Tag Archives: Bariatric surgery

It’s not vanity and it’s not easy: NHS agrees

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As reported on Sky News and the New York Times, there has been a radical turn around regarding the use of bariatric surgery to prevent/ control and even “cure” diabetes.

vanity

Not a vanity procedure

Once relegated to the category of a” vanity” procedure, bariatric surgery has emerged as a legitimate,  life-saving intervention which has been scientifically proven to have multiple major health benefits.

For years, patients have had to jump numerous hurdles to be considered for this procedure.  One of the biggest hurdles was often that patients were not considered fat enough to qualify for this procedure.  The traditional guidelines restricted surgery to morbidly obese people, and then required these patients to perform numerous tasks to be considered eligible candidates of surgery such as attaining a diagnosis of “carbohydrate addiction” and losing weight prior to surgery as a sign of “commitment” to weight loss.  This was in addition to several months of therapy with nutritionists and counselors.

hoops

A punitive process

While including this ancillary education may have assisted patients post-operatively, it also felt punitive to people who were seeking medical help.  No one forces lung cancer patients to attend smoking cessation courses or counselling before having their cancer treatment nor do we require several sessions of pre-operative classes prior to a bowel resection.

No, not this kind of scale

New guidelines – perform surgery earlier (2012)

But as the data started to emerge that showed long-lasting health benefits of surgery-assisted weight loss, debates raged between International and American physicians.  Several years ago, several international organizations such as the International Diabetes Federation began to recommend lowering the eligibility criteria for bariatric surgery – particularly for patients with documented complications of obesity present (diabetes, coronary artery disease, severe orthopedic injuries).  But these recommendations were ignored by American medical societies and many physicians including the doctors responsible for initiating referrals to bariatric surgery programs.  Americans. it seemed were reserving the the more effective treatments (like gastric bypass or gastric sleeve) for the super-obese, and the prototypical 600 pound patients.

Obese patients who did not meet these rigid guidelines were often sent for less effective procedures like lap-band or balloon placement.  Insurance companies often denied payment stating that surgery in these patients were ‘not medically necessary’  and thus it was considered a ‘vanity’ procedure.  Additionally, in most cases, the procedures failed to produce meaningful or long-lasting results.

Adding stigma and shame to a medical condition

Patients who were overweight  and seeking definitive treatment were often made to feel “lazy” for being unable to lose weight without surgical assistance.  They were also told to return only if they continued to fail (or gain weight).

The Diabetes Pandemic

But as the obesity pandemic continued to escalate at breakneck speed along with obesity-related complications (and healthcare costs skyrocketed), the evidence began to become too overwhelming to ignore.

New guidelines were passed for eligibility criteria for gastric bypass procedures.  These guidelines reduced the necessary BMI to qualify for surgery, especially in patients with co-morbidities such as diabetes.  But it still ignored a large segment of people; non-morbidly overweight people with early diabetes – the very group that was most likely to have a high rate of success and immediate normalization of blood sugars*.

But now the government of the United Kingdom and the National Health Service (NHS) have adopted some of the most progressive recommendations world-wide; aimed at stemming the tide of diabetes and diabetes-related complications such as heart attacks, strokes, renal failure, non-alcoholic fatty liver disease (NASH) and limb ischemia leading to amputation.

The NHS should be commended for their early adoption of eligibility criteria that lowers the BMI requirement to 30 in diabetic individuals and eliminates this requirement entirely in diabetes of Asian descent**. Conservative estimates believe that this change will make an additional one million British citizens eligible for bariatric surgery.

* As a ‘cure’ for diabetes, gastric bypass is most successful in people who have had the disease for less than eight years.

Surge of patients but few surgeries

But can supply keep up with demand?  Last year, according to the our source article (NYT), only 9,000 bariatric procedures were performed in the UK.

**Diabetics of Asian and East Indian  heritage (India, Bangladesh, Pakistan) often develop a more severe, aggressive, rapidly progressive form of diabetes which is independent of BMI or obesity.

