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Grinnell Bariatrics& Grinnell Regional Medical Center

Experts in Morbid Obesity SurgeryAmerican College of Surgeons

Center of Excellence

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Surgical Associates, LLP, of Grinnell has provided advanced surgical

care in Central Iowa for more than 30 years. Under the leadership of

Warren Bower, MD, and Victor Wilson, MD, Surgical Associates began

providing care for bariatric patients in 1980. They had the unique

opportunity to work with Ed Mason, MD, PhD, the father and creator

of modern gastric-bypass surgery; and thus they also became pioneers in

this challenging field. They were joined in 1991 by David D. Coster, MD.

Keeping pace with advancements in the field, this group of talented

surgeons consistently applied new techniques in bariatric surgery. In

response to their growing reputation, Grinnell Bariatrics was formed

and Grinnell Regional Medical Center proceeded to become a Center of

Excellence for Bariatric Surgery. Today under the leadership of surgeons

David Coster, MD, Nicholas Kuiper, DO, and Mathew Severidt, DO,

Grinnell Bariatrics works with GRMC, to provide a comprehensive,

multi-disciplinary approach to ensure our patients’ success.

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GRMC has an optimal healing environment for bariatric patients with

equipment, furnishings, and services designed for a Bariatric Center

of Excellence.

Our weight-loss team includes internal medicine physicians, a physician

assistant bariatric program director, a psychologist, dietitian, social

worker; care coordinators, physical therapists, and exercise specialists.

The team works closely with cardiologists, pulmonologists, radiologists,

and other specialists in the coordination of patient care. We also offer

individual and group psychotherapy. We care for our patients before

surgery, throughout the recovery period and for many years beyond

surgery. In addition, we offer a support group comprised of patients,

surgeons, and hospital staff who meet on a quarterly basis as well as a

group education meeting that is available twice a month.

More than 30 years experience!

WEIGHT-LOSS Surgery

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Grinnell Bariatrics and team

David D. Coster, MD, Medical Director of Grinnell Bariatrics and Bariatric SurgeonDr. Coster leads the bariatric program with more than 20 years of experience caring for bariatric patients. He performs open and laparoscopic gastric bypass, laparoscopic sleeve gastrectomy, and complex revision procedures. Dr. Coster is experienced in all areas of general surgery and has a special interest in skin reconstruction after weight-loss from surgery for obesity. Dr. Coster has two board certifications:General Surgery and Critical Care.

Nicholas J. Kuiper, DO, Bariatric SurgeonDr. Kuiper joined Surgical Associates, LLP, in July 2010. As a general surgeon, Dr. Kuiper provides expert surgical care for a broad range of bariatric and general surgical problems. He is well-trained in all types of laparoscopic minimally invasive procedures including: DaVinci Robotic Surgery and SILS (single incision laparoscopic surgery). Dr. Kuiper is board certified in General Surgery.

Mathew W. Severidt, DO, Bariatric Surgeon Dr. Severidt joined Grinnell Bariatrics and Surgical Associates in July 2012. Dr. Severidt provides expert care in general surgery, minimally invasive surgery, and bariatric procedures including laparoscopic sleeve gastrectomy, laparoscopic gastric bypass, and revision procedures.Dr. Severidt has a special interest in Critical Care Medicineand Surgery.

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Grinnell Bariatrics and team

Stefanie H. Noun, PA-C, Bariatric Program DirectorMs. Noun is a board-certified physician assistant with extensive experience in medicine and psychiatric care. Noun directs and integrates the bariatric program for Surgical Associates and Grinnell Regional Medical Center. Noun sees patients in the office and hospital. She provides medical care, education, and long term follow-up for our patients.

Jarrod Phelps, PA-CMr. Phelps is a board-certified physician assistant with experience in bariatric and general surgery procedures. He assists the surgeons in the operating room during bariatric surgeries. He also provides follow up with patients in the hospital and office.

Bridget Baechtel, LISW Ms. Baechtel provides group, individual, and family psychotherapy for the bariatric program as well for the local and state wide community. She received her undergraduate degree and her master’s degree in Social Work from the University of Iowa. Baechtel belongs to the Academy for Eating Disorders, the National Association of Social Workers, and the Post Traumatic Stress Disorder Academy.

