• TABLE OF CONTENTS
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 Front Cover
 Table of Contents
 Introduction
 Weight loss surgery team
 Patient selection
 Path to surgery
 Clinic visit
 Why surgery?
 History of surgical therapy for...
 The surgical procedures
 Diet overview
 Possible complications
 Nutrition questionnaire
 Physician questionnaire
 Written agreement to comply with...






Title: Combining surgery, diet, and exercise to change lives
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Permanent Link: http://ufdc.ufl.edu/UF00088875/00001
 Material Information
Title: Combining surgery, diet, and exercise to change lives
Physical Description: Book
Language: English
Creator: Weight Loss Surgery Center, Shands at the University of Florida
Publisher: Weight Loss Surgery Center
Place of Publication: Gainesville, Fla.
Publication Date: 2008
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Subject: University of Florida.   ( lcsh )
Spatial Coverage: North America -- United States of America -- Florida
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Bibliographic ID: UF00088875
Volume ID: VID00001
Source Institution: University of Florida
Holding Location: University of Florida
Rights Management: All rights reserved, Board of Trustees of the University of Florida

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Table of Contents
    Front Cover
        Front Cover
    Table of Contents
        Table of Contents
    Introduction
        Page 1
        Page 2
    Weight loss surgery team
        Page 3
    Patient selection
        Page 4
    Path to surgery
        Page 5
    Clinic visit
        Page 6
        Page 7
    Why surgery?
        Page 8
    History of surgical therapy for obesity
        Page 9
    The surgical procedures
        Page 9
        Page 10
        Page 11
        Page 12
    Diet overview
        Page 13
        Page 14
        Page 15
        Page 16
    Possible complications
        Page 17
        Page 18
        Page 19
        Page 20
    Nutrition questionnaire
        Page 21
        Page 22
    Physician questionnaire
        Page 23
        Page 24
        Page 25
        Page 26
        Page 27
        Page 28
        Page 29
        Page 30
        Page 31
        Page 32
    Written agreement to comply with therapy
        Page 33
Full Text





















Shands at the University of Florida

Weight Loss Surgery Center

"Combining Surgery, Diet, and Exercise to change lives"


Contact info:
Phone: (352) 265-0535
Fax: (352) 265-0190

















Table of Contents


1. Introduction........................................ Page 1-2
2. Weight Loss Surgery Team........................ Page 3
3. Patient Selection..................................... Page 4
4. Path to Surgery....................................... Page 5
5. Clinic Visit............................................ Page 6-7
6. Why Surgery......................................... Page 8
7. History of Surgical Therapy for Obesity......... Page 9
8. The Surgical Procedures.............................. Page 9-13
A:)Laparoscopic Roux en Y Gastric Bypass
B:)Lap-Band Procedure
9. Diet Overview........................................ Page 13-17
10.Possible Complications............................. Page 17-20
11.Nutrition Questionnaire.......................... Page 21-22
12.Physicians Questionnaire......................... Page 23-32
13.Written Agreement to Comply with Therapy. Page 33









Introduction


Thank you for your interest in the Shands at the University of Florida Weight Loss
Surgery Center. Let us begin by stating that morbid obesity is a serious disease. Morbid
obesity is an epidemic affecting over 15 million Americans. Obesity impacts both the
quantity and quality of life. Being obese can cause many life threatening problems, and
too commonly it interferes with social and personal activities.




Obesity Trends* Among U.S. Adults
BRFSS, 2006
(*BMI a30 or N 30 Ibs. overweight for 5' 4" person)















SNo Data --

Source: Behavioral Risk Factor Surveillance System, CDC



Recent medical research has showed that obesity is a genetic abnormality that is
expressed in variable degrees, even between individuals within the same family. When a
person's weight increases in excess of 100 pounds above one's ideal body weight or a
Body Mass Index (BMI) greater than 40, medical implications become very important as
there exists an increased risk for cardiac and pulmonary disease, diabetes mellitus, and
most importantly, a 20-fold increased risk of early death. For these types of patients,
structured dietary programs have universally been unsuccessful. For many individuals,
dieting, hypnosis, self help groups, and behavior modifications are met with minimal or
only temporary success. Drug therapies, such as Meridia and others in the developmental
stage have offered hope to obese patients. However, the data suggests that the only long
term solution for many morbidly obese patients is surgical intervention.









Patients often report that whatever weight loss is accomplished is ultimately followed by
weight regain and all efforts are associated with feelings of guilt and depression. Life for
people with morbid obesity can be difficult. Weight spirals up and plummets down,
resulting in feelings of failure, frustration, and hopelessness. It is this population of
seriously obese patients that weight loss surgery also known as Bariatric surgery is
intended to help.

Bariatric surgery is the field of surgery devoted to weight loss. Bariatric surgery offers a
surgical option for the treatment of morbid obesity when other measures have been
unsuccessful. The currently applied surgical procedures of Roux-en-Y gastric bypass and
Lap-Band have consistently resulted in 80 to 140 pounds of weight loss in properly
selected patients. As you might expect, such significant weight reduction has a
tremendous impact on all aspects of life, and as you lose your excess weight, the way you
feel about yourself, your family, and friends will change.

