manual

• Overview
• The Recommended Diet Following Bariatric Surgery
• Hospital Day 1: Stage One: Water Only
• Hospital Day 2: Stage Two: Full Liquids
• Discharge Diet - Through the First 3-Weeks
• Preventing Dehydration
• Vitamin and Mineral Supplementation

Overview

Bariatric Surgery is an excellent tool to aid you in limiting the amount of food you eat and facilitate weight reduction. However, after Bariatric Surgery, significant adaptation of your diet and lifestyle are required to achieve maximum success. After your Bariatric Surgery, you will be losing weight very rapidly. Proper nutrition is essential to maintain lean body mass, hydration, skin elasticity, and to minimize hair loss. The post Bariatric Surgery meal plan requires a significant change in meal planning for most people. We recommend that you begin now adapting your current meal plan to prepare for this change.

The primary nutrition goals after surgery are as follows:

•  Learn proper eating habits that will promote weight loss while maintaining health at a reduced weight.
•  Consume adequate amounts of protein to minimize loss of lean body mass, and facilitate healing.
•  Take adequate amounts of fluid to maintain hydration.
•  Obtain adequate nutrients for optimal health through supplementation.

Due to the change in size and function of your stomach after surgery, there are certain foods that should be limited or avoided for at least 3-6 months post-op.

They include but are not limited to the following:

• Carbonated drinks (avoid)
• Sugar sweetened caffeinated beverages (use diet or sugar free)
• Shredded coconut (use coconut extract)
• Tough dry meats (use moist heat preparation, stew, boil, roast)
• Skins, membranes and seeds of fruits and veggies (peel prior to eating)
• Fibrous veggies (i.e. corn, celery, sweet potatoes)
• Fresh bread (use toast, or crackers)
• Fried or high fat foods (bake, broil, grill, use added fats conservatively)
• Whole milk products (use skim or 1% milk products)

Your post-op diet will be a very low calorie diet, approximately 800-1100 calories per day, with 40-60 grams of protein daily. Due to the volume restriction of your new stomach, it will be difficult to consume adequate amounts of nutrients, therefore a vitamin and mineral supplement is required. We recommend that you begin taking a multivitamin and calcium supplement prior to surgery to establish this habit. For the first three weeks after surgery, a chewable multivitamin is recommended for best absorption.
Options include:

• Centrum® chewable (take one daily)
• Children's chewable (take two daily)

(Your multivitamin must include a minimum of 18 mg iron 15 mg Zinc and 400 mcg of folic acid.)

You will also be required to take at least 1000 mg of calcium daily. For best absorption, calcium citrate is recommended, a chewable form is preferred if available but regular calcium tablets can be crushed or dissolved in water. Take 500-600 mg twice a day. (Chewable calcium citrate is available at www.bariatricadvantage.com)

After your Bariatric Surgery, adequate protein and fluid intake are essential to successful recovery. We recommend that you try a variety of high protein, low sugar beverages prior to surgery to find one that will be palatable to you for three weeks post-op. We also recommend trying a variety of low-or no-calorie fluids to help establish the habit of adequate hydration. These fluids should be decaffeinated since caffeine is a diuretic and may lead to dehydration.

Your diet will progress after surgery in the following manner:

Hospital Day 1:
Stage One: Water Only

An x-ray procedure will be performed the morning after your surgery to evaluate your new stomach and check for leaks. If there are no leaks, you will be cleared to start taking 1 ounce of water (30 ml) at room temperature each hour while awake. To avoid irritation of your new stomach or development of gas, you will need to...

•  Sip slowly
•  Do not use straws
•  Take no carbonated beverages

If you tolerated room temperature water on day one, your diet will be advanced to full liquids on the second postoperative day. You will be required to drink 2oz or ¼ cup (60 ml) of a high protein fluid every hour while awake. In addition, to maintain hydration, you should drink 1oz of no-or low-calorie, decaffeinated, non-carbonated fluid every 15 minutes while awake.

Sample Fluid Schedule Day 2

You will remain on a full liquid diet until you return to the clinic for your three-week follow-up. At that time you will attend a diet advancement class with the Dietitian. Please do not start solid foods until after your three-week follow-up.

Discharge Diet - Through the First 3-Weeks:
Protein Supplementation

In the first 3 weeks after your surgery you are restricted to liquids only. A HIGH PROTEIN, LOW SUGAR beverage should be chosen to aid you in meeting your liquid nutrition goal of 40-60 grams of protein per day.

