Remember to take your Bile Acids before you go to bed, Dear.

From NPR.org

Bile Acids?

For Metabolic Diseases, like Diabetes?

Maybe this ad from the 1940's wasn't to far off - touting the health benefit of bile-like ingredients.

And maybe someday taking a bile acid pill will be a pleasant reality for those suffering from T2DM, thanks to a recent "breakthrough" finding from Sahlgrenska Academy in Sweden, and the University of Cincinnati.

As reported in the Journal Nature recently, in a study just concluded, found that metabolic surgery-induced (in this case Vertical Sleeve Gastrectomy) elevation in bile acids in the blood, was the principal effect that causes such a rapid improvement in obesity-related Diabetes.

Not only is this interesting and exciting news unto itself, but it may shed some new light on an area that could be developed in the future as a pharmacological intervention, without surgery, to positively effect Diabetes.

The research led to pinpoint a receptor, named FXR, that is directly involved in bile acid signaling.
The study showed that signaling through FXR is essential for the metabolic effects of surgery to be achieved.

This was demonstrated by performing the equivalent of a Vertical Sleeve Gastrectomy on two sets of mice: those with the FXR receptor, and those who genetically were altered to not have the receptor.  The researchers observed that the operation produced weight loss and improved glucose metabolism in the mice with the FXR receptor, yet no effect n the mice that lacked FXR.

The study also showed that VSG produced changes in gut microflora, and that may or may not be working in concert with the FXR receptor to drive the beneficial metabolic results.  More study is needed to investigate those relationships.

"Can't I Just Take A Pill For That?"

From surgerywithoutmedicalinsurance.com

Admittedly, it would be nice.  To have a Bariatric surgical  procedure, with the weight loss and the metabolic benefits of the procedure, without the hassle and potential risk of the surgery itself.  None of the associated surgical and anesthetic risks. Just the benefits. Like the frosting without the cake, right?

So, are we yet to the point yet that medical therapy, in today's advanced age of interventions, non-surgical treatments and pharmacotherapy, that we can duplicate the wide-ranging effects that Bariatric Surgery can provide?

I have spent some time reviewing an article in the International Journal of Obesity, from 2014, that sets out to illuminate us on such a question.

In "Can medical therapy mimic the clinical efficacy or physiological effects of bariatric surgery?" the authors from London, England make their case, and describe where we are as of now. 

Certainly we have come a long way in new medical (Non-surgical) interventions and pharmacotherapy, as we have also come a long way in our understanding of the significance of the benefit and some (but not all) of the physiologic mechanisms of how / why bariatric surgery works.

But, as the article concludes, we are not totally there yet.  Closer than we ever have been to purely medical treatments, yes, but not all there yet.

And, as I have said many times in this blog, surgery is not for everyone.  For most obese patients, with their obesity and their comorbidities, weight loss is weight loss, and in a perfect world if they can lose a substantial amount of weight, and keep it off, we are still talking apples and apples (or pears in the morbidly obese world).

But, in the real world, there aren't many that are very successful with non-surgical weight loss, especially in the context of keeping it off.

And there aren't many that see the long term benefit of weight loss, either to degree or duration, to make a longstanding difference in their comorbidites, their quality of life, or to their longevity of life.

However, that being said, as the article details, there have been many 'new' developments that help us to inch closer to mimicking what a Bypass, Band or Sleeve can do, for example. Here are a few of the developments.

* T2DM benefit after surgery seems to come from improved beta cell function and reduced insulin resistance, as well as a change in gut nutrient sensing.  As the search for how bariatric surgery seems to work physiologically, it has opened new potential metabolic targets for medical therapy to effect.  Both a change in diet amount / portion, calories, and makeup of the diet have been studied to carry about a similar effect.  New T2DM agents, such as GLP-1 agonists and DPP-4 inhibitors and SGLT-2 inhibitors have a new role in the step care approach to T2DM.

