Central Valley Bariatrics' Patient Handbook

CENTRAL VALLEY BARIATRICS

PATIENT HANDBOOK

Your Guide to Successful and Healthy Weight Loss surgery:

Duodenal Switch Sleeve Gastrectomy Revisional Weight Loss Surgery

Ara Keshishian, MD, FACS, FASMBS www.dssurgery.com 818-812-7222

Central Valley Bariatrics – Patient Handbook

TABLE OF CONTENTS Introduction ...... 2 Normal Anatomy ...... 3 Weight loss Surgical Options...... 4 Sleeve Gastrectomy ...... 4 Gastric Reduction Duodenal Switch ...... 5 Gastric Bypass- Roux-En Y ...... 6 Adjustable Gastric Banding ...... 6 Comparison Table for Weight Loss Surgical Options ...... 7 Complication Associated With Weight Loss Surgery ...... 8 Out of Town Patient Protocol ...... 9 Pregnancy After Weight Loss Surgery ...... 9 Pre-Operative Section ...... 11 6 Weeks Before Surgery ...... 11 2 Weeks Before Surgery ...... 12 10 Days Before Surgery ...... 12 Two Days Before Surgery ...... 13 One Day Before Surgery ...... 13 Morning of Surgery...... 13 Hospital Section ...... 15 Post-Operative Section...... 17 Bariatric Diets ...... 19 Nutrition Section ...... 20 Sample Vitamin and Protein Schedule ...... 22 Vitamin Section ...... 23 Shopping Guide Suggestions ...... 23 Intestinal Issues (Associated with the Duodenal Switch) ...... 24 Hair Loss and Skin Changes ...... 25 Vitamins-Benefits-Deficiency ...... 27 A Lifetime With Your Duodenal Switch ...... 28 Weight loss Surgery Quiz ...... 30 Bariatric Surgery Contract ...... 32 Teaching Guidelines ...... 33 References ...... 34

Central Valley Bariatrics – Patient Handbook Introduction:

Dear prospective patient,

This workbook is provided as an educational tool for an individual considering weight loss surgery for treatment of obesity and its associated illnesses. It is by no means an all-inclusive source of information. It is a supplementary source to your formal consultation that you will have with me in the office.

This represents my opinion as supported by published scientific data. It is critical that any patient considering weight loss surgery, to research with due diligence, by investigation the procedures being considered. I also strongly advocate for patients to seek second opinions.

The order in which the surgical procedures are discussed is to only facilitate the flow of the information and not based on outcomes. The details of the each procedure and their relative outcomes are discussed in detail.

A copy of this is also available on our website at www.dssurgery.com.

Central Valley Bariatrics – Patient Handbook

Normal Anatomy

Digestion begins in the mouth with the chewing of food and the addition of salivary secretions. The esophagus carries the swallowed food to the stomach.

In the stomach certain secretions are added to begin the breakdown of the food in the stomach. The role of the stomach is to prepare the food for delivery to the small bowel where almost all the absorption takes place. The Pylorus is the gatekeeper of the stomach, not letting food pass into the small intestines until it has been optimized for absorption, by the added secretions of the stomach.

When food enters the small intestines, within a short distance of the pyloric valve, bile and digestive enzymes from the liver and pancreas are added. From this point on, over the entire length of the small bowel all the absorption of the carbohydrates, fat and protein is taking place. The nutrients absorbed are then taken to the liver, where they are converted to either energy to be utilized at that time, or is processed to be stored away for later use. There are a number of very intricate and complex biochemical pathways that dictate what is absorbed at what rate, and how the absorbed is stored. It is also through this process where minerals, vitamins, and micro and macronutrients are absorbed. Vitamins, specifically fat-soluble vitamins, are very closely dependent on fat absorption.

In the Colon (large intestines) water is absorbed, bacterial fermentation takes place and feces is formed.

Central Valley Bariatrics – Patient Handbook Weight loss Surgical Options Sleeve Gastrectomy

With the sleeve gastrectomy (lap. sleeve gastrectomy, vertical sleeve gastrectomy) approximately 75-80% of the outer curvature of the stomach is removed. This results in reducing the size of the stomach, not only restricting the amount of food that may be eaten at each meal, but also reducing the stimulation for hunger, since the a large portion of the cells of the stomach that secrete Ghrelin is also removed.

Ghrelin is a hormone primarily produced by the cells lining the fundus of the stomach that stimulate hunger. The pancreas also has a portion of Ghrelin producing.

The pylorus is retained and all normal digestive actions in the stomach take place just as in a normal anatomy. There is no change in the arraignment of the bowels.

All food, calories and nutrients that are accommodated in the stomach are all fully absorbed.

This procedure can be classified as a restrictive procedure, since it only causes restriction of the food volume.

The functional end result of the sleeve gastrectomy is a scaled version of the normal stomach. Almost everything that takes place in normal intact stomach, takes place in a sleeve stomach in a smaller scale. Sleeve Gastrectomy can be the first stage of the two-stage duodenal switch operation.

Central Valley Bariatrics – Patient Handbook

Gastric Reduction Duodenal Switch

The outer curvature of the stomach is removed, reducing the size of the stomach, therefore restricting the amount of food that may be eaten at each meal. The pylorus is retained and all normal digestive actions in the stomach take place just as in a normal anatomy. This segment of the operation is identical to the sleeve gastrectomy described previously.

The small bowel has three segments: Duodenum, Jejunum and Ileum. First, the Duodenum is divided. One end (Alimentary Limb) carries food down to the Ileum which is connected to it. The other end (Biliopancreatic Limb) carries Liver and Pancreas secretions (“digestive juices”) down the Jejunum and joins the Ileum to form The Common Channel; where fat and protein are absorbed.

The Alimentary Limb carries only food from the stomach, as it is attached to the pyloric valve and a segment of the duodenum. The Biliopancreatic Limb (BPL) carries the biliary secretions (from the liver) and the pancreatic enzymes (from the pancreas), also known as the digestive juices.

Carbohydrates/sugars are absorbed through most of the GI tract, where food is exposed to the mucosa of the small bowel (Alimentary limb and the common channel).

Fat and protein is primarily absorbed in the common channel. The common channel is where the food from the alimentary limb and the secretions of the biliopancreatic limb mix. This is where the food, as brought down by alimentary limb, is mixed with the biliopancreatic secretions brought down by the biliopancreatic limb and form the common channel. This configuration limits the absorption of the fat and the protein. There are both benefits and some potential down sides to this. One of the benefits of the Duodenal Switch is the decreased caloric absorption. This is primarily due to a decrease in functional absorptive surface area of the small bowel. This is one of the major reasons why the duodenal switch operation provides the best long-term success of the all weight loss surgical procedures being offered. 1

The colon continues to function as in a normal anatomy. There is no blind loop in the duodenal switch operation.

The duodenal switch (DS) operation has also been referred to as, gastric reduction duodenal switch (GRDS), and Biliopancreatic diversion- duodenal switch (BPD-DS). The nomenclature of the procedure has evolved over the years.

Central Valley Bariatrics – Patient Handbook

Gastric Bypass- Roux-En Y

Gastric Bypass operation is most commonly known weight loss surgery procedure. In the gastric bypass procedure (RNY gastric bypass) a small stomach pouch is created. This is then connected to a short segment of the small bowel. The food directly enters the esophagus to the stomach pouch and then the small bowel. It completely bypasses the stomach. This results in a number of nutritional deficiencies, including B12, Iron deficiency, protein deficiency in addition to complication such as dumping syndrome (nausea, vomiting, and dizziness) ulcers, and weight regain.

Adjustable Gastric Banding Adjustable Gastric banding (AGB) is a device (foreign object) that is surgically inserted around the upper part of the stomach. There is an adjustment port that is placed under the skin for future access. This access port is not visible, but can be felt under the skin most of the time. The weight loss mechanism is restricting the amount of the food that can be consumed at any given time. Any excessive food intake will result in vomiting, or regurgitation of the food into the esophagus. The AGB requires significant, intense patient participation for any substantial long-term weight loss. Even with most compliant patient, the long-term weight loss result of AGB is the worst of all surgical procedures. There is published data that advocate limiting use of adjustable gastric banding since it has a very high complication rate, and up to 24% of the patient will require their band be removed 23 Any reduction of the food consumed by a patient who had the AGB is accomplished by the limited size of the stomach pouch and not by a reduction of the Ghrelin that may partially control appetite. It is also important to remember that if for any reason, the band is removed, the weight lost will return. Weight regain can be addressed by the band removal and performing surgical procedure, such as the sleeve gastrectomy, or Duodenal switch operation.

