Please obtain the following items to bring with you at your first clinic appointment:

• Documentation of your weight for the last five years from your primary care physician
• Documentation of non-surgical weight loss attempts
• A supporting letter from your primary care physician recommending surgery

Your first visit to the Duke University Health System Weight Loss Surgery Clinic will include necessary laboratory studies, a medical examination, a psychological interview, and a nutritional evaluation. This visit will take about two to three hours. A full body photograph will be taken (fully clothed) for your medical record.

Medical evaluation: You will meet with one of our nurse practitioners, Hilary Blackwood, NP, or Deborah Brown, RN, FNP-C, who have special knowledge and experience in the diagnosis and treatment of morbid obesity. They will perform an examination and evaluate any medical problems that have resulted from your obesity.

Psychological interview: As part of the evaluation for weight loss surgery, you will first complete a set of of questionnaires. You will then be scheduled for a 45-minute interview with one of our health psychologists Katherine L. Applegate, PhD, or Kelli Friedman, PhD. in that interview, they will discuss behavioral and life-style issues that can impact on the adjustment to surgery. At the conclusion of their assessment, you will be provided feedback and given specific suggestions that may assist you both before and after bariatric surgery.

Some patients will be recommended to participate in individual psychotherapy or to see a physician for a medication evaluation as part of their treatment plan. For some, surgery will need to be delayed until an identified psychological condition can be thoroughly addressed. Patients given substantial recommendations to complete prior to approval for surgery may be scheduled for a follow-up minute visit to assess progress. This session will be provided at no additional cost. Patients are required to comply with their treatment recommendations if they wish to have surgery with our program.

If approved for surgery, this initial assessment will be followed by a five session cognitive-behavioral group series facilitated by our psychologists. During these sessions, patients will learn behavioral and lifestyle changes that can enhance their long-term success with weight loss.

The cost for the pre-operative psychological assessment is $300, and the cost for the behavioral group series is an additional $250. Patients are required to pay these fees up front. The first installment will be due at the initial visit with the psychologist, and the second installment will be due just prior to surgery.

Insurance plans may or may not reimburse all or a portion of these fees. The psychologists do not participate in any insurance plans; thus, the out of network benefit may apply. We will provide you with the necessary documentation to submit to your insurance company to seek any available reimbursement (see below). The initial assessment will be billed as CPT code 90801, and the group sessions will be billed as CPT code 90853. Although they may represent an additional personal expense, it is well documented in the literature, and in our own experience, that behavioral interventions can enhance your eventual success with weight loss surgery.

The psychologists will provide insurance claim forms to patients on the day of their assessment to submit to the insurance company to determine if they are eligible for reimbursement for the assessment visit. Also, after each of the four group therapy sessions, patients will receive a claims form for $68 dollars to submit to the insurance company for possible reimbursement. Claim forms cannot be issued for sessions that have not yet occurred; they cannot be issued for sessions patients do not attend. Reimbursement for these expenses is not guaranteed.

Nutritional evaluation: You will meet with Patrick Mahaney, RD, to assess your current eating and exercise habits. He will take measurements to determine your body mass index and total body fat (please do not apply body cream or oils to your feet before this first visit as it will interfere with this test).

You will meet with Patrick Mahaney, RD, to assess your current eating and exercise habits. He will take measurements to determine your body mass index and total body fat (please do not apply body cream or oils to your feet before this first visit as it will interfere with this test).

In addition, the number of calories you are burning each day will be measured from collection of the air you breathe out. Finally, he will evaluate your baseline respiratory and skeletal muscle function At the conclusion of the evaluation, he will share his findings and discuss recommended dietary changes to prepare for surgery. He will advise you on a low sugar, low fat, small portion meal program that you will need to follow until surgery.

Laboratory studies: As part of the medical evaluation, you will need to complete several studies. There are two ways that this can be done:

1. You can have your primary care physician order the tests locally -- give the explanatory letter and order form on the last page of this booklet to your physician. If you elect this option, please bring the results of these studies to your initial appointment, or have them sent to us (fax: 919-660-2256).
2. If you would prefer to do the studies at Durham Regional Hospital, we can arrange for them to be done on a day separate from your first clinic visit.

The necessary studies include:

• Barium swallow to evaluate your esophagus/swallowing
• Arterial blood gas to evaluate your oxygen levels
• EKG to look for any heart disease
• Pulmonary function test to evaluate your breathing
• Blood work, to be drawn while fasting:
  • Comprehensive chemistry panel (to include an albumin level and liver function tests)
  • HbA1c
  • CBC with differential
  • Ferritin level
  • Thyroid stimulating hormone level
  • Fasting lipid panel

In addition, if you have had any of the following studies or procedures, please bring copies or the reports to your initial appointment:

• Sleep study

Patient Manual Index

• Introduction

• Questions to Ask Your Insurance Company

• Your Health Care Team

• Roux-en-Y Gastric Bypass

• Lap-Band Procedure

• Path to Surgery

• The First Clinic Visit

• The Second Clinic Visit

• The Third Clinic Visit

• Preparation Instructions for Surgery
• Day of Surgery and Postoperative Stay
• Hospital Course Following a Roux-en-Y Gastric Bypass
• Hospital Course Following a Lap-Band Procedure
• Post Surgery Follow-up Care
• Potential Complications of Roux-en-Y Bypass Surgery