*Lifestyle modification for weight loss begins with caloric intake restriction. In a perfect world, it is certainly aided by appetite reduction, as occurs at least temporarily with bariatric surgical procedures, and is reinforced longer term by the restrictive element of the surgical 'tool' that is created through the patient's Sleeve, Bypass or Band.  Medically, newer agents such as Qsymia, in addition to conscious lifestyle modifications, may offer a somewhat similar effect. Further studied dietary makeup, both for calorie amount (?1000-1200) as well as composition (Low glycemic, high protein, high fiber) may offer additional benefit in conjunction with the above. 

*Furthermore, Devices that are now available are also in play.  An endoscopically-placed duodenal-jejunal bypass liner, is a potentially less invasive treatment that aims to recreate the 'bypass' of the duodenal-jejunal region as occcurs in the Gastric Bypass surgically.  Studies have shown that this is a powerful part of the rerouting of the ingested nutrients that changes how the body, and the GI tract specifically, handles the ingested nutrients, and seems to greatly benefit how blood sugar is regulated. The experience with this approach is very early, and has had some complications, in so far as the need for explantation by 6-12 mos, some reports of bleeding, obstruction, abdominal pain, vomiting, etc. Gastric stimulators and intragastric balloons are other devices also in trials at a very early stage in their usage. Results remain to be seen.

So, yes, we have come a long way in our understanding of how and why surgery works so well for obesity and especially it's associated metabolic disease.  We are closer now than we have ever been to maximizing those medical therapeutics and procedures that may avoid surgery, but retain some of the benefits that surgery has shown to exact.

But, in summary, we are still a very long way away, I think, from being able to believably say that a pill, or a device, or a lifestyle change (or a combination of all of these) can mimic the established effects that bariatric surgery can produce for obesity and it's attendant comorbid disease states.

And so my job at this time is still somewhat secure, at least from the fate that has take the cardiac surgery subspecialty by storm over the past 10+ years. In somewhat of a similar phenomenon of scale that is potentially prposed here, with the advent of endovascular techniques (PCI - Percutaneous Coronary Interventions), the rate of CABG  for CAD decreased per hospital caseload by 28% from 2001-2008 in one study, whereby the rates of PCI stayed about the same over that time.

I guess in the area of medicine, and surgery specifically, the more things change, the more they stay the same...

What Happened?

From maniacworld.com

Into every life a little rain must fall.

Frequent music lyrics from a number of artists.  And, apropos for a patient who came in for a post op visit last week.

In the course of an unusually predictable day, I had a patient that I had seen a number of times in the past, and was in the office for her post op Sleeve Gastrectomy visit, closing in on 1 year post surgery.

She had a pre op history of HTN, OSA, Asthma, T2DM, and Depression.  Her start weight was 249 with a BMI of 45.5.

One of her ongoing issues from previous visits was the scarcity of her weight loss, and resultantly, the lack of significant positive change in her comorbidities .  At her visit last week, she had lost only a few pounds more than previous visits, had a history of a few pounds up and down in past visits, and her weight loss total, (including her 15# loss preoperatively) stood at a net of 0. 

That is, she was back to her pre operative weight.


How can that happen?


This issue, and this patient example, fortunately is not a common finding.  It is actually quite rare for a patient within their first year to lose very little, or actually start to gain at some time, already working against their expected mounting weight loss after their surgery.

As you can imagine, is is usually a neon red flag that something is up.

We had interactive, ongoing discussions from her previous visits, and the lack of her post op weight loss did have a cause.  She was going through some very rough times psychologically, with depression and having binge eating issues in response.  Some of the stress was likely brought on by her surgery, at least indirectly, but she also had new and significant stressors at home to deal with.

She fully admitted her issues, and her awareness about it's impact on the lack of success thus far from her surgery.  She was embarrassed and saddened about it, but was actively engaged in counseling and was slowly on the road to getting better in the mental health area.

A few key points.

Interesting, how most patients have a degree of "automatic" weight loss after surgery, most seeing the expected 60-80% loss of excess weight loss within that first year, but on occasion they do not.  Of those that do not, there are some practical prognostic signs can give us a tip off that something is up.