Central Valley Bariatrics – Patient Handbook

Comparison Table for Weight Loss Surgical Options Sleeve Gastric Reduction Adjustable Gastric Gastric Bypass Gastrectomy Duodenal Switch Band (RNY)

Modality of Restrictive Restrictive Restrictive Restrictive Malabsorptive Weight Loss 4-8 oz. stomach 1-3 oz. stomach Malabsorptive 4-8 oz. stomach 1-3 oz. pouch Description Sleeve gastrectomy, An adjustable silicone - A very small pouch of Sleeve gastrectomy, Pyloric valve constricting band is place fundus connected to a Pyloric valve functional. functional. completely around the limb of small bowel. The biliopancreatic top part of the stomach Pyloric Valve bypassed. secretions are kept creating a very small separated from food to pouch. limit absorption until the last 50-100cm of small bowel.

Long term 60-70% Excess 40% Excess weight loss 60-70% Peak results Best. 70-80% Excess success weight loss 18-24 months. weight loss maintained

Complications Reflux, inadequate 89% of patients have at 68.8% “continued” Fat-soluble vitamin weight loss, non- least one side effect. vomiting, 42.7% deficiency- avoided with resolution of some Nausea and Vomiting plugging of the gastric supplements, plus a of the 51%, Heart Burn 34%, pouch outlet. 12% normal healthy diet. comorbidities. Need for re-operation or stenosis & 12% Protein malabsorption with band removal as high as ulceration, with over all healthy well balanced diet 25%. stomach complication is far less common than 20%. Patients develop seen in RNY patients with Dumping Syndrome stenosis or who only (76%) with no benefit consume high to weight loss. sugar/calorie drinks.

Opinion Preferred over the Actually not a new idea Frequent complications Technically a difficult band. However, and was abandoned years and hospital visits. operation to perform. long-term weight ago. Some top surgeons Division of the post loss is questionable. in the field feel its pyloric duodenum is a resurgence will give difficult step and could be bariatric surgery a bad dangerous with an reputation. inexperienced surgeon.

Long Term Patients tolerate Extremely poor diet. Significant dietary Patients tolerate “normal” Dietary “normal” diet. Patients are not able to restriction. Meat diet. Modification consume any solids since intolerances Patients it plugs the opening at resort to high calorie the restriction site of the drinks because silastic ring. “regular” meals not tolerated. Nutritional Multi-vitamin, Iron, Multi-vitamin, Iron, Multi-vitamin, Iron, Multi-vitamin, Iron, Supplement Calcium, Calcium, Magnesium for B12, Calcium, Calcium, Magnesium, Magnesium for life. life. Magnesium for life. Vitamins A, D, E & K for life. Summary Restrictive Restrictive procedure A restrictive procedure The best surgical solution procedure with no with no long-term rendering a patient to a available for treatment of long-term studies. studies. Preliminary very limited diet, with morbid obesity. Allows a Allows for normal results disappointing. significant patient to lead a normal diet with smaller complications. Long life with normal dietary volume. No term results acceptable. intake of meals in smaller dumping, vomiting, volume, without the side plugging, etc. effect of dumping syndrome, continued vomiting, plugging, etc.

Central Valley Bariatrics – Patient Handbook Complication Associated With Weight Loss Surgery

There are potential complications associated with any surgery for the obese patient. The overall complication rate of surgery is between 5-10%. Complications are listed below but are not limited to this list. Complications range from the simply treated urinary tract infection to possible re-operation for a leak at a suture line. Some of the complications may not surface for months after surgery. The mortality rate for surgery is approximately one percent (1-2 in 200 patients).

 Pneumonia  Atelectasis (collapsed lung)  Deep venous thrombosis (DVT, a deep vein blood clot) (may occur weeks after surgery)  Pulmonary embolism (PE, a blockage of an artery in the lung) (may occur weeks after surgery)  Stroke  Urinary tract infection (UTI)  Phlebitis (IV site irritation)  Wound infection and dehiscence (opening of the incision and the skin)  Hernia  Sepsis (overwhelming infection)  Abscess formation  Bleeding  Splenic injury, possible need for splenectomy (removal of the spleen).  Biliopancreatic tree trauma (the ducts from the liver and pancreas)  Leak from the suture or staple lines  Injury to the bowel resulting in leaks  Injury to solid organ (liver, spleen, Kidney, pancreas, diaphragm, etc.)  Bowel obstruction due to scar tissue forming around the small bowels possibly necessitating surgery to open the obstruction  Inadequate or excessive weight loss, necessitating re-surgery, possibly years later.

Any of the above mentioned might require prolonged hospitalization, need for reoperation, extended recovery and in some cases even death.

Central Valley Bariatrics – Patient Handbook

Out of Town Patient Protocol

We have a very detailed and structured program for all our patients including those traveling long distances. Our goal is for the out-of-town patient to receive continuity of care during the critical post-operative period. This is vital to the progress of the patient as it reduces the chance of complications and promotes excellent long-term success.

The patients who are farther than one hour from the hospital will need to stay reasonably close to the facility during the immediate 7-10 days following discharge. You will need to arrange for lodging and transportation during your stay. Hotels can be reserved through websites such as hotels.com . Another alternative is to rent apartments through airbnb.com on very short-term basis. Also note that transportation expenses can be manages by using services such as uber.com .

Weight loss surgical procedures are major operations. A patient will need a support person after they are discharged from the hospital. It is most important during the postoperative period for the support person to assist with activities of daily living and hygiene. Out-of-town patients will need a support person that is both emotionally and physically capable to assist after surgery. Depending on your preference, the support person may or may not stay in the hospital room with you. However, the support person is required after discharge to stay with you in the hotel/home setting.

After you are released to return home, we will work closely with your primary care physician to maintain continuity of care. Due to the nature of weight loss surgery, it is essential to your wellbeing that a long-term working relationship between doctors is established and maintained.

Pregnancy After Weight Loss Surgery

Pregnancy: Maternal malnutrition may impair normal fetal development. All patients who are losing weight at a rapid rate are in some ways suffering some form of malnutrition. We ask that you prevent pregnancy for at least 18-24 months after your surgery or until cleared by your surgeon. This is the time for rapid weight loss and is not conducive to maintaining the health of a fetus. We ask that you use 2 forms of birth control. Examples: barrier and chemical forms, or barrier and pill forms of birth control (once the doctor has released you to start taking birth control pills). Many morbidly obese patients also have fertility problems, but after weight loss surgery they will frequently be able to become pregnant once the weight loss has begun.

Pregnancy should be postponed until your weight has become stable for some time. After the initial 18-24 months, your meal portions should become normalized and your nutritional status becomes adequate to sustain health for a growing fetus. Women who become pregnant after weight loss surgery should receive specific attention from the surgical care team along with their obstetrician. We will need to know the name and address of you OB/GYN so that we may send them an information packet to inform them as to the procedure you have undergone and what to monitor. Many patients have become pregnant after Duodenal Switch without any difficulty, but

Central Valley Bariatrics – Patient Handbook they do need to be watched more closely. They also need to make sure they are taking all necessary vitamins, minerals and proteins.

 Folic acid, one of the B vitamins, has been found to prevent neural tube defects (NTD). Increased intake of folic acid reduces the risk of NTD such as anencephaly and spina bifida (exposed spinal cord) by as much as 50% to 70% if women take enough of it before conception and in the early months of pregnancy. Take your multivitamins containing 400 mg of folic acid (the standard in most multi-vitamins) every day.  Vitamin A is also important to prevent blindness in the fetus. Vitamin A levels should be drawn prior to becoming pregnant and during the pregnancy.  Protein is important in all structural formations of the fetus and the mother needs to increase protein intake to around 130 grams daily. Nearly all tissue formation involves the necessity of protein.  Vitamin D can be protective of the fetus against autism, schizophrenia, asthma and diabetes to name a few. Therefore, you do not want to go through a pregnancy with a deficiency.

DO NOT GET PREGNANT UNTIL YOUR WEIGHT HAS STABILIZED AFTER 18 TO 24 MONTHS.

Please notify the office immediately upon learning of a pregnancy.

Use at least TWO (2) forms of birth control during the first 18 to 24 months!

Depo-Provera Contraceptive Injection may cause you to lose stored calcium in your bones and are known to cause significant weight gain. Our recommendation is to avoid it.

