Bariatric Surgery
- It's the newest craze in surgery today. Some surgeons net up to $16,000 each for the Lap Band procedure and other surgical weight loss options, most of which take only a few hours to complete. The staggering demand for these procedures has led to abuse of the system - patients eager to jump straight to surgery without going through the proper channels and greedy surgeons hounding after patients who are willing to pay cash like blood thirsty animals will tell them anything they want to hear if they think it will convince the patients to go under the knife.
If you or anyone you know is undergoing preparation for bariatric surgery - take a real look at the medical guideline criteria that is supposed to be met before surgical steps are taken. The reason the guidelines exist is to ensure that before a patient goes into any surgery that he or she has exhausted ALL other realistic options and the surgery is merely the final resort to achieve a healthy weight. By the way – weight watchers does NOT count!
1. The Risks -
The risks are one of the first things your surgeon should discuss with you, in fact if they were truly responsible – they wouldn’t even discuss bariatric surgery without discussing the risks first. As with any abdominal surgery the risk for post operative complications like incisional hernias, infection, or non-healing wounds is very high. Specific to bariatric surgery; other post-operative risks include:
- Peptic ulcer
- Esophageal stricture
- Kidney stones
- Anemia
- Chronic dehydration
- Gastric dumping syndrome
- Malabsorption of nutrients
- Severe depression
- Vitamin B12 deficiencies
- Neurologic complications
- Other personality disorders
The intra-operative risks are even more severe. Intra-operative risks in any abdominal surgery (whether laparoscopic or open) apply here.
- The surgeon could nick the intestine, then a bowel resection would be necessary possibly leaving the patient with a permanent colostomy.
- Open abdominal operations lead to a very high risk of leaving instruments or surgical sponges inside patients (forgotten instruments)
- Improper handling of laparoscopic instruments can damage any number of organs within the abdomen.
2. The Planning -
When going by clinic guidelines agreed upon by both the American Medical Association and The American Society for Metabolic and Bariatric Surgery your pre-operative workup would generally require at least 6 months of planning and that is a conservative figure, some patients need up to 1 year of pre-operative workups and dieting before they meet guidelines for bariatric surgery (if they meet the requirements at all).The following is typically required pre-operatively of anyone below a Body-Mass Index (BMI) of 49.0:
- Psychiatric evaluation
- 6 months of physician supervised weight loss counseling/therapy
- Documented evidence of treatments tried/failed for any and all co-morbidities related to your planned surgery – meaning if you have arthritis due to morbid obesity you need documentation of failed treatments for the arthritis, if you have obstructive sleep apnea secondary to your obesity you need a documented sleep study and documentation of failed treatments for the sleep apnea.
Understand that bariatric surgery is not going to solve your weight problem in and of itself. The surgery is a pre-cursor to the extremely strict diet, and strictly controlled exercise program that is a necessity to maintain for up to 15 years after your surgery. You will also be required to be closely followed by your psychiatrist to make certain you are not showing signs of suicidal thoughts or depression.
Your surgeon will (should) require regular follow ups at least once a year sometimes for the rest of your life to track and follow you progress, and if you have a Lap Band you will at some point require a saline injection or “fill” to make sure the band has not loosened up over time.
3. The Reasons -
With the heavy advertising done by up and coming bariatric surgery clinics and even the suppliers of the Lap Band system – it is of no surprise that a large portion of people suffering from obesity are clamoring into surgeons offices by the thousands to talk about bariatric surgery options. I would warn you that this is only good for the surgeons and not you as a patient. Your surgeon is sure to be a great talker – he could probably convince you of anything (as most doctors can after so many years) but you should do your homework before hand as regardless of what the surgeon said – you may need to try more conservative options before considering any surgery to help you lose weight!
Bariatric surgery is clinically indicated for the following situations:
Patients with a BMI >35 **
At least one of the following *
AND
- Attempted and failed at least 4-6 months of physician supervised weight loss counseling and therapy
- Been alcohol and drug free for at least 1 year
*Depending on your insurance you may need to have 2 or even 3 co-morbidities related to morbid obesity to qualify for coverage
**Some insurance will not cover bariatric surgery for patients with a BMI under 40.0
Note: Not all insurance companies cover bariatric surgery
I urge you – take a step back and look at the situation objectively (for real). Bariatric surgery is a relatively new concept and as such it should be utilized only in severe cases where patients have put forth a very determined and focused effort to lose weight and it truly has failed. If one is considering bariatric surgery – do your research first and be honest about it’s applicability to yourself – and do not take it lightly!
4. The after care -
As previously stated – surgery is not the end of your journey. There is extensive aftercare and follow up needed if you actually expect bariatric surgery to help you lose that weight.
Post-operative Diet
Nothing about your diet after surgery will be pleasant, flexible, or negotiable! You will fail in every aspect if you do not follow the diet assigned to you after surgery.
