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Eviva Surgical Center Main Office, Clinic and Surgery Center EvivaMD.com Robert Landerholm, MD FACS | Peter Billing, MD FACS | Eric Harris, MD FACS | Jedediah A. Kaufman, MD FACS | Kurtis A. Stewart, MD | Bruce Baker, MD 21911 76th Ave. W., Suite 106 | Edmonds, WA 98026 Phone: 425-778-2220 | Toll-Free: 1.844.EVIVAMD Fax: 425-778-7701 | Open M-F, 9am to 5pm Contact us at 1.844.EVI.VAMD (1.844.384.8263) for a consultation, or learn more at www.evivamd.com.


Bariatric Surgical Guide Your pathway to successful bariatric surgery

Bariatric Surgery p3 An overview, laparoscopic surgery, surgery locations Bariatric Surgery Types

p6

The First Steps p11 The initial contact, bariatric consultation the opportunity to meet your bariatric provider and your bariatric team Surgical Screening p14 What is the next step? An explanation of the preoperative requirements leading up to your surgery. A place to keep track of your screening appointments.

Postoperative Concerns An overview, of postoperative concerns and care

p26

Financial Planning An overview, of financial considerations

p29

Frequently Asked Questions p30 Some common questions shared in bariatric surgery, references, resources, and reccomended reading Our Providers and Team

p36

Locations and Contact Information, Directions and Hotel Accomodations

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Comprehensive Bariatric Aftercare Program

p45

Surgical Screening Review, p24 Clearance and Surgery Scheduling

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Bariatric Surgery Overview of the Process

“I was always fairly active, and enjoyed skiing, biking, sailing and swimming among other activities. After high school I gained a significant amount of weight, and this weight would ‘yo-yo’ as I got older. It became much more difficult to lose weight, and somewhere along the line, food became ‘the activity.’ It became painful to do basic activities; back injuries, knee surgeries and foot pain made even basic walking very uncomfortable. Since the LapSleeve surgery, I have begun working out, swimming, walking and most importantly, ‘playing!’ I am in training for an eight-mile open water swim in Bellingham, WA, to raise money and awareness for weight loss surgery! This not only saved my life, but gave me back the activities that make life fun!”

FOP

- Pete S.

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Bariatric Surgery Bariatric surgery has become an important option for patients who are struggling with being overweight or obese, and are facing lifelong health challenes resulting from their excess weight. The growing awareness of bariatric surgeries ability to potentially halt and sometimes reverse the conditions associated with excess weight have resulted in the acceptance of this important choice as a way to improve long-term health and wellness. The awareness of the positive surgical impact of bariatric surgery on chronic weight related disease has also increased among the members of the medical community. This has resulted in more advocacies for patients from their health care providers as a valid health care choice.

Bariatric surgery has become an important option for patients who are struggling with being overweight or obese, and are facing lifelong health challenges resulting from their excess weight. The growing awareness of bariatric surgeries ability to potentially halt and sometimes reverse the conditions associated with excess weight have resulted in the acceptance of this important choice as a way to improve long-term health and wellness. The awareness of the positive surgical impact of bariatric surgery on chronic weight related disease has also increased among the members of the medical community. This has resulted in more advocacies for patients from their health care providers as a valid health care choice.

The conditions commonly associated with being overweight or obese include, but are not limited to - Type II Diabetes, osteoarthritis, high blood pressure, high cholesterol, infertility syndromes, obstructive sleep apnea, liver disease, and a relationship to increased incidences of some cancers. The ability of bariatric surgery to reduce long term medical costs associated with these conditions range from reduced spending on medications, reduction of hospitalizations, recovery of lost productivity, and a refocus of quality of life issues.

The success of your bariatric surgery will be determined by your ability to incorporate the long-term lifestyle changes, follow-up care, and adherence to the recommendations set forth by your bariatric team. Your success is our success! We will help you achieve your goals through a relationship that starts with your initial consultation and continues for life. We are ready to help you turn your life around!

What is Laproscopic Surgery Laparoscopic surgery, also referred to as minimally invasive surgery, is a modern surgical technique in which operations in the abdomen are performed through small incisions (usually 0.5–1.5 cm) as opposed to the larger incisions made during ‘open’ surgery. Surgical trocars are used as a means of introduction for cameras (the camera is called a laparoscope) and laparoscopic hand instruments to perform surgery. The surgeon will pass the laparoscope and the instruments needed to perform the surgery through these openings.You will receive general anesthesia before this surgery. This will putyou to sleep and you’ll be pain free. The key element in laparoscopic surgery is the use of a laparoscope connected to a video camera.

