Goooooooaaaaaalllllll! Part 2

And now for the punch line, although this really is no joke-

In fact, we had a clinical meeting at the office just the other day to discuss the weight goal issue itself, as well as reinforcing the complex and delicate nature of assigning the "Goal Weight", and reinforced what it means to the patient as well as to our own staff here at the Bariatric Center.

So brace yourself, here it comes.

Let's organize it this way - the 'What it is, What it was, and What it shall be' classification.

What It Is

*  Not just a number.  There's so much more involved, some of it actual, and some of it artificially associated by the patient, trying to recapture what life was like when they were "that weight".  I guess it's the same as your 70 year old Dad wearing the same style of clothes he did back in his glory days of the Air Force, connecting with his days of old.

*  Based on a "Healthy Weight", as stamped out in concrete fashion by the BMI wheels, and the Insurance tables that delineate a certain weight for a certain height, related to actuarial data.  This certainly does not tell the whole story.

*  A Big Deal.  This cannot be overstated. (Just ask your patient) Having surgery is a big deal unto itself.  Having surgery for being overweight is just as much a big deal, if not bigger.  "What if it doesn't work, like all the other weight loss things I've done didn't work?" Also. "What if it does work, what will my life be like then?" The self-talk can be numbing or fear-inspiring for these folks.


What It Was

*  Again, the association between weight and a "feeling" of how it used to be when I was at that weight.  For me, a personal example is how 80's music takes me down my own memory lane... And for me, not a bad time of my life, but I don't really want to get back there to those now glorified days of early adulthood.  Although I'll take the hair back, that I lost somewhere along the line.

*  In another sense, misleading is a often a better way of a patient's rigidity to get back to a certain weight.  It is not uncommon to have a patient discouraged or even a bit depressed despite having getting to their goal after surgery, only to not "feel" the way they thought it would fell at that weight.


What it Shall Be

*  Reasonable.  I look for a weight around a BMI of 27-30 based on start weight, how much they have to lose, and their age.  I adjust to a higher BMI for more advanced age (above 60 let's say), as well as accept a higher BMI dependent upon how much they have to lose.  For example, a patient who starts out with a weight of 450 and a BMI in the 60s will not be expected to get to a BMI of the same range because the BMI wheel (and insurance company tables of ideal weight) 'requires' the patient to get to a BMI of 24.99 or less the be healthy.

*  Relatively dependent upon procedure and when it was done. Sleeves and Bypasses enable most patients to lose the majority of their weight over a 9-12 mos time frame.  For Bands, they can get to a similar end result, but generally over an 18-24 mos period or more.  Additionally, for most patients, there is a limit to what they can reasonably lose.  Expecting that 450 pound patient to lose 250 pounds is likely not all that reasonable, although not impossible, especially in the 9-12 mos after surgery.  Most Bypass patients, for example, can lose around 200+ pounds, but this is not hard and fast.  Weight loss after that first year can continue in the right behavioral setting, but happens at a much slower rate.  Duodenal switch patients, however,  tend to lose more weight as it is a much more malabsorptive surgery, but we do not offer that surgery at this time, and my experience with it is very limited.

*  Centered on becoming more healthy based on the many benefits of weight loss.  Isn't that the ultimate goal of surgery and weight loss in the first place?  Many categories, some difficult to measure,  summate to embody "Health" for our patients.

Here are some of the questions we ask to get a handle on this measure.  Some answers resonate to certain patients more than others.  What comorbidities are improved or gone, associated medicines reduced or not needing to be refilled? What activities can you now comfortably participate in that you only dreamed of before?  What are others saying about your new appearance, your new clothes, your new attitude?  More importantly, how do you  feel about yourself with more control over your weight and your health?

The sometimes unexpected benefit to patients, and providers, (who thoughtfully take stock of these parameters) is that there are some very unexpected scenic vistas along the way to the the top of the mountain, the end goal if you will, that a patient dreams of reaching.  It doesn't take arriving at a "goal weight" to appreciate very substantial gains in Quality of Life in most of the above markers of health. Studies routinely bear that out.

We as Health Care Providers just have to remember that. We need to remind them of where they are on their journey, help them set a reasonable goal weight, not further burden them, and get out of their way as they journey on the trail to the top.

Photo by M Clock

Goooooooaaaaaalllllll!

Although I love sports, I am honestly not a big fan of soccer. I am more of baseball guy.