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grinnelll bariatrics

Jamie BrennanMs. Brennan graduated from Kirkwood Community College with a degree in health information technology and medical coding. She has been at Surgical Associates since 2010. She works closely with the surgeons, healthcare professionals, and insurers both pre and post operatively to prepare patients for surgery.

Sammi Bryan, RNMs. Bryan graduated from Marshalltown Community College with an associate’s degree in nursing. Bryan has worked as a registered nurse since 1985. She has been employed with Surgical Associates since 1990.

Elissa Hotchkin, RNMs. Hotchkin graduated from Des Moines Area Community College in 2015. She has worked as an RN since 2015. She has been employed with Surgical Associates since February 2016.

Stacey Simbro, RNMs. Simbro graduated from Mercy College of Health Science with an associate’s degree in nursing in 2005. She has worked in surgery since 2005. She has been employed with Surgical Associates since September 2011.

Lynn Stone Moorman, RNMs. Stone Moorman graduated from Marshalltown Community College with an associate’s degree in nursing. She has worked in surgery since 2006. She has been employed with Surgical Associates since April 2011.

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Jennifer R. Paisley, MDPediatric Medical Director and HospitalistDr. Paisley is an internal medicine specialist and pediatric specialist on the Bariatric Review Committee. She, along with her internal medicine colleagues, provides diagnostic and treatment care to bariatric patients admitted to the medical Center. She also provides comprehensive medical care for pediatric patients of the program.

Elaine Hammes, MS, RD, LD, DietitianMs. Hammes specializes in weight loss, bariatric surgery and heart health. She has a special interest in incorporating nutrition into overall wellness and health promotion.

Lily Swedenjhelm, RD, DietitianMs. Swedenjhelm is a clinical dietitian at GRMC. She has an interest in overall wellness and translating nutrition research into practical lifestyle tips.

Chad Nath, Director of Wellness and FitnessMr. Nath graduated from Buena Vista University with a BA in education and athletics in 1996. Mr. Nath is responsible for developing and directing fitness and wellness programs and services to meet the needs of the community.

GRMC bariatric center of excellence staff

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GRMC bariatric center of excellence staff

Emily Vesely, RN, Care CoordinatorMrs. Vesely ensures that the patient has all that they need before and after surgery for a safe and successful recovery. She has nursing experience in medical/surgical, obstetrics, intensive care unit and surgery.

Linda Romero, LISW, Social WorkerMs. Romero helps patients with issues regarding the adjustment to weight loss and the impact on emotional and social well-being.

Weight (pounds)

Heig

ht (f

eet a

nd in

ches

)

6'4"

6'2"

6'

5'10"

5'8"

5'6"

5'4"

5'2"

5'

4'10"100 150 200 250 300 350 400 450

Healthier Weight Obesity Morbid Obesity

BMI under 30 BMI 30–35 BMI 35–40 BMI 40 and over

Obesity in AmericaMorbid obesity is an epidemic resulting from a variety of influences such as overabundance of food, consumption of highly processed foods, lack of exercise, and genetics. The physical and psychological problems that are associated with morbid obesity affect life expectancy and quality of life. Like other diseases, morbid obesity limits opportunities. Unfortunately, unlike many diseases, morbid obesity also carries a social stigma. This social stigma is prevalent in our society, and like any prejudice, causes tremendous emotional pain.

Obesity is described as “morbid” when an individual reaches 100 lbs. or more over their ideal weight. At such weights, the occurrence of diseas-es such as diabetes, hypertension, high cholesterol, sleep apnea, reflux, and osteoarthritis become common and sometimes life threatening. An individual with morbid obesity and its associated illnesses may be unable to lose their excess weight in spite of their best efforts. In such cases, surgical options may be considered.

