Welcome from Dr. Rutledge and CLOS

Dear Future MGB/CLOS Patient,

Hello from myself (Dr. Rutledge) and the staff at The Centers for Excellence in Laparoscopic Obesity Surgery (CLOS) and the MGB experience (www.clos.net).
We care for people who come from all around the world and all 50 states in America. To safely manage this effort we have put in place a process for you to learn more about us and for us to learn more about you.

We are also happy to announce New Pricing/New Procedures and a streamlined New Process for the preop evaluation of the MGB.

This "Notebook" is designed to help you complete the "Preop Evaluation Packet" (the "packet" is the collection of documents you send to us for review prior to approval for surgery).

The Notebook has two main sections. Section 1 explains the parts of the packet that you will need to complete. And the second section contains printable pages that act as dividers. You will print those pages then insert the required material behind the divider page.

In the left column below is an explanation of the parts of the "Preop Evaluation Packet "("The Packet") and second is a list of pages for you to print and put in the front of each part of the packet to help you get the whole thing organized. The printable pages act as dividers to divide each part of the packet you will submit.

This notebook will help you to better understand the surgery and better prepare you for surgery by increasing your knowledege about obesity, obesity surgery, and the MGB and will enable us to take much better care of you when you come to have your surgery with us.

Doing the packet is difficult and demanding but is designed to maximize your education and safety.

Section 1: Read the manual and complete the online form	Learn about the MGB and tell us about you
Section 2: Dr's History and Physical/ Lab tests etc.	PreOp Medical Evaluation
Section 3: Psych evaluation	Determination of coping skills
Section 4: Join the e-mail group to get your 5 patient contacts	Talk to previous MGB Patients
Section 5: PreOp Permission Form	Show understanding of the surgery
Section 6: Family Permission Form	Show your family understands and supports you
Section 7: PreOp Pictures	Baseline
Section 8: HIPAA Form	Patient Privacy
Section 9: Insurance Release	Dr R Does not take insurance
Section 10: Medications and Allergies	Double check
Section 11: Contact / Billing Information	How to get in touch with you
Section 12: Prescriptions	Recommended Pre and Post Op Prescriptions

Organizing Your Packet to Submit

This is your Patient Packet notebook. If you will follow the check list and helpful hints, you should have few problems with preparation. You will need to purchase dividers with tabs that can be labeled. Label each section as directed. Place the documents or items called for in back of each divider. Then place the completed packet in a folder. Please do NOT punch holes or staple any of the contents. You may write on the check off list and the other forms that are designated to write on.

MGB Patient Packet Helpful Hints

	· We need time to review the details of your case. Your packet must be received in the CLOS office in a folder and complete a minimum of two weeks prior to your surgery date. If your packet is late, your surgery could be cancelled.
	· We need your lab data to evaluate you. Your lab work and EKG must be in packet (unless arrangements have been made in advance).
	· Every patient must attend a clinic prior to surgery. We try to schedule patients so that their time away from home is minimal.
	· You will be advised of seminar dates and times. You will also be advised of your clinic appointment if you have not or could not attend a seminar.
	· Your support person must attend the clinic with you.
	· When you send your notebook, please be sure to put our suite number, 302, in the address.
	· Please do NOT require a signature for your packet's delivery.

Our Schedule

Scheduling your surgery or coming to clinic to meet us? Check with us in advance. This schedule is regular, but is subject to change.

Tuesday: 8:30 a.m. - Registration is held on the first floor conference room. Please check in with admitting in the front lobby, they will bring you to the conference room.

9:00 a.m. - Preoperative Clinic as well as staple removal from last week's surgical patients - Annex room of the hospital

Wednesdays and Thursdays: Surgery days

Thank you.
Dr. Rutledge

Some other things you’ll need to know:

Be sure to check your email frequently and follow any instructions you receive.
You will receive a call for hospital registration and nursing assessment prior to your arrival for surgery.
You will have your staples out the Tuesday morning after a Wednesday or Thursday surgery.
The day before your surgery you need to go to the St. Rose Delima Hospital, 102 E. Lake Mead Pkwy, Henderson, NV 89015 to register for surgery.
You will pay the hospital portion at this time.
The hospital will give you a receipt.
You will pay the portion for Dr. Rutledge and Anesthesiology at the Tuesday morning preop clinic. Your receipts will be in your discharge instructions the day following your surgery.
The email containing your surgery instructions will explain the distribution for the cashier’s checks
Remember, if you live more than two hours away, you promise to remain in the area for seven days.
Please contact any of our staff members should you have any questions. We’re here to assist.
Sandy Brubaker, 702-376-3647, Email: sandyb@clos.net
Jen Brubaker, 702-376-9339, Email: jen@clos.net
Trish Lanman, 702-376-3446, Email: trish@clos.net

Now let's start working on your packet!

