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Care of the Bariatric Patient February 15, 2012

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1 Care of the Bariatric Patient February 15, 2012
Nursing Grand Rounds Care of the Bariatric Patient February 15, 2012

2 Presented and Planned by:
Needham 3: Jessica Kaloyanides, RN Marjorie Petit, RN, BSN Kayleen Sussman, RN Kelly Donahue, RN, BSN Operating Room: Eric Starble, RN, BSN, CNOR Leslie Schneiderhan, RN, BSN, MEd, CNOR Al Ghilardi Orthopedic Tech Photography Weight Management Center: Lisa C. Luz, RN, MSN, CBN Nutrition: Dana Eiesland, RD, LDN Stacey A. Nelson, BS, RD, LDN

3 40.0 and higher Morbid obesity
Obesity is defined as having an excessive amount of body fat. Doctors often use Body Mass Index to determine obesity BMI Weight status Below Underweight Normal Overweight 30.0 and higher Obese 40.0 and higher Morbid obesity

4 Obesity in the US About one-third of U.S. adults (33.8%) are obese. (Center for Disease Control and Prevention) During past 20 years there has been a dramatic increase in obesity in the United States

5 The Dangers of Obesity Obesity results in many co-morbidities such as:
sleep apnea joint disease hypertension stroke diabetes respiratory diseases World health organization estimated that being overweight and inactive accounts for ¼-1/3 of all cancers of the breast, colon, endometrium, kidney, and esophagus

6 Obesity Attitudes in Health Care
self-report studies show that physicians, nurses, and other medical personnel view obese patients as: non-compliant lazy dishonest lacking in self-control unsuccessful sloppy

7 Surgical Weight Management
4/6/2017 Surgical Weight Management Lisa C. Luz, RN, MSN, CBN

8 Surgical Weight Management
Under the direction of expert bariatric surgeons: Julie Kim, MD, FACS Associates from TMC: Dr. Abeles, Dr. Shah, Dr. Tarnoff, fellows Multidisciplinary Team Dietitian Psychologist Program Coordinator/Nurse Insurance Specialist

9 Who is a Surgical Candidate?
Meets National Institutes of Health Criteria: BMI > 40 >35 with significant obesity-related co-morbidities 18 years or older No endocrine cause of obesity Stable psychological condition Absence of drug or alcohol problem/Non-Smoking Understands surgery and risks Acceptable operative risks (patient and procedure) Consensus after bariatric team evaluation: psychologist, dietitian, surgeon Dedicated to lifestyle change and follow-up

10 The Surgical Process Information Session Immersion Day
Preliminary Application Health History Questionnaire Immersion Day Psychologist/Behavioral Assessment Nutritional Counseling Medical Clearance from PCP or Specialist Medical Testing: Labs, X-ray, EKG Consultation with Surgeon Support Groups Insurance Approval

11 The Surgical Process Mental Health Evaluation Preparing for new Life
Identify the support needed to be successful Individual Nutrition Appointments Minimum 2 visits (for insurance approval) Individual Diet Planning and Education Medical Testing Labs, Chest X-ray, EKG and any testing TBD by team

12 The Surgical Process This process takes approximately 3-6 months!
Surgical Consultation One on One consultation to answer all questions and individual concerns Medical Clearance By PCP, or specialist Support Groups~ Make the Difference This process takes approximately 3-6 months!

13 Bariatric Surgery Eric Starble RN
4/6/2017 Bariatric Surgery Eric Starble RN

14 Review of the Digestive System
4/6/2017 Review of the Digestive System Esophagus Stomach Small Intestine (Duodenum, Jejunum, Ileum) Large Intestine Describe both function and size.

15 Bariatric Surgery Today
4/6/2017 Bariatric Surgery Today Three Types of Most Commonly Performed Bariatric Surgery Procedures Malabsorptive Restrictive Combination Currently, there are three types of bariatric surgeries being performed: Malablsorptive, where weight loss is due to absorptive dysfunction caused by the reconstruction of the small intestines – the biliopancreatic diversion is considered a malabsoptive procedure. Restrictive procedures, such as banding, simply limit the size of the stomach. The patient loses weight because they will feel full or satiated after consuming very little food. In combination procedures, such as a Roux-en-Y Gastric bypass, the size of stomach is reduced by creating a small pouch, but the small intestines are also altered to limit absorption, particularly the absorption of foods high in fat and in carbohydrates. Biliopancreatic Diversion with Duodenal Switch Adjustable Band Gastroplasty Roux-en-Y Gastric Bypass

