 All right, well, welcome everyone this evening. I'm Dr. Benachi. I'm gonna be giving the seminar talk here this evening. This first picture is not me. I'm gonna show you pictures of all the surgeons in our group, because chances are, if you go through this process, you will meet more than one of us along the way. So this is Dr. Tujo. This is Dr. Smith, Dr. Pilkington, and then myself. So the goal or the objectives of this talk tonight is to help you identify obesity as a chronic disease and a growing public health concern, help you recognize the indications or reasons for performing bariatric surgery, give you a brief history of bariatric surgery as it's evolved through the ages, and also review the various, I'm sorry, the various procedures that we perform, including laposcopic band, gastric bypass, and sleeve gastrectomy. So this is a map of the United States in 1995. And what this map is showing are rates of obesity amongst the 50 United States. So here you can see in 1995, most states have ranges of obesity anywhere between 15 to 20% or 10 to 15%. So pay attention to how this map changes as we go through the years. So here in 2000, another color has cropped up as many states now have rates of obesity between 20 to 25%. 2005, you see that trend growing even further. Now there's even a few states with rates of obesity greater than 30%. 2009, you can kind of understand and appreciate that trend continues to grow more and more as the time goes on. Comparing 1990 to 2010, you can see the drastic change as far as rates of obesity amongst the United States. And currently one third of the US adult population is considered obese, and that number continues to grow every year. Here's the most recent data we have from 2013. You can see that there's even some states now with rates of obesity above 35%. So this is again a growing public health concern that continues to get worse and worse. So what is it that we use to define obesity? That is a number called the body mass index, and this is a ratio based on somebody's height and weight. If you go to a doctor's office, chances are you see these charts on the wall that help you calculate what your BMI is. So all you would have to do is find your height on the top line and then fall that down to where the weight is and where those two lines intersect that is what somebody's body mass index is. Unfortunately, we can't do much to change our height. It's the weight that fluctuates really to change somebody's BMI. Somebody is considered to have a healthy BMI if the BMI is 18 to 25. Someone's considered overweight if the BMI is 25 to 30. Obese is considered 30 to 35. Severely obese 35 to 40. And morbidly obese is greater than or equal to 40 for the BMI. So who is it that qualifies for weight loss surgery? Well, that's typically here on the end, the class two and class three are morbidly obese patients. Those patients are gonna stand to benefit the most based on the risks of surgery. Obesity is a deadly disease. It is the second leading cause of preventable death behind only smoking. And as more and more people stop smoking, you'll see that that is likely gonna replace smoking as the leading cause of preventable death. About 400,000 people die unnecessarily every year as a direct result of obesity. All right, so why is it that obesity is so deadly? Well, that's because some of the health problems that are related to obesity. This is a diagram that's kind of showing the risks of obesity, especially when somebody is younger in age. If you look at, in this example, here's a patient whose age is 20. And for that person who is 25, you can see, well, they don't stand to lose any years out of life as a result of obesity. But as their BMI gets higher and higher, you can see that that same 20 year old who now has a BMI of more than 45 could potentially lose anywhere between 12 to 14 years of their life as a result of obesity. So the younger somebody is with the higher rate of obesity, the more years of life that they can lose as a result of that. I mentioned that there's certain health conditions related to obesity that that's part of the reason that obesity is so deadly. Well, this diagram here kind of shows rates of diabetes, heart disease, hypertension, that are closely linked to obesity. And as the BMI increases higher, the chance of developing these conditions go right along with it. There is a syndrome called syndrome X or metabolic syndrome where patients with obesity can also suffer from cardiovascular disease, diabetes, or high blood pressure. And so for these unfortunate patients right here that where those three circles intersect, they have a very high rate of immortality because of those health problems. So when we look at treating obesity, these are some of the things that we're helping to hopefully resolve or correct in addition to just losing weight. There's various cancers that are associated with obesity as well. Cancers of the colon and men prostate cancer. Cancers of the esophagus are more common in patients with obesity. In women, cancers of the ovaries, the uterus or the inside lining of the uterus called the endometrium, the cervix, or even the breast are higher in patients with obesity as