The referral letter from the family doctor to the insurance company is important. If your letter to the insurance company documents that the prospective weight loss surgery patient has been under your supervision for at least six months, you are providing the key to insurance approval. Sometimes weight loss surgeons have long wait-times so you can use thistime to have patients on a supervised diet/weight loss program. But a letter will often not be enough. Many insurance companies also want chart notes. Having a chart note that says they are obese and should lose some pounds will not be enough to convince an insurance company that your patient has been under a “physician” supervised program. Notes are proof that the patient has been under your supervision for their diet, that they have seen a nutritionist or dietician, and that they are being supervised in a manner that shows their primary care doctor has been involved. Putting together a program for all your obese patients, having classes and activities is a great thing to offer not only morbidly obese patients but others who want to lose a few pounds before the swimsuit season.
Learn about your weight loss surgeon
Some bariatric surgeons offer one type of operation, and some another. Some will be on the same insurance plans as your patients and some will not. Ask a couple of these bariatric surgeons to come to your office or to the hospital and give a talk to your patients about bariatric surgery. It is a good way to learn the types of operations they perform and a little about their office procedures. Some bariatric surgeons prefer to follow every laboratory value of the patient and some will quickly turn the task over to you. Either way, stay in the loop so you know what is happening with your patients. It will provide you with bariatric surgeon referral choices, and you will learn what the they expect your role to be. If your patients are going out of state for bariatric surgery, ask the surgeon to call you so you can create a game plan for the patient. That way both you and the patient will know what to expect.
Weight loss surgery and Vena Cava Filters
Some weight loss surgery patients, knowing that pulmonary embolism is the most common cause of death, will request that a filter be placed in their Inferior Vena Cava. These filters are not without morbidity risks and can cause permanent problems for a bariatric patient, especially if their IVC clots off. There are some “removable” filters, which might be an option, although some of these filters have their own associated morbidity. This is not something a patient should decide. You should discuss it with the hematologist and the weight loss surgeon. While there are some general guidelines for placement, there are no absolutes.
Consider a pre-operative Vena Cava filter if:
- The patient has had a pulmonary embolus before
- The patient has had DVT while on Coumadin or Heparin
- The patient has an allergy to heparin
Medicines—before and after weight loss surgery
After bariatric surgery, a patient’s reaction to medication is different. It is important to know how he will react after the guts are re-arranged. Some medications cannot be swallowed well after a RNY or lap-band (particularly large pills). Some medications—especially time-released, are not absorbed as well, and weight loss surgery patients who had a distal bypass should not be on a time released medication. Go through the list of medications with your patient—if there are liquid forms available, or chewable forms, then change to those.
After weight loss surgery:
- Convert time release medicines to regular, non-time released forms
- Find chewable or liquid forms of medicines
- Determine if the medicines can be crushed and retain their effectiveness
Some medications clearly need to be stopped before bariatric surgery, such as blood thinners (Coumadin, Plavix, Aspirin), and may need to be substituted with other medications. Other medicines that should be stopped include birth control pills and hormone replacement therapy, as the incidence of deep venous thrombosis with these medicines is increased. The statins (Lipitor, Pravachol, etc.) have been associated with a small, but real, incidence of rhabdomyalysis after the operation, so these medications should be stopped at least one week prior to the procedure.
Stop these medicines before weight loss surgery:
- Aspirin, Plavix, Coumadin
- Lipitor, Pravachol, and other statins
- Estrogens, Hormone Replacement Therapy, Birth Control Pills
Oral hypoglycemic medications should be stopped the day before bariatric surgery, and should not be started until after the procedure. They should be restarted only if the patient develops high blood sugars. Weight loss surgery patients obviously cannot consume the same quantities of calories after the operation so their blood sugar will drop, and many will not need these medicines following the procedure. Insulin requirements will also decrease, and these patients need to be monitored carefully and doses adjusted accordingly.
Continue beta-blockers throughout the hospital stay. If weight loss patients don’t need these for blood pressure control, then wean them off carefully.
Patients will come home from the hospital with excess fluid in their extremities
This is quite normal. While some diuretics are helpful in mobilizing these fluids, this is short term, and the patient should be encouraged to continue with protein drinks and supplements. The colloidal action of protein will help to mobilize the fluid. Generally it will only take a few days of diuretics to mobilize these fluids.
Anti-hypertensive drugs are tricky in the postoperative period
Generally, a patent’s blood pressure decreases in the initial postoperative period only to rise a bit when they return home. These patients may need to monitor their own blood pressure, or come to the office for weekly visits with the nurse, to monitor their blood pressure and adjust medication. While they may not need medication in the first couple of weeks, their high blood pressure hasn’t gone away. It has just been moderated a bit from the operation, and they will need their usual dose again. Most bariatric surgeons note that real changes in blood pressure medications occur after the first forty pounds are lost.
Immediate bariatric surgery Post Op:
- Monitor blood glucose, do not start oral hypoglycemics
- Watch blood pressure levels