The amount of weight loss at post op visits varies widely, patient to patient.  There is no 'normal' so to speak, but lack of meaningful weight loss at earlier visits post op (1 mos, 3 mos, 6 mos), or weight gain often requires us to delve more into the history to see if there is a behavioral or dietary issue.

Specific and detailed questioning about portion sizes, junk food / empty calories, lack of protein, snacking, etc. may yield some clues.  A thorough exercise / activity review also is needed.

This being said, I also have a low threshold to call a patient out on a self-reported glowing history of bariatric lifestyle adherence, when it's in the face of fair to poor weight loss.

In the case of this patient, fairly superficial questioning allowed her to explain her psych issues, diet issues, and her understanding about the interaction between those factors and her lack of weight loss. Somewhat refreshing, actually, as I have had patients in the past with admittedly less obvious lack of weight loss, who have a hard time admitting to any correlative behavioral issues that may be at cause.

I did bring back this patient more frequently than our usual Q3 mos visits, in an effort to try and stay in touch with her, offer encouragement, and review proper lifestyle changes that were needed for better weight loss.

Sometimes you can only do what you can do.

We will continue to work with her, and support her as we can, and hopefully get her on track to realize some of the benefits she anticipated from her referral to us in the first place. Both for the weight and comorbidity benefit.

The honeymoon phase of 12 mos after the surgery is now nearly gone, but there still is hope if she can start to consistently use her 'tool' of her Sleeve the proper way long term.

I Can See Your Halo

Nature or nurture?

When it comes to obesity, the answer is Yes.

Both.

So, if those two factors undeniably contribute to obesity, might the opposite be true?

That is, could weight loss from surgery, and efforts at lifestyle change make a difference on all the members of a family? That is, a "Halo effect"?

That topic was studied in a 2011 report from researchers at the Stanford University of Medicine, as published in the Archives of Surgery journal.

The article notes that obesity is in essence a familial disease, and the study looked at the potential for healthy behavior transmission as enhanced by family relationships.  They specifically looked at the change in weight, and healthy behaviors of adult family members and children of patients that underwent Gastric Bypass.

Eighty-five participants were studied, broken down as 35 patients, 35 adult family members, and 15 children <18 years old.

The results showed some interesting findings.

Before the operation on the family member, 60% of adult family members were overweight, as were 73% of the children of those patients.  At 12 mos post surgery, significant weight loss was achieved in the obese adult family members, from an average of 234 to 226 lbs. The obese children showed a trend to have a lower body mass index than expected for their growth curve (31.2 expected vs. 29.6 observed).

As far as behavior, family members increased their daily activity levels, and demonstrated improved eating habits with less uncontrollable eating, emotional eating, and alcohol consumption. They noted that lifestyle changes can be socially contagious.

It is also mentioned that each of the family members in the study were required to accompany their family member-patient, when they went for their pre- and post-operative clinical visits, where they received dietary and lifestyle counseling.  Those sessions emphasized a high-protein, high-fiber, low sugar diet and small, frequent  meals.  Further discussed were goal setting for daily exercise, a good night's sleep, alcohol moderation, and minimizing time in front of the TV.

"Can you imagine if every one of these bariatric patients were an ambassador for good health? You would have a huge, grassroots movement with bariatric surgery providing a vehicle for healthy change for patient and family alike", Dr. Morton said, one of the authors of the study.  Obesity is a family disease and bariatric surgery sets the table for future, healthy family meals." The total number of bariatric cases worldwide in 2011 was reported to be over 340,000.

The authors also concluded that bariatric surgery programs should also encourage family members to be a part of support groups and office visits to not only provide support for healthy changes taking place after surgery, but also potentially for their own health benefit, directly.

Keep this in mind in your Family Practice, when you see a patient considering weight loss surgery. There may be more potentially at stake for the associated members of the family as well.

And keep an eye out for the halo effect.  Patients I see often make mention of it in their post-operative office visits. They should get some credit for that as well!