The abdomen is inflated with carbon dioxide gas. This elevates theabdominal wall above the internal organs like a dome to create a working and viewing space. CO2 is used because it is common to the human body and can be absorbed by tissue and removed by the respiratory system. There are a number of advantages for the patient with laparoscopic surgery versus an open procedure, including: • • • •

Reduced pain Lower risk of hernia or infection Less scarring Shorter recovery time

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Our ASC (Ambulatory Surgical Center) Eviva provides an ideal setting for your surgery in our state-of-the-art Ambulatory Surgical Center (ASC) in Edmonds, WA. Our ASC is an accredited Comprehensive Center through the Metabolic and Bariatric Surgery Accredidation and Quality Improvement Program (MBSAQIP), as well as a designated Center of Blue Distinction+. We provide comfortable pre-op and recovery areas for each patient.

Our operating room

Pre Op Patient Area

Our ASC (Ambulatory Surgical Center) Our goal is to be able to perform your surgery in our Ambulatory Surgical Center in Edmonds. Most surgeries are performed here. However, certain indications may lead to surgery in a hospital setting.

Some reasons for surgery in a hospital setting are: • Current or past medical conditions may cause some patients to be of higher risk. The surgical team will inform, educate and consult with you on this matter if it arises. • Insurance coverage criteria may include the necessity to utilize a hospital. You will be made aware of this during your Intake appointment at the very beginning of your journey.

• Your Body Mass Index (BMI) is very high. In this case, you may consult with the surgeon and nutritionist if you are motivated to bring your BMI down prior to surgery. We can give you the tools to help achieve this goal. • All Laparoscopic Gastric Bypass Surgeries are performed in a hospital setting.

Evergreen Hospital Medical Center 12040 NE 128th St. Kirkland, WA 98034 (425) 899-1000 www.evergreenhospital.org

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Bariatric (Weight Loss) Surgery Types “I can tell you, with pure honesty, that since meeting the staff, I became family. The staff made me feel very relaxed and confident every time I was there. They connected me with an excellent nutritionist and people who were able to relate to my needs and cravings.� - Mark C.

FOP

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LapSleeve During LapSleeve® (also known as a vertical sleeve gastrectomy) surgery, the majority of the greater curvature of the stomach is removed and a tubular stomach is created, which will be the size of a small banana after surgery. The new tubular stomach has a small capacity, is resistant to stretching and has few ghrelin producing cells (a hormone involved in regulating hunger and food intake). This is considered a less invasive procedure as the intestines are not rerouted. • The surgery does not involve cutting or changing the sphincter muscles that allow food to enter or leave the stomach. • Typically this surgery is performed in under an hour. When you eat after having this surgery, the small pouch will fill up quickly. You will feel full after eating a very small amount of food.

Laproscopic Gastric Bypass The gastric bypass reduces the size of the stomach by well over 90%. The gastric bypass pouch is formed from the part of the stomach that is least susceptible to stretching. The intestines are also rerouted during this procedure. The stomach pouch is connected directly to the middle portion of the small intestine, bypassing the rest of the stomach and the upper portion of the small intestine (duodenum). When the patient ingests a small amount of food, the first response is a stretching of the wall of the stomach pouch, stimulating nerves that tell the brain that the stomach is full. The patient feels a sensation of fullness, as if they had just eaten a large meal—but with just a small amount of food. This reduces the amount of food you eat and the calories consumed. Bypassing part of the intestine also results in fewer calories being absorbed.

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vBloc The Vagus Nerve sends signals between the brain and the stomach that control the sensation of hunger. vBloc Therapy intermittently blocks those signals, delivering consistent therapy to control hunger. vBloc® Therapy, delivered via the Maestro® System, is now approved by the Food and Drug Administration for weight loss in adults with a BMI of 40 to 45 or a BMI of 35 to 39.9 with a related health condition such as high blood pressure or high cholesterol levels.

The device intermittently blocks vagal nerve signals throughout the patients waking hours. The Maestro System is recharged using an external mobile charger and transmit coil worn by the patient. The device can be noninvasively programmed, and it can be adjusted, deactivated, reactivated or completely removed if desired. Dr. Peter Billing is the first surgeon in Washington state to offer the vBloc procedure.

The Maestro® System consists of a subcutaneously implanted rechargeable neuroregulator and two electrodes that are laparoscopically implanted by a bariatric surgeon. It delivers vBloc® vagal blocking therapy via these electrodes that are placed in contact with the trunks of the vagus nerves just above the junction between the esophagus and the stomach.

Adjustable Gastric Band and Band Adjustments Laparoscopic gastric banding is a purely restrictive procedure that compartmentalizes the upper stomach by placing a tight, adjustable band around the entrance to the stomach. The gastric band consists of a soft, locking silicone ring connected to an infusion port placed in the subcutaneous tissue. The placement of the band creates a small pouch at the top of the stomach. This pouch holds approximately half a cup of food, whereas the typical stomach holds about 6 cups of food. The pouch fills with food quickly, and the band slows the passage of food from the pouch to the lower part of the stomach. As the upper part of the stomach registers as full, the message to the brain is that the entire stomach is full, and this sensation helps the person to be hungry less often, feel full more quickly and for a longer period of time, eat smaller portions, and lose weight over time.