16 Adjustable Band Gastroplasty
4/6/2017 Restrictive Surgery Relatively easy surgical procedure Less dietary deficiencies Less weight loss More late failures due to dilation Less effective with sweet eaters Significant dietary compliance Approved by the FDA in June 2001, the BioEnterics® LAP-BAND® Adjustable Gastric Banding System is the newest and the only adjustable surgical treatment for morbid obesity in the United States. It induces weight loss by reducing the capacity of the stomach, which restricts the amount of food that can be consumed. Since there is no cutting, stapling or stomach rerouting involved in the LAP-BAND System procedure, it is considered the least traumatic of all weight loss surgeries. The laparoscopic approach to the surgery also offers the advantages of reduced post-operative pain, shortened hospital stay and quicker recovery. If for any reason the LAP-BAND System needs to be removed, the stomach generally returns to its original form. The most frequently occurring complications associated with the LAP-BAND (INAMED Health, Santa Barbara, CA) include gastric prolapse, stoma obstruction, esophageal and gastric pouch dilatation, erosion, and access port problems. Adjustable Band Gastroplasty

17 Malabsorptive Surgery
4/6/2017 Malabsorptive Surgery Greater sustained weight loss with less dietary compliance Increased risk of malnutrition and vitamin deficiency Constant follow–up to monitor increased risk Intermittent diarrhea The immediate result of the surgery is a restriction of food intake due to the smaller stomach size; this assists the initial weight loss. Within 18 months the stomach pouch will gradually stretch to hold a normal-size meal. Weight loss will taper off and stabilize. An added benefit of stomach size reduction is decreased stomach acid production, thereby reducing the chances of ulcer formation. Additionally, fewer calories are absorbed in the abbreviated 30-inch section of small bowel where food and digestive juices combine. This results in continued weight loss due to malabsorption. In the first 18 months after surgery, fats are incompletely absorbed, proteins are somewhat more absorbed, and simple sugars are completely absorbed. As the bowel naturally accommodates the surgery, fats will continue to be incompletely absorbed, but both protein and carbohydrate absorption generally increase over time. WEIGHT LOSS RESULTS: Drs. Robert Rabkin and John Rabkin have performed over 900 duodenal switch surgeries through August 2002 (including open and laparoscopic procedures). The initial results for all laparoscopic patients are as follows: Average excess weight loss at 3 months is 29%. Average excess weight loss at 6 months is 51%. Average excess weight loss at 24 months is 91%. Biliopancreatic Diversion with Duodenal Switch

18 Laparoscopic Sleeve Gastrectomy
Restrictive procedure Purpose: Suppression of hunger hormones No intestinal connection Considered a standard procedure by national society (ASMBS) Newer procedure Covered by many but not all insurance companies

19 Mechanics of Sleeve Gastrectomy
Permanent removal of the lateral portion of the stomach Creates a long, narrow, "banana" shaped stomach or "sleeve" Reduces the capacity of the stomach by 2/3rds No foreign body or needle sticks required The body's natural pyloric and gastroesophageal valve act to restrict the passage of food with removal of many of the hunger hormones

