1 Obesity treatment is always clinical and based in the triple reeducation, that is, nutritional, physical and psychological reeducation. It is necessary to eat the right food and the right amounts at every three hours, considering the taste of every patient, though. Also patient must have in mind that reeducation and the consequent change of habits/lifestyle is a long-term commitment, which he/she has to carry out throughout life. Additionally, weight-loss drugs are neither recommended nor helpful.

2 Clinical treatment has always good results for non-severely obese patients. However, for severely obese patients, that is, BMI greater than 40 Kg/m2 (see BMI Calculation), it usually does not have such beneficial results.

3 The only current treatment for Morbid Obesity (BMI greater than 40 Kg/m2) is surgery, according to the NIH (National Institute of Health) Consensus Conference Statement of 1991.

4 Bariatric Surgery is only recommended for patients with BMI greater than 35 and less than 40 Kg/m2, if there are 2 comorbidities, i.e., diseases coming from obesity, such as hypertension (high blood pressure), diabetes type 2, cardiovascular diseases, high blood cholesterol, arthrosis, and so on.

5 We recommend the Gastric Bypass Surgery only if we are sure that clinical treatment would not be successful.

6 The majority of children and adolescents should be treated with nonsurgical options.

7 The patient must learn everything that is to know about the surgical procedure before he/she takes the decision of being operated. It has to be a technical decision instead of an emotional one.

8 It is of great significance that the patient's family take part of that decision.

9 Since 2001, we, Franco e Rizzi Clinic, have been promoting monthly gatherings among patients and the multidisciplinary care team for general information exchanges. Pre-operative patients benefit by figuring out how their lives will be after the surgery. The patients already operated profit by not forgetting about obesity, which helps them not regain weight.
10 Bypass is a different surgical process from an appendectomy (removal of the appendix) because "fat does not simply leave" the body. A normal stomach is operated and not the origin of obesity. So, preserving the resulting weight loss due to surgery must be kept on through a lifelong medical, nutritional and psychological surveillance after surgical therapy. Patients must be aware that the surgical procedure is not a "silver bullet". A partnership among patient, his/her family, surgeon, nutritionist, physiotherapist and other professionals is indispensable throughout the endeavor. Patient and family have to be properly educated and psychologically prepared, only then patient should undergo surgical procedure. It's worthy waiting for the "perfect moment" for the operation, even if it takes longer. This is a procedure that should be performed only once and the outcome has to be perfect. For all those reasons, it's impossible to meet the surgeon and having the operation performed within the next 5 days.

11 The psychologist analyzes the state of mind of the patient to be assured that he/she fully and completely comprehends what is going to happen to his/her body after the surgical procedure. The professional also has to be certain that the decision of being operated is technical rather than emotional, in addition to adjust the patient's expectations as much as possible to reality to avoid disappointments. Such adjustment is vital to a psychologically healthy life after the operation, because many times patients have the illusion that by loosing weight, they would solve issues related to other areas of their lives. For instance, by losing weight one could expect to save a failed marriage, or even getting a promotion or a better job.

Another important task for the patient/psychologist relationship is to find "sources of pleasure" other than eating, even before the surgery. It is vital for the success of the procedure to fulfill the possible feeling of "emptiness" that might come with the patient not being able of getting so much pleasure from eating.

12 The nutritionist evaluates the particular origin of the patient's obesity. The professional also appraises the percentage of fat mass, fat-free mass and total body water through Bioimpedanciometry, and the basal metabolic rate through Calorimetry, which quantifies the amount of energy expended while at rest. Those data are important to the weight loss follow-up. The nutritionist analyzes the dosages of the blood components, as erythrocyte (red blood cells), albumin, vitamin B12, iron, calcium, zinc and so on, to correct any deficiencies before the operation. And also, before the surgery, the professional instructs the patient on how his/her food habits should change after the procedure.

13 The physical therapist evaluates the patient's respiratory conditions and then instructs patient to utilize a portable respiratory exerciser apparatus to improve his/her ventilation to prevent lung complications, such as pneumonia and atelectasis. Besides, the professional also appraises patient's leg muscles to program physical exercises to prevent venous thrombosis and pulmonary embolism, and also aerobic activities for the next seven months after the surgery, in order to burn calories.