This information guide is an introduction to the surgical treatment for obesity offered at
Shands Hospital at the University of Florida. Questions that are not answered in this
patient guide should be directed to members of the Bariatric surgery team. These team
members include surgeons, psychiatrists/psychologists, dietitian, physical therapist,
nurses, physician assistants, and the program coordinator.

Weight loss surgery 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. We currently offer two surgical
approaches for the management of morbid obesity: the laparoscopic Roux-en-Y gastric
bypass procedure and the laparoscopic Lap-Band 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 maintenance of weight loss.
The Lap-Band procedure results in less weight loss, requires more frequent office visits
for adjustment, but is a less invasive surgical procedure and is associated with fewer
major complications. Therefore, it is very important for you to carefully consider the two
surgical options, and for us to conduct a complete evaluation before surgery to make sure
which surgery is right for you.










Weight Loss Surgery Center Team


Surgery:

Kfir Ben-David, M.D., Director
Juan C. Cendan, M.D.
Tamara Lux, PA
Rachel Allen, RN

Plastic Surgeon:

Matthew H. Steele, MD

Anestesia & Critical Care

Joseph Layon, M.D.
Andrea Gabrielli, M.D.
Lawrence Caruso, M.D.

Psychiatry

Richard Holbert, M.D.
Lisa J. Merlo, Ph.D.

Internal Medicine

Eric Rosenberg, M.D.

Nutritional Services

Sherri Findley, R.D.
Lee Marlowe, R.D., L.D.

Administrative Staff


* Amelia Redic









Patient Selection


There are no absolute guidelines that determine which patients are accepted and which
patients are rejected for surgery. Each case is reviewed and evaluated on an individual
basis. Some of the factors considered in patient selection are given support by the
National Institute of Health and include:
1. Being approximately 100 pounds or more above ideal body weight as described in
the standard life insurance weight/height tables. Generally, this corresponds with
a BMI greater than or equal to 40.
2. Failure of previous attempts to produce lasting weight loss.
3. Evidence of physical problems or disease associated with obesity. These include
but are not limited to diabetes, high blood pressure, elevated blood fats, heart
problems, breathing problems, chronic back pain, or degenerative arthritis. In the
face of such potentially life threatening problems, a patient may be deemed a
candidate for surgery at a BMI of 35 to 40.
4. Ability and willingness to cooperate in follow-up after surgery, including clinic
visits, blood work, diet modifications, and exercising.

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 it 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 Lap-Band procedure give them the CPT Code of: 43659 (many
insurance companies do not approve the Lap-Band procedure so check thoroughly with
your insurance company). Finally ask if Shands at the University of Florida is an
approved facility under your insurance provider. Shands hospital uses the tax I.D. of
591943502, giving this number to your insurance company may facilitate a faster
response in your query.

2. If your policy does not cover the diagnosis of morbid obesity or the operative
procedure itself, you still have a few options:

* You could obtain another insurance carrier, but you need to make sure that the new
policy covers morbid obesity and the surgical procedure before making this decision.

* You can continue to participate in alternate 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 the financial burden. We will review this major decision with you extensively and will
help in any way we can.









Path to Surgery

Even if surgery for obesity is a covered benefit, 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.
Be 18-65 years old.
Weigh less than 450 pounds.
No previous Bariatric Surgery


Body Mass Index (BMI)


D Underweight E Low Risk E[ Overweight U High Risk with the medical diagnosis of obesity

The path to surgery typically spans a 2 to 4 month period AFTER your first clinic visit.
Each individual is carefully evaluated for any and every related medical condition. This
often requires special studies and occasionally consultations from accredited medical
specialists. Only after we are completely satisfied that weight loss surgery is right for you
and that both you and the Bariatric team are fully aware of associated risks will we
proceed with the scheduling of surgery.









Clinic Visit

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

Documentation of your weight for the last 12 months from your primary care
physician.
Documentation of non-surgical weight loss attempts.
A supporting letter from your primary care physician recommending surgery.


Psychological Interview:


As part of the evaluation for weight loss surgery, you will need to be evaluated by our
Psychiatry Department (352-265-7041). They often times will discuss behavioral and
life-style issues that can have an impact on your adjustment to life before and after the
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.

Nutritional Evaluation:

You will be required to meet with our registered dietician, Sherri Findley R.D. to assess
your current eating and exercise habits. She will discuss and recommended dietary
changes to prepare you for surgery, while you are in the hospital, and once you are
discharged.

Laboratory Studies:

As part of the medical evaluation, you will need to complete several studies.

The necessary studies include:


A Barium Swallow to evaluate your esophagus/swallowing
Arterial Blood Gas measurement, to evaluate your oxygen levels
EKG to diagnose the presence of any heart disease
Blood work to be drawn while fasting :









1. Comprehensive Chemistry Panel (to include an albumin level and liver
function tests)
2. HbAlc
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 original reports to your initial appointment:

Sleep Study
Cardiac Studies stress test, echocardiogram, cardiac catheterization
Operations
1. Stomach or intestinal surgery
2. Hernia repair hiatall hernia or abdominal wall hernia)
3. Cancer surgery

After we review the above studies or procedure notes, 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 conducted.