20 Laparoscopic Sleeve Gastrectomy

21 Roux-en-Y Gastric-Bypass
4/6/2017 Roux-en-Y Gastric-Bypass Long-term sustained weight loss No protein-calorie malabsorption Little vitamin or mineral deficiencies Technically difficult procedure The complications of gastric bypass are much less severe than those of Intestinal Bypass, and most large series report complications in two phases, those which occur shortly after surgery, and those which take a longer time to develop. The most serious acute complications include leaks at the junction of stomach and small intestine. This dangerous complication usually requires that the patient be returned to surgery on an urgent basis, as does the rare acute gastric dilatation, which may arise spontaneously or secondary to a blockage occurring at the Y-shaped anastomosis (jejunojejunostomy). Then there are the complications to which any obese patient having surgery is prone, these including degrees of lung collapse (atelectasis) which occur because it is hard for the patient to breathe deeply when in pain. In consequence a great deal of attention is paid in the postoperative period to encouraging deep breathing and patient activity to try to minimize the problem. Blood clots affecting the legs are more common in overweight patients and carry the risk of breaking off and being carried to the lungs as a pulmonary embolus. This is the reason obese patients are usually anticoagulated before surgery with a low dose of Heparin or other anticoagulant. Complications which occur later on after the incision is all healed, include narrowing of the stoma (the junction between stomach pouch and intestine), which results from scar tissue development. Recall that this opening is made about 10 mm in diameter, not much wider than dime. With an opening this small, a very little scarring will squeeze the opening down to a degree that affects the patients eating. Vomiting which comes on between the 4th and 12th week may well be due to this cause. The problem can be very simply dealt with by stretching the opening to the correct size, by endoscopic balloon dilatation, which usually involves a single procedure on a day stay basis to correct the problem. Wound hernias occur in 5-10% and intestinal obstruction in 2% of patients an incidence similar to that following any general surgical abdominal procedure. Another late problem which is fairly common, especially in menstruating women, after gastric bypass is anemia. Since the stomach is involved in iron and Vitamin B12 absorption, these may not be absorbed adequately following bypass. As a result anemia may develop. The patient feels tired and listless, and blood tests show low levels of hematocrit, hemoglobin, iron, Vitamin B12. The condition can be prevented and treated, if necessary, by taking extra iron and B12. Since the food stream bypasses the duodenum, the primary site of calcium absorption, the possibility of calcium deficiency exists, and all patients should take supplemental calcium to forestall this. Dumping is often mentioned as a complication of gastric bypass, but it really is a side effect of the procedure caused by the way the intestine is hooked up. Dumping occurs when the patient eats refined sugar following gastric bypass, this causes symptoms of rapid heart beat, nausea, tremor and faint feeling, sometimes followed by diarrhea. Of course no one likes these feelings, especially patients who love sweets! The upshot is, of course, that sweet lovers avoid sweets after gastric bypass and this is a real help to them in their efforts to lose weight. It should be noted that a few surgeons, expert at endoscopic/laparoscopic surgery, are performing Gastric Bypass using laparoscopic techniques. Listing of complications following gastric bypass: Early: Leak Acute gastric dilatation Roux-Y obstruction Atelectasis Wound Infection/seroma Late: Stomal Stenosis Anemia Vitamin B-12 deficiency Calcium deficiency/osteoporosis Roux-en-Y Gastric Bypass

22 The Roux-en-Y Gastric Bypass
4/6/2017 The Roux-en-Y Gastric Bypass A small, 15 to 20cc, pouch is created at the top of the stomach. The small bowel is divided. The biliopancreatic limb is reattached to the small bowel. The other end is connected to the pouch, creating the Roux limb. In the United States today, the Roux-en-Y gastric bypass is the gold standard for weight loss surgery. When performing the procedure, 1. A small, 15 to 20 cc, pouch is created at the top of the stomach. 2. The small bowel is divided. The biliopancreatic limb is re-attached to the small bowel. 3. The other end is connected to the pouch, creating the Roux limb The small pouch releases food slowly into the Roux limb, causing a sensation of fullness with very little food. The biliopancreatic limb preserves the action of the digestive tract. Roux-en-Y Gastric Bypass

23 Roux-en-Y Gastric Bypass
Small pouch releases food slowly, causing a sensation of fullness with very little food Biliopancreatic limb preserves the action of the digestive tract

24 Open and Laparoscopic Technique in Bariatric Surgery
4/6/2017 Open and Laparoscopic Technique in Bariatric Surgery Open Increased post op pain, longer hospitalizations Increased incidence of wound complications - infections, hernias, seromas Return to work in 4-8 weeks Laparoscopic Less post op pain, early mobility Wound complications are significantly reduced 2-3 day hospital stay Return to work in 1-3 weeks Traditional Surgery: Once the only method used for surgical procedures, traditional open surgery involves making a 10- to 12-inch incision to access the stomach and intestines. Then the surgeon performs a restriction or gastric bypass operation. Minimally Invasive or Laparoscopic Surgery In minimally invasive, or laparoscopic, surgery, the surgeon uses five or six small incisions (each 1/4 and 1/2 inch long) to access the stomach and intestines. The laparoscope is a probe-like tool with a video camera attached. The surgeon inserts the laparoscope through the incisions and gets a magnified view of the patient's organs on a television monitor. The entire operation is performed inside the abdomen after gas has been inserted to expand the abdomen. Surgeons continually find ways to use ever-smaller incisions, lower operative risk, reduce postoperative pain, and shorten hospital stays. Minimally invasive surgery techniques have cut recovery times for many operations from weeks to days.