14 It is the surgeon, during the operation, who modifies the digestive tube of the patient, however it is the patient's responsibility to make good use of that modification. Therefore, the patient has to be trained on how to take advantages of the "new equipment". It is like giving a state-of-the-art car to someone whom does not know how to drive.

We believe that the patient and our multidisciplinary team are in partnership, although major responsibility lies with the patient. The patient must stick to the instructions given by us and attend to every appointment we make.

15 When the team and the patient are ready for surgical process, the patient is submitted to obligatory preoperative exams (Endoscopy, Ultrasonography, Lab Tests and Cardiac Evaluation). Whenever necessary, the patient is also submitted to evaluation with a pneumologist and with a specialist in sleep apnea.

16 We prepare the patient the best way possible, however, obesity sometimes causes such severe diseases that we are not able to equilibrate all clinical parameters and we operate the patient even if he/she has high blood pressure or high glycemia levels. We put all our best efforts, though.

My suggestion is to add or replace with: In these cases, we decide for the operation because the patient's life is in serious risk due to obesity.

17 The patient reads and signs Informed Consent, which is given by the Clinic. That document instructs and discusses many aspects of the surgery and its outcome.

18 Twenty days before the operation, the patient needs to lose as much weight as possible for two reasons: first, it considerably improves heart and lungs conditions; besides, this weight loss causes a fast downsizing of the liver which helps substantially the videolaparoscopy surgery. Some livers are so big and heavy that it is impossible to operate through videolaparoscopy and the surgeon is obliged to choose the conventional surgery (surgeon makes an incision, about 20 cm long).

19 The patient must stop taking acetyl salicylic acid (ASA), contraceptive pills and avoid smoking before surgery. We recommend that patient talks to his/her cardiologist to know for how many days would be advisable stop taking those medicines.

20 Pregnant patient can not be operated. If there is any suspicion about the possibility of pregnancy in the day of operation, the patient must tell us so we provide β-hCG blood test.

21 The day before surgery, patient is put on a strained liquid diet. Ten hours before the procedure, patient must be in absolute fasting (not even water is allowed).

Patient arrives at the hospital two hours before the scheduled surgery and brings all the test and evaluation results from cardiologist, pneumologist, endocrinologist and any other physicians involved. Also, he/she brings compression socks, respiratory exerciser apparatus and blue food coloring dye.

The team's anesthesiologist visits the patient in his/her room and prescribes a preanesthetic, which causes some sleepiness, then the patient is transferred to the Operating Room. We advise that patient has companion during the period in the hospital.

22 In the Operating Room all the preparations are made for the procedure (punches, catheters, probes and videolaparoscopy equipment setup).

The interval between patient leaving the room and the beginning of surgery is from one hour and a half to two hours. The actual surgery takes from two hours and a half to three hours. When the procedure is finished, the surgeon calls the companion in the patient's room to report how the operation went. The patient wakes up still in the Operating Room and then transferred to the Recovery Room (Post Anesthesia Care Unit), where stays for observation for more two hours and a half to three hours. After that, the patient usually goes to the room. So, the interval between getting out and coming back to the room takes approximately eight hours. Exceptionally, the patient can spend all day long in the Intensive Care Unit, if he/she presents high blood pressure, uncontrolled diabetes or serious bronchitis.

23 At this point, the patient comes back to the room, around 16:00 o'clock. He/she is asleep with intravenous fluids and vesical (urinary) probe. The patient continuos in absolute fasting until the next day.

Whenever the companion realizes the patient is awake and willing to get out of bed, he/she must warn the nurse on duty, who has already been oriented to pull the vesical probe out, when the patient is awake. Then, nurse and companion help the patient to sit down. After thirty minutes sat in bed and feeling good, the patient can slowly and carefully stand up and take his first steps through the hospital corridor, always with the help of nurse and companion. From this moment on, it is important that patient do not lie in bed again. He/she has to walk and sit down in the room armchair. Some patients prefer to sleep on the armchair, because lying-down posture causes backaches and bad breathing. If nauseous, patient needs to spit the saliva in a face towel, which must be kept near the patient all the time.

Every night, patient takes a subcutaneous injection containing anticlotting substances to avoid pulmonary embolism. This medication is maintained during seven days, according to patient condition.
24 Post-operative day # 2 is a repetition of the first day: fasting, spitting saliva, walking and sitting on the armchair. Patient should not lie in bed.

25 In the morning of postoperative day # 3, surgeon prepares a 20 ml solution containing the blue food coloring dye that patient brought. Patient drinks the solution slowly and watches the drain. This is called "Blue Test".