I am a fan of goals, though. Not just in the sporting sense, but as a futuristic concrete stretch to encourage effort and measure performance.

In the weight loss surgery world, a weight goal sounds simple enough, but commonly has a lot of emotion and coupled baggage associated with it.

"Why do you think that is your goal weight?"I will often ask...  Here's what I often hear in response

   * "That was the weight I got married, before we had our 2 kids"

   * "That's the weight I think I need to get into my old clothes that are a size 5"

   * "I think that weight will be good, because that will be 100 pounds less than I am now"

   * "If I can just get under 200 I will be happy"

   * "I need to get to that weight because my Doctor told me that to be healthy I need to be a BMI of 25 at the most"

 "I don't know, what weight do you think I should be?" they often ask.

Conflicting information from well meaning sources, including the patient themselves, can lead to unneeded frustration and angst.  And, the 'goal' they are pursuing may be nowhere close to what is reasonable and necessary.  In fact, it's often less than what they are working toward.

Given that the fact this topic is a very important to clarify for us and for you as PCPs, I think it best to keep you all on the edge of your seats for a couple more days and give a complete answer to this multifaceted response in a part 2, to follow...

How do you typically respond to the 'goal weight' question, whether it's a surgical weight loss patient, or a non-surgical weight loss patient?

The answer may surprise you.

Photo by M Clock

Snore Galore.....Zzzzzzzzzz

Snore no more!

Probably too much to promise, but yet another benefit of the weight reduction that comes from Bariatric surgery.  This speaks to another common issue - Obstructive Sleep Apnea (OSA).

I know you are aware of this diagnosis, presentation, and likely even the consequences of untreated OSA on various organ systems.  We are seeing a slightly larger percentage of patients coming to us as new patients, who have been already worked up or diagnosed with Sleep Apnea.  However, There still are a large number of patients we need to send for Pulmonary evaluation, and /or a sleep study (polysomnography) prior to surgery to suspected long term OSA.

I thought it would be nice to briefly review it here, and tie in the applications to weight, surgery, and preparation for surgery.

OSA is present in a significant number of middle aged adults, but much more common in our overweight population. Risk factors do include obesity, as well as the physical presence of a short and thick neck, as well as a small recessed jaw.

Roughly 70% of patients with OSA are obese.  Similarly,  the prevalence of OSA in obese men and women is estimated at 40%. For every increase in BMI by 6, OSA risk increases by 4x.

Symptoms are usually related to loud snoring, excessive daytime somnolence, and possibly witnessed apneic spells as reporter by a sleeping partner. Often the sleeping partner will present with the patient to report on his /her sleep disruption caused by the offending snoozer.

Disease states that have been associated with untreated OSA include heart failure, HTN, pulmonary HTN, MI, Cerebrovascular disease, chronic CAD, stroke and TIAs.

When we suspect OSA based on presentation, we will schedule a Pulmonary eval, and then a Sleep Study (polysonography) may be appointed for formal testing.  Some insurance companies have recently adopted a policy of starting with a home screening sleep study, involving oximetry, which is not as sensitive a test but certainly less expensive.  However, a negative home test does not rule out OSA.

Once a positive test is noted, there may be further studies with an appliance (BiPap, CPap) for comparison, and eventual titration.

From the Bariatric Surgery perspective, OSA for us is surrounded by a number of issues:

1.  Preoperatively, we need to screen patients when necessary to appropriately prepare them for surgery, anesthesia, and post op narcotics that may cause increased risk of hypopnea and hypoxia if not identified.

2.  Due to the referral process and the testing and retesting that may be required with Pulmonology, as well as obtaining and using a new appliance, time is of the essence! A patient may be ready for the OR otherwise, but occasionally end up due to an incomplete Pulmonary evaluation.  Having a patient already appropriately diagnosed, or at least evaluated for OSA could greatly expedite their preoperative process.

3.  And now the good news - A great proportion of patients that lose weight after Bariatric Surgery do in fact  see significant improvement, or even resolution of their OSA. It is thought that this result is secondary to reduction of adipose tissue in the parapharyngeal tissues.  Patients who primarily have a fixed structural etiology to their OSA (soft palate, uvula, peripharygeal tissues, tonsils, mandibular structure) may not see the same improvement, but his subset of patients is less common than the former. For some, a uvulopaltopharyngoplasty or jaw surgery may be required.