Gastric bands will need adjustments, or “fills ” to ensure comfort and effectiveness. The gastric band is adjusted by introducing or removing a saline solution through a small access port placed just under the skin. A specialized non-coring needle is used to avoid damage to the port membrane and prevent leakage. Over the course of several visits to the doctor, the band is filled until the optimal estriction has been achieved—neither so loose that hunger is not controlled, nor so tight that food is unable to move through the digestive system. The number of life-long adjustmentsrequired is an individual experience and cannot be accurately predicted.

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‘Revisional’ Bariatric Surgery The option for revisional surgery represents an increasing population of patients who have previously had gastric banding, vertical banded gastroplasty, or other bariatric surgery and now wish to proceed to LapSleeve® or gastric bypass. There are also rare occasions when patients with older bariatric surgeries are seeking a revision of their original procedure. Patients are seen in consultation to discuss their surgical options. The need for revisional surgery can arise, as patients may not experience successful longterm weight loss with their first choice such as

gastric banding. Additionally, the revisional bariatric patients with gastric bands may have experienced difficulty with slippage or other band complications and will need the band removed opting for LapSleeve® or gastric bypass to maintain or continue their weight loss. The revisional bariatric surgical patient may have their surgery “staged” in steps if they currently have a gastric band, with the first step being the band removal, followed by a physician determined waiting period (i.e. 6-8 weeks), and then proceed to LapSleeve® or gastric bypass surgery.

We welcome you to discuss this option if you have had gastric banding or another bariatric procedure and are considering revision. We will have one of our bariatric surgeons meet with you to discuss your revisional bariatric surgery.

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Comparison of Weight Loss Surgeries

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Your First Steps: Surgical Consultation

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Your Bariatric Consultation The bariatric consultation is an important opportunity to meet with your bariatric care provider and discuss bariatric surgery options. This appointment will review your surgical pathway and the requirements set forth by your bariatric team.

The completed consultation will set you on your pathway to surgery and you will receive information about further testing, evaluation, or referrals to other providers. It is important that you follow up in the recommended time frame so there is no delay to surgery.

The bariatric provider will review your medical history, surgical history, family medical history and your current medical status. Themedical history and current medical status may require that, in addition to standard preoperative testing, you may need further evaluations such as cardiac clearance, pulmonary clearance for lung conditions such as sleep apnea, or studies to evaluate your digestive tract.

You will be notified as you proceed regarding test results that need further evaluation. We appreciate your patience in advance in getting any recommended testing, as your safety is our first priority. After meeting with your surgeon, you will meet with a Bariatric Pathway Coordinator who will review your pathway to surgery in detail and provide more information about your comprehensive The surgical options with the risks, benefits, and poten- aftercare program. tial complications associated with the choice of bariatric surgery are explained in depth during your bariatric consultation. You are encouraged to ask questions and address concerns about your surgery at this appointment so you will feel well informed. It is recommended that your support person attend your clinic visits with you so that they have an opportunity to learn and ask questions as well. The bariatric provider will review your medications and medical conditions, and will complete a physical examination during your consultation. The physical examination will be an opportunity to evaluate for any additional medical concerns and also to explain the anatomy and postoperative expectations as they relate to your surgery.

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Bariatric Intake - Meeting with a Bariatric Pathway Coordinator This meeting takes place immediately after your surgical consultation is complete and is generally 30 to 45 minutes to complete. Your meeting with your Bariatric Pathway Coordinator is an informative meeting. This meeting is free of charge. We will cover the following information: • Your path to surgery and surgical screening – Necessary assessments and clinical screening needed will be reviewed as a whole, giving you a better timeline of events. Insurance criteria (i.e. BMI requirements, supervised diet requirements etc.) will also be reviewed if applicable. • Your financial planning – Insurance coverage or private payment options are discussed. • Your aftercare – A complete overview of our comprehensive aftercare program is reviewed.

The purpose of this appointment is to outline the full program taking into consideration your specific needs. You will receive reference information outlining every detail. Our goal is to help you along your path to surgery. Some of our Bariatric Pathway Coordinators are also bariatric patients themselves.

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Surgical Screening What are the next steps?

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What is the next step? The pre-surgical pathway will have been explained during your initial bariatric consultation. The bariatric provider will have outlined the steps in your individual pathway based on your medical history, surgical history, and current medical status - you may have additional requirements to meet before your surgery. The presence of other medical conditions such as diabetes, heart disease, or lung disease can affect the possibility of surgical complications and may prompt referrals to other specialists who can better evaluate the status of those medical conditions. You should have received your referrals and will need to make sure that those appointments are made. If you need help with obtaining a referral, please contact your surgeon’s medical assistant. It is important that copies of any pertinent medical records such as blood work and imaging such as CT scans, ultrasounds, or recent hospitalizations/surgeries are sent to your bariatric team.