Measuring Obesity: BMIOne measure of how a person’s weight relates to their body frame and age is the Body Mass Index (BMI). A BMI of less than 30 is considered a healthy weight. Above 30 the categories of obesity are: obese, morbidly obese BMI >40, super obese BMI >50, and super super obese BMI >60.

facts about obesity and its treatments

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surgical weight-loss solutions

Those with a BMI >35 and severe obesity related illnesses or anyone with BMI >40 may be considered for obesity surgery if they:

• Have failed to successfully maintain weight loss in a supervised medical weight-loss management program for three years or more.• Do not have serious eating disorders.• Are psychologically and physiologically fit for surgery.• Can follow through with all dietary and exercise instructions, attend appointments, and meet all other requirements necessary for success.

Description of Normal Function

• The esophagus transfers food from the mouth to the stomach.• The stomach churns food, begins the digestive process, and adds proteins that help absorb vitamins and nutrients such as Vitamin B12.• The duodenum is the first part of the small intestine and is important for breaking down fat and absorbing iron, calcium, folate, and B Vitamins.• The jejunum is the middle part of the intestine and is important for absorbing fat, protein, amino acids, carbohydrates, and various vitamins and nutrients.• The ileum is the lowest portion of the small intestine and is important for recycling bile and cholesterol and serves important immunological functions.• The large intestine absorbs water and processes waste.

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The National Institutes of Health have determined that surgery for weight loss (along with proper education, diet, exercise, and social and psychological support) offers long-term, weight-loss success. The following operations modify the natural functions of the intestinal system to aid weight loss and return to normal health. Your surgeon will determine a procedure most suited to your specific situation.

Sleeve GastrectomyThis operation lapa-roscopically removes the outer curve of the stomach, re-moving the storage portion along with the appetite center in the fundus. It is a purely restrictive procedure, convert-ing the stomach into a long narrow tube. It does not disrupt the usual intestinal continuity and does not require implants. Hospital length of stay is typically 48 hours. This surgical procedure can be done as a primary procedure. It can also later be converted to a gastric bypass, if necessary. The sleeve gastrectomy has a lower overall complication rate than the traditional gastric bypass.

Roux-en-Y Gastric BypassThe Roux-en-Y gastric bypass uses a staple line to separate the stom-ach into two parts: an upper “pouch” and a lower, unused portion of the stomach. Food that is swallowed goes into the pouch and on through the connected piece of intestine. The lower part of the stomach, liver, and pancreas provide enzymes to the intestine to help digest food.

The “pouch” is a small pocket that initially can only hold about 1 ounce of food, or about 1/8 of a cup. Over time this pouch will be able to hold approximately 3/4 of a cup. A part of intestine is brought up and

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surgical weight-loss solutions

connected to the pouch, thus “bypassing” the lower part of the stomach and a few feet of small intestine.

Your anatomy is changed significantly by gastric bypass and thus requires a very careful dietary plan. Food will not go into the lower part of your stomach or the first portion of your small intestine, but both will still contribute enzymes for digestion in the lower intestines. This is both a restrictive and mal-absorptive procedure since the pouch restricts the amount of food that can be eaten and the bypassed intestine restricts the amount of nutrients absorbed by the intestine.

Because the pouch restricts what you can eat, overeating can cause pain, nausea, and vomiting. In addition, foods that are high in sugar or fat can dump into the intes-tines and cause severe nausea and diarrhea. Alcohol similarly can be absorbed quickly and can cause toxicity at surprisingly low levels.

Gastric bypass patients must be very attentive to how and what they eat. A gastric bypass always results in de-creased absorption of certain vitamins and minerals. Thus all bypass patients require lifetime vitamin and calcium supplements. Patients with a gastric bypass must consume 60-80 grams of protein ev-ery day. Gastric bypass may be a more beneficial surgery for patients who have a higher BMI, diabetes or have trouble avoiding sweets in their diet.

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Laparoscopic Adjustable Gastric BandingThe lap band is a procedure in which the surgeon places a hollow loop around the stomach. The loop is made of the same inert material used in heart stents. It is like a donut-shaped balloon that is filled with sterile saline. The loop squeezes the upper part of the stomach and effectively makes the stomach about third of its usual size.

We are no longer performing or recommending this procedure to most patients.