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 bariatric surgeons. If they approve your
application, our office will submit the accumulated medical information to your insurance
company for their review and final authorization for surgery.










Why Surgery?


Pre-operative Medications Post-operative Medications


















1991 NIH Consensus Conference on Surgery for Obesity
Surgical intervention is the only method proven to have a significant long-term
impact on the disease.
Medical interventions have failed.
Obesity Research 1998; 6 supplyl 2):51S-209S

Risk of Surgery versus No Surgery
McGill University compared five-year survival of their 5,746 morbidly obese
patients managed medically with 1,035 patients who underwent surgery, matched
by sex, age, and duration of being obese
Five-year mortality 6.17% in the no surgery group
Five-year mortality 0.68% in the surgical group
Christou NV, et al.: Ann. Surg., 240: 416-422, 2004

Risk of Surgery
National Data 136 scientific reports totalling surgical results of 22,094 patients
Average operative mortality 0.5%= 1 in 200 patients
Diabetes Mellitus: Complete resolution 76.8%
Resolved or improved 86%
Hyperlipidemia Improved 70%
Hypertension: Resolved 61.7%
Resolved or improved 78.5%
Sleep Apnea: Resolved 85.7%
Buchwald H, et al: Bariatric Surgery: A systematic review and meta-analysis. JAA4 292:1724-1737, 2004









History of Surgical Therapy for Obesity


Shands at the University of Florida is a private, not-for-profit hospital that specializes in
tertiary care for critically ill patients. Shands at UF is one of the most comprehensive
hospitals and one of the leading referral medical centers in the Southeast. It continually
receives recognition as one of the best hospitals in the nation by U.S. News and World
Report because of its dedication to patient care, education and research.

Shands at UF is the primary teaching hospital for the UF College of Medicine. More than
500 physicians representing 110 medical specialties work with a team of healthcare
professionals to provide quality care for patients. The faculty from the UF College of
Medicine includes nationally and internationally recognized physicians whose expertise
is supported by intensive research activities. Shands' affiliation with the UF Health
Science Center allows patients to benefit from the latest medical knowledge and
technology.

The University of Florida and Shands Teaching Hospital have been pioneers in the
surgical treatment of obesity. Our first Chairman of Surgery, Dr. Edward R. Woodward,
began performing obesity surgery in the late 1960's. Since then the University of Florida
Bariatric program has performed close to 3,000 operations for weight loss.

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 the "Gold Standard" of weight loss surgical
procedures. It results in weight loss by significantly reducing the size of your stomach, so
you cannot eat as much, and by bypassing your small intestines so you absorb less fat
from the foods you eat. This operation has been accepted by obesity surgeons' throughout
the country and major medical societies as being the most effective in weight reduction
and maintenance of weight loss. We perform this 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 surgical history. See the
picture below for an idea of the placement of incisions.









History of Surgical Therapy for Obesity


Shands at the University of Florida is a private, not-for-profit hospital that specializes in
tertiary care for critically ill patients. Shands at UF is one of the most comprehensive
hospitals and one of the leading referral medical centers in the Southeast. It continually
receives recognition as one of the best hospitals in the nation by U.S. News and World
Report because of its dedication to patient care, education and research.

Shands at UF is the primary teaching hospital for the UF College of Medicine. More than
500 physicians representing 110 medical specialties work with a team of healthcare
professionals to provide quality care for patients. The faculty from the UF College of
Medicine includes nationally and internationally recognized physicians whose expertise
is supported by intensive research activities. Shands' affiliation with the UF Health
Science Center allows patients to benefit from the latest medical knowledge and
technology.

The University of Florida and Shands Teaching Hospital have been pioneers in the
surgical treatment of obesity. Our first Chairman of Surgery, Dr. Edward R. Woodward,
began performing obesity surgery in the late 1960's. Since then the University of Florida
Bariatric program has performed close to 3,000 operations for weight loss.

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 the "Gold Standard" of weight loss surgical
procedures. It results in weight loss by significantly reducing the size of your stomach, so
you cannot eat as much, and by bypassing your small intestines so you absorb less fat
from the foods you eat. This operation has been accepted by obesity surgeons' throughout
the country and major medical societies as being the most effective in weight reduction
and maintenance of weight loss. We perform this 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 surgical history. See the
picture below for an idea of the placement of incisions.











Laparoscopic Roux en Y Gastric Bypass Procedure


Before Surgery


After Surgery


stomach


A small stomach pouch is created with a stapling device. The small intestines are also
divided and one end is brought up and connected to the small stomach pouch using a
stapler.



Roux-en-Y Type of Gastric Bypass Procedure
New Stomach Pouch
Esophagusjm St

Di ,prar, rr. Staples


-Flow of Food


-Small Intestine









Expected Weight Loss


Weight loss is greatest during the early months following surgery. During this time, it is
very important that you take in enough protein so that you can recover form your surgery.
The rate of weight loss slows during each succeeding month, and usually stabilizes
between 12 and 18 months after surgery. The amount of weight loss cannot be precisely
predicated as weight loss depends on many factors, including your age, preoperative
weight, and the amount of physical activity that you do.

