The Ohio State University Wexner Medical Center
The Comprehensive Weight Management, Metabolic and Bariatric Surgery Program

Bradley Needleman, MD: Hi, I'm Dr. Brad Needleman, Medical Director for the Comprehensive Weight Management Metabolic and Bariatric Surgery Program at The Ohio State University Wexner Medical Center. Together with Dr. Sabrina Noria, Dr. Stacy Brethauer, and Dr. Vimal Narula, we are the Ohio State Bariatric Surgical Team.

First and foremost, we want anyone considering bariatric surgery to know that your health and safety is our primary concern. We understand that losing weight can be a challenge for so many reasons. Our role is to give you the tools you need to help you lose weight, improve your health, as well as the motivation, encouragement, and support that's so crucial for long term success.

Now we'd like to discuss the different types of bariatric surgery as well as what to expect before, during and after any procedure.

Sabrina Noria, MD: All types of bariatric surgery involve making changes to your stomach or digestive system to help you lose weight, either by limiting the amount of food you can eat or by changing how your body processes food. No option is a quick fix. You'll still have to make changes to your lifestyle, which we will help you do. But these types of surgeries can be the right option when diet and exercise haven't worked to help you lose weight or keep the weight off and or you have a serious health problem as a result of your weight.

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Bariatric surgery:
- Surgery not a quick fix
- Must make changes to your lifestyle
- Valuable tool to help you be successful
- When diet and exercise have not worked
- When you have serious health problems as a result of your weight]


Stacy Brethauer, MD: To be considered a candidate for bariatric surgery and to get approval from most insurance companies, you must have a body mass index
above 40 or a body mass index of 35 to 39.9 with a qualifying medical condition, which is something that can be made worse by obesity, such as high blood pressure or type two diabetes.

BMI is a formula of your body weight divided by your height squared, and anything above 30 is considered obese.

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To qualify for bariatric surgery you must have:
- Body mass index (BMI) above 40
OR
- BMI of 35 to 39.9 with a "qualifying" medical condition, such as high blood pressure or type 2 diabetes

BMI = body weight / height^2]

In addition, you must have already attempted medical weight loss as a doctor supervised treatment, and you must understand the risks of the operation and be able to provide informed consent. We ask that each bariatric surgery candidate formally commit to the required lifestyle changes following surgery, including regular follow up appointments. 

At the same time, there are some factors that may make you ineligible for bariatric surgery. These include an untreated or uncontrolled endocrine or metabolic condition that causes weight gain. You will also not qualify if you are considered too high risk for the surgery itself, intend to become pregnant within a year of the surgery, or have a current substance abuse addiction, an eating disorder, or an untreated or unresolved major psychiatric condition.

Please know that these disqualifiers are only intended to protect your health and we can work with you to resolve any of these barriers if possible.

Vimal Narula, MD: If you meet the qualifications and are motivated to move forward, we're here to help you achieve the best possible results. For people with severe obesity the reality is that simple diet and exercise usually doesn't work long term, and any weight loss is typically followed by even more pounds regained. In fact, it's actually proven by research that surgery is the only effective solution for long term weight loss and control in people with a BMI of 35 or greater.

[Chart: most effective weight loss solution by BMI range

BMI of 25 to 29: Diet and/or exercise
BMI of 30 to 34: Medically managed weight loss
BMI of 35 to 39 with qualifying medical condition: Surgically managed weight loss
BMI of 40 and greater: Surgically managed weight loss

"Only surgery has proven effective over the long term for most patients with clinically severe obesity." - NIH Consensus Conference Statement, 1991]

For this reason, please know that you're not admitting failure if you choose surgery. You're actually choosing success.

Dr. Noria: There are many benefits to bariatric surgery, and the positive results won't take long to appear, but you will need to commit to the lifestyle changes. It's important to understand that the changes you make or don't make in the food choices and activity will have a direct impact on your success.