well. There are various lung related complications or what we call pulmonary complications related to obesity as well. Asthma is actually very common in patients with obesity. And obesity acts or works as a restrictive lung disease where there's excess weight that's carried on the chest or midsection and actually limits the amount or the ability of the lungs to expand. Part of the reason this is a problem, well for a long time, the prescribed treatments for obesity is exercise. Well, obesity leads to a decreased exercise tolerance. So it's unfortunately a vicious cycle. Patients aren't able to exercise, so they end up gaining weight and then they can't even exercise even further. Sleep apnea is very common in patients with obesity. Chances are somebody in the audience here tonight uses a CPAP machine. We see these very commonly in patients with obesity. There's higher rates of what's called pulmonary hypertension where there's a higher blood pressure in the blood vessels that go to the heart and lungs. And this can be severe enough that patients actually need to end up having a harder lung transplant as a result of that. There's various metabolic complications related to obesity as well. High levels of cholesterol or a cholesterol related molecule called triglycerides can be seen in higher rates in patients with obesity. There's also higher levels of circulating estrogen and in some women they suffer from something called polycystic ovarian syndrome and this can lead to issues with fertility and it's often linked to obesity as well. And a lot of these women who have difficulty conceiving children when they're successful with weight loss, they're actually able to go on and have children. Also what we call hyperquagulability or the higher tendency of forming blood clots. This can happen partly because if blood doesn't circulate well it can tend to collect and form blood clots. This can happen in the veins and the legs. So if obesity is limiting the blood flow draining from our legs to go back to the heart that blood will tend to pool in those veins and can start to form blood clots and can lead to some serious problems as a result of that. Gastrointestinal complications. Gird or what we refer to as acid reflux or heartburn very common in patients with obesity. The body is a pressure system. So whenever we carry excess weight or on the midsection that pressure is exerted on the wall of the actual stomach organ and there's a muscle at the end of the esophagus which is working to try and control acid from coming up in the esophagus. Well if you increase the pressure on the wall of the stomach that pressure of that muscle can be overcome and now you start getting stomach acid to come up into the esophagus. So that's what leads to heartburn or acid reflux. Gallstones or gallbladder disease is very common in patients with obesity. In this country we spend about $800 million every year on obesity related gallbladder disease. So not an insignificant amount of money. Genitourinary complications, stress and continence. Again this has to do with the pressure system of the body. This is more common in women compared to men because the urethra which is the tube that carries urine from the bladder to the outside world is shorter in women and women often undergo the stress of childbirth which can kind of take a toll on that anatomy as well. So if somebody were to cough or sneeze they can have a leakage of urine as a result of that. In some cases the pressure in the pelvis is so significant that it can actually cause the pelvic organs to extrude their openings and that's what we call a prolapse. It can happen to the uterus, it can happen to the bladder, it can even happen to the rectum as well. There's also higher rates of sexual dysfunction in patients with obesity as well. Orthopedic complications, I see many patients in my office suffering from arthritis or joint pains, what we call arthralgias. Chronic back pain, again this excess weight takes a toll on the joints, the hips, the knees, the back. All these joints are dealt the task of carrying this excess weight and it can take a toll over several years. Many patients I see may have had a joint replaced already or they have been in contact with an orthopedic surgeon to see about having a joint replacement. Well what the orthopedic surgeons are realizing is that patients actually fare better if they are successful with weight loss before they have their joints replaced. So what the surgeons are telling patients is, well you may wanna seek out bariatric surgery and lose weight first so you'll have a better outcome with the joint replacement. Psychosocial complications, well depression is very common in obesity. It's about 90% rate of patients with morbid obesity also suffer from depression. There's a higher levels of anxiety and overall lack of self esteem. Unfortunately obesity is still one of the accepted social biases if you will, where somebody can make a judgment about you based on the way that you look. Well a good example of this is if you fly in an airplane you might be asked to pay for an extra seat as a result of that. So unfortunately that's the way things still are. There's quality of life issues