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Frequently Asked Questions
What is the youngest patient you can operate upon?
We have performed surgery on patients as young as 16 years of age. In this age group, we are concerned that the patient make the decision for surgery him- or her-self, and that there be a full understanding and commitment to the altered eating pattern which will be necessary for success.
What is the oldest patient you can operate upon?
Patients over 65 require very strong indications for surgery, and must also meet MediCARE criteria, which are stringent. The risk of surgery in this age group is increased, and the benefits, in terms of reduced risk of mortality, are reduced. In many instances, this argues against the surgery.
What are the routine tests before surgery?
We always do certain tests: a Complete Blood Count (CBC), Urinalysis, and a Chemistry Panel, which gives us a readout of about 20 blood chemistry values. We do a Glucose Tolerance Test to evaluate for diabetes, which is very common in overweight persons, and frequently is undiagnosed. Most persons, except the very young, get a Chest X-Ray and an Electrocardiogram. We do a vaginal ultrasound (women only), to look for abnormalities of the ovaries or uterus, and a gallbladder ultrasound (everybody) to look for gallstones. Other tests which we frequently order when indicated include Pulmonary Function Testing, Echocardiogram, Sleep Studies, GI Evaluation, or Cardiology Evaluation.
What is the purpose of all these tests?
Primarily, we need an accurate assessment of your health, before undertaking a big operation. The best way to treat a complication is to never have it in the first place, due to advance knowledge.
We want to know if your thyroid function is adequate (hypothyroidism can lead to sudden death post-operatively), if you are diabetic (we will have to take special steps to control your blood sugar), if your heart is sound (surgery increases cardiac stress). We look for signs of liver malfunction, breathing difficulties, excess fluid in the tissues, abnormalities of the salts and minerals in body fluids, and abnormal blood fat levels.
Why do I have to have a GI Evaluation?
Patients who have significant gastrointestinal (GI) symptoms such as upper abdominal pain, heartburn, belching sour fluid, may have serious underlying problems, such as a hiatus hernia, gastroesophageal reflux, or a peptic ulcer. For example, many patients have symptoms of reflux, and we know that up to 15% of such persons may have early changes in the lining of the esophagus which could predispose to cancer. It is important to identify these changes, so that a suitable surveillance program can be planned for the future.
When our doctors detect GI symptoms on your preliminary evaluation, we ask that you have an evaluation before surgery, so that we can take care of them at the same time, and avoid complicating surprises at surgery.
Why do I have to have a Sleep Study?
The sleep study detects a tendency for abnormal cessation of breathing, usually associated with airway obstruction when the muscles relax during sleep. This condition is associated with a high mortality rate, just during ordinary living. After surgery, you will be sedated, and will be receiving narcotics for pain, which also depress normal breathing drive, and reflexes. At that time, airway obstruction becomes even more dangerous, and we need to have a clear picture of what to expect, and how to handle it.
Why do I have to have a Psychiatric Evaluation?
We do not believe that people with weight problems are crazy! When our office asks for a psychiatric evaluation, by far the most common reason is that your insurance company has required it, or we already know that they usually do, and we are trying to shorten the process for you. Normally, we ask the psychiatrist to evaluate for understanding and knowledge, and ability to follow the basic recovery plan. Very few persons are disqualified by the psych evaluation, it is usually painless, and it may be very helpful to you in defining your goals and your decision.
How long does it take to schedule surgery?
We can ordinarily schedule surgery within about 2 - 3 weeks, once financial arrangements are made. Insurance approval is a pre-requisite for many persons. When we obtain approval, we contact you to determine if, and when, you wish to schedule surgery. From that time, surgery can be done in 2 - 3 weeks, or at your convenience (we recommend that you do not wait more than about 90 days, or re-approval may be needed).
Why does it take so long to get insurance approval?
