FREQUENTLY ASKED QUESTIONS

 

 

What is the youngest patient on whom you can operate?

 

Dr. von Rueden will perform the surgery on a patient as young as eighteen years.  For patients under twenty years of age, the concern is that the patient makes the decision for surgery him or herself.  There also needs to be a full understanding and commitment to the altered eating pattern, which will be necessary for success. 

 

What is the oldest patient on whom you can operate?

 

Patients over sixty-five years of age require very strong clinical indications for surgery and must also meet the Medicare criteria, which are very 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 cases, this argues against the surgery.  However, surgery can be indicated and successful in patients over sixty-five and individual consideration will be given.

 

What routine tests are required prior to surgery?

 

Some of the tests include, but are not limited to blood tests (lipid profile, comprehensive metabolic profile, vitamin B12 & folate level, complete blood count with differential, thyroid panel, prothrombin time (PTT), iron (iron binding capacity), electrocardiogram, cardiac stress test, echocardiogram, pulmonary function tests, arterial blood gas, upper gastrointestinal series, ultrasound of abdomen and chest x-ray.  You will be required to have a psychiatric consult, and possibly consults with a cardiologist and pulmonologist.  Each person is treated individually and each test ordered is to ensure the best possible treatment for the individual patient.

 

Why do I have to have a psychiatric evaluation?

 

We do not believe that patients with weight problems are crazy!  The most common reason you may be required to have a psychological evaluation is because your insurance requires it.  Also, if you are under a psychiatrist’s care for any reason, we would like a letter of approval/ disapproval of the surgery.  What we are looking for from the psychiatrist is to evaluate the patient’s understanding and knowledge of the surgery, complications, and long-term care and the ability to follow the basic recovery plan.  Very few people 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?

 

Surgery can be scheduled, usually within 6 months of your comprehensive visit.  Insurance approval is a pre-requisite for many persons.  However, finance options are available should insurance not cover the cost.  Once you decide to have the surgery, you will come in monthly for supervised weight loss.  After you have met all criteria for insurance approval, we will submit your claim to your insurance carrier for approval.  Once the approval is obtained you will be contacted and given a surgery date.  All of your pre-op tests and evaluations need to be completed by your visit two weeks before surgery.

 

How can an insurance company deny coverage for a life-threatening disease?

 

Coverage may be denied because there are specific exclusions in your policy for obesity surgery, or “treatment of obesity,” which is a manifestation of the attitude of our society toward obesity, and the discrimination which people of size suffer.  Such an exclusion can often be attacked by 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- dieting, exercising, behavior modification, and some medications.  Usually, medical necessity denials hinge on the insurance company’s demand for some form of documentation, such as 1-5 years of physician-supervised dieting or psychiatric evaluation.  The best approach to these demands is to try and 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 to 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 primary care physician and consultations 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.

 

SURGERY

 

Does Laparoscopic surgery decrease the risk?

 

Laparoscopic operations carry the same risks as an open operation though at a reduced rate in experienced hands.  The benefits of laparoscopy are typically less discomfort, shorter hospital stay, earlier return to work, and much reduced wound complications and scarring.

 

How long does the operation last?

 

Typically, the gastric bypass requires a total time in the operating room of 2-4 hours- the operation itself takes 1-3 hours.  If your family will be waiting, they should understand that the operation might not begin immediately, so they should not watch the clock.  If the operation is lasting longer, the doctor may be able to send a message to the waiting party. 

Gastric banding typically takes 1 hour.

 

Will I have a lot of pain?

 

Our surgeon and the Staff will try very hard to control pain after surgery to make it possible for you to move about quickly and become active.  This helps to avoid problems and speeds recovery.  There are various drugs that can be used via a system called Patient Controlled Analgesia (PCA).  This is an intravenous medication dispensed through a pump, which allows you to push a button and give yourself pain medication on demand, whenever you need it.  Most of the patients are pleasantly surprised at how little discomfort they experience after laparoscopic surgery.

 

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 outpatient for the Lap Band, and 1-2 days for laparoscopic gastric bypass.

 

Will I have a tube coming out of my nose after surgery?

 

We do not typically insert a nastrogastric tube.  You will have a Jackson Pratt drain, which is a small drain that has a bulb on the end to remove any accumulation of fluid.  This will be removed at your first post-op appointment after surgery and may produce only minor discomfort, if any discomfort at all.

 

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 of your personal needs, however you will need help with shopping and transportation.

 

How soon can I drive?

 

It is recommended 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 safety and the others on the road.  Usually this takes several days after surgery.

 

When can I leave the area?

 

Patients who come from outside the Baltimore area for surgery arrive the day of surgery.  There are local hotels you can stay in the night before surgery.  You can have one support person stay in the room with you post-operatively.   Typically, you will be discharged on the evening of the second day.  Therefore, you will need transportation at that time.  We do need to see you in the office within two weeks from surgery.

 

 

LIFE AFTER SURGERY

 

Can I drink carbonated beverages after surgery?

