Center for Metabolic and Bariatric Surgery<br>New Patient Information Session

Center for Metabolic and Bariatric Surgery
New Patient Information Session

Dr. Scott Shikora, Director at the Brigham and Women's Center for Metabolic and Bariatric Surgery, alongside, Laura Andromalos, Bariatric Nutrition Coordinator, and Kellene A. Isom, Program Director, discuss the important first steps for new weight loss surgery patients. 

By watching this video you will complete the first step in getting started at our center. We will discuss the risks and benefits of surgery, the lifestyle and behavior changes necessary for successful outcomes after surgery, as well as discuss the finance and insurance requirements associated with bariatric surgery.

At the end of the video, click the Next Step button to fill out your contact information. You will then be asked to complete a quiz about the information discussed in the video. If you pass the quiz, you will receive a certificate of completion. If you are already a registered patient, you can contact our New Patient Coordinator to schedule your appointments at (617) 732-6960. If you need to register as a new patient, please call 855-278-8009.

Thank you for your interest in our program.

Scott Shikora, MD
Director, Brigham and Women’s Center for Metabolic and Bariatric Surgery

Neil Ghushe, MD
Malcolm Robinson, MD
Eric Sheu, MD
David Spector, MD
Ali Tavakkoli, MD
Ashley Vernon, MD

 

Transcript:

Congratulations on Taking Your First Step!

Hello! I’m Dr. Scott Shikora and I’m the Director of the Center for Metabolic and Bariatric Surgery at Brigham and Women’s Hospital. Over the next hour or so, I and my colleagues will review the general information necessary to determine whether you want to go forward with bariatric surgery.

Today on our agenda, we will cover a number of topics. We’re going to introduce our program to you. We’re going to discuss the different surgical options available. You’re going to hear from one of our dietitians about the dietary changes that will be necessary both before and after surgery. You’ll hear a little bit about the insurance and financial issues related to bariatric surgery. And then next steps: How do you get started?

First of all, let me congratulate you. You’ve made a great decision in coming to Brigham and Women’s Hospital. Why our program? We’re one of the most experienced programs in the region. Our surgical team and staff have been involved with this for many years and have performed thousands of operations. We are accredited with the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program of the American College of Surgeons. And to maintain this standard of excellence, our program offers dedicated operating rooms for our bariatric patients, dedicated units in the hospital for our bariatric patients after surgery, we have a dedicated nursing staff, and our inpatient dietitians are without equal. We also have specialized equipment, so that we can perform bariatric surgery as safely as humanly possible with the best results.

Our Team

Our team consists of 6 surgeons. I am the director of the program. We have a program director, Kellene Isom, a number of dietitians, 2 behavioral therapists, and 3 physician assistants who function as the glue of our program. You’ll get to meet them and work with them in the clinic. We have a New Patient Coordinator, a Financial Coordinator, and a Database Coordinator. As you can see, we are a large team dedicated to doing bariatric surgery as best as it can be performed.

Benefits

What are the benefits of these operations? Traditionally, it was for weight loss. People wanted to look better in their bathing suits or their clothing. But there are actually many more important reasons we do these procedures. They improve health. Conditions such as type 2 diabetes, hypertension, sleep apnea, heartburn, skin problems, asthma, etc. get better, and in many cases, go into remission. These operations improve quality of life because people look better, feel better, and are healthier. And, if someone has a lot of medical problems that improve, they will likely live longer. That’s why we do these operations.

The "Truths of Surgery"

I’m going to start off with what I like to call “The Truths of Surgery”. These surgeries are not miracles; they are tools. They are not for everyone. Some people listening to this might determine that this isn’t right for them, and that’s fine. It’s important to know before they go into surgery whether they think it should be right for them or not. These surgeries, like all surgeries, have risks, and we won’t sugarcoat what they are. We will explain to the patient what each and every associated risk is when they come to see us in the clinic. Now, it’s important to know that surgery is not a cure for obesity. Obesity is a very complicated disorder. It’s genetics, it’s environment, it’s social, and a host of other factors. These surgeries are treatments. If you take pills for your high blood pressure every day, your blood pressure will likely be normal; but if you stop taking your pills, your blood pressure will go back up because you have a condition called hypertension or high blood pressure. Well, obesity is the same way. These operations can treat the disease of obesity, but can’t cure it. If these operations were ever reversed, or dilated or broken down by the patient’s poor eating habits, one can anticipate the weight to go back up. And another truth of surgery is that the surgery alone is not sufficient. Lifelong follow-up in the program and long-term effort by the patient is essential for a good result.

