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VA Ann Arbor Healthcare System

 

Bariatric Surgery

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INTRODUCTION

The VA Ann Arbor Healthcare System Bariatric Surgery Program’s goal is to help obese individuals improve their health through weight loss surgery. Bariatric surgery, also known as weight loss surgery, accomplishes dramatic and long-lasting weight loss. With modern minimally invasive surgical techniques, your recovery will be rapid, you will have less post-operative pain, and you will return to your normal activities quickly.

Our multidisciplinary approach offers treatment that goes far beyond surgery, including a full range of psychological, nutritional, and other specialty medical services to help you before and after your operation. Our surgeons are experts in bariatric surgery and provide state of the art care for our patients.

Our team consists of surgeons, nurse practitioners, registered nurses and registered dietitians who will accompany you on your journey to wellness through weight loss. Welcome to the Ann Arbor VA Hospital Bariatric Surgery Program!

CLICK HERE to learn more about VA Ann Arbor Health Care System's Bariatric Surgery Program.

ABOUT WEIGHT LOSS SURGERY, also known as BARIATRIC SURGERY

What is “obesity”?

Obesity is a medical term determined by calculating your body mass index (BMI). BMI=your body weight /your height squared. If your BMI is 30 or greater, you are considered obese

You can click on this website to calculate your BMI.

What are the risks of obesity?

Obesity places extra strain on your heart, lungs and joints. It also increases your risk of many diseases and health conditions that will shorten your life.
These diseases include:

• Type 2 Diabetes
• Hypertension
• Sleep Apnea and respiratory problems
• Dyslipidemia
• Stroke / Heart disease
• Arthritis
• Gastroesophageal reflux disease
• Many Cancers

What are the benefits of bariatric surgery?

Among people who are overweight and obese, weight loss can help reduce the chances of developing these health problems. Studies show that reducing your body weight will improve your health.

Most obese patients are not able to lose weight and keep it off with diet and exercise alone. When such efforts fail, bariatric (weight loss) surgery is an option. Bariatric surgery is a major life-changing process. Patients considering bariatric surgery should seek out information and discuss their goals with family and their physicians. Our goal at the Ann Arbor VA Hospital Bariatric Surgery Program is to provide you with information regarding bariatric surgery and help you make an informed decision.

The results of bariatric surgery are dramatic. Most individuals undergoing bariatric surgery lose 50 - 70% of their excess body weight (about 100-150 pounds on average). Most bariatric operations can be performed through small incisions, otherwise known as laparoscopy. With laparoscopic surgery you will experience a much faster recovery, less pain and fewer wound healing complications than those recovering from traditional open surgery. Weight-related health factors such as Type II diabetes and sleep apnea are dramatically improved and are often resolved after weight loss surgery. Medical literature demonstrates that patients who undergo bariatric surgery live longer, and enjoy lower risks of cancer, diabetes, and many other obesity-related diseases.

AM I A CANDIDATE?

Bariatric surgery is reserved for patients whose BMI is >=40, or >=35 with serious obesity-related diseases such as diabetes, sleep apnea, high blood pressure, and high cholesterol. If you fall into one of these BMI categories and have not been successful with dieting to lose weight, you and your primary care doctor should consider bariatric surgery.

Our criteria for bariatric surgery include the following:

1. You must be between the ages of 18 and 65 years. For those 65-69 years of age, decisions will be made on a case by case basis. We do not offer surgery to patients 70 years of age or older.

2. You must have a Body Mass Index (BMI) of 40 or greater, or 35 or greater with obesity-related diseases such as hypertension, heart disease, diabetes, polyarthritis, pulmonary hypertension, sleep apnea, and hyperlipidemia.

3. You must have a primary care provider who you see regularly and who is supportive of bariatric surgery and who is willing to assist in pre-and post-operative care.

4. You must be enrolled in the Ann Arbor VA MOVE Program. This program will provide critical education and strategies for dietary and nutrition habits that will ensure your success before and after surgery.

5. You must not smoke cigarettes or use tobacco products in any form, including chewing tobacco, snuff, or nicotine patches.

6. Absolute contraindications to bariatric surgery include active substance abuse, end-stage cardiovascular or pulmonary disease, end-stage liver disease, history of a liver or heart transplant, severe or uncontrolled psychiatric disorders, and anorexia nervosa.

7. Relative contraindications which may exclude you from bariatric surgery include end-stage renal disease, active binge eating disorder, or bulimia nervosa. Patients with end-stage kidney disease being considered for transplant will be considered on a case by case basis.