Following are some options:

•  Boost High Protein or Ensure High Protein
•  Sugar free Carnation Instant Breakfast with 8oz skim or 1% milk
•  8 oz skim or 1% milk with 1/3-cup non-fat dry milk powder. (16 total grams protein)
•  Low sugar Ensure (Glucerna) (available at the grocery store)
•  Any low sugar whey or soy protein shake (Carb Solutions, Spiru-tein, Designer Whey, Isopure, Revival soy.)
These can be found in the grocery and nutrition specialty stores such as GNC.
•  EAS high protein low sugar drinks and shakes (www.eas.com)
•  Nectar high protein low sugar drink (www.wlssuccess.com)
•  Isopure® available at nutrition specialty stores

*Look for a protein supplement with no more than 15-20 grams of sugar and at least 13 grams of protein in 8 fl oz.

If you do not tolerate a protein drink after surgery it is usually due to the sugar content and you will want to reevaluate the amount of sugar in your chosen protein drink.

REMEMBER: You will be required to drink 2oz or ¼ of a cup of a high protein beverage every hour. Try a variety of these options to find one you will be happy with for three weeks. You will need to drink 24-32floz of this beverage daily to meet your protein goal.

Preventing Dehydration

Dehydration is one of the most common complications after Bariatric surgery. In addition to drinking 2 oz of a high protein fluid every hour you are required to consume 2 oz of a calorie free, caffeine free, non-carbonated beverage , every 15 minutes while awake; taking a minimum of 64 fl/oz per day. Using the following schedule it will take you about 12-15 hours each day to reach your fluid goal.

Following are some options:

•  Water
•  Crystal Light®
•  Sugar free Koolaid®
•  Unsweetened, decaffeinated tea
•  Decaffeinated coffee
•  Fruit 2o®
•  Propel Fitness Water®
•  Sugar free popsicle
•  Diet Snapple®

Sample Fluid Schedule for First 3 Weeks

(At Home)

Vitamin and Mineral Supplementation

Due to the change in your stomach and the limited amount of food you will be able to consume, you will need to take a multivitamin and calcium supplement for the rest of your life. After 3-weeks, you no longer need take these in the chewable form. Obtain a good multivitamin - preferable with minerals including iron. Your multivitamin must include a minimum of the following 18 mg iron, 15 mg zinc, and 400 mg folic acid.

Calcium:
When you are three weeks post-op you will need to start taking at least 1000 mg calcium per day. Calcium citrate is recommended since it is the best-absorbed form of calcium for your new stomach. For best absorption, take no more than 500-600 mg of calcium at a time (ex 500-600 mg in the a.m. and another 500-600 mg at bedtime).

Post Gastric Bypass Meal Planning Guide

   The following are dietary guidelines to help manage patients following gastric bypass surgery. Patients typically go home on a liquid only meal plan for 3 weeks. After three weeks they can be advanced to soft foods for the next 5-6 weeks then gradually converted to regular consistency foods over the next 6-9 months. Included here are suggestions for making this a safe and smooth transition.

• Stage 1: Clear liquids only
• Stage 2: Modified Full Liquids
• Vitamins and Minerals
• Stage 3: Soft Foods
• Stage 4: Solid Foods
• How to Make Your Transition to Solid Food a Success

STAGE 1: Clear liquids only

   On the day after surgery, if your swallow study is OK, you will begin sips of water (1 oz. each hour while you are awake). Please do not use straws or drink carbonated beverages, as these will cause you to swallow more air/gas, which is poorly tolerated and uncomfortable. You will start with small amounts of water to avoid overfilling your new stomach and possibly tearing your sutures, and to test that it empties well. If you tolerate water, the next day you will be advanced to the Stage 2 diet that consists of 2 oz. (2 medicine cups) of a high protein nutritionally complete fluid each hour while awake (your choice of Boost, Boost Plus, Choice DM, Skim milk or Carnation Instant Breakfast with Low fat milk). In addition to the protein liquid, if tolerated you may have 2 oz (2 medicine cups) of a non-carbonated, non-caffeinated beverage (water, decaf tea, or decaf coffee) every 15 minutes for a total of 8 ounces (8 medicine cups) per hour.