Central Valley Bariatrics – Patient Handbook

Pre-Operative Section

6 Weeks Before Surgery

Stop All Smoking At Least 6 Weeks Prior to Surgery: Smoking can increase your risks of complications such as deep venous thrombosis (blood clots in the legs), which also increases risk of pulmonary embolism (blood clot to the lungs), pneumonia, and atelectasis (collapsing of the tiny air sacs in the lung). Nicotine patches may be used until 2 days prior to surgery.

Stop Drinking Alcohol: You will want to go into surgery with a healthy liver. The liver is very sensitive to toxins after surgery, partially due to the rapid weight loss. It is, therefore, imperative that you refrain from consuming alcohol of any type before surgery and for at least 2 years post-operative. You will continue to be alcohol sensitive for an extended period of time due to the limited absorptive properties of this procedure (liver affected, intoxicated faster & longer). Alcohol after the second year can be tolerated in small quantities, but avoid operation of vehicles or machinery with alcohol use.

Start Reading Food Labels: Become familiar with the content of protein, fats, vitamin levels, and lactose. Pay close attention when reading a label as to what constitutes a “serving”. Is a serving one or two scoops, pills, oz., cups?

Start Taking Daily Vitamins: Minerals and Vitamins are important in all functions of the body, down to the individual cells. Let’s start getting your cells healthy before surgery! After surgery the vitamin requirements will change.  1 multi-vitamin  1500 mg. of calcium citrate divided into 3 doses. Citracal (or a generic equivalent like Costco’s Kirkland Calcium Citrate) is easy to find and known to work well. When taking calcium you will need to divide it into doses of 500 mg with at least 2 hours between doses. The body will only absorb around 500-600 mg of calcium at a time. If you do not divide the doses through the day, you will not absorb the correct amount.  600-800 mg Magnesium Glycinate divided into 3 doses. Magnesium and calcium rely on each other and should be taken together for best absorption. If you have problems with constipation, magnesium citrate (pills/capsules) may be substituted as it will help loosen the stool.  50,000 IU’s Vitamin D taken ONCE A WEEK (or 5,000 IU’s per day).

You will need to take vitamins and minerals for the rest of your life. What vitamins you take will be adjusted as needed by your general health and lab values. The limited absorption component of the surgery affects the absorption of vitamins. Calcium, magnesium and vitamin D are important to maintain strong and healthy bones. Refer to Vitamin Section-Shopping Guide to help you find the needed supplements.

Home Care: Give some thought to your living environment. Climbing stairs may be difficult after surgery and you may need to move to one level of your home. For a few weeks after surgery many people find it difficult to sleep lying flat. A recliner could be useful. Extra pillows or a way to prop your head up in bed may be needed. Items that could be helpful for some people are lift recliners, walkers and bedside potty chairs. They can be rented from a medical supply store.

Central Valley Bariatrics – Patient Handbook

Select a Support Person: Make sure you will have a support person during your first several days at home. The support person should be both emotionally and “physically capable” to assist you after surgery. Depending on your preference, the support person may or may not stay in the hospital room with you. However, the support person is required after discharge to stay with you in the motel/home setting.

Out of Area: Any patient living more than an hour away from the hospital needs to discuss with the surgeon if they may return home after surgery or if they will be required to stay in the immediate area. Please see the section for “Out Of Town Patient Protocol”.

Exercise: Now is a great time to get your body prepared for surgery. You will be expected to start walking every 4 hours after surgery. The sooner you start exercising the easier it will be. We also want you to take care and insure that you do not injury yourself prior to surgery. Start moving more than normal. Walking is the best way to prevent deep venous thrombosis, pulmonary embolus and improve your lung and heart function. This increase in exercise will help prevent complications.

2 Weeks Before Surgery

Stop Taking Birth Control Pills & Depo-Provera: Patients on birth control pills or Depo- Provera shots need to stop taking these forms of birth control for at least 2 weeks prior to surgery, or as the doctor orders. Please be sure to inform us if you are taking either of these types of birth control. The above form of birth control increases your chances of forming deep venous thrombosis and/or pulmonary embolus. You will need to ask the doctor when you may start taking the pill or the shots for birth control after surgery.

You must not become pregnant before surgery. Do not neglect the next step!

Start at Least TWO (2) Forms of Birth Control: From the point of stopping the pills or shots until your weight stabilizes and your doctor says it is appropriate for you to stop using two methods of birth control (i.e. condoms, diaphragm, cervical cap, contraceptive sponge…) It is imperative that you DO NOT become pregnant during the weight loss period after surgery. It could be detrimental to you and the fetus. You will not have adequate nutritional status needed to sustain a healthy fetus and this could lead to birth defects.

10 Days Before Surgery

Stop Taking: Aspirin, alcohol, all forms of tobacco, vitamin E, herbal medications, marijuana, St. John’s wort, ginkgo biloba, ginseng, kava-kava and valerian root. These have blood-thinning properties or are known to interact with anesthesia; therefore should be stopped at least 10 days prior to surgery. Discuss with Doctor anything else you may be taking, prescription or not.

Do Not Shave: The operative field (abdomen) 10 days or more before surgery. Shaving can cause microscopic abrasions to the skin, which can increase risk of infections.

Central Valley Bariatrics – Patient Handbook Pre-operative Exam: You will need to make an appointment 1-7 days prior to your surgery date. Your medication/supplements and surgical plan will be reviewed. Any additional test, health concerns or questions will be addressed at this time.

Please bring to this appointment:

 A detailed list of all your medications and supplements. Including strength, dosages & times per day  Your Sleep Apnea Machine (C-Pap)  Driver’s License  Insurance Card  Any requested items not yet supplied to office.

Hospital Registration: After the pre-operative exam, you will be directed to the hospital for registration. There, you will need your insurance card and driver’s license. The hospital may require co-payments at this time. If you have not had your pre-operative blood work, x-ray or EKG done, these will also be done at this time. A nurse will discuss with you the pre-operative preparation as well as the time and place of check-in on the day of surgery. The anesthesiologist may also come and speak with you at that time to ask about your medical/surgical history and look at your airway.

Two Days Before Surgery  Full liquid diet only – creamy soups, milkshakes, liquid protein shakes, ice cream and pudding  Drink plenty of water  No alcohol- Wine, beer, and spirits are not clear liquid diet.  Stop using all forms of nicotine

One Day Before Surgery  Clear liquid diet only – coffee, tea, broth, Jell-O, clear sodas, NO MILK OR ORANGE JUICE  Drink plenty of water - all day long to prevent dehydration  NO ALCOHOL  ‘Before’ 3 p.m., drink one full bottle of magnesium citrate. This “beverage” may be purchased at any drugstore without a prescription. It is known to be more delicious served cold. Once consumed it is advisable to stay within close proximity of bathroom facilities  Shower - with attention to scrubbing all parts of your body, especially in any skin folds  Do Not Shave the operative field (abdomen)  Medications – to be discussed with your surgeon  After midnight – NOTHING to eat or drink, including the morning of surgery

Morning of Surgery  Shower again with close attention to scrubbing all parts of your body, especially skins folds, shampoo hair. If you have long hair, please pull it back in a ponytail low on your neck  NO lotion or talc powders after showering

Central Valley Bariatrics – Patient Handbook  Do Not Shave operative field (abdomen)  NOTHING to eat or drink  Medications – to be discussed with surgeon

Items to bring to the hospital: Your C-Pap machine. You may also want to bring a few items to the hospital for your convenience and comfort. Some things you may want, your cell phone, bathrobe, slippers, sanitary pads (stress may change your cycle), clothing to wear home (open front top, elastic waist pants and shoes), Chap Stick, pillow, glasses, toiletries such as shampoo, shower gel or lotions, toothpaste and toothbrush, hairbrush/comb, electric razor, and your SUPPORT PERSON! Do not forget your Patient Handbook.

Do not bring valuables to the hospital! You will not be able to wear jewelry (including wedding rings) or contact lenses during the surgery so it is best if they are left at home. There is a significant amount of swelling that takes place after surgery and we do not want to cut off rings that may be compromising blood flow to your fingers.

Central Valley Bariatrics – Patient Handbook

Hospital Section

Your hospitalization will depend on the type of procedure you are having. In general, Sleeve gastrectomy patients may stay overnight or be discharges the same day. Duodenal switch patients will require 2 days overnight. Revisions from Gastric Bypass may be in the hospital for 3 days. Adjustable band revisions to the Sleeve are frequently an overnight stay, and adjustable band to the duodenal switch are in the hospital for 2 days.