• Lab Studies: (checking blood counts, kidney function, liver function, cholesterol, thyroid, and diabetic markers; abnormal results may prompt further evaluation) • EKG: (checking for heart abnormalities; an abnormal EKG may prompt further evaluation) *this is typically done at your consultation appointment. • Psychological Evaluation: This is an important tool that will help identify any issues or concerns that can serve as obstacles to your surgical success. • Nutrition Assessment: Your opportunity to meet with your nutrition provider who will get a baseline nutrition and weight history and educate you to the nutritional changes and needs as they relate to your surgery.

• Initial Biometric Assessment: Your current and past physical activity, experiences and results will be reviewed. Any physical or medical limitations hindering exercise will be discussed. Your pre-operative The pathway to bariatric surgery includes the measurements will be recorded. Biometric testing following requirements with specific variations (Bod Pod & Med Gem) is completed to ensure your depending on the patient’s individual medical needs. care meets your individual needs. Education and goals will be addressed as your physical activity will be a key factor in your long term weight loss. • Supervised Diet: This may be a requirement of some insurance providers and can vary from three to six months prior to their approval for surgery.

You will be contacted to schedule your surgery once all your evaluations are complete (insurance authorization is in place - if applicable) and your chart has been reviewed by the surgical team for clearance. It is very important to maintain communication during this time and update your bariatric team to any changes in your medical history, surgical history, or current medical status as they may be important to know for your surgical safety.

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Psychological Evaluation The psychological evaluation is a fundamental requirement for all bariatric surgical patients. We recognize that the choice to have bariatric surgery is an important one that can affect patients both physically and emotionally. The need to identify any obstacles or issues that may be affecting a patient’s emotional health is critical to a successful outcome for bariatric surgery. These issues may include (but are not limited to) depression, anxiety, addiction, or disordered eating patterns and can be addressed if recognized so that you achieve long-term success with your bariatric surgery. You will meet with one of our therapy specialists to conduct this evaluation in a comfortable setting. It is truly a benefit to begin your journey with an Eviva specialist to set the stage for your mental healthcare throughout your entire program. Our providers specialize in caring for the bariatric patient and are delighted to begin this connection at your psychological evaluation. The possibility of delaying surgery based on the evaluation exists if issues are identified by the bariatric team that may be an obstacle to your success or affect your surgical safety. We provide you resources to address any identified issues such as depression, anxiety, addictions, or additional recommended therapies. You will need to follow up on these recommendations, and be aware that received documentation will keep your bariatric team apprised of your progress and ability to proceed toward surgery.

We want to ensure that our approach is holistic and one that incorporates your physical, emotional, and medical well-being. The result of this approach will be that you experience sustained, successful weight loss through bariatric surgery. We thank you for following through with this recommendation and encourage you to contact us at any time with questions regarding the psychological evaluation requirement.

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Nutrition Assessment The nutrition assessment conducted by a dietitian specializing in bariatric surgery, is one of the most important steps on your surgical pathway. The purpose of the nutrition assessment is to get a baseline history of your eating patterns and weight history and educate you to the process of nutritional success before, after, and in the long term following your bariatric surgery.

You can pinpoint previous challenges that may have hindered your weight loss efforts and learn new strategies on how to cope with issues such as emotional eating, night eating, or mindless eating.

The nutrition assessment may also include assistance to reduce your BMI to overall prepare your body for upcoming surgery. Once surgery is scheduled you will again meet with one of our dietitians to The assessment will also explore any areas of needed review pre and post op diet considerations. nutrient improvement, proper hydration patterns after You will be on a preoperative diet two to three weeks surgery, and explain the role of vitamins and supprior to surgery to make your surgery safer as it plements after your surgery. The nutrition follow-up relates to liver size. The surgical technique requires appointments after surgery are critical to your sucmanipulation of the liver. The preoperative diet cess as they are important sources of ongoing supreduces liver size and will help make your surgery port to ensure that you feel well, are eating well, and are meeting your nutrition needs. It is also important safer and successful. to discuss how to incorporate the needed changes to your new eating patterns into your lifestyle. It is important to discuss eating behaviors, food preferences, and the role of food as it relates to your daily life at the nutrition assessment. The need to identify cultural specifications is also important, as is the planning for special events, religious/spiritual considerations, and lifestyle nutritional preferences such as veganism or vegetarianism.

The follow-up support given by your nutrition team is very valuable. Their guidance will aid you in achieving optimal health and wellness by providing education on nutrient intake, optimal hydration and healthy weight loss. The long-term appointments will strengthen your commitment to making your bariatric surgery a success.