Risks of SurgeryPatients who are considering surgery should know these risks. Should you choose to have surgery; the surgeon will discuss these in detail. The risks include:

• Infections• Bleeding• Problems with anesthesia• Breathing problems• Blood clots• Leaks• Hernias• Heart Attack• Stroke• Problems with swallowing or vomiting• Death

Medical Weight-loss ManagementFor some patients surgery is not the right path. Perhaps the patient’s co-morbidities make general anesthesia or surgery too risky. Sometimes a patient’s psychological qualities may make surgery a poor choice. Some-times an individual has not been properly educated about nutrition and has never been enrolled in a well-managed weight loss program. For these patients, an intensive medical weight-loss program may be the solution. Grinnell Bariatrics works with its medical weight-loss patients so they can succeed and have the intensive support necessary to continue

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What to expect

succeeding.RespectIt is an integral part of our mission to treat all of our patients with respect. Throughout our healthcare system, we have specially trained nursing and administrative staff and thoughtfully selected equipment to meet your needs. Our bariatric patients are not sequestered in a dedicated wing, but are integrated into the regular surgical post-operative care wing.

Surgical ConsultationYou or your doctor may call to make an appointment to see a surgeon. Your provider may call, fax, or send our office a letter requesting an appointment. In addition, your provider will need to fax or send all of your pertinent medical records including dietary history and any treatments for obesity.

On the day of your consultation, you will meet with our staff and surgeon. During this visit, the surgical options will be explained to you. If surgery is indicated, the surgeon will discuss which type of surgery best fits your health needs. At the consultation you will also learn about the bariatric program, the potential risks and benefits of surgery, the hospital stay, recovery, future diet, and long-term follow-up. We will give you educational material that will also explain the surgery and the life changes that are necessary when you have this surgery.

We may ask you to have additional tests to make sure that the surgery will be successful for you. These tests may include cardiac work-up, sleep and breathing studies, nutritional studies, or physical therapy evaluations. After we have medical clearance, we will submit the request for your surgery to your insurance company. This process can take six or more weeks, depending on your insurance carrier.

If surgery is not the best treatment for you, our doctors will help facilitate a medical weight-management program tailored to your

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specific situation. Preparing for SurgeryWe will encourage you to start right away making the changes that will be necessary after surgery. That means:

• Moving your body. To prevent blood clots from forming and to encourage weight loss, all of our patients must be able to walk. We encourage daily walking the moment you leave our office.

• Eating small portions. When your body has excess weight, your liver is large and fatty. The surgeon will have to move your liver out of the way to do the surgery. Starting to eat smaller portions will begin the weight loss and has proven to markedly reduce the size of the liver.

• Eating a balanced diet of lean meats, dairy products, vegetables, fruit, and a 20 gram protein supplement every day. The supplement is a powder that you can mix into drinks or sprinkle on food. Look in health stores or discount stores for powders that use whey or soy protein and have at least 20 grams of protein per serving. This will help with healing after surgery. (Whey protein appears to be easier to digest after surgery.)

• One multi-vitamin every day. Gastric bypass patients must take vitamins for the rest of their lives. The risk of vitamin and mineral deficiency is increased with a gastric bypass. We encourage patients to start immediately the habit of taking a daily vitamin.

Mental Health ConsultationA mental health consultation is required for all patients considering bariatric surgery. If you are currently under the care of a psychologist or psychiatrist, you may request an evaluation by them. We can also facilitate an appointment with mental health professionals in Grinnell. You will need to have tests performed called the MMPI and the MBMD as part

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What to expect

of your evaluation.Pre-surgery Education SessionOnce your surgery has been approved by our Bariatric Review Commit-tee and your insurance carrier (or you have made arrangements to pay for the surgery yourself ), we will schedule an educational session, a pre-operative interview, and a surgery date for you. The education session is mandatory. We want to make sure you get to know the people who will be helping you, the details of the surgery and recovery, and the facility in which you will have surgery. On the education day, you will meet with the dietitian, wellness staff, social worker, nursing staff, care coordinator, and director of bariatric services. The education sessions will be a half day.

Pre-operative InterviewThis interview allows the hospital staff to evaluate your medical needs during your stay at the hospital and during the surgical procedure. The pre-operative interview is mandatory. You will meet one of our out-standing anesthesiologists who will tailor the anesthesia medical care to your health needs. The pre-operative interview may take one to two hours.