More from the Diabetes & Bariatric Archive:

Life after bariatric surgery

Bariatric surgery and the family

Bariatric surgery and CV risk reduction

The Diabetes Pandemic

Part II

Diabetes as a surgical disease

Gastric bypass as a cure for diabetes

Start here…

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This is a page re-post to help some of my new readers become familiarized with Latin American Surgery.com – who I am, and what the website is about..

As my long-time readers know, the site just keeps growing and growing.  Now that we have merged with one of our sister sites, it’s becoming more and more complicated for first time readers to find what they are looking for..

So, start here, for a brief map of the site.  Think of it as Cliff Notes for Latin American surgery. com

Who am I/ what do I do/ and who pays for it

Let’s get down to brass tacks as they say .. Who am I and why should you bother reading another word..

I believe in full disclosure, so here’s my CV.

I think it’s important that this includes financial disclosure. (I am self-funded).

I’m not famous, and that’s a good thing.

Of course, I also think readers should know why I have embarked on this endeavor, which has taken me to Mexico, Colombia, Chile, Bolivia and continues to fuel much of my life.

Reasons to write about medical tourism: a cautionary tale

I also write a bit about my daily life, so that you can get to know me, and because I love to write about everything I see and experience whether surgery-related or the joys of Bogotá on a Sunday afternoon.

What I do and what I write about

I interview doctors to learn more about them.

Some of this is for patient safety: (Is he/she really a doctor?  What training do they have?)

Much of it is professional curiosity/ interest: (Tell me more about this technique you pioneered? / Tell me more about how you get such fantastic results?  or just tell me more about what you do?)

Then I follow them to the operating room to make sure EVERYTHING is the way it is supposed to be.  Is the facility clean?  Does the equipment work?  Is there appropriate personnel?  Do the follow ‘standard operating procedure’ according to international regulations and standards for operating room safety, prevention of infection and  overall good patient care?

I talk about checklists – a lot..

The surgical apgar score

I look at the quality of anesthesia – and apply standardized measures to evaluate it.

Why quality of anesthesia matters

Are your doctors distracted?

Medical information

I also write about new technologies, and treatments as well as emerging research.  There is some patient education on common health conditions (primarily cardiothoracic and diabetes since that’s my background).  Sometimes I talk about the ethics of medicine as well.  I believe strongly in honesty, integrity and transparency and I think these are important values for anyone in healthcare.  I don’t interview or encourage transplant tourism because I think it is intrinsically morally and ethically wrong.  You don’t have to agree, but you won’t find information about how to find a black market kidney here on my site.

What about hospital scores, you ask.. Just look here – or in the quality measures section.

Cultural Content

I also write about the culture, cuisine and the people in the locations I visit.  These posts tend to be more informal, but I think it’s important for people to get to know these parts of Latin America too.  It’s not just the doctors and the hospitals – but a different city, country and culture than many of my readers are used to.

Why should you read this?  well, that’s up to you.. But mainly, because I want you to know that there is someone out there who is doing their best – little by little to try to look out for you.

How the site is organized

See the sidebar! Check the drop-down box.

Information about surgeons is divided into specialty and by location.  So you can look in plastic surgery, or you can jump to the country of interest.  Some of the listings are very brief – when I am working on a book – I just blog about who I saw and where I was, because the in-depth material is covered in the book.

information about countries can be found under country tabs including cultural posts.

Issues and discussions about the medical tourism industry, medical safety and quality are under quality measures

Topics of particular interest like HIPEC have their own section.

I’ve tried to cross-reference as much as possible to make information easy to find.

If you have suggestions, questions or comments, you are always welcome to contact me at k.eckland@gmail.com or by leaving a comment, but please, please – no hate mail or spam.  (Not sure which is worse.)

and yes – I type fast, and often when I am tired so sometimes you will find grammatical errors, typos and misspelled words (despite spell-check) but bear with me.  The information is still correct..

Thank you for coming.

Anthony Bourdain does Colombia

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It’s not his first visit – he’s done several other programs highlighting Colombia, but tonight’s episode on his new CNN show, “Parts Unknown” is definitely his best.  It’s the first time I think  he actually ‘got it’ and was really able to convey a real sense of Colombia to his viewers.