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Biometric Assessment Fitness and biometric testing play a crucial role in long term weight loss success. At the Biometric Assessment you will meet with your Bariatric Exercise Physiologist. Within this appointment many topics will be discussed; the goal is to assess your current and past fitness programs, abilities, and goals. Biometric testing using the Bod Pod速 and Medgem速 to determine body composition and resting metabolic rate are completed to accurately track physiological changes and tailor your dietary and exercise prescription accordingly. Time will be spent reviewing past fitness programs to determine why they were successful or unsuccessful. We will also provide education on the importance of fitness before and after bariatric surgery. We pride ourselves on having available fitness programs tailored to each individual based on current physical and medical conditions. This assessment will be reviewed by your bariatric team to provide a better understanding of your skills, abilities, and specific needs. Maintaining a complete fitness program that encompasses resistance, cardio and flexibility training is essential to maximize weight loss and maintain muscle mass during rapid weight loss.

BodPod速 Body Composition Measurement The Bod Pod is a highly accurate test to determine your individual body composition of lean body mass and body fat. This test will also be used to track even the smallest changes in your body composition. The feedback you receive from the Bod Pod can be used to determine the success of your nutrition and exercise program, monitor for obesity, help you lose or gain body fat safely, fine tune your athletic performance and more. How accurate is it? The BodPod, which uses air displacement technology, is considered to be the gold standard of body composition measurement. MedGem速 Resting Metabolic Rate Measurement The MedGem test accurately measures your Resting Metabolic Rate (RMR). Your RMR is the total amount of calories burned each day through normal cellular activities and can be influenced by a number of factors such as: Age, gender, body weight, hormones, medications, muscle mass, etc. Knowing your RMR will determine your unique metabolism so we can develop a personalized plan to help you reach your goals. The MedGem is a handheld indirect calorimetry device, clinically-validated and FDA-approved, for measuring resting metabolic rate (RMR). It has a lightweight mouthpiece that you breathe through while your nose is plugged. The test takes approximately 7-10 minutes, you just sit still and breathe.

Long-term health benefits and your overall quality of life will be enhanced by a well-rounded fitness program that is specifically integrated into your care post-surgery. Forming lifelong habits and enjoying physical activity will enable you to be successful with an improved quality of life.

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Pulmonary Assessment Obstructive sleep apnea is a serious respiratory disorder with a well-documented weight relationship. Sleep apnea is linked to such conditions as high blood pressure and insulinresistance and may increase risks of abnormal heart rhythms, heart attack, or stroke. In addition, individuals with untreated sleep apnea experience such symptoms as morning headaches, memory and concentration impairment, low energy, and daytime sleepiness, which can reduce quality of life. The presence of undiagnosed, untreated sleep apnea significantly raises the risks of complications in the postoperative period. The combination of anesthesia and pain medications may further decrease effective breathing and, in the setting of untreated sleep apnea, this can be a life-threatening event after your surgery. The need for testing for sleep apnea will be determined by a number of factors such as BMI, neck size, personal and/or medical history, and physical assessment by your bariatric provider. The treatment for diagnosed sleep apnea will be determined by your pulmonologist, or lung doctor, whom you will be referred to if you are deemed to be at risk for sleep apnea.

recommended sleep equipment is working and that the fittings or settings are correct (if you are found to have sleep apnea). Depending on the recommendations of your pulmonologist and your insurance requirements (if applicable), you may be able to conduct a sleep study at home with a small equipment kit. If you do not have a pulmonologist, a referral will be made at your first consultation with your bariatric surgeon. We work closely with area providers who are ready to help you along this journey. Once this information is gathered you will be given clearance for your bariatric surgery by the pulmonologist who determines your risk of postoperative problems due to sleep apnea. You will need to bring your CPAP machine with you to surgery and plan to spend the night in the ambulatory surgery center following your bariatric surgery. You will continue to use the CPAP until you are reevaluated by the pulmonologist who will determine if you still need to wear it.

The pulmonologist will see you for an initial consultation and will take all of your information or history into account when determining testing needs. You may be required to do a sleep study, which will be a separate appointment usually done at a sleep center. Once your sleep study is completed you may be required to attend follow-up appointments to determine if your

Eviva works closely with area providers to provide the best in Sleep Apnea testing and treatment. We recommend utilizing our sleep medicince services to help expedite your process.

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An Overview of Sleep Apnea Normal airway during sleep This figure shows how the tongue, uvula, and soft palate. (which make up the upper airway should normally look in a person who is sleeping.)

Sleep Apnea Normally when a person sleeps, the airway remains open, and air can pass from the nose and mouth to the lungs. In a person with sleep apnea, parts of the throat and mouth drop into the airway and block off the flow of air. This can cause loud snoring and interrupt breathing for short periods.

