Exhibit J: Ted's Red Chair in Fenway

Photo by M Clock

I was lucky enough to get to a raucous playoff win for the Red Sox a couple of weekends ago.  We were able to get in early enough to take a look around and watch some BP on a beautifully warm October twilight, with just a subtle suggestion of Fall in the air.

I was able to go and see the infamous Red Chair that sets itself apart in an otherwise uniform sea of green seats in the RF bleachers.  Some of you, I am sure, have seen it and are aware of it's significance.  That seat marks the landing spot of the longest HR hit at Fenway park - 502 feet - by Mr. Ted Williams, many years ago.

I thought of that chair when I saw a post op Bypass patient in followup this week, and her 'smashing' success is worth mention here as one of our metabolic case studies.

Demographics:  45 y/o F

Start Weight:  267 lbs  BMI:  42.9

Date of Surgery:  3/13  Gastric Bypass

DM 2 History:  She said her Diabetes began when she was pregnant with her first child in '93.  She was diet controlled, and remitted after delivery.  She retained some of her "baby weight", then gained some more, and by '95 she had elevated sugars again, this time in the absence of pregnancy.  Her blood sugar control was fair to poor since that time, and she saw an endocrinologist, and despite persistent additions and alterations to her med list she came to us with an A1C over 10.  Her med list she held in hand as she came for her initial visit:

Lantus 95 units bid, Humalog 20 units at meal time, Metformin 1 G bid, and Januvia

Other comorbidities are h/o MI, Dyslipidemia, and HTN.

Current DM History:  She is ecstatic about her newfound control on a much simpler regimen with Lantus 20 units daily, and scaled Humalog up to 10 units  pre-meals.  Her most recent A1C was 7.2 and she was enjoying eating again, with controlled portions and getting in sync with her sugars, diet, meds, and activities / exercise.  In the past she related that no matter what she did, 'even without eating', her sugars were elevated and uncontrollable. She is very happy she initiated the referral to our Center, and had a relatively easy time getting her PCP and Endocrinologist to endorse her to us.  She has lost 60 lbs to date, and is also off her BP med.

Take Home Points:  Standing (or sitting in the case of Ted William's chair) out in the crowd is usually a good thing.  With the crowd of folks with obesity and its associated metabolic diseases out there these days, it remains unusual for someone to take charge of their health situation, such as this patient has, have surgery, and follow through to see the dramatic benefit that bariatric surgery can offer.

As I have stated many times earlier, having the patients come to us as early as possible, once they qualify for surgery BMI-wise, and have failed more conservative approaches (lifestyle, weight loss, meds, specialty care), will ensure the best possible result for them in terms of preserving pancreatic function, lessening the chance of end-stage complications from their DM, and getting them successfully off meds for glycemic control, and more likely keeping them off them.

As you can see here, we didn't get to this patient all that early in her Diabetes disease process, yet a marked improvement in her Diabetes, and therefore both her short and long term health, has been realized.

And I still can't say it enough...Earlier is better.  Earlier is better. Earlier is better.

Unless it's shaving we speak of, then better to wait...  Go Sox!

"This ain't my first rodeo..."

I honestly have never been to a rodeo, and I paused when I thought of the title for this blog this week, as this saying is a little tired.  But I think I can make it work here....

From meco1.blogspot.com

Please read on.

I discovered another weight loss surgery article this week, entitled Surgical Skill and Complication Rates after Bariatric Surgery, from this week's NEJM.

The article was intriguing for a couple of reasons. It revealed an effective way to assess an independent factor for surgical complications, one that has heretofore been either overlooked or avoided, for it has been difficult to assess.  The implication of this lack of published data on this specific variable, that seemingly defies logic, has been that this factor is not truly a primary determinant to surgical outcomes. It has been easier to study related issues, such as perioperative care algorithms, but not the central issue on full display in this study.

The surgeon and his /her skills were on review, and there was a significant correlation with complication rates and the aptitude of their skills, as reviewed by a group of their peers.

In the study, 20 Bariatric surgeons in Michigan were involved in a statewide collaborative improvement program, and submitted a single representative video of one of their Gastric Bypass cases. A group of their peers reviewed the critical aspects of the recorded procedure (creation of gastric pouch,  gastro-jejunomostomy, and jejuno-jejunostomy). The blinded video was assessed in a number of established categories for an overall score rating surgeon skill.

The background for this study acknowledged a few important points. It is known that surgical skill, in any specialty can vary widely. Results of surgery, and specifically Bariatric surgery, can also vary significantly, in terms of weight loss results as well as complication rates. In many previous studies involving outcomes and complications, numerous other factors have been evaluated, mostly in the realm of perioperative care protocols.  Again, studying complications was the focus here, including such untoward effects as surgical site infection, wound dehiscence, intrabdominal abscess, anastamotic stricture, bowel obstruction, bleeding, respiratory failure, VTE, MI, cardiac arrest, and death, as well as unplanned reoperation, readmission, and ER visits.

