On another topic I was posting my brilliant musings about surgeons and pre-op diets and I wanted to say this because sometimes I'll answer a post and it will sound like I'm stating some authoritative opinion when I'm really thinking out loud.

I've been watching these boards for a couple of months and looked into getting surgery in my home state but it was very expensive. I knew it was going to be but then I realized the other thing I really did not want to deal with was six months of "pre-op" nonsense. I realized this when I contacted Dr. Aceves' office a second time and spoke to his patient coordinator, who was very direct but also very clear about what was truly necessary and what was not. In their practice. My pre-op is a week long lowcarb diet. I had to quit smoking ten days beforehand and start blowing up balloons. She told me about many other patients, their concerns, what could possibly come up, and why they needed me to do what they needed me to do.

Dr. Aceves has performed over 600 sleeves with very few complications as far as I can tell. I know of one rumored leak and then another phantom guy who came on here and said he almost died and that translates to a .03 serious complication rate for his sleeves. Yet his pre-ops are pretty lenient. I can use NRT. I did not need a psych evaluation. I put down my deposit, bought a plane ticket and was scheduled two weeks from that date. If Dr. Aceves were this lenient and he was sending people home half-dead, I would be suspicious. But he does appear to know what he's doing and there is a strong track record behind his methods so I'm happy to do what he tells me to do.

One other thing I noticed is that less people come around, online, on youtube, on boards like this and describe serious early or late complications of any kind if they've come from Dr. Aceves. Now either he is paying off his broken patients off or he is rolling the dead ones up in rugs and driving them into the desert for the coyotes -- OR more people are coming away pretty much whole when he is done with them. Which leads me to my suspicion about a number of surgeons in the US who are approveable by insurance: some of these people -- not all, I haven't done any data mining in this regard -- but unscientifically it seems some of these surgeons just have not done many sleeves and so they have to learn the hard way -- on us.

One way to mitigate potential disaster in that case is to make the patient's pre-op extremely rigorous. For example, a surgeon might say he can't operate on you until you lose ten percent of your body weight -- why is that? Because the literature and the insurance actuarial studies have said that this lessens risk by some margin, and it's possible that without certain patient requirements the hospital or the doctor will not be paid the insurance portion of the procedure. Also - surgeons work how they need to work - if he has learned to do the surgery using a 48 bougie on patients with very tiny livers who are under 45 BMI, these are the only people he is going to operate on. I am not faulting a surgeon who has only done a couple surgeries for doing another one -- he'll do what he needs to do to be reasonably sure his patient is going to live through it. But as of 2008, three years ago, a local news story on the sleeve said that " only a few surgeons in the country" knew how to do this procedure.

Anyway my suspicion is that your pre-op diet reflects what reassures the surgeon according to certain criteria and what will appease your insurance company. Whether it is specifically *necessary* to do the operation is another thing. It's the only logical conclusion I can come to based on what I've been reading. Why would a person need to lose ten percent of his body weight *before* surgery? It makes no sense -- but it might make sense according to some JAMA study the insurance companies like.

The other thing I've noticed is that while Dr. Aceves' pre-op is not the most rigorous in the world -- his POST-OP is incredibly strict. Why? Because complications don't occur before surgery. They occur afterwards. That's why his patients ( and some others I'm sure) leave the hospital on Clear liquids for ten days, not three. Or more actually. It seems like the majority of post-op complications come from patient noncompliance some time after surgery, like the person who goes to a barbecue three days out and attempts chili. It seems more important that you don't do that than *anything* you do beforehand within reason.

So what it comes down to is this -- at this point this surgery is unique to the surgeon. His experience, whatever pressures there are from the money or the hospital, and his specific expertise in punching you open and refashioning your internal organs. And this is why I say the American system is fuqed. It would all be so much easier if some of those pressures were lessened, and insurance didn't put so many roadblocks in the way -- not just for patients but for the whole procedure.

Thats what I think!

Actually I think the real true reaason for the pre-op diet is because if I wasn't on it I would do what any normal fat or thin person would do if you told them they would not be able to eat for a month and then very very carefully forever thereafter. I would go insane trying to stuff everything in my mouth I would tell myself I would never taste again. If you want to make an obsessive overeater out of anyone, just tell them the world will be all out of food next week...

seriously, seriously true. LOL-true!

