What is standard?

[unavidanueva]

Some posts on one of the fb DS sites have me wondering.

My surgery is coming up next month at the University of Chicago hospital. I've done a lot of reading over the past few months, and right from the start, I was looking at established bariatric programs in large teaching hospitals. I want to be someplace where they have the resources to handle all of my comorbidities and anything else that might go wrong during or after the surgery.

From all I have read, and all that is required at U of C, there were things I assumed were just common sense, standard, best-practice policies. I thought that everyone must do these things. But from the responses I've seen on fb, I've been startled to find DS post-ops who (for instance) were not required to have a pap or mammo as part of pre-op testing, or who were not sent home on blood thinners to prevent DVTs.

Who in their right mind operates on obese, MO, and SMO people and does not take precautions against DVTs and pulmonary embolisms??? Startled was not the right word; I am shocked. And I wonder, is this just the tip of the iceberg? Are these examples of a lack in precaution that might explain why some (doctors'?) patients seem to have so very many problems, and others do just fine after the surgery?

You all have much more experience with this than I do. What are your opinions?

 

[southernlady]

Some posts on one of the fb DS sites have me wondering.

My surgery is coming up next month at the University of Chicago hospital. I've done a lot of reading over the past few months, and right from the start, I was looking at established bariatric programs in large teaching hospitals. I want to be someplace where they have the resources to handle all of my comorbidities and anything else that might go wrong during or after the surgery.

From all I have read, and all that is required at U of C, there were things I assumed were just common sense, standard, best-practice policies. I thought that everyone must do these things. But from the responses I've seen on fb, I've been startled to find DS post-ops who (for instance) were not required to have a pap or mammo as part of pre-op testing, or who were not sent home on blood thinners to prevent DVTs.

Who in their right mind operates on obese, MO, and SMO people and does not take precautions against DVTs and pulmonary embolisms??? Startled was not the right word; I am shocked. And I wonder, is this just the tip of the iceberg? Are these examples of a lack in precaution that might explain why some (doctors'?) patients seem to have so very many problems, and others do just fine after the surgery?

You all have much more experience with this than I do. What are your opinions?

Standard varies ALL over the board. Usual standards include a note from your PCP, a cardiac clearance, and blood work. And possibly a sleep apnea test. Anything beyond that is entirely up to the surgeon or the insurance company.

While I was on blood thinners at the hospital, no, I was not sent home with them. They just told me to walk to avoid DVT's, but then I am also not prone to them.

As far as pap smear and/or mammo...those systems aren't affected by the actual surgery. May be affected after. Mammo is not a standard of care for women til they hit 40 anyway. And they are TRYING to make it not a standard of care at all. And pap...while it is suggested yearly for sexual active YOUNG women.

I do get a mammogram yearly and a pap smear every other year. I am also 61. And post menopausal.

Most DS surgeons do not work thru a Teaching Hospital. I know that while there is one in the town where I had my DS, it did NOT have a center of bariatric excellence and did NOT do the DS at all. The teaching hospitals in SC do not do the DS. But then again, we don't have a DS surgeon either that I know.

 

[OldBroad]

This is just a wild guess, but there are lab tests (INR, prothrombin time) that relate to clotting and some doctors may only give the blood thinners to patients whose readings suggests that they need them. I know that my readings indicated that I was not at high risk for thrombosis.

 

[DianaCox]

I was not put on blood thinners either - part of the pre-op blood work and history (including family history) is looking to see if the patient is at risk. And blood thinners in patients who don't need them, especially immediately post-op, are not risk free either.

My blood work indicated no risk, as did my personal history and family history (note: OldBroad is my sister, so of course we have the same family history, which is chock full of obese and morbidly obese people with no DVTs at all), so there was no need for blood thinner.

On the other hand, my husband's father died of a pulmonary embolism after breaking his hip (he was dying of brain cancer at the time) - every time he has had a big surgery (his own broken hip, knee surgery, abdominoplasty with multiple hernia repairs), he has been put on thinners.

 

[DSRIGGS]

No blood thinner for me after the hospital and I refused the lovenox while in the hospital. I didn't want more sticks in an already tender abdomen and I was not a clot risk.

My DS was done at a teaching hospital but that isn't necessarily a good thing. It simply means a snot nosed intern who is scared of the attending, will be more than likely be the person following you. Don't hesitate to tell them you want to see your surgeon if you have any issues or questions.

The most important things I would be asking about if I was you and know what I know now:

1. Will you measure my entire small bowel and do Hess Method?
2. If not, why?
3. What is your plan for Common Channel and Alimentary Limb length?
4. What size bougie will you be using for my sleeve and do you suture tight or loose to the bougie?

