By Adem Lewis / in , , , , , , /

♪ I’d like to congratulate you for taking this huge first step toward considering bariatric surgery. Based on our experience of thousands of patients I think you will find that this is extremely rewarding. Bariatric surgery can be life changing. It’s very likely going to allow you to lose a large amount of weight and keep it off and improve your life. This journey you’re about to begin, it’s not quick, it’s not easy, but it will be worth it. Every phase, the preparation, the actual surgery itself and the aftercare is critical. We have multiple locations to help make your weight loss journey and travel easier before, during, and after surgery. What distinguishes our program from some of the others is the extent of the expertise, the passion that every single care provider in our team has to help our patients. We certainly understand that this process of preparing for surgery can be overwhelming. There are lots of visits, patient tests to be completed. At Cleveland Clinic all of our patients are assigned to one of our staff, a patient navigator. They shepherd our patients through the process. I felt like the team actually became like a part of my family. The help they give you is tremendous and that’s the key to success. ♪ We found over the years that the patients that had the very best results from surgery are patients who are actively engaged in the program. I’ve lost the weight, 128 pounds. All my diabetic medications were gone. We are conveying lots of information in this video. We want to make sure that you retain it and understand it. So we’re going to provide a quiz for you. So you can go on to the next phase of your preparation for surgery. There’s not one day that I regret having the surgery done. I’ve never felt better in my life. ♪ We’re glad that you have chosen to take control of your health and seek effective treatment for your disease of obesity and the many diseases associated with obesity. Bariatric surgery is a covered benefit with many insurers. Check with your provider beforehand. You could be a candidate for surgical weight loss if you meet any of the following criteria: You are more than 100 lbs. over your ideal body weight, have a Body Mass Index (BMI) of over 40, you have a BMI of 35 and over and are experiencing severe negative health effects, related to being severely overweight. Or if you have a BMI of 30 and over and you have poorly controlled diabetes. When considering surgery, your safety and success are our primary concerns. Our surgeons have performed thousands of bariatric operations and there is no substitute for experience when it comes to safely performing these complex laparoscopic operations. Over the last 15 years, bariatric surgery has become very safe and is now as safe as many other routine surgical procedures like gallbladder surgery and appendectomy. We offer a variety of surgical options. Sleeve Gastrectomy and Gastric Bypass are two of the most common. The sleeve gastrectomy is an operation in which about 75-80% of your stomach is removed. After it is freed up from its attachments, the part of your stomach that currently holds most of your food and can stretch to hold more is removed. What is left is a banana-shaped tubular stomach that holds much less food and allows you to feel full after eating much smaller portions. In addition, the sleeve gastrectomy does change some of the hormones made by your gut and this results in decreased hunger for several months and improvement in diabetes and feelings of fullness. The typical patients will lose 80 to 100 pounds in the first year after sleeve gastrectomy. The most rapid weight loss occurs in the first six months but this is largely determined by how active you are. Since your food intake is very limited in the first few months, the more you can increase your metabolism with exercise, the more weight you will lose. Along with the weight loss, we see dramatic improvements in diabetes, blood pressure, cholesterol, sleep apnea, and many other medical problems after sleeve gastrectomy. The Roux-en-Y gastric bypass operation has been around the longest and has the longest track record. During gastric bypass surgery, we don’t remove anything but we do make your stomach smaller and rearrange your intestines to produce weight loss. The stomach is divided into two parts, the small gastric pouch at the top that will hold your food and the excluded stomach that remains in place but is disconnected from the flow of food. The pouch we create is about the size of a ping pong ball which means you will feel full with small portions of food. We then divide the small intestine near the top and bring the intestine up to the small pouch to create the bypass where the food will travel. The bowel carrying the digestive juices is then connected downstream at the “Y” connection and that is where the food and digestive juices meet and digestion begins. When we re-route the food past the stomach and top portion of the intestines, it has a powerful effect on type 2 diabetes and results in remission rates of over 80 percent. Other conditions like high blood pressure, high cholesterol, sleep apnea, and joint pain improve significantly and over 75% of patients are able to decrease or stop their treatment for these diseases. The gastric bypass is an excellent operation for patients with heartburn, as well. We do both operations laparoscopically over 98% of the time which means there are five or six small incisions. The sleeve gastrectomy takes 1 to 1 ½ hours to complete and patients are usually in the