At the Hospital for Surgery: Please report to the hospital as directed per your pre-operative nurse. You will then be prepped for surgery. Once surgery begins, it can take between 45 minutes for 3 hours, based on the surgery that you are having. The surgeon will come update your family when your surgery is over. You will stay in the recovery room 1-2 hours until you are awake and stable enough to be transferred to your private room. If you should have to go the ICU, family members may visit but not stay.

After Surgery: In some cases (duodenal switch and revisions from the gastric bypass) you may have 2 drains placed. These are clear tubes that are coming out of your abdomen. In the majority of cases the drains are removed prior to the discharge from the hospital. You will also have an abdominal binder on to keep the incision secure and prevent stretching of the incision. You will need to wear this throughout your hospital stay, except when showering, and for the first 6 weeks after surgery. You may also have a Foley catheter, nasogastric tube, an oxygen mask and two IVs.

In addition, you have a PCA machine (Patient-Controlled Analgesic pump-“pain pump”). You will be shown how to use this button to control your pain. Because this is a major surgery, there will be some discomfort that the pain medicine will not be able take away. However, you need to keep your pain level tolerable so that you can use your incentive spirometer (breathing exerciser), cough, and deep breathe (all important to prevent pneumonia and atelectasis), and walk after surgery. If the PCA is not controlling your pain, please let the nurses know.

You may also have nausea. It is common when having surgery on the stomach and after anesthesia for patients to become nauseated. Again, please let your nurses know and we can give you medications to help.

You will be getting up to walk 4-5 hours after surgery: If you would like to get up sooner, you may. The more you are up moving and walking the better you will feel. Increase movement will decrease your risk of complications such as blood clots and pulmonary embolus. You also need to start using your incentive spirometer (breathing exerciser) and coughing and deep breathing at least every hour while you are awake the entire time you are in the hospital and for the first month after surgery. This is an important task that your support person can help remind you to do.

Day 2 Through Discharge: The second day will be filled with more walking and breathing exercises. It will hurt to get up, but the more you move the easier it will get and the less pain you will have. Walking can also help relieve gas pains and soreness of your back.

Central Valley Bariatrics – Patient Handbook You may experience nausea and odd tastes in your mouth. You may have ice chips. Your surgeon may have you drink a blue-colored drink in the afternoon of the second day. Drinking the blue drink can give us information about the possibility of leaks at the stomach and duodenal suture lines. You may start eating a clear liquid diet then advance as ordered (Bariatric Diet Schedule follows). It is your responsibility to know your bariatric dietary guidelines within this handbook and do not eat any food brought to you that is not on the “Bariatric Diet” Schedule.

You will be showering in the hospital, usually the second or third day depending on when your surgeon feels you are ready. During your shower you should get your incision wet and wash it with soap and water, then dry it well. There may be drainage from the incision and you may need gauze dressings to cover it. The nurses will help you in the shower and with your dressing.

If at any time you experience shortness of breath, pain in your legs, severe or sharp abdominal pain, bleeding or any unusual symptoms, you need to tell the nurse IMMEDIATELY!

Central Valley Bariatrics – Patient Handbook

Post-Operative Section

Hospital Discharge: You will receive a discharge instruction form when you leave the hospital.

Follow-up Appointments: On the day of discharge, the doctor will let you know when he needs to see you (usually 7-10 days post-operative). You are responsible for calling the office to set the date and time.

Usual Follow-up Appointment Schedule Unless Otherwise Directed by Surgeon (*When Labs Will Be Ordered) 7-10 Days 9 Months 1 Month 12 Months* 3 Months 18 Months 6 Months* 2 years* Yearly thereafter* Fasting for Labs Not Required

Medications: You will receive needed prescriptions and be told which preoperative medications to take when you leave the hospital. You may have been taking other medications prior to your operation, but after your discharge from the hospital take only those recommended by your surgeon. The doctor should clear over-the-counter medications before starting.

Do Your Breathing Exercises: Continue to use the incentive spirometer you were using in the hospital. Do 10 repetitions, 4-6 times a day.

Incision Care: If you do have a dressing over your incision, remove it and wash over the incision with soap and water in the shower daily, dry it well after you shower. The general principal is to keep it clean and dry. In the beginning: Do Not Shower While Alone. The incision should be left open to air to prevent infection. There may be some drainage from the incision; it should be clear or pink and, in this case, you may put clean gauze dressing over the incision. If there is any drainage other than clear or pink such as green, white, yellow, or redness around the perimeter of the incision or foul smell, CALL THE OFFICE IMMEDIATELY.

Your incision may open slightly and leak or ooze fluid. Do not panic. If the oozing is new or your incision opens, call the office. Note the color of the fluid, color of the skin around the incision site, if you have an elevated temperature, the amount of drainage, odor (if any), and consistency of the drainage. If the incision opens, note in inch-increments how much it has opened. Do not submerge your incision in a bathtub or pool for 3 weeks unless cleared by your surgeon. Take your temperature every a.m. and p.m. for the first month after surgery.

Drainage Bulbs: IF you are sent home with a drain, do not cut the tubing on drain bulbs. Bulbs need to be squeezed after draining and the top closed while the bulb is being squeezed for adequate suction. Drainage may be pink/red to yellow/clear fluid with clots.

Abdominal Binder: Wear the abdominal binder for at least six weeks while you are up and about. This helps to keep your incision secure while it is healing. Wearing a thin undershirt between you and the binder can help with comfort.

Central Valley Bariatrics – Patient Handbook

If you have any fever (101 degrees Fahrenheit or higher) with chills, nausea, vomiting, bloody diarrhea, increase in pain, foul-smelling or purulent, pus- like drainage from the incision, shortness of breath, chest pain, calf pain and/or tenderness call the office IMMEDIATELY! (818) 812-7222 If you have any questions, call the office. If you believe, you have a LIFE THREATENING emergency call 911.

Restrictions – You should not drive for 2-3 weeks post-op due to the chance of an accident and the steering wheel causing damage to your incision. No pulling or lifting (greater than 15 pounds) for 6 weeks after surgery. No abdominal exercises, until cleared by your surgeon- usually around 10-12 weeks.

Returning to Work – Most patients will be off work for 4-6 weeks. Depending on the job, some patients may go back to work part-time around the 4th week to ease back into a work schedule

Exercise – Continue walking at least 4 times a day. Start with short walks and increase your distance. Walking is the best postoperative exercise and since you have been doing laps around the nurse’s station in the hospital, you are all geared up! Walk around your home initially and then go outside adding both time and distance to each walk. You will feel fatigued at times. Listen to your body. Learn to push yourself gently. NOTE: Take your water bottle with you on your walks and continuously sip, sip, sip. While exercising you need to pay attention to your hydration. You will need to take in increased amounts of fluid if you are perspiring. Adequate fluid intake is essential to prevent and fight dehydration that could lead to possible kidney damage. Of course, water is your fluid of choice and must be continually sip, sip, sipped all day.

When you are cleared to start abdominal exercises, listen to your body. Start slowly; if it hurts give your body more healing time. The average Duodenal Switch patient will lose an average of 100 pounds. Exercise will affect the weight loss tremendously. If a patient has 200-300 pounds to lose, the surgery may not be as successful unless exercise becomes an integral part of the program.

If you want to feel good, maintain and build muscle mass, you must exercise. Exercise also helps to keep your bone tissue dense and strong, maintains weight loss, increases strength and balance, boosts energy, and improves quality of life. Research has shown that the patient who decreases sugar intake and exercises 3 or more times a week for at least 30 minutes has a 22% increase in their weight loss.

Do not cheat your body of this important aspect of exercise and weight loss. You will need to make a lifelong commitment to exercising!

Walk! Walk! Walk! - Sip! Sip! Sip!

Central Valley Bariatrics – Patient Handbook

Bariatric Diets Please remember the following principals as a healthy dietary guide: o Water o Protein o Everything else (carbs and fat) o Avoid artificial sweeteners o Avoid carbonated drinks o Stay “close to the dirt” the less processed food the better it is for you o Eat Less More Often (ELMO) Diet.

Allowable food items During Hospital Stay You may also be discharged from the hospital on one of the following diets. Do not vary from your discharge diet until progressed by your surgeon.