From the time when your telephone interview consultation is completed, it usually takes us 1 - 2 days to send a letter to your insurance carrier, to start the approval process. The time it takes to get an answer can vary, from about 3-4 weeks, to as long as they can dawdle without being asked. Our insurance analysts try to follow-up regularly on approval requests, and each telephone call can consume several minutes of frustrating waiting, just to get through. Try calling the claims service of your insurance company yourself, about a week after your letter is submitted, and ask them what the status of your request is our insurance analysts do that all day long.
We are trying to speed up our process, and have added several new analysts in our office. It really does help, when you get behind the process and call your carrier regularly to inquire.
How can they deny insurance coverage for a life-threatening disease?
Coverage may be denied because there is a specific exclusion in your policy for obesity surgery, or "treatment of obesity", which is manifestation of the attitude of our society toward obesity, and the discrimination which obese persons suffer. Such an exclusion can often be attacked, by the reasoning that the surgical treatment is recommended as the best therapy for the co-morbidities, which usually are covered.
Coverage may also be denied for lack of "medical necessity". A therapy is deemed to be medically necessary when it is needed to treat a serious or life-threatening condition. In the case of Morbid Obesity, alternative treatments are considered to exist according to conventional wisdom such as dieting, exercise, behavior modification, and some medications. Usually, medical necessity denials hinge on the insurance companys demand for some form of documentation, such as 1 to 5 years of physician-supervised dieting or a psychiatric evaluation. The best approach to these demands is to try to produce reasonable information. Once you have successfully jumped over all the obstacles, it is more difficult for you to be denied.
What can I do the help the process?
First, help us to get all the information (diet records, medical records, medical tests) together in your case, so the carrier cannot deny for failure to provide "necessary" information. Letters from your personal physician and consultants, attesting to the "medical necessity" of treatment, are particularly valuable when one or several physicians corroborate the necessity of treatment, it will be hard for the carrier to contradict them.
When the letter is submitted, call your carrier regularly (about once a week), to ask about your status. You may also be able to protest unreasonable delays through your employer or human relations/personnel office.
Does Laparoscopic Surgery decrease the risk?
No. Laparoscopic operations carry the same risk as the similar procedure, performed as an open operation. The benefits of laparoscopy are typically, less discomfort, shorter hospital stay, earlier return to work, and much reduced scarring.
How long does the operation last?
Typically, the gastric bypass or the gastric banding requires a total time in the operating room of 2 - 3 hours the operation itself takes 1½ to 2½ hours. If your family will be waiting, they should understand that the operation may not begin immediately, so they should not watch the clock. If the operation is lasting longer, the doctor may be able to send word.
Will I have a lot of pain?
We try very hard to control pain after surgery, to make it possible for you to move about quickly, and become active, which helps avoid problems and speeds recovery. We use several drugs together, and a system called Patient Controlled Analgesia (PCA), which allows you to give yourself a dose of pain medicine on demand, whenever you need it. Most of our patients are pleasantly surprised at how little discomfort they experience.
How long do I have to stay in the hospital?
As long as it takes to be self-sufficient. Typically, the hospital stay (including the day of surgery) is 1 day for a Laparoscopic Band, 2 days for a Laparoscopic Gastric Bypass, and 3 days for an Open Gastric Bypass.
Do you use a drain.
Most patients will have a small tube to allow drainage of any accumulated fluids from the abdomen. This is a safety measure, and can be removed a few days after the surgery. It produces no more than minor discomfort.
How soon will I be able to walk?
Almost immediately after surgery. Patients walk or stand at the bedside on the night of surgery, and take several walks the next day and thereafter. On leaving the hospital, you will be able to care for all your personal needs, but will need help with shopping, and with transportation.
How soon can I drive?
We recommend that you do not drive until you have stopped taking narcotic medications, and can move quickly and alertly to stop your car, especially in an emergency. This is for your own safety, and that of others on the road. Usually this takes 7 -14 days after surgery.
When can I leave the area?