hospital just one night. The gastric bypass takes about two hours to complete and patients will be in the hospital one or two nights after surgery. The sleeve gastrectomy generally has fewer complications than the gastric bypass because the bowel connections we make during gastric bypass surgery can add some risk of blockage or ulcers that are not present with the sleeve operation. The duodenal switch is another, less commonly performed procedure because it is a more aggressive operation than the sleeve and the bypass. The duodenal switch is a longer bypass operation combined with a sleeve gastrectomy that is used for patients with very high BMI’s. The duodenal switch is referred to as a malabsorptive procedure because the bypass is very long and the length of bowel used to absorb nutrients is made intentionally short. While this operation is extremely effective for long-term weight loss and diabetes control, it does has a higher risk of certain nutritional deficiencies and should be used in carefully chosen patients who are able to take extra vitamin supplements and protein. If you previously had bariatric surgery our surgeons have extensive experience doing reoperative bariatric surgery for all kinds of reasons. Reoperation may be needed due to bleeding, hernias, ulcerations, separation of stitches or staples, leakage, blockage of the intestines or for patients with unsuccessful results after gastric banding or other weight loss procedures. If you are coming to our program for reoperational surgery, make sure you let us know that up front and attempt to get the records from your original operation. ♪ There are risks of surgery which are important to know and complications that can occur after surgery. Our efforts to prevent complications start right when you enter the program. Your initial medical evaluation and pre-surgery appointments are intended with one goal in mind, to make sure you have a safe and uneventful recovery after surgery. Of course, any operation has risks. The major complications we want to avoid after bariatric surgery are bleeding, infections or bowel leaks, and blood clots in your legs or lungs. These are all serious complications that may require more treatment or another operation and can delay your recovery. The good news is that these are extremely rare events in our program. In fact, these complications occur less than 1% of the time overall in our patients. Other things that can happen after surgery include nausea, minor wound or urinary tract infections, respiratory or heart problems in patients with chronic heart or lung disease, stomach ulcers and bowel narrowing or obstructions. Most of these can be managed without further surgery and these minor complications generally occur less than 5% for gastric bypass and less than 3% of the time after sleeve gastrectomy. We allow you to start sipping on clear liquids the night of surgery and have you walking within hours after the operation. It is critical that you start walking the night of surgery to help prevent blood clots in your legs. We have several strategies to make sure the pain after surgery is adequately controlled. It is important to know that you will have some pain after surgery, but we use a variety of non-narcotic medications to control your pain and we really try to minimize the amount of narcotics our patients receive after surgery. If you are in extreme pain or distress after you go home from weight loss surgery, you should call your doctor. Lifelong follow-up is very important for all of these operations. Everyone who undergoes bariatric surgery needs to commit to take vitamin supplements for life and the duodenal switch patients require more than the sleeve or bypass patients. Also, it is important to know that if you want to start a family or have another child after your bariatric surgery, you should wait 18 months after your operation to conceive. By then, your weight loss will be stabilized and you will be able to have a much healthier and more active pregnancy. When you come in to meet your surgeon, we will discuss these options with you again, and determine what’s right for you. If it’s determined surgery isn’t right for you, we also offer non-surgical treatment such as less invasive endoscopic procedures, like the intragastric balloon and medical management. Most of the endoscopic treatments are temporary for 6 to 12 months and may require repeated treatment or something more durable later. If you are interested in these endoscopic options, ask your surgeon about them and we can make sure you see one of the surgeons who also perform endoscopic bariatric procedures. ♪ Our team here at the Bariatric and Metabolic Institute is here to help every step of the way. Weight loss surgery is a tool that will help you feel full and satisfied with less food. Like any tool in a toolbox, the procedure must be used carefully with specific instructions to ensure safe, effective, life-long weight loss. Your success combines our operations with some permanent changes in your food choices, eating behaviors and activity level. Patients that do not adapt their lifestyle may not be as successful as they would like. Our team approach is designed to help you achieve excellent results. The program starts with a pre-surgery evaluation phase consisting of four core visits with your surgeon, a dietitian, a medical provider and a psychologist. A pre-operative exercise evaluation is also available. At each visit you will learn more about surgery, activity, behavior modification and how best to prepare for surgery both physically