An open letter to all referring Health Care Providers:
Greetings, Thank you for considering sending us your patients for consideration for Weight Loss Surgery (WLS). We very much appreciate the referral, and want to work closely with you, your patient, and the rest of our Team of consultants and perioperative specialists to carefully prepare your patient for surgery, and to return them safely back to your care. WLS is a significant step, and very demanding of everyone involved. Please do carefully consider whether your patient is a good candidate, so as to avoid the emotional upset and the expense of being seen and declined by our office. We generally adhere to the following guidelines though we individualize our care for each of your patients. Sincerely, Michael A. Todd, MD, FACS
We appreciate your sending us patients who have a BMI of 40 or more, or 35 to 40 with significant co-morbidities (Use this table for help in determining your patients BMI. Please do weigh patients in your office, without coats or shoes, and best without clothes on. Please also measure their height, as generally people remember being taller than they are.
We do not routinely accept all referrals for patients with BMI's less than 40, though some of our most successful and satisfied patients have had a BMI of 38 to 39. The best candidates from this group are those who can clearly document that they have previously had a BMI of 40 or more, who are relentlessly gaining weight despite a full weight loss and exercise program, and who have significant co-morbidities.
We expect to find your patient troubled by multiple co-morbidities. It is very helpful to list these carefully in your referral letter. Please ask the patient to either bring an accurate list of their medications with them, or the medications themselves.
Weight Loss Attempts
Please do ask your patients about weight loss attempts, and provide information on any attempts that you have made with them. Documentation of supervised weight loss attempts are most helpful, and at best a minimum of 6 months of attempts occurring in the last 5 years.
Successful patients demonstrate a high level of compliance and emotional maturity. If you doubt a patients ability to understand the issues at hand, comply with instructions, deal with upset, or if you feel they are looking for a "quick fix" without commitment on their part, please carefully consider this patient for further attempts at non-surgical weight loss. Overall patients who make their way to us quickly grasp the concept of a supportive therapeutic environment with responsibility shared between the patient and medical team. Many of our patients have been emotionally traumatized by events occurring before or after their onset of severe morbid obesity. Please consider whether your patient should be referred for counseling, beginning preoperatively, to help them deal with these issues.
We do accept patients who are under 18 years of age. Such patients will usually be asked to see a panel of Pediatricians specializing in Gastroenterology, Pulmonology, Psychology, and Endocrinology, as we wish to have the support of each of these specialties before proceeding. We have had successful and satisfied patients who are over 59 years of age. As of this writing our oldest patient at the time of surgery has been 64. Please document that you believe these patients to be sufficiently vital to expect a long term benefit from the surgery to help us justify to our WLS Team and to the patients' insurance companies our decision to consider surgery for your older patients. Supporting arguments include an Orthopedic surgeons report that your patient would be candidates for joint replacement surgery if they could achieve significant and lasting weight loss, such as is expected after WLS.
Patients who have a BMI of 60 or more or who weigh over 400# are considered high risk in our office. A large portion of our patients do fall into this category. Patients over a BMI of 90 or 500# are asked to try to reduce below this BMI and weight before undergoing surgery. These patients are of course at increased risk for serious adverse medical events while waiting for surgery, and in rare instances super-super-morbidly obese patients who continue to gain weight while waitinga to complete their preoperative evaluation and to obtain authorization should perhaps be considered for admission to accelerate both processes and to prevent further weight gain.
Our preoperative workup is extensive, consisting of a CXR, EKG, abdominal ultrasound, UGI, CBC, CMP, Free T3, TSH, AM Cortisol (or dexamethasone suppression test), H. pylori IgG, PT/PTT, Tox Screen, PFT's/ABG, Dietary Consultation, Psychological Evaluation. EGD may be ordered for long standing GERD or for abnormalities seen on UGI. PSG may be ordered for OSA symptoms. Pulmonology and Cardiac consultations may be ordered as indicated. We do consider patients for Echocardiograms if they have a history of 60 days of more of Phen-Fen use, and usually discuss this with the primary care provider. You may wish to start referring patients for the above studies prior to their first appointment with us, but bear in mind that they may incur a significant amount of unnecessary expense should they later not be found to be a candidate for WLS.
Internal Medicine Backup
To provide your patient with the best and most expeditious care and as a courtesy to other hospital staff my personal preference is to have your patient followed by a local Internist or Pulmonologist who has seen your patient preoperatively and is available to help care for them in the perioperative period. We will make such a referral should you not be in active hospital practice in the Anchorage area, and will promptly return your patient to your good services postoperatively.