Next Stop, Vegas Baby!

 That old adage won't be true this time.

 Presently at a Bariatric Surgical conference for ASMBS in Vegas, and will bring home the latest info on weight loss surgery and Diabetes, Sleeves, etc.

So, at least that part of what happens there will not stay there...as for the rest, we'll leave it at that.

Stay posted.



Photo by M Clock



Backstage Pass, Part 2...

                                                                                                     Photo by M Clock

   Banding is a kind of enigma.

   There are Bariatric Surgery practices that are almost exclusively Banding practices, offering few, if any other options.  There are leaders in the field of weight loss surgery that are staunchly opposed to Gastric Banding as an acceptable procedure.  Emotions flow on both sides.

  Practically speaking, it works, but as in most medical interventions that require a behavioral input from the patient, the results can be variable.

   So, for Diabetes,  the major drawback is that without any transection of the stomach, or intestinal malabsorption, there is no immediate metabolic benefit to placing the band, as does occur perioperatively with a Sleeve or Bypass.  The upside is potentially less complications, no staple lines, outpatient-type of  length of stay, and likely less micronutritional deficiencies as the procedure is only restrictive, and not malabsorptive.  Further, the downside of that is a slower (1-2 # / week) weight loss, vs. more drastic weight changes early on with the other procedures.

   Even so, weight loss is weight loss, and with the 10% weight loss requirement we have before surgery, and the attendant weight loss after surgery, especially if coupled with appropriate changes in dietary content (more protein, less CHO) and volume / portion size, easier regulation of blood sugars  will usually be seen early in the post operative period, just not in the immediate postoperative time frame.  Medicines for Diabetes are often steadily reduced in the preoperative weight loss phase, and monitored to be reduced in subsequent post surgery visits as we adjust the band for optimal restriction.

   Studies have been done on looking to find the optimal patient for a Band, and there really is no consensus that can be drawn from them.  They have looked at BMI, socioeconomic status, dietary practices, and psychological profiles. Some suggest this may be the best approach for a surgical treatment of adolescents, avoiding more 'irreversible' surgical methods, while potentially reinforcing proper dietary habits.  This is experimental at this time and not FDA - approved.

  The other way to look at the lack of a clear cut patient profile that is likely to succeed is that anyone is as likely as another to succeed that applies themselves and follows the rules of proper diet and followup with adjustments as needed.  It is easier to 'beat the Band' than the other procedures if the patient does not comply with regular follow up and adjustments, but most that do adhere to the rules usually do well.

   The FDA did approve last year an indication for Gastric Banding starting in the 30-35 BMI range for a patient with Diabetes, although insurance companies have been reluctant to approve this, and it usually requires a case review, but may be approved on an individual basis. Traditional NIH criteria, as you are likely aware,  starts at 35-40 BMI with comorbidities to qualify for surgery.

    This may be a nice niche for the Band in Diabetes - catch it early, reduce a mild amount of weight, and maintain that balance of weight and insulin sensitivity for a prolonged amount of time.  Success!

   In the third and final part of this Band discussion, I will focus on the practical standpoint of side effects and complications from Gastric Banding.



 

 

Your Backstage Pass to The Band, Part 1

 

                                                                                                    Photo by M Clock

   And now for a few posts on the Band.  The other Band - not DMB.

   Gastric Banding is one of the surgical options we offer for weight loss, and it does have a role in Diabesity as well.  There are patient factors to consider, both behavioral and medical, as you (their PCP) either guide a patient to or from this choice as an appropriate surgical option.  Again, as detailed earlier, the surgeon that sees the patients before surgery go over each option with your patient, centering on the patient's choice and why, and their medical history and what can be expected from their desired procedure.  Rarely do they "talk them out of" their procedure of choice.

   Occasionally a patient has done their research and ONLY wants a Band, due to the "extreme" nature of the other options that require either intestinal "rewiring"(Gastric Bypass), or removal of a good part of their stomach (Sleeve Gastrectomy).  For these patients, it's likely a Band or nothing else.  Interestingly enough, other patients choose "anything but the Band" due to their worries about the safety of a long term implant.  Obviously, both have their merit.

   Is there a perfect patient for the Band that will definitely have long term success?  No.

   We have many Band patients that do well, sometimes losing over 100 lbs over 1.5 to 2 years, and love their Band.  We have some lesser BMI patients that plateau or don't lose much, usually owing to poor followup- which is the most important way to "guarantee" success with the Band.  Let's face it- the advantage of adjustability with the Band is also it's greatest downfall in that if the band is not adjusted properly, and/or  the patient does not "adjust" their lifestyle and dietary practices to the Band, suboptimal results will be realized.