 

[Munchkin]

Best practice for you VS best for the doc. I understand you are trying to do the best for you. But more testing isn't always for you. Many times it's to protect the doc, and next it's to make money. There are many tests done out there that SEEM ridiculous. But I don't know the patient or their history. Just whatever they choose to share on an internet forum. Sometimes the insurance company adds to the list in the hopes you will give up before they have to pay.

I was heparinized during surgery and had lovenox while I was in the hospital. A PTT is almost always in presurgery bloodwork and unless you have some history, that's usually enough. Seriously...a mammogram and a pap smear? These aren't expensive test but certainly not necessary. Whatever do your girlie bits have to do with your being a candidate for WLS? Sure they don't want to open you up and find cancer but presurgery doesn't need to be endless either. And hopefully, if they are doing a DS they won't be spending much time in your vagina. And even less time on your boobs. Why not just order a full body MRI? Another one is the EGD and swallowing test. Nothing is done to the esophagus and the way it is attached to the stomach. We swallow quite well. Look at the number on the scale, we are getting enough food. Again, unless you have some sort of history they are inflating your bill and making money for their organization. The basic stuff makes sense. More is not always better. There is always another test they could do.

My presurgery was an EKG and the basic pre-surgery blood work and that's it.

I have a relative who is 65 and has arthritis in one knee so he is disabled and walks with a cane. He is low income so he gets everything free. He has medicare/medicaid. No co-pays and even his prescriptions are free. They see him coming a mile away. He has nothing to do so he spends several days a week going to doctors and having tests done. Expensive tests and LOTS of specialists. He has more bloodwork done than we do. And more often. He sees more doctors in six months than I have in a lifetime. I asked him what they are doing to help him and the answer is nothing. I think it's his retirement hobby. This is how they make money. The government pays them over and over so they see this guy over and over.

More is not always better. And I always ask why they want to do this or that! And if there is no logical reason, I decline.

 

[KathrynK]

If you have a history of pulmonary embolism or DVT, you will get prophylaxis. I had an IVF filter inserted surgically before DS surgery, because I had a PE history, my family has a history, and I wasn't very active because of arthritis. I also had a sleep apnea test, because apparently the neighbors could hear me snore (an exaggeration, but it was bad!). It's your GPs responsibility to do the routine maintenance and prevention. The surgeon is there to get you through the surgery and they usually stop there. Even though bariatric surgeons have made a commitment to monitoring nutritional status after surgery, I wouldn't expect them to order any annual general health monitoring. My surgery was at a teaching hospital and it was 10 years ago and I was more complicated medically than most patients (long story). There isnt a cookbook when it comes to patients; we are all so different. Ask questions about your individual risks for this partiular surgery, treat those, and then, if you get the answers to the DS-specific questions provided by DSRIGGS, you'll be where you need to be. It's good to read up on everything, but better to ask your surgeon about what he does and why.

 

[brooklyngirl]

I responded to that thread on FB, and I agree it is perplexing just how wide the range is in precautions beforehand, and after. I think I was somewhere in the middle, I definitely had more tests than some, but not as many as you. It all depends on the doctor/hospital, but yeah, I'd be leery of a doc that required hardly any pre-op testing.

 

[hilary1617]

I had my DS done at U of C . They were *very* thorough in terms of patient prescreening and I took that as a sign of caring about their patients as whole people. Due solely to their due diligence process, both (a) very severe sleep apnea and (b) large precancerous polyps in my colon were detected and treated. I had a history of DVT and PE so they had a Greenfield Filter placed prior to surgery.

 

[brooklyngirl]

@hilary1617 and @KathrynK do you know any info about filters and long-term placement? I have an IVC filter and I wonder sometimes if it's gonna cause me problems down the road...

 

[southernlady]

I can understand the need for an endoscopy and a colonoscopy. Those make sense as they are checking parts of the systems involved in a DS.

My surgeon required an endoscopy, and since my colonoscopy was less than a year old, that I did not have to repeat that one.

And I had to have a psyche clearance (which in my case was a joke but I had it anyway). But those were requirements by my surgeon, not the hospital and not my insurance company.

Treatment for possible DVT's make sense while "tied down" in the hospital setting. It's also why the hospital typically uses the compression thingy's that massage your legs. But if you are not prone to clotting, injecting a blood thinner at home can actually be dangerous. It could cause excessive bleeding and if not in a clinical setting could be life threatening. And they can tell from your blood work if you are prone to clotting.

 

[GirlFriday]

My pre-surgical from the surgeon's office/hospital requirements were:
A pap smear within the last 18 months
A mamogram within the last 24 months if you are over 40 (which I was)
The psyche clearance - which was a joke
An endoscopy
Then, I had all of the regular blood work, breathing tests, EKG, sonogram, etc.
I was given a spirometer to practice with at home before surgery.