Patients who've had gastric bypass surgery can lose between 60 to 85% of their excess body weight over a period of 12 to 18 months. And with a sleeve procedure, patients typically lose 50 to 70% of their excess weight in 24 months.

After bariatric surgery, many people find that they need fewer medications because they've improved or completely eliminated some of their weight related conditions,
such as type two diabetes, high blood pressure, sleep apnea, high cholesterol, infertility, heart disease, joint pain and more. They may also enjoy a more active lifestyle, increased confidence and improved physical strength and endurance. It's also important to note that on average patients who have bariatric surgery have lower rates of premature death caused by heart disease, stroke, diabetes and cancer.

Dr. Needleman: Our primary responsibility is your health and safety. Although the experienced surgeons at Ohio State perform nearly 600 bariatric surgeries each year, we understand that this is your first experience with bariatric surgery. Or if you're coming to us for revision surgery from a previous procedure, it may only be your second. In either instance, this is a big step for you, and we want you to feel confident in your choice.

Dr. Brethauer: We are consistently recognized as one of America's best hospitals by U.S. News and World Report with more than 40 years of bariatric experience. Ohio State is also accredited as a comprehensive bariatric surgery center by the American College of Surgeons and the American Society for Metabolic and Bariatric Surgeries Accreditation and Quality Improvement Program.

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- More than 40 years of experience
- More than 4,000 surgeries performed over last 10 years]

We have an entire hospital floor dedicated to bariatric surgery with private rooms and a staff trained in providing dignified, sensitive care to those undergoing this life changing surgery. We perform more bariatric surgeries at Ohio State than any other program in central Ohio. In short, you're in qualified, experience hands at Ohio State.

[View of private room showing amenities: television, couch with table, hospital bed with bedside table, and Maxi Sky ceiling lift]

[Surgeon and care team sanitizes their hands before entering private room to talk to patient. All are wearing masks.]

Dr. Narula: We will always be open and honest, pushing you to do your best, no matter your procedure. We know this is more than just a surgery. That's why we offer a full range of support to make it as easy and convenient for you as possible. Depending on what you need, you will find a genuine partnership from not only your surgeon, but from every member of your care team, which could include a nurse practitioner, registered nurse, health coach, exercise physiologist, endocrinologist, pulmonologist [or sleep specialist], psychologist, cardiologist, dietician, and even other health experts such as plastic surgeon, transplant surgeon, neurosurgeon, or orthopedic surgeon if needed.

This comprehensive care will continue after you leave the hospital, too. Surgery is just the beginning and we'll be by your side for every step following, whether that is for continued nutrition education, exercise programing, or other health and wellness treatments.

Dr. Noria: Now let's review the types of bariatric surgery available at Ohio State. With all procedures, the average hospital stay is 1 to 2 days with recovery time from 2 to 4 weeks. In addition, almost all bariatric surgeries at Ohio State, over 98% are done laparoscopically, which means they are minimally invasive and don't require a big incision.

[Animation showing 5 laparoscopic ports placed in a V-formation on the abdomen.]

The benefits include less post-surgical pain, fewer noticeable scars, less skin and muscle tissue trauma, fewer wound complications, and quicker return to full mobility. 

While we'll explain the benefits, risks and details of each procedure at an in-person appointment, the main procedures we perform include gastric bypass, gastric sleeve, loop duodenal switch, gastric balloon, endoscopic sleeve gastroplasty and revision surgery.

All these operations affect your appetite, such as reducing the amount that you're able to eat and how your food is processed. There may be a reason that one is better for you than another, and we will work to help you understand which approach is best for you based on your unique medical history and your expectations.


Dr. Brethauer: The most common operation we perform is the gastric bypass. Also called the Roux en Y gastric bypass, this procedure has been used for over 50 years to treat obesity and associated metabolic conditions like diabetes, high cholesterol and high blood pressure. Ohio State surgeons were the first to perform minimally invasive gastric bypass surgery in central Ohio, and during this procedure, a pouch about the size of an egg
is made from the stomach and connected to a rerouted portion of the small intestine, thus changing how food travels through your digestive system. The gastric bypass keeps you from eating a lot of food at one time, and it also changes the way you process food, especially sugar.

