Prime Care Surgical Weight Loss ProgramPrime Care Surgical Weight Loss Program““A comprehensive program integrating body, mind & spirit”A comprehensive program integrating body, mind & spirit”

Gaylord Kavlie, M.D., F.A.C.S.Gaylord Kavlie, M.D., F.A.C.S.Brandon Helbling, M.D.Brandon Helbling, M.D.

Jean Ellefson, RNJean Ellefson, RN Jessica Miller, RN, BSN, CPANJessica Miller, RN, BSN, CPAN Clinical CoordinatorClinical Coordinator Clinical Coordinator Clinical Coordinator

Mid Dakota ClinicMid Dakota Clinic St. Alexius Medical CenterSt. Alexius Medical Center

Bernie Kraft, LRD CDEBernie Kraft, LRD CDE Laura Russell, LRD CDE Laura Russell, LRD CDE

Affiliated With:Affiliated With:

Mission StatementMission Statement

To provide support to those committed To provide support to those committed to a healthier lifestyle and improved to a healthier lifestyle and improved quality of life through medical and quality of life through medical and

surgical treatment of obesity.surgical treatment of obesity.

What Is Morbid Obesity?What Is Morbid Obesity?

Clinically severe obesityClinically severe obesity at which point at which point serious medical conditions occur as a direct serious medical conditions occur as a direct result of the obesityresult of the obesity

Defined as >200% of ideal weight, >100 lb Defined as >200% of ideal weight, >100 lb overweight, or a overweight, or a body mass index of body mass index of 4040

Degrees of Obesity

NORMAL

BMI 18.5 – 24.9

OVERWEIGHT

BMI 25 – 29.9

OBESE

BMI 30 – 34.9

SEVERE OBESE

BMI 35 – 39.9

MORBIDLY OBESE

BMI 40

Do You Know Your Own BMI?

Obesity Related Co-MorbiditiesObesity Related Co-Morbidities(Health Risks)(Health Risks)

– DiabetesDiabetes– HypertensionHypertension– HyperlipidemiaHyperlipidemia– Cardiac diseaseCardiac disease– Respiratory disease Respiratory disease

sleep apneasleep apnea– ArthritisArthritis– DepressionDepression– Stress IncontinenceStress Incontinence– Menstrual Menstrual

irregularityirregularity

– Infertility ProblemsInfertility Problems– FatigueFatigue– Adult Onset Type II Adult Onset Type II

Diabetes Diabetes– Fatty LiverFatty Liver– Gallbladder DiseaseGallbladder Disease– Venous InsufficiencyVenous Insufficiency– HerniaHernia– Premature DeathsPremature Deaths– CancerCancer

These are just a few. There are over 30!

Surgical Weight Loss

At present surgery is our mosteffective option in achieving

SUSTAINEDweight loss in the

morbidly obese patient.

“Not a Miracle”

Medical Benefits of SWLMedical Benefits of SWL

Type II Diabetes 76.8% remission rate, significantly Type II Diabetes 76.8% remission rate, significantly improved in 86%improved in 86%

High Blood Pressure eliminated in 61.7%, significantly High Blood Pressure eliminated in 61.7%, significantly improved in 78.5%improved in 78.5%

High Cholesterol reduced in more than 70% of patientsHigh Cholesterol reduced in more than 70% of patients

Sleep Apnea eliminated in 85.7% of patientsSleep Apnea eliminated in 85.7% of patients

Joint Disease, Asthma, and Infertility dramatically Joint Disease, Asthma, and Infertility dramatically improved or resolvedimproved or resolved

Plus many other important medical benefitsPlus many other important medical benefits

JAMA 2004JAMA 2004

NORMAL

DIGESTIVE

SYSTEM

PrimeCare Weight Loss ProgramPrimeCare Weight Loss ProgramSurgical OptionsSurgical Options

Restrictive only:Restrictive only:

– Adjustable Gastric BandingAdjustable Gastric Banding

– Sleeve GastrectomySleeve Gastrectomy

Restrictive and Malabsorptive:Restrictive and Malabsorptive:

- Roux-en-Y Gastric Bypass- Roux-en-Y Gastric Bypass

Laparoscopic Adjustable Gastric Laparoscopic Adjustable Gastric BandingBanding

A siliconeA silicone band is placed around band is placed around the upper part of the stomachthe upper part of the stomach– The band is attached to a portThe band is attached to a port– A small pouch is createdA small pouch is created– Stomach holds less foodStomach holds less food– Induces feeling of satiety Induces feeling of satiety

OR time = 30-45 minutesOR time = 30-45 minutesGenerally outpatient procedureGenerally outpatient procedureReturn to work in 3-5 daysReturn to work in 3-5 daysFrequent evaluations and Frequent evaluations and adjustments needed to meet adjustments needed to meet individual needsindividual needs