You say "easy" like it's a bad thing. I had all the pre-op workups that my friend had in the states (except for the psych eval) the only difference was that I had them all in one day. Easy? Yes, just the way it should be. "Assembly line-ish"? No. I had more attention paid to me than with any other surgery I have had in the states. And by two doctors, I might add. They also required me to stay in the hospital for 4 days. They wisk you outta the hospital in much less time in the states. At least from what I've read. My friend only stayed 2 days and I have seen where some stayed only overnight. That may be fine for some, but I personally was happy to be monitored that long.

Surely you are not suggesting that the surgeons in the states DON'T make "A LOT" of money doing this surgery, are you?

You know, I was thinking this might be part of the secret to the low complication rate. In the states no insurance is going to pay for hospital stays that are longer than absolutely necessary. That's where the money really adds up here, and people are sent stumbling off into the world far too early. If you have a four day recovery time - your fluids are monitored, your pain is monitored, your nutritional intake is monitored, etc. You are not suddenly called in to work by your boss, your dog is being fed by someone else, your sheets are sterile...well, on and on. It seems to me that might make a difference in how well a person would recover anywhere.

I like the lower risk of complications, also. I think we all do, right? But I do like hearing answers to my questions from my surgeon's mouth, not other staff members. I mean, you're right, the surgeon is the surgeon, and knows a bit more than they. I agree, we are all different, and I, as a nurse also, do not like my surgeon to be unapproachable. I've worked with both types, and hands down, patients appreciate the care and concern from their surgeon in addition to an excellent operation. I really don't think taking time with your patients is a form of cuddling

Good luck to you!

Well, just because a surgeon is an "assembly line" surgeon, doesn't mean he doesn't take his time with you... For example, my surgeon spent a lil over an hour with me answering my two pages of questions lol.. Thankfully my surgeon is both approachable AND skilled... But if I had to choose between the two, I'd most definitely go with skilled. My whole point is that even if your surgeon is called "assembly line," that it isn't necessarily a bad thing... I don't know anything about the Mexican surgeons but I have heard the assembly line jargon before... So, essentially, I am defending the fact that the most important thing, regardless of the 'assembly line' feel, is surgical skill.

You know, I was thinking this might be part of the secret to the low complication rate. In the states no insurance is going to pay for hospital stays that are longer than absolutely necessary.

I completely agree... Our hospital stays here are ridiculous!! We send home patients that should not be sent home just yet... I do hear the hospital stay in Mexico is longer, which is better... Gives you more time to acquire the diet (since you are being fed hospital food lol), pain is better managed, etc... Did you ever find insurance post-op?

I completely agree... Our hospital stays here are ridiculous!! We send home patients that should not be sent home just yet... I do hear the hospital stay in Mexico is longer, which is better... Gives you more time to acquire the diet (since you are being fed hospital food lol), pain is better managed, etc... Did you ever find insurance post-op?

I resurrected a COBRA plan that I was planning not to use. When I first started this process I didn't even know I could be denied for being overweight. I actually am not over 40 bmi but the rep for BCBS said I might be denied anyway because I'm so close. I'm not holding my breath.

I think the best thing for people to do when they're not insured and they're self-pay is to try to lock in some kind of basic coverage before they go in if there's no BLIS being offered. If a person is denied because they're a BMI of 39, maybe think about trying to drop just like five pounds to get in the door. If none of that is applicable, well...cowabunga.

I resurrected a COBRA..

Wow, thanks for the info!!!

I'm not a person to take risks and all I'm saying is, really; for me, going to Mexico is too risky. And expensive, out of pocket which is not an option for me right now. I'm half Hispanic/native American, I'm afraid they wouldn't let me leave. LOL And I'd get picked on for not speaking spanish. (no, i'm not illegal)

But anyways, I was just stating an opinion. There's so many loops that we have to get thru for the insurance and surgeon and I don't mind them because I know I'll be ready. For example, Kaiser requires a full psych evaluation and group/individual sessions. I like that. Being able to vent to a psych who specializes in bariatric patients and has probably seen it all, is very comforting to me. CUZ I'm scared! I want to do it but I'm so scared about the surgical complications, not being able to stay away from my old eating habits, or gaining it back. There's a whole team I'm accountable to; dieticion, nutritionist, a nurse who calls me periodically to check in, the pshychologist and the surgeon.