and loss of job potential. There's been studies looking at income potential for people who are obese compared to their non-obese counterparts and those studies do show that people who are obese tend to make less than their non-obese peers. Also patients with obesity tend to develop inappropriate coping strategies. So one of the things that a lot of patients turn to is food because it makes you feel good. You know if you have something that you enjoy eating it relieves anxiety, makes you feel better. Well again this is kind of a vicious cycle. If you turn to food to make yourself feel better it ends up leading to increase in weight gain as well. So these are some of the things that we have to kind of address in order to be successful as far as our treatment strategy. To understand obesity you have to know it's a complex, complicated disease that has many things that contribute to it. There's approximately a 25 to 30% genetic component to obesity where if you look at parents that are obese they tend to have children that are obese as well. There's also an environmental component. Well here in Michigan unfortunately in another couple of months we're gonna start seeing some white stuff fall to the ground and that can make it difficult or even dangerous to try and get outside to exercise. In some of the southern states you know obviously it's not as much of a problem but that's one of the things that we have to understand here in Michigan. So to have an effective treatment strategy we have to understand these various contributing factors. There's been changing perceptions about obesity through the years. In the past it was seen as a weakness or a failure and the only prescribed treatments for it were diet and exercise. Weight loss surgery used to be viewed as dangerous and extreme. Presently however obesity is considered a disease that is chronic, progressive and debilitating and in many people will ultimately lead to an early death. Surgery is now an acceptable and proven method of treating obesity and surgery is also an acceptable and proven method of treating the comorbidities related to obesity as well. So things like high blood pressure, diabetes, sleep apnea. These are things that we can help significantly improve if not completely reversed with surgery as well. Surgical treatment's not for everybody though. We have to establish criteria as I mentioned before to see who's gonna benefit most by undergoing the risk to surgery. So as far as diet and exercise, this is what we refer to as nonoperative weight loss. Most programs believe it or not are quite successful. Up to 90% of patients lose weight with diet and exercise programs. The reason they fail though is the maintenance of the weight loss. About 95% of the weight that is lost will be regained usually within five years after patients go out of these programs. And many patients ultimately will regain more than they lost initially. So that's why diet and exercise alone fail to achieve the long-term weight control in most people. What about weight loss medications? Well, there's been various ones through the ages. A lot of people may remember the Fen-Fen combination was popular back in the 90s. Well, unfortunately this led to many severe arrangements of the heart valves and so FDA ultimately took it off the shelves. And that seems to be the trend for a lot of these medications is they're on the market for a matter of several months, two years. And then as more people take them, they find side effects, they end up pulling them from the shelves. Back in 1991, the National Institutes of Health looked at how we treat obesity and this is kind of their banner statement that they made is that weight loss surgery was the only proven method of long-term weight loss for the severely obese patient. So as far as establishing criteria, like I mentioned before, at our treatment center we treat adults so patients are 18 years or older. Most insurances require a BMI or body mass index of 35 or greater with another comorbidity. So as I mentioned before, diabetes, high blood pressure, sleep apnea, high cholesterol. There's a lot of them out there that insurances will use to justify surgery. Or if patients have a BMI of 40 or greater alone without any health problems, insurances will often cover surgery as well. Often many insurances want documentation of failed non-surgical approaches to weight loss. And patients have to be prepared to attend both pre and post-surgery follow-up sessions in order to be successful. You're gonna hear me say several times through this talk tonight as far as these surgeries are not a perfect magical answer. They are a tool to help you be successful. But most patients that are making these changes and are committed to the changes will be successful. You have to be prepared to make these lifestyle changes and hopefully be a permanent change for you. Many insurances will require that patients undergo mental health stability as well. So I tell patients, well, just like we're going through a process of making sure your heart and your lungs are ready to tolerate surgery, we wanna make sure that your mind is ready to tolerate the stresses that come after surgery as well. So as far