Eric J. DeMaria, M.D., received his medical degree at the Boston University School of Medicine in 1983, and then completed seven years of general surgical training at Brown University. He served on the faculty of the Medical College of Virginia at Virginia Commonwealth University between 1990 and 2005 where he rose through the ranks to assume leadership of the Minimally Invasive Surgery Center and the Obesity Surgery Center. In 2001, he was appointed General Surgery Division Chairman and received the Paul Nutter Professorship in Surgery in 2004. Dr. DeMaria joined Duke University in July 2005.

Dr. DeMaria is nationally known for his contributions to bariatric, advanced laparoscopic, and minimally invasive surgery. He is active in many surgical organizations. He is a member of the executive committee of the American College of Surgeons’ Committee on Peri-operative Care. He served as Co-Chair of the Bariatric Surgery task force from 2002 to 2004 and Chair of the 2006 Bariatric Surgery postgraduate course for the Society of American Gastrointestinal Endoscopic Surgeons. DeMaria serves as a reviewer for a number of journals including Surgery for Obesity and Related Disorders and JAMA. He is associate editor for clinical surgery for the journal Surgical Innovation. He is the Program Committee Chairman and Co-Chair of the Training Committee for the American Society for Bariatric Surgery. He has co-authored more than 80 original scientific publications in the surgical literature on various topics, co-authored 30 chapters in surgical texts, co-edited 3 books on surgical subjects, and been an invited guest-speaker across the United States.

Dr. Portenier grew up in Greenville, South Carolina. He attended the College of Charleston from 1991-1995 and completed a degree in Biochemistry, receiving the College of Charleston Biochemistry Departmental Honors Award.

In 1999, Dr. Portenier completed medical school at the Medical University of South Carolina in Charleston, South Carolina. His general surgical training took place in Detroit, Michigan at Providence Hospital. During training he received the Charles G. Johnston Excellence in Research Award by the Detroit Surgical Society for excellence in research. In addition, he received the General Surgery Resident of the Year Award in 2003 and 2004, the Society of Lapro-endoscopic Surgeons Resident Achievement Award in 2004, as well as a medical student teaching award.

He spent the next year gaining extra experience in upper GI surgery including: liver, pancreas, and stomach surgery. This training was split with rotations at the Mayo Clinic in Rochester, Minnesota; Memorial Sloan-Kettering, New York City; and in Leeds, England.

In 2006, Dr. Portenier completed an Advanced Fellowship in Laparoscopic and Bariatric Surgery at Duke University and joined the Weight Loss Surgery Center's surgical staff. Dr. Portenier's clinical interests include minimally invasive and open approaches to advanced upper GI surgery, with a focus on weight loss surgery. The dramatic impact weight loss has on patients life has focused Dr. Portenier on surgical means of achieving lasting weight loss. He will perform Roux-en-Y gastric bypass, Lap Band, and revisional bariatric surgery.

Hilary Blackwood received her Batchelor's degree in Nursing from the University of North Carolina in Chapel Hill. She worked for several years in critical care nursing, caring for burn and trauma patients, first as a bedside care nurse, then as a Nurse Manager. She has also practiced as a Nutrition Support Nurse. She obtained her Master's degree in Nursing and an advanced degree as an Acute Care Nurse Practitioner from the University of Virginia in Charlottesville Virginia. While in Virginia, she had the opportunity to work with the highly respected Weight Loss Surgery Program at the University of Virginia for two years until she was recruited to join our program in October, 2002.

Within the Duke Weight Loss Surgery Program Ms. Blackwood has assumed responsibility for the clinical management of both pre-operative and post-operative Roux-en-Y Gastric Bypass and LapBand patients. To this end, she performs the initial history and physical examinations, coordinates and evaluates the preoperative studies, and provides long-term postoperative care.

Another of her important activities is the organization and management of the very valuable Duke Weight Loss Surgery Patient Support Group.