Pre-operative Clinic VisitOn the same day as your pre-operative interview, you will meet with a surgeon or the bariatric director again. This is a time when you can discuss any remaining questions or concerns.

Pre-operative Physical ExaminationThe last step before you have surgery is a full physical examination by your family healthcare provider. By state law, anyone undergoing major surgery must have a full history and physical within thirty days of the planned surgery. This last step makes sure that nothing has come up between your consultation and the surgery that may negatively affect the outcome of your surgery, such as a fever or respiratory infection. We cannot perform your surgery without this physical.

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SurgeryThe day prior to your surgery (Friday if you are having surgery on Monday), please call the surgery department between 12:30 and 1:30 p.m. (641-236-2328). The surgery staff will give you final instructions and tell you what time to be at the hospital.

During your hospital stay, the surgeon, physician assistant, family practice physician, director of the bariatric program, dietitian, social worker, wellness staff, and care coordinator will visit you. Family members and friends are the other part of your support team. Please feel free to have family members and friends visit you while you are in the hospital.

Follow-up after SurgeryAfter surgery, you will follow up with the Grinnell Bariatric team routinely for medical check-ups. The medical follow ups are important to ensure that you are staying on track with diet and exercise as well as vitamins and supplements. We also offer a group education/support meeting and monthly Saturday support groups. This is open to all bariatric patients. At these meetings, a dietitian, exercise specialist, medical provider, and therapist provide information and encouragement to our patients.

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insurance Approval

Insurance ApprovalNot all insurance carriers cover bariatric surgery. We recommend that you call your insurance carrier and ask whether a medically necessary bariatric surgery is a covered benefit on your plan. The phone number to call is usually on the back of the insurance card. If it is not a covered benefit, you may choose to proceed and pay the fee out of pocket.

Upon receipt of appropriate documentation and completion of the consultation notes, Surgical Associates will submit your proposed surgery to your insurance company for approval. In cases where a patient has a primary and a secondary insurance carrier, we submit to both carriers.

The approval from your insurance company can take four to six weeks depending on how quickly Surgical Associates receives all the docu-mentation required and on the efficiency of the insurance carrier once the documentation is received. If you have not heard by six weeks, please call your insurance carrier to check on the status. We cannot schedule your procedure until we have written authorization from your insurance company.

Medicare: Grinnell Regional Medical Center is one of a select few hospitals in Iowa that have been approved to perform morbid-obesity surgery on Medicare patients. The American College of Surgeons award-ed the highest level of accreditation to GRMC: Level 1.

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Insurance co-payment and feesGrinnell Regional Medical Center and Surgical Associates, LLP, partic-ipate with numerous insurance plans. We and the patients have contrac-tual obligation to the insurance companies and the federal government. One of these obligations is that we always collect co-payments. This is also an obligation of the patient, that he or she always pays a co-pay or co-insurance when applicable. GRMC, Surgical Associates, LLP and the patient must further abide by the rules guiding deductibles. Surgical Associates requires deductible and co-insurance amounts to be paid 10 days prior to your surgery.

If you have any questions about our financial policies or billing practices, please ask the receptionist. Also, remember that you are a customer of your insurance company and you may contact them and ask them ques-tions at any time regarding your plan coverage.

Surgical Associates, LLP, of Grinnell and GRMC know that some patients do not have insurance or do not want to involve their insurance companies with certain aspects of our medical care. Below, we outline these three options. If you have questions, please ask your Surgical Asso-ciates/Grinnell Bariatrics nurse or physician assistant.

Cash DiscountsSurgical Associates will provide a 40 percent discount for patients who have signed an agreement to not involve their insurance companies in any fashion with regard to the procedure or visit in question. Further, if addi-tional services are required due to unforeseen medically related problems, the patient will not involve their insurance company. The 40 percent discount is an estimate of the savings in administrative costs associated with coding, submitting, appealing, posting, and accounts receivable for the procedure or visit.