as surgical management, there's a number of operations that have been used in the treatment of obesity and collectively they're known as what's called bariatric surgery. So this comes from a Greek word meaning weight and treatment. In the United States last year, more than 220,000 bariatric procedures were performed. I am part of what's called Great Lakes Surgical Associates so myself and all the other surgeons that I showed you pictures earlier. And so we partner with the hospitals to provide these surgeries. We perform the laposcopic adjustable gastric band, the ruin my gastric bypass and the sleeve gastrectomy. And we actually here in Midland are doing the robotic da Vinci sleeve gastrectomy here as well so some patients may prefer to have that done. So I mentioned all these are performed laposcopically. The advantages of laposcopic surgery are quite profound. Fewer wound complications because the incisions are smaller. There's less risk of infection, less chance of hernia because those incisions are smaller. With smaller incisions comes less pain so patients have faster recovery compared to what's called open surgery where you make a large incision. And believe it or not we actually have a better view of the anatomy inside because most of those structures and organs are tucked up high up underneath the rib cage. So we actually have a better view of surgery when we perform things laposcopically. So to kind of illustrate that point and kind of see on the left side of the screen this is typical incisions for laposcopic surgery. And then compared to what we term open surgery with a larger incision where there's higher rates of infection, hernia formation, more pain and discomfort. Next we'll talk about the ruin why gastric bypass. So again this procedure is performed laposcopically. The average amount of weight loss as far as excess weight loss at three years is about 62%. So if you have somebody whose current weight is 250 pounds and their ideal body weight is 150 pounds that person has 100 pounds of excess body weight. So if we were using those numbers for this patient that'd be about 62% or about 62 pounds for that weight loss. What happens with the gastric bypass is the upper part of the stomach here is cut and partitioned and stapled into a small pouch. And then part of the small intestine downstream is divided and then reconnected to that pouch. So when somebody with a gastric bypass eats food's gonna come down the esophagus it's gonna go into this pouch here and then it's gonna empty into the small intestine. And it's not until it joins up with the rest of the digestive juices from the small intestine here that things start to get absorbed. So not only does it limit the volume of calories somebody eats by creating restriction but it also limits the amount of calories that are absorbed. This is the one that a lot of people have thought about when they talk about having their stomach stapled because this has been around for several years. These surgeries are quite safe and we'll go through the various risks of them all. But the gastric bypass does have low rates of complications. These surgeries help change some of the signals to your stomach where we don't necessarily completely grasp all the hormones that are involved in this process but patients will often feel full or longer they don't feel the hunger they used to feel beforehand. And so a lot of patients with issues like diabetes they can have improvement in their blood sugars and resolution of their diabetes not strictly because of the weight loss that they have but sometimes some of the changes that happen after these surgeries. When we do this procedure if somebody's had a lot of prior surgeries and there could be a lot of scar tissue in there it may limit our ability to do the surgery because we have to not only work on the stomach itself but also on the small intestine. So if I have somebody who's had a lot of prior abdominal surgeries I might tell them well it may not be possible to do a gastric bypass. As far as the male absorption part this is something that the body does adjust a little bit too as well because our body does adapt. So as far as how long that lasts sometimes that can be lifelong sometimes patients may not notice as much male absorption as time goes on over several years. So as far as the risks and complications well what we call dehiscence or separation if you will that's where any of these tissues that we cut, divide or reconnect can we have to hope we count on those areas healing together. And so if that weren't to happen and those areas separated well you could have a leakage of either stomach or intestinal contents inside the abdominal cavity. Now that can make somebody very sick if it happens. So one of the things you'll hear for us after these surgeries is there's a very structured diet that patients follow to help allow things healing okay. There's a risk of forming ulcers after a gastric bypass and this can happen at the connection between the stomach and the small intestine. Our stomach has protection against its own stomach acid but the small intestine doesn't necessarily have that same protection. So if you have a patient that has this