Qualifying for Metabolic and Bariatric Surgery

How does one qualify for surgery? In 1991, the National Institute of Health developed the regulations we still use today for determining who’s a candidate for surgery. We go by something called the body mass index (BMI). You don’t need to know the formula for BMI, you just need to go on the internet and Google “body mass index”, or go on the Brigham and Women’s website, and you’ll see a chart that has weight across the top, and height down the side. You’ll look at your weight and your height, and bring them together on the chart, and the number that is at the intersection of the two is your body mass index. To qualify for bariatric surgery, your BMI has to be 40 or greater, which is roughly 100 pounds overweight. If you have health conditions, you can qualify if your BMI is greater than 35, which is approximately 80 pounds overweight. Once again, look at the table, match up the column and row for your height and weight, and the number you see will be your body mass index.

On occasion, a patient may not qualify for bariatric surgery. What are the reasons for this? As we just talked about, your BMI has to be at least 35, or possibly 40. If your BMI is below 35, say 32 or 33, even if you really want it, and have health issues, you can’t qualify for surgery in the current environment. There are also patients who won’t meet insurance requirements. After I’m done, Kellene Isom will go over some of the insurance issues to make that clearer for you to understand. Patients who are noncompliant with the program requirements may not qualify. We ask patients to sometimes lose a little weight in preparation for surgery. Patients who don’t lose that weight or gain weight may be disqualified from surgery. Patients who smoke, abuse alcohol or recreational drugs, miss appointments, or for that matter, any behavior deemed inappropriate for surgery may make that patient unqualified to go forward with surgery.

How Can I Be Successful?

These operations are complex, and the condition is complex. What are the 3 simple rules for success? 1, that the patient has a comprehensive preoperative assessment and preparation. That’s our responsibility, and I think that’s what we do best. It will be over numerous visits with many different physicians and other clinicians. This includes consults as needed to make the operations as safe as possible by fully understanding the health of the patient and how to make it as good as possible to reduce the operative risks. In addition, behavioral and dietary changes are necessary to get the best results from the operation long-term. It also requires sacrifice. Patients have to change their lifestyles. We hope for the better, but they can’t go on living the life they were living before; the bad eating habits, the lack of exercise, and even with a good operation, expect a good result. And lastly, they have to buy into the concept of lifelong follow-up with us. That will maximize the weight loss, reduce the likelihood of complications, reduce the likelihood of weight regain, and as we would say, “nip the problems in the bud.” We want our patients to be proactive with their care and their long-term success, instead of reactive.

A commonly asked question is, “how long will it take from this point to my surgery?” And that’s a very understandable question. Patients who come to see us are unhappy. Their joints hurt, they can’t breathe, they’re taking insulin or other medications for health issues, they don’t feel good in their own body, and they finally make the decision to have surgery and they want to have it right away. But the time will vary from one patient to the next, so we really can’t put a timeframe on it. Sometimes there are insurance requirements, which again, you’ll hear more about later. Sometimes, it’s surgeon requirements; we may need a patient to see a cardiologist, or have an upper GI or an endoscopy prior to surgery. We may ask patients to lose some weight prior to surgery, and we would likely wait for them to achieve that before scheduling them. And there might be behavioral issues that are picked up by our behavioral therapists who want to work with the patients to get them as fine-tuned as possible before surgery.

Risks

These operations are abdominal operations, and when we talk about the risks of them, firstly, we should mention what would be the risks of any abdominal operation, not just the gastric bypass or a sleeve or a band, but what would be the complication of a gallbladder operation or hysterectomy. So, there are going to be some common complications that I’m going to discuss first, and then we’ll talk about the complications more unique to these procedures.