A word of caution: your surgery limits the amount of solid food that you can tolerate, but
has less of an effect on the consumption of liquids. Drinking high calories liquids will
slow your weight loss. After the sixth week, you will be encouraged to eat a regular diet
so be sure to eat solid foods and drink low calorie fluids.

If food consumption or calorie intake increases after weight stabilization, some weight
may be regained. Patients who desire to loose additional pounds must restrict caloric
intake and/or increase their amount of daily exercise. Discuss the method and plan
for additional weight loss with the dietician, physical therapist, and other members
of the bariatric surgery team. This is an extremely important point, the procedure will
give you the "kick start" to lose weight, but you must help by exercising and using
caution/judgment with your food intake.

Lap-Band Procedure

Australia and Europe have provided considerable experience with the placement of an
inflatable adjustable gastric band which also creates a small gastric pouch, without the
need for any bowel anastomoses. This procedure is performed laparoscopically and is
called the Lap-Band Procedure.


















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. The amount of water in the access port is adjusted by placing a needle into
it and adding or withdrawing fluid from the band.

















Expected Weight Loss

Results of the Lap-Band procedure have been encouraging; however weight loss is less
than for patients electing the Roux-en-Y gastric bypass. The Lap-Band procedure
requires more stringent management and 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 made in respect to the tightness of the band. Weight
loss is slower with this procedure with most of the weight loss occurring after the first 3-6
months.

What You Can Expect

Most patients do very well after surgery and have a minimum of adjustment problems or
complications. There is a special diet after surgery that is necessary for the healing of
your stomach, its readjustment to solid food, and its new stapled condition. Most patients
make the transition back to a regular diet without much difficulty. The dietician will
instruct you in what to do and provide you with any additional information you desire.
He/She and other members of the bariatric surgery team will be available to answer your
questions or handle any problems that occur. You will not be on your own after surgery.
Our team will be available to help you for as long as you need any advice,
encouragement, information, or help in adjusting to your "new stomach".









Follow-up Care:


You will return to the clinic in one month, three months, six months, nine months,
twelve months, and every year after surgery. You will see the team dietician, as well as
other members of the team, to ensure that your dietary intake is adequate for your health
needs. They will also counsel you regarding exercise, as well as your emotional and
physical adjustments to your weight loss.

Medications You May Not Take:

There are several non-prescription and prescription medications that you should not take
unless you receive permission and instruction from us in how to take them. Among the
medications in this category are all arthritis medications, aspirin, and aspirin- containing
products, including many cold medications. Alka Seltzer, BC powders, Goody
powders, Bufferin, Ascriptin, and many other medications that contain aspirin or
salicylate compounds are prohibited. These can greatly irritate you stomach pouch and
cause a number of serious problems. You should also avoid taking Nuprin, Advil,
Aleve, ibuprofen, or other over-the-counter arthritis pain or menstrual cramp
medications. If you have any questions about whether a prescription medication or a non
prescription medication contains aspirin or other stomach-irritating compounds, check
with your doctor or pharmacist. Do not take any of these medications unless you have
first spoken with your surgeon or someone from the bariatric surgery team for permission
and instructions on how an exception might be made in your case.



Diet Overview

Bariatric surgery is an excellent way to limit the amount of food you eat and assist in
weight reduction, but significant adaptation of your diet and lifestyle are required to
achieve maximum success. After your bariatric surgery, you will be losing weight very
rapidly. Hence, proper nutrition is essential to maintain lean body mass (muscle),
hydration, skin elasticity, and to minimize hair loss.

The primary nutrition goals after surgery are as follows:

Learn proper eating habits that will promote continued weight loss
Consume adequate amounts of protein to minimize loss of lean body mass, and
facilitate wound healing
Take adequate amounts of fluid to maintain hydration
Take in nutrients for optimal health via healthy food choices
Replenish vitamin and mineral supplementations
The post bariatric surgery meal plan requires a significant change in meal
planning for most people. We recommend that you begin adapting your current
meal plan to prepare for this change









* Avoid fried or high fat foods at all costs


EK !f-


Nutrition Plan In order to loose weight effectively and permanently, you must be an
active participant in your weight loss program. The stomach stapling surgery will help
you to lose weight, but it is not "magic". A well balanced nutrition plan is necessary to
help you reach and maintain your goal weight. Making changes in your eating habits will
also leads to a lifetime of good health and weight control. The following describes the
plan's progression from liquids to solid foods, following your discharge from the
hospital.

Weeks 1 & 2 (high protein, low calorie liquids)

Protein is essential for every function of your body. After surgery, protein is needed for
healing and infection prevention. It is necessary for you to continue on liquids for two
weeks after your discharge from the hospital to avoid putting stress on your staple line.
Hence, your dietician will prescribe a number of high protein liquid supplements. In
addition to these supplements, you will be allowed to have coffee, tea, broth, Gatorade,
clear, and cream soups (strained), cooked cereals (soupy), low fat yogurt (no sugar added
and blended), diet soft drinks (gone flat), fruit juices (small amounts), sugar free drinks,
diet Jell-O, popsicles, and water. You need a good fluid intake during this time, so that
you do not get dehydrated.


