Dr. Maria Iliakova guides you through the bariatric surgery process, a transformative but complex journey that changes lives. You'll emerge from this episode with a clear roadmap of what lies ahead, including the financial considerations, insurance intricacies, and the essential medical and psychological evaluations that pave the way to the operating room. We promise to equip you with the knowledge to confidently navigate the pre-surgery maze, understanding the why behind every blood test, heart check, and specialist consultation, and how they contribute to the safety and success of your surgical endeavor.
With the soothing voice of experience, Dr. Iliakova shares her insights into the medical intricacies and the compassionate approach necessary for candidates of bariatric surgery. You'll learn about the potential twists in the path, such as delayed surgeries for additional health improvements or alternate treatments like lifestyle changes and medication. We'll also explore the comprehensive postoperative support vital for your journey—because surgery is just the beginning. Stay tuned to discover how we, alongside your bariatric team, can support you in making an informed decision about your body, health, and future.
Dr. Maria Iliakova guides you through the bariatric surgery process, a transformative but complex journey that changes lives. You'll emerge from this episode with a clear roadmap of what lies ahead, including the financial considerations, insurance intricacies, and the essential medical and psychological evaluations that pave the way to the operating room. We promise to equip you with the knowledge to confidently navigate the pre-surgery maze, understanding the why behind every blood test, heart check, and specialist consultation, and how they contribute to the safety and success of your surgical endeavor.
With the soothing voice of experience, Dr. Iliakova shares her insights into the medical intricacies and the compassionate approach necessary for candidates of bariatric surgery. You'll learn about the potential twists in the path, such as delayed surgeries for additional health improvements or alternate treatments like lifestyle changes and medication. We'll also explore the comprehensive postoperative support vital for your journey—because surgery is just the beginning. Stay tuned to discover how we, alongside your bariatric team, can support you in making an informed decision about your body, health, and future.
Welcome to Core Bariatrics Podcast hosted by Bariatric Surgeon Dr Maria Iliakova and TMA LaCose, bariatric Coordinator and a patient herself. Our goal is building and elevating our community. The Core Bariatric Podcast does not offer medical advice, diagnosis or treatment. On this podcast, we aim to share stories, support and insight into the world beyond the clinic.
Speaker 2:
Let's get into it. Hi there, this episode is going to be on my own today. This is Maria Iliakova, and it is the pathway before bariatric surgery. I really wanted to help those who were considering surgery or who just wanted to know a little bit more about the process of how to get to surgery, to understand what the steps involved are. Typically, most programs have a designated pathway that they put people through in order to get to surgery itself. That can be helpful, because you can understand what's expected of you ahead of time, and without it it can be very challenging. Let's go ahead and get started.
Speaker 2:
When we are assessing whether somebody can go through the program or not, typically we do a check of insurance. The reason for that is because, without insurance, this is a pretty expensive, out-of-pocket process. Some places that do bariatric surgery or weight loss surgery do offer these kinds of surgeries in a way that you can pay for them entirely on your own. That said, if you have insurance that covers bariatric surgery, oftentimes having it paid for, at least in part, by insurance can be a much more inexpensive way to get this kind of care. The other thing to consider is if you don't have insurance coverage for this or you're paying out-of-pocket for these kinds of services. You may not be covered in the same way for any complication, if there were to be a complication during surgery or in any other part of this process. Just some things to think about. You also do want to figure out if you actually need a referral to your program or whether you can sign up with that program just off the bat. Most programs will have a website or have a contact number or email and you can find out how to get in that program. If you have a specific program in your area you really want to go to, or a specific provider, you can find out what the requirements are for them. You can also ask your primary care doctor, your orthopedic surgeon, your OB-GYN or any other doctor taking care of you if they would refer you to a program if you're interested in that too.