You will be eating nothing solid for upwards of 4-6 weeks after your surgery. For the first 4 weeks you will likely be gradually moving from clear liquids only to light juices and protein drinks.
You will more than likely be slowly moved to semi-solid foods like apple-sauce etc. and then you will be eating blenderized foods almost exclusively for a period of time. Some doctors standard post-op diet plans even include blenderized fish, pizza, and hot dogs! You honestly NEED to be prepared for this – it is not pleasant at first (if at all) almost anyone who has at any point in life needed to eat blenderized fish or meat will tell you so.
You will be moved to solid foods (obviously in small portions) eventually.
It is typical for your dietician or nutritionist to recommend that you eat very very small portions every hour or two as opposed to the normal 3 meal a day diet most of us are used to. Fluid intake is recommended in small portions – in some cases, every 30 minutes.
Your diet will almost always include a set minimum amount of protein (your choice of powders, drinks etc.) that you must intake every day.
Follow Up visits
Every member of your bariatric team needs to be someone you are comfortable with because you are going to be following up regularly with all of them – in many cases you will for the rest of your life.
Your psychiatric follow ups in some cases are not necessary after a few years, however in the case that you develop depression or other psychiatric problems after your surgery – the follow ups will continue until you are cured of them.
5. The Doctor -
As I have stated in previous posts – there are a lot of doctors out there so hell bent on getting patients to agree to surgery that they will tell them whatever sounds good. NOT ALL DOCTORS but there are many of them out there. If after considering and discussing the options and risks you decide to not jump to surgery right away – do not let them try and convince you other wise. In fact if they do continue to try and cite reasons you should go ahead with it after you stated you did not want to – I would recommend you not go with that doctor at all. It may be a hassle to find another doctor, it may have cost you a co-pay but do you really think a doctor who wants to operate on you after you said “no” is worthy of your trust?
I really hate to stereotype anyone however there is a big trend among the newest generation of surgeons (like the ones who just got out of residency and are really energetic and enthusiastic) to be way too quick to jump straight to surgery. A lot of them tend to boast about how they were trained on robotic surgery and they love the latest technology and so on, or how many hundreds of surgeries they did in their residency etc. As a general rule I would recommend you lean away from any surgeon who brags about anything – most of the truly skilled surgeons (or any doctor really) won’t feel a need to brag about anything. If you specifically asked them about their previous experience they would usually offer up the information gladly.
Doctors in general and surgeons in particular are as human as everyone else. As such they are subject to the same mental tendencies as the rest of us. For example when it comes to bariatric surgery – many surgeons who are not directly involved in the field of surgical weight loss will recommend against it at all costs because of the risks involved. Whereas many who specialize in bariatric surgery exclusively will recommend it to (literally) 9/10 patients they see. Some have even falsified their own records in order to facilitate payment for surgery where the patient did not actually meet the criteria.
In short – be aware that some doctors become better at making money than making medical recommendations after awhile. Read between the lines on that one!
The doctor you chose may also have influence over whether or not your insurance company will pay on your surgeons claim. Almost all insurance companies base their policies on Medicare Guidelines, the fair majority use parts of it word for word. Medicare guidelines state: “Coverage is provided only if the bariatric surgery is performed at a medical center designated a Center of Excellence by the American Society for Bariatric Surgery (ASBS) or certified a Level 1 Bariatric Surgery Center by the American College of Surgeons.”
If the surgeon who is to perform your bariatric surgery is not affiliated with such a facility then obviously he or she won’t be performing the surgery at an approved facility – which in turn will most likely end up in the claim being denied leaving you stuck with the bill; and it will be a very large bill.
You can to some degree avoid this by making sure you are going to a Medicare approved bariatric facility. Even if your insurance is one that does not require that the facility meet those guidelines – it is still a good idea to go with with one anyways as they have gone through proper measures to prove that bariatric surgery was successfully preformed their before.
Conclusion
As a patient you may be inclined to believe that you absolutely need bariatric surgery – but you need to take your time considering the real world risks and truly huge commitment necessary for a good result. If you have tried your hardest (and really REALLY tried) and have failed at losing weight, and it’s effecting your medical well being – then by all means, talk to your doctor and make sure you are choosing the right one.
DISCLAIMER
This article is not intended to be the only basis on which anyone bases a decision to have surgery. I am in no way saying you should or shouldn’t have or consider having surgery – I am merely warning of some of the risks you may or may not be taking. Some of the content within this article is based on my personal experience in working with doctors and surgeons.
References
ASMBS – Post-operative concerns
ASMBS – General guidelines for surgical weight loss
ASMBS – Patient Resources
Medicare – Bariatric surgery criteria
Medicare - Approved bariatric facility Search
No comments:
Post a Comment