While his previous shows were primarily about food, and local food culture – his episodes on Colombian cuisine were always very wide from the mark..  Sure, he had the names of dishes and such – but he didn’t really bring home the feel of Colombia and it’s people.

http://www.youtube.com/watch?v=qNiF0R1QJpk&feature=share&list=SP6XRrncXkMaVZxpButSnMywWvtINMmjXv

Or that Colombian food isn’t really about intense spices, it’s about the intense and rich flavors that comes from the rich textures of the foods themselves – without overpowering curries or heavy sauces..

Better quality, fresher ingredients and a wide variety make for richer flavors

Better quality, fresher ingredients and a wide variety make for richer flavors

Dr. Marco Sarinana and Dr. Joel Ramos,Bariatric surgeons

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Busy day yesterday – spent the morning shift with Jose Luis Barron over at Mexicali General..  Then raced over to Hospital de la Familia for a couple of general and bariatric cases.

The first case was with the ever charming Drs. Horatio Ham, and Rafael Abril (who we’ve talked about before.)  with the always competent Dr. Campa as the anesthesiologist.   (Seriously – Dr. Campa always does an excellent job.)

Then as we prepared to enter the second case – the director of the hospital asked if I would like to meet Dr. Marco Sarinana G. and his partner, Dr. Joel Ramos..  well, of course.. (Dr. Sarinana’s name has a tilde over the first n – but try coaxing that out this antique keyboard..)

So off to the operating room with these three fellows.  (This isn’t my usual protocol for interviewing surgeons, etc. but sometimes it works out this way.)  Their practice is called Mexicali Obesity Solutions.

Dr. Marco Sarinana and Dr. Joel Ramos, Bariatric surgeons

Dr. Alejandro Ballesteros was the anesthesiologist for the case – and everything proceeded nicely.

After that – it was evening, and time to write everything down!

Today should be another great day – heading to IMSS with Dr. Gabriel Ramos for a big case..

Back in the OR with Drs. Ham & Abril, bariatric and general surgeons

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My first case this morning with another surgeon was cancelled – which was disappointing, but I still had a great day in the operating room with Dr.  Ham and Dr. Abril.  This time I was able to witness a bariatric surgery, so I could report back to all of you.

Dr. Ham (left) and Dr. Abril

I really enjoy their relaxed but detail oriented style – it makes for a very enjoyable case.  Today they performed a sleeve gastrectomy** so I am able to report – that they (Dr. Ham) oversewed the staple line (quite nicely, I might add).  If you’ve read any of the previous books, then you know that this is an important step to prevent suture line dehiscence leading to leakage of stomach contents into the abdomen (which can cause very serious complications.)  As I said – it’s an important step – but not one that every doctor I’ve witnessed always performed.   So I was a pleased as punch to see that these surgeons are as world-class and upstanding as everything I’d seen already suggested..

** as long time readers know, I am a devoted fan of the Roux-en-Y, but recent literature suggests that the sleeve gastrectomy is equally effective in the treatment of diabetes.. Of course – we’ll be watching the research for more information on this topic of debate. I hope further studies confirm these results since the sleeve gives patients just a little less of a drastic lifestyle change.. (still drastic but not shot glass sized drastic.)

Dr. Ham

They invited me to the show this evening – they are having several clowns (that are doctors, sort of Patch Adams types) on the show to talk about the health benefits of laughter.  Sounds like a lot of fun – but I thought I better catch up on my writing..

I’ll be back in the OR with Los Doctores again tomorrow..

Speaking of which – I wanted to pass along some information on the anesthesiologist for Dr. Molina’s cases since he did such a nice job with the conscious sedation yesterday.  (I’ve only watched him just yesterday – so I will need a few more encounters, but I wanted to mention Dr. Andres Garcia Gutierrez all the same.

the Weight of a Nation: the obesity epidemic

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There’s a new series on HBO that is a collaboration between the Institute of Medicine, the CDC and the National Institute of Health (NIH) that begins airing tomorrow night.  This is a huge undertaking that took over three years to bring to the screen.