Kelli E. Friedman was born in Livingston, NJ. She earned her BA from the University of Wisconsin-Madison, majoring in psychology. She then attended Harvard University where she earned a master's degree. She continued her education at Duke University where she earned another master's and a doctoral degree in Clinical Psychology. During graduate school, Dr. Friedman focused on health psychology, specializing in psychological issues related to weight and weight loss. She completed her APA-approved clinical psychology internship at the Durham Veteran's Affairs Medical Center working with a variety of patient populations.

Following her clinical internship, Dr. Friedman completed a two-year, NIH funded, Behavioral Medicine Research Fellowship at Duke. During her fellowship, her primary research focus was on how mood impacts blood sugar control among patients with diabetes. She also worked clinically with individuals seeking weight-loss treatment, focusing on motivating patients to adhere to the lifestyle factors that are related to long-term weight loss. Additionally, she worked with individuals with a variety of eating disorders, including those with Binge Eating Disorder. Dr. Friedman joined the faculty in the School of Medicine, Department of Psychiatry and Behavioral Sciences, in 2004 as an Assistant Clinical Professor.

Dr. Friedman's clinical work has focused on the assessment and treatment of a variety of conditions including obesity, eating disorders, depression, anxiety, sleep disorders, and chronic illness. She has clinical experience in smoking cessation, stress management, coping skills training, individual and group cognitive-behavioral psychotherapy, and consultation. She has also developed a variety of workshops related to obesity and weight loss.

Dr. Friedman is invested in furthering our understanding of psychosocial issues related to weight and weight loss, which she believes are critical to effective long-term weight loss. In particular, she has researched body image, depression, and binge eating within an overweight population. Most recently, she completed a study exploring the prevalence weight-based stigmatization and how such discrimination is related to psychological health.

Kelli Friedman, Ph.D. has over eight years of professional experience in the weight loss field. Kelli holds a Ph.D. in clinical psychology from Duke University and has a M.Ed. degree in education from Harvard University. As a psychologist with expertise in obesity treatment, She has authored numerous professional publications and presentations exploring psychological issues related to weight. In additional to her clinical experience in obesity treatment, Kelli gained first hand knowledge of summer camps working for 10 summers at a residential camp, serving in a variety of capacities from counselor to waterfront director. With her knowledge of both obesity treatment and summer camps, Kelli brings a unique perceptive to the development of obesity intention within a camp setting

Excellence In Anesthesia for Bariatric Surgery

Anesthesia, historically, is a discipline that has been practiced in as many different ways as there were communities using the services of any anesthesia providers. Recent technological explosions, coupled with physiological and pharmacological breakthroughs, all subjected to the pressure of an ever shrinking health care dollar, has led to the conclusion that the practice of anesthesiology is best approached through the anesthesia care team.

The Certified Registered Nurse Anesthetist is the primary provider and the anesthesiologist is the perioperative physician. This combination provides the complete components of quality assurance to all consumers of anesthesia services. This anesthesia team has proven to be the most cost effective, safe and efficient delivery system at every step from patient to payor. Over 8,600 anesthesia services per year at Durham Regional Hospital and over 300 Bariatric surgeries.

Anesthesia Providers

• Board Certified or Board Eligible Anesthesiologists
• Board Certified or Board Eligible Certified Registered Nurse Anesthetists
• All Certified Registered Nurse Anesthetists are Re-Certified every two years by Council on Recertification, AANA

Student Nurse Anesthetist Clinical Education in Bariatric Anesthesia:

Durham Regional Hospital is the primary clinical site for the Duke University School of Nurse Anesthesia. Student Registered Nurse Anesthetists (SRNAs) are a valued member of our anesthesia team. The SRNAs are continually under direct supervision of the Certified Registered Nurse Anesthetists and/or Anesthesiologist. Educating future CRNAs on the administration of anesthesia and perioperative care of the bariatric patient is a valuable asset to the consumer of anesthesia services and society. The Duke University School of Nurse Anesthesia has access to a human patient simulator (HPS) and simulation center. They utilize the HPS their first semester and anytime they need to simulate specialized anesthesia experience during their 28 months of study. The HPS prepares the SRNA for their bariatric clinical experience.