Possible ComplicationsPossible Complicationsof Lap Bandingof Lap Banding

Stomach Perforation

Device Malfunction

Esophageal Dilation

ErosionErosion

ProlapseProlapse

SlippageSlippage

InfectionInfection

ObstructionObstruction

The LAP-BAND System

Advantages•Adjustable – customized per patient

•No stomach stapling, cutting or intestinal rerouting

•Removable and reversible

•Low malnutrition risk

•OR time = 1 hour or less

•Generally outpatient procedure

•Mortality rate 0.02-0.10%

Disadvantages•Slower initial weight loss than gastric bypass

•Soft calories such as ice cream, Soft calories such as ice cream, milk shakes, etc can be milk shakes, etc can be absorbed absorbed and may slow and may slow weight loss.weight loss.

•Regular follow-up is critical for optimal results

•Only trained practitioners can do adjustments

•Less long-term information is available because it hasn’t been done as long

•Foreign body

Roux-en-Y Gastric BypassRoux-en-Y Gastric Bypass

Combination procedureCombination procedure

First done in 1967, done First done in 1967, done laparoscopically since laparoscopically since 19931993

Gastric pouch is Gastric pouch is approximately size of approximately size of your thumbyour thumb

Considered the “Gold Considered the “Gold Standard”Standard”

ASMBS

SUCCESS OF GASTRIC BYPASSSURGICAL TREATMENT

In a 5 Year Study of 500 Roux En Y Surgical Weight Loss Patients:

•77% Of Excess Body Weight Was Lost in 1 Year & Maintained For 60 Months

•96% Of Severe Co-Morbidities Were Eliminated Within 1 Year

•98% Of Type II Diabetes Was Clinically Reversed

Dr.’s Wittgrove & Clark, 1993 - 1999

POSSIBLE SURGICAL COMPLICATIONSOF GASTRIC BYPASS

•Abscess•Deep Vein Thrombosis•Pulmonary Emboli•Gastric Leaks•Bleeding•Development of a Fistula•Obstruction•Pulmonary Complications•Infection

•Hernias•Strictures•Stomal Ulcers•Ventral Hernia•Anemia•Vitamin & Mineral Deficiencies•Perforation

Bariatric Surgery Has Become Bariatric Surgery Has Become More SafeMore Safe

Mortality rate related to bariatric Mortality rate related to bariatric surgery dropped 78.7% from 0.89% in surgery dropped 78.7% from 0.89% in 1998 to 0.19% in 2004.1998 to 0.19% in 2004.

Additionally, morbidly obese patients Additionally, morbidly obese patients have a longer life expectancy after have a longer life expectancy after bariatric surgery due to resolution of bariatric surgery due to resolution of comorbidities.comorbidities.

Gastric BypassGastric Bypass

AdvantagesAdvantagesRapid initial weight lossRapid initial weight lossMore effective, rapid co-More effective, rapid co-morbidity improvementsmorbidity improvementsFood restriction with the added Food restriction with the added weight loss benefit of minor food weight loss benefit of minor food malabsorptionmalabsorptionBetter long term weight loss Better long term weight loss results than restrictive only results than restrictive only proceduresproceduresAssists those who consume too Assists those who consume too many calories by making them ill many calories by making them ill – “dumping”– “dumping”Has been done the longestHas been done the longestIs the “Gold Standard” and Is the “Gold Standard” and remains the most researched remains the most researched obesity surgery to dateobesity surgery to date

DisadvantagesDisadvantagesCutting and stapling of stomach and Cutting and stapling of stomach and bowel is requiredbowel is requiredMore operative & post-op More operative & post-op complications complications Portion of digestive tract is Portion of digestive tract is bypassed, reducing absorption of bypassed, reducing absorption of essential nutrientsessential nutrientsNonadjustable, difficult to reverse Nonadjustable, difficult to reverse Technically more complex Technically more complex

Sleeve GastrectomySleeve Gastrectomy

POSSIBLE SURGICAL COMPLICATIONSOF SLEEVE GASTRECTOMY

• Deep vein thrombosis

• Pulmonary embolus

• Pneumonia

• Acute respiratory distress syndrome

• Accidental perforation of internal organs

• Gastric leak

• Postoperative bleeding

• Small bowel obstruction

Sleeve GastrectomySleeve GastrectomyAdvantagesAdvantages

Stomach is reduced in volume but Stomach is reduced in volume but tends to function normally. Most food tends to function normally. Most food items can be consumed in small items can be consumed in small amounts.amounts.Eliminates the portion of the stomach Eliminates the portion of the stomach that produces the hormones that that produces the hormones that stimulate hunger (Ghrelin). stimulate hunger (Ghrelin). No dumping syndrome because the No dumping syndrome because the pylorus is preserved.pylorus is preserved.By avoiding the intestinal bypass, By avoiding the intestinal bypass, protein deficiency and vitamin protein deficiency and vitamin deficiency are almost eliminated.deficiency are almost eliminated.Very effective for high BMI patientsVery effective for high BMI patientsAppealing option for people with Appealing option for people with existing anemia, Crohn's disease and existing anemia, Crohn's disease and numerous other conditions that make numerous other conditions that make them too high risk for intestinal bypass them too high risk for intestinal bypass procedures.procedures.It can be converted to almost any other It can be converted to almost any other weight loss procedure.weight loss procedure.