As many of you know – Obesity, diabetes and bariatric surgery are some of the topics that have been covered fairly extensively here at Cartagena Surgery.  In fact – it’s the heart of Cartagena Surgery – since the very first surgeon interview I ever performed back in 2010 was Dr. Francisco Holguin Rueda, MD, FACS, the renown Colombia bariatric surgeon.  (Shortly after that first leap – came Drs. Barbosa and Gutierrez – which is how we ended up here today.)

I’ve also been spending time, both last week and this week in the company of several bariatric surgeons here in Mexicali. MX and plan to go to several surgeries this week – so it seemed only appropriate to publish a few articles on the topic.

Talking with Dr. Horacio Ham – Bariatric surgeon, part 1

Talking with Dr. Ham, part 2

(I’m still transcribing notes from another one of my recent interviews – with Dr. Jose Durazo Madrid, MD, FACS).

I’d also like to encourage readers to take a look at HBO’s new mini-series (four episodes over Monday and Tuesday).

In the OR with Los Doctores, Dr. Ham & Dr. Abril

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Haven’t had time to sit down and write about my trip to the operating room with Dr. Horacio Ham and Dr. Rafael Abril until now, but that’s okay because I am going back again on Saturday for a longer case at a different facility.  Nice surprise to find out that Dr. Octavio Campa was scheduled for anesthesia.  Both Dr. Ham and Dr. Abril told me that Dr. Campa is one their ‘short list’ of three or four preferred anesthesiologists.  That confirms my own impressions and observations and what several other surgeons have told me.

campa

Dr. Campa (left) and another anesthesiologist at Hispano Americano

That evening we were at Hispano – Americano which is a private hospital that happens to be located across the street from the private clinic offices of several of the doctors I have interviewed.  It was just a quick short case (like most laparoscopy cases) – but everything went beautifully.

As I’ve said before, Dr. Campa is an excellent anesthesiologist so he doesn’t tolerate any hemodynamic instability, or any of the other conditions that make me concerned about patients during surgery.

Dr. Ham  and Dr. Abril work well together – everything was according to protocols – patient sterilely prepped and draped, etc..

laparoscopy

laparoscopy with Dr. Ham & Dr. Abril

I really enjoy talking with the docs, who are both fluent in English – but I won’t get more of an interview with Dr. Abril until Saturday.

w/ Dr. Ham

with Dr. Horacio Ham in the operating room after the conclusion of a successful case

Then – on Wednesday night – I got to see another side of the Doctors Ham & Abril on the set of their radio show, Los Doctores.  They were interviewing the ‘good doctor’ on sympathetectomies for hyperhidrosis – so he invited me to come along.

Los Doctores invited me to participate in the show – but with my Spanish (everyone remembers the ‘pajina’ mispronunciation episode in Bogotá, right?)  I thought it was better if I stay on the sidelines instead of risking offending all of Mexicali..

Los Doctores

on the set of Los Doctores; left to right: Dr. Rafael Abril, Dr. Carlos Ochoa, Dr. Mario Bojorquez and Dr. Horacio Ham

It really wasn’t much like I expected; maybe because all of the doctors know each other pretty well, so it was a lot more relaxed, and fun than I expected.  Dr. Abril is the main host of the show, and he’s definitely got the pattern down; charming, witty and relaxed, but interesting and involved too.. (my Spanish surprises me at times – I understood most of his jokes…)  It’s an audience participation type show – so listeners email / text their questions during the show, which makes it interesting but prevents any break in the format, which is nice.  (Though I suppose a few crazy callers now and then would be entertaining.)

Dr. Ochoa did a great talk about sympathectomy and how life changing it can be for patients after surgery, and took several questions.  After meeting several patients pre and post-operatively for hyperhidrosis, I’d have to say that it’s true.  It’s one of those conditions (excessive palmar and underarm sweating) that you don’t think about if you don’t have – but certainly negatively affects sufferers.  I remember an English speaking patient in Colombia telling me about how embarrassing it was to shake hands -(she was a salesperson) and how offended people would get as she wiped off her hands before doing so.  She also had to wear old-fashioned dress shields so she wouldn’t have big underarm stains all the time..  This was in Bogota (not steamy hot Cartagena), which is known for it’s year-round fall like temperatures and incredibly stylish women so you can imagine a degree of her embarrassment.