STAGE 2: Modified Full Liquids

When you go home:

   Starting on the day you go home from the hospital, you should drink 2 oz. (60 ml) of a high protein liquid every hour, on the hour, while you are awake. This must be a nutritionally complete liquid, which is something that would pass through a standard strainer. In addition, if you are thirsty, you can have another 2 oz. of any non- carbonated, non-caffeinated, liquid every 15 minutes after the hour. This liquid should not be high calorie and can be with or without protein.

   Your first priority is to drink enough fluid to prevent dehydration; protein is a secondary priority. You should drink a total of 6-8 cups of fluid each day to avoid getting dehydrated. This will take some effort on your part because you may not feel hungry or thirsty at first. For best tolerance, do not use straws, take small sips, and start with room temperature liquids.

Sample Meal Schedule

8:00 a.m. - 2 oz Boost High Protein
8:15 a.m. - 2 oz water (optional)
8:30 a.m. - 2 oz beverage (optional)
8:45 a.m. - 2 oz water (optional)

You should choose a high protein drink with no more than 30 grams of sugar and at least 10 grams of protein in an 8 oz serving.

PROTEIN:

   Protein is essential to aid in healing and healthy weight loss after surgery. It may also help avoid (but not necessarily prevent) hair loss associated with rapid weight loss. Try to consume at least 45-60 grams of protein per day.

STAGE 2: Modified Full Liquids (continued):

Vitamins and Minerals

   Due to the change in size and function of your stomach you will need to take a complete vitamin/mineral supplement every day. For the first three weeks post op your multivitamin will need to be chewable or liquid. We suggest you start with an adult chewable vitamin such as Centrum Chewable (take one daily) or Children’s Flintstones (take two daily). Thereafter you can change to an adult complete multiple vitamin with minerals (ex: Centrum Advanced Formula, One-A-Day Maximum). You can take generic equivalents but be sure to compare the contents to the recommended vitamins to make sure they have adequate nutrients of at least 18 mg of Iron, 15 mg of Zinc, and 400 mcg of Folic Acid.

   After the first month you will need to add a calcium supplement as well. Calcium Citrate is the preferred form of calcium since it is better absorbed. You will need to take 1200 mg of Calcium daily. For best absorption take no more than 600 mg of calcium at one time (ex) 600 mg in the a.m. and another 600 mg at bedtime (Citracal, or Bariatric Advantage Chewable Calcium Citrate from www.bariactricadvantage.com are acceptable options).

Follow up:

   At your three-week follow up clinic visit you will have a diet advancement class with the program Dietitian. In this class you will learn how to successfully incorporate soft solid foods back into your meal plan.

*Please do not start solid foods until after your three-week clinic visit!

STAGE 3: Soft Foods

   During your 3-week clinic visit, you will have an hour session with the Nutritionist to explain how to add these new foods. Please do not begin STAGE 3 on your own before this visit. You will slowly begin adding soft foods to your meal plan over the next 6 – 8 weeks. After your new pouch tolerates the soft foods you can add easily tolerated solid foods to your meal. Remember your new stomach is still healing so treat it gently.

   During this phase, you must still focus on high protein foods and avoid foods that are high in fat, sugar, or fiber. You will probably still need to get some of your protein from supplements until you are able to eat enough solid food to meet your nutritional needs, (see the list of protein supplements on page 2). Getting enough protein in your diet will help you stay healthy and maintain your muscle mass as you lose weight. During meals, eat the high protein foods first; making sure you fit them in. You will be instructed to add only one new food at a time and observe your reaction to it. If you do not tolerate a food well, the problem may be with the food itself, how you prepared it, or the way you consumed it. Please see page 5 for tips on making your diet progression and weight loss successful.

Learn to recognize when you are full. Indications of fullness may be a pressure or fullness in the center of your abdomen just below your rib cage or feelings of nausea, regurgitation or heartburn. Please stop eating when you feel full.

   If you have a problem with vomiting, it is most often the result of eating inappropriately and rarely a complication of surgery. Common eating related causes of vomiting are: eating too fast, not chewing food properly, eating too much food at once, eating solid foods too soon after surgery, drinking liquids either with meals or right after meals or eating foods that do not agree with you.