The Patient Packet Checklist

There are 12 sections if the Packet. Section 1: Read the manual and complete the online form (Learn about the MGB and tell us about you); Section 2: Dr's History and Physical/ Lab tests etc. (PreOp Medical Evaluation); Section 3: Psych evaluation (Determination of coping skills); Section 4: Join the e-mail group to get your 5 patient contacts (Talk to previous MGB Patients); Section 5: PreOp Permission Form, (Show understanding of the surgery); Section 6: Family Permission Form, (Show your family understands and supports you); Section 7: PreOp Pictures, (Baseline); Section 8: HIPPA Form, (Patient Privacy); Section 9: Insurance Release, (Dr R Does not take insurance); Section 10: Medications and Allergies, (Double check); Section 11: Contact / Billing Information, (How to get in touch with you); Section 12: Prescriptions, (Recommended Pre and Post Op Prescriptions.) Below are the tips to completing the Packet process

SECTION 1: Read Manual & Complete Online Form

Download or Buy the Manual and Read it

Download and print the Manual

To do this got to http://www.clos.net. Look at the links on the left border and click the link that says, “Get the Manual.”
http://clos.net/get_patient_manual.htm or http://goo.gl/GApm
It is over 130 pages so make sure to have plenty of paper handy. Print the manual out. You will refer to it over and over. Any time you come to clinic or a seminar, be sure to bring your manual with you. Many people three-hole punch their manual and keep it in a three ring binder.

Or Buy a copy of the Manual

You can also buy a copy of the Manual online at "Lulu"
http://www.lulu.com/commerce/index.php?fBuyContent=217348

Complete the Online Patient Application

http://clos.net/patinfox.htm
Submit your patient application online. To do this, go to http://clos.net and look to the left border. Click on the link that says, “Pt Application.”
http://clos.net/patinfox.htm or http://goo.gl/FkKe

You cannot save it, so once you start completing the form you need to finish or you’ll lose the information. Most people print out a blank, fill it out by hand, and then go back and enter it. When you submit it, you will receive a form confirmation on your screen.
PRINT out the confirmation pages. You will need a copy of it for your packet.
You need to include the confirmation pages from your initial Patient Application online form. Contact us or note if you did not print the confirmation pages at the time it was submitted.

SECTION 2: Doctor's Information

Your Doctors Information (Doctor's History and Physical Examination and Laboratory Data.)

This section is the most difficult in some ways the most important. It has been simplified. If possible your Doctor is asked to fill out the attached "Check Box" History and physical Form. It includes many little tips and pointers to help your Doctor complete your preoperative history and physical examination and the needed laboratory studies. This notebook also includes a letter to your Doctor from Dr. Rutledge describing the "Check Box" form and other tips and pointers to safely evaluate your for the MGB. You can read these comments and Dr. Rutledge's letter but a quick summary is provided below:

Pre-Operative History and Physical Examination

Dr. Rutledge asks your Doctor to perform a routine preoperative History and Physical Examination. As a possible aide in the rapid performance of this examination Dr. Rutledge has created "Check Box" History and Physical Examination Form that your Doctor may want to use to shorten the time it takes to perform the examination and to guide him/her in some of the details in the preoperative preparation process for special patients.

Other Medical Problems/Other Doctors/Other Specialists

If you have other serious medical or psychological illnesses and see another medical doctor for these problems we would like a letter describing you health issues and giving any guidance related to your surgery. For example if you see a cardiologist we will need an examination and letter from your cardiologist and any additional testing he/she recommends.

Drugs and Medications

Preparing for surgery requires a careful review of your medications with your Doctor and Dr. Rutledge. Below are some guidelines, Tips and Pointers:

Warning!! Do Not Stop Any Drug before Surgery without Careful Discussion with Your Primary Doctor First

Anti-Depressants: We usually Do Not Stop Anti-Depressants Before Surgery

Blood Thinners/Anti-platelet Drugs, Aspirin and similar drugs: We ** Usually ** all blood thinners/anti-platelet agents, aspirin and similar drugs as well all herbs, Vitamins and Supplements need to be stopped prior to surgery.

Narcotic/Alcohol/Benzodiazepine/cocaine, amphetamine: Narcotic/Alcohol/Benzodiazepine/cocaine, amphetamines use are all relative contraindications for Mini-Gastric Bypass with Dr. Rutledge. We require physician supervised drug withdrawal programs documented by the physician and patient and family. (Klonopin use is an absolute contraindication)

Steroids (prednisone etc.): Steroid use (prednisone etc.) is usually a contraindication to Mini-Gastric Bypass surgery with Dr. Rutledge

Anti-platelet Therapy (aspirin or clopidogrel (Plavix)): Our ** Usual ** Peri-operative Management of Patients Who Are Receiving Anti-platelet Therapy (aspirin or clopidogrel (Plavix)): stop treatment 7 to 10 days before surgery. We ** usual ** Resuming aspirin when there is adequate hemostasis. Stop (Plavix) clopidogrel at least 5 days and, preferably, within 10 days prior to surgery. We prefer "bridging" therapy with a Lovenox 40 mg/d

Coumadin (warfarin sodium): Usually If on Coumadin (warfarin sodium) there is a $5,000.00 Surcharge. We usually Stop warfarin 5 days prior to surgery Therapeutic dose sc LMWH D/C 24 hours before surgery. Resume therapeutic doses of heparin post-operatively resume warfarin on 1-3 days after surgery LMWH pre- and post-operative.

