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Chat with Dr. Cirangle, November 14, 2002

<**MODERATOR**> LINDA YOU HAVE THE FIRST QUESTION TONIGHT:)

Thank You. I am trying to lose weight on my own but have been fairly unsuccessful. Actually I've lost about 15 lbs and am now 195. This drops my BMI to about 32 and I have severe sleep apnea, migraines, lower back pain, and have had surgery on both knees about 20 years ago for injuries. Could I still be a candidate for surgery now?

Good question, Linda. What is you height?

5'6"

The sleep apnea has placed me on BiPAP at a high setting.

I was just checking you BMI. At this point your BMI is only 31.5 kg/m2 and you would not be considered a good candidate for weight loss surgery. Even with the extra 15 lbs, your BMI is only 33.9. The reason for these stringent criteria, established by the NIH consensus panel in the early 90's is mainly because the risk of surgery would outweigh the benefits for your weight, even your history of sleep apnea

Thank you for your help and honesty. Best of luck to all able to take advantage of this great opportunity.

More importantly, your risk of higher mortality and developing severe comorbid diseases related to obesity. Finally, do not under any circumstance, gain weight to qualify for surgery. For you, diet and exercise is essential and probably not surgery.

I do not plan on it. I will continue to do all I can on my own. Again Thank you.

Good luck Linda.

<**MODERATOR**> LYNETTE YOU HAVE THE NEXT QUESTION:)

What do I need to do special for food and drink the last 24 hrs before surgery?! Do I need to stop taking my effexor? or duradins before surgery?

What do I need to do special the last 24 hrs for food and drink before surgery?

For the last 24 hours, you should probably just stay on a liquid diet and nothing after midnight. You should follow your surgeon's instructions...

he didn't say anything.

that is why I am concerned

You DEFINITELY SHOULD NOT "eat your last meal."

Lynette, for medication you should probably take most things except for NSAIDS, aspirin, blood thinners, etc. Also, you should not take your morning diabetes medication on the morning of surgery. Good luck.

<**MODERATOR**> JEAN YOU HAVE THE NEXT QUESTION:)

I am having surgery in 10 days. I am excited and anxious at the same time. Crazy question, but what happens to the staples after surgery? Do they just become a permanent part of your body? Our normal concept of staples is that they are something to be removed. How does this work?

Jean, good question. Staples are permanent. They are very small and not to be removed ever. They will become incorporated into your tissue where they are used. Good luck.

<**MODERATOR**> CONNIE YOU HAVE THE NEXT QUESTION PLEASE:)

My sister is 65 with a BMI of 46, but she has taken PhenPhen in the past and now has a MINOR heart problem, should she even try to pursue getting approval for this type of surgery

Connie, that is a tough one. Currently, a person who is 65 years old is at much higher risk for having complications and I'm not sure that the benefits of surgery will be as evident for someone of that age whose heart and lungs have been working for so long supporting all that stress. At this point, my partners and I have decided that we would probably not operate on patients over 60 years old in most circumstances. Hope that helps. Nevertheless, it never hurts to ask. Good luck to you and your sister.

She had mentioned that the age would make a big difference, thanks Dr. F I understand, just thought I would ask. Thank you

<**MODERATOR**> KRIS YOU HAVE THE NEXT QUESTION:)

Kris)Dr Dr. Cirangle< Iam 5'3 and 230 I want this surgery I also smoke, But am willing to quit! I have back problems and all that comes with being this heavy! Would I be a candidate for this kind of surgery? And what about hair loss/I already have thin hair.?

Kris, you need to quit smoking for reasons not just related to surgery...

Kris I know Dr .I truly do I am 33 yrs old Would I be a candidate?

Your body mass index is 40.8, so by that criteria you would be a candidate. Of course other criteria include lack of severe disability, untreated psychiatric disease, etc....

Thank you I will be looking into it:)

Please look on our website www.LapSF.com for more information regarding candidacy for weight loss surgery. We ask that our patients quit at least 3 weeks before surgery for better wound healing, lung function, etc. Good luck. Hope that helps, Kris.

<**MODERATOR**> E*D YOU HAVE THE NEXT QUESTION:)

156LBS> I AM 1OMTHS POST I WEIGHED 4O3 MY DOC SAID I MIGHT ONLY LOSE UP TO 175.... HE WAS TALKING ABOUT WINDOW OF OPP. WHAT DO YOU THINK. AND HOW CAN I LOSE MORE WEIGHT.

Hi Ed. What is your height and current weight?

156LBS> 5/5 246 FEMALE

Thus, your starting BMI is 67.1 and your current BMI is 40.9. Your target is actually to get under 180lbs. Your ideal body weight is 125 lbs with an excess weight of 278 lbs. What kind of surgery did you have?

156LBS> I HAD OPEN RYN DISTAL 5FT

I perform 3 surgical procedures since I believe that there is not just one procedure for all the different people in the world. The Lap-Band, lap RouxenY gastric bypass, and the lap BPD-DS. With the RNY gastric bypass you are expected to lose around 65-75% excess body weight (that's why I mentioned that number)...

