Mixed Nuts

From Walmart.com

"Your patients are nuts!" a nurse at the hospital said to me recently.  She had a difficult time with one of our patients on the surgical floor post op, and was frustrated in trying to care for her.

This is not the first time I've heard this, and I've always thought this broad summation of a fairly diverse population with obesity was understandable, but unfair.  Or was it?

I've rationalized to myself, with nearly 10 years of bariatric surgical care experience (both inpatient, intraoperative, and outpatient) that those comments were due to inexperience with seeing the full spectrum of care as I see it on a daily basis, with mixed types of patients on their journey toward wellness at various points along their preoperative and postoperative course.

There is something deeply satisfying about caring for this population, which we are all seeing, and acting as part of a multidisciplinary skilled team to assist them to wellness /"wholeness" if you will, in a way that no other health care facility in our area can. Good stuff.

Are we occasionally effected by a "nutsy" patient, or a difficult patient care situation? Do similar or even more dramatic situations occur in a Family Practice or ER setting, or other similar venues? Most assuredly, the answer to both questions is yes.

I would argue, though, that the patient's BMI is not the common denominator in most of these cases.

Which brings me to the subject of this Blog: What does the literature say about the psychological profile of the morbidly obese?

I looked up just such an article recently, and it had some interesting descriptors of the morbidly obese.  The article was written in 2004, but did have a nice systematic literature search on the subject and came to some interesting conclusions.

As the article states, Bariatric surgery does in fact represent 'forced' behavior modification.  However, the surgery does not result in equal results in each patient.  Psychological factors do play an important role in these results.  The degree that patients can successfully adapt to use their "tool" that the surgery provides, quite directly reflects their success in losing weight and keeping it off after surgery.

The article went through the published results on the morbidly obese, as studied in terms of Personality, Psychopathology, Eating Behavior, Social Integration, and Quality of Life.

Let's start with the first two.

Personality

Personality studies in the morbidly obese described three main interactions.  Firstly, personality may predispose to overeating and weight gain. Secondly, existing with long term obesity can certainly influence personalty.  Also, personality and weight can also relate in a way that is a combination of the two.

No specific personality was found that was consistent in the majority of the population studied.  There was a wide variety of traits discovered as commonly associated.

*Passive-dependent as well as Passive-aggressive
*Overly sensitive interpersonally, and most had difficulties expressing their aggressive feelings
*Poor impulse control
*Despondency and Hopelessness
*Eccentric, Anxious,  and Dramatic cluster traits
*Tended toward Somatization
*Passive Coping Behaviors, with a 'wait and see' approach

Psychopathology

This was reported as difficult to assess, as even the methodology as to discerning whether specific pathology exists is highly controversial.  More recently, this is becoming more acceptable as an identified co-morbidity, either leading to the obesity primarily, or becoming a diagnosed condition secondarily.

Some studies seemed to show what was described as psychopathology as the result of the burden of obesity, whereas others did not show that direct of a link.  Some researchers noted a 40-50% prevelance of psychiatric disorders in the obese.  The most common disorders were

*Depressive Disorders
*Anxiety either associated with above, or as a singular entity

In terms of family relationships, many obese patients studied had a history of early parental loss, parental alcoholism, and also have marital dysfunction in their own lives.  The presence of sexual and non-sexual abuse was also common.  One study did comment, however, that the rates were not all that different than that of abuse in the general, non-obese population.

Also, females, more than males, were shown to be more likely per capita to have preoperative pathology, in terms of depression, interpersonal sensitivity, somatization, obsessions-compulsions, anxiety, as well as hostility.

For the next segment, we will go over the findings on Eating Behavior, Social Integration, and Quality of Life.

K.I.$.$ : Annual Diabetes Pharmaceutical Sales

Photo from Schenectady Gazette

K.I.$.$

You know the phrase.  Simple and true.  Even so when it comes to money, disease, and cost / benefit ratios.

I saw this graphic in the paper the other day, and just had to use it.

In place of a lot of potentially pompous verbiage, I will elect to rely on the intelligence of the reader (that would be You) to sort out the impact for yourself and your patients as to the impact of what we all do every day, on the front lines of Diabetes.

It is impressive, however,  to see where Diabetes treatment lies among the total costs of medicines, the amount spent ($40 Billion dollars in the year 2012), and the potential for significant impact with earlier treatment with more efficacy for long term effect, and / or resolution.

I will leave the rest to You...

STAMPEDE Trial Follow up Substudy

pastorblog.cumcdebary.org

I had mentioned the results of the STAMPEDE trial (Surgical Therapy and Medications Potentially Eradicate Diabetes Efficiently) in a past Blog post, but there is new information that is worth mentioning.  In the new substudy, the same participants have been reevaluated and the findings are interesting.