I was born with no thyroid so having this team, for me, is what I feel I need. I'm sure it's not everyone's preference. I was dead set against this surgery til a few months ago. Actually, I was set against the gastric bypass but then they told me about the sleeve and I jumped on board. I've watched so many youtube videos of people who have had the courage to do this and they inspired me.

As for the money, I know they all make a mint, here and all over the world.

THe US health care system is just that - a system. This system has its own code of how to deal with things. I have worked on the business side of patient safety for years and I have also had 4 different abdominal surgeries - 2 in the US and 2 in Mexico. The problem is that the system is set up to mitigate liability and is TRULY designed to push as many people through the system as possible. This is a bad thing.

That is why you can't stay overnight after a lap surgery. That's why they kick you out after 2 days when you have a c-section. The problem with that is infection and other complications.

The other problem with the system is that it prohibits innovation and is resistant to any sort of change. These days, the lap-band is promoted as the greatest thing to ever happen when there are tons of people (like me) who know it doesn't work for a majority of patients. My Kaiser post-op contact was STUNNED that I had my lap band revision to sleeve in one surgery and in a laparoscopic mode.

The people working in the system are good people and their hands are tied by the FDA and Jpint Commision guidelines, which are put in place to keep people safe. It's just so institutionalized, that the patient seems to get the short end of the stick. In addition to government mandate, they tend to base an entire care modality on one paper that was written years ago. One study, one precedent, and that's it---

Dr Aceves is good at what he does. There are good and bad doctors everywhere.

Great discussion!!

Lara

THe US health care system is just that - a system. This system has its own code of how to deal with things.

I completely agree. Our system is not the best, that's for sure... It's a shame really... We provide unnecessary tests and diagnostic imaging just for liability sake... My background is ER, and I cannot tell you how many CTs we do on people... No one really considers the amount of radiation because they believe their risk of liability is > than the risk of cancer from multiple CTs... It's horrible.. Man, don't even get me started on EMTALA! LOL.. THAT is something that needs to be fixed, right along with malpractice!!! I really believe that if are able to start refusing patients in an ER setting, healthcare costs will go down.. not necessarily malpractice costs LOL.. but healthcare cost will go down... Not enough facilities practice the "medical evaluation" portion of EMTALA... Why not?? Liability... In fact.. my husband is a paramedic... he has received a call where someone gave a bogus complaint like back pain, and instead.. he just wanted the paramedics to bring him a pepsi from the fridge.............. Yes, patients call 911 to have the paramedics help them with household chores or even making them dinner!!! I'm sorry, but if you cry wolf too much....................... that's how I feel... probably just the jaded ER nurse coming out LOL!!

I self paid for both my "crap" band 3 years ago in FL. Still took so long about 3 months. One week for the blood work, one week for the next test and so on. My band surgeon was very good and at that time I thought about going to Mexico but was too scared.

Forward 3 years and so much research. Emailed Dr Aceves office and 10 days later had my band removed and revised to a sleeve. He is a great surgeon AND has a really great manner about him. Dr Campos is also great.

Much "easier" than my band surgery and other than the cleaning lady always mopping the floor I can't say enough about my experience with him.

My husband and I are self employed and pay very high health insurance premiums. No weight loss surgery in the policy. My husband has/had skin cancer and by the time we get the bills in we still pay $1000.00's out of pocket. Our system is broken, takes too long, and too much red tape.

Back to Dr Aceves!!!! HE ROCKS and so does all of the kind and those who work with him. This is coming from a very BIG chicken regarding surgery!

Good Luck.

THe US health care system is just that - a system. This system has its own code of how to deal with things. I have worked on the business side of patient safety for years and I have also had 4 different abdominal surgeries - 2 in the US and 2 in Mexico. The problem is that the system is set up to mitigate liability and is TRULY designed to push as many people through the system as possible. This is a bad thing.

That is why you can't stay overnight after a lap surgery. That's why they kick you out after 2 days when you have a c-section. The problem with that is infection and other complications.

The other problem with the system is that it prohibits innovation and is resistant to any sort of change. These days, the lap-band is promoted as the greatest thing to ever happen when there are tons of people (like me) who know it doesn't work for a majority of patients. My Kaiser post-op contact was STUNNED that I had my lap band revision to sleeve in one surgery and in a laparoscopic mode.