25 What Happens in the OR?

26 Bariatric Surgery: Beyond the Surgery
4/6/2017 Bariatric Surgery: Beyond the Surgery Bariatric Surgery will NOT work alone Intricate parts of your weight loss success: Commitment to: Diet Exercise Support groups

27 Resolution of Comorbidities
4/6/2017 Resolution of Comorbidities N=104 1 year post-op Number Prior to Surgery % Worse % No Change % Improved % Resolved Osteoarthritis 64 2 10 47 41 Hypercholesterimia 62 4 33 63 GERD 58 24 72 Hypertension 57 12 18 70 Sleep Apnea 44 5 19 74 Hypertriglyceridemia 43 14 29 Peripheral Edema 31 55 Stress Incontinence 6 11 39 Asthma 69 13 Diabetes 82 Average 1.6% 7.8% 35.1% 55.7% 90.8% Improved or Resolved Studies have also shown that there is an almost complete resolution of a patient’s obesity related comorbidities following gastric bypass surgery. Shown here are the results from a single institution: Philip Schauer, MD, University of Pittsburgh Medical Center Focus on presenting a few of the key comorbidities and point out the % of the patients that either improved or completely resolved their obesity related health problems In particular serious conditions, such as - GERD - Hypertension - Sleep Apnea and Diabetes are all improved or resolved after surgery [columns on the right] [moving the slide forward (with mouse click) highlights the “improved” and “resolved” areas of the slide] Then point out that overall, 90.8% of patients had improved or resolved their obesity related comorbidities. Schauer, et al, Ann Surg 2000 Oct;232(4):515-29

28 Possible Complications
4/6/2017 May Lead to Short or Long-term Hospitalization and/or Re-operation Infection, bleeding or leaking at suture/staple lines Blockage of the intestines or pouch Dehydration Blood clots in legs or lungs Vitamin and mineral deficiency Protein malnutrition Incisional hernia Death

29 Possible Side Effects Nausea and vomiting Gas and bloating
4/6/2017 Possible Side Effects Nausea and vomiting Gas and bloating Dumping syndrome Lactose intolerance Temporary hair thinning Depression and psychological distress Changes in bowel habits such as diarrhea, constipation, gas and/or foul smelling stool

30 Post-Operative Summary
4/6/2017 Post-Operative Summary On Average, Gastric-bypass Patients… Lose 65-80% of their excess body weight, the majority of it in the first 18 to 24 months after surgery. May have rapid improvements in the morbid side effects of their obesity, such as type 2 diabetes, high blood pressure, sleep apnea, and high cholesterol levels.

31 Dana Eiesland, RD, LDN Stacey A. Nelson, RD, LDN
4/6/2017 Bariatric Surgery Nutrition Education Dana Eiesland, RD, LDN Stacey A. Nelson, RD, LDN 31

32 Pre-Surgery Nutrition Education : Immersion Day
4/6/2017 Pre-Surgery Nutrition Education : Immersion Day Education Provided: Mindful eating (eating speed, environment) Self- monitoring (keeping daily food journal) Dietary changes to promote pre-op weight loss (ie. Meal planning, lean protein sources, snacks) Exercise Recommendations Post-op diet progression Long-term food selection guidelines Fluid guidelines Protein supplements Vitamin & mineral supplementation Reading nutrition fact labels 32

33 Pre-op Bariatric “To Do” List
4/6/2017 Pre-op Bariatric “To Do” List ___ Read the Nutritional Guidelines ___ Buy everything on shopping list ___ Follow low-calorie diet (to lose ~5% of start weight pre-op) ___ Keep daily food dairy (Measure & weigh all food & drinks) ___ Count daily protein & fluid intake ___ Begin taking vitamin/mineral supplements ___ Practice using approved protein supplements ___ Exercise: Goal = 30 minutes most days ___ Practice eating slowly (30min/meal) ___ Practice drinking ONLY between meals; avoid drinking 30 minutes before & after eating ___ Avoid caffeine, soda, carbonation, juice, & sweetened beverages ___ Try Stage 4 (pureed & soft moist protein foods) for 2 full days ___ Attend support groups 33

34 Pre-Surgery Nutrition Education: Individual Counseling
4/6/2017 Pre-Surgery Nutrition Education: Individual Counseling •Min. 2 individual visits with Outpatient RD Re-enforce information provided at Immersion Day Pre-op weight loss Practicing portion control Meal planning Self-monitoring of eating & physical activity Strategies to adopt more mindful eating habits Increasing regular physical activity Increasing intake of fruits/vegetables/low-fat dairy &proteins/whole grains/water 34