It (bilateral sympathectomy) is also one of those procedures that hasn’t really caught on in the USA – I knew a couple people in Flagstaff who told me they had to travel to Houston (or was it Dallas?) to find a surgeon who performed the procedure..  So expect a more detailed article in the future for readers who want to know more.

Tomorrow, (technically later today) I head back to San Luis with the good doctor in the morning to see a couple of patients – then back to the hospital.. and then an interview with a general surgeon.. So it should be an interesting and fun day.

Dr. Horacio Ham, and Los Doctores

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Just finished interviewing Dr. Horacio Ham, a bariatric surgeon with the DOCS (Diabetes & Obesity Control Surgery) Center here in Mexicali.  Later this evening, we’ll be heading off to surgery, so I can see what he does first-hand.

Tomorrow sounds like a jam-packed day for the young doctor, he’s being interviewed for a University television series on Obesity in addition to his normal activities (surgery, patients) and of course, the radio show.  Turns out his guest doctor tomorrow evening is none other my professor, the ‘good doctor.’

Sounds like a great show – so if you are interested it’s on 104.9 FM (and has internet streaming) at 8 pm tomorrow night..

I’ll report back on the OR in my next post..

Bariatric surgery and non-alcoholic fatty liver disease

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Interesting article over at Medscape on the role of bariatric surgery in the treatment of non-alcoholic fatty liver disease (NAFLD) and (NASH).

For the uninitiated, non-alcoholic fatty liver disease is a serious condition where functional tissue of the liver (used to metabolize and detoxify everything we ingest including medications) is replaced with fat tissue, and eventually fibrosis.  As more and more healthy tissue becomes fatty & fibrotic, the liver function deteriorates until it progresses to cirrhosis and eventual liver failure.

Currently, the only treatment for cirrhosis and liver failure is liver transplantation (which is still only a temporary measure, even in the best case scenarios*.)

But why is the happening?  and who does it affect?  Obesity and obese patients.

To better understand what’s going on – we need to review some basic pathophysiology:

First, lets look at food.  Not in cultural or psychosocial way, or even in food preferences, but food as the body sees it: Fuel for all of our cellular functions.  Just as we run our houses, appliances and cars on different types of fuel – gasoline, natural gas, electricity etc.  our body runs on different types of fuels (proteins, fats, sugars) that all get broken down to serve as energy.  Like fossil fuels – the metabolism of each of these fuels requires different mechanisms (ie. gas-powered versus electric cars) and creates different by-products.

Now I want you to think of a scale.

No, not this kind of scale

No – I want you to think of a scale, as in a delicate balance between differing metabolisms for different fuels.

Think of a multi-tiered scale, where a delicate balance between the types of metabolism and waste products is required for continued good health – anything that upsets the balance such as diabetes – throws everything out of whack.

Normally, as fuel (food) in consumed – the body uses insulin to transport the fuel into the cell for processing (metabolism), so think of insulin as a wheelbarrow carrying in complex carbohydrates (sugars) into the cell.

Now, in a person with obesity & diabetes – two things are occurring – too much fuel and not enough wheelbarrows**.  These means that:

1.  Excess fuel is converted into fat (adipose tissue – which we are all familiar with).

2.  Without the wheelbarrows, the body has to find another way to break down the fuel.  This other pathway – for fat metabolism has a lot of by-products  – namely free fatty acids (cholesterol and triglycerides.)  This leads to numerous problems (hypercholesterolemia and cardiovascular disease for one), and fatty liver disease.

(This is a gross oversimplification of a series of very complex mechanisms, but for today’s discussion – it is sufficient.)

Just as the rates of obesity, and diabesity (diabetes caused by obesity) have skyrocketed, so has cardiovascular disease (which we’ve talked about before) and the prevalence of non-alcoholic liver disease. In fact, the authors of the study below found that 70% of the people with a BMI greater than 35 have some degree of non-alcoholic liver disease, and over 30% have the more severe form – NASH.

The article by Rabl & Campos (2012) looks at the literature on the outcomes (progression or regression of disease) after bariatric surgery in patients previously diagnosed with NAFLD.  (I’ve linked a pdf version of the entire article under the full reference.)