From Reddit.com

A Body Recontouring Primer, Part 2

So, after the ins and outs of the most basic, and essential recountouring procedure for our weight loss patients, and the differences in Abdominplasty and Panniculectomy, (and the attendant insurance games to be played) now we turn to finish up this topic with a few areas of concern.

These remaining procedures / anatomical locations, are almost always purely cosmetic, and therefore NOT covered by insurance.  Of the three - Breasts, Thighs, and Upper Arms-  on occasion, Breast work may be covered by a patient's insurance carrier.  Let's start there.

Breast recontouring is very often highly desired after massive weight loss.  While the abdominal area is almost universally effected by massive weight loss, the breasts (for females) are a close second, and a close second as well in their list of potential body image issues after surgery.

Depending on the degree of weight loss, and on the degree (or lack thereof-) of breast / glandular tissue in an individual patient's breasts, very significant ptosis often occurs with massive weight loss. This often creates a cosmetic concern for a patient, but can also lead to functional issues of intertrigo, rashes, and having challenges with finding a special bra that can fit their new shape and size comfortably.

On the occasion where breast size remains large, and is associated disproportionately with the rest of the upper body habitus, and also in the setting of supportive signs and symptoms of back pain and shoulder divots, I have heard of an occiasional case here and there that may be covered.  The procedure performed is usually a bilateral reductive mammoplasty or mastopexy, and/or may involve implants if needed (which may not be covered).

As far as the upper arms (Brachioplasty) and the thighs (Thigh lift), these are somewhat lesser desired, as some but not all patients have significant issues in these anatomical areas post op. Both are always cosmetic cases and not covered by insurance, but may be an individual patient's main concern and they may be willing to pay for it out of their pocket or on a payment plan set up with the Plastic Surgeon.

Both procedures involve taking a triangle of excess skin off along the long axis of the extremity, with the apex situated distally.  Patients are often willing to 'trade a scar' for the benefit of "tightening up" of the skin in those areas, but the scarring can be at least moderate at times, yet is confined to the inner portion of the arms and the legs, and fairly easy to conceal. Most are very happy with their results.

Of additional note, for Plastic Surgeons that have an interest in the area of body recontouring after massive weight loss, and most these days do, patients and their surgeons can negotiate to an extent on prices and procedures that aren't covered by insurance, or mix and match procedures to fit the desired services and a patients financial status.  The surgeries can be done at one time, or over a couple of procedures, sometimes in an office setting or in the hospital. It pays to have a few Plastic Surgeons in whom you trust their work and their personality / relatability to your patients, to refer your patients to.

I have attached a link to the American Society of Plastic Surgeons for a nice Before and After gallery of recontouring procedures for you to see.

Patients often feel their weight loss mission is well on their way to 'completed' once they lose their weight, keep it off for a year or two, and have some of their 'excess skin' removed to improve their self image. They often feel that by having their body recontouring done, it can put them on a fresh start to their new life mentally and physically.

I do want to say though, taking in to account this Blog post and the previous one as well, most patients do not have recontouring surgery done after weight loss.

Most are not that concerned afterward, or are willing to have some mild to moderate body / skin issues as a trade off for their substantialy improved new health, new abilities, reduced medicines, and toleration of ADL's and beyond.

Those post op patients that do not have surgery easily represents the majority of the patients I see... but for those who have skin and anatomical needs after surgery, there is hope out there, you just need to know where and how to find it!

"What can I do about all this extra skin?" A Body Recontouring Primer

Just returned from a nice and warm week to Florida to catch some Spring Training baseball and some Vitamin D and Vitamin C (as in Citrus).  Great week.

Got to thinking about the next topic for this Blog. When I thought of writing on excess skin removal, and body recontouring, I had to look back to see if I had already covered it.  Looks like  really haven't thus far, and yet it's one of those often recurring questions we get from both patients and providers alike, and a great post-op topic to get into.

As I said, one of the most common questions / concerns patients have at sometime along their massive weight loss journey is again in regard to body image.  It may have been at least somewhat of a psychological issue pre op, and now paradoxically can resurface post op in a different light.