and mentally. Some visits will lead to other preparation classes or medical testing depending on your individual needs. We encourage you to make notes and update your journey on your personal tracker. If any of this sounds overwhelming – relax. You will be assigned a patient navigator who will be your point of contact during the pre-operative preparation phase. Your navigator is available to answer questions, and offer support and encouragement along the way. Many patients are anxious to proceed with the surgery as soon as possible. We will do our best to accommodate your schedule and time goals, but also want you to know that many insurance companies think it is important to take your time and begin with a series of nutritional appointments. Your navigator will check to see if you have coverage for weight loss, also called bariatric surgery, and what types of appointments are required by your insurance company. From this seminar and your completion of the registration form, the process generally takes 7 to 10 days after which you will receive an e-mail verifying your coverage and a team member will call you to see if you would like to set up your first appointments. Appointments can be scheduled in any order. Out of town patients may want to schedule more than one visit per day. If you do not have e-mail we encourage you to start an account and check it regularly. E-mail allows us to send you important information you can review at your convenience. ♪ After completing the pre-surgery appointments your navigator will take care of collecting the needed information and obtaining insurance approval. A few of you will learn you do not have coverage and may elect to self-pay for the operation. In that case our financial counselor will assist you with the necessary arrangements. Following approval, you will select the time frame for your surgery. This involves a pre-op day of education, and medical visits about one week from your desired surgery date. So after you listen to this video seminar, please know the education has just begun. By the time you reach your surgery day, we intend for you to feel completely comfortable about what to expect, what to do, and how you will eat and drink. In addition, to the live instruction, you will receive a Guide to Surgery Book detailing everything you need to know to be safe and successful. We also have several videos on our website to reinforce what you learn. The average time spent in the pre-surgery program is about six months depending on insurance requirements. You are in control of your journey and can move quickly or take your time. Medical weight loss programs are also available if you change your mind along the way. Having bariatric surgery means you will be the owner of a powerful tool that will keep you losing weight even when you have never been able to maintain weight loss before. As a practitioner who has helped patients take this journey for over 30 years, my best advice is stick with the program. The months and years after surgery are just as important as the surgery itself. After surgery you will see us at one week, one month, 3 months, six months, one year, 18 months and yearly after that. Additional visits may be scheduled if needed. Our out of town and country patients can return home to their primary care physicians with instructions on how to monitor progress at home. Being a member of the Cleveland Clinic Metabolic and Bariatric Surgery weight loss program means that your journey starts NOW. If you are like most people, you know how to lose weight, you just need some help with maintaining your efforts. During the pre-op appointment phase most patients lose significant amounts of weight which is a kick start for their post-surgery weight loss. My experience as a bariatric surgery caregiver helping patients through this process has been highly rewarding. I have seen thousands of individuals regain their health and enjoy life to the fullest free of the disease of obesity. Along with all the weight loss, you’ll likely see improvement in comorbidities such as diabetes, high blood pressure, back pain and similar health problems. What’s even more important is that with 20 years of data we can say with confidence that 85%-90% of people achieve significant long-term weight loss. ♪ The BMI treats the whole patient. We evaluate and manage your surgical, medical, nutritional and psychological needs. Patients are often surprised and a little nervous about the psychological evaluation. You have finally decided-maybe after years of consideration that you’re ready for a major life change, you’re ready for bariatric surgery. However, many people are a concerned that this is going to be a pass/fail test, but that’s really not the case. All of our patients are seen by a BMI psychologist as part of their pre-operative evaluation. Prior to your evaluation, you will complete psychological testing on a computer that helps us better understand you and your personality style. Next, you’ll spend an hour talking with one of our psychologists. Our role is to help patients understand what some of the factors have been in their weight gain, what their strengths are in undergoing this major life change and how we can build upon them to improve the odds of your success. In addition, we’ll help you identify what some of your vulnerabilities are. What are some of the roadblocks that might get between you and losing as much as weight as you can for long term? Once those challenges are identified, we help patients address them so that they can have the best possible outcome. At