First of all, any time a patient has surgery on their belly or abdominal cavity, there’s always a risk of bleeding or hemorrhage, blood clots forming in the legs which can break up and go into the lungs, there’s a risk that any organ in the abdomen can be damaged by surgery, that there could be leakage from the stomach or intestines, that a patient can develop infections, whether it be pneumonia, a urine infection, a wound infection, etc. A patient can have a heart attack or a stroke, or most rarely, but most seriously, patients can die.

Types of Surgical Procedures

The simplest and least effective operation we perform is the laparoscopic adjustable gastric band. It is a silicone rubber belt that we place around the top of the stomach and buckle, thereby choking the stomach with the band. The little bit of stomach above the band, we call the pouch. It is essentially the new working stomach and is about a half of an ounce in size – very small. The stomach below the band is untouched by the procedure, as are the intestines, so the only way this operation works for weight loss is by reducing how much food one can eat in a given sitting, because it is a little pouch and the food sits there and slowly goes through the band, like sand into an hourglass. The band is adjustable in the office, because it is connected to a hollow tube with a metal disk. By injecting saline, into the disk, the band can be inflated or deflated like a balloon, to tighten it, or by removing fluid, reducing the choke to make it a bit looser. The idea is wonderful, and the band was extremely popular around 10 years ago, coming close to being the most common operation performed. Unfortunately, over time, the results of the band have showed themselves to be less than satisfactory, and at this time, very few bands are being placed. In fact, many people who had bands placed in the past are having them removed.

On the other end of the spectrum is the gastric bypass. The gastric bypass is a much more complex operation that is extremely complex at the time of surgery, but is extremely effective for both weight loss and improvements in health and well-being. With the gastric bypass, we cut a small stomach chamber off of the main body of the stomach, not much bigger than the little pouch we make with the band. The difference is that it’s actually cut off the body of the stomach, not made smaller by a belt. That pouch, with the gastric bypass, is approximately 1 ounce. We then take the intestine and connect it directly to that little pouch, so that the food comes from the food tube, or the esophagus, into the pouch and directly into the intestine, skipping, or bypassing the body of the stomach and the very beginning of the intestine. That is the gastric bypass, which is the most effective weight loss operation performed throughout the world.

Between the two is a compromise, called the sleeve gastrectomy. This operation right now is extremely popular and well-liked by the patients that have it. In this operation, we free up the outer edge of the stomach and remove it. What we leave behind is a stomach shaped like a tube, or a “sleeve”, and we remove about 75% of the stomach. We do not do anything with the intestine and we don’t rely on a band to reduce intake. The sleeve is much safer than the bypass, which is very attractive to patients, and gives us results almost as good as the bypass. It seems to be a compromise between the safety and the simplicity of the band, with the results of the gastric bypass.

Talking more about the band, it’s a silicone belt that goes around the stomach, but the problem with it now is that about 20% of patients will not lose any weight and another 20% will have inadequate weight loss. Nearly half the people who have the band do poorly, and for that reason, it’s become less and less popular worldwide, so very few are actually placed these days.

Even though the band is totally safe, there are complications that we can see from it: the band can tilt or slip or prolapse, and that occurs 3-4% of the time. What happens is the angle of the band as it sits on top of the stomach changes, thereby causing the stomach to be blocked or heartburn to occur. If that’s the case, we can improve it by removing fluid from the band and letting it settle, but very often we have to go back surgically and readjust the band or remove it. The band can also erode into the stomach occurring 2-3% of the time, where over time, the band starts to work its way into the wall of the stomach where part of the band is actually inside the stomach. If that’s the case, the band must be removed and the stomach repaired. Band patients can suffer from heartburn or vomiting or food getting stuck, particularly if the band is too tight. What’s the secret for people who have the band to do well? They have to come in early and often to have the band adjusted to get the tightness just right on the stomach, and most importantly, they have to limit their intake of sweets, junk food, juices, soda, alcohol, ice cream, and other forms of calorie-dense, mushy, liquid foods that, regardless of how the band is placed or tightened, will adversely affect weight loss. We would also like to get a periodic upper GI X-Ray in patients to assess how the band is positioned even in patients who have no symptoms because sometimes you may find a problem that hasn’t presented itself with symptoms yet, and “nipping it in the bud” is the best way to remedy it without having to ultimately remove the band.