Most commonly, we do not see the blue dye coming out of drain which indicates Negative Test Result. From this point, we start with oral feeding, and patient drinks 20 ml of liquids, such as water, tea, coconut water and isotonic beverage, within ten minutes interval. The Blue Test must be repeated three times a day, (in the morning, at two p.m. and at night) during seven days. Usually, the blue dye does not go out in the drain.

Note: If there is any blue dye solution in the drain, it means that a staple is pulled loose, causing a fistula. In such event, the physician places a nasoenteral feeding tube to nourish the patient during a month. During this period, patient is in oral fasting. Ordinarily, by this procedure the fistula is healed and the patient, even with the feeding tube, can have a normal life (work and drive).

26 If the postoperative day 3 # was a good one, that is, Blue Test is negative, patient drinks liquids, walks enough and presents no dizziness, pain or vomit, he/she is able to leave the hospital in the postoperative day # 4.

27The routine at home is the same as the day before, i.e., the patient slowly ingests
20 ml of liquids and waits ten minutes before next sip, walks, climbs stairs, always with company, and lies in bed as minimum as possible. The patient also takes the Blue Test three times a day. If there is any leakage, that is, any signals of blue dye solution, patient must call the surgeon (Dr. Roberto Rizzi) immediately. Together, patient and surgeon, go to the hospital to place a nasoenteral feeding tube, as described before.

Patient must wear compression socks at all times (except during shower). He/she also must take subcutaneous injection with anticlotting substances at 19:00 o'clock every night. Early in the morning, for the next thirty days, patient ingests a smashed pill of a medication called Nexium 40 mg. Patient may be prescribed with analgesic and anti-flatulence medicines. It is important to emphasize that all medication for the next three months has to be crushed (in case of pills) or drop solution.

The first month after the surgery, patient must talk to his/her physician to adjust dosages of medication for hypertension or diabetes type 2, or any other comorbidities, because the weight loss is so severe that causes impact on those diseases.

During this period, patient may experience weakness and dizziness, due to poor caloric intake. For that reason, patient can not drive or be left alone.
Postoperative day # 8, patient returns to surgeon's office for the drain removal. However, Blue Test must continue for two more days. After drain removal, patient may do whatever he physically feels like. As soon as the incision from the removed drain is healed (from two to three days), the patient can even go swimming.

28 Until the thirtieth day after the surgery, there is always a risk of a staple pulling apart, which may cause a fistula. So, it is important to keep with a strained liquid diet, according to the nutritionist orientation.

Thirty days after surgery, there is no more risk of fistulas and patient can eat normal food, according to the nutritionist orientation; one of them is to have three small meals (around 250 g each) a day, chewing slowly and thoroughly.

29 During first months some few patients may experience temporary greenish
oily diarrheal episodes.

30 Patient must eat red meat for the entire life. Red meat prevents the risk of anemia, because it is an outstanding source of iron, proteins and vitamins.

31 It is forbidden to eat fruit pulp (in fruits like orange), peel (like grapes) or pit. Those can clog up the stomach and intestine. Due to high caloric content, it is not permitted to eat sweets. Finally, it is also forbidden to take any anti-inflammatory agent, because they can cause stomach ulcer. Those are lifetime prohibitions for patients who undergo Bypass Surgery.

32 Fat burning period occurs during the first seven months after surgery, if the patient has a routine of aerobic exercises. We strongly suggest that the patient goes walking or swimming for three hours a day, in order to maximize the fat burning results. During this period, patient must refrain from practicing high impact sports or activities to avoid fractures or sprains, since being immobilized would jeopardize the process.

At the end of the seventh month, the weight loss results are the best ones and after that period it is unlikely to drop off much more weight. For that reason, we recommend patient to exercise over anything else during that time. So, whenever the patient chooses a data for the surgery, he/she has also to schedule some free time to exercise for three hours a day, for the following seven months. And once again, we remind that it is prohibitive the ingestion of sweets since they get in the way of loosing weight.

33 The first year after the surgery, patient loses weight very fast which can cause anemia. For this reason, we suggest that women patients talk to their gynecologist to interrupt the menstruation cycle for a year. Actually, any patient who has heavy menstrual blood loss should interrupt it before the procedure. The only restriction is to make use of hormones that cause body water retention.