35 Inpatient Bariatric Diet Diet stages 1-3
Nutrition Consult ordered upon admission Review diet progression, stages 1-3 Discuss fluid intake journal: focused on hydration, sipping slowly, 1-4 oz/hour between meals, no straws Work with inpatient team to identify and minimize complications post-op Confirm patient post-op RD appointment

36 Inpatient Bariatric Diet Diet stages 1-3
Stage 1: Water (provided by RN) No straws 1oz/hr Fluid intake journal Stage 2: Clear Liquids (standard tray) Non-carbonated, caffeine-free, sugar-free: Water, diet cranberry juice, sugar-free jello and ice pops, broths, decaf coffee and tea Stage 3: High Protein Full Liquids (self-order) Low-fat, high protein food items: Broth, low-fat milk, protein shakes (SF CIB), tomato soup, low-fat yogurt, and diet custard/ pudding

37 Bariatric Diet Advancement Diet Stage 4
Stage 4: Soft & Moist Protein Start: 2 wks post-op; Duration 4-6 wks Examples of protein sources: Chicken salad made w/ low-fat mayonnaise Chili made w/ lean ground turkey/beef Moist fish/shellfish Avoid fluids 30 min before & after each meal/snack. Will begin taking chewable/liquid vitamin & mineral supplements. Multi-vitamin w/ iron 200% DRI, Vit D3 1000IU, Vit B mcg, Calcium Citrate mg Keep daily food journal.

38 Bariatric Diet Advancement Diet Stage 5
Stage 5: Low Fat, Low Sugar, High Protein Start: 4-6 wks post-op; Duration: lifelong Balanced solid food diet. Continue to practice mindful eating & separate fluids from your meals. Vitamin/Mineral supplementation for life. For More Information on Diet Stages Clinical Portal > Bariatric Center > Bariatric Nutrition

39 Post-Op Nutrition & Support
4/6/2017 Post-Op Nutrition & Support Immediate (2wks- 12mo. post-op): * Diet Advancement * Protein & Hydration Status * Vitamin & Mineral Status/ Supplementation * Lifestyle and Behavior Changes * Meal Planning & Appropriate Food Choices Long-Term (>1yr post-op): * Prevention of Vitamin/Mineral Deficits & Deficiencies * Co-morbid Conditions (i.e. DM, HTN, Dyslipidemia) * Managing Changes to Bowel Habits * Promotion of a Balanced Diet * Weight Maintenance & Weight Loss * Exercise * Promotion of Self-Care * Lifestyle & Behavior Changes 39

40 Thank you! Dana Eiesland, RD, LDN (outpatient)
Stacey A. Nelson, RD, LDN (inpatient) Pager: #6052

41 Postoperative Care on N-3
Jessica Kaloyanides RN Marjorie Petit RN, BSN

42 PACU (Report from PACU RN- N3 RN
5 incisions total (one is JP drain) 100mg IV thiamine for all pts. on arrival Hct within 2hrs : Drop of 4 points wait on transfer to floor/redraw If vomiting or spitting up blood CALL MD Wake to assess every 10 min during first hr Fentanyl Dilaudid PCA Shoulder pain/left side trocar pain ( CO2 gas in abd) Wean O2 to NC

43 Setup of the bariatric room
Bariatric bed – holds up to 750lbs Bariatric tray fits under each bariatric bed Telemetry monitor with continuous 02 monitoring Pneumatic Compression Sleeves Incentive spirometry Bariatric menu Moving IV pole: pt OOB ambulating same day as surgery (unless up to floor too late)

44 Bariatric room pic (plus say pt will have lap sites)

45 Possible Complications: Anastomotic Leak
Symptoms tachycardia fever abdominal pain purulent drain output nausea/vomiting shoulder pain hypotension Treatment surgical vs medical stability of patient size of leak

46 Possible Complications: Pulmonary Embolism
Symptoms sudden SOB (active rest) chest pain cough with bloody sputum tachycardia leg swelling/weak pulse Treatment CXR/CCT anticoagulant therapy embolectomy

47 Possible Complications: Pneumonia
Symptoms classic symptoms sudden onset fever/chills coughing chest pain Treatment CXR antibiotics

48 Possible Complications: Small Bowel Obstruction
Symptoms constipation abdominal swelling vomiting (green or fecal vomit) passing jelly like mucous abdominal cramping Treatment needs ABD CT/UGI Possible IR procedure (place drain) or return to OR