CLEAR LIQUID FULL LIQUID DIET SOFT DIET RESTRICTIONS DIET (BARIATRIC 1) (BARIATRIC 2) (BARIATRIC 3) (All diets)

(2-3 ITEMS PER (2-3 ITEMS PER (2-3 ITEMS PER MEAL) MEAL) MEAL)

Gatorade Yogurt Eggs, soft boiled or No chunky, crispy or (1) per day (NO FRUIT CHUNKS) scrambled fried foods

Apple juice Creamy/blended soups Soups No milk (1) per meal (NO MILK) Low fat blended

No Bread Popsicle Small amount of Applesauce (1) per meal crackers if nauseated No Spicy Foods Tea and Coffee Oatmeal Cream of Wheat No Very Hot/Cold Snapple Malt-O-Meal Food or Drinks

Broth Applesauce No carbonated beverages Protein supplement

SMALLPORTIONS SMALL PORTIONS SMALL PORTIONS ONLY! ONLY! ONLY!

May eat food from this May eat foods from May eat foods from all column only both the Bariatric 1 & three columns 2 columns

With few exceptions, all these restrictions are limited only to a certain time frame. Most patients are able to resume a normal healthy diet within a few weeks of surgery.

Central Valley Bariatrics – Patient Handbook

Nutrition Section

Dehydration is the Most Common Problem After Surgery: Constant sipping of water or other acceptable fluids is required. You need to drink 48-64 ounces of fluids daily! Do not gulp of drink large amount of fluids at one time. This may make you vomit. Your stomach size is too small for gulping. You should be drinking ½ cup of water for each hour you are awake. If you wake through the night, sip on water. Keeping hydrated is your first priority. You want to avoid a return visit to the hospital because of dehydration. You want your blood to be well hydrated to prevent blood clots. Symptoms of dehydration include fatigue, dark-colored and/or strong-smelling urine, dry lips and dryness inside the mouth, light-headedness when standing, dizziness, and fainting. Call the office immediately if you experience any of these symptoms. The best treatment is prevention.

Hints for drinking water: If having trouble drinking plain water, try adding a squeeze of lemon/lime, a splash of juice, or Gatorade. You may also want to try water at different temperatures. No carbonated beverages. Always keep your water within reach.

Eating After Surgery: You should not drink 30 minutes before and after a meal. We want you to start your meal with an empty stomach. Your goal will be to eventually eat 30 grams of protein per meal. Remember, your stomach size is only 4-6 ounces (1/2 to 2/3 of a measuring cup at MAXIMUM STRETCH). You should only be able to eat 1-2 teaspoons of food at a time or drink 1-2 sips at a time. You do not want to stretch your stomach. Visualize an egg…that is the approximate size of your new stomach. Eat slowly and allow at least 30 minutes or more to eat and chew each bite thoroughly. Stretching your stomach can cause suture lines to break or to slow your weight loss. Take small bites putting your fork down between each bite. It will usually take a minute or two before your stomach feels full. When you eat too fast, or overfill your new stomach, it can lead to vomiting. It may be helpful to use a baby spoon so you eat slowly with small bites.

If nauseated try eating something such as a cracker, a teaspoon of peanut butter or yogurt between meals. Lack of protein can be associated with nausea. Your foods should be soft, lactose-free, low fat with low sugar content and limited carbohydrates, as they will slow your weight loss because they are easily absorbed right from the mouth. After surgery for the first couple weeks avoid non-moist meats, anything fried or crispy, raisins and nuts.

80-100 Grams or More of Protein a Day: Most patients will not be able to eat anything close to 80 grams early on. The key is to continue to focus on proteins and increase the amount over time. Protein drinks will help you reach your goal. With your new stomach size you will want to mix a full serving of protein powder in only 3-4 oz. of water (rice or almond milk can be used for a creamier shake). The body absorbs approximately 30 grams of protein at a time. Drinking a protein shake in the morning, eating protein foods through the day, then a protein shake in the evening will help you achieve your goal. Protein shakes should be consumed within a ½ hour of mixing and should not be mixed in hot liquids (warm is ok) as high heat kills the protein. I would be satisfied with a patient taking 30grams of protein per day in 30 days, 60 grams/day in 2 months, and up to 90 grams/day by 3 months.

Meat may take some time to be tolerated. Most people tolerate meats after a few months. Anything “dry” may cause discomfort – beef, white chicken or turkey may need a low-fat sauce

Central Valley Bariatrics – Patient Handbook with it. Healthy Choice Deli Slices – low-fat ham, chicken or turkey are well tolerated. Imitation crab, shrimp and fish are generally well tolerated. Remember common sense works!

Protein Reminder: Protein helps to fight infection and dehydration. If you do not take in adequate protein your body will start to breakdown its own source of protein – MUSCLE. It is just as easy for the body to breakdown muscle as it is fat cells. Lack of protein can also affect healing, cause you to feel nauseated and cause swelling of the extremities. It is important to prevent this from happening. Research shows patients who consume 80-100 grams of protein daily lose more weight.

Once you are progressed off the hospital diets you should eat 3 small meals per day with 2 protein snacks or protein shakes. Gradually add 1 new food item at a time to see if it agrees with you. If a new food causes issues stop eating it and try adding it again a few weeks later. Continue to stay away from milk, sugar & high fat foods. Tastes and odors may change after surgery – sour or tart may taste particularly good. This is an excellent time to LISTEN to your body and re- learn how it is communicating to you the signals of fullness, hunger, and satiety. Portion size needs to remain small. You do not want to stretch your stomach size prematurely. If you do not make lifelong dietary and nutritional changes, you can and will re-gain weight. Duodenal Switch and Sleeve are not a cure for bad eating choices and will not be effective if you are eating unhealthy or overstuffing yourself.

Food ideas for the first several days…expand your diet slowly as tolerated

 Whey Isolate Protein (Mix a full serving of powder in only 3-4 oz. of water, soy or unsweetened almond milk)  Tofu-can be added to foods for extra protein  Eggs  Bacon  Fish, imitation crab, shrimp, etc.  Dark meat chicken- (Dark meat is moist and is usually tolerated)  Soups (no milk)  Cottage cheese, yougurt, string Cheese or any low moisture, hard cheese  Oatmeal, Cream of Wheat and Grits  Mashed potatoes  Peanut butter or peanut butter powder (if not allergic to) can be added to food or shakes.

A meal may only be a few bites of protein and 2 bites of potato, or a small 4-oz cup or less of yogurt. Give yourself 30 minutes or more to eat. Remember no carbonated drinks.

Order of Dietary Importance  Water  Protein  Everything else (carbs and fat)  Avoid artificial sweeteners  Avoid carbonated drinks  Stay “close to the dirt” the less processed food the better it is for you  Eat Less More Often (ELMO) Diet.

Central Valley Bariatrics – Patient Handbook Sample Vitamin and Protein Schedule

Vitamins – Taking vitamins is now a lifelong commitment. Upon discharge from the hospital, and after you are able to tolerate adequate water and protein intake, then you should start taking the multivitamin and the calcium as recommended below. Additional vitamins/minerals may be required and recommended. Your surgeon will adjust your vitamins based on your lab reports. Some medications should not be taken at the same time as vitamins, check with your physician.

Protein – The ideal protein intake is 1 gm/kg of ideal body weight. This translates to approximately 80-100 grams of protein a day. Realistically however, I expect the patients to be able to consume the same grams of protein as the number of post op days, i.e. 30 grams of protein a day by end of the first month, 60 grams a day by end of 60 days and close to 90 grams by the end of third month.