Speaker 2:
So typically let's just talk about a couple of overall big picture things. One is that the process usually takes a minimum of three to six months before surgery. You typically have at least monthly visits with your program. You will need a mental health evaluation. You will need to complete some labs and typically an EKG, which is an electrical study of your heart you may also need to complete some other procedures like an upper scope or an esophagal gastro-diodinoscopy and EGD. You also may need to complete some consults like with a cardiologist or a lung doctor or some others as well. Lastly, your health insurance company most likely will have to issue permission for you to actually undergo surgery if you have health insurance car-burying this in any part. So all of those things typically, overall, take about three to six months at a minimum on average to complete. So now let's drill down into the nitty-gritty of all those different steps.
Speaker 2:
So, first of all, that three-month minimum is usually a national standard. There's very few programs who will move people through faster than three months, and if a program is moving you through faster than three months, that typically isn't covered by insurance. Under any insurance plan that I've seen nationally, they do require at least three months of participating in a program, at least at this point in February of 2024. Most often, though, there are requirements that are up to six months in some programs. Some programs actually have 12 months of required documentation and participation in a program. There are others that even have more than that. In fact, there was one that we saw when I was working in Iowa City program in Alabama that required three years of documented weight loss attempts, specific BMI of over 35, and even photographs that accompanied that three-year preparation period. So do check with your insurance plan whether or not bariatric surgery is covered and what the requirements are of that. If you're in a bariatric surgery program, most will actually do some of that legwork with you or for you, because that bariatric surgery program can't put you through to surgery and be paid for that surgery if they don't meet the requirements that are requested by your health insurance company. If you are paying for this completely out of pocket, then you will just need to understand what the requirements of your program are. There is actually a program out there that I know of that essentially does a several day preparation for a sleeve and then you can get a sleeve the next day. There are programs like that outside of the US as well that sometimes people do. I wouldn't necessarily recommend going that route unless you have had other kinds of preparation in the past for these surgeries.
Speaker 2:
Personally, I think that people do require at least a month to several months, even in the best case of scenarios to be really mentally and physically prepared for the changes that they're going to go through during surgery as well as afterwards. Monthly visits in programs typically occur both with a health care provider like a doctor or nurse practitioner, or and or with a dietitian. Your monthly visits are not necessarily with both of those providers, but they're usually at least with one or the other. You will typically meet your bariatric surgeon the one who is doing your surgery or is evaluating you for surgery at least once in the process before surgery. In some cases, you'll meet them at every visit. That just depends on the program. Typically, you will be meeting your dietitian at least once a month. By the way, there are programs that do all of their visits in person. There are some that do them, mostly telehealth, and there are some that outsource them to other programs or to other providers, online and in person.
Speaker 2:
You will also be required to do a mental health evaluation. That's a really important part of this process and I know that there's a stigma around mental health and talking about these kinds of issues with someone else, but the reason why it's so important is because you're going to undergo body and mind changes throughout bariatric surgery and afterwards. This will help identify any underlying mental health conditions that may stop you from safely going through surgery. This will also help you find the support that you need to, such as medications or other people, or even a really good therapist, potentially to help you deal with some of those things that are uncovered. It also helps you understand some of the risks involved in surgery. Some of the mental health risks that people undergo are depression, anxiety, changes in body image, changes in their relationships with other people. People do also experience slightly higher divorce rates, for instance, after surgery. There's lots of different things that it's really important to prepare yourself for before you make the decision to proceed with surgery.
Speaker 2:
You may also uncover that you'd like to continue doing mental health work with somebody after surgery or throughout the entire process, either with the same person that's doing the evaluation or with somebody else. We really support that, too. In your monthly visits with the program, whether it be with a dietitian, a nurse, a doctor look at those visits as a chance to understand what your goals are for after surgery. Whether it be you want to play with your kids or grandkids, whether you want to come off of some medications, sleep better, have a better sex life, have a baby or really anything at all that you can think of. Those are things to really engage that team on. It's important for even your dietitian to know about those goals because they can really help you understand what are your thoughts and habits around food currently and how can you change those and in what ways will those changes support the kind of goals that you establish for yourself. We really prioritize making realistic, sustainable goals and typically those things are pretty slow and they happen over time. Very little change that is sustainable happens overnight in this process. In fact, I would argue that none of it happens overnight.