49 Possible Complications: Internal Bleeding (immediately post op)
Symptoms hypotension tachycardia decreased hct bloody drainage melena Causes r/t internal organ damage r/t stapled sites

50 Possible Complications: Infection
Symptoms: fever foul smelling odor from lap sites/drain sites lap sites or drain sites yellow discharge Treatments antibiotics

51 General Nursing Guidelines: Activity
Pt out of bed same day as surgery Ambulate in hallway 3x per day Out of bed to chair as much as tolerated IS 10x/hr while awake

52 General Nursing Guidelines
Foley DC post op day 2 PCA pump/IV fluids DC post op day 2 when pt tolerating liquids JP drain removed by MD post op day 2 abd incisions checked Q4 VS Q4 Maintain accurate I’s/O’s

53 Bariatric Diet Stage 1: Water Typically start day of surgery NO STRAWS
Nurse to administer 1oz water per hr via med cup Sip slowly and stop if feeling full All meds in IV or liquid form IV fluid until tolerating liquid

54 Discharge Instructions
Activity: walk inside/outside may climb stairs avoid rigorous exercise Pain: use pain meds as prescribed pain should improve over time/ call MD if pain is not under control

55 Discharge Instructions
Diet: stage 3 diet each meal slowly over one hour drink at least 48 ounces of fluid per day, goal is 64 ounces per day 60-80 grams protein a day no straws/no chewing gum Incision Care: adhesive will fall off on its own if incision reddened, thick drainage or foul odor - call MD

56 Discharge Instructions
Meds: one med at a time cut or crush large pills vitamins and calcium post op visit don’t take NSAIDS until checking with MD Contact MD If: uncontrolled nausea or vomiting unable to tolerate meal plan redness, swelling or incision site/ fever of or greater diarrhea more than 24hrs /constipation more than 5 days

57 Patient Testimonials 64 Year old female Surgery date: 7/20/2011
“My hospital experience was great. I’m very pleased with the program. I’ve done every diet and it’s gone nowhere. I was reluctant on surgery, but when I met the staff I was very impressed. I can’t say enough of Dr. Kim, she’s beyond great. Everyone was positive and reinforcing. My only regret is that I hadn’t done this sooner!”

58 Patient Testimonials 34 Year old female Date of surgery: 8/1/2011
“I’m feeling fantastic. The surgery has been a success. So far I’ve lost almost 90 pounds, and it’s the most amazing thing I’ve ever experienced. Life changing. Besides my kids it’s the most wonderful thing I’ve ever done.”

59 Patient Testimonials 51 Year old female Date of surgery: 9/26/2011
“Extremely thankful to the staff and couldn’t be happier with the surgery! I’ve lost 60 pounds. I no longer need insulin, and my hypoactive thyroid is now dormant.”

60 Post-op Care and Follow-up
Lisa C. Luz RN, MSN, CBN

61 Follow-up: Initial Post-op visits 2 weeks, 6 weeks, 3 months
Gastric Band: adjustment visit every 3-6 weeks Labs: every three months x1 year; then every 6 months Annual appointments after 2 years with Medical Team Plastic Surgery Pregnancy Lifetime Dietary, Behavior Modification, and Support Groups available to every patient!

62 Newsletters, website, email and telephone follow-up
Weight Loss Surgery Post-Op Care and Follow-up Life long commitment Support group Nutrition classes Exercise guidance Guideline literature Office visits Newsletters, website, and telephone follow-up

63 Results of Bariatric Surgery
Improvements in overall health Improvements in quality of life Longer life expectancy Resolution/Improvement of: Type 2 Diabetes Asthma High blood pressure Skin problems Sleep apnea Bone and joint disease Cancer Infertility Heart disease Fatty liver disease Heartburn Urinary incontinence

64 Some Surgery Truths Surgery is ONLY a tool Surgery is NOT for everyone
Surgery HAS risks Surgery is NOT a cure but rather a treatment Surgery does NOT FAIL the patient, the patient fails the surgery Long term effort and follow up ARE ESSENTIAL for success

65 Patient Successes

66 “Rather than feel anger or revulsion toward this person, my first obligation, especially if I am in the helping professions is to understand him or her: to gain insight into what it is like to be him or her; to imagine and to interpret the world from his or her perspective of experience…” Source: John Banja, PhD Obesity, Responsibility, and Empathy, The Case Manager, Nov/Dec 2004

67 Thank you! Questions / Comments

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