Co-Coordinators of the Bariatric Anesthesia Team:
Edward G. Sanders, MD - Staff Anesthesiologist and Ruth E. Long, CRNA - Staff Anesthetist

Principles of Practice For the Bariatric Anesthesia Team

Developing a defined set of Principles of Practice helps affirm the quality of care provided by each professional on the Bariatric Anesthesia Team. Fostering realistic expectations among anesthesia staff and patients affirm dignity, excellence, and help create stability and a high standard of care.

• Accuracy and thoroughness should never be sacrificed for convenience
• Patients have a right to any information about their anesthesia
• It is our responsibility to let the patient know what we can do for him or her and not wait to be asked
• We will treat patients as human beings, and not as “something” to plug into all our high technology.
• We will remain current in our chosen profession and anesthesia for the bariatric patients.
• We will have ongoing outcome studies with the bariatric patient.
• Pre and Postoperative anesthesia history will be made on each bariatric patient.
• A patient satisfaction questionnaire will be made available to all patients.
• Continuing education on Bariatric Anesthesia will be a high priority goal of each team member.
• Up to date anesthesia techniques are encouraged, as is clinical research.
• We will be actively involved as a mentor for Nurse Anesthesia Students in the specialty of Bariatric Anesthesia.
• Anesthesia Services will be conducted as quickly as possible, but a short waiting time will not take priority over the standard of care.
• Anesthesia equipment will be maintained and monitored on an ongoing basis by the Bio-Med Department.
• Communication will be a priority between all members of the surgical team and the anesthesia team and perioperative health care professionals.
• We believe it is important to decrease costs when possible, to benefit both patients and society, but never at the expense of increased risk to the patient.
• All members of the Anesthesia Team will treat the patient with respect and dignity at all times.
• Benefits and risks of anesthesia will be discussed with all patients and questions answered to patients satisfaction.
• Preoperative education of the patient on their participation in a complete medical history and pharmacological history to help assure a safer anesthesia experience.
• Equipment - “State of the art” Anesthesia equipment is available to our patients. Difficult airway carts are available to all our patients. No bariatric anesthetic is started without this cart available to the patient. Electrical operating room beds with proper weight limits are available to the patient. Transport stretchers are available for patients transported to the operating room appropriate for BMI of patient. Accessory Anesthesia Equipment is available for safe positioning of the patient. Equipment is available to help maintain patient’s body temperature.

PREPARING THE PATIENT FOR ANESTHESIA

Presenting for Anesthesia for Bariatric Surgery - Most commonly asked questions.

• Will the anesthesia provider be with me the entire time I am under anesthesia? Yes. Once the anesthesia team assumes your care we never leave you, unless a qualified anesthesia provider relieves us.
• Will the Anesthesiologist and Certified Registered Nurse Anesthetist both be with me at all times? Not necessarily Either one or both of the anesthesia providers will be with you all the time.
• What should I tell the person taking my anesthesia history? Everything about your past and present medical history.
• Should I give a history of my surgical history? Yes. Have a written history of all your surgeries with dates and location of surgeries.
• Should I give a list of all my medications? Yes. Have a written list of all drugs you are taking. This should include drugs the doctors has prescribed, drugs you buy over the counter, and any herbal medications. Make sure you include the name, dose, and how often you take any of the above drugs mentioned.
• When should I stop eating and drinking? Nothing to eat or drink after midnight the night before your surgery.
• Can I brush my teeth the morning of surgery? Yes. Make sure to only rinse your mouth. Do not drink water after you brush your teeth.
• Do I need to give a history of any recent falls or injuries? Yes. Any falls, bruises, scratches.
• Should I give a history of limited joint movement? Yes. Please show how your arms, legs, or neck are limited in movement and any pain related to that movement.
• What about any family history of anesthesia problems? Yes. Any problems your extended family may have had with anesthesia is important. Also any problems you may have experienced with anesthesia.
• How much of my body will be exposed while I am asleep? Your privacy is protected while you are asleep. Only areas necessary to accomplish the surgery will be exposed.
• Should I bring my CPAP machine to the hospital the day of surgery? Yes. You will need your C-Pap machine.