[Animation: A small portion of the top of the stomach is detached from the remainder of the stomach. The small intestine is cut and connected to the small portion of the stomach. Food now proceeds from the esophagus into the small stomach and into the connected small intestine.] 

The next most common operation and the most commonly performed operation in the United States is the vertical sleeve gastrectomy or gastric sleeve. In this procedure, a narrow vertical sleeve of stomach is created about the size of a small banana, and then the rest of the stomach is removed. This procedure limits the amount of food you can eat and it helps you feel full sooner. And it also results in improvement in many obesity related metabolic conditions.

[Animation: The stomach is divided vertically, and a portion is removed.]

Dr. Narula: A loop duodenal switch, also known as SADI S, or SIPS changes your stomach and changes how food travels through your digestive system. We first perform a sleeve gastrectomy to reduce the size of your stomach, and then we divide the first portion of your small intestine right after your stomach called the duodenum and reroute to bypass much of your small intestines. This reduces the amount of calories and fat you eat and absorb. The result should be more weight loss than a sleeve gastrectomy alone. 

If your BMI is between 30 and 40, you may consider a gastric balloon procedure. For this, a medical balloon is inserted in the stomach to restrict food intake and leave you feeling full. Unlike the other procedures, this one is temporary because the balloon must be removed within six months. It is definitely the least invasive option and is not covered by insurance, which means you must pay for it yourself. But a gastric balloon may be all you need while working to establish new nutrition and lifestyle habits.

Dr. Needleman: Ohio State also offers revision surgery, which is for patients who have already had a previous bariatric procedure but experienced complications, had inadequate weight loss or regained weight. Revision surgeries for patients with complications include band removal (with or without conversion to gastric bypass or sleeve), sleeve conversion to gastric bypass or loop duodenal switch, revision of gastric bypass for ulcer disease,
gastro gastric (GG) fistula or for weight loss. For patients wanting more weight loss or have regained weight, surgery is determined on a case by case basis.

Kristen Tychonievich, APRN-CNP (Nurse Practitioner): If you think bariatric surgery might be the right option for you, you've started the first step of the process already, which is required viewing of this informational video.

Next, you'll download the surgery application from our website and call your insurance provider to check your insurance coverage. Ask if they pay for bariatric surgery, which they may also call treatment for morbid obesity or weight loss surgery, and ask if you need a referral. Are Ohio State and our bariatric surgeons covered by your policy? Specifically doctors Bradley Needleman, Sabrina Noria, Stacy Brethauer or Vimal Narula.

Each insurance provider has different requirements that must be met before approving your bariatric surgery, and some require you to complete a weight management program for a specific number of months or visits before they will grant approval. Once you understand insurance requirements, you'll need to complete and submit the surgery application.

Next, we'll schedule appointments for consultations with our medical team to make sure you're indeed ready for surgery and understand the associated risks, benefits and expectations.

Ashleigh Pona, PhD, (Psychologist): Bariatric experts will assess your overall health, determine your surgery readiness, and help identify which procedure may be best for you. You'll meet with a psychologist to learn more about your current and past habits, how you handle stress or major life events, how weight has affected your decisions, and more.

Weight loss surgery is a life altering procedure that requires addressing emotional, behavioral and physical components. Making lifestyle changes can be challenging. But our behavioral health team is here to provide you with support to help you experience a long term successful outcome.

All patients complete a behavioral health evaluation, which includes completing questionnaires and an interview with a psychologist. We will discuss your eating habits, weight, history, psychological history, and social and lifestyle behaviors. Our behavioral health team provides individualized recommendations and additional support with implementing healthy lifestyle changes.