So... the next time a couple comes in to complain about some snoring in the bedroom, don't be too quick to reach for the Viagra. Notice the BMI of the offending snoozer, and consider it an opportunity to review other comorbidites that together may make a compelling case for weight loss surgery!

Worth The Wait

Patience

is not 

the ability to wait

but

how you act

while waiting

                                                        -Joyce Meyer

Waiting is always difficult.

It usually involves expectations unfulfilled, and adds at least temporary disappointment to the physical act of having to pass the time, a delay until what you wanted to happen, does.

We've had a couple of interesting situations in the office this week, instances that do happen from time to time, but I thought I'd mention them here in this Blog.

Qualifying for surgery by insurance-reimbursable standards follows the NIH guidelines as mentioned earlier in this blog.  That part is fairly concrete.  

The sometimes more challenging part of the equation for the patient is the acceptance that surgery is the next best necessary option, and coming to grips with the decision to actually go through the process to have surgery.  

Yes, Surgery... because "I have to", or "I need to", or "I don't have any other option" is what we commonly hear.

That can be quite a stretch for some, and appropriately so.  

It's not unusual for our secretarial staff to have patients shed tears of joy when we call them with a date and time to set up their initial visit after they have attended our Bariatric Surgery orientation session.  Or be so excited after that session that they go gung-ho, and lose some weight to get a running head start on the 10% they are required to lose preoperatively...

Thereby causing an issue.

We saw two such patients last week that barely qualified by BMI and comorbidities prior to their orientation, and were just underweight at the time of their intake H & P.  Unfortunately, that's the exact time when the note goes in to their insurance to initiate the approval process for weight loss surgery.

You might say that they probably really didn't need surgery in the first place... But how about this one?

52 y/o Male

Uncontrolled DM2 x 7 years on Lantus, Levmir, Metformin

Last glyco 7+

OSA. HTN, Dyslipidemia, Weight bearing Joints with OA

5' 4"  195  (BMI 33.5)

The better question to ask is , "Where will he be without surgery?" if not done soon.

It surely puts us in the awkward position of spelling out options, although, honestly, in this metabolic scenario, the result of surgery (Bypass / Sleeve) is much better for quicker impact and likely longer duration,  than even the same weight loss achieved via the traditional means.

In case you are wondering, the option he chose was to find the few pounds he lost recently, and get the ball rolling toward surgery.

But What About the Children? part 2

From WorldMakerMedia.com

And now, after an appropriately pregnant pause...

Part 2 of another way obesity effects 'the children'.  The ones that are waiting to be born.

I had a nice discussion with a OB-GYN MD the other day, one who specializes in infertility, about the role of obesity in infertility. We also discussed the issue of deciding when is it appropriate to discuss female weight and BMI with a prospective couple - after or before the typical infertility workup?

The typical infertility workup is as follows, after we define some terms.

An infertility evaluation is usually indicated after one year of regular unprotected intercourse in women under age 35, and after six months of unprotected intercourse in women aged 35 and older.  An earlier evaluation may be performed in women with irregular menstrual cycles, or known risk factors for infertility, such as PCOS, endometriosis, a Hx of PID, or reproductive tract malformations.

The initial basic workup obviously includes both partners.  It is also common to have multiple factors resulting in infertility.  Male testing includes semen analysis.  Female testing starts with documentation of normal ovulatory function, and then imaging to r/o tubal occlusion, usually via an hystersalpingogram (HSG).

Should all these come back normal, but the patient is overweight, there is evidence that initiating basic lifestyle modification to lose as little as 10% of their body weight can significantly improve fertility.

However, with a female that is overweight, there are known direct associations between obesity and infertility.  Women with evidence of anovulatory cycles and hirsutism was positively correlated with weight, and being overweight was directly proportional to the percentage of that finding, making it increasingly likely as weight increased beyond 30# overweight.

Weight loss after Bariatric surgery is usually more than that 10%, with the vast majority occurring in the first year.  That is not the time to conceive, as we mandate our patients to sign a contract to wait until 2 years after surgery.  The risk is that rapid weight loss, and a potentially tenuous nutritional state at that time may result in miscarriage or significant fetal abnormalities.

Reproductive aberrations induced by obesity do improve after surgery, usually by improvements in menstrual cyclicity.  PCOS is also shown to improve, by demonstrating marked improvement in both clinical and biochemical hyperandrogenism.