They looked at the current bariatric procedures including the ever popular lap-band procedure and it’s effectiveness in treating NAFLD. What they found was that in the majority of cases – with certain procedures (formal gastric bypass surgery aka Roux en Y, and biliopancreatic diversion procedures) the disease process was not only halted, but regressed as a result of both weight loss, and a reversal of altered metabolism.  They also found that as a result of a reduced stomach surface area (in comparison to lap-band procedures where the stomach remains intact) – reduced ghrelin leads to increased weight loss.

(If you don’t know about ghrelin – think of it as an evil gremlin (the one that makes you want cookies when you know you are about to eat dinner) – since it is a potent appetite stimulant produced by the stomach.  The larger the stomach – the more ghrelin released – so the surgical procedures such as gastric bypass where a portion of the stomach is actually surgical removed are significantly more effective overall that lap-banding procedures.)

This is a significant advancement for medicine and the treatment of obesity related disease – since as we suggested above, multiple authors including Burianesi et. al (2008) suggest that the true prevalence of non-alcoholic fatty liver disease is much higher than we realize, (thus affecting a lot more people.)

Notes

* There is a tendency in American society to ‘gloss over’ many of life’s harsh realities, and no where is this more evidence than in the public perceptions of organ transplantation as a ‘cure’ or permanent solution for organ failure.  Transplanted organs do not have the same life expectancy as native organs (even in the best case scenarios) – and for most people who need non-kidney transplants – they get one opportunity, not multiple.  Transplanted organs last ten years – maybe fifteen at the outside – so this is not a cure (particularly in young patients).  Transplantation also carries a whole host of other problems with it – such as the development of opportunistic infections and cancer from the drugs used to prevent rejection, or rejection itself.  The very drugs used to prevent rejection of some organs may cause failure of others – so relying on transplantation as a ‘cure’ for a disease that is becoming more and more prevalent is a pretty poor strategy.

** This balance between mechanisms can be upset in other ways – by starvation, for example, when the body starts catabolizing proteins..  Catabolizing – think cannibalism – as the body consumes it’s own muscle tissue because there is nothing left for it to eat, after it has exhausted all other sources of fuel.

References and Resources

Rabl, C. & Campos, G. M. (2012)  The Impact of Bariatric Surgery on Nonalcoholic Steatohepatitis. Semin Liver Dis. 2012;32(1):80-91 [Article under discussion above].

Body Mass Index calculator – West Virginia Dietetic Association.

Bugianesi et. al. (2008).  Clinical update on non-alcoholic fatty liver disease and steatohepatitis. Annals of hepatology, 2008; 7 (2): April – June 157-160.  The authors ask, “What is the real prevalence of disease?”

Goldstein, B. J. (2001) Insulin Resistance: Implications for Metabolic and Cardiovascular Diseases.  This is a good presentation that explains how alterations in glucose metabolism (from diabetes) affects fat metabolism.

Overview of NASH/ NAFLD with classifications, diagnostics, prognostics : University of California, San Diego – Dan Lawson, 2010 [notes]. Good reference for medical students, health care professionals wanting a brief review.

Salt, W. B. (2004).  Nonalcoholic fatty liver disease (NAFLD): A comprehensive review.  J Insur Med, 2004; 36: 27 -41.

For more about Bariatric surgery – including the Pros & Cons

We knew it would happen…

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well, I guess we all knew what was coming next.. There was no way I could really stay still – and not interview some more surgeons while I was down here. So I thought I would start with two more specialities that are near and dear to my heart – and those of my readers; cardiac surgery and bariatric surgery.

I will be talking to Dr. Vasquez – who you may remember from a previous post (during an earlier visit to Mexicali) and Dr. Horatio Ham, a bariatric surgeon who also hosts the radio show, Los Doctores on 104.9 FM.

The Pros & Cons of Bariatric Surgery

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As my loyal readers know, I do my best to try to give fair and balanced depictions of surgical procedures, as well as reviews of medical and surgical news and research.  Over at Medscape.com – there is a new video discussion by Dr. Anne Peters, MD.  Dr. Peters is an endocrinologist and a certified diabetic education.  In this video – she talks about the realities of bariatric surgery, and these are things I think that people need to hear.