The sleeve gastrectomy, as I have mentioned, is a very attractive operation for patients and is becoming one of the most popular operations done throughout the world because it has simplicity similar to the band and results similar to the bypass – patients can achieve 50 to 60 percent excess weight loss. The major complications we see are few; one would be leakage from that long seam that we make by removing the larger part of the stomach. That occurs anywhere from 0.4% in our program to about 2% nationally, and that could be a very serious problem – no less serious than the leak of a gastric bypass. The sleeve can also stricture, or narrow, where it’s not wide enough for food to pass through, and that will often require us to send a patient to the GI service to see if they can dilate it down the mouth with a scope. On occasion, that might have to be repaired surgically. Patients with sleeve gastrectomies can also have vitamin deficiencies. The death rate throughout the US is 1 in 1000, which is about the same as gallbladder surgery, and we’re very fortunate in our program to say we haven’t lost a patient yet.

The last thing to talk about is the gastric bypass. The gastric bypass has been around almost 50 years, and it’s been the preeminent gold standard for weight loss almost that whole time. Once again, we create a small stomach chamber by cutting the top of the stomach off of the rest of it, and then we connect it up to the intestine. There are a number of potential complications we can see with the bypass, but the actual incidence of any of these complications tends to be quite low. The most common complication is leakage, which is reported to be 0.5% to 1% nationally, but we’ve been fortunate to not have a leak in our program in any of our patients. We worry about strictures, or narrowing of the connection, that would have to be dilated if present; ulcers, which form at the connection, and we’ll talk more about ulcers later; and the death rate from the gastric bypass is about 2 out of 1000 nationally, and so far, 0 in our program. Weight loss is the best out of the operations, reported to be 60 to 70 percent of excess body weight.

I want to talk for a moment about ulcers with gastric bypass, because the ulcers are generally preventable. The ulcer occurs right at the connection of the little pouch to the intestine, and generally appears as a white plaque. There are many reasons why these ulcers may occur, but the most common include tobacco use, alcohol abuse, or the chronic use of non-steroidal anti-inflammatory drugs such as Motrin or Advil.

Patients who choose to have the gastric bypass must be smoke free, drink alcohol responsibly, and use NSAIDs as necessary. These ulcers can cause serious pain and vomiting, and in more serious circumstances, can lead to bleeding or even perforation.

There are times when patients who have these operations require another operation. They may require that the operation be revised, if there’s a problem with it. For example, a stricture at the connection of the pouch with a gastric bypass, or if a LAPBAND has slipped or prolapsed. They may need to be converted, for example, if a patient has the Band and the band is not functioning well for them, they may decide they want to have the band out and instead, have either a bypass or a sleeve, or on occasion, a reversal: removal of the band and not doing anything else, or taking a gastric bypass apart and putting it back together the way it was before surgery.

It’s important to understand that these operations are taken very seriously. The risks of these surgeries are often three times greater than the risks of the first operation, due to scar tissue and changes in blood supply that occur with surgery. What we often see is a patient who has been out of the program for a while, had one of the procedures, gained back some weight and comes in asking if he or she can have the operation revised to get him or her back on track with weight loss. We do a lot of these surgeries, but it must be understood that it’s on a case-by-case basis. There are people who put weight back on who don’t warrant or qualify for another operation – they may be best served by working with our dieticians and behavioral therapists. We will go case-by-case and determine with each patient whether there is a need or isn’t a need for revisional surgery, and often the indications are whether the anatomy has been disrupted in some way, if there were health problems related to the patient’s surgery, patient choice, or weight loss failure or weight regain.

From the Surgery and Beyond: What should the patient expect? Often for patients who have the bypass or sleeve, a urinary catheter is inserted into the urinary bladder at the time of surgery and kept in overnight. Urine output is a good marker of how one is doing, so it’s easy for us to look and see if the patient is doing well since having his or her surgery. The catheter is placed in while you’re asleep; you don’t feel it, and it’s taken out the next morning. Patients will have compression sleeves or air pockets on their legs that massage the legs and reduce the risk of blood clots. Patients will be given adequate pain medication, often narcotic pain medication, which is administered through something called the PCA – patient controlled analgesia, which will enter the patient through an IV and the patient will hit a button on the pump that will deliver the medication when they need it. This tends to be a much better system than waiting for the nurse to come into the room to give a shot. Some patients will have an abdominal drain for a day or two that will survey whether there’s any bleeding or leakage, which will be removed before the patient goes home.