156LBS> SO YOU THINK I WILL ONLY GET TO 180?

156LBS> WOW 156LBS> THAT IS NOT GOOD

Then you are expected to lose 180 to 208 lbs on the AVERAGE, some people lose more some less. The RNY pouch enlarges and the bowel adapts..

156LBS> HOW CAN I INCREASE MY CHANCES

You might even experience some weight regain after several years. The best way to optimize your weight loss at this point is to choose a healthy diet and exercise regimen. The equation for successful weight loss is (calories in) - (calories out). This must be a negative number. Our dietitians aid our patients in choosing a healthy diet in high protein, low fat, low sugar and improving aerobic exercise as the weight loss continues. This is best done in the first 6 months to a year. You can still do this now...

156LBS> THANK YOU Dr. Cirangle

Good luck. Hope this information helps, E.D.

156LBS> THANKS DOC IT DID.

<**MODERATOR**> CUDDLYANGEL YOU HAVE THE NEXT QUESTION:)

> How long does it on an average basis for the insurance approval ...when you have all the medical documentation when the Auth is submitted ....my BMI is 53....Diabetes II....Gerd....Arthritis ..history of High Blood Pressure and Family History of Heart Disease ....and Foot Problems and I have Medical documentation's all of this and have turned it all into the surgeon

Hi Cuddly Angel. I have billing specialist who better individualize answers to such questions, but in general, insurance authorization can take anywhere from 2 days to 2 months, depending on who the insurer is, what type of surgery your are going to get, etc. Good luck CA!

Thanks ....Getting Open RNY

Why not laparoscopic?

Because the surgeon I have has 14 yrs experience wth Open ..less than a year with lap ....

<**MODERATOR**> SUSAN39 YOU HAVE THE NEXT QUESTION:)

I have heard that people over 350 should not have the LAP surgeries.. Is this true? and why?

Greetings Susan! That is an interesting statement. If that were true, I think as surgeons we would be operating less. Patients over 350 are those who especially need surgery, since it is often their last resort...

I heard it was not safe.... that we should have open

We have certain criteria that we use but this is not the right forum to discuss those since I spend at least an hour with a patient during a surgical consultation discussing the basis and overall mission for our surgical weight reduction program in my practice. Susan, the decision for selecting a specific type of surgery is based on BMI and other factors, not necessarily the absolute weight, but it does play a role.

ok, thank you

<**MODERATOR**> GRAM YOU HAVE THE NEXT QUESTION:)

I AM A 50 YO FEMALE, 5'5'', 267 LBS. IHAD MY GALLBLADDER TAKEN OUT 27 YRS. AGO (I WS 23). I HAVE A 8 TO 10 INCH SCAR. CAN I SUCCESSFULLY HAVE A LAP DONE ?

Gram, good question.

A Lap what?

I guess the RNY

I prefer to not have an open done

Yes, for most patients who have had an open gallbladder operation, the area where the gallbladder dissection took place usually does not interfere with the critical aspects of the laparoscopic RNY. Good luck Gram.

thanks so much !

<**MODERATOR**> STEVE YOU HAVE THE NEXT QUESTION:)

I am one month out from an open RNY, 2 openings appeared on my incision. My surgeon said not to worry unlesss they became infected or the discharge began to stink. I cleaned with peroxide 4 times daily, and dressed with the corner on gauze pushed into the incision. One has fully healed. The other is 90% closed. My question is why does this sort of thing happen? And what is the yellowish clear fluid that seeps out of these wounds?

Hi Steve. I'm going to get on the soap box a bit. This is exactly one of the reasons that the laparoscopic approach is advantageous in order to avoid such wound issues, but, Steve, you wound is open since it hasn't properly healed. Adipose tissue is not well perfused with blood and parts of it have "opened up" because of that. For open surgery in morbidly obese patients I leave the staples on for at least 3 weeks. Your wound is draining wound fluid which accumulates in all wounds, but the bigger the wound the more fluid.

my staples came out in 19 days

Your surgeon is correct that as the wound heals the fluid will decrease. Unless it actually smells really bad you should only have to keep it clean and follow his instructions. Good luck.

Thanks Doc

<**MODERATOR**> RHONDA YOU HAVE THE NEXT QUESTION:)

What if someone who has had the bypass later on in life they might need tube feeding would he/she be able to have this done? when can you have sex ? my wls is monday 18th. BMI 42, 228lb 5' 2 ht could u tell me my ideal wt plzzz???im having lap RNY and we have staples w/this ???????

Congratulations Rhonda! How old are you?

33yr old

Your surgeon should be able to answer many of your questions.

what if later on in life i might need tube feeding would i be able to have this done???