For more on Bariatric surgery – see my other posts

One of the points that she makes, is (in my opinion) critical.  While bariatric surgery has been shown to cure diabetes in many individuals – there is no medical/ surgical or other treatment to cure much of the pathology related to the development of obesity in the first place.  Obesity is more than poor dietary and exercise habits – it is a psycho-social and cultural phenomenon as well.

For people who don’t want to go to the Medscape site – I have re-posted a transcript of the video from Medscape.com below.

Bariatric Surgery a ‘Magic Bullet’ for Diabetes?

Anne L. Peters, MD, CDE

Transcript
Hi. I’m Dr. Anne Peters from the University of Southern California. Today I’m going to talk about the role of bariatric surgery in the treatment of type 2 diabetes.

There have been a number of recent studies that show just how good bariatric surgery can be for patients with type 2 diabetes.[1,2] In many cases, it seems to cure type 2 diabetes (at least for now), and I think it is an important tool for treating patients with obesity and diabetes.

However, I also have concerns about bariatric surgery, concerns that go back for years as I watched its increased use. When I was a Fellow, I developed a sense of the benefit of extreme caloric restriction for the treatment of type 2 diabetes. I will never forget the first patient I had, an extremely obese man with type 2 diabetes who was on 200 units of insulin per day. His blood sugar levels remained high no matter what we did. He was a significant challenge in terms of management.

One day, he got sick. I don’t remember how or why he got sick, but he ended up in the hospital and I thought that his management would continue to be incredibly difficult. In fact, it was miraculously easy. Within 2 days, he was completely off of insulin and his blood glucose levels remained normal for the entire time he was in the hospital.

This was only a short-lived benefit, however. After he was discharged, he went back to his old habits. He started eating normally, regained the weight, and went back on several hundred units of insulin per day. But it really impressed me how acute severe caloric restriction could, in essence, treat type 2 diabetes.

I have seen many overweight and obese patients with diabetes over the years, and I have seen the frustration as patients go on drugs (such as insulin) that are weight-gain drugs, and they keep gaining more weight. Although I am a big advocate for lifestyle change, many patients can’t do much better. They can’t lose appropriate amounts of weight by their own will or through weight loss programs, or increase their exercise. Therefore, bariatric surgery remains a reasonable option.

For many of my patients who have a body mass index > 35 and type 2 diabetes, I recommend that they at least consider bariatric surgery. Interestingly, very few of my patients actually go for the procedure and I ponder why this is. In part, I think it’s because of the initial evaluation, when you are told what bariatric surgery is like and how much you have to change your habits after the procedure. Before surgery, you are eating however you want to eat and, although you may be trying to diet, there is no enforcement of that diet. After surgery, you have to change how you eat, the portions you eat, and when you eat. I know that people feel fuller, and this is a lot more than just changing one’s anatomy. I think there are significant changes in gut hormones that regulate appetite and satiety. Nonetheless, it is a big change, and many people don’t want to change their habits that much. I know I would be somewhat leery if I were to undergo a surgical procedure that would change my whole way of being. For lots of people, food has many different associations. It’s not just caloric intake; it’s festival, it’s party, it’s joy, it’s sadness. It’s something people like to do, and it hasn’t a lot to do with just maintaining a positive or neutral caloric balance.

I find that people are reluctant to change, and that is understandable. We also don’t know the long-term complications of the procedure. As an endocrinologist, I see 2 things. First, I tend to get sicker patients, so my patients who are on insulin when they undergo bariatric surgery may not get off insulin entirely. They become very disappointed because they think that bariatric surgery will cure them of their diabetes. I also see patients who are too thin, who are nutritionally deficient, who have severe hypoglycemia, or who have significant issues from the surgery itself. In some cases, these patients have needed a takedown of the surgical procedure, restoring them back to their native anatomy.

I think of bariatric surgery as a tool. It is one of many ways to treat our patients with type 2 diabetes. I am a little concerned because we don’t have long-term follow-up data. I think that all bariatric surgery programs, in addition to doing a very thorough preoperative evaluation and counseling, need to do long-term, lifelong follow-up of these patients to see how they do, to see if their obesity returns. In many cases, this does happen. [Patients need to be followed up] to see what happens to their lipids, their blood pressure, and their blood sugar levels over time, and to monitor for other complications.