How do we know when a patient is able to go home? We want the pain controlled. We don’t tell people they’ll be pain-free a day or two after surgery, but the pain should be well-managed and controlled particularly through oral pain medicine. The patient must be able to get out of bed, walk, urinate, and breathe comfortably. Most importantly, the patient must be able to consume enough fluid to stay hydrated.

After the hospital discharge, patient follow-up is straightforward. There’s a post-operative visit with the surgeon or PA 2-3 weeks after surgery, and then again at 6 weeks, and then quarterly thereafter for the first year. In the second year the patient will see the surgeon every 6 months and yearly thereafter. Band patients may require more frequent visits for band adjustments, and it goes without saying that if a patient’s next visit is in 6 months but the patient is having problems, we will always see them in the clinic. The follow-up visits with the dieticians will often mirror the follow-ups with the surgeon so that the patient doesn’t have to have twice as many trips to the hospital to make. We also highly recommend follow-up with our psychologist, and usually that’s 6 weeks and 6 months post-operatively. The psychologist sees patients individually as well as in groups, so each patient who sees the psychologist can be accommodated.

I would like to conclude the first part of this talk by saying that bariatric surgery can be and should be very rewarding and life changing for those candidates who have it. Good results require a comprehensive preoperative assessment and preparation, a good operation, and that a patient commits to lifestyle changes and long-term follow-up. If you have questions, bring them with you to the clinic and we’ll be happy to answer them for you. I am now going to turn this over to Laura Andromalos, who is our senior dietician.

Working with the Dietician

Hello, my name is Laura Andromalos and I’m the nutrition coordinator for the center, as well as one of the registered dieticians. I’m going to speak today to give you an overview of the types of appointments you’ll have with the dieticians and also to explain why the dietician team is so important to your success before and after surgery.

One of the great perks of our program is the lifetime nutrition membership. When you join our program, you will have unlimited nutrition appointments as part of your program fee. We don’t bill your insurance company for your nutrition appointments because most insurance companies don’t offer unlimited nutrition appointments, and we want you to have as many nutrition appointments as you need to be successful with surgery. Our dietician team is available by phone during office hours, and with online messaging through our Patient Gateway Program.

Let me tell you about the types of appointments you’ll have with the dietician team. Your first nutrition appointment will be a group nutrition class, where you’ll learn about the pre-op diet as well as the diet stages for after surgery. You’ll also learn about the types of lifestyle changes that you’ll need to make to be successful with surgery. After your class, you’ll come back for a one-on-one nutrition assessment. This is our chance to get to know about your lifestyle, and how it impacts your eating habits. We also want to make sure you understood everything from the nutrition class, and we’ll talk about the next steps to continue to prepare for surgery. Most patients have at least one more dietician appointment before surgery, but some patients might have several more, depending upon how much support they need to continue preparing for surgery. After surgery, you will follow-up with the dietician team forever. As Dr. Shikora mentioned, lifetime follow-up is extremely important for your success. We’ll see you about 5 times during the first year after surgery, and usually 2 times per year after that, but remember that you can have lifetime nutrition appointments as part of your nutrition membership.

As life goes on, events will come up that you’ll need to navigate, such as weddings, family reunions, holidays, etc. and we want to help you every step of the way to be successful with your surgery.

 

Many patients wonder what their eating habits will be after surgery. As Dr. Shikora mentioned, these surgeries impact your stomach in a drastic way, so it makes sense that your stomach will need some time to slowly heal as we reintroduce foods to your stomach. In the 8 weeks after surgery, you’ll transition from liquids, to soft, mushy textures, to regular textures. In the long term after surgery, we expect you to be able to eat a variety of foods, and will help you to plan meals based around lean proteins, fruits and vegetables, whole grains, and small amounts of healthy fats.