Treatment of Sleep Apnea Continuous positive airway pressure (CPAP) for sleep apnea The CPAP mask gently blows air into your nose while you sleep. It puts just enough pressure on your airway to keep it from closing. The mask in this picture fits over just the nose. Other CPAP devices have masks that fit over the nose and mouth. There are variations of equipment that can be tailored to your preferences.

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Appointment Worksheet

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Pathway to Surgery Your Eviva team is dedicated to helping you reach your surgery in a timely manner. Be sure to complete your Surgical Screening items on the previous page. You can begin scheduling your needed screening items now.

Your Bariatric Pathway Coordinator You will hear from patient support staff while you are working towards completing your surgical screening items. If you have any questions or concerns about your steps to surgery, please call the office to speak with your Bariatric Pathway Coordinator. We are here to help. Please be sure to keep your coordinator updated on your progress to surgery.

Eviva Main Office, Clinic and Surgery Center 21911 76th Ave. W., Suite 106 | Edmonds, WA 98026 Phone: 425-778-2220 | Toll-Free: 1.844.EVIVAMD Fax: 425-778-7701 | Open M-F, 9am to 5pm Call the main office line for the after hours surgeon on call for urgent matters only. For Medical emergencies dial 911 My Bariatric Pathway Coordinator is: ____________ ext. _____

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My Notes:

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Surgical Review Clearance and Scheduling

After the completion of your surgical screening items (and your insurance approval, if applicable) and once all records and test results are in your chart, your chart will be reviewed by the surgical team for official surgery clearance. This is typically completed within onebusiness week. Once you are cleared for surgery, you will hear from our surgery scheduler to officially schedule surgery and your pre and post operative appointments.

so you can have them filled and ready for surgery ahead of time. Any out-of- pocket surgical payment is due at this time. Diet Education Class: This is your preoperative appointment with your dietitian two to three weeks prior to your surgery date. You will receive education and materials on the Preop low-carbohydrate diet as well as the post-operative ‘transitional diet.’

The ‘Final’ Appointment: This is your preoperative appointment, which typically takes place within 30 days prior to your surgery date. It is the final clinic appointment prior to surgery. You need to bring your personal support person to this appointment. You will review any last-minute questions, sign consent forms, and discuss your surgery and recovery process. Prescriptions will also be given at this appointment Contact us at 1.844.EVI.VAMD (1.844.384.8263) for a consultation, or learn more at www.evivamd.com.


Surgery Schedule My Checklist and Resources

Diet and Education Class 1.5 hrs Date______________ Time______________ With your Dietician about 2-3 weeks before surgery; to review pre-op diet and post-op transistional diet. Bariatric ‘Final’ Appointment – Preop at Clinic 1 - 1.5 hrs Date______________ Time______________ With your bariatric provider within 30 days prior to surgery; you must be joined by your personal support person at this appointment. Surgical payment is collected at this visit. self-pay package payment for self-pay patients or co-insurance/aftercare estimate for insurance patients. Surgery Day! Date______________ Check-in Time______________ Location______________ My Personal Support Person______________ Post-op Clinic Appointment Date______________ Time______________ One to two weeks postop visit to clinic, additional post-op appointments may be requested by your provider. Nutrition Post-op Phone Appointment Date ___________ Time___________ A dietitian will call you for this scheduled phone appointment about 2 weeks.

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Postoperative Concerns Comprehensive Healthcare Overview

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Treatment of Sleep Apnea The weeks and months following bariatric surgery can bring a number of issues that patients often discuss at their follow-up bariatric care visits. These issues may include mild depression, as the changes from weight loss and lifestyle may trigger a sense of loss or mourning surrounding food.

You may notice hair loss in the two to six months after surgery which may be a stress response to surgery and rapid weight loss. However, the hair loss is transient and your hair should grow again after this phase. You should continue with vitamins as instructed to help lessen the hair loss you experience. These issues are important to discuss at It is important to develop healthy outlets that can your follow-up bariatric care appointments to gain assist with shifting the focus from food as the main strategies to help cope with physical and emotional event to making food a part of your lifestyle activities. symptoms after surgery. It is very important you reach out to your bariatric provider or primary health care provider if your deWith impending weight loss you may experience pression is severe and/or accompanied by thoughts subsequent concerns about loose skin, which can of self-harm or suicide. make activities difficult, cause skin irritations, and make clothing challenging to fit properly. We have The social expectations with weight loss surgery may on staff a full-time cosmetic, as well as a plastic come from friends, family, coworkers, and others who surgeon, who are available to discuss options to remay be interested, excited, or concerned with the move and tighten the excess skin after weight loss. changes they witness. We recommend you prepare individuals close to you for these changes as much It is very important to discuss these issues that you as possible, as they will be important support sources may experience and any others you note during and it may lessen the social stressors you face after your weight loss journey after bariatric surgery. We surgery. will assist you in your transition as well as provide tools and resources to help with your long-term You may notice that your moods and energy change success, health, and well-being. or fluctuate following surgery. You may experience changes in your bowel habits, either no hunger feelings or emotional or “head hunger�, and nausea or reflux if you eat too quickly.