And lastly, it is also widely understood that the skill level in performing Gastric Bypasses, as a common but technically demanding and complex procedure, would therefore likely demonstrate what they aimed to appraise - the suspected relationship between surgeon skill and complication rate.

So..... What did they find?

1.  Greater skill, as demonstrated by the peer video review process, did correlate positively with a lower complication rate, (along with less reoperations and readmissions) as well as with a shorter duration of operative procedure time.

2. Those surgeons with higher skill, and thus lower complication rates (etc. as above) had an important common bond. It wasn't related to years in Bariatric surgery practice, status in terms of completion of a fellowship in an advanced or laparoscopic bariatric fellowship, or current practice at a teaching or non teaching hospital. What was it?

The higher skill level was strongly related to surgical volume, as in the number of cases already performed.

3. On a personal note, the article specifically noted that the possible extent to which the First Assistant to the surgeon (that would be one of my job duties) could influence the ease of the procedure by the surgeon, and therefore complication rates, was not studied at this time*.

4. And finally, as researchers have a proclivity to do, the results of the study seemed to validate that the peer rating process of surgical skill itself, looks to be an effective strategy for assessing a surgeon's proficiency.

Good stuff overall, and an effective current and trustworthy resource for the argument that high volume centers are the standard for the most effective patient care in terms of a lower complication rate, and perhaps even can be extrapolated to results as well, but that was not covered here.

All of this kind of flies in the face the recent CMS proclamation that Medicare will no longer require that designation in order to approve bariatric surgery for one of their patients (see previous blog post, "One Bad Apple Could Spoil the Whole Bunch (Girl)"), but such is life...


*Note:  The surgical "team", inclusive of a well-trained OR Tech, Nurse,  First Assistant, as well as Anesthesia personnel,  PACU and Med-Surg Floor staff were studied in the past and deemed essential to good outcomes, as occurs in other surgical subspecialties such as CardioThoracic surgery.

Mixed Nuts, Part 2

From Fineartamerica.com

I thought I would mix it up a bit.

Change the metaphor.

You know, the "Crazy as a Loon" thing.  Just trying to keep it interesting...

So, part 2 of this salient topic will cover the latter parts of the article I recently reviewed on the psychological profile of the morbidly obese.  Still to get to will be Eating Behavior, Social Integration, and Quality of Life.

Eating Behavior

No stereotypical surprise here.  The reviewed studies did show significant differences in the eating behavior of normal subjects as opposed to the morbidly obese.  More often, morbidly obese subjects exhibited patterns of compulsive eating, binge eating disorder (BED - a rapid ingestion of a large amount of food with a resultant feeling of loss of control and subsequent guilt and self-condemnation), and/or "grazing" (eating smaller amounts of food frequently throughout the day).  'Mindless eating' is also more common, as well as self-reported frequent snacking on high calorie foods.

Going back to the BED, most studies showed that its incidence was closer to 2-5% in the general population, as opposed to the morbidly obese, where it is noted to be present in 30-50% in one study of those seeking medical care for their obesity.

Behaviorally, there was also a notable correlation with emotional eating, that is, overeating in response to emotional distress.

Social Integration

Social discrimination and numerous stigmata are frequently cited in articles. Psychological consequences can lead to low self-esteem,  as patients deal with prejudice and social bias.  The negative social judgements, such as name-calling and labels ("stupid", "ugly", "lazy", "sloppy") reflect negative attitudes that imply that these individuals are responsible for their obesity through lack of control and lack of will power.

That sense is frequently reinforced by their environment, one that can cause embarrassment in regard to fitting in chairs, clothes that don't fit, difficulties with aisles and hallways to name a few, as well as having challenges with personal cleanliness and odor.

Social isolation, as well as employmental isolation often leads the morbidly obese patient to stay at home, which only serves to reinforce the problem.

Quality of Life

Quality of Life refers to the patient's satisfaction with his or her personal life and the overall effects of medical conditions on the physical, mental, and social functioning and well-being of the subject being evaluated.  It is self-reported by the patient.

The article's review of the literature showed those seeking surgical care for their obesity reported a significantly lower Quality of Life.  Often those patients stated that they had little to fear, given they had the perception of little to lose vs. the potential benefit that weight loss surgery could bring.


So, in summary, there were some new discoveries for me, as far as the implication for some of the trends described.  What the article did say was that, all in all, the obese are not a truly homogenous group.  A number of distinct subgroups were noted, but to be fair, not enough to allow for generalities that are an accurate representation.  Many of those generalities persist, even among health care providers.

The NHLBI expert panel from the recent past described obesity as 'a heterogeneous chronic disorder'.  

However, there is no looking past a lot of the similarities that the morbidly obese present with, or "as".  And, as with most other medical disorders that impact patient's lives, those common traits can be used for gain by health care providers in order to make a profound connection with the patient, in order to get them the medical care they need to improve their total health and better their life situation.