Beta Blocker Management: Beta blockers such as propranolol and atenolol may reduce the risk of cardiovascular complications for patients undergoing surgical procedures. Patients undergoing MGB on a beta blocker as a "home" or "current" medication will receive their usual beta-blocker therapy at the "usual" time prior to surgery.

Preoperative Laboratory Tests & EKG

Patients are evaluated for common issues prior to undergoing surgery. The usual tests are listed below:

We Recommend Vitamin D Level: Check for Vitamin D Deficiency:

Vitamin D deficiency is common. Vitamin D is connected to a variety of other diseases that include different cancer types, muscular weakness, hypertension, autoimmune diseases, multiple sclerosis, type 1 diabetes, schizophrenia and depression. Because gastric bypass can further worsen vitamin D absorption We recommend Preop patient be tested for and treated for vitamin D deficiency prior to surgery. (The usual Rx if abnormal is daily sun exposure, Rx vitamin D deficiency 2,000-7,000 IU vitamin D/d to maintain D levels 40-70 ng/mL, (1000 IU of vitamin D is only 25 μg;)

We Recommend H. Pylori Test: Check for H. Pylori Infection:

H. pylori is responsible for most ulcers and many cases of stomach inflammation (chronic gastritis) and many stomach cancers.

Since weight loss surgery can also cause stomach ulcers and gastritis the combination of H. Pylori and stomach surgery can be additive. We now recommend that all patients undergo preoperative testing and treatment for H. Pylori if found.

Usually Treatment for taken for 10 to 14 days. Medications may include: Two different antibiotics, such as clarithromycin (Biaxin), amoxicillin, tetracycline, or metronidazole (Flagyl), Proton-pump inhibitors, such as omeprazole (Prilosec), lansoprazole (Prevacid), or esomeprazole (Nexium) Bismuth subsalicylate (Pepto-Bismol), in some cases.

Test: CBC Complete Blood Count (Hemoglobin and Hematocrit) Look for Iron Deficiency (Common in Women)

Low blood iron levels (iron deficiency) anemia is common in American women (3%) because of menstrual blood loss. Weight loss surgery can exacerbate this problem and we require preoperative assessment and initiation of treatment in conjunction with your Doctor’s advice. (Usually STEP 1; See your gynecologist to decrease monthly blood flow!, STEP 2: Iron deficiency anemia Dx/Rx if abnormal: Proferrin, Heme Iron Polypeptide, http://www.coloradobiolabs.com/ http://www.coloradobiolabs.com/ClinicalStudies/Studies.aspx Am J Kidney Dis. 2003Aug;42(2):325-30 PROFERRIN (Iron) WARNINGS Accidental overdose of iron-containing products is a leading cause of fatal poisoning in children younger than 6 years. Keep this product out of reach of children. If overdose does occur, seek immediate medical attention or call a

poison control center.

Preoperative EKG hypertension; chest pain; congestive heart failure; diabetes; cerebral vascular and peripheral vascular disease; syncope or presyncope; dizziness; shortness of breath; dyspnea on exertion; paroxysmal nocturnal dyspnea; palpitations; leg/ankle edema; and abnormal valvular murmurs.. *An EKG performed within 3 months of scheduled surgery is acceptable unless there has been a change in the patient’s medical status requiring a repeat EKG. If you do not think an EKG is clinically indicated it may be omitted. “Abnormalities on preoperative ECGs are common but are of limited value in predicting postoperative cardiac complications in older patients undergoing noncardiac surgery.”

Chest x-ray is recommended for patients: with significant cardiac, pulmonary or neoplastic disease or when indicated by the primary care physician (A chest x-ray taken within 6 months of scheduled surgery is acceptable unless there has been a change in the patient’s medical status.)

Urinalysis is only indicated at the request of the primary physician.

Liver Function Tests indicated; only for History of recent/active liver disease or biliary tract disease, etc.