Patients who come from outside the San Diego area for surgery are required to remain in the vicinity for 10 days after the day of surgery. There are important educational sessions, as well as post-operative tests and X-Rays, that must be done during this time. Most patients stay at a nearby hotel (our office has a list), or sometimes with relatives or friends in the area.
Life After Surgery
Can I drink carbonated beverages after surgery?
Many centers advise against this. We do not, and believe that they will not harm you, or your operation. Many patients do find carbonated beverages uncomfortable, from the gas they produce.
We do recommend that you avoid any flavored drinks between meals, such as diet soda, coffee and tea use of these tends to activate your hunger mechanism.
Why cant I eat red meat after surgery?
You can, but you will need to be very careful, and we recommend that you avoid it for the first several months. Red meats contain a high level of meat fibers, or gristle, which hold the piece of meat together, preventing you from separating it into small parts when you chew. It can plug the outlet of your stomach pouch, and prevent anything from passing through, which is very uncomfortable.
What is Dumping Syndrome?
Dumping syndrome is caused by eating sugars, or other foods which contain many small particles, on an empty stomach. These substances produce a high osmotic load. Your body handles these by diluting the food particles with water, which reduces blood volume, and causes a shock-like state. Sugar may also induce insulin shock, due to the altered physiology of your intestinal tract. The result is a very unpleasant feeling, as you break out in a cold clammy sweat, turn pale white, feel butterflies in your stomach and a pounding pulse. This may be followed by cramps and diarrhea. This state can last for 30 - 60 minutes, and is quite uncomfortable most have to lie down until it goes away. It can be avoided by not eating the foods which cause it, especially on an empty stomach. A small amount of sweet, such as fruit, is well-tolerated at the end of a meal.
What is the problem with milk products?
Milk contains a special sugar, called lactose, or milk sugar, which is not well digested. This sugar passes through undigested, until bacteria in the lower bowel act on it, producing irritating byproducts, as well as gas. Depending on individual tolerance, some persons find even the smallest amount of milk or milk sugar will cause cramps, gas and diarrhea.
What do I do to use the Gastric Bypass "tool" successfully?
The basic rules are simple, and easy to follow:
When each meal is satisfying, this is not a diet, but a style which you can easily achieve, and which will result in rapid weight loss followed by weight maintenance.
Why cant I snack between meals?
Snacking is the worst thing you can do to your weight control process. Snacking, nibbling or grazing on foods, usually high-calorie and high-fat foods, can add hundreds of calories a day to your intake, while defeating the restrictive effect of your operation. Since most snacking is done out of impulse, hunger-limitation or satiety has a limited effect in preventing it. Snacking will definitely slow down your weight loss, and can lead to late regain of weight (usually not all of it, unless you get really ridiculous). Snacking is also a habit, which is easier to avoid, than to stop once it is started.
If you start snacking after a while, and notice the bad effects, well help you to stop. Its a lot easier, and more rewarding, never to start.
Why drink so much water?
When you are losing weight, there is a heavy load of waste products to eliminate, mostly in the urine. Some of these substances tend to form crystals, which can cause kidney stones. A high water intake protects you, and helps your body to rid itself of waste products efficiently, promoting better weight loss.
Water will also fill your stomach, and will help to prolong and intensify your sense of satisfaction with food. If you feel a desire to eat between meals, it is because you did not drink enough water in the hour before.
Whats so important about exercise?
When you have a Gastric Bypass, you lose weight because the amount of food energy (calories) which you are able to eat is much less than your body needs to operate. It has to make up the difference by burning reserves, or unused tissues. Your body will burn any unused muscle first, before it begins to burn the precious fat it has saved up. If you do not exercise daily, your body will consume your unused muscle, and you will lose muscle mass and strength. Daily aerobic exercise for 20 minutes will communicate to your body that you want to use your muscles, and force it to burn the fat instead.
The idea of having an operation is to become slender and healthy, not skinny and weak. If you lose most of your excess fat, and retain most of your muscles, imagine how much power and energy you will have, to enjoy your new life!
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