Other Considerations:

• Men with beards are required to shave prior to surgery for safety reasons. Beards can create a problem placing the breathing tube necessary to deliver oxygen to you.
• Remove eye makeup for your safety.
• Remove any piercings, i.e. earrings, tongue rings, belly button rings, artificial nails, and all other piercings.
• Remove all other jewelry.
• Remove dentures, partial plates, or any removable teeth just prior to coming to surgery.
• Remove any hair pieces, hair pins, or any metal objects from your hair.
• Remember to empty your bladder just prior to coming to the operating room.
• Do not use breath mints, or hard candy after midnight prior to your surgery.
• Do not smoke as many days as possible prior to your surgery.
• Do not take Viagra or any other similar type medications 48 hours prior to your surgery. These drugs may cause an adverse effect with your anesthesia agents.
  Ask with the nurse doing your anesthesia history about what medications you should or should not take prior to surgery.Please give a history of all use of diet pills.
• Please advise us of any broken, missing or loose teeth, and of any permanent partial plates.
• Your participation with a complete medical history will allow the anesthesia team to better establish your plan of anesthesia care and safety.
• Bring a list of questions you have about your anesthesia to your preoperative anesthesia appointment.

What Should I Expect the Day of Surgery?

• You will be called the day before your surgery to be given a time to arrive at the hospital the day of your surgery.
• You should go to the Main Lobby (3 rd Level).
• When the time is close, the receptionist will call for you and escort you to your bed space.
• You will be given a gown and slipper socks.
• The nurse will take your blood pressure, pulse and temperature.
• Give all of your valuables to your family or the responsible person with you.
• You will get one shot with a very small needle by the nurse.
• After the nurse has finished, make sure you empty your bladder.
• You will meet the anesthesia team, which consists of a Certified Registered Nurse Anesthetist and Anesthesiologist.
• You will sign an anesthesia permit after all your questions have been answered.
• You will now leave the room by stretcher and go to the Preoperative Holding Room.
• You will have an I.V. placed by the anesthesia team.
• Local anesthesia will be used to start your I.V. We feel this makes starting the I.V. less painful.
• You will then receive an antibiotic ordered by your surgeon.
• You will then go to the Operating Room. Your anesthesia team will inform you of everything we are doing to facilitate a safe anesthetic. • A number of monitors will be placed. E.K.G. to trace your heart, blood pressure cuff, pulse oximeter on your finger to measure the oxygen in your blood, BIS monitor pad on your forehead. This measures your brain waves and indicates the depth of anesthesia. This pad is prickly when it is applied.
• Now, we will ask you to breathe oxygen by a clear plastic mask.
• We will start to give you medications through your I.V., that will start to make you feel sleepy.
• Then you will receive medicine through your I.V. that will put you off to sleep.
• The anesthesia team will monitor your blood pressure, pulse, oxygen saturation, and depth of your anesthesia while you are asleep.
• Once you meet the anesthesia team, we will be with you continuously until we take you to the Post Anesthesia Care Unit (PACU). At that time, we will report your care to the nurse in PACU.
• While you are asleep, the anesthesia team will be your advocate. We will protect your privacy and dignity.
• We will monitor your recovery in the Post Anesthesia Recovery Room.
• We will visit you the next day to check on your recovery.
• We will give you anti nausea medicine while you are asleep to help prevent nausea.
• We will keep you warm while you are asleep with a special warming blanket. We will monitor your temperature while you are asleep.
• A catheter will be placed in your bladder in the Operating Room, after you are asleep.
• After you wake up, we will place an oxygen mask on your face to make sure you get enough oxygen while you wake up.
• The Post Anesthesia nurse will stay with you in the Recovery Room. They will monitor you and keep you warm, give you pain medication and anything else you need.
• This is an attempt to let you know what to expect. This process may have additions, we will keep you informed and your questions answered to your satisfaction.
• Remember, you are the most important member of our team. The information you bring to us about your health history will help guide our anesthesia plan for you.
• We look forward to meeting you and delivering your anesthesia, care for your surgery.