NOTE: FOR DUODENAL SWITCH…VITAMINS A, D, E & K MUST BE TAKEN IN A “DRY”, WATER MISCIBLE OR WATER SOLUBLE FORM DUODENAL SWITCH SLEEVE GASTRECTOMY 500 MG. CALCIUM CITRATE 500 MG. CALCIUM CITRATE 200-250 MG. MAGNESIUM GLYCINATE 200-250 MG. MAGNESIUM GLYCINATE MULTI-VITAMIN MULTI-VITAMIN EARLY PROTEIN SHAKE PROTEIN SHAKE MORNING *50,000 IU DRY VITAMIN D3-50

500 MG. CALCIUM CITRATE 500 MG. CALCIUM CITRATE MID 200-250 MG. MAGNESIUM GLYCINATE 200-250 MG. MAGNESIUM GLYCINATE MORNING

PROTEIN SHAKE PROTEIN SHAKE *25,000 IU DRY VITAMIN A *5,000 IU VITAMIN D3-50 LATE **HEME IRON **HEME IRON AFTERNOON

500 MG. CALCIUM CITRATE 500 MG. CALCIUM CITRATE 200-250 MG. MAGNESIUM GLYCINATE 200-250 MG. MAGNESIUM GLYCINATE EVENING MULTI-VITAMIN

*Patients may be required to take additional supplements. These recommendation may be based on the pre-operative lab results.  Vitamin K (150 Mcg Dry Vitamin K2 (Mk-7)  Probiotic  Heme Iron **For menstruating women or as required

Central Valley Bariatrics – Patient Handbook

Vitamin Section

Required –Mandatory supplements needed life long Multi-Vitamin: Any adult multi-vitamin such as Centrum, One a day or Costco’s Kirkland Brand Calcium: Must be taken in divided doses of 500 mg. (that is all you absorb at a time). Calcium must be CITRATE or Hydroxyapatite, NOT carbonate Please pay special attention to the labels! Magnesium: You need to take 250 mg. of magnesium for every 500 mg. of calcium  Magnesium Oxide: Least absorbed, stays in the bowel causing loose stools  Magnesium Citrate: Better absorbed, some stays in the bowel causing mild loose stools which can help offset constipation caused by calcium or some irons  Magnesium Glycinate: Best absorbed usually does not cause loose stools

As your pre operative lab results are returned further recommendations will be made. These include: Vitamins A, D, E and K: Must to be taken in ”DRY”, water miscible or water soluble form. If they are in a gel/oil capsule they are not appropriate for the GRDS patient because fats are insufficiently absorbed. Make sure you are NOT taking Vitamin A “as beta carotene”.

Iron: Heme Iron is well tolerated and absorbed. It can be taken with food and calcium/vitamins. Other types of iron should be taken with Vitamin C and separated by at least one hour from intake of caffeine, dairy, eggs, whole grains, calcium, vitamins and medications.

Shopping Guide Suggestions Calcium Citrate: Citracal or generic equivalent such as Costco’s Kirkland Calcium Citrat brand. You are looking for “Citrate” forms of calcium. Probiotic: Garden of Life Primal Defense Ultra  GNC, Vitamin Shoppe, Vitamin World, VitaCost, Swanson Vitamins, Amazon Magnesium Glycinate: Any Brand such as KAL. KAL Brand magnesium glycinate comes in 400 mg. for “2” tablets (take ONE at a time)  GNC, Vitamin Shoppe, Swanson Vitamins, VitaCost, Amazon Vitamin D: BioTech D3-50 or Tender Dry D3-50 (Vitalady’s Tender brand same formula as BioTech) Vitamin A: BioTech A-25,000 IU or Tender Dry Vitamin A 25,000 IU (same formula as BioTech) Vitamin K2 (as MK-7): (Vitalady) “dry” 150 mcg of Mk-7 Heme Iron: Proferrin ES or Standard Process Ferrofood. Heme iron can be taken with calcium and meals, other iron types must be taken separately. Protein Shakes: Choose based on personal taste, being watchful of calorie to protein content. Protein “Isolates” are more absorbable with less chance of diarrhea than protein “blends”. www.amazon.com www.gnc.com (877-GNC-4700) www.vitaminshoppe.com (866-293-3367) www.vitalady.com (253-848-5118) www.swansonvitamins.com (800-824-4491) www.vitaminworld.com (866-667-8977) www.biotechpharmacal.com (800-345-1199) www.vitacost.com (800-381-0759) www.bariatricadvantage.com has a selection of chewable vitamins, calcium and Iron

Check with your pharmacy about special ordering a vitamin/mineral they do not stock.

Central Valley Bariatrics – Patient Handbook

Intestinal Issues (Associated with the Duodenal Switch)

Bowel Movements: will be loose for the first few weeks until the food you eat becomes more solid. You may use Pepto Bismol (can turn your stools dark) and increase your fluid intake. Taking Probiotics can help normalize your bowels.

If after the initial few weeks watery diarrhea persists, lactose intolerance, a high-fat diet, MSG or sugar substitutes are generally the culprits. They may cause increased gas and loose stools, even long term. You may want to try Devrom, (similar ingredient as Pepto-Bismol in tablet form and safe for long-term use). Always look at what you are eating. If loose stools continue, add rice, go to a bland diet and temporarily eliminate any fruits and vegetables you may be eating. Bananas, which are a good source of minerals, will usually not cause diarrhea. If cramping and loose stool persist for more than 2 days, please call the office.

Flatulence: For most people gas is a problem because it causes (sometimes painful) bloating and (often mortifying) odors. Everyone has gas; the average person generates 1-3 pints a day. However, some people produce a lot more than others. Certain foods are gassier than others; gas- producing food for one person may not be for the next. Extremely flatulent foods (more than 40 passages per day) vary from one person to another. Carbohydrates are largely to blame for large volumes of gas due to sugars, starches, and fibers that reach the colon (large intestine) without being digested or absorbed. Once in the colon the colonies of harmless bacteria eat the carbohydrates and give off byproducts of hydrogen, carbon dioxide and in some people methane. Taking probiotics such as Primal Defense Ultra Probiotics, Ultra Dolhilus, Ultra Bifidus, Reuteri lactobacillus and acidophilus will replace the “good bugs” (bacteria) that are wiped out with antibiotics. Devrom is also another good medication that can be taken to reduce the odor of flatulence.

Stay away from sugar of any kind, including fruit and juices.  One of the most common sources of gas is lactose, which is a sugar that occurs naturally in milk products. Many people do not have the enzyme to digest lactose.  Another source is soluble fiber, like the pectin in fruits and the beta-glucans in oat bran.  Researchers have shown that gas-producing bacteria feed off small amounts of starch that escapes digestion by enzymes in the small intestine. So far, wheat, oats, potatoes, corn and virtually every starchy food has been implicated; even innocuous foods like bread and pasta made with white flour can cause gas. The worst offenders are any processed white flour products. These products contain sorbitol and the bacteria react with the sorbitol and cause gas.  The fourth and most infamous source of gas is the family of raffinose sugars found in beans and in smaller amounts in many vegetables and grains. No one has the enzyme alphagalactosidase to break them down. When they hit the large intestine, our bacteria have a feast.  Sugar Substitutes, these food additives, can be found in a variety of foods. They cause gas, bloating & loose stools because they are not well absorbed by the intestines. Extra water gets pulled in to the intestines and bowel by these additives. In addition, bacteria in the bowel eat these sugars and produce even more gas. Stevia may be your best option for a sugar substitute.

Central Valley Bariatrics – Patient Handbook Some products you may find helpful in preventing or deodorizing gas:  Devrom: available over the Internet at www.parthenoninc.com or by telephone 1-800- 453-8898.  Pepto-Bismol, Gas-Ex, Beano: over the counter in most drug and health food stores. Take with your meals.  Natural Chlorophyll /Alfalfa Chlorophyll helps with gas odor, found in most health food stores.  Lactaid tablets: found in most drug and grocery stores.  Probiotics: found in health food stores.

Causes Of Increased Flatulence and Loose Bowel Movements

Loose Bowel Flatulence movements primarily caused primarily by carbs and caused by fat fiber.

Note that both Carbs and Fat can cause increased gas and loose bowel movements.

Hair Loss and Skin Changes

Hair loss is a side effect of all forms of rapid weight loss, including surgery. It can be a disheartening problem. Hair loss happens because the hair follicles grow in cycles over several months. The effect of reduced calorie and protein intake can cause the hair follicle to stop growing. Because this may happen anywhere in the growth cycle, you may not notice the hair loss right after surgery but a few months after. The hair loss will stop. The tips below may help slow hair loss and encourage new hair growth. However, because of the hair follicles growth cycle, it may take some time before you start seeing new hair growth.

The same reason for the hair loss can also cause changes in your skin texture and appearance. It is not uncommon for patients to develop acne or dry skin after surgery. Some patients also complain of brittle nails. The protein, vitamins and calcium are all vital to the growth and maintenance of healthy hair, skin and nails.

 Protein intake is extremely important for healing, hair growth, and to prevent muscle wasting. After surgery you need 80-100 grams or more of protein every day.

Central Valley Bariatrics – Patient Handbook  Multivitamins with minerals taken daily are also an important supplement because if you are deficient in vitamins and minerals, then your body takes the essential vitamins for the general maintenance of your body and does not give the unessential things like hair and nails what they need to grow.

 Zinc 50 mg tablets every other day for no more than a month. Zinc blood levels can get too high after this period of time. Zinc can interfere with iron absorption at higher levels. Zinc helps with protein synthesis and collagen formation (both ingredients for hair growth). Inactivity can lower the body’s levels of zinc; another reason why exercise is important.