Weeks 3 & 4 (Pureed Stage)

During the pureed stage of the plan it will be necessary for you to belnderize most of
your food, or you may want to use baby food. It will also be important for you to develop
an eating schedule for yourself that fits your lifestyle. The following are a number of
guidelines that you will find helpful in making the necessary changes from liquids to
semi-solid to solid foods.









1. Relax and enjoy mealtimes. If you are under stress or feeling anxious before a
meal, you may want to avoid eating until you are more relaxed. Highly stressful
situations often cause food intolerance.
2. Eat six times a day, three meals and three snacks. Eating often is necessary to help
you meet your nutritional needs and continue with your weight loss goals.
3. Limit the size of each meal to approximately four tablespoons of food. You will
discover that you can drink more liquid, so be sure to select low calories
beverages. The more solid a food, the less of it you will be able to eat, so you will
be getting fewer calories and losing more weight. Learning your capacity of
certain foods is essential so weight management.
4. Take small bites, chew well, and put your fork or spoon down between bites.
Taking small bites will help you in chewing your food better. Chew each bite at
least 20 times before swallowing the food.
5. Take at least 20-30 minutes to eat or drink each small meal or snack. Be sure to
make time in your daily schedule for meals. Eating slowly will help you to avoid
problems with intolerance.
6. Drink liquids between meals only. You may take small sips of liquid with your
food, but drinking liquids with meals will cause your pouch to reject the food.
Drink liquids one hour before or one hour after a meal.
7. Include high protein foods at each meal. The dietician will discuss with you
protein food selections and how to include these foods in your menus. Also
include foods from all food groups in your meal plan on a daily basis.

It is not necessary for you to eat completely different meals from anyone else in your
household during this stage of the nutrition plan. You are encouraged to select low
calorie, high protein, and low fat foods.


Week 6 (Soft Stage)

This stage of the nutrition plan could be called the soft-semi-solid stage because you will
be consuming solid foods that are well cooked. You can continue to consume soft foods
you have already been eating in addition to the following foods that should be included in
your meal plan at this time:

Baked fish, chicken, and turkey
Dried beans, peas, and lentils
Lean Ground beef and veal
Creamy peanut butter
Steamed or boiled vegetables
Canned fruit, packed in its own juices or soft fresh fruit
Cooked or dry cereals, crackers
Toasted breads, baked potato (no skin), Melba toast

Remember to continue eating slowly and chewing well. Avoid drinking liquids with your
meals, and continue to follow the guidelines previously outlined.










Week 7 (regular stage)


Continue to advance the consistency of the foods you eat by including raw fruits and
vegetables into your meal plans. Continue to select low calorie, high protein foods, and
low fat foods. Always ask yourself, "Is there a lower calorie, more nutritious choice?"

Foods to avoid

You are encouraged to avoid the following foods:

Nuts, seeds, skins (includes potato skins, onion skins, fruit peelings, and the membrane
between orange and grapefruit sections), the stringy portion of celery, asparagus, string
beans, un toasted bread, high caloric, high fat foods, and high caloric beverages. Steak
and pork may or may not be tolerated depending on the individual.

You may discover individual intolerances with certain foods; this is very common. You
should concentrate on the positive behaviors and good eating habits you are developing.



Dieticians Role

Prior to your discharge from the hospital, the dietician will instruct you on the bariatric
surgery nutrition plan. You will be provided written and verbal information on how to
advance from liquids to solid foods. She will discuss with you how to meet your
nutritional needs as well as how to avoid possible intolerances. In your return visits you
will meet with the dietician on a regularly.

They will evaluate your overall nutritional intake and make recommendations on how to
improve if necessary. The dietician will also help you identify problems and make
suggestions on how to correct them, as well as answering any questions you may have
regarding your nutritional plan.

Remember that surgery is not the magical answer to losing weight. The more involved
you are in your nutritional plan, the better your results will be. Be an active participant.


Vitamin and Mineral Supplementation

The first few months after your surgery you will consume a very low calorie diet, and due
to the volume restriction of your new stomach it will be difficult to eat enough of a
variety of different foods each day to consume adequate amounts of various nutrients.
Hence, vitamin and mineral supplements are required.









Daily Multivitamin
Chewable
Must contain at least
o 400mg Folate
o 18mg Iron
o 15mg Zinc
Calcium Citrate
Calcium must be in a citrate form.
You must take a total of 1200 mg of calcium per day.
If you are on Iron supplements you must separate your iron supplement from your
calcium by at least 2 hours
Iron
Women who are menstruating or who have a history of anemia will need to take
supplemental iron.
Supplemental iron
Take your iron with your multi-vitamin or a vitamin C for enhanced absorption.

You may also wish to take an over the counter stool softener when starting iron
supplements as they may cause constipation

B-12
You will need to receive an injection of B-12 by your 6-month post-op visit and
every 6 months thereafter.





Possible Complications

Vomiting: Gastric bypass produces a small stomach with a narrow opening. Vomiting is
often a result of overfilling the small stomach pouch, drinking liquids too soon after a
meal, or not chewing food well. Eat slowly, chew your food well, and stop at the first
indication that you are full. Excessive nausea or vomiting should be reported to the team
to be evaluated.