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Paying for medical Care

If Surgical Associates and the patient agree to the terms of the discount, the patient will be responsible in full for the payment due 10 days prior to the date of surgery.

GRMC offers a flat fee cash option for your hospital stay and anesthesia services. Full payment of the discounted price is due prior to the surgery.

CareCreditGRMC and Surgical Associates participate in CareCredit, an inde-pendent credit company. Patients who are interested in using the credit option can contact CareCredit and discuss the loans available to them. The patient may then choose to enter an agreement with CareCredit. The arrangements for payment of the loan are strictly between the patient and CareCredit with the projected medical expense and if the loan is approved, the payment for the expense will be sent to Surgical Associates, LLP and GRMC. We can provide information on how to contact CareCredit. CareCredit can be used for paying deductibles, co-pays, cash-discount arrangements, and procedure expenses.

Thank you for choosing Grinnell Regional Medical Center and Surgical Associates for your care.

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r 1. At least six months of a supervised diet within previous three years. Under the care of your healthcare provider, you need to have been in a supervised weight-loss program for at least six months. Usually this includes regular progress visits and a medically approved weight-loss diet plan. The requirement for supervised weight loss varies by insurance company. For Medicaid and Medicare, the diet needs to be within the last six months. Other insurance companies are less restrictive and require the supervised diet to be within the last two years.

r 2. Written documentation from your provider. You need to bring a referral letter from your provider and written documentation regarding your supervised weight-loss program (usually a copy of your doctor’s chart notes regarding the diet). Please bring these with you on the day of your consultation or have them faxed ahead of time. Fax 641-236-0680.

r 3. Smoking Cessation. You do not need to be smoke-free to have a consultation. However, you must be smoke-free for at least three months prior to your surgery. We strongly encourage you to quit as soon as you can, smokers have higher risks of infection, blood clots, and other complications of surgery. If you are a smoker, your healthcare provider can help you achieve this goal; the healthcare providers at Surgical Associates can also help. All bariatric patients are tested for carbon monoxide at their pre-op interview to assure that they are safe for surgery.

r 4. Psychological Evaluation. To help ensure that you are successful with weight-loss surgery, you will need a full mental health examination by a licensed psychiatrist or psychologist that includes the MMPI and MBMD tests. These results must be faxed or mailed to Surgical Associates, LLP.

CHECK LIST FOR BARIATRIC SURGERY

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CHECK LIST FOR BARIATRIC SURGERY

r 5. Educational Session at the Hospital and Pre-operative Interview. If the surgeon has determined that surgery is indicated and appropriate for you and your insurance approves your surgery, you must schedule your education day and pre-op interview. You will need to call the hospital 641-236-2412. These meetings are mandatory and your surgery cannot be performed if you do not attend both of these sessions.

r 6. History and Physical by your Family Provider. Within 30 days prior to your surgery, you will need to have a full physical examination with your family healthcare provider. You will need to call your provider and make this appointment. Your provider will need to fax the history and physical to the Pre-Op Department; fax: 641-236-2958. This is a state law and your surgery cannot proceed without this physical.

r 7. Surgery Time. Please call GRMC Surgery Department the day before your surgery to find out what time you need to arrive at the hospital. Please call 641-236-2328 between 12:30 and 1:30 p.m. Call on Friday at 11 a.m. if your surgery is on a Monday.

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Notes:

Phone Numbers

210 4th Ave. • Grinnell, IA 50112641-236-7511 • Emergency: 641-236-2380

Fax: 641-236-4048 • www.grmc.us

122 4th Ave. • Grinnell, IA 50112641-236-4323 • Fax: 641-236-3411

www.grinnellsurgeons.us

Surgical Associates, LLP 641-236-4323Surgical Associates Fax 641-236-3411Surgical Associates Toll Free 866-613-4323GRMC Hospital Pre-Op 641-236-2412GRMC Hospital Dietitian 641-236-2435GRMC Hospital Wellness 641-236-2999Smoking Cessation 641-236-2385Grinnell Regional Mental Health Center 641-236-2347Emergency Calls 641-236-2380Surgical Associates Website www.grinnellsurgeons.comGrinnell Regional Medical Center Website www.grmc.us

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