   Furthermore, if you ask a patient how they are doing with their Band, and they have realized a modest weight loss, have newfound control over their dietary intake, and have either an improvement in quality of life or their medical co-morbidities, they definitely feel like they are on the road to success (See previous posts on Success in this Blog).  Again, all it takes, in most cases of obesity, is a sustained 10% weight loss to see modest benefit in quality of life and associated medical conditions.

   So, yes, the Band has a definite role in the surgical treatment of Diabesity.  In the next post, I will detail the Diabetes benefit and how the Band assists in that realm.

Exhibit D: The End of the Rainbow

                                              Photo by M Clock

We haven't had a Sleeve Gastrectomy Case Study yet.  Wait no longer.

I saw this patient in the office last week. She was ecstatic that she took charge of her health care, went to see her Endocrinologist in regular followup earlier this year, and popped the question: "What do you think about a Sleeve for my Diabetes?"

Here's what happened...

Demographic:  46 y/o F

Start Weight:  240#   BMI:  35.6

Date Of Surgery: 10/16/12 
                               Laparoscopic Sleeve Gastrectomy

Diabetes Hx: DM2, uncomplicated, on Insulin. Lantus 65u BID, Novolog scale with meals, averaging 38 units TID. Glycohemoglobin A1C 9.2 upon entry to program.  Sees PCP and has Endocrine also helping to manage her Diabetes.

Current Diabetes Hx:  Currently 3 mos post op, weight down to 181, with BMI of 27.  Off Insulin, and now "Diet-Controlled". BGs at home normal, Glycohemglobin pending from Endocrine visit recently.  Was told on her last visit there last week that she and her PA provider would have to "Break-up" seeing each other, as her sugars, and her (DM2) disease process, was essentially in remission.

Take Home Point:  Sleeve Gastrectomy, as mentioned earlier and in numerous places in this Blog, works well for Diabetes.  Studies have borne this out, and the data is increasing as these patients experience long term results.  In the past, the Sleeve was a portion of the BilioPancreatic Diversion / Duodenal Switch (BPD-DS), but 'recently', within the past 5-10 years, it is now an accepted stand-alone procedure producing sound results.

Due to recent improvement in insurance coverage for the procedure, and it's additional appeal as far as lack of malabsorption (and the patient's conception of what that entails surgically, as with a Gastric Bypass), and a typically shorter stay in the hospital (1 day vs. 2), it has garnered notable patient interest.  

Of additional note, again an example of a patient taking it on themselves to become educated about their health, seek out alternative treatments, and, as detailed here, reap significant benefits.  Weight reduced.  Eating in check.  HTN and Hyperlipidemia much improved, off meds.  Improved quality of life.

Where would she be, health-wise, in 10-15 years with stable weight, or more likely slight but steady weight gain,  and further increasing insulin resistance?

Success, Defined!

So, here are a few of those success principles we look at to ascertain the degree of success, or lack thereof, when evaluating a patient post operatively.

1.  Weight Loss of approximately 60-80% of Excess Body Weight, generally achieved one year after a Bypass or Sleeve, and 2 years after the Gastric Band.                                         

                                                                  Photo by M Clock

2.  Maintenance of that weight loss to a reasonable proximity, years after surgery.

3.  Resolution of CoMorbidities, such as DM2, which may occur independent of the weight loss component of aforementioned success principles.  The improvement / resolution of other disease states (HTN, Lipids, OSA, Chronic Pain / Arthritis, PCOS / Infertility, etc) usually includes great financial benefit, as well as #4 Quality of Life benefit, below.

4.  Quality of Life is still a central, and somewhat less-precisely measured, point on the Success curve.  It likely is not as definable an endpoint as the others may be, but again, query a patient on how their life has changed in the context of where they are currently reside on their weight loss journey after surgery. These are usually very personal, and emotion-laden mile posts on that journey, and carry much more impact for most folks than a 'goal weight', even if achieved, can ever give, such as these:

     *Fitting in a chair on an airplane comfortably for the first time.

     *Being able to see my shoes to tie them.

     *Being recognized at a store as a 'true customer' at Walmart, as I shopped for clothes I actually fit in.

     *Going to see a movie with a friend for the first time since childhood.

     *Making my daughter angry that I could wear her clothes!

     *Being able to play on the floor with my Grandchildren comfortably.

     *Knowing that I am modeling to my kids the priority of good health, and hopefully prevent their need for surgery someday.

     

...And the list goes on and on...

So, you can see 'It's not (all) about the weight', but it really is, in a way.  

I guess the point is this.  It's not as easy /simple as a "100 #" weight loss, and from the patient's side, it's not as hard as that in order to get benefit from such a drastic thing as surgery for being overweight.            

 And, also, one thing we stress to our patients is that once the surgery is done, the journey to better health is really just beginning.  However, keep in mind,  there are many scenic vistas along the way before the patient, and their health care providers, consider them arriving at success!