Wound Problems: Wound separation, or splitting open of the surgical wound, can occur
following bariatric surgery. The wound separation that you may experience is usually not
very deep, and is not a serious problem. In this case, the wound will heal from the inside
out. Although it may gape open originally, as it heals toward the top of the skin, the
wound naturally pulls together. The scar is usually just slightly wider than it would have
been had it healed without separation.

It is common to have drainage of clear to reddish fluid from your wound in the first week
or two after surgery. This fluid is liquefied fat along with a small amount of blood. You
will notice the drainage of warm fluid from your wound, which may occur during or
following straining. The quantity may seem alarming, but it is not anything to worry









about. You must remember that only a small amount of blood can make the fluid appear
bright red. Therefore, a reddish appearance is no cause of alarm. You should contact our
office with any concerns.

Stricture or Obstruction: The opening from the created small stomach pouch may
narrow or close in a small number of gastric bypass patients. This may result from
swelling in the area of the connection to the intestine. This will manifest 3-6 weeks after
surgery with vomiting as you try to eat more and more solid foods. Usually, the
obstruction can be opened up by performing an endoscopic examination and using a
balloon catheter to stretch the opening. You will be given medication to make you sleepy,
as well as local anesthetic of the throat prior to the endoscopy; this is an outpatient
procedure.

Staple Disruption: Your diet will be slowly advanced after surgery to allow time for the
staple line to heal. It is very important that the staple line not be stressed by a large intake
or excessive vomiting during the period while it is healing.

If the staple line is stressed the staples may come loose. Food would then pass more
freely out of the small pouch. Without the full sensation provided by the pouch, the
tendency is to eat more. This will result in inadequate weight loss and could also result in
an ulcer.

Perforation or Leaks: A small hole or leak can occur through the stomach wall early
after the operation. Although rare, this leakage of stomach juices will cause an infection,
which may progress to an abscess or even peritonitis. You will be watched closely for
this serious complication and may need to be taken back to the operating room to fix the
leak or perforation.

Blood Clots: Blood can clot in the veins of your legs during and after surgery, a
condition known as thrombosis. These clots can break loose and travel to the lungs, a
condition known as a pulmonary embolism. You will be given blood thinner before,
during, and after surgery to help prevent this from happening. Special stockings will be
placed at the time of surgery, which help to keep your blood circulating in your legs. This
complication can occur even once you are at home following surgery. Therefore, it
remains important for you to continue physical activity such as walking, even short
distances several times per day.

Hair Loss: A few patients find that their hair thins out between three and six months
after surgery. The anesthetic and the operation will sometimes cause hair follicles to stop
producing new hair temporarily. In about one year your hair will grow back completely.
There is no good treatment and the condition is entirely harmless.

Ulcer: Because your intestine is hooked directly up to your stomach pouch, your chances
of developing an ulcer, although very small, are increased as compared to prior to
surgery. Food, especially protein, neutralizes stomach acid created in your new stomach
pouch. However, at night when you are sleeping, there is no food in the pouch to









neutralize the small amount of acid made by the stomach lining your pouch. Therefore,
we recommend that all patients take an antacid pill such as Pepcid or Zantac at night,
before going to sleep.

Dumping: Because the pouch is directly connected to your intestine, food and
particularly highly concentrated sweets may cause what is referred to as the dumping
syndrome. When concentrated fluids enter the small intestine, they signal the body to
release hormones. These hormones spill into your circulation and cause the blood vessels
in your legs to dilate. This will cause you to feel like you are going to pass out, as the
blood rushes to your feet. In addition, you may develop cramping, diarrhea, and nausea or
vomiting. Some patients are highly sensitive and frequently develop this syndrome, while
others may not develop these symptoms at all. Most patients will find that they develop
these symptoms with certain foods and learn to avoid these foods. Most patients also find
that the symptoms lessen with time.

Nutritional Deficiencies: Because of the bypass of the bottom part of your stomach and
the first part of your small intestine, you will have a marked reduction in food intake.
This can result in deficiencies of proteins and vitamins. In addition, you will not absorb
vitamin B-12, iron, and calcium normally. The dietician will meet with you in the
hospital prior to your discharge to arrange a supply of liquid protein supplements. At
your one month visit after surgery, he/she will review your protein intake and help you to
meet your goals.

It is essential that vitamin supplements be taken on a daily basis. In addition, you also
will need calcium supplements after surgery.

Gallbladder: 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 judgment with respect to its removal at the time
of 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.









The following table shows the incidence of complications we monitor following surgery.
Postoperative Complications

Complication Published Percentage

Conversion to Open from Laparoscopic 5-15

Postoperative Heart Attack 1-2

Postoperative Pneumonia 1

Postoperative Bleeding Requiring Blood Transfusions 2-5

Wound Infection N/A

Return to Operating Room
Positive Findings 3-5
Negative Findings

Anastomotic Leak Requiring Emergent Re-Operation 4.6

Readmissions 5-20

Anastomotic Strictures Requiring Dilatation After 2 Months 5.0

Marginal Ulcers at Gastrojejunostomy 1- 15

Blood Clots in Legs 1

Pulmonary Embolism 1

Need to Remove Gallbladder Later 10-20

Inadequate Weight Loss 5

Death Immediately Following Surgery 5

Death Total 5 Years After Surgery 0.68









Nutrition Questionnaire


Please bring the form with you on your initial clinic visit.