connection between the stomach and the small intestine and stomach acid is going into that small intestine it can sometimes lead to an ulcer. This is seen a lot more commonly in patients that smoke after surgery so we really strongly stress the patients smoking is a big no-no after these surgeries because of some of the complications it can lead to. There's also something called dumping syndrome which is sometimes seen in patients with a gastric bypass. It's often where somebody ingests a high carbohydrate meal that will empty quickly into the small intestine and with all those carbohydrates it sucks a lot of fluid into the small intestine so somebody can feel pretty miserable when that happens. They can feel faint, they can feel sick to their stomach or vomit, they may have some diarrhea. They just feel pretty lousy for about half hour 45 minutes but often it's related to that high carbohydrate meal that they took in so if somebody takes a step back and says oh yeah I ate that piece of chocolate cake well I don't wanna feel that way ever again so they often realize what they need to avoid to prevent dumping syndrome. I mentioned the malabsorption component of the surgery well that can sometimes lead to vitamin or mineral deficiencies things like B12, calcium, iron these things can sometimes become deficient in patients after a gastric bypass because of the malabsorption component. And also because of the way the surgery is conducted when we divide the stomach and create this pouch we no longer have typical access to the old part of the stomach or this very first part of the small intestine if we were to do what's called an upper endoscopy because that pathway has now been averted. It may be difficult to detect if somebody were to have an ulcer in that old part of the stomach or develop bleeding from that. So these are some things that patients have to understand and realize if somebody was developed a cancer in the stomach we may not be able to detect that through normal means because of change in the pathway or the highway if you will that we create. Sometimes patients can experience increased gas or flatulence after surgery. Part of this again speaks to the malabsorption part of the surgery where whatever your body doesn't absorb in the small intestine empties into the colon and there's millions upon millions of bacteria in the colon that make use of that extra nutrition and sometimes a byproduct of that can be increased gas. So what can you expect after the gastric bypass procedure? Well recovery takes time and patients and again the diet is strict. So what the diet after surgery to allow those staple lines and areas of connection to heal involves basically two weeks of a clear liquid diet mixed with protein powders or protein shakes. And then after that six weeks of basically a full liquid diet. So things like yogurt, pudding, cream soups are included on that but nothing that you're really gonna have to chew at all. And the concern is that if you have to chew something to swallow when it gets into the stomach pouch or in those connections it can put undue stress on them and cause them to break down. So the length of time to return to normal activities can vary from patient to patient. Most patients the majority are gonna feel pretty well back to normal within the first couple of weeks after surgery. We do ask that patients follow activity restriction of usually nothing more than 15 pounds for about four weeks. And that's really just to protect the incisions so that patients don't get hernias at those incisions. Again some patients are able to turn to work within a few weeks and weight loss happens fairly quickly after surgery. Other patients may take a little bit longer. So it just depends on the individual patient as far as how rapid the weight loss is. But typically we expect usually about three to four pounds of weight loss per week is what we tell patients primarily. There was a study that looked at the median time for various things for gastric bypass patients. And so the majority of patients were started on an oral diet within a day and a half after surgery. The majority of patients left the hospital after two days and the majority returned to work at 21 days. So those are kind of some averages. But I'd say that like I said, most patients within a couple of weeks are gonna feel well enough to return to work. So I mentioned about dumping syndrome earlier. This is kind of a diagram that displays that. So again, some people consider it a complication. Others use it as a reinforcement partly because they recognize that okay, there was something that had a lot of carbohydrates that made me feel pretty miserable and so I don't wanna do that again. So they tend to avoid those things. So next we'll talk about the sleeve gastrectomy. So this is a laparoscopic procedure. This was actually the first stage of a two-stage procedure called the duodenal switch where patients with a really high BMI, the plan was to do the sleeve gastrectomy first and then they would do the second part which was the duodenal switch at a later date. Well, what they found for these patients is they often lost a fairly significant amount of weight with the surgery of