Travis Goodnight MD FACS

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Interesting that your surgeon is pushing you toward the bypass. A recent study out of Japan showed that severe diabetics may benefit more from the bypass and have resolution of their diabetes but that study was a "mini gastric bypass" which is very commonly done in the U.S. and the patient population was a bit different. At the International Sleeve Gastrectomy Summit this year, it was discussed whether patients with severe GERD should have sleeves and many thought that gastric bypass would serve them better. There was no consensus on that and I don't push my patients in any direction. As long as a patient is well informed of the pluses and minuses, I believe it's their choice. Now if you take a lot of NSAIDs for arthritis, then I would stay away from the bypass. Most of us like the sleeve because it can always be converted to a gastric bypass or duodenal switch if needed. Thank goodness most don't need that. Just talk to your surgeon about your worries. Why does he/she think bypass would benefit you better? And remember, this is your decision and your body.

No difference in leaks whether you oversew or not. Good studies to show that. What it can help is decreasing the risk of bleeding. Oversewing or using the SeamGuard strips on the stapling devices have shown to decrease bleeding but haven't changed the leak rate a bit. I'm with Dr. Pleatman on this one. Your surgeon should do what they are most comfortable with and have had the best results with, IMHO.

Smoking is a killer obviously. At the International Sleeve Gastrectomy meeting this year, a paper was presented with patients having delayed leaks (>3 weeks out). All patients had one thing in common....they smoked. I ask my patients to quit 4-6 weeks pre-op. It's a life changer....stopping smoking and losing weight. You'll be a new you.

An IVC filter is a pretty straightforward procedure with a low complication rate. It is definitely a patient-by-patient choice to place a filter or not. Most of us rarely use them routinely but if we do, we place a removable filter so we can take it out 4-6 weeks after surgery. Permanent filters used to be all we had but, long-term, there are some of these which can clot completely off which isn't a good thing. Definitely something to talk to your doctor about including the plan of removable vs. permanent, what time period to remove it, etc.

It's the most ridiculous requirement ever. Definitely a "weed-out" insurance technique. The good thing is, most of them just require a 6month medically supervised program but you don't have to be successful at all. I truly believe the insurance hopes you give up or miss a month or something to not approve you. But I'm bitter about insurance companies! They make everything harder than it should be.

It's pretty variable across the country (and world) and depends on the patient's overall health. Almost all of us require the nutrition evaluation. That never slows anything down because I require a 10 day pre-op diet and get the nutrition eval during that time. Many routinely require the psych eval and some do it selectively based on the patient and your history. Very rarely does anyone require the 6 months of medically supervised weight loss. That seems to be an insurance hoop although they did derive that from NIH guidelines/recommendations. Usually it's: Seminar, consult with the surgeon, nutrition eval, +/- psych eval, +/- pre-op diet, surgery

I feel your anxiety and it's legitimate. Every surgeon has to do their first sleeve. I've recently started doing them as well. Some of us tend to wait until the 5 year studies came out to assure that the sleeve was as good as we thought it was...and it seems to be. We as surgeons know that the best bariatric surgeons are the ones who have done plenty of advanced laparoscopy. Most of us trained doing the Lap RNY gastric bypass which is one of the more advanced technical operations we do laparoscopically. Also, Nissen fundoplications (i.e. stomach wrapped around the esophagus for reflux) or large hiatal hernia repairs are both technically more difficult to do than a sleeve. But the sleeve is not an appendix or a gallbladder so technique for advanced laparoscopy is key. Being close to your home, I just want to know which insurance company doesn't require you to have the 6 months of medically supervised weight loss! That's awesome and I wish they would all go to that. It has never shown to be of benefit or be an indicator of your success after a bariatric operation. The psych eval is similar but we all tend to do them because the NIH recommends it. I've gone away from the psych eval on self-pay patients unless they have indicated the need for an evaluation. Go with your gut. Meet with the surgeon or go to the seminar. I do highly recommend a board certified general surgeon.