the end of that visit, you’re going to be given a list of requirements before surgery, if any, and recommendations for both before and after surgery. Making your surgery as successful as possible requires changing for the rest of your life. This can be a very big task as we’re asking you to make changes, not just for the first year after surgery, but, for decades. BMI psychology is here to help you succeed. For example, sometimes individuals have problems with unhealthy eating behaviors and feeling out of control with their eating. This is very common and not a contraindication for surgery. However, problematic eating patterns can make it harder for you to lose weight and keep it off. As a result, we offer brief interventions that help patients learn skills and strategies so that they can get better control over these behaviors. After surgery, with these new skills, most of our patients are quite successful even if they’ve had that history. Similarly, many of our patients have relied upon food as their primary way of coping. They eat when they’re stressed, they eat when they’re bored, and they eat when they’re feeling sad or depressed. We have multiple groups and individual options that teach patients about how to change eating habits, new strategies for coping with stress and how to develop healthy patterns rather than fall back into old ones. BMI Psychology is also available to help you with post-operative challenges. The first few weeks after surgery can be medically challenging but they bring psychological challenges as well. Feeling sad, blue or anxious after surgery is not uncommon. Many people also experience grieving the loss of food. Others may be challenged by social relationships during this period of enormous change. You’ll see your psychologist at post-operative visits to help ensure that you’re making a good adjustment and to address any early problems that may develop. Lifestyle changes can be difficult but we ask each patient to become responsible for their own commitment and effort to this program. Additionally, I would encourage you to come to one of our support groups. They are a wonderful opportunity to meet people who’ve gone through bariatric surgery, hear their stories and learn from one another. Research tells us that some behaviors are associated with better long-term success after weight loss surgery. These include regular exercise; ongoing follow-up with your bariatric program; attending support groups; and not resuming any loss of control eating. If any of these are vulnerabilities for you, we are here to help. Whether you’re a month pre-op or five year post-op, you have a great advantage here at Cleveland Clinic – whether in person at your appointments or anytime through MyChart message you have access to and the support of all members of our multidisciplinary team. ♪ Our team at the Cleveland Clinic will determine if you are at a medically acceptable risk for bariatric surgery. This means we will make sure that all underlying medical issues such as hypertension, diabetes, heart disease, and lipid disorders are all managed appropriately making you a safe patient and an acceptable risk for bariatric surgery. Additionally, if indicated, a sleep study will be ordered based upon screening tests to determine if you have sleep apnea. This specific treatment for sleep apnea is called continuous positive airway pressure which involves using a device that prevents the airway from collapsing during sleep, immediately after surgery or after discharge from the hospital. The other important purpose of the initial medical visit is to determine if there are any underlying medical conditions which are unknown or have never been diagnosed before. Conditions such as prediabetes, fatty liver disease or sleep apnea may be first diagnosed after your initial lab testing, ECG, chest x-ray, sleep study, and ultrasound are completed and reviewed. All of the testing during the initial visit and subsequently is endorsed by the America Society for Metabolic Bariatric Surgery or ASMBS. The ASMBS clinical practice guidelines recommend an ECG, chest x-ray, ultrasound of the liver and gallbladder, labs including a complete blood count, complete metabolic panel, diabetes test and screening for nutritional deficiencies for all patients that are on a pathway for bariatric surgery. The complete blood count will determine if you are anemic. If an iron deficiency is found before surgery and you have not had a colonoscopy, this diagnostic test is highly recommended to determine the cause of the anemia. Iron deficiency will be adequately treated before bariatric surgery to lessen the chance of it appearing as a late medical complication after surgery which can occur due to poor absorption of iron. In situations where your blood pressure is elevated, diabetes is poorly controlled, or a pulmonary condition such as asthma is not well controlled, a referral to a specialist that deals with these specific medical conditions may be recommended. Once the specialist has completed the medical consultation and clearance, you may be able to proceed with bariatric surgery. If you are being followed by a specialist, such as a cardiologist, pulmonary specialist or other physician, it is suggested that a medical consultation with your medical specialist be conducted prior to surgery. After all the medical tests and consultations are completed and all medical conditions optimized, the final medical assessment is submitted along with your psychological and nutritional assessments to your insurance company for approval. ♪ Your nutrition is a vital part of your success during your weight loss journey at the Cleveland Clinic Bariatric Institute. You will be evaluated, based on the Nutrition Care Process developed by the Academy of Nutrition and Dietetics, so we can help you better prepare for a successful and permanent lifestyle change. Your dedication to making behavioral, diet and exercise adjustments is the key to a successful journey. Many insurance companies have a monthly requirement that has to be met prior to the nutritional clearance for surgery. Insurance requirements generally run from zero to 12 months. Your Bariatric Navigation Team will make sure you are aware of the monthly requirement that your specific insurance company has requested. The dietitian team will also help you achieve a pre-surgery weight loss goal established by guidelines that our medical and surgical teams have requested and approved. During your pre-surgery nutrition assessments and follow-up, the dietitian team will help you evaluate your past weight loss attempts; assess your current eating patterns; identify factors that may alter your meal schedule; assist our multidisciplinary team with evaluating graze or binge eating patterns, help to identify social and financial constraints; and evaluate your exercise patterns. We will also assist the medical team with evaluating and correcting nutrient deficiencies. The dietitians are also skilled at disease specific nutrition therapy and can assist the medical team with improving your dietary intake associated with these diseases. The Nutrition Team will continue to provide nutrition therapy and guidance after surgery. We will evaluate your macronutrient intake, such as protein, carbohydrate and fat. You will need to limit fat and sugar intake after surgery. The dietitians will meet you on a regular basis following surgery to make sure you are eating enough protein and calories. You will need to drink 64 ounces of water per day to remain well hydrated. You will also be required to take lifelong vitamin and mineral supplementation. This is not optional, but required to prevent nutrient deficiencies. Every day you will take a daily multivitamin and mineral supplement, Iron, Vitamin B12, Vitamin D and calcium citrate. Following surgery, it is also recommended that you participate in a minimum of 150 minutes of exercise per week to help sustain your weight loss. A patient for example could exercise for 30 minutes, 5 times per week, to meet this goal. And, remember, you’re not in this alone. We’re here for you. You can always contact us through email or MyChart messages. ♪ Physical activity plays an important role throughout your weight loss experience and beyond. An exercise physiologist uses exercise to increase function, improve fitness, manage weight, manage disease, and help improve quality of life throughout your bariatric weight loss journey. We help you implement your exercise regimen with proper mechanics and modifications, specific to your needs. We can help you achieve your fitness goals. It is recommended to work up to and maintain cardiovascular exercise for 30 minutes 5 days a week. Such exercise includes treadmill, stationary bicycle, jogging or running. Consider monitoring activity level by wearing a pedometer and continue increasing steps each day until 8,000-10,000 steps per day is achieved. As a part of the medical team, we work with your physician to help you become active and successful in managing your weight. We encourage all patients to take responsibility in the program and own their goals. The most difficult aspects of any weight loss program include weight plateauing and maintaining the weight loss. This is where an exercise physiologist can help. We will incorporate resistance training to improve your resting metabolic rate or RMR to help your body burn more calories at rest. You will learn ways to increase activity and remain active. You will also discover ways to make exercise enjoyable and tailored to your needs. And we will help you determine that the exercise you are doing is performed safely. Meeting with an exercise physiologist is optional but highly recommended and appointments can be made at any point during your weight loss journey. Not all appointments are the same and will be individualized based on medical concerns and physical ability. We get to know you and learn your personal health and fitness goals. The assessment can include, but is not limited to cardiovascular function, strength, flexibility and balance. Based on the assessment the exercise physiologist will develop a maintainable exercise program that you can perform on your own. ♪ Cleveland Clinic is the right team for you and your success. We have the experience, dedicated surgeons, medical doctors, psychologists, dietitians, patient navigators, and other support personnel to help you every step of the way through your journey. The Cleveland Clinic team has been amazing. They’re supportive though they’re for every question that you have. It feels like a family. This is an important decision that will affect the rest of your life. Our team is always ready once you feel you’re ready to make the commitment. I want to say thank you very much for giving me my life back. I never thought I would get off that couch. We hope that you found this seminar informative and helpful. After this video, there will be a short quiz to take then we’ll reach out to you about starting your journey together. We look forward to welcoming you into the program. ♪

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