the sleeve gastrectomy alone and many patients didn't have to go back and have that second procedure performed. So it kind of grew into its own surgery. And so this is easily the most common surgery that's now performed in the U.S. for weight loss and part of that reason is because about four or five years most insurances started to cover it and so that's what really helped it catch on. So the mean excess weight loss at three years is about 66%. There's no foreign body, no implanted medical device and part of the reason the surgery works is it does change the hormone signaling that happens. There is a hormone in our body called Graylin that stimulates our appetite and at least in part it's released from this part of the stomach here what's called the fundus which has been removed during surgery. So we're turning the stomach into a long slender tube just like the sleeve of a shirt that's kind of how it gets its name. There's not any plastic sleeve of material though. So when we have done the surgery this part of the stomach over here now has no blood supply to it. So we have to take that part of the stomach out. So that one part I mentioned the fundus is removed as well and so a lot of patients that have the surgery will say, you know, I don't have a constant hunger I used to feel beforehand. You'll also notice that if you follow the path that that food goes, well it's gonna go the exact same route that it did before. We're not rerouting the intestines. So the risk of vitamin deficiencies or malabsorption is significantly reduced with this surgery compared to the gastric bypass. So essentially what this surgery does to be effective is it invokes restriction. The amount of the stomach that we remove is about 80 to 85% of the volume. So patients who used to consume lots and lots of calories at one sitting just aren't physically able to do so because of the much smaller volume of the stomach. So as far as the risks of the sleeve gastrectomy, well, hernias can happen after any surgery that would also apply for the gastric bypass again just at the incisions. That's partly why we do limit activity afterwards. Constipation diarrhea, again sometimes this can happen after bariatric surgeries. Constipation might be a little bit more common than diarrhea partly because we're affecting somebody's overall fluid intake with these surgeries. And so one thing to help combat constipation is actually drinking adequate liquids and water. Well, when we limit the volume of the stomach, patients may have a harder time getting in their fluid at least early on after surgery. Dehydration can happen. Again, that speaks to not taking in as much fluids as patients often do beforehand. Gallbladder disease can happen after any weight loss surgery and partly because if your body is losing a lot of weight, part of the byproducts that are broken down can lead to forming gallstones. So that's why sometimes patients can end up needing to have their gallbladder out after they have these surgeries. It used to be where when they did these surgeries, they would go ahead and take out the gallbladder to kind of preempt that from happening. But what they found is a number of patients actually would have never had problems with their gallbladder whatsoever. So we don't usually take the gallbladder out at the same time because it's the minority that will end up developing issues. Vitamin deficiency, again, for the gastric sleeve, it's much less compared to the gastric bypass because there's no malabsorption. But we still do encourage patients to take multivitamins to help combat or prevent that from happening. Acid reflux, GERD can happen, again, partly because of the pressure system. When we reduce the volume of the stomach, it does lead to an increased pressure in the stomach. And so if somebody has a fairly weak valve at the end of the esophagus, that can lead to sometimes acid reflux or heartburn. A lot of times, it's behavioral. I tell patients, well, if you eat to full capacity of that sleeve, well, you're gonna have potentially more of an issue with acid reflux, whereas if you take your time and eat slowly, often your body will realize, okay, I'm full, I'm at that point, I don't need to have any more. Gastrointestinal inflammation or swelling, well, again, this can happen anytime after or any type of abdominal surgery. Intestinal leakage, again, that stapline where we're dividing the stomach, we're expecting that to heal, so we have to be very strict as far as the diet afterwards to allow that to happen. Something called a stoma obstruction. This can happen, let me kind of go on this diagram here. So along this stapline, when we do the surgery, we have what's called a bougie inside the stomach to help gauge the size that we're leaving behind. Well, after surgery, sometimes there can be some swelling in that area, and so if this area becomes narrowed down because of the inflammation, well, that can make it harder for fluid to go through there. Most of the time, if patients experience this, it's short-lived within the first day or two after surgery and just allowing enough time for that inflammation to subside helps it resolve. Stretching the stomach, well, this is partly where