Eva Panigrahi, PhD (Psychologist): Addressing eating behaviors can be challenging, especially for individuals who may use food to cope with emotions or stress. A unique resource that we offer in our program is a four-session, evidence-based cognitive behavioral therapy group that focuses on replacing unhealthful eating behaviors such as emotional, stress and binge eating with healthier coping strategies and addressing the relationship between eating and our emotions, thoughts and behaviors.

Roy Gildersleeve, RDN CSOWN, LD (Dietitian): A registered dietitian will make sure your nutrition is on target prior to surgery and you understand what it takes to be successful long term. Blood tests and other procedures may be scheduled to make sure you're optimized for a safe procedure.

At the end of these visits, you'll have a written plan to decrease your personal health risk for surgery, including medical testing and goals, as well as confirmation of insurance requirements and expected coverage.

Once your procedure is approved by your insurance company and you're ready for surgery, you'll have an in-depth, preoperative meeting with your surgeon and dietician to address any remaining questions or concerns and schedule surgery.

Tychonievich, APRN: All operations are performed at The Ohio State
University Wexner Medical Center main campus [410 W. 10th Ave. Columbus, OH 43210]. Outpatient consultations and office visits are offered in Columbus at Ohio State's Martha Morehouse Pavilion on Kenny Road [2050 Kenny Road, Concourse Suite 1222 Columbus, OH 43221]. But if you live in northwest Ohio, you can also have much of your preparation and follow up performed at Mary Rutan Hospital in Bellefontaine as part of a cooperative relationship with Ohio State and our bariatric program.

Typically, patients are admitted to the hospital on the morning of their surgery. The procedure itself will last about 1 to 2 and a half hours, and your hospital stay will be 1 to 2 days, during which time you'll be placed on a medically directed diet with support from our inpatient bariatric team. Following the diet is important to allow your stomach and intestines to heal.

Joann North, RN (Bariatric Inpatient Care Team): During your time at the hospital, where you will have a private room, our team will work closely with you to minimize your risk for potential side effects from surgery. The inpatient bariatric team will provide step by step dietary instructions for fluid intake to avoid dehydration and for keeping your sugar consumption low so you don't develop what's known as dumping syndrome, which can cause nausea or weakness.

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Dumping syndrome can cause
- Abdominal pain and cramping
- Diarrhea
- Dizziness
- Sweating
- Nausea
- Weakness]

In addition, the nurse practitioner on the inpatient team will provide guidance on what home medication adjustments may be needed in the early weeks following surgery and the importance of monitoring changes in your blood
pressure and blood sugar as your weight decreases.

With all bariatric surgeries, the average hospital stay is just 1 to 2 days. Once you have regained your strength, are able to move around and are consuming 40 to 48 ounces of fluid on your own you'll be discharged. 

Tychonievich, APRN: The support from Ohio State continues long after you head home. You'll have a follow up appointment with your surgeon about two weeks
after surgery, as well as 1 to 2 more appointments in the next two months. 

At six months, and then annually you'll do lab tests and a follow up appointment to discuss test results and any other concerns you may have related to your procedure. We'll continue to coordinate your care as needed with the bariatric care team. Later, if desired, we can refer you to an experienced plastic surgeon to remove excess skin that you may have after your weight loss.

Dr. Needleman: In the end, we understand that losing weight is difficult. So the entire bariatric team at Ohio State is here to make it easier in any way that we can.

We pledge compassionate care that is personalized to your specific needs. We will treat you with respect and assure you that your goals will become our goals. Bariatric surgery by a board certified surgeon at Ohio State is only the beginning. Although it doesn't guarantee a specific or permanent amount of weight loss, that requires significant lifestyle changes on your part, it can be your best option for living a healthy life.

Let's find out if it's right for you. We look forward to meeting with you to discuss different bariatric options when you're ready. And we thank you for investing the time to watch this video today.

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Next steps: If you are interested in pursuing bariatric surgery, please download and complete the surgery application located on our website. For more information, visit wexnermedical.osu.edu/bariatricsurgery]