Quanita L.

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Why I want to Have Weight Loss Surgery
- I have a family history of Heart Disease, Type II Diabetes
- I suffer from lower back pain and I snore because of my weight
- My weight has increased from 75kg (165 lbs) when I was 22 to 110Kg (242lbs) then back down to around 100Kg (220lbs)
- I occasionally have elevated liver function tests (and dont drink much alcohol so not related to that)
- I have slightly elevated cholesterol
- A long history of weight loss failures with various methods of weight loss - Weigh Less (South Africa); Weight Watchers (numerous occasions); Jenny Craig; SureSlim; Gym and Personal Training; other crash diets like Scarsdale, Soup Diet, etc
- I am currently classified as morbidly obese
- My Self Esteem is very low
- I would like to increase my fitness levels by going to the gym more regularly
- I would like to have healthier pregnancies and have a greater ease of getting pregnant
- I believe my weight is a factor in my depression
- I will have a longer life expectancy
- I would like to be able to go bushwalking and fishing and do other outdoor activities comfortably with DB
- I have to sit down to put on socks and tie my shoe laces without being breathless
- There is a higher statistical chance of me keeping the weight off
- I would like to do this before I get worse and surgery would be more risky

Why I Would like to Have a Sleeve Gastrectomy
- Part of stomach that secretes Grehlin (hunger hormone is removed) so I will experience less hunger
- Greater amount of food tolerance than in other WLS, foods do not get stuck
- No Follow Up Required (like for fills with Lap Band)
- Faster Weight Loss than with Lap Band, Comparable Weight Loss with Bypass

From 3 Year Study Lap Band vs Sleeve Gastrectomy - (Click Here for study)
- Median Weight Loss After 3 Years 29.5Kg
- Median Decrease of BMU after 3 years 27.5
- Median Percentage of Excess Weight Lost after 3 Years 66%
- Loss of Feeling of Hunger after 3 Years 46.7%
- Loss of Sweet Eating after 3 years 23.3%

Questions I asked my Surgeon About his Sleeve Gastrectomy and Practises

1. I have read that the procedure involves the insertion of a bougie as a kind of 'template' for the new stomach and that surgeons use varying sizes to perform the procedure. I have read about doctors using anything from a 32Fr to a 60Fr bougie. Do you use a standard size? Is this determined on a case by case basis?

Bougie size, the majority of patients will have a size 36 to 40 Bougie. A few smaller patients ie BMI less than 35 may have a larger bougie size such as a 48

2. How many sleeve gastrectomies have you performed? What is your mortality Rate? What are the rate of and the most common complications?

I have performed around 20 sleeve gastrectomies, without any major or minor complications including death. The sleeve gastrectomy technically is a relatively simple procedure compared to gastric bypass which I was initially trained in. I have been involved in obesity surgery for 5 years during which time I have been involved in over 200 cases including gastric bypass, both open and laparoscopic, gastric banding, sleeve gastrectomy and revisional surgery for older obesity procedures. I have personally performed 50 laparoscopic gastric bypasses which is by far and away the most technically demanding of all the procedures. I have also extensive experience in many other types of laparoscopic surgery many of which also involves the stomach. I am very happy to say that thus far I have not had a single death, not to say that it will never happen because many of the factors are related to how big and how many illnesses patients have. I generally quote a death rate of 1 in a 1000 which is based on a larger series. I do however stress to my patients that this is an up front risk, and the risk of remaining morbidly obese in terms of premature death are much greater than the risk of surgery. A person with a BMI of 45 will statistically die 10 to 15 years before a normal weight counterpart and perhaps just as importantly have a much poorer quality of life.

3. I would have to self pay for surgery so would be interested in knowing ballpark, the cost of surgical fees, cost of anaesthesia, cost of hospital stay, any ongoing costs for post op consultations, cost of any pre op tests or consultations?

I will get my secretary to get an updated quote, last time we did a quote it was around $10,000 I think. Most of the expense is hospital fees, including operation theatre costs and equipment involved in the surgery which is $3,000 alone. I often recommend to patients that they take out private health insurance for themselves which will cost around $800 to $1000 for a year. After 12 months they would then be eligible for most of the above to be covered by their private insurance.

4. I am not planning on getting pregnant in the near future and have only been in a relationship for a short term. I am currently 31 and I would like to have children before my mid 30s. How does this operation affect pregnancy? How long after the operation would I have to wait in order to get pregnant?

Obesity procedures such as sleeve and even gastric bypass do not appear to have any effect on the baby. We normally recommend that people wait a year after surgery before getting pregnant but I have had 1 patient get pregnant within a few months of a gastric bypass and both her and her baby are very healthy. Infertility is much higher in morbidly obese patients so many arent overly careful when it comes to birth control. Suddenly when they lose a lot of weight following their surgery they become fertile and before you know it they are pregnant.

5.Would I have to take any supplements pre/post op or ongoing?

For most patients I have started placing them on a low calorie diet such as optifast for 2 weeks prior to surgery to help shrink there livers and make surgery safer and easier to perform. After surgery patients need to stay on a multivitamin for the rest of their lives. This is not a big deal and interestingly most morbidly obese patients often already have vitamin deficiencies and would benefit from a multivitamin.

6. I have read some patients experience hair loss, Have you experienced this?

A few patients experience hair loss for a few months, more commonly with gastric bypass. Hair loss is not complete more like thinning and is short term, is the hair thickens up again. Normally the loss relates to not enough protein intake.