IS WEIGHT LOSS SURGERY RIGHT FOR ME?

When considering bariatric surgery, you need to be well informed and understand how surgery will affect your life.

Surgery for weight loss is a serious undertaking and should be considered only after failed efforts to lose weight with diet and exercise. Bariatric surgery is reserved for patients with obesity-related disease who remain severely obese after failed attempts with weight loss with non-surgical approaches.

To see if you are ready to undergo weight loss surgery, answer the following questions.

Are you:

1. Unsuccessful at keeping weight off long-term through traditional diet and exercise programs?

2. Determined to lose weight and improve your health?

3. Willing to make permanent, major, life-long lifestyle changes including:

  • accepting that food is no longer being a major focus in your life?
  • monitoring what and how much you eat and counting calories?
  • adhering to dietary restrictions and take daily vitamin/mineral supplementation for the rest of your life?
  • exercising most days of the week?
  • adhering to lifelong medical follow-up?

4. Aware of the potential for complications of surgery?

5. Well-informed about the surgical procedures and the effects of the surgery and extremely weight loss?

If you answered YES to all of these questions, you are ready to take the next steps towards surgery:

1. Check the criteria on this website. You must meet the criteria to be considered a candidate for Bariatric Surgery.

2. Do your own research on the internet- our website is a good place to start. Learn about bariatric surgery in general, and the specific options of sleeve gastrectomy and gastric bypass, and make a list of questions that we will help you answer when we meet you in person.

3. Make an appointment with your primary care provider (PCP) to discuss bariatric surgery. You will need to have a complete physical exam and will be screened for treatable causes of obesity. You will need to be prepared to discuss all your past attempts at weight loss. Your PCP will order blood work and testing which may include a sleep study as well as any age-appropriate cancer screening tests such as colonoscopy, mammography, and other tests.

4. Ask your PCP to put in a consult to the AAVA Bariatric Surgery Program for consideration for bariatric surgery.

Once your evaluations and medical tests are completed and your consult is placed, and your PCP submits a consult to the AAVA Bariatric Surgery Program, your case will be reviewed by our AAVA Bariatric Surgery Program Nurse Practitioners who will determine if you are an appropriate candidate for weight loss surgery. You will then be contacted to make an appointment in the AAVA Bariatric Surgery Clinic.

At your appointment in the AAVA Bariatric Surgery Clinic, you will meet our program Nurse Practitioners and one of our Bariatric Surgeons. They will perform a thorough examination and evaluation, to determine what steps must be taken to make you a safe candidate for surgery. You will also receive an outline of the next steps in the process.

SURGICAL OPTIONS

The VA Ann Arbor Healthcare System Bariatric Program offers two types of bariatric surgical procedures, gastric bypass and sleeve gastrectomy, which are the two most –time tested, well-studied bariatric operations worldwide. Gastric bypass has been performed for over 30 years, and has a long track record of safety and proven weight loss. Sleeve gastrectomy has been performed for close to ten years and has generated much enthusiasm among surgeons and patients because of its simplicity and excellent results. Both procedures result in significant improvement and in some cases complete resolution of obesity-related diseases including diabetes, high blood pressure, high cholesterol, and sleep apnea. Both operations achieve excellent weight loss ranging between 50-70% of excess weight.

Gastric bypass and sleeve gastrectomy operations are most commonly performed through a laparoscopic (small incision) approach. The decision of which operation is best for you will be made with your surgeon. For some patients, gastric bypass results in slightly greater weight loss than sleeve gastrectomy, and may be more effective in management of type 2 diabetes and severe gastroesophageal reflux disease.

Sleeve gastrectomy may be the preferred operation for some patients as it involves less anatomic rearrangement of the intestine and for this reason, may be associated with fewer long-term complications.

Both gastric bypass and sleeve gastrectomy significantly limit the amount of food patients are able to eat for the rest of their lives and require that patients monitor their caloric intake and take vitamin supplementations for life. Patients may drink alcohol only rarely after bariatric surgery, and may not smoke cigarettes or use any tobacco or nicotine products.

ROUX-EN-Y GASTRIC BYPASS

Roux-en-Y gastric bypass, sometimes called gastric bypass for short, involves creation of a small stomach pouch, about the size of an egg, followed by rearrangement of the small intestine to reconnect the stomach pouch to the intestinal tract. Food bypasses the lower stomach and the first portion of the small intestine. The gastric pouch limits the amount of food patients can eat, while the intestinal rearrangement reduces the amount of calories and nutrients the body absorbs.