Massive weight loss resulting from bariatric surgery can be both exciting and anxiety producing. While patients are essentially universally pleased with their resultant weight loss, new problems of sagging skin, or markedly absent regions of their previous anatomy ("...where did my butt and breasts go?") do get them on edge and frustrated.  Most I see do admit, though, that they would generally trade the weight loss and its attendant health benefits for their new found body makeup and shape.

So, what is there that can be done?  This is well within the domain of the Plastic Surgeon, and the increasingly popular field of Body Recontouring after massive weight loss, usually associated with weight loss surgery.

As may be expected, and it can be argued that it truly is a medical problem, and it results from a procedure that was medically necessary (and approved by the insurance company), playing the "excess skin insurance game" to see what can be covered is a fairly complicated process.  It certainly is not automatic. Much less complicated are the excellent results that patients obtain after the surgery, whether they self-pay or are able to have it covered by their insurance company. Let's see if I can cover this in a way to at least let you in on the process, so you are aware what we and the patient often goes through, and may need from us (you and me) on their way to have their plastic surgery done.

The most common desire our patients have after successful weight loss surgery has to do with their abdominal pannus, or panniculus.  This redundant drape of skin is the result of the 'overstretching' of the abdominal wall skin from prolonged obesity and increased sub cutaneous tissue.  Their may or may not be associated striae, as is seen post pregnancy, and the extent of the excess skin may further extend posteriorly, bilaterally, around to the flanks, depending on the amount of weight lost, as well as the degree of skin elasticity and compliance.  It is well known that persons of color do tend to have better collagen and elasticity, and may show comparatively less redundancy and disfigurement after massive weight loss.  Age is also inversely proportional to elasticity and compliance of the skin, and certainly smoking as well as other disease states and medicines can accelerate skin changes negatively systemically with associated massive weight loss.

In broad terms, a Panniculectomy may be covered by insurance, whereas an Abdomioplasty (Panniculectomy with muscular / fascial tightenting, possibly with some Liposuction for added contouring) is essentially never covered.

The good side of the issue is that if insurance covers it, that's great.  It is a mostly functional procedure, and will go a long way to get rid of the associated recurrent skin fold rash (intertrigo, bacterial +/- fungal), and the cosmetic issues of what to do with the bunch of skin near the belt line that is difficult to hide.  Patients say that the extra abdominal skin acts as a constant reminder of the patient's previous body habitus that they frustratingly still cannot change. Patients are usually very happy with their results, and for the most part tell me, "I'm not looking to get into a bikini at the beach, I just can't get rid of this big wad of extra skin". The weight from the extra skin can go 7-15# or more  depending on the amount that is resected, and whether or not a circumferential (Belt Lipectomy) approach is necessary.

The down side to the insurance issue is that it frequently is not covered by the patient's insurance carrier.

This often stems from their view that the procedure is essentially a cosmetic procedure, and not medically necessary.  Each insurance company has a slightly different view, and it's often difficult from our side of the equation to know how to best play the game in order to try and get it approved. We rely on the Plastic Surgeons and their staff to guide the patient through this as able.  Often at an initial consult, based on the exam, the history, and the known quirks of an individual patient's insurance company, a Plastic Surgeon may advise the patient outright that it won't be covered.

Other instances may require more information and documentation to get it covered.  Usually, the patient must be 15-18 months plus post surgery, in order to be at or near their reasonable goal weight, and demonstrating both weight stability as well as sound nutrition and normal lab work and nutritional parameters (protein, CBC, vitamin levels, Fe, etc.).  They must also be  non-smoking, as this semi-cosmetic procedure is elective, and concomitant smoking greatly increases the risk of unwanted wound complications and healing issues, as well as increasedpulmonary and DVT risks.

The documentation required is often a retrospective look the weight loss history, abdominal skin fold rashes, their treatments, and their recurrences.  This can be from a PCP and/or us at the bariatric surgery office.  As is often the case, the more documentation the better.