Date


Name


1. How long have you been considering weight loss surgery?


Weight History

2. What is your current weight? LBS
3. What is your desired goal weight at 12-18 months after surgery? LBS
4. How many pounds do you need to lose to achieve your weight goal? LBS


5. When did your weight problem begin?
teenager 10 years ago
throughout life other


childhood
20 years ago _


adolescent
30 years ago


6. What do you think is reason for your weight gain?
injury pregnancy overeating poor eating habits
lack of exercise marriage smoking cessation stress
divorce other


heredity


7. What has been your highest adult weight? LBS
8. When you lost weight in the past, how many pounds did you lose on average with each
attempt?
Weight loss small (<15 lbs) moderate (15-49 lbs) large (>501bs)
9. What has been you most successful diet?
Why


Exercise History
(for staff use only MIP
10. Do you currently exercise? yes
If yes, what do you do for exercise,
Exercise Days/week


MEP
no


HGS


Time spent


If No,
Why


Diet Assessment
11. How many meals per day do you eat? one meal
meals one to two meals two to three meals


two meals three
three or more meals










If you skip meals what meal(s) do you usually skip:
breakfast lunch dinner
How many days a week do you skip this meal


12. I eat out for Breakfast
Lunch
Dinner
13. Are your meals?
large portion
high sugar


rarely
rarely
rarely


sometimes
sometimes
sometimes


extra large portions


14. How often do you snack?
a.m. snack p.m. snack
grazing on food throughout the day


high fat


evening snack


often
often
often


daily
_daily
daily


high carbohydrate



snack between all meals


15. What beverages do you drink (please mark how many ounces you drink of each daily)
water whole milk
diet soda 2% milk
regular soda 1% milk
regular coffee skim milk
decaf coffee uice
regular tea sweet tea
decaf tea unsweetened tea


16. Do you drink alcohol? yes no If yes w
often.
17. Do you take a Multivitamin? __ yes no
18. Do you smoke? __ yes no if quit, when
From the list below what triggers you to eat:
availability of food depr
loneliness borei
habit hung
lack of appetite awareness self r
external cues comic
stress PMS
social situations anxi


sadness ott
anger
How would you describe your eating habits?
SSkip one meal per day Of
[Reported often eating (i.e. grazing) ov
ORapid eating IO
OEating until uncomfortably full thr
[Eating alone out or embarrassment 1i


that type how much and how





session
dom
er
eward
fort

ety


ler


feelingg disgusted or guilty after
creating
Eating large amounts of food
oughout the day
diddle of the night eating















Physician Questionnaire


Personal Data


Today's Date:

Full Name:

Birth Date:


Soc Security #:


Address:

City, State,
ZIP:

Work Phone:

Home Phone:
E-mail
Address:

Occupation:

Marital Status:


-i


-i


-i


Insurance Information
Insurance
Company:
Policy Holder's
Name:
SS# of Policy
Holder:

Policy Number:

Address:
City, State,
ZIP:































Section II


Body Size and Weight Information- List Maximum for Each Year
Weight 1992: Weight 1997:
Weight 1993: Weight 1998:
Weight 1994: Weight 1999:
Weight 1995: Weight 2000:
Weight 1996: Weight 2001:
Current
Weight:
Height: Waist
Measurement:


Previous Attempts at Weight Loss
Program: Year: Months: Physician Lbs. Weight Regained?
Supervised? Lost:


Person
Contacted:

Telephone:

Fax Number:

Family Physician Information
Family
Physician:

Address:

City, State,
ZIP:
Office Phone

FAX number:







































Section III


Do you have a Yes No
Psychiatrist:
If Yes:
Psychiatrists
Name:
Address:
City, State,
ZIP:
Office Phone:
Date Last Seen:


List any other
Attempts:




List
Medications
Used to Lose
Weight and
Results:

Describe any
Family History
of Obesity:


I I I I


















Please List all
Allergies:
Please List all
Medications
Currently
Taking and
Dosages:



List Prior
operations
(indicate if
done with
laparoscope):



Describe in
your words
how your
obesity is
affecting your
life:

















Section IV
Obesity and Selected Organ Function


Check all that apply
Cardiovascular
Heart problems (requiring medication)
Chest Pains
Racing Heart/skipping
High blood pressure (requiring medication)
Chest tightness
Shortness of breath (SOB)
High Cholesterol (requiring medication)
High Triglycerides (requiring medication)
Feel tired all the time
Diabetes
Diabetes Type I or II (requiring medication)
Pre-Diabetic (abnormal glucose tolerance test)
Gestational Diabetes Age of Diagnosis
Hypoglycemia (low blood sugar)
Thyroid Problems
Thyroid Problems (requiring medication)
Gastrointestinal
Gallbladder Problems Removed?
Stomach Ulcers (requiring medication)
Heartburn Daily? Nocturnal?
Regurgitation? Requiring Medication?
Diarrhea or constipation

Respiratory


Asthma Last attack?
? Bronchitis # of times in past 2 years
Pneumonia
Blood clots in lungs
Smoker Starting age
Smokeless Tobacco
Sleep Apnea
Snore
Wake up gasping with a smol
Using CPAP or BI-PAP


Is it recurring? Yes No


WVhen did you stop?


there feeling?

