My insurance company required me to have six session with a psychiatrist before the surgery and six sessions afterward, too.

When I left the hospital, I was given 14 lovenox shots to take once per day when I got home along with my other prescriptions. I was told by my Bariatric nurse that walking would do more good than any drug to prevent DVT. So I took the lovenox for the first, like three days and walked and walked and walked the rest of the time. Like, @DSRIGGS, I couldn't stick anything else into an already sore belly. The few shots that I did give myself hurt so very bad.

 

[brooklyngirl]

I had to have:

Psych clearance
Cardiac clearance (stress test and I believe it was a heart sonogram)
Sleep study
Doppler scan & another sonogram to check for clots
Chest X-ray
Endoscopy
Endocrinologist/"metabolic specialst" to do some tests and decide what the pre-op diet should be
3 months of weigh-ins with the PCP (but then I missed the 3rd when everything in NYC was shut down after hurricane sandy and had to start all over. Don't schedule these at the end of the month, people! {plus it was extra bullshit since she didn't have a scale that could accommodate me and she only wrote down the same number each month!})
2 support group sessions
2 nutritionist visits
Blood work

I *think* that was it

 

[southernlady]

I didn't have the 6 month diet or even 3 month diet. Medicare doesn't require those steps.
And since I was SO close to the edge of not qualifying at all, no diet at all for me...just NPO the night before surgery. In fact my surgeon told me NOT to lose weight.
I had already been diagnosed and treated once for sleep apnea (had the UPPP) but it was still on my medical record. Thanks to a later jaw surgery, my oral surgeon tells me I am cured of sleep apnea.
And with an insulin pump on board, the comorbid was painfully obvious.

Standard seems to be all over the place...nothing is really standard.

 

[unavidanueva]

Best practice for you VS best for the doc. I understand you are trying to do the best for you. But more testing isn't always for you. Many times it's to protect the doc, and next it's to make money. There are many tests done out there that SEEM ridiculous. But I don't know the patient or their history. Just whatever they choose to share on an internet forum. Sometimes the insurance company adds to the list in the hopes you will give up before they have to pay.

I was heparinized during surgery and had lovenox while I was in the hospital. A PTT is almost always in presurgery bloodwork and unless you have some history, that's usually enough. Seriously...a mammogram and a pap smear? These aren't expensive test but certainly not necessary. Whatever do your girlie bits have to do with your being a candidate for WLS? Sure they don't want to open you up and find cancer but presurgery doesn't need to be endless either. And hopefully, if they are doing a DS they won't be spending much time in your vagina. And even less time on your boobs. Why not just order a full body MRI? Another one is the EGD and swallowing test. Nothing is done to the esophagus and the way it is attached to the stomach. We swallow quite well. Look at the number on the scale, we are getting enough food. Again, unless you have some sort of history they are inflating your bill and making money for their organization. The basic stuff makes sense. More is not always better. There is always another test they could do.

My presurgery was an EKG and the basic pre-surgery blood work and that's it.

I have a relative who is 65 and has arthritis in one knee so he is disabled and walks with a cane. He is low income so he gets everything free. He has medicare/medicaid. No co-pays and even his prescriptions are free. They see him coming a mile away. He has nothing to do so he spends several days a week going to doctors and having tests done. Expensive tests and LOTS of specialists. He has more bloodwork done than we do. And more often. He sees more doctors in six months than I have in a lifetime. I asked him what they are doing to help him and the answer is nothing. I think it's his retirement hobby. This is how they make money. The government pays them over and over so they see this guy over and over.

More is not always better. And I always ask why they want to do this or that! And if there is no logical reason, I decline.

Well ... I see your point, IF they were the ones making the money on the tests that they require. Maybe the pap and mammo have to do with my age, maybe they require them of all their female patients, I do not know. To me, it makes sense for them to verify that I have had the appropriate wellness checks done (I believe the requirement was that it be within the last year) before such a life- and body-changing (and -challenging) surgery. Also, they did not require me to do any of these tests at their hospital, and they have no financial connection to the doctors and facilities that I used. My insurance company did not add any additional requirements whatsoever -- not even the famous "XX months of doctor-supervised weightloss diet" that so many people must complete.

Personally, I am glad they are asking me to do these tests. If they hadn't asked for the colonoscopy, I wouldn't know about a) my colitis diagnosis that could make the DS more risky for me; and b) my now redundant colon, which gives me more info on what my c-section adhesions are doing in my gut and would probably also have had implications for the intestinal part of any WLS.

EDIT: I say "would have had implications" because I am no longer scheduled for the DS; due to the colitis, I will only be getting the sleeve at this time.