To review, the STAMPEDE trial, with its initial results published in 2010, compared the efficacy of intensive medical therapy (IMT) alone, vs. IMT combined with one of two Bariatric procedures, Sleeve Gastrectomy or Gastric Bypass.  The studied participants had Type 2 DM, and a BMI of 27-42.

After 12 months, the main outcome was measured: HbA1C of <6.0%.  They found that among the groups, 12% of the IMT group got to goal, and 42% of the Bypass and 37% of the Sleeve groups got to goal.  It was also concluded that all groups improved in their glycemic control, but the surgical groups did outperform the IMT group, and showed superior weight loss and measured improvement in insulin resistance.

In the follow up substudy, 60 of the original participants were rechecked at 24 months after the study was completed.  They were evaluated for the ongoing effects of the three original treatments in terms of glucose regulation, pancreatic beta-cell function, and body composition.

Glycemic control improved for all three groups at 24 months.  Reduction in body fat was similar for each of the 2 surgical groups, but the Bypass groups showed a greater absolute decrease in truncal fat vs. the Sleeve Gastrectomy group, which did correlate positively with an associated improvement in insulin sensitivity and significantly improved beta-cell function over the Sleeve patients.

The take home point?  Both bariatric surgery groups had a durable and significant improvement in glycemic control, with the addition of improved body composition / decreased body fat.  The favoring of the Bypass results seems to go along with its likely heightened mechanism of metabolic action, as to how and where the weight loss occurs.

Beta-cell failure defines the pathophysiology in DM2, and the exact surgical effects on reversing this cascade to end stage disease is an area of  ongoing study and research.  The exact placement, practically, of metabolic surgery in the aramentarium against Diabetes is the next real question that needs to be answered.  Studies like STAMPEDE, and now its 24 month substudy, will go a long way toward developing these protocols, and best practice scenarios.

And in case you wondered, there are a number of additional studies in the works on similar subjects, as well as another substudy in 24 more months to the same STAMPEDE group.

Nuts and Bolts of Band Revisional Surgery, Part 3

From fun107.com

We just got back from returning one of our kids to college.  Talk about a time ripe for the unexpected!  As one of my sons says,  sometimes in a taunting fashion, "You don't know what you don't know".

How true, especially when it comes to this time of (hopeful) maturation into adulthood, a journey that college automatically provides on so many levels.

I think the corollary to the saying of what you don't know is equally as helpful, and can take some of the angst out of what is coming up.  If you know you don't know (everything), then that's a safer place to start from.  Because not to know that you really don't know, is really the truest definition of not to know... Ya know?

If you can follow that, the rest of this entry will be a piece of cake (no bariatric pun intended).

Part 3

To quickly summarize, we have discussed the issues leading to the necessity of Band revisional surgery,  and have covered what it takes to undergo an additional surgery to improve upon some form of an undesirable situation with a Band patient. And now,  the final portion.

Which surgery type is the best for a patient to have once they have "failed" their Banding procedure, either through lack of weight loss (or substantial weight regain), or they have experienced an untoward effect of the Band, or both, as described earlier?

There are subtleties involved here, as the only 2 other procedures we perform in our practice are Bypasses and Sleeve Gastrectomies.  Both will work here, and we have successfully done both as revisional procedures.  Yet, as much as we may want to separate the two, from a revisional sense, they are essentially more similar than different, and both excellent options for a number of reasons.

Both are metabolic, that is they have beneficial metabolic effects, as contrasted to the Band which essentially does not.  Both have a better track record of generally inducing a larger degree of weight loss than the Band, and certainly at a faster rate than the Band.  Most studies also show that each procedure keeps off weight longer and to a greater extent than the Band does.

Either procedure can be performed as a one stage procedure, (that is Band out to Bypass, or Band out to Sleeve) but occasionally it is safer to do it in 2 stages. That situation may arise if the stomach is significantly inflamed or irritated from a pre-existent mechanical issue with the Band, or if surgical landmarks are just not clear enough to risk the conversion in one stage.  In that case, we would take out the Band and access port at the first operation, then come back for the new procedure.  Certainly it is better to wait than risk a complication that may either delay or even negate the chance at performing a revisional surgery.

So, in summary, all is not necessarily lost if a patient does not do well after Band surgery,  or if they develop a significant untoward effect from the Band.  Revisional surgery, for those who qualify, is a possible option to be reviewed with the patient by our Bariatric staff,  keeping in mind that old standard yet simple equation: risk vs. benefit.

We are here to help in any way we can, especially if we can reduce what a patient doesn't know about what they may not know :)