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Comprehensive Aftercare Overview One of the most important aspects of bariatric surgery is long-term support to assist with maintenance of your successful outcome following surgery. If you are discharged the same day as surgery, you will be seen within the first 24 hours following your bariatric surgery for a general assessment and intravenous fluid administration to prevent dehydration in the early postoperative period.

We will keep your primary care doctor apprised of your progress and health changes following your surgery. We will also be available to you and your providers for any questions or concerns following your surgery. We are happy to educate fellow health care professionals about bariatric surgery, as we are passionate about improving your health and well-being.

Your next appointment will occur approximately one week following your surgery at which time you will have a general physical assessment, wound check, and possible removal of any drains placed during surgery. Once you are deemed to be progressing well and as expected, you will then be scheduled for ongoing bariatric follow-up appointments and laboratory monitoring for adequate nutrient levels, as well as ongoing nutrition, fitness and psychological care.

We will track your nutrition status and lab results to discuss them with you and to provide your entire Eviva team with information to optimize your health during your weight loss journey and lifestyle changes. We understand the challenges our patients may face and pride ourselves on being available at all times to assist you in meeting these challenges to ensure your success.

The bariatric follow-up appointment is an opportunity to discuss progress, issues, weight loss, activity, and changes in medications or health status. It is important to discuss any health changes or surgeries at each visit. We will continually revisit the improvement of any obesity-associated health conditions at your visits. You should plan on being seen frequently during the first year following your bariatric surgery. At your one year anniversary appointments you will work with your care team to determine your individual needs for your second year of aftercare. Once you have completed your two year program, we look forward to meeting with you anually.

We are pleased to have cosmetic and plastic surgeons on our care team who are happy to consult with you to discuss your resultant cosmetic concerns with your weight loss.

Contact us at 1.844.EVI.VAMD (1.844.384.8263) for a consultation, or learn more at www.evivamd.com.


Financial Planning I have insurance for bariatric surgery:

If you have insurance, but no coverage for surgery, If you have coverage for bariatric surgery on your cur- you may be able to utilize insurance coverage rent insurance plan, the detailed coverage for surgery throughout your surgical screening process. Please note, appointments and clinical testing prior to your will be conveyed at your Bariatric Intake - Meeting with your Bariatric Pathway Coordinator. Any patient surgery are the financial resonsibility of you, the responsibility for surgery will be due prior to surgery, patient, and these costs are not included in any ‘package pricing’ for surgery. typically at your ‘final’ preoperative appointment two weeks prior to surgery. Our insurance coordinator will obtain your estimated out-of-pocket amounts closer Postoperative Costs: Throughout your comprehensive aftercare program, to your surgery date. some clinical testing may be needed. For example, Please note, these specific amounts will be for surgical blood tests are necessary throughout your program for medical and nutritional monitoring. Insurance coverage only; your surgical pricing does not include patient responsibility/copays throughout your surgical is key to aiding in miscellaneous costs that may accrue over the next two years. If you have concerns screening process or throughout your aftercare program. Anesthesia and hospital charges (if applicable) about keeping your insurance, COBRA options, retiring, or switching insurance plans, please conare a separate financial consideration. tact the office. It is recommended that you maintain I do not have insurance for bariatric surgery: contracted insurance benefits throughout your entire program. Patients who are paying out of pocket for surgery will receive an explanation of costs and a copy of the financial ‘package pricing’ (breakdown of payments) at their Bariatric Intake - Meeting with your Bariatric Pathway Coordinator. Pricing varies depending on the surgery of choice as well as the location of surgery. Payment is due prior to surgery, typically at your ‘final’ preoperative appointment two weeks prior to surgery. Funding surgery is an important decision; we are here to help and have a financial coordinator on staff to assist with any questions or concerns. There are financing companies that can provide loans for your surgery. Please note, financing your surgery through our contracted third parties is valid for payment to Eviva only. Please consult our financial coordinator with any questions regarding financing.

Aftercare program costs will be addressed at your Bariatric Intake - Meeting with your Bariatric Pathway Coordinator. If you are paying out of pocket for surgery, your aftercare appointments with Eviva are included in your package pricing as noted in your financial package agreement.With a goal of successful and healthy weight loss, you, the patient, will need to prepare for ongoing postoperative costs related to supplementation, vitamins and even new wardrobe items. Please note: Your cost structure will also be affected by the location of your surgery. Your surgery may be determined as appropriate for the outpatient setting or, with medical concerns, may be recommended for an inpatient setting. The difference in surgical setting will affect cost and can be discussed with our business office personnel.