We really just look at the thousands of patients that got gastrectomies in the 1970's and 80's prior to the invention of Pepcid and Prilosec for ulcer disease. These patients do remarkable well. Now usually in that type of operation, those patients lose the antrum of their stomach so Vit B12 is more of a concern. Sleeve patients keep a large portion of their antrum so Vit B12 is less of a worry. So, although the sleeve has been around for only about 10 years or so officially, gastrectomies have been around for many years. I will say one thing, I have not operated on too may morbidly obese 85 year olds. The obesity brings along so many health problems that longevity is more difficult with diabetes, heart disease, high blood pressure, sleep apnea, etc. There just aren't many (if any) 350-400lb 85 year olds. It's a great question though. I have an 18 year old patient who is wanting the sleeve and asked the same question. He is actually the one who asked the question then immediately followed it with this answer..."Well, that's kind of dumb question I guess because if I don't do something about my weight now, I'm going to die before I could ever see what would happen anyway". I told him no dumb questions but he's absolutely right that his health is suffering tremendously.

Hiccups are a weird thing. They are often associated with irritation of the diaphragm. Your diaphragm is right above your stomach so it would make some sense that if your sleeve got distended, it would irritate the diaphragm. I usually see it shortly after surgery when we operate on the area and irritate. Obviously, you guys are living with it for some time. It would be interesting to see if it resolves after a year or so. It should, as Lap Nissen patients have the same issues. Dr.G

There really is no chance of the staple line "breaking" down the road. The staples hold the stomach together while it heals so once it's healed, it's healed. Most leaks happen in the first 5-7 days. That's my biggest worry point which is why many of us require liquids that first week. One of the biggest risk of leaks is overdistending the new sleeve...difficult to do that with liquids alone (although not impossible). Occasionally, leaks are seen 2-5 weeks out from surgery but that is definitely a rare finding and often we wonder if there was a very tiny leak early on that slowly enlarged until it became "clinically relevant".

Most of us require much of the same things except the ridiculous 6 months of medical weight loss. That's an insurance thing to "weed people out" I believe but that's another story. Not all of us require the psychological evaluation. It isn't very helpful most of the time and has no bearing in how well people do following weight loss surgery. I require the psych eval if the patient is on psych medications to assure they are well controlled on those. For me: Most Self pay patients get: Nutrition evaluation (out of state patients can just see their local nutritionist) Pre-op Lab, chest x-ray, ECG Surgical consult Operation Some patients will need a psychological evaluation and some will need an EGD/Upper GI. But those are patient dependent. Except for the pre-op EGD/Upper GI, everything else is included in the price. It's definitely the easier route although not the least expensive route. Our self pay patients usually pay $12,500 total....although it's going to be $9,900 for January-March which is great for the patients. Sorry, didn't mean for that to be an advertisement. Dr. G www.goodnightsurgical.com

Well, the tissues never get to 100% of their original strength so 85% is where we get. Of course the stomach completely heals and at 6 weeks, we consider people "fully healed". Hang in there. This isn't a short ride....it's forever. Dr.G

vicki, I tell my patients to avoid the scale for at least the first 2 weeks. It's tough to do but the scale is worthless during that time and can be discouraging. In fact, it takes your body a minimum of 6 weeks to get to 85% healed (which is where we want it). The first 2 weeks are filled with significant Fluid shifts and marked changes in your body's metabolism. Your body is used to getting 2500 calories per day (or more) and all of a sudden it's getting 800-1200kcal. Your body doesn't like that. It was very comfortable at 100lbs overweight (or whatever you were) and an old, and I believe true, theory is the "set-point". Your body was happy at its former weight and will do everything it can to conserve that. You will win this battle. Just stick with it. Try to not obsess about the scale, especially the first 6 weeks. Dr.G

Cheap and American Medicine don't go hand in hand unfortunately. We have just started a Lap Sleeve program at our facility and the current self pay is $12,500 which includes the surgeon, anesthesiologist, nutrition, one year of follow-up, overnight stay in the hospital, and any and all lab/x-rays/gastrografin swallows. It's an additional $1000 per day in the hospital if you have to stay additional days. Usually, patients have the surgery Monday morning and are discharged Tuesday late afternoon/early evening and do quite well. Because our program is new, I am working with the hospital to really do the first 50 self pay patients at a reduced price such as $8,995. They are very receptive to that and I believe we'll start doing that next month. My training is mostly in Lap RNY gastric bypass but I have left that behind for the Sleeve. We also have weight (<350lb) and BMI (<50) limitations as we proceed to obtain Center of Excellence verification. So, there are places out there. You just have to search around for places that are close to you and that you are comfortable with.