 Folate, folic acid or Vitamin A can be helpful if you develop a fine acne-type rash on your skin. You can add an additional tablet daily for 30 days and the rash should resolve. Please call the office if it persists or does not get better after a week of taking the additional supplementation.

 Biotin tablets or powder are great for healthy hair, skin and nails. Biotin also assists the body in turning fat mass into usable energy. A dose of 600-1000 mg daily is recommended. This can be found in most health food, vitamin or beauty supply stores.

 Cancer and chemotherapy patients have traditionally used Nioxin shampoo, but some weight loss patients have had good luck with it as well.

 Folicure tablets and shampoo can also help. This can found at a beauty supply store.

Central Valley Bariatrics – Patient Handbook Vitamins-Benefits-Deficiency Vitamin Benefits Deficiency Mineral Duodenal Switch results in reduction of the fat soluble vitamins- A, D, E & K Essential for vision, skin, healing, new cell growth, immune Night blindness, reduced Vitamin A system, hair, bones, teeth. Heart & stroke protection. Protects hair growth, dry eyes, against respiratory infections, colds, and cancers. Needed to infections, dry bumpy utilize protein. skin, weak tooth enamel, kidney stones, diarrhea Enhances calcium, phosphate & magnesium absorption. Osteoporosis, dental Needed for bones/teeth, protective against auto-immune issues, spontaneous Vitamin D diseases like arthritis, lupus, chronic fatigue, preventive against fractures, bone curvature, cancers, flu, and stroke; important to overall wellness. auto-immune disease, Maintains muscle strength & heartbeat. cancer, depression, chronic pain Antioxidant helps form/protect red blood cells, muscles & other Poor muscular and tissues, circulatory system, reduces risk of cataracts, aging, circulatory performance Vitamin E Alzheimer’s, stroke, leg cramps, immune system. Use caution if you have an overactive Thyroid, diabetes, blood pressure, heart issues or retinitis pigmentosa. Vitamin K1 Blood clotting, liver function, bone density. Bleeding, low bone (Phytonadione) Do not take K1 or K2 the first 2 months Post-op. density, Excessive diarrhea (To reduce incidence of DVT or PE) Same as above plus it is better absorbed & stays in the blood Bleeding, low bone Vitamin K2 longer at lower doses. Activates osteocalcin, a protein that density, hardening of the (Menaquinone-7) binds calcium to the bone. Additionally it inhibits and reverses arteries, cancer Arterial Calcification lowering the risk of vascular damage. (The better Vitamin K choice.) Helps build strong bones & teeth, muscle contraction, and Bone-joint pain, Calcium regulates heartbeat and nerve function. Helps blood clot osteoporosis, heart formation. Activates enzymes needed to convert food to energy. palpitations, muscle cramps, depression, Works with calcium in bones/teeth, enzyme activity & health of Muscle weakness, Magnesium heart arteries. Protein production, nerve and muscle function. nausea, irritability, Regulates heartbeat, blood sugars & blood pressure. twitching, leg cramps, cardiac arrhythmias Multi Vitamins Covers a variety of macro and micro nutrients that promote overall health Known as ‘the friendly bacteria of the gut’. Supports the Digestive problems are immune system, digestion and is a barrier against micro- the main deficiency bacterial infection. Promotes a healthy gut that can utilize symptoms. Frequent nutrition, thereby promoting overall health. indigestion, stomach Probiotics pain, diarrhea, gas, May be taken long term but highly suggested for 8 weeks after constipation, nausea, surgery or anytime you take antibiotics. yeast infections, urinary tract infections, fungal infections/athlete's foot Essential for making hemoglobin that carries oxygen to tissues, Anemia, fatigue, enzyme functions, and regulation of cell growth, immunity. shortness of breath, pale skin, and pica (desire to Iron crunch ice or eat dirt). Trouble regulating body temp.

Central Valley Bariatrics – Patient Handbook

A Lifetime With Your Duodenal Switch

Lifetime Commitments: Remember this surgery is only a tool; a tool to help you win the battle against morbid obesity. How effectively you use this tool will affect your weight loss. Please follow the recommended guidelines within this handbook.

12-18 Months is Your Window of Weight Loss: This is the most effective time to take advantage of exercise, eating healthy and behavior modification. You can extend the weight loss up to 24 months if you are diligent with dietary/nutritional changes and exercise. Only with improved nutrition and increased activity can you expect to reach and maintain your goal weight. You will need to change the amount and types of foods that you eat. This surgery can assist you in making these changes, but you need to actively pursue and maintain these changes. Utilize your “Window of Opportunity” to its fullest potential.

70% to 85% is the Average Excess Weight a Duodenal Switch Patient Loses: To achieve this or a greater weight loss, you must consider your sugar and carbohydrate intake. Choosing to eat 3 small meals and 2 protein-based snacks with increased activity will help keep you on track. Having surgery DOES NOT give you a license to eat as much as you want, whenever you want. You will regain weight if a healthy life style of increased exercise and nutritious eating behavior are not adopted. Please use this tool to gain back your health and well-being.

Lifetime Follow-up is Crucial: Following up with your surgeon and doing scheduled lab work will help you identify any nutritional deficiencies and problems you might develop which should be easily corrected. It is important to remember that you have altered your anatomy and you need to be followed by a surgeon who is familiar with the intricacies of the procedure. Blood work will be ordered at 6 months post-op then annually after that (or as needed). The office staff will inform you when you are due for blood work. Be diligent in your after-care, if you do not hear from the office please do call. It is also important to keep the office current on any changes to your contact information i.e. phone numbers, address, email. Blood work, vitamins and minerals are your best defenses against nutritional deficiencies. Donating blood is not recommended as it could contribute to nutritional deficiencies.

Notify the office any time you become pregnant so your obstetrician can receive pertinent information to keep you and the baby healthy (see Pregnancy section)

Drink 64 oz. of Water Daily: Because of the malabsorption aspect of your surgery, you will always be susceptible to dehydration. Drink up!

Eat or Drink 80-100 Grams of Protein Daily: Your body does not store protein; it must be eaten on a daily basis. You malabsorb protein and will always need to concentrate on getting in proper amounts. Protein shakes are an excellent way to accomplish this and are highly absorbable. Research shows patients who consume 80-100 grams of protein daily lose more weight.

Daily Vitamins: The limited absorptive part of the surgery makes it necessary for you to be committed to taking vitamins daily for the rest of your life. If you are a menstruating female, you may be at risk for iron deficiency anemia and may need to take iron supplements as well. We will be monitoring your labs and making adjustments to your vitamins accordingly. The

Central Valley Bariatrics – Patient Handbook limited absorptive properties of the surgery can put you at risk for vitamin deficiencies, which can lead to other health concerns, but with compliance this can be avoided. Taking your vitamins is not an option; it is a mandatory component of your surgery. See Vitamin Schedule.

Medication: Time released-slow released medication is not recommended due to the malabsorption and rapid transit component of the Duodenal Switch. Anti-inflammatory medications such as NSAIDS (aspirin, ibuprofen, acetaminophen, naproxen) may be taken as directed.

Alcohol: No Drinking for 2 years after surgery. Thereafter, be mindful and limit consumption, as you will continue to metabolize alcohol differently.

Exercise: The more weight you lose the easier exercising will become. While losing weight you will also lose muscle mass, exercise helps retain muscle mass. This is important because a pound of muscle burns approximately 45 calories a day…whereas a pound of fat burns only around 2 calories a day. Exercise will help relieve stress, depression and suppress your appetite. Setting a consistent (at least 3-4 times a week) aerobic and weight bearing exercise program is the most beneficial. However, any increase in activity is constructive; go for walks, play baseball, swim, mow the lawn…”Off your Seat, and on your Feet” to a healthier, thinner you. If you make exercise an integral part of your lifestyle, it will help you achieve greater weight loss and help prevent weight re-gain.

Preventing Weight Re-gain: Keeping protein the focus of your meals (shakes or food), limiting highly absorbed simple carbohydrates and sugars will help prevent re-gain. Do not slip back into old eating habits including consuming sugary drinks. Remember, you malabsorb proteins but you absorb carbohydrates starting from the mouth.

Monthly Group Meetings: We recommend attending group meetings. They are for you, for education, support, and nutritional and practical advice. Studies have shown that patients who regularly attend group meetings achieve greater weight loss. Family members are always encouraged to attend. Advice provided in a group meeting by our staff is not to be taken as medical recommendation, but rather a general discussion of topics.