Speaker 2:
You will also be asked to do a set of labs. In most programs, those labs include things like thyroid function, but they also include blood analysis of things like your white cell count, your hemoglobin, your electrolyte levels and other things as well. For women of childbearing age, before menopause, we also typically do a pregnancy test and we actually have diagnosed a pregnancy in this process before. It's really unsafe for people to undergo massive weight loss during pregnancy and it's not safe for people to undergo bariatric surgery if they're also considering pregnancy. So we do ask people to have a form of contraception as they go through this process, whether that be abstaining entirely from sex or whether that be pills and IUD or something else, it's really important to try to not have a pregnancy within 12 months of surgery, so we highly recommend that be the case. In fact, I had one patient who had a what's called weekly positive test for pregnancy the day of her surgery. When we tested her she had been negative before when we did her initial labs and then tested weekly positive the day of. So we actually ended up doing a second test to verify whether or not she was pregnant. She swore up and down and we totally believed her, but we had to verify with a blood test and luckily that was negative. We did proceed with surgery on her.
Speaker 2:
But it's really important to know whether there are one underlying other medical conditions that we need to treat, for instance low thyroid function or something like pregnancy or even others. As we go into this process, in many programs you will also do an EKG, which is also called an electrocardiogram, an electrical study of your heart. This is when people place little pads across your chest, arms and legs and we do a little electrical study of the heart. If anything abnormal is found during this process, it's very likely that you will be referred to a heart specialist and also asked to do an ultrasound of your heart called an echocardiogram or an echo. That's to make sure that when we put you to sleep for surgery, that you don't have a complication with your heart or lungs. We also want to make sure that if you have conditions such as atrial fibrillation or coronary artery disease, that those are things that are being evaluated by a cardiologist ahead of any surgery.
Speaker 2:
While bariatric surgery is routine at this point and very safe to undergo in fact, it's one of the most safe specialty surgeries out there it's in part because we do all of this work up to make sure that people are as safe as they can possibly be before undergoing this kind of surgery. We also will want to have you have a plan for your blood thinners, if you're on any. If you're on a blood thinner, whether it be for atrial fibrillation or stents or something else it is absolutely safe to undergo bariatric surgery if it's planned, but we definitely want to make sure that there's a plan ahead of time. You may also be asked to do an x-ray of your chest to look for any underlying lung disease, and in many programs you'll also undergo a scope, also called an endoscopy or EGD. This is a procedure where you put partially to sleep and a camera is used to look from your mouth through your esophagus, the tube between your mouth and your stomach, your stomach and the first portion of your small intestine. This helps us to understand the anatomy of your stomach and the structures connected to it so that your surgery can be done as safely as possible.
Speaker 2:
We sometimes diagnose things like H pylori, bacteria, infections or reflux or hiatal hernias or even masses during this process. In fact, I remember in fellowship we diagnosed somebody with a cancer during this process once and obviously that changed our plans for doing bariatric surgery on them. Sometimes these kinds of procedures will also guide us to choose one surgery over another because it's better suited to other medical conditions that a person may have in addition to excess weight. You may also be referred to other consultants, so if you have kidney disease, for instance, you may be referred to a kidney specialist before your surgery to make sure that it's safe for you to undergo surgery and that there's nothing else that needs to be made safer. The same thing applies if you have sleep apnea or a suspicion for sleep apnea. You may need to undergo sleep testing and treatment for that before surgery is safe to do. You've probably heard the term safe or safety about 15 times by now in this episode alone, and that's because we prioritize safety over everything else in this process.
Speaker 2:
When we choose to do bariatric surgery, it's what we consider elective surgery, which means that you are choosing to do the surgery. There is no emergency bariatric surgery. There is no such thing as somebody getting a bypass or a sleeve for weight management as an emergency. These surgeries are things that we choose to do and, as a result, when we choose to put you through these kinds of surgeries, we have to make sure that it's safe, done with good preparation, and that we're doing everything possible to optimize your health everywhere we can. Lastly, we do an evaluation once all of this kind of workup is done, to make sure that you can actually go forward to surgery successfully.