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SLEEVE GASTRECTOMY

Sleeve Gastrectomy, also known as Vertical Sleeve Gastrectomy (VSG) or Gastric Sleeve Resection, involves removing about 85% of the stomach, while keeping both ends of the stomach intact.

Unlike gastric bypass, sleeve gastrectomy does not involve cutting or rerouting the small intestine. The gastric sleeve significantly limits the amount of food patients can eat.

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PREOPERATIVE WEIGHT LOSS

Why do we ask that you complete a weight loss program before surgery?

Weight loss programs start you on your path of healthy lifestyle changes. Studies have shown that a modest weight loss before your surgery decreases the risk of surgery and results in greater weight loss after surgery. Weight loss prior to surgery allows you to begin practicing the lifestyle changes that are necessary for success after surgery.

What is a weight loss program?

A weight loss program is any system which allows for you to safely loss weight through a healthy, balanced diet and exercise. While there are many diets and weight loss programs out there, you need to focus on a balanced diet of typically 1200-1500 calories per day to achieve your goal weight. Programs teach you how to “count calories”, make healthy, balanced low calorie meals, choose healthy alternatives when you cannot eat at home and provide support during your journey. The MOVE! Program (link) is the official VA weight loss program. This program provides you direct contact with dietitians who are experts in nutrition and guide you on your way.

What is modest weight loss?

We ask for a preoperative weight loss of about 5%. For most people, this is about 10-20 pounds. Your surgeon and NP will discuss the right amount of pre-operative weight loss for your individual case to maximize safety and optimize results.


Why do we recommend you use a weight loss programs that involves exercise?


Exercise will not only help you lose weight, it will lower your risks during and after surgery. Exercise can be as simple as increasing the amount you walk every day. You should always discuss your ability to exercise with your primary care physician to find the correct program for you.

HOSPITAL STAY, HOME CARE

Most patients will go home 2-4 days after surgery. You will be up and walking right away, and will be able to get around your house immediately. Pain after surgery is modest, and usually easily controlled with pain medication for about 2 weeks after surgery, after which most patients do not require pain medication. Most patients are able to return to work within 2-3 weeks after surgery. You will not need a significant amount of home care, as you will be able to be up and about right away. You will need your family members and friends to be available to drive you to the hospital and other destinations in the first few weeks after surgery, as you will be on pain medication and not be able to drive.

POST-OPERATIVE CARE

Your surgery is over but your new life has just begun. Your success depends on you! It is critical that you follow all post-operative instructions carefully and take advantage of the support that the bariatric team has to offer.

After your surgery, you will see need to have appointments with your surgeon and dietitian. This is typically 2 weeks and 2 months from the date of surgery. Your PCP will then oversee your care along with the dietitian at the 6 month and 12 months following surgery. You will need to keep your yearly physical with your PCP for life.

Healthy Lifestyle Changes for Success After Surgery

Making healthy dietary choices

  • Lower fat dairy foods
  • Lower fat and lean high protein foods
  • More fruits and vegetables
  • More whole grain products
  • Limiting / avoiding foods high in added sugars
  • Limiting / avoiding fried foods
  • Limiting / avoiding sweetened beverages
  • Avoid drinking beverages with meals as this can flush the food out of your pouch leaving you feeling hungry again
  • Caffeine-free before the surgery and after your surgery as caffeine contributes to dehydration
  • Avoiding all carbonated beverages, for life, these contribute to expanding the pouch, requiring more food to make you feel full
  • Limiting / avoiding alcohol, following surgery, your stomach no longer metabolizes alcohol therefore it enters your bloodstream at a much faster rate and stronger concentration, which can increase your risk of alcoholic liver disease
  • Chewing all of your foods to applesauce consistency to avoid blockages
  • Avoiding the use of straws which can cause expanding of the pouch
  • Engaging in some form of exercise or activity with a goal of 45-60 minutes for most days of the week

Medications After Surgery

  • More than 95% of patients can take pills after surgery and will go back to taking their regular medications within a day to two of surgery. For the few patients in whom pills are a problem for a few weeks after surgery, it may be necessary to crush pills or use a liquid replacement medication. It is important to be in close touch with your or primary care provider (PCP) in the first few months after surgery because he or she may need to adjust doses of your medications as you lose weight.
  • You will be instructed to take an acid-blocking medication for 3 months after the surgery to decrease your risk of stomach and bowel ulcers.
  • Vitamin and mineral supplements daily for the rest of your life.
  • 1 multivitamins with minerals daily
  • 4 calcium citrate tablets daily
  • Vitamin B12 sublingual lozenge daily or monthly injection
  • Additional vitamins and or minerals may be required based on your blood tests

Diet Advancement After Surgery

Liquids - you will be on a liquid diet for 2 weeks after your surgery. This allows you to heal and take in nutrients to avoid malnutrition. This also significantly decreases any discomfort or pain which is associated with eating solids this soon after the surgery. You will learn which liquids are recommended during this phase during the pre-surgery visits with the dietitian.

