Healthcare Providers

Physicians

• Bariatric Surgery - A Systematic Review and Meta-analysis
• Primary Care Perspective on Bariatric Surgery

“Support System” Approach

Hope Bariatrics utilizes multiple healthcare disciplines as part of the bariatric program to create a “Support System” for the bariatric patient. An important component of this Support System is pre and post-operative education that begins at a one hour seminar presented by the surgeons. Potential patients have an opportunity to participate in a question-and-answer session after the seminar with the surgeons and other members of the healthcare team. Patients who may be physically unable to attend the seminar may view a seminar on our website and take a post-seminar quiz.

Dietary education, an important part of our program, is directed by our dietitian, Denise Stuart, RD, LD. Ms Stuart stays informed of the current vitamin and protein recommendations to guide patients post-operatively. She also does our pre-operative dietary evaluations, educating patients on pre-operative diet requirements.

Psychological evaluations are required before a patient can move forward with gastric bypass surgery. The Staunton Clinic (Heritage Valley Health System) and qualified mental health professionals (i.e. psychiatrists, clinical psychologists) chosen by the patient, may conduct these evaluations.

Fitness evaluations for bariatric patients may be conducted by an exercise physiologist before or after gastric bypass surgery. We encourage all patients to increase physical activity gradually and safely.

Hope Bariatric Protocol

Indications for Surgical Treatment

• BMI greater than or equal to 40 kg/m2; or
• BMI greater than or equal to 35 kg/m2 with at least two of the following comorbid conditions which have not responded to medical management and which are generally expected to improve as a result of obesity surgical treatment:
• Hypertension
• Dyslipidemia
• Type 2 diabetes
• Coronary heart disease
• Sleep apnea
• Documentation of attempts at non surgical weight loss
• 3 to 6 consecutive months in structured, medically supervised visits with a primary care physician
  Assessment and counseling concerning weight, diet, exercise, and behavior modification; and
  Either weight loss or no further weight gain over the course of 6 months.
  Participation is required by most insurances and should occur during at least within the 12 months prior to the request for surgery Patients who have had previous bariatric surgery (failed Vertical Banded Gastroplasty, or gastric bypass) MUST participate in a pre-operative 6 month medically supervised diet
• Evaluation by a registered dietitian
  
  Determine patient’s current eating behaviors
  Determine nutritional knowledge
  Determine readiness for compliance after surgery.
  Nutritional education and behavior modification are to be demonstrated prior to gastric bypass. Readiness is based on results of our written nutrition test, ability to keep a dietary journal, actual pre-op weight loss, keeping scheduled appointments, participation in Support Groups, and scheduling required tests.
• Evaluation by a licensed psychologist or psychiatrist
  
  Documentation of the absence of significant psychopathology that can limit an individual's understanding of the procedure or
  Ability to comply with medical/surgical recommendations (e.g., active substance abuse, schizophrenia, borderline personality disorder, uncontrolled depression); and
  Documentation of willingness to comply with preoperative and postoperative treatment plans; and
  Age greater than or equal to 18 years.
  

Contraindications for Surgical Treatment

• Age < 18, or > 70
• Serious comorbidities indicating extreme surgical risk (eg. advanced cardiac or pulmonary disease)
• Active alcohol or illegal drug addiction
• Psychological evaluation indicating severe, untreated depression, suicidal tendency or mental illness
• Psychological evaluation indicating uncontrolled eating disorder
• Unwillingness to comply with pre-operative guidelines
• Cognitive inability to sign informed consent (without demonstrable support system: family, mental health)
• BMI < 35 with no comorbid conditions
• No past history of medical or non-surgical weight loss attempts  

Pre-op testing
At the first office visit we will order:

• Upper GI or EGD if indicated
• Psychological evaluation by a qualified mental health professional
• Dietary evaluation by our registered dietitian
• Cardiac evaluation/Clearance (if indicated)
• Sleep study (if indicated)
• Pulmonary Function Test or Pulmonary evaluation (if indicated)
• An evaluation (for post-op) by an exercise physiologist
• TSH (if indicated)

For insurance approval the patient must provide to us:

• Documentation of 3 or 6 consecutive months supervised diet with a primary care physician (whichever is applicable per your insurance)
• A Letter of Medical Necessity from primary care physician

When we receive all the above information and test results, the insurance company is contacted and authorization is obtained. After surgery is authorized, the patient has a second office visit.
Pre-Op Tests (to be completed within 4 weeks of gastric bypass surgery):
Lab work:

• CBC
• CMP
• PT
• PT
• Lipid Panel
• Urinalysis

Additional tests:

• Chest X-Ray
• EKG 

Post-op follow-up
Post-Surgery Follow-Up Protocol /Office visits are required at (at least)

• One to 2 weeks after surgery
• 1 month
• 3 months
• 6 months
• 12 months
• Yearly for 5 years
• Lab work at 3 months, 6 months, yearly
• CBC, CMP, B12, Ferritin, Folate, Vitamin D and HgbA1C and Lipid panel as needed

Nurses

• Care of the Morbidly Obese
• Resources
• Best Practices for Perioperative Nursing Care for Weight Loss Surgery Patients

Pre and Post Op Issues

Pre-Admission Review

• Instruct patient on clear liquid diet
• Review hospital pre-op instructions (per facility)
• Review specific weight loss surgery procedure (lap and open)
• Review medication guidelines for the week prior to surgery
• Review allergies to medications and note reaction/ indicate on surgical admission form
• Review possible risks/complications, patient commitment, consent forms
• Discuss what patient can expect during hospital stay:
• Identify special needs of the patient such as ambulation difficulty
• Identify types of bariatric equipment needed /address safety
• Remind patient to be out of bed and moving as soon as possible to prevent DVT
• Remind patients they will have clear liquid Phase I in the hospital and at home

Dietitians

• Medication and Nutrient Administration Considerations after Gastric Bypass

Psychologists

• ASMBS Guidelines

Exercise Physiologists/Fitness

• www.bariatricrehab.com

Pharmacists

• The Skinny on Gastric Bypass: What Pharmacists Need to Know

Internet Resources

• Obesity Action Coalition
• The American Society for Metabolic & Bariatric Surgery
• The Obesity Law and Advocacy Center
• Bariatric Support Centers International
• Obesity Help
• The National Association of Bariatric Nurses
• Centers for Disease Control and Prevention
• The American Obesity Association
• Bariatric Rehab
• American Dietetic Association
• Bariatric Advantage Nutritional Supplements
• Weight Loss Surgery Center (Barbara Thompson, author of Weight Loss Surgery: Finding the Thin Person Hiding Inside You)
• Bariatric Eating (Susan Leach, author of Before & After – Living & Eating Well After Weight Loss Surgery)