CINDY SANDERS

Sheila Allen, a registered nurse for Baptist Hospital bariatric surgeon Dr. Albert T. Spaw, discusses the access port of the Lap-Band with patient Jay White, who has lost 150 pounds since his bariatric surgery.

With approximately two-thirds of the adult American population classified as overweight or obese, more physicians have begun routinely addressing the topics of diet and exercise.

For the morbidly obese, however, simply eating healthier and moving more might not be a realistic solution to their weight problem. Bariatric healthcare professionals widely cite a 95-98 percent failure rate of sustained weight loss in the obese population at the 5-year mark using only diet, exercise, behavior modification and anti-obesity drugs.

“Once you hit that morbidly obese category, it is much more difficult to achieve a healthy weight and to maintain that without surgical intervention,” stated registered nurse Pam Davis, bariatric clinical manager for the Centennial Center for the Treatment of Obesity.

Dr. Albert T. Spaw, co-medical director for the Metabolic Surgery Center at Baptist Hospital, noted his patients have become diet experts long before they undergo weight loss surgery.

“They know all about the diet industry, and they understand diets do not work for them,” he said, adding the paradox in the American approach to achieving a healthy weight is that dieting actually causes additional weight gain in the long run.

That isn’t to say balanced nutrition and exercise aren’t key elements of long-term weight reduction and maintenance, but both Spaw and Davis noted that a surgical intervention is necessary to begin the process for most of their patients.

“Surgery is not a ‘get out of diet and exercise jail free’ card,” Davis said. “It is a tool to allow diet and exercise to work for you.”

She is well aware of the hard work that goes along with surgery. Davis underwent laparoscopic gastric bypass more than six years ago and has maintained a healthy weight.

“I’ve lost 160 pounds, and I also lost my high blood pressure and my reflux,” she said, with a laugh. “I feel better at 42 than I did at 22.”

Davis added that she believes her personal experience is important to patients who are at wit’s end and frustrated with their current condition.

“It’s commonly said that obesity is the last socially-accepted form of discrimination, and I wholeheartedly believe that is true,” she noted.

“I think it helps tremendously for patients to talk to someone who has been there and done that,” Davis continued, adding that seven staff members at the Centennial Center for the Treatment of Obesity have undergone bariatric surgery.

Spaw pointed out that weight loss surgery is different from most surgical procedures in that it is primarily patient driven. He added that a diagnosis of a co-morbid medical condition such as hypertension or diabetes is often the tipping point to encourage someone to take action.

By the time patients arrive on the doorstep of a bariatric center, they have typically already decided which surgical option would work best for them.

“These are well-informed patients who are highly intelligent and very careful about the choices they make,” Spaw said. “You can’t find a better patient than one who is motivated and who has done their homework.”

Both Spaw and Davis said the major surgical procedures could all achieve good results but work in different manners and require different lifestyle modifications, which is generally why surgeons agree to the procedure selected by patients unless there is a medical contraindication.

“The philosophy of our practice has really been that patients do better when they choose their own procedures,” said Spaw. “They know their own eating habits better than anyone.”

There are a number of requirements a patient must meet before surgery becomes a realistic option. Generally, a surgical candidate must have a body mass index of 40 or greater or a BMI of 35-39 with a co-morbid health condition such as hypertension or diabetes. Patients generally fall in an age range of 18-65, but Davis said that surgeons would look outside the range on a case-by-case basis. Insurance companies also have very specific criteria, which vary widely by company, which a patient must meet prior to gaining approval for surgery.

Laparoscopic adjustable gastric band-commonly called the Lap-Band® - is newer, less invasive, has fewer complications and is reversible, noted Spaw. “The strategy for the Lap-Band is purely restrictive,” he explained, adding there is no malabsorption associated with this procedure. The surgeon inserts an inflatable band around the uppermost part of the stomach, which limits solid food intake. “For the person who overeats, he will get an unpleasant regurgitation of the last bite,” Spaw noted of the behavior modification mechanism. “It is very successful,” he continued of the results. “The weight loss is slower than with the other two procedures and continues gradually for up to two-and-a-half years.”

Roux-en-Y Gastric Bypass, which is both restrictive and malabsorptive in nature, is considered the “gold standard” and has been available for several decades. In this procedure, the surgeon creates a small, one-ounce pouch from the original stomach and then connects the detached stomach pouch to a segment of intestine. “So the stomach is bypassed; the big stomach is now a cul-de-sac. There’s no traffic,” explained Spaw. He added that while the pouch remains the same, surgeons can manipulate the amount of malabsorption by the placement of the reconnection to the intestine-the lower the connection, the greater the degree of malabsorption. Spaw noted that with gastric bypass, patients seem to lose their appetite for several months following the surgery and generally have a very precipitous weight loss in the first six months. However, weight typically begins to level off by 18 months post surgery and patients will have some weight regain.

Duodenal Switch is the most aggressive of the procedures performed at Baptist and is the most physically altering. There is minimal restriction with this procedure but maximum malabsorption. A surgeon removes approximately 75 percent of the stomach and bypasses about 60 percent of the intestine. “Because it’s more aggressive, we tend to offer it to our biggest patients,” Spaw said. “It’s a bigger hammer in your tool box so you want to use it carefully on the right nail.” He added that there is greater risk with this procedure because there is more alteration to the GI tract. However, it also tends to have the greatest percentage of excess weight loss and a highly sustainable rate of loss 10 years out from surgery.

Sleeve Gastrectomy is a new procedure Centennial will soon offer to complement Lap-Band and gastric bypass. Considered the first step if a duodenal switch was to be done in two steps, the surgeon removes approximately 60 percent of the lower portion of the stomach causing it to look like a sleeve but doesn’t bypass the intestine. Therefore, Davis explained, this new option is completely restrictive like banding and leaves a larger stomach pouch than gastric bypass. “I think sleeve gastrectomy might be a good option for someone who is worried about malabsorption but who doesn’t want to have a foreign body placed (like a band),” she noted.

No matter which procedure is ultimately chosen, surgery is only a small part of a patient’s transformation. Those who undergo surgery become patients for life.

“We never discharge them,” Spaw said.

He and Davis both added that bariatric patients are monitored for nutritional deficiencies, supported during difficult times and counseled on lifestyle changes and maintenance routines.

“It’s more than just weight,” Spaw said. “There’s an emotional element. Food is addictive, and I think that’s an area that we don’t understand as well. A lot of people go through depression afterward because they had a relationship with food they didn’t realize. It’s like taking alcohol away from an alcoholic … it’s tough.”

To maximize success, Davis said Centennial really encourages patients to involve their primary care physician in the process.

“We need to be working together to decrease medications as appropriate. It does help if everybody is on board and working toward the same goal,” she stated.

Despite the peaks and valleys, Spaw said working with bariatric patients is extremely gratifying. “It’s changing lives in a very, real way. The more I do it, the more I realize it’s a spiritual transformation as well as a physical transformation.”



Caption: Sheila Allen, a registered nurse for Baptist Hospital bariatric surgeon Dr. Albert T. Spaw, discusses the access port of the Lap-Band, which is placed underneath the skin and allows physicians to adjust the band size, with patient Jay White, who has lost 150 pounds since his bariatric surgery.


January 2008