34 Due to fast weight loss during the first year, some women experience weakness, maybe because of the menstrual cycle. Women should not get pregnant during that period since they may feel tired and there are also possibilities of fetal malnutrition.

Many studies have shown that there is improvement of female fertility after weight loss, and pregnancy risk is high. So it is fundamental a rigorous gynecological follow-up, at least for a year after Bariatric Surgery, to avoid pregnancy.

35 It is usual some hair loss after the operation. The nutritionist helps by prescribing mineral supplements. After the first year, it gets back to normal.

36 The communication between pouch and intestine is calibrated in 1.2 cm in order to limit the food receiving capacity of the stomach, causing fullness sensation, without provoking vomit. In case of swallowing a big chunk, without properly chewing it or food with high fiber contents, the patient may experience discomfort. The discomfort is caused by the food blockage between pouch and intestine. In such event, usually the patient vomits and feels better; otherwise the clogging has to be removed by Digestive Endoscopy. If the episode becomes recurrent, we perform a dilatation of that communication also by Digestive Endoscopy.

37 Fatigue is a usual complaint. Anemia, malnutrition or psychological depression may cause it. In such event, patient must talk to the multidisciplinary team for precise diagnosis and specific treatment.

38 Female patients frequently complain about an extreme loss of skin elasticity after Bypass Surgery and they want to undergo body-contouring procedures. Our suggestion is that they wait until all the skin is fully loose, which may take a year and a half, to schedule any cosmetic procedure for a better outcome. Another criterion to be followed is to wait for the complete stabilization of weight and results from Bioimpedanciometry, during six months.

39 Gastric Bypass modifies the digestive tube anatomy and it provides clear advantages for the morbidly obese patient. After surgery, patient needs to go regularly to the surgeon's office. During the first year, we suggest consultation once a month. From the second forward, an annual meeting is advisable.
In the consultations, we evaluate:

• Passage of food from the pouch to the intestine. If it is too narrow, it causes vomit, so we have to perform Endoscopic Dilation;
• Existence of gastroesophageal reflux or gastrojejunal ulcer. If any of those are present, patient is medicated;
• Existence of biliary calculi (gallstones).

Every fast weight loss (through surgical means or not) has 20% probability of causing gallstones. The calculi can cause acute pancreatitis, which may be fairly serious. So, as soon as we find out that patient suffers from biliary calculi, we recommend a procedure called Colangiography (radiographic examination of the bile duct) during the Cholecystectomy (gallbladder removal) under videolaparoscopic guidance.

40 Usually patients who undergo Bypass Surgery have the tendency to nutritional unbalance, so it is advisable that patient returns frequently to the Clinic for examination to avoid complications.

Post-operative day # 15, patient comes to the Clinic for first consultation to evaluate his/her nutritional condition. Also a new Bioimpedanciometry is made to evaluate muscle mass loss, and correct it with protein supplement, if necessary.

Postoperative day # 30, a new appointment to orient patient how to make a slow and gradual transition from liquid to solid diet. Also the patient is once again oriented about the importance of chewing food thoroughly.

During the first year after the surgery, patient has a mandatory appointment with the nutritionist once a month. The professional evaluates:

• Weight loss and percentage of water, muscle and fat loss through Bioimpedanciometry;
• The acceptance of the new dietary pattern. What kind of food the patient has been eating: red meat, vegetables, fruits, milk and its derivates;
• If patient vomits and if there is any alteration in the bowel rhythm;
• If there is alteration in the menstrual cycle;
• Hair and nails condition;
• Nutritional unbalance through Lab Tests, for preventive diagnosis;
• Necessity of vitamin, protein and mineral supplements.

Finally, every three months during the first year after surgical process, we perform a Calorimetry Test. One year after surgery, patient must return each semester for new evaluation.

41 Any psychological or physical alterations that the patient would ever experience after the Bypass Surgery must be immediately reported to the surgeon or to the nutritionist from the Multidisciplinary Team. Once Bariatric Surgery is a very specific specialty, the only ones capable of understanding symptoms coming from it are surgeon and team. For example, cramps in a non-operated person may be lack of potassium, however in a patient who has undergone Bariatric Surgery may be lack of vitamin B12. For that reason, it is very important that patient keeps a close relationship with the Multidisciplinary Team for his/her entire life. Patient should keep surgeon and nutritionist phone number at hand, and call whenever necessary.