Of additional note, once pregnancy is established, obstetric complications (Gestational DM,  macrosomia and hypertensive disorders) are greatly reduced compared to morbidly obese women.

So, another reason to keep bariatric surgery in mind for a patient unable to make changes in their lifestyle that could result in durable weight loss resulting in comorbidity reduction or resolution.

And, for those of you trying to convince that patient that may otherwise not be interested in surgery, this may prove to be your trump card to get them thinking...

From Gagaoverbabies.blogspot.com

But What About the Children?

When I read the book about how to have a whiz-bang Blog, the first thing they said to do was to have a catchy title.  This one is kind of random, but it gets the point across.

As I write this entry, there really are two ways I can go with this one, so here's part 1.

Childhood Obesity and Surgery

You've heard all the statistics and seen the evidence these days.

Constant is the news regarding childhood obesity rates soaring, associated Diabetes also skyrocketing, and even Michelle Obama is in on the situation trying to clean up school lunches to help slow the pending epidemic.

We all know about adults with obesity, and its comorbidities, and it is frightful to consider what this group of kids / adolescents have in store for them over time if they can't get their behaviors back in check, such as increased regular energy expenditure / exercise, consistent portion control and more optimal and wholesome diets overall.

Anyone can pick their favorite aspect of the equation that needs to be altered in order to ensure improved health overall, both now and for future well being.  You may even have championed programs in your office based on your view of the main cause of childhood obesity, and the causative factors that bring about the problem. You've gotta start somewhere!

So the question is often asked- "What about kids or adolescents and surgery?"

More than 20 million adults and 2 million children and teenagers in the USA have extreme obesity (body mass index ≥ 40 kg/m²), a condition associated with premature morbidity and mortality. In adults, bariatric surgery results in prolonged weight control and improvement in serious obesity comorbidities . Bariatric surgery performed late in the course of comorbid conditions may not be as effective as surgery performed earlier. Based on these factors, we proposed that surgery for extreme adolescent obesity may be a beneficial option for highly selected teenagers, but large-scale prospective studies using reliable and valid measures that are systematic assessed are still lacking.

The data is currently being compliled, as the NIH is following 250 cases longitudinally.  The Teen- Longitudinal Assessment of Bariatric Surgery (LABS) was started in April 2006. Federally funded studies such as Teen-LABS are needed to provide answers to clinical and economic questions about the benefits and drawbacks of bariatric surgery in adolescents.


I came across an excellent article from the New York Times last year, as they followed the journey of an overweight adolescent who ended up having a LapBand placed.  Just as interesting, the article not only follows her for a year after surgery, but goes through some of the issues surrounding younger patients and surgery for weight loss: cost, insurance reimbursement, ethics of the procedure, behavior modification necessary, lack of success with other non-surgical methods and where that is headed if unchecked, the psychosocial nature of the adolescent patient, and what friends think of the whole situation (maybe the most important for her!).  In addition, find the link for the editorials written after the article to get a taste of just how polarizing an issue surgery for weight loss in adolescents really is.

Currently, at our office, we have approval to do surgery on patients that are 18 years or older.  There are programs, usually in academic centers, that do handle pediatric cases, usually as a part of a  multidisciplinary pediatric center for weight loss.

So, now for a tease for part 2....

The comorbidity that flies under the radar that is a challenge to treat, and is usually a diagnosis of exclusion after work-up is performed.

We commonly see this in result of successfully treating an obese female in our office quite a bit, whether it was an issue that was treated or formally diagnosed in the past. Sometimes that result is intentional, and sometimes not.

Part 2 will be about Infertility.

You Are Why You Eat: A Psychological Primer

Providers will often ask, "Do you have A Psychologist see them before or after surgery?"

Not to be disrespectful, but it's often asked in a semi-judgmental tone, implying to me that we best check "under the hood" before we do surgery to assess the likelihood of future success in a surgical candidate with obesity, and/or try to uncover the reason why they are overweight on the first place.  There's got to be one...right? (There are likely many reasons, actually...)

Sticky stuff...

Well, it's like the ads for Prego Sauce in the past: It's In There!

We have as part of our preoperative evaluation a mandatory Psych evaluation and clearance, which is and has been a standard of care for Bariatric Surgery programs, especially Centers of Excellence.

During the preoperative Psychological screening, as performed by a qualified Psychologist or Mental Health Care provider, many components are discussed.