Contact us at 1.844.EVI.VAMD (1.844.384.8263) for a consultation, or learn more at www.evivamd.com.


Frequently Asked Questions Rescources and Other Information

Contact us at 1.844.EVI.VAMD (1.844.384.8263) for a consultation, or learn more at www.evivamd.com.


FAQs 1. How long do I need to be off work? The recommended time off from work is generally two to three weeks. This time may be longer for patients with a physically demanding profession. You will have this discussion with your bariatric provider to determine your plan. vBloc® therapy recovery is about one week.

5. Will I have a lot of pain? We make every attempt to control your pain level postoperatively. The level of pain you will experience is different for each patient. You will receive a prescription for some medication to help keep your pain under control after surgery while you are beginning to heal.

2.What is a personal support person? A support person is a legal adult who will be with you after surgery, helping you through your recovery and after. This is usually a spouse, significant other, or family member with a valid driver’s license.

6. What do I need to do to be successful after surgery? Perhaps the most crucial aspect of your success is your willingness and compliance when participating in the aftercare program. It is imperative that you come in for postop visits, bariatric follow-up visits, nutrition and mental health counseling sessions so we can evaluate areas where you are doing great and areas where we can help you along your journey. We have created a comprehensive program to teach you how to use your new tool. Fitness sessions and repeat biometric testing will enhance your results and long term success. Surgery is a lifestyle change that requires a strong commitment to behavior modification.

3.Effectiveness of weight loss surgery? The amount of weight a bariatric surgery patient can expect to lose after surgery varies and can depend on several key factors. These factors include: • Patient’s age • Weight before surgery • Overall condition of patient’s health • Surgical procedure preformed • Patient’s ability to exercise • Patient’s commitment to our comprehensive aftercare program • Motivation of patient and cooperation of his or her family and friends. 4. How long does it take to get insurance approval? Insurance approval time frames vary from patient to patient based on a number of factors. Requirements for every insurance company and plan are different. You can help expedite the process by completing any additional testing ordered by your surgeon in a timely manner. The sooner we have all the information we need, the sooner we can submit your claim to your insurance company.

7. Can I get pregnant after weight loss surgery? Our surgeons strongly recommend waiting 12-18 months after surgery before becoming pregnant. By that point, your weight should be stable and your body nutritionally sound to nourish a growing fetus. vBloc® therapy has not been established for use during pregnancy; discuss with your bariatric provider. 8. What is dumping syndrome? Dumping is a group of symptoms caused by eating or drinking high-sugar or high-carbohydrate foods and causes increased “racing” heart rate, sweating, cramping of the bowels, and potential diarrhea.

Contact us at 1.844.EVI.VAMD (1.844.384.8263) for a consultation, or learn more at www.evivamd.com.


FAQs cont. 9. Will I lose my hair after surgery? Many patients experience some form of hair loss or thinning after bariatric surgery. This usually occurs starting at month four and should resolve itself. Proper protein consumption is the number one way to help prevent hair loss. 10. How long will I be off solid foods after surgery? It will take you five weeks to transition from clear liquids back to solid foods after surgery. You will work closely with a dietitian while you are in this phase. vBlocÂŽ patients may have a short transition to solid foods. 11. What are the physical activity/lifting limitations after surgery? This concern will be addressed by your surgeon at your preop appointment. The resumption of physical activity will be different for each patient and surgery type. 12. Will I be allowed to drink alcohol? Alcohol can affect you very differently after surgery. Alcohol has the ability to cause ulcers when your stomach is healing from surgery and should be completely avoided for the first three months following your surgery. After three months it should be consumed sparingly, if at all, to help sustain weight loss and ensure you are getting proper nutrition.

14. Will I have to take vitamins forever? Vitamins will play an important role in your well-being postoperatively. You will most likely need to take these supplements forever to maintain proper vitamin levels. 15. What if I have excess skin? Excess skin can be an unpleasant side effect of dramatic weight loss. Some patients will choose to have plastic surgery to address their concerns. Usually, insurance doesn’t cover cosmetic surgery, but there are cases where insurance companies do cover some procedures to remove excess skin when complications from this skin arise. 16. How long will I follow up with my bariatric team? You will participate in a two year comprehensive aftercare program. We would like to see you annually after your program is complete.

13. How long does it take to get to surgery? The time frame for surgery varies greatly from patient to patient. Typically self-pay patients will get to surgery sooner, as they don’t have to wait for insurance authorization. Remember, you can control getting to surgery sooner by completing your assessments and clinical tests ordered by your surgeon as soon as possible.

Contact us at 1.844.EVI.VAMD (1.844.384.8263) for a consultation, or learn more at www.evivamd.com.


Bariatric Surgical Guide Sample