 

For the first six months post-operation, it is advised not to use carbonated beverages.  Some patients try carbonation after six months and it still gives them a problem such as feeling uncomfortable from the gas produced.  Some patients are able to drink sugar free carbonated beverages.  However, it is recommended not to drink any beverages thirty minutes prior to eating a meal and thirty minutes after eating a meal.

 

Why can’t I eat red meat after surgery?

 

You can eat red meat but you need to be very careful.  It is best to avoid it for the first several months.  Red meat contains a high level of meat fibers, or gristle, which holds the 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 typically by eating foods with high sugar or carbohydrate content on an empty stomach.  These substances produce a high osmotic load.  Your body handles this by diluting the food particles with water, which reduces blood volume and causes a shock-like state.  Sugar may also induce shock due to the altered physiology of your intestinal tract.  The result is an unpleasant feeling causing you to break out into a 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 thirty to sixty minutes and it 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 sweets, such as fruit, is well tolerated at the end of a meal.  Dumping Syndrome does not occur in patients that have the Lap Band procedure because their intestines are not altered.

 

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, which produces irritating byproducts as well as gas.  Depending on individual tolerance, some people find even the smallest amount of milk or milk sugar will cause cramps, gas, and diarrhea.  Patients with lactose intolerance can use Lactaid products or supplemental enzymes.

 

What do I do to use the gastric bypass “tool” successfully?

 

The basic rules are simple and easy to follow:

1)      Eat three meals per day.  During those meals eat your protein first.  The goal is to obtain at least 60 grams of protein per day.

2)      A mid-morning and/or afternoon high protein snack is acceptable. 

3)      Drink water.  The goal is to drink two to three quarts of water a day.

4)      Exercise daily.  Walking is a wonderful form of exercise and you may not be able to do much in the beginning, but you will increase your endurance with time and practice.

5)      Take the recommended vitamins daily.

 

Can I snack after surgery?

 

One to two snacks per day is acceptable to increase your protein or fiber intake but 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 on the wrong foods will definitely slow down your weight loss and can lead to a late regain of weight.  Snacking is also a habit, which is easier to avoid than stop once it is started.  

 

Why drink so much water?

 

When you are losing weight there is a heavy load of waste products to eliminate, mostly in 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 in between meals it is because you did not drink enough water the hour before.

 

What is 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 that means you will lose muscle mass and strength.  Daily aerobic exercise for twenty minutes will communicate to your body that you want to use your muscles and force it to burn the fat instead.

 

Is pregnancy a possibility after surgery?

 

It is very important not to get pregnant for the first year after surgery.  During this time there could be a high risk (up to 90%) of miscarriage due to the inability of the fetus to obtain all the required nutrients.  Other forms of birth control will be necessary during this time.  It has been reported that hormonal based birth control is ineffective for the first eighteen months.  That would include birth control pills, injections, and implanted hormones.  After the first year post-operatively there have been studies completed to indicate that normal pregnancy occurs without any complications.

 

Do I have to attend the support group meetings?

 

It is highly recommended that you attend the support group meetings.  You would be surprised how helpful it is to listen to the experiences of other people in the same situation.  Many questions will arise along the way and the best way to get them answered is by the people who have had the same experience.  Various emotions will accompany the changes experienced and it is important to process this in a group with others.  Remember for some people isolation was part of being morbidly obese and the support group will ensure no one is alone.

 

 

If I lose all this weight, how will my life change?

 

Of course, we can’t predict exactly how your life will change after losing 100, 150 or 200+ pounds.  That old motto, “everyone is an individual” is wise and true!  We can ASSURE you that your life WILL change and the changes are very likely to be quite dramatic!  Over the last 2 years that we have monitored our patients, we find some of the major changes to be:

Ø      Improved physical status (for example, blood pressure, blood sugar and respiratory regulation), more energy, less body aches and pains, improved sleeping.

Ø      Improved psychological status, including decreased depression, improved self-esteem, improved social skills, more confidence and realistic hope for the future.

Ø      Changes in relationships, including family, love relationships, friends and co-workers.

In general these changes are positive and exciting.  They are also demanding.  In order to cooperate with our program, patients must really put their own health care choices first.  This is very often a change for our patients, since many have felt depressed and hopeless; they have given their own lives the lowest priority.  Our patients have to learn to make assertive, healthy decisions for themselves, even when these decisions upset their loved ones.  For example, they may choose to go on their exercise walk instead of sitting down and eating pretzels, OR they may have to deal with their spouse’s jealousy or discomfort when they become increasingly attractive and independent.

 

Body Image: Patients undergo incredible changes in how they see and feel about their bodies.  Losing 100 or more pounds creates drastic changes in body size, appearance, and related areas such as dressing choices, feelings of being attractive and sexy.  Accepting normal body image is sometimes a major challenge for obesity surgery patients!  Even though wearing a size 8 dress may be a lifetime goal, some patients require some adjustment time to accept this reality, sometimes still “feeling fat”, or worrying that they will gain weight back.  We find that as more time passes and patients learn to become experts in managing the program guidelines with their individual lives, they experience more real success, and the new healthy body image becomes more comfortable and reliable.

 

If you have any questions that were not answered or you need clarification on any of the questions in this brochure, please feel free to call Dr. von Rueden’s office at 410-368-3003.