After obtaining a brief medical history and a history of their weight issues, patients are asked about prior mental Health issues or treatments, Social History, and a brief MSE is usually done. 

Insight into their weight issues as well as their understanding regarding the "tool of choice" /i.e. their surgery, is also elicited, to ensure that they understand the behavioral imperative that accompanies their surgical procedure, in order to lose weight.

Support systems are reviewed, as well as PsychoSocial stressors, as well as asking about current alcohol, smoking or drug use.

Their report is a summation, as long as there are not any absolute contraindications to surgery,that  the patient is usually cleared to have surgery from a Psychological standpoint.  Should they not be cleared, they will be told why and proceed toward resolving the inhibiting issue as much as able, in order to be reconsidered.

Interestingly enough, there have been no conclusive studies demonstrating which patient will do the best after surgery, from a behavioral/social/economic/intellectual or demographic standpoint. The same stands true for which patient is more likely to be successful with which procedure choice.

And, as a final word, it is not uncommon for a patient to return to see a Psychologist or counsellor or Social Worker after surgery for an exacerbation of underlying issues brought on by their rapid weight loss, or for help with coping behaviors.  The changes in their world are usually relatively rapid and profound, and although most are for the better, they can be overwhelming to some patients.

Exhibit H: An Adventure with C Peptide - The Word is Out

Photo by Wonderlane

The word is out.

Patients are starting to come to the office more frequently and ask the informed questions:

"What are the chances I will be able to get off my Diabetes medicines after surgery?"  and

"What procedure is best for me with my Diabetes?"

This is a great place for the fasting C Peptide test.  I haven't seen anyone yet come in as a new patient with a recent C Peptide result, but it can be a great starting point for the discussion about having another point on the curve to more accurately predict metabolic response to surgery (Bypass, Sleeve) in terms of Diabetes improvement / regression / remission. As mentioned earlier, other studied and non-studied points on that curve seem to be:    

     *Duration in Years for DM2?
     *Insulin use Currently?
     *Hgb A1C at Time of Presentation for Surgical Consult? / Degree of Current DM Control
     *Age of the Patient?
     *BMI?

I still suspect that the C-Peptide result trumps other indicators, as it directly reflects current endogenous insulin secretion, which is essentially the net effect of the above factors. It summarily mirrors the 'up to the minute' status of pancreatic B-cell function, which is what are looking to preserve, and capitalize on, with surgery and its attendant metabolic advantages, and additional weight loss.
 (See previous Blog post on the Number 3)

Today's Case...

Demographic  54 y/o WF

Start Weight  248  BMI 48

Date of Surgery  1/16/13  Gastric Bypass

DM2 Hx:  At the time she was referred to us for evaluation for weight loss surgery, she was on Levemir 60 u daily, Humalog scale generally 50 u BID, and Glimepiride 4 mg daily.  Her control around the time of our evaluation was deteriorating, as reflected in her most recent Glyco of 10.7.  Associated comorbidities were poorly controlled HTN, Hyperlipidemia, and Chronic Fatigue, and a questionable Hx of an ICU admission in the recent past for acute renal failure brought on by an illness with dehydration, but she did bounce back and did not require dialysis or any long term additional treament.

Current DM Hx:  Perioperatively, she was placed on scale and required light dosing of Novolog for BGs in the range of 150-170s.  No basal was ordered, as we waited to see how she would settle out after her Bypass.  

We were also armed with a C-Peptide of 2.3, which was indicating her pancreatic reserve was limited, and I suspected she would need some insulin, either Basal and/or short acting as her diet picked up post D/C.

At last check, after her 1 week visit, and since (I spoke with her just this past week) she is off all insulin and takes no PO antidiabetic meds, and her BGs are in the 100-120 range with her advancing diet.

Take Home Point:


As the title of this Blog post indicated, our patient came into the office very concerned, and asking those 2 big questions. They were of such importance to her, that if we couldn't have given her at least a qualified response, she was leaning hard toward not having surgery.  She wanted some kind of guarantee that her DM would at least be substantially improved, but hopefully put into remission or regression.  

Her other medical issues, her quality of life with her obesity, and her awareness of her likely shortened lifespan from her aggregate medical status was not enough to initially convince her of the need for surgery.