we tell patients it's important to pay attention to your body signals to eat slowly, because if patients are eating to full capacity of that sleeve, that's the concern is that as time goes on, are they gonna stretch the stomach back open? Well, I'll guarantee you they will never stretch the stomach back to the original size, but will they stretch it enough so that they affect their long-term weight loss? And so that's partly why we tell patients you need to avoid carbonated beverages. There's certain things that we want you to avoid to help lessen that from happening, but the most important thing usually is just taking time to eat. We do live in a society where we eat too quickly, and as a result of that, we consume a lot of excess calories, which we would have otherwise avoided if we just take our time to eat. Vomiting and nausea, well, that can happen anytime you do surgery on the stomach, and that's kinda how the body responds to that stress. Again, this is often short-lived and related primarily to some of the anesthesia, perhaps, or just some of that swelling that happens along the stomach. So after a sleeve gastrectomy, well, recovery will take time in patients, and as I mentioned before, the diet is strict. You can experience discomfort and pain as your body heals. Obviously, having surgery, having incisions, there's gonna be some healing that's involved with that. The length of time to return to normal activities will vary from patient to patient, but it's fairly similar to the gastric bypass that I talked about before. Again, the capacity of the stomach is gonna be drastically altered after the surgery, so being very cautious and taking in fluid and oral intake slowly is gonna be very important, and myself and members of the healthcare team will advise you as far as returning to work and so forth, but again, those same rules I mentioned before usually apply, so most patients within a week or two are gonna be feeling well enough to go back to work. As far as the actual lifting restrictions or strenuous activity, usually that's four weeks. I tell patients that it's really a matter of letting their body be their guide as far as when they can go back to work. I had some patients return to work as quickly as three or four days. Granted, they just sit at a desk all day, they don't have to do much in that respect. I tell patients, those are kind of the exceptions, but I have had some patients go back as soon as quickly after the procedure. So at this point, you must be telling yourself, well, this has to be magic. Well, of course, it's not magic. These surgeries are only tools to help you lose excess weight. You still need to make these permanent lifestyle changes in order to have long-term success. However, the bariatric surgery benefits are profound. Over 96% of the health problems related to obesity are completely resolved and reversed, usually within days to months after surgery. Again, there's huge physical and emotional benefits. Looking at some of these disease processes that we help improve, depression, there's actually 47% reduction in that. There can be a 46% improvement in migraine headaches, 25% to 66% controlled diabetes, 42% to 66% resolution of high blood pressure. There's a disease that'll deliver that is tied to obesity called non-alcoholic fatty liver disease, and there's a 37% resolution of that. Arthritis and joint pain, 41% resolution. Stress incontinence, 50% resolution. There's a 39% improvement in asthma. Sleep apnea, 45% to 76% resolution. So again, significant improvements that we can make for patients with various comorbidities related to obesity. So at our treatment center, we have a team approach, myself and my partners in our group that are trained in advanced laparoscopic and bariatric surgery. We have various experience office staff, skilled nurses, dieticians at the hospital, as well as other hospital staff. We have various support groups as well. We have behavioral specialists, insurance specialists, medical specialists as well. Various medical specialists including cardiologists, pulmonologists, psychiatrists that have special training as far as treating patients with obesity. So the next steps to regaining your life, well the first one is you're here at the seminar this evening hearing the information I have to tell you. We are gonna give you some paperwork tonight and also most insurances do ask that you obtain a letter from your primary care physician stating why you'd be a good candidate for surgery. We'll contact you and you'll have a consultation scheduled with myself for one of my partners and that's where we'll go through your specific health issues, prior surgeries, go through all your history and kind of discuss what surgeries may or may not be a benefit for you. Depending on somebody's baseline health, we might have to schedule some other appointments as well. So if I have a 35 year old female having the surgery, am I worried about them having a heart issue during surgery? Well, of course not, not likely. But if I have a 60 year old male who's had two prior heart attacks, well obviously that patient's gonna have to go undergo further testing, likely having to see a cardiologist before they