The people working in the system are good people and their hands are tied by the FDA and Jpint Commision guidelines, which are put in place to keep people safe. It's just so institutionalized, that the patient seems to get the short end of the stick. In addition to government mandate, they tend to base an entire care modality on one paper that was written years ago. One study, one precedent, and that's it---

Dr Aceves is good at what he does. There are good and bad doctors everywhere.

Great discussion!!

Lara

Absolutely what I was trying to say . If the US doesn't have the cheapesst healthcare in the world, it really should have the best given the money and energy that goes into it. And it's amazing about the lap band. When I was looking into surgery it only took a couple of youtube videos -- not even very negative ones -- to decide I did not want that. A port in the stomach? "Fills"?Productive burping? Wha?

I am not sure how I happened upon this procedure or actually even what came over me to get me to this point. But I never heard anyone say " I love my lapband" the way I see people loving their sleeves all over the internet.

The other interesting thing is what we're articulating. The "system" is so institutionalized that it interferes not only with care but with medical innovation and improving practices. At a certain point we might have to hand over our crown of hightech healthcare to some other country that doesn't try so hard to keep its doctors away from its patients. You can't get better at medicine your real job is filling out forms.

'That is why you can't stay overnight after a lap surgery. That's why they kick you out after 2 days when you have a c-section. "

2 days? i had one in 08 and i got stuck there 4 days, no complications or anything, that was the required stay.. 4 days csection, 2 days natural.

You have to do what YOU are comfortable with. I talked to a surgeon who told me that before he had his patients do the pre-op diet, it took him about 1 1/2 hrs to do a bypass, with the pre-op diet, its only 45 mins. Because its lapro there isn't a lot of room to move and the liver certainly gets in the way. However, he did indicate that its definitely more impactful for higher BMI patients. I'm at the lower end of the BMI scale and my pre-op diet is only 1 week. But if there's a chance the pre-op diet shrinks my liver and therefore makes my surgery time less, I'm all for it (not to mention the healthier liver). I'm a self pay too, here in the states. And if I had to choose a 4 day hospital stay or 2 years of aftercare with a 1 day stay. I'll choose the 1 day stay and aftercare anytime.

I completely agree. Our system is not the best, that's for sure... It's a shame really... We provide unnecessary tests and diagnostic imaging just for liability sake... My background is ER, and I cannot tell you how many CTs we do on people... No one really considers the amount of radiation because they believe their risk of liability is > than the risk of cancer from multiple CTs... It's horrible.. Man, don't even get me started on EMTALA! LOL.. THAT is something that needs to be fixed, right along with malpractice!!! I really believe that if are able to start refusing patients in an ER setting, healthcare costs will go down.. not necessarily malpractice costs LOL.. but healthcare cost will go down... Not enough facilities practice the "medical evaluation" portion of EMTALA... Why not?? Liability... In fact.. my husband is a paramedic... he has received a call where someone gave a bogus complaint like back pain, and instead.. he just wanted the paramedics to bring him a pepsi from the fridge.............. Yes, patients call 911 to have the paramedics help them with household chores or even making them dinner!!! I'm sorry, but if you cry wolf too much....................... that's how I feel... probably just the jaded ER nurse coming out LOL!!

I know but I think those 911 calls are hilarious.

http://www.oddee.com/item_96669.aspx

You have to do what YOU are comfortable with. I talked to a surgeon who told me that before he had his patients do the pre-op diet, it took him about 1 1/2 hrs to do a bypass, with the pre-op diet, its only 45 mins. Because its lapro there isn't a lot of room to move and the liver certainly gets in the way. However, he did indicate that its definitely more impactful for higher BMI patients. I'm at the lower end of the BMI scale and my pre-op diet is only 1 week. But if there's a chance the pre-op diet shrinks my liver and therefore makes my surgery time less, I'm all for it (not to mention the healthier liver). I'm a self pay too, here in the states. And if I had to choose a 4 day hospital stay or 2 years of aftercare with a 1 day stay. I'll choose the 1 day stay and aftercare anytime.

FBG -- it's great to have aftercare. The self-pay surgeon I was looking at here had a package with the hospital, anesthesia, BLIS and I think a year of global aftercare for 20K. I was really going to do that but I did this instead -- I'm almost trying to figure out why after the fact. In the OP I was theorizing about the lack of complications ( as far as I know) with this particular surgeon after so many sleeves. My theory was that rigorous patient monitoring immediately after surgery, and within a longer time frame to let problems develop, might be one reason there are less complications so far with this doctor.