DisadvantagesDisadvantagesSoft calories such as ice cream, milk Soft calories such as ice cream, milk shakes, etc can be absorbed and may shakes, etc can be absorbed and may slow weight loss.slow weight loss.Potential for leaks related to long Potential for leaks related to long staple line on the stomach.staple line on the stomach.Because the stomach is removed, it is Because the stomach is removed, it is not reversible.not reversible.

Frequently Asked QuestionsAbout Bariatric Surgery....

Q: Is Weight Loss Surgery Reversible? A: Lap Band- Yes, Gastric Bypass- No, Sleeve Gastrectomy- No.

Q: Is There Guaranteed Success? A: No. These surgeries can be defeated if

healthy lifestyle changes are not maintained.

More Frequently Asked Questions

Q: Will you take my gallbladder out when you do my surgery? A: No. We do not remove healthy gallbladders.

If you have evidence of stones or disease it may be removed.

Q: What are the age limits for these surgery? A: 18 is the youngest. Patients up to age 65 have had these surgeries, however, all patients are individually considered.

More Frequently Asked Questions

Q: When can I go back to work? A: Depends- based on the procedure done and the type of work you do.

Q: When can I drive? A: When off of narcotic pain medication.

Q: When can I exercise? A: Walking is recommended in moderation

immediately after surgery. 6 weeks for more intense exercise.

More Frequently Asked QuestionsMore Frequently Asked Questions

Q: Can I drink alcohol? A: No beer because of carbonation. Wine and other alcoholic beverages are fine but contain many empty calories.

Q: Q: Am I going to have loose skin after I lose weight?Am I going to have loose skin after I lose weight? A: Probably. Reconstructive surgery to correct A: Probably. Reconstructive surgery to correct this is usually covered by insurance if you lose this is usually covered by insurance if you lose 100 pounds or more.100 pounds or more.

NutritionNutrition

Bernie Kraft, LRD, CDEBernie Kraft, LRD, CDE

Laura Russell, LRD, CDELaura Russell, LRD, CDE

Diabetes & Nutrition CenterDiabetes & Nutrition Center

Mid Dakota ClinicMid Dakota Clinic

Pre-Operative ExpectationsPre-Operative Expectations

Goals of Goals of optimumoptimum weight loss during the weight loss during the

pre-op period:pre-op period: Reduce liver sizeReduce liver size Increase the odds that surgery can be completed Increase the odds that surgery can be completed

laparoscopicallylaparoscopically Demonstrate commitment to the nutritional Demonstrate commitment to the nutritional

program that has been prescribed for youprogram that has been prescribed for you Demonstrate your commitment to making Demonstrate your commitment to making

lifestyle changes.lifestyle changes.

Lifetime Rules for EatingLifetime Rules for Eating

Eat slowly and chew wellEat slowly and chew well

Avoid overeatingAvoid overeating

Moisture rich foodsMoisture rich foods

Limit sugar and high fat foodsLimit sugar and high fat foods

Total of 64 oz. fluid daily, taken between mealsTotal of 64 oz. fluid daily, taken between meals

Avoid carbonated beverages- includes beerAvoid carbonated beverages- includes beer

Take your prescribed supplementsTake your prescribed supplements

Insurance RequirementsInsurance Requirementsfor Pre-Authorizationfor Pre-Authorization

Surgical EvaluationSurgical Evaluation

Psychological EvaluationPsychological Evaluation

Pre and Post-Op Nutrition with LRDPre and Post-Op Nutrition with LRD

Documented weight loss attemptsDocumented weight loss attempts

Medical Records with documented Medical Records with documented weightsweights

Jean Ellefson, RN Jean Ellefson, RN MDC Clinical Coordinator MDC Clinical Coordinator

Surgical Weight Loss ProgramSurgical Weight Loss Program

Call with questions or to enroll in our Call with questions or to enroll in our program:program:

(701)530-6330(701)530-63301-800-472-2113, ext. 63301-800-472-2113, ext. 6330

Fax: (701)530-6387 Fax: (701)530-6387