   Following are lists of foods allowed and those to be avoided for Stage 3 of your diet progression. The foods on the avoid list are there because most patients don't tolerate them for the first 2-3 months after surgery. Some patients do tolerate these foods, but it is best to start with the foods on the allowed list. Once you have learned how to eat with your new gastric pouch and have healed from surgery, you can start to add other foods one a time over the next few months. If you follow these suggestions you should transition to solid foods and lose weight successfully!

   Remember, your gastric bypass surgery is a crutch to help you lose weight, but it is not magic. If you overeat or eat mostly high calorie foods or beverages this will reduce the amount of weight you lose. Try to eat protein-dense foods to get the most nutrition from the smaller amount of foods you will be eating.

   Congratulations, you made it to STAGE 4. It is now 10-12 weeks post surgery and you are ready to progress from soft solids to regular consistency foods. Below you will find some tips on how to transition from soft foods to solid foods. Remember you will begin to try solid foods one at a time, to test your tolerance to them. Do not worry if you cannot tolerate or do not want foods you used to eat. Most people experience some problems at first, especially with meats and breads. Most people find it easier to tolerate seafood first, ground or tender cooked pork and beef next then ground or tender cooked poultry. Eventually, you will probably be able to eat most of what you were eating before surgery, only in much smaller amounts. A few patients become vegetarians. Overall you should be making healthy food choices including lean meat or vegetable protein, low fat dairy, incorporating fruit and vegetables as you are able; and avoiding empty calorie or “junk” foods as they are typically high in fat and sugar. Remember you must be very careful with foods or beverages high in sugar as they may cause the Dumping Syndrome.

   Long term, patients must choose foods with good nutritional value. Each meal should have at least 3 ounces of protein (such as eggs, cottage cheese, fish, poultry, beans, meat, or tofu). Learn to read food labels and limit fat and sugar intake, choose low fat (5 grams or less per serving), low sugar (5 grams or less per serving) and lean protein foods. The volume you can tolerate will always be limited so choose foods wisely to avoid filling up on foods with little nutritional value.

How to Make Your Transition to Solid Food a Success:

1) Eat slowly and be aware of when you feel full.  When you feel full, stop eating! If you continue to eat, you may develop intense chest pain and vomit. You may only be able to eat a few bites of food at a time, eating up to 6 “meals” a day.

2) CHEW, CHEW, CHEW! You need to make sure you chew your food very well before you swallow it. This makes it easier to digest and pass from your gastric Pouch into your small intestine.

3) Avoid drinking fluids 30 minutes before and with your meals. If you fill up your small gastric pouch with liquid, you won't have room for your food. Furthermore, the liquids may accelerate passage of the solid food out of the stomach and possibly cause some discomfort. If you need to, take only small sips of liquids while eating, but don’t drink large amounts during meals.

4) Drink enough fluid between meals to meet your fluid requirements. You need 6-8 cups of fluid per day to avoid dehydration. You may need to carry a water bottle with you and sip on low/no calorie liquids throughout the day to get enough fluids.

5) Avoid sticky foods. These foods can stick together and form a ball in your gastric pouch, causing nausea and sometimes vomiting. Sticky foods include: white bread, rolls, buns, pasta (especially if overcooked and large pieces), rice that clumps together, macaroni and cheese.

6) Avoid crunchy, hard to digest foods for the first 2-3 months. Crunchy and hard to digest foods include: raw vegetables, nuts, popcorn, chips, coconut, olives, pickles, tough fruit/vegetable skins (such as apple, cucumber skin), dried fruit, corn, iceberg lettuce.

7) Avoid tough or rubbery meats. Avoid steak, pork chops, ham, and other tough meats for the first few months. Meat is a great source of protein, but it needs to be soft and tender for you to digest it. Try a slow cooking method to make your meat tender, such as a crock-pot, boiling or cooking at a low temperature over a long period of time.

8) Avoid food/beverages high in sugar. High sugar foods can cause "dumping syndrome." After gastric bypass surgery, some people feel light-heated, sweaty or faint soon after consuming sugar.

9) Avoid extremes in the temperature of your foods and beverages. Some patients experience spasms or cramps with very hot or cold food/beverages.

10) Limit high fat foods. These foods may make you feel nauseated. They are also high in calories and will slow down your weight loss. Try changing to a fat-free comparable product. If you don't like the fat-free product, try the light product, which usually has half the fat and calories of the regular product.

11) Only try one new food at a time. This way if you cannot tolerate the food you will know exactly what your new pouch does not like.