Pureed / mushy foods - you will be on these very soft foods for 4 - 6 weeks after your surgery. This allows the pouch to continue healing while gradually becoming accustomed to solid foods again.You will receive specific instructions on which foods are tolerated best during this phase when you meet with the dietitian.

Soft, Regular foods - As you become completely healed, your pouch is able to tolerate a greater variety of foods, which you will gradually add into your diet. It may take up to year before you become comfortable with what you can eat and how much you can eat.

Weight Changes After Surgery

  • The rate of weight loss varies greatly between individuals. It is very important not to compare your rate of weight loss with others.
  • The average amount of weight loss is typically 60% of excess body weight in the first 12-18 months after surgery. Your surgeon will discuss with you in clinic appropriate expectations for weight loss after surgery.
  • Everyone experiences "mini-plateaus" throughout the first 6 months or so. If your plateau lasts longer than 6 weeks and you want to lose additional weight, adjustments in your diet and/or exercise regimen are required to restart your weight loss. Our dietitian can help you with these "stalls".
  • It is common to regain a small amount of weight (10-20 pounds) before your weight finally stabilizes at your personal goal weight. Your body is readjusting to its new form and weight. Diet and exercise are essential to lose additional weight and/or maintain your weight loss.
  • It is possible to gain weight back after surgery if you do not change your lifestyle to include healthy dietary choices, eating in moderation and incorporating activity/exercise into your daily life.

LEARN MORE- LINKS

To learn more about weight loss surgery at AAVA, , please read our Frequently Asked Questions. You may also be interested in the information provided by the related links below.

American Society for Bariatric Surgery (352) 331-4900
www.asbs.org

American Society for Bariatric Physicians (303) 770-2526
www.asbs.org

Centers for Disease Control and Prevention BMI Web Calculator
www.cdc.gov/nccdphp/dnpa/bmi/calc-bmi.htm

Obesity Help.com
www.obesityhelp.com

National Institute of Diabetes and Digestive and Kidney Diseases
www.niddk.nih.gov

Prevention-Smart Ways to Live Well
www.prevention.com

United States Department of Agriculture
www.nal.usda.gov - (search 'obesity')

FAQ

1. Why should I have my weight loss surgery at the Ann Arbor VA Hospital?

The VA Ann Arbor Healthcare System offers a specialized, multi-disciplinary Bariatric Surgery team who works with you on an individual basis to provide you with the knowledge and skills needed to be successful after your weight loss surgery. We provide pre- and post-operative nutritional education and counseling to help you deal with the nutritional, lifestyle, and emotional changes you will experience. Our staff includes surgeons, nurse practitioners, registered nurses, dietitians, and psychologists, all of whom specialize in bariatric surgery and obesity medicine and are available for life-long care and support. Our surgeons are nationally known experts in bariatric surgery with many years of experience and a track record of excellent outcomes.

2. How much weight will I lose after bariatric surgery?

Weight loss is variable from patient to patient but on average you can expect to lose 65-70% of excess body weight following Gastric Bypass or Sleeve Gastrectomy.

3. Which weight loss procedure should I choose?

The choice between gastric bypass and sleeve gastrectomy is an important one, and one your surgeon will help you make. Sleeve gastrectomy is rising in popularity, but gastric bypass remains the most commonly performed bariatric operation worldwide. Depending on your medical and surgical history, one operation may suit you better than the other. We will help you make this important decision in the preoperative evaluation.

4. What is laparoscopy?

Over 95% of bariatric operations are performed via laparoscopy, which involves making several (5-6) small 1cm incisions on the abdomen, through which your surgeons places a camera and instruments that allow him to perform the operation while viewing it on a video monitor., Laparoscopy has tremendous benefits over traditional open surgery, in that it avoids the large incisions associated with open surgery and patients thus recover much more quickly with less pain and few complications. Laparoscopic bariat4ric surgery has thus become the standard of care. Your surgeon will discuss with you the issue of laparoscopy and whether you are a candidate for a laparoscopic approach- the majority of patients will be candidates for laparoscopy.