Speaker 2:
Not only do we want to make sure that surgery is safe and the right option for you, but we want to make sure we're setting you up for success. If we just do the surgery and hope for the best, it's very likely that people will have either complications, weight regain or just simply not get what they want out of this. So we want to make sure that people understand what they're getting into, have appropriate preparation of the expectations of how to support themselves afterwards, both in their diets, their physical health and their mental health, and that they know what kind of follow up comes afterwards. We also want to make sure we have all of our decks in a row so that we could submit all of the information to health insurance and actually receive an approval for the procedure ahead of time. In most cases, you'll spend at least a night over in the hospital when you have your surgery, so we also need to have authorization from your health insurance company for that overnight stay.
Speaker 2:
If you are paying for this out of pocket, you may have a different process in how you go through the preparation before surgery. If that's the case, it's really important to talk about expectations and cost directly with your health care provider and with your team. The expectations to have of surgery itself will vary by where you're having surgery, who's doing it and what surgery you're having. Those are all discussions that is not super appropriate for us to have in general on this podcast, but is really important to have with your specific bariatric surgery team. Other things to ask is what kind of follow-up is expected of you.
Speaker 2:
In most programs, you'll have a follow-up after surgery and then at least several times within that first year and then once a year afterwards. In some cases your long-term follow-up may actually be done by your primary care doctor or someone else. In fact, your primary care doctor actually plays a really important role before surgery too. In most programs we'll want to make sure that your primary care doctor has agreed that you should have bariatric surgery too and at least has a chance to evaluate you as well Throughout the process before surgery. In many programs, if you haven't already had a colonoscopy and you're over the age of 45, or you haven't had a mammogram and you're over that age, or you haven't had other kinds of screening tests and you qualify for them, you may be recommended to undergo those kinds of screening tests. In fact, in my program in Iowa City we did diagnose breast cancer in a patient, we diagnosed colon cancer in a patient during this workup and even a blood clotting problem in a patient through this workup. So it's really important that we're doing all of these kinds of evaluations to look at the big picture and not just see weight out of context for anyone.
Speaker 2:
I hope this helps you understand the pathway to bariatric surgery. While there may be local variations from program to program. Overall, this is a pretty commonly accepted pathway. I'd really like to hear about your questions or concerns about this kind of approach and to hear more from you.
Speaker 2:
The other thing that I did want to mention that I didn't throughout this pathway is what to do actually if you're not a candidate for surgery throughout this process, if there's something that's found out that makes it not safe for you to go through surgery. Those kinds of things include having mental health that's not yet ready to proceed with a big life change, if you have a job change that doesn't allow you to take enough time off of work to recover after surgery or to undergo an inpatient stay, if you're not able to actually have the time available for any reason to go to your pre-op or follow-up appointments, or whether you have a medical condition that makes it unsafe to have surgery. For example, we had a patient in our program who was discovered right before her surgery to have a narrowing in her windpipe that made it impossible for us to safely intubate her for anesthesia that made it impossible for us to be able to actually help her breathe during her surgery. We luckily discovered this problem before we started it. Before we even started anesthesia on her. We were able to have her treated at a nearby facility and she did become a candidate through that treatment for surgery down the road.
Speaker 2:
But there may be many reasons that it's not the right time for your bariatric surgery throughout this workup.
Speaker 2:
If that's the case, it's really important to work with your bariatric surgery team to understand what's next. They may need you to take some steps towards your physical or mental health before surgery becomes a better option for you, or you may need to have a change of insurance, for instance, to have different coverage if your insurance does not allow you to have bariatric surgery, and in some cases you may instead be put on a pathway that doesn't include surgery at all. You may be put on a pathway that includes medications or dietary changes and physical activity changes with mental health. It really depends on your specific circumstances in that case in your program. So I hope that also clarifies sometimes when people may not be the best candidate for surgery and why, and that many times those are temporary things rather than a forever decision. If you have any questions or any concerns, please don't hesitate to reach out to us and please do listen to the rest of our podcast episodes on any platform you choose. You can reach us on Instagram and TikTok, and thanks so much for listening. Goodbye.