It's as easy as:

     Success is getting what you want. Happiness is wanting what you get. 

          - Dale Carnegie

Or as complicated as:

If your success is not on your own terms, if it looks good to the world but does not feel good in your heart, it is not success at all.

          -Anna Quindlen

Success, Defined?

                                                                   Photo by M Clock

Success   \suk-'ses\

1a :  degree or measure of succeeding

1b :  favorable or desired outcome

2.  one that succeeds


Even Webster's took a stab at it, but it's still not all that clear.  Especially in the Bariatric / Weight Loss Surgery world.

I had an interesting talk with a patient the other day, that revolved around her goal weight / BMI, and a recent comment from her PCP at a recent office visit there.  She had told her that she wasn't a "success" because she hadn't lost 100# yet.

This patient was somewhat taken aback by the comment, as she is 9 mos out from her Bypass, down 80#, BMI reduced to 31, and much improved with her Co morbidities (HTN, OSA, Back Pain -DJD now off regular analgesics), and genuinely enjoying a new lease on life in her body and current renewed state of health have given her from her daily efforts at diet and exercise.

We had a general discussion about goal weights, how we should not pay attention to the BMI wheel of "healthy weight"  that ends at 24.9, or the potentially elusive hard and cold 100 # mark.

In fact, determining success after surgery is hard thing to do indeed.  In the office, we give general goals for weight if asked, but that's only one determinant.  Each procedure, as studied, has ranges of accepted amounts of weight loss to be expected in certain time frames.  If Lance Armstrong was obese, he may have written a book entitled, "It's not about the weight".  Weight loss is an easy, concrete, definable, "attainable" statistic, and it certainly is part of the success-journey.  Just ask any patient what they want their weight to be, and they will give you a very specific response.  The answer gets in to much more depth when you ask why that certain weight, and what it means to them.  Sometimes it's reasonable and attainable, sometimes it is not.

But there is more, much more, that goes in to determining the level of success a patient attains after surgery.  Next post I will put up a few, attained somewhat pragmatically, as a search for a formal definition, and a discussion about 'success' with 'high-ranking' officials at the Bariatric Center, left the issue still a bit murky.

So, Part 2, to follow soon... But before you see the next post, think of yourself as the referral source of your patient to us at the Bariatric Center.  Did you have clear-cut ideas regarding how you wanted this patient to be revamped by the surgery? What were the different areas of his /her health did it involve?  What time frame did you envision for those changes to reasonably occur?

Referring someone for Weight Loss Surgery is a big deal for you and a big deal for your patients.  Having a good idea of what you, and your patient, want to get out of the surgery is the backdrop, the starting point, for defining success. Part 2 will get into that in more detail...

Exhibit C: A Walk on the Beach

                                                                  Photo by M Clock

Time to take a walk in the shoes of a patient I recently saw in the office in followup. We'll review the case, and I'll talk about an important aspect of practical risk assessment for a complicated patient such as this.

Demographic:  63 y/o Male

Starting Weight: 365  BMI: 59

Date of Surgery:  10/09  Gastric Bypass

Diabetes Hx:  Moderate disease, duration since 2006, generally well controlled on Metformin 500 BID

Co-Morbid Conditions: OSA, O2 Dependent COPD, ASHD s/p MI and CABG, Hyperlipidemia

Current State of Health:  Weight of 256 / BMI of 41. 

Resolved OSA, off CPAP. Off O2, COPD stable.  ASHD stable per Cardiology. Normal glycohemoglobins, off Metformin per his PCP.

Take Home Point:  Diabetes, especially of somewhat recent onset and under control with entry-level PO med and dose, was not this patient's biggest concern.  

Given his age, his severe mix of co-morbid conditions, and his associated self-admitted poor (and deteriorating) quality of life, aggressive weight loss via surgery was really the only potential path toward rapid improvement for this patient's health  at this time.  His PCP had been discussing this with him on multiple prior visits, and strongly encouraged him to contact us to get the process going soon.  His Cardiologist was on board as well, noting increased CV risk of surgery, but acceptable from a risk-benefit ratio perspective.

He certainly feels well now, very excited about his "turning back the clock" back to healthier and more active times.  Down over 100#, with regressed / controlled / resolved co-morbidities, and more than willing to talk at length to anyone that will listen about his story!  I had a hard time getting to see the next patient, but I needed to hear his story that day, so it was mutually beneficial.

Interesting from the medical standpoint, this is the type of patient anyone would agree would dramatically benefit from a successful weight loss surgery... but how many of you would feel comfortable initiating a referral for someone who appears to be at such high risk?  Is it fair to include in the risk assessment what will likely be the near future endpoint of this patient should he not lose weight aggressively?  

His PCP did, and the last comment the patient made before he left his most recent office visit was one we happily hear often at the Bariatric Center. "I wish I would have done this years earlier!"