We have also found that sending our patients to different Plastic Surgeons in our area can yield different results.  Some Plastic Surgeons participate more easily with certain insurance types, and some honestly have more of an interest in doing the legwork to get the patient to surgery and get the procedure done than others do.  I can understand that the process with some patient's insurance companies is cumbersome, and can demand a lot of effort.   And then the aspect that the extra effort is for a case that may not pay very well, and take their time away from cosmetic specialty cases that may be reimbursed at a better rate for less burden on the staff.  This may just not be a desirable trade off for a busy Plastics practice.

However, as far as the patient goes, a brief investment of time on our part (or yours) to document some needed history for the patient, and get it to the insurance company in an effort to get a panniculectomy reimbursed, they are very appreciative.

So, for part 2 a little more about body recontouring in respect to Breasts, Axillae, and Thighs to complete the primer.

"It's in the Bone!!" (The New Union of Weight Loss Surgery and Orthopedic Surgery)

From Marnaynay.tumblr.com

Jim Carrey is a goof.

I'm an opportunistic fan of his- if I come across a viewing of one of his movies, I will watch and render a few laughs, sometimes a chuckle, sometimes unrestrained, and other times I can laugh and push the limits of continence (notable coming from a male).  There can be long expanses in his productions that it seems I am just waiting for the next laugh, other instances that i am in comedic rapture. Just my opinion-

So, why the reference? One scene I remember from Ace Ventura When Nature Calls, is the fight scene. Ace as the "White Devil", is a target for the Woochachu (phonetic spelling) Warrior that throws a spear and it hits its mark, in Carrey's leg.  Then another direct hit, in the other leg. The motion he makes as he emphasizes the arrows in his leg always makes me roll, and then he goes one step further, as if it's necessary, to explain why it is so painful..."It's in the Bone!!" and dances around holding each of the arrows to try and relieve the pain.

If you saw the movie, I am sure you remember the scene.  If not, sorry; guess you had to be there.
Lastly still, maybe you were there and didn't find it funny (like my wife, if I remember correctly), and then I just offer condolences for wasting so much of your time getting to topic....


Orthopedics and Bariatric Surgery - A New Union?

Total joint replacements of the weight bearing joints are on the rise, both in number and on younger patients than ever. Up a reported 165% in the past two years, according to JAMA.

The main reason for the procedures, of course, is pain and limited ROM.  And, with the obesity epidemic we are experiencing, irreversible degenerative joint disease is a direct byproduct of that environmental condition.

A interesting study was done recently in Canada that followed 125 obese knee replacement-candidates, who had to lose 10% of their body weight before they had surgery.  In the yet to be published study, about half of the patients dropped out of the study, and opted not to have their total joint surgery as they were symptomatically much better off.

It is known that six to eight times your body weight is borne through the knee, so for every 10 pounds lost, roughly 60-80 pounds less pressure is experienced situationally and therefore additively diminished over time. Obviously if the DJD is present / advanced enough, the Xray won't change, but the symptoms likely will.  And still further, without significant weight loss that may come from surgical or medical means, destructive joint forces continue to increase over time, with resultant progressive increase in pain and immobility. The boney changes to the joint are not reversible, and the cartilage is a finite entity as a cushion in the joint- once it's gone it's gone. No way to replace that.

In effect, weight loss is weight loss, as far as the joints are concerned, and the quicker it comes off - maybe even just 10% to start to make a demonstrable difference- as well as the more significantly it comes off, and stays off, the better for the skeletal system.

I have seen numerous patients in the office over the past few years that have had bariatric surgery, or are in process to have it, who have in essence been referred by their orthopedic surgeon as a safer / expedient way to get to their total joint replacement to treat their irreversible and very symptomatic DJD.

The benefits of substantial weight loss before total joint surgery are multiple: safer for the patient, less post op complications, easier airway management, better wound management, easier PT / Rehab post-surgery, reduced risk of DVT, and less risk of hardware needing to be replaced prematurely. This is my own and likely partial list, mostly common-sense, but not taken from any specific study.

The downside? Maybe less surgeries for our local orthopedists, but I think they would all agree that total joint surgery is a good surgery if necessary, but avoiding or postponing it in a patient with obesity is quite uniformly a good thing.