Digoxin level=On Digoxin, Lithium, Dilantin On Lithium, Dilantin (phenytoin) or other anticonvulsant drugs (phenytoin), phenobarbital, Tegretol/Carbatrol (carbamazepine), Depakote (valproic acid) level

SECTION 3: Psychological Evaluation

The preoperative process includes a psychological evaluation. This can be with a psychiatrist or psychologist. You will need a letter from him stating that you’re capable of making a proper decision and of making the life changes that will take place as a result of surgery. You need to show that you do not have an alcohol or other drug problem and that you do not have an active mental illness which is untreated or which would render you unable to do the self-care that is necessary following gastric bypass surgery.

SECTION 4: Patient Contacts

As part of the preoperative process we ask that you talk to five MGB patients before having the surgery.

The New Packet Requirements: You ONLY Need five Patient Contacts! A good way to meet former MGB patients is to join our on line mailing list. To join, go to http://health.groups.yahoo.com/group/Mini-Gastric-Bypass.

The required number of patient contacts has been decreased from 10 to 5. You need to make contact with ** FIVE ** former patients who have had the MGB. Another easy way to do this is to go to http://www.mgbhelp.com. Also you can email all of the CLOS Staff at EveryOne@clos.net for help.
Once you have five contacts, go to http://www.clos.net/contact-patients.htm Be sure to print what next appears on your screen and include it with your packet.

SECTION 5: Patient Consent Form

The patient letter and the Preoperative Informed Consent have been combined. The patient letter requirement has been replaced by completing the Informed Consent Form. A separate patient letter is no longer required.

Fill out and sign the Consent Form. The consent form is included later in this file under Section 10. It says, do not sign until you’re with a health professional witness, but the copy that you are mailing in with your packet needs to include your signature and date. You will need TWO copies of this. One will go in your notebook and be sent with your packet. The other copy needs to be brought with you when you have surgery. You will be given another on a hospital form to fill out so if you have your copy with you, you can just copy it over onto the properr form. A nurse in the holding area will witness your signature..

SECTION 6: Family Consent Form

The family support letter has been replaced by the Family Consent Form. It is much the same as the Patient Consent Form. It must be filled out by a member of your family who will be in your life to support you through the surgery and beyond. This can be your mother, father, sister, brother, husband, wife, adult child or life partner. This form should be filled out completely and signed then notarized just as the former family support letter needed notarization. This should be returned with your packet signed and notarized. You may want to assist your support person in understanding what you have learned about the surgery and the risks and benefits. In fact, it's a good idea to sit down with your support person and together read, discuss and fill out the form. This consent form is purposely complete listing every possible risk. We want you to be a well-informed patient and have well-informed people to support you.

SECTION 7: Photographs

You will need two pictures of yourself. Wear something that will show your body shape clothed, so that the doctor will know before he meets you where your weight is concentrated. Please also submit a photo of your abdomen if you have a significant scar on it. This is helpful to determine if its location may be something the surgeon needs to be aware of prior to your arrival for surgery. Note, all photos are only reviewed and placed in your private medical chart of the CLOS office. There will be NO publication of these photos unless you were to submit or display them online or any other means of publication. We prefer 4X6 color prints.

SECTION 8: HIPAA Form

Sign and date the HIPAA form under Section 8

SECTION 9: Insurance Release

This is a two-part process. There are two forms. Everyone must sign the release form whether they are paying cash or not. The form clarifies whether or not you will be working with the hospital to bill insurance (if pre-certified with St. Rose). The second part of the form is the form you will need if you intend to seek reimbursement from your insurance company. This is a 9-10 page form that is based on the information you supplied in your original patient information form (patient application). If you are asking for an insurance letter, the request form must be notarized. There is a $25 fee for this form, however many patients have found it very helpful. If you plan on having the hospital bill your insurance please contact Linda Johnson at (702) 616-5000 after you have a surgery date.

SECTION 10: Medications and Allergies

Complete the sheet enclosed. This form will provide us the most current list of medications and supplements.

SECTION 11: Contact / Billing Information

Complete the form with your information.

SECTION 12: Prescriptions

Because of changes in the laws we no longer offer to send out prescriptions. Sorry. You can take these suggested enclosed prescription sheets to your doctor and he can have them filled prior to arriving in NV for surgery or we can fill them after clinic in Las Vegas. Please checkwith Sandy Brubaker, sandyb@clos.net to confirm you have picked them up. There is nothing to submit in the packet with this section.

Once your packet is complete:

Your packet must come to us in a folder. Make sure it is completed before sending it. If you receive your notebook in the form of a CD or electronic file, please purchase dividers with labeled tabs for each section and mail in. Your packet must be received not less than 14 days before your desired surgery date. Your packet should be sent Fed-ex, Priority Mail, or UPS. It should ** NOT ** require a signature.

Dr. Robert Rutledge

CLOS

98 E. Lake Mead Pkwy, Suite 302

Henderson, NV 89015

Office Phone: 702-714-0011

The Mini-Gastric Bypass Surgery

MGB Patient Packet Helpful Hints