Everyone will take vitamins and minerals after surgery forever. With the gastric bypass and sleeve gastrectomy, your stomach may have some trouble absorbing some vitamins and minerals, and with all surgeries, you won’t be eating as much food as you used to. A multivitamin with calcium, iron, and Vitamin B12 will be your baseline supplements. If we find that you need other supplements based on your blood levels, we’ll add on as needed.

Lastly, exercise is extremely important before and after surgery. And it’s not just for weight loss – exercise is extremely important for your health and well-being – it helps your body to stay strong, it’s good for your heart and other muscles, and it’s great for your mood and energy levels as well. We do know that many of our patients have conditions that make exercise difficult, so we want to find a way to exercise that is safe and feels good to you. If you need any resources such as physical therapy, there are many great programs in the Partners system. The Brigham and Women’s/Mass General healthcare system and the Dedham healthcare complex offer great and affordable exercise programs for beginning exercisers. Our main goal is to find a way to exercise that you enjoy and will keep you moving for life.

I’m now going to introduce our program manager, Kellene Isom, who’s going to speak about the very important parts of our weight loss surgery approval process, such as insurance approval and the financial aspects of the program.

Insurance and Finance Information

Hello, my name is Kellene Isom, and I’m the program director for the Center for Metabolic and Bariatric Surgery. I appreciate you taking the time to hear about the services we offer. I’m going to talk about the insurance coverage for the surgeries we just discussed, and I’m also going to talk about how to get started in our program.

The first thing that a patient needs to do is contact their insurance company to make sure that bariatric surgery is a covered procedure and that our hospital is considered within network. If your insurance is through your employer, you can always ask for HR department for an exclusions list. If bariatric surgery is on this list, it is not a covered procedure. For the most part, it is covered by insurance, and the next step would be for you to contact your primary care office. When you contact your PCP, you’ll need to ask for a Letter of Medical Necessity – this is one of many documents that we send to your insurance company for prior authorization for bariatric surgery. You may need to get appointment with your PCP because you may need a physical in order to write this Letter, so you’ll want to give yourself plenty of time to do so. Some insurances will require that a patient has a referral in place – for example, an HMO would require a referral if a surgeon is a specialist. The next thing you’ll do is contact our patient service center. If you’re a new patient, they’ll assign you a medical record number, which will allow us to schedule you into our system. If you’re an existing patient, I still encourage you to contact the Patient Service Center so that they’ll be able to update your information. Lastly, you’ll call our New Patient Coordinator, who will schedule you for all of our core appointments.

Everyone will have the same core appointments: a surgical consult, an hour-long group nutrition class, an individual nutrition assessment and follow-up, and a psychology assessment. You should also contact your insurance’s mental health benefits to determine whether our psychologist is within your network. You may also have to schedule other appointments based on past medical history, your surgeon’s requirements, or insurance requirements. We do our best to schedule you for your appointments, but if you cancel and reschedule them, your surgery date may change.

Some insurance companies require that patients attend medically-supervised weight loss (POWL) prior to surgery. You may be required to attend monthly for 3-6 months. I recommend going earlier in the month because if you miss one, your insurance company will require that you start over. You don’t need to register; just walk in and we’ll get you set up. Some insurances require 6 months, 3 months, their own program that you need to set up on the phone or online, or no POWL at all.

We require that patients pay an out-of-pocket $550 administrative fee with a non-refundable $100 deposit at the first group nutrition class or the first POWL visit – whatever comes first. The remaining $450 is due 6 weeks later. This fee covers all services not covered by insurance that are required by an accredited bariatric surgery center, including access to unlimited dietician appointments, physician assistant telephone support, and educational materials.

To get you set up, you can contact our new patient coordinator to set up your appointments at (617) 732-6960. If you have any questions about our program fee or your insurance, you can contact our insurance and finance coordinator at (617) 732-6408. I also encourage you to visit our website at www.brighamandwomens.org/weightlosssurgery to access all of our educational materials and other resources.

Presenters

Scott A. Shikora, MDScott A. Shikora, MD

Kellene A. Isom, MS, RD, LDN Kellene A. Isom, MS, RD, LDN

Laura Andromalos, MS, RD, LDNLaura Andromalos, MS, RD, LDN


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