7. Are there any pre/post op diets?

See 5. Post op patients are on a pureed diet for 4-6 weeks whilst post op swelling settles and then solid foods are introduced. Out of all obesity operations sleeve patients can eat the largest range of foods, pretty much what they could eat before, just in smaller volumes.

8. What is the approximate size of the incisions and scar?

5 small incisions most around 1cm in length, and generally they dont cause much discomfort

9. What tests have to be done pre-op before surgery can be scheduled?

Varies from patient to patient but for most its just a few blood tests

Questions I asked my surgeon at the 2nd Consult (17th October)

1. In the USA I have read about patients requiring a psych evaluation, EKG, GI Tract test, Chest X-ray and blood tests, why dont you require all of these?

In the states a lot of the tests are required to get approval from insurance, especially the psych evaluation. He would do an EKG for older patients, he does do an endoscopy, a chest x-ray doesnt really tell him much.

2. Can I donate my blood for my surgery, in case a transfusion is required?

Yes I could, but my iron levels are currently low, so I would have to wait till my iron levels were good again and also until I built up that blood. It is highly unlikely that I would require a transfusion anyway.

3. What is the final quote for cost of the surgery? Explain how complications can effect the cost?

Theatre Fee $2,369
Bed Fee $713
Prosthesis $1,621
Surgeon Fee $1,700
Anaesthesia $1,000
HD Unit $799
TOTAL $8,202

4. How long should I wait? - as a cooling off period, to think about my decision

this is a personal choice, the last sleeve patient he had waited around 4 weeks between making a decision and having surgery.

5. Can you show me where the incisions will be?

There will be 5 small incisions in a line approximately 15cm below the breastbone, above the belly button. One will be 4 mm, 3 will be 12mm and 1 will be 15mm

6. Can you show me how big my stomach will be compared to what it is now?

This varies, you will lose approximately 80% of your stomach (antrum and pylorus intact) and he will use a 36 bougie on someone of my age and size

7. Can you take photos in surgery? (very low importance)

Yes, he will happy dvd the surgery for me if I want

8. I have my belly button pierced does that matter?

All piercings matter, I will need to place a plastic retainer in my belly button piercing and my tongue and rook piercing

9. What happens with my regular medications post-op?

I will probably miss one or two days of my medications - so birth control will be ineffective for this month and can continue to take medications thereafter. Will take medications on morning before surgery.

10. Do you do a leak test post op?

During operation use a blue dye to test for leaks along staple line and will suture any sites that look like they are leaking. Next day will do swallow test.

11. I watched a video of the surgery where suturing was done over the staple line, do you do this?

probably an old video previously staples were of lesser quality. In some cases he will suture where staple lines cross over or look weak.

12. I saw in another video of the surgery both small staples and large staples, what do you use?

Larger staples are used near the bottom of the stomach (close to the antrum) because this is the thickest part of the stomach

13. How hard/easy would it be to stretch the pouch and regain the weight down the track?

You would have to actively and consistently attempt to stretch the pouch by eating beyond the point where you are full. The stretchier part of your stomach will be removed. If stretching does occur a new sleeve can be done or the sleeve can be converted to a bypass if weight loss is not enough.

14. How do you get enough nutrients for pregnancy when your food intake is limited?

Choose good quality foods. The foetus and placenta have a higher priority for nutrient absorption than the mother does. If you are not eating enough, your fat stores will be used.

15. What is skin elasticity like with weight loss, I would like to lose about 40Kg (90lbs). What would you expect with someone with my skin and age in relation to excess skin?

Because I am young and not that big, I have a good chance of my skin stretching back into place

16. How succesful are your sleeve patients in losing weight?

the patient that had just left was 4 weeks post op and had lost 18kg (39.6lbs), an unplanned sleeve patient has lost 50kg 110lbs in 6 months

17. In a 'normal' sleeve, how long does it take you to perform the surgery?

this varies with patient size, for me it would probably take an hour to an hour and a half

18. How long do you prefer your patients remain in hospital?

2 to 3 nights

19. Do you have a hospital preference for performing surgery (he operates out of 3 hospitals)? Where have you performed most of your sleeves?

He prefers either Calvary Hospital or Ashford Hospital because they are the 2 that have both a High Dependency ward and an Intensive Care Ward.

20. Does menstruation effect surgery?

No

21. When do you recommend patients commence an exercise program post op?

After a week

22. I have seen a lot of sites and read alot saying that sweets alcohol and carbonated drinks are no longer tolerated and should be banned, what do you recommend in relation to this?

Carbonated drinks will add to a feeling of fullness and cause burping; alcohol has a lot of calories but can be used in moderation, some peoples tastes change and they no longer like sweets or coffee

23. Why did you think a sleeve gastrectomy would be good for me?

I didnt have time to ask this

24. What are my responsibilities as far as you are concerned?

to be sure that I am aware of the consequences of the surgery have clearly made up my mind and am willing to change my diet and exercise habits

25. How long before I can return to work? - I work in a desk job

2 weeks

26. How long before I can drive?

a couple of days

27. Risks - please discuss the risks with me? what is a hernia?

Leak, clots, hernias - where wound breaks down

28. Other surgeons I have read about have an assisting surgeon, do you?

yes

29. Walk me through what you would do if something goes wrong?

Didnt have time to ask this question

30. Nausea - I have previously had a reaction to local aneasthetic, do you anticipate me having problems with general?


some people do get nausea after surgery, will give you meds for this