I will answer them now...

ok ty

Your ideal body weight is 115 lbs for your height but your goals for successful weight loss after surgery is 164 lbs. You need to lose 64 lbs to become just "overweight." Why do you expect to need tube feedings?

u never know doctor !!! ive worked so much w/ elder so i think about it

I never know whether I'm going to be struck by lightning either... :)

ok dont stress over the ? ty

Seriously, you should be able to get tube feedings if that's what you need in the distant future. Good luck Rhonda!

THANK YOU!!!

No problem Rhonda, I hope I didn't offend you! :)

no you didnt . goodnight

Good nite, Rhonda!

<**MODERATOR**> AMY PREOP PITTSBURGH YOU HAVE THE NEXT QUESTION:)

Hi Dr. Cirangle - I attended a support group meeting where I heard of a 2 stage rny procedure. Essentially there are two surgeries 1/2 the RNY is done then after some weight is lost the rest is completed How would this work? I have also read of mini-gastric bypass. Can you define these two procedures and compare them to the classic RNY that I have been researching? I'm 356 5'6". Approximately 200 lbs excess. At what point do you suggest a BPD-DS?

Amy good question. Where was this support group meeting? Are you sure they were talking about the RNY?

yes I was a support Group for Dr. Schauer of Pittsburgh. I walked in late (after work) so I didn't get all the info, only that for some higher risk patients they are splitting the procedure in two.

Dr. Schauer is a wonderful surgeon. I trained close by in New York with Dr. Michel Gagner...

I'm going to Dr. Hamad ,she also trained with him and just left his practice to head her own at Magee hospital

The idea behind a 2 stage procedure is fairly straightforward... The RNY usually involves a gastric or stomach "bypass...." I believe that the 2 stage procedure for the RNY involves separating the stomach part of the operation from the RNY part. We are doing this more for patients who are undergoing the BPD-DS. I think the term "mini-gastric bypass" is a procedure performed by Dr. Rutledge; correct me if I'm wrong...

I'm not sure. I heard about it in passing and heard some negatives as well

In general, the classic laparoscopic RouxenY gastric bypass involves dividing the upper portion of the stomach from the lower. The upper stomach pouch has the volume of a small egg (10-20 cc), restricting intake; and the small intestine is divided and the RNY performed to empty the food entering the pouch. That's a schematic. For more detailed drawings and information, please refer to my website www.LapSF.com. Hope that helps Amy!

thank you

<**MODERATOR**> BEV YOU HAVE THE NEXT QUESTION:)

Hi, I noticed that you said that 350 normally isn't too large for lap. My insurance co will only pay for open because they say that lap is too 'new'. Is this normally the case? Also, I have severe sleep apnea, high bp, edema, pcos, arthritis, bmi of 53.1 with no psych problems. Do you think I will have a hard time getting approved? Thank you for your time.

Bev, which part of the country are you in?

I'm in East TN

Bev, laparoscopic weight loss surgery is probably the preferred method for many patients, but not all. You need to find a surgeon who has the proper skills and training to do you procedure and with the cooperation of your primary care physician, they can help you help seek an appeal for authorizing an appropriate procedure. Which surgical procedure are you interested in? I do know an excellent surgeon who resides in Charlotte, NC.

I have had a consult and am now waiting on the insurance company .. My PCP wrote a nice long letter to the surgeon telling all my past diets/history/etc. He is supporting my decision. He's a fantastic man :)

Wonderful! That's great but what did the surgeon say?

he's the same one that someone else mentioned .. has many yrs doing open and only one doing lap .. he would prefer the lap, but my ins says it's too dangerous

I am interested in the rny

I don't know what to tell you then. It is a decision you need to make with your chosen surgeon and yourself. What type of surgery are you going to get?

most likely open rny because the insurance company says lap is too new . I also have to have my gallbladder out .. it's not working at all. Do u think with all the comorbidities that I will have a hard time getting approved?

The laparoscopic RNY gastric bypass has been done for the last 7 years. The laparoscopic cholecystectomy has been around for over 15 years. You should talk to your surgeon. If he thinks it's unsafe, then you should follow his advice unless you really want it lap. Then you should seek a second opinion. Good luck, Bev!

Ok. I will talk with him again. thanks!

<**MODERATOR**> AMY M YOU HAVE THE LAST QUESTION FOR OUR GUEST TONIGHT:)

When I have blood drawn, it is very thick and they have trouble even filling the vials completely. Could this be indicative of problems I might have with surgery? Like blood clots? What could cause this thick blood?

Amy, that's an interesting question. Your best course of action for this question is to ask a hematologist, but most likely, you probably have small blood vessels and the needles they use to use to fill the vials are small...

I'll never bleed to death ha ha

The resistance in a small needle versus a larger one is much higher and therefore slow filling. You could potentially have trouble with your blood but there are tests to examine this. Please talk to you primary care physician regarding this, since I'm not an expert in this field. Good luck!

<**MODERATOR**> THANK YOU SO MUCH TO Dr. CIRANGLE FOR TAKING THE TIME TO CHAT WITH US!

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