5.What is the recovery time following surgery?

For both procedures you are generally up and walking on the first day. The day after surgery you are able to begin a liquid diet. For most individuals pain is well controlled with liquid oral pain medication after the first day and you are sent home on day 3 or 4 after surgery, and return to normal activities and back to work within 2 to 4 weeks.

6.How often am I required to see the surgeon/nurse practitioner and dietitian after surgery for follow-up?

Following surgery you will see the surgery team and dietitian at 2 weeks and2 months. Further appointments with the surgery team vary with your needs. Most patients will resume follow up with their PCP and our dietitian at 6 months, 12 months and annually. You can schedule additional appointments with our dietitian, as you feel you need.

OUR SERVICES

Nutrition Education & Counseling

Our dietitians are experienced in the unique needs of those going through bariatric surgery. You will receive nutrition education to be successful before and after your operation during visits with our experienced registered dietitians. We will schedule these visits for you once you are enrolled in the program.

OUR TEAM

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Dr. Amir Ghaferi is a board certified general surgeon and graduate of the University of Michigan General Surgery Residency. He has specialized training in advanced minimally invasive surgery and bariatric surgery. He has been on staff at VAAAHS for 3 three years. Dr. Ghaferi is the Chief of General Surgery at the VA Ann Arbor Healthcare System, a member of the American Society for Metabolic and Bariatric Surgery, and a national expert in bariatric surgery and obesity care. He is also an active member in the Michigan Bariatric Surgery Collaborative that aims to advance the science and practice of bariatric surgery in Michigan and across the United States.

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Dr. Robert W. O’Rourke is a board certified general surgeon with over a decade of experience in advanced laparoscopic and open bariatric surgery. Dr. O’Rourke was co-Director of the Bariatric Surgery Program at Oregon Heath and Sciences University in Portland Oregon for ten years prior to moving to the Ann Arbor VA Hospital in 2013. Dr. O’Rourke is fellowship trained in advanced laparoscopic and bariatric surgery, a fellow of the American Society for Metabolic and Bariatric Surgery, and a national expert in bariatric surgery and obesity care.

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Marilyn Woodruff, NP is a Board certified Adult Nurse Practitioner with career focused on caring for surgical patients. She has worked at the AAVA for over 15 years. She has specialized expertise in preoperative risk assessment and optimization and postoperative management of a wide range of surgical issues.

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Isiriel Paulino, NP is a Board Certified Adult Nurse Practitioner with experience caring for surgical patients. He has worked for the VA Health Care system for 15 years. He has specialized expertise in dealing with cardiovascular disease and Internal medical conditions that impact on the care of the surgical patient.

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Jenna Arnould, MS, RD is a Registered Dietitian, receiving her undergraduate degree in Dietetics with a specialization in Health Promotion from Michigan State University; after which she went on to complete her dietetic internship at the Louis Stokes VA Hospital and subsequently completed her Masters of Science in Nutrition at Case Western Reserve University in Cleveland, OH. Jenna returned to her home state of Michigan and continues to work at the Ann Arbor VA. She has been blessed in being able to work with our wonderful veterans for the past 4 years, in both the inpatient and outpatient clinical settings. Jenna’s main focuses, as a dietitian, are empowering veterans to make healthier lifestyle changes, as well as improving chronic disease management; she also assists veterans throughout their weight loss paths for bariatric surgery.

Dr. Carol Lindsay-Westphal, PhD earned her degree in Clinical Psychology from Northwestern University, where she completed the health psychology training track. Her primary interest is facilitating lifestyle change for enhanced health and has worked extensively with the MOVE! program for weight management, as well as many other areas for health behavior changes. As the Bariatric Psychologist, she completes pre-surgical psychosocial evaluations for weight loss surgery candidates, and assists with their pre-and post-surgical adaptation.

CONTACT INFO, NEXT STEPS

If you are interested in bariatric surgery at the Ann Arbor VA, please ask your Primary Care provider to place a consult into CPRS for Bariatric Surgery. The Bariatric Surgery Team will be in touch. We look forward to working with you to help you accomplish your health goals.

CLICK HERE to view additional information about VA Ann Arbor Healthcare System's Bariatric Surgery Program.

Contact Info

Location

  • VA Ann Arbor Healthcare System

Contact Number(s)

  • 734-769-7100

Hours of Operation

  • Mon-Fri 7:30am-4:00pm