At her first visit to the office, we did discuss obtaining the C-Peptide test, which did turn out to be well below the 3.0 threshold that usually correlates with substantial and rapid DM improvement after surgery according to the literature.  I reviewed the importance of the blood test in her situation, and once we had the result,  gave her the news about the reduced likelihood that we would likely not "hit a Homerun" with surgery, and she would most likely not walk out of the hospital as a new member of the sugar-free gang.  

Looking back, though, as part of the initial discussion I had with her I did go into detail about her current health status, and where she was headed should she not experience any reasonable weight loss in the near future.  This is also an important part of the full disclosure of her options as well, I feel.   

Obviously, Surgery has risks, but "doing nothing"(as far as making a significant difference in sustained diabetic control through medicines, lifestyle, and weight loss) certainly has real risk as well.  

And, as far as DM2 goes, 'Time is Pancreas'. 

There is a finite amount of insulin those B-cells can produce, and when it's done, it's done.

So, currently for this patient, she is definitely better for the time being, and we will have to see how she does long term, as indicated by her C-Peptide. Even if her DM does recur in subsequent years, it will be much easier to control for the long term.

"Which Procedure is Best for My Patient?"

We were at a "meet and greet" lunch meeting for one of our referring Primary Care offices in the area yesterday, and an excellent, fundamental question came up by one of the MDs.

"Which procedure is best for my patient?"

If you scan through this Blog, you will find the answer to that question, and a whole bunch more, but I thought I would draw up a shorter answer here that may cut to the chase.

First off, when your patient comes in to see us, they will see their Surgeon twice before surgery.  That enables the patient to be able to go over their thoughts and concerns about their procedure of choice, should they have any, as the Surgeon reviews each procedure and their inherent risks and benefits. And again, we don't generally force a patient into any procedure, we just inform them and guide them into making the best decision for them on their weight loss "tool"/surgery.

Here's my attempt at an encapsulated view.

Gastric Band

*Probably best for lower BMIs, in the range of (30-35 with DM2*) 35 to 45 or so.  That being said, we have many successful patients that have started with much higher BMIs, although those with less to lose often do better, as the weight loss expected with the Band is slower (1-2#/week). 

The FDA has approved the Band for DM2 and a BMI of 30 -35, although insurance companies have been sluggish to adopt this standard. As you probably know, NIH, and generally insurance standards, dictate a BMI of 35-40 with comorbidites to be an acceptable candiate for surgery, and a BMI of >40 even in the absence of comorbidities.

*As far as Diabetes goes as a comorbidity, the weight loss is the driver for the resolution in this process, rather than the immediate benefit from Gastric transection as with the other 2 procedures.  If a patient is "mildly" Diabetic (diet-controlled, just on PO meds with decent control /glyco's, onset of DM < 5 years) they may do fine, and a Band is certainly better than no tool at all, if they won't even consider any other procedure type.

Sleeve Gastrectomy

Long term Data is in the process of being gathered, and substantiated by increasing numbers of sleeves being done since the recent past.  data thus far shows a little less  % Excess Weight Loss (EWL) than the Gastric Bypass, and perhaps a little less weight loss long term.  So,

*Perhaps more beneficial in patients with mid to lower range BMIs (<50) due to above reasons.

*Diabetics do nearly just as well for the immediately beneficial metabolic effect on Glucose regulation than do the Bypass patients, so a big benefit there over a Band.

*May be relatively contraindicated inpatients with severe GERD or Barretts, due to higher likelihood of GERD after surgery in some.

*Potentially more favorable in patients on a lot of meds, especially NSAIDS, which we generally like to have patients discontinue after surgery.  With the Sleeve, they should generally fare better than the Bypass with ulcer risk.

Gastric Bypass

*Bypass still is the gold standard Bariatric procedure, with the best success, and has the most data to support its long term impact on weight  loss and comorbidities.  So, correspondingly, any range of BMIs is acceptable, and certainly with Diabetes, slightly better DM2 resolution and remission rates (than Sleeve Gastrectomy) have been documented, as well as generally more weight loss with both its restrictive and malabsorptive effects..


I hereby fully admit my bias- Any surgery type for the right candidate is better than no surgery at all for weight loss. 

Optimizing which patient type for which procedure can be done to a degree, but again, surgery beats medical weight loss hands down.  That being said, there are some subtleties that are good to be aware of, and hopefully this brief guide will help you as you guide patients to a surgical "tool" that will work the best for them.

Please feel free to post a comment or question at any time on this blog entry, or any other one you see, as it may be helpful to others who are following along and may have the same issue.