Check all that apply
Musculoskeletal
Mild Moderate Severe
Hip Pain
Knee Pain
Ankle Pain
Feet Pain
Back Pain
Neck Pain
Arthritis

Check all that ap ly
Degenerative
Joint Disease
Using anti-
inflammatory
or pain
medicine
Swelling in the
legs
Swelling in the
feet
Swelling in the
hands
Varicose veins
Ulcers of the
legs
Problems with Pain Inflamed Red
leg veins


SFor Females

Problems Conceiving
Are you regular?
Any pain with period?
Loss of urine

















Nero- Psychiatric
S Depression because of obesity? requiring medication?
Seizures requiring medication?
Severe Headaches _requiring medication?
Visual Problems


Been in counseling
History of alcohol abuse.
History of drug abuse.
Eating disorder.


How long have you been dry
How long have you been clean
Bulimia Anorexia-Nervosa


Family History (parents, grandparents, brothers, sisters)


Parents Grandparents Brothers Sisters Other
Obesity
Diabetes
Heart
Disease
High
Blood
Pressure
Cancer &
Type
Arthritis
Early
Death &
Cause

















Sleep Apnea Self Test
(You do not need to complete if you know you have sleep apnea)


YES NO
Do you Snore?
Have you been told that you hold your breath or stop
breathing during sleep?
Do you wake up Gasping for Breath?
Do you awaken with headaches
Do you fall asleep frequently while reading?
Have you fallen asleep while driving or stopped at a
light?
Do you have jerking movements while sleeping?
Do you still feel exhausted after 8 hours of sleep?

Total # of YES answers:

If you answered YES to more than four of the above questions, you may have sleep
apnea and you should talk to your doctor about a sleep study.

















Impact of weight on Physical Functions

Please check the answer in the right column according to how well it describes you in the
past week:

Physical Function Always Usually Sometimes Rarely Never
true true true True true
Because of my weight I have trouble
picking up objects
Because of my weight I have trouble
tying my shoes
Because of my weight I have trouble
using stairs
Because of my weight I have trouble
putting on or taking off my clothes
Because of my weight I have trouble
with morbidity
Because of my weight I have trouble
crossing my legs
I feel short of breath only with mild
exertion
I am troubled by painful or stiff joints
My ankles and lower legs are swollen
at the end of the day
I am worried about my health
Self Esteem
Because of my weight I am self
conscious
Because of my weight my self esteem
is not what it could be
Because of my weight I feel unsure of
myself
Because of my weight I don't like
myself
Because of my weight I am afraid of
being rejected
Because of my weight I avoid looking
in mirrors or seeing myself in photos.
Sexual Life










Because of my weight I do not enjoy
sexual activity
Because of my weight I have little or
no sexual desire
Because of my weight I have difficulty
with sexual performance

Because of my weight I avoid sexual
encounters whenever possible
Public Distress
Because of my weight I experience
ridicule, teasing, or unwanted attention
Because of my weight I worry about
fitting into seats in public places
Because of my weight I worry about
fitting through aisles or turnstiles
Because of my weight I worry about
finding chairs that are strong enough to
hold my weight
Because of my weight I experience
discrimination by others
Work: (if you are a homemaker or retired,
answer this questions with respect to your daily
activities)
Because of my weight I have trouble
getting things accomplished or meeting
my responsibilities
Because of my weight I am less
productive than I should be
Because of my weight I don't receive
appropriate raises, promotions, or
recognition at work
Because of my weight I am afraid to go
to job interviews


i + I I I


-+ + + 4


i i i I I














Written Agreement to Comply with Therapy


I have reviewed all the information provided to be by the Shands at the University of
Florida Weight Loss Surgery Center about my obesity, the Roux-en-Y Gastric
Bypass/Lap-Band, the strict postoperative dietary program, lifestyle modifications
including and not limited to increased exercise. I also understand that follow-up clinic
visit is an important aspect of care to avoid potential complications; and for optimal
weight loss.

I have been given an opportunity to ask questions about management of my obesity,
alternative forms of treatment, risk of non-treatment, the procedures to be used, and the
risks and hazards involved. I believe that I have sufficient information concerning the
Roux-en-Y Gastric Bypass/Lap-Band surgery.

I agree to comply, to the best of my ability with all therapy and recommendations made
by my physicians and healthcare providers including:
D I will take vitamins and supplements as directed for the rest of my life.

D I will follow the guidelines of the postoperative diet.

D I will exercise on a regular basis after surgery.

D I will come in for follow-up appointments at 4 weeks, months, 6 months, and 12
months and at least every year after.

D I will not get pregnant for at least 1 year after my surgery.



(Signature of Patient) (Date)
Please sign legibly


(Signature of Provider)


(Date)




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