Visit our website www.dssurgery.com often for newsletters, updates and general information. For additional support and information please visit our Facebook page at https://www.facebook.com/dssurgery or the blog at http://blog.dssurgery.com.

Central Valley Bariatrics – Patient Handbook

Weight loss Surgery Quiz

Please write TRUE/FALSE in the space the left of the numbers.

1. The Duodenal Switch involves both reducing stomach size and limiting absorption.

2. Bile enzymes and food are divided into separate channels and are combined for nutritional absorption in the “common tract”.

3. The gallbladder is removed with duodenal switch procedures.

4. After obesity surgery, the patient is committed to taking vitamin and mineral supplements and having periodic nutritional assessments/studies for life.

5. A high-fat diet or lactose may cause diarrhea, gas, and cramping with duodenal switch procedure, and may slow down the weight loss after the other surgical procedures.

6. Since malabsorption may occur, I do not need to worry about protein intake.

7. Exercise will help increase my weight loss, decrease mental stress, help maintain weight loss, help prevent complications and decrease appetite.

8. Since I am having limited absorption, I do not have to watch what I eat.

9. Annual follow up with my surgeon and lab work is necessary for life.

10. Statistically speaking, 1-2 in 200 patients die in the U.S. from bariatric surgery.

11. Anemia may be present in menstruating females.

12. Iron anemia and osteoporosis may occur if I do not take supplements that are needed.

13. Monthly Group Meetings will not be so important after surgery.

14. Due to the decrease in required caloric intake after weight loss surgery, dry skin, temporary hair loss, and acne may be some of the symptoms I might experience with the weight loss.

15. Any medications I might be on should be monitored for dosage changes.

16. Dehydration the first few weeks postop is not a common problem.

17. Sugar is easily absorbed whether it is fruit juice or a candy bar and can slow weight loss.

18. Postoperative complications such as infection, pneumonia, bleeding, blood clots, hernias, ulceration, leakage, blockage of the intestines or stomach may occur and may require re-operation during the same hospitalization or later.

19. Alcohol consumption will be tolerated after surgery.

20. If I smoke, I must stop 6 weeks prior to surgery.

Central Valley Bariatrics – Patient Handbook 21. If I do not take my daily supplements and protein, I may develop complications such as osteoporosis; weakness, wound healing problems, depressed immunity, and pronounced hair loss. In some cases these complications may still happen if I take the supplements as recommended.

22. Many medical conditions such as diabetes, hypertension, depression, asthma, sleep apnea, and arthritis generally improve significantly after surgery.

23. My new stomach size is approximately 4-6 ounces (1/2 cup to 3/4 cup) at its maximum capacity.

24. After I recover from the surgery and go home, I should just be patient with any medical problem I may have and not call my surgeon for at least 2-3 days.

25. The hospital may try to serve you milk, meat, or something you know you should not have; you should eat and drink whatever is served to you.

26. Postoperatively I will only be able to eat few bites at a time; if I eat more, I could rupture my suture line or prematurely stretch my stomach and slow my weight loss.

27. I have to take calcium supplements after surgery.

28. I only need to take in 80 grams of protein per week.

29. Females should not become pregnant during the weight loss period because of the possible birth defects that can arise due to the nutritional deficit of the mother.

30. Because of malabsorption I can eat all the carbohydrates we want and not gain weight.

31. Because of the rapid weight loss after surgery I will only lose fat and do not need to exercise to retain muscle mass.

32. Fat soluble vitamins A, D, E & K must not be in an oil capsule, I need to take these vitamins in a “dry” or water soluble form.

33. Sleeve Gastrectomy is part of the Duodenal Switch operation.

34. The long term outcome of the Duodenal Switch and the Sleeve Gastrectomy is identical to each other.

35. Sleeve Gastrectomy can be considered as the first stage of the two stage duodenal switch operation.

Patient signature ______Date ______

31 30, 28, 25, 24, 19, 16, 8, 13, 6, False: 35 32 29, 27, 26, 23, 22, 21, 20, 18, 17, 15, 14, 12, 11, 10, 9, 5, 7, 4, 2, 3, 1, True: Answers

34 , 33, ,

Central Valley Bariatrics – Patient Handbook Bariatric Surgery Contract Ara Keshishian, MD, FACS, FASMBS

HAVING ELECTED TO UNDERGO BARIATRIC SURGERY FOR MY OBESITY, I UNDERSTAND AND AGREE TO THE FOLLOWING:

1. I have been informed of my personal medical problems, the dangers of morbid obesity, and the operations available to me, including the Duodenal Switch, Adjustable gastric banding and gastric bypass. 2. The dangers and complications of surgery have been completely explained to my satisfaction including the possibility of death. Re-operations may also be necessary either during the same hospitalization or later after being discharged. 3. I am voluntarily electing to have this surgery without coercion or deception on the part of the surgeons or other medical staff. 4. I realize the importance of post-operative appointments and blood work; I will keep those scheduled appointments and have labs drawn. 5. Specific vitamin and mineral supplements shall be required after surgery; I will purchase and be committed to taking these supplements the rest of my life. 6. I realize the importance of attending the monthly group meetings and understand they may help me with my long-term success. 7. It has been emphasized to me that behavior modification is critical in attaining acceptable long- term weight loss 8. I am now aware that behavior modification is an important educational process. I do understand that it involves increasing my activity level, changes in the types and amount of food I eat, liquids I drink, and the number of meals I eat each day. I am aware that if I do not make these changes, it is possible to re-gain some weight back. 9. I realize my liver may be sensitive after this surgery and I should stay away from alcohol and any drugs that may cause liver damage. 10. I understand the importance of long-term follow-up; I agree to be seen in the office and have necessary blood drawn or communicate with the office and have blood drawn on an annual basis. 11. I will read and follow the guidelines within the Patient Handbook that I have been given. 12. I understand why I should not become pregnant during the weight loss period and until cleared by my surgeon. 13. I am also aware that there is no implicit or explicit guarantee or assurances given with regards to the amount of weight loss or the success of the weight loss surgical procedures. The information presented was the most updates scientific data available.

I, ______, have read the foregoing contract. I do understand and agree to abide by these terms.

Patient signature ______Date ______

Witness signature ______Date ______

Central Valley Bariatrics – Patient Handbook

Teaching Guidelines

Normal Anatomy

Gastric Reduction Duodenal Switch Anatomy and Physiology

Adjustable gastric Banding Anatomy and Physiology (Lap Band, Realize Band)

Different Weight Loss Procedures: Anatomy, Physiology, and Outcomes

Complications, Morbidity, and Mortality of Surgical Procedures

Nutrition, Vitamin and Mineral Requirements and Complications of Non-Compliance

Exercise, Psychological Changes

Preoperative Instructions, Hospital Course of Care, Discharge Instructions

Support Group Meeting Attendance and Importance of Reading and Studying the Handbook

Pregnancy and Weight Loss Surgery

Given Patient Handbook

I, ______, acknowledge that in my preoperative teaching session(s) I have received detailed explanation as outlined above. I was given adequate opportunity for questions and answers to my satisfaction. The risks of weight loss surgery, potential complications, including bleeding, infection leaks, blood clot in legs and their travel to the lungs, pneumonia, and others were all explained. The chance of death was also discussed in no uncertain terms. The options available to me, the different procedures with the different outcomes were all discussed in detail and explained to me. I am aware that the Bariatric surgical staff (surgeon, Nurse and office staff) are by phone or e-mail to answer questions I may have at any time. I am also aware that I will attend Bariatric Support Group Meetings before my surgery. I have received the Patient Handbook and I will read and follow the guidelines within the handbook.

Patient signature ______Date ______

Witness signature ______Date ______

Central Valley Bariatrics – Patient Handbook

References

1 Bariatric Surgery, A systematic Review and Meta-Analysis, Buchwald et.al. JAMA October 13, 2004, Vol 292, No.14, P 1724-1728 2 Long-Term Results of a Prospective Study on Laparoscopic Adjustable Gastric Banding in Morbid Obesity, Y.Van Nieuwenhove et.al, Obesity Surgery, 2001, 21, P 582-587. 3 A 10-year Experience with Laparoscopic Gastric Banding for Morbid Obesity: High Long- Term Complication and Failure Rates, M. Suter et.al, Obesity Surgery, 2006, 16, P 829-835.

Special Thanks to Jo Diniz, and Vicki Blackburn (dec.)