had surgery. We also perform what's called an upper endoscopy on all of our patients. So this is an outpatient procedure so you go home the same day and we use a flexible camera to look down the throat at the inside lining of the esophagus, the stomach and the start of the small intestine. That's gonna allow us to see if there's anything that we would need to treat before surgery or might prevent a patient from going forward with surgery. So the good news is you get sedated when you have that procedure. So you're probably not gonna remember much of anything from it. You can go home the same day as I mentioned but because of that sedation, somebody else has to give you a ride home. So one of the things that we check for is there's a bacterial infection that can occur in the stomach from a bacteria called H. pylori and that bacteria can actually lead to stomach ulcers. So we often will do a biopsy of the stomach lining to check for the bacteria. The other thing that we do is we will look to see if there's a hyal hernia because that's something that at the time of surgery we might be able to fix at the same time as well. So we also ask that patients attend a support group meeting before surgery and support group meetings are very important because you're gonna hear a lot of information from previous patients that have gone through this process. And the hope is that if patients, if other patients are very involved in these support groups that they're gonna be a beacon of information for other patients to come after them. And actually there's been studies looking at participation in support groups and those patients that are more active and involved in support groups actually do better in the long term. We also have a nutrition class that you attend before surgery and you also meet with some members of the anesthesia department where they'll explain or discuss their role in your care as well. So you have various decisions when you go through this process. Discuss options with our weight loss team. Attend the support groups because they're a wealth of information. Talk with your own doctor because chances are they've had some other patients in their practice that have gone through this process as well. Talk with your family as well because after surgery, they're gonna be a huge resource for you as far as your recovery. And I always shudder when I first meet patients only on the day of surgery and they just have their family members, oh, I'm just having my sleeve done. Well, I mean, it's a big surgery so it's important to have these family members involved early on. And also do your own research. Learn as much as you can. The internet is a wealth of information. If you so desire, you can go on YouTube and actually watch these surgeries being done, okay? But keep in mind that not everything that you read or see on the internet is necessarily true. That's why we say get the facts, not the fiction. So the bottom line is if your BMI is 35 or greater, you have three choices. Non-operative weight loss, like we talked about with diet and exercise, where there's nearly 100% chance of failure. Operative weight loss that we talked about here tonight where there's an 85 to 90% chance you will lose the life-threatening weight and have a chance to get your life back. Or a patient can try and just live with their weight and deal with it and unfortunately miss out living life until it's fullest. So the good news is we can help you regain your life. We perform these surgeries at two locations here in this hospital in Midlands and then also the hospital in Elma. Both hospitals are part of Mid-Michigan Health and both medical centers are accredited by an accrediting agency which is abbreviated MBSAQIP. Some insurances in the past have required that patients have their surgeries performed at centers that are accredited by this. So we can meet that need for patients. And both centers have been designated as a Blue Cross, Blue Shield, Blue Distinction Center and also both centers are accredited by the Joint Commission. So everything that most patients would potentially require to have their surgeries done. This is a picture of the hospital that's in Elma, Mid-Michigan Medical Center, Gratiot. And this is a drawing of the building that we're in here this evening in Midland. Here's a picture of one of the hospital rooms in Elma. Patients that have a gastric band typically it's a one day stay or sometimes even outpatient procedure. Gastric bypass and sleep gastrectomy is typically a one to two day hospital stay. Part of that just depends on how patients are feeling after surgery to decide when they go home. As far as the support groups, again, we do ask that you attend one before surgery. And as I mentioned earlier, there's been studies that show improved success after patients that are very involved in support groups. So we do encourage patients to be active in the support groups. We have four locations where we perform these, Elma, Gladwin, Midland, and Mount Pleasant to help the needs of patients throughout our center of our state. So that is where I'm going to stop here. So if there's any questions, I'd be more than happy to take any questions you guys may have.