I think [bariatric surgery] is something that we need to recommend to our patients, and for those in whom it’s appropriate, it is a reasonable step. This has been Dr. Anne Peters for Medscape.

 References
  1. Mingrone G, Panunzi S, De Gaetano A, et al. Bariatric surgery versus conventional medical therapy for type 2 diabetes. N Engl J Med. 2012 Mar 26. [Epub ahead of print]
  2. Schauer PR, Kashyap SR, Wolski K, et al. Bariatric surgery versus intensive medical therapy in obese patients with diabetes. N Engl J Med. 2012; Mar 26. [Epub ahead of print]

Life after Bariatric Surgery

There is also an excellent article by two nurse practitioners about the long-term interventions and health monitoring needed for wellness promotion and health maintenance after bariatric surgery.  While this article is written for other health care providers – it gives an excellent look at life after bariatric surgery, as well as an overview of the surgical techniques, pre-operative evaluation and anticipated post-operative outcomes.

Thomas, C. M. & Morritt Taub, L. F. (2011).  Monitoring and preventing the long-term sequelae of bariatric surgery.  J of the American Academy of Nurse Practitioners, 2011, 23 (9).

Gastric bypass to ‘cure’ diabetes goes mainstream

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A full year after we reported it here (and several years after initially being reported in the literature), mainstream media has finally picked up the story about gastric bypass surgery for the definitive treatment of diabetes.   The story made all of the heavies; the Washington Post, the Wall Street Journal, and the Los Angeles Times.

Unfortunately, all of these outlets seem unaware of the existing literature in this area – these results while encouraging, are not surprising.  Similar results have been demonstrated in several other (but smaller) studies for the past ten years, which led to previous recommendations (last summer) for the adoption of gastric bypass surgery as a first-line treatment for diabetes in obese patients.

The publication of two new studies showing clear benefits for diabetics undergoing bariatric surgery has brought this news to the forefront.  In both of these studies, diabetic patients were able to stop taking oral glycemics and insulins after surgery within days..

As this front page story from the New York Times notes – these results do not apply to the more widely marketed ‘lap-band.’  This comes to no surprise to dedicated followers at Cartagena Surgery, who have been reading articles on this topic since our site’s inception in late 2010.

You heard it here first.  For more information on this topic, see our tab on Diabetes & Bariatrics under the ‘surgery’ header. We’ve included a small selection from our archives here.

Bariatric surgery headlines – August 2010

Gastric bypass surgery gets the international federation of diabetes approval.

Gastric bypass as treatment for diabetes

Looks like Panama may bite off more than they can chew..

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In a recently published story, the government of Panama is now offering medical  insurance for all tourists to Panama for free.  This insurance is not  ‘Complication Insurance’ which is offered by private surgeons in Colombia and other countries for patients traveling specifically for medical tourism.  Complication insurance covers all possible medical complications resulting from medical procedures at the designated clinic or destination..

No – Panama is taking the European and socialized medicine approach and is offering general medical coverage for ALL short-term travelers to Panama.  (The long-term exclusion is a wise move given the numbers of Americans and other overseas residents who make Panama their retirement home.)  This insurance resembles typical travel policies in that it covers injuries, accidents and other medical situations that may occur while on vacation..  I just hope the Panamanian government hasn’t underestimated its tourists and their injury/ illness potential.

Now readers – don’t get any wild ideas.. This is not the time to stress that ‘trick knee’ while hiking to visit the Naso-Teribes..

Meanwhile, Costa Rica is making a pitch for more corporate clients such as Pepsi-Cola.  These multi-national corporations can potentially bring hundreds of millions of healthcare dollars by diverting their employees to medical tourism destination such as Costa Rica.  (Like Colombia – Costa Rica is an ideal destination for North Americans due to proximity, quality and diversity of services available.)

A new medical center for Bogota?

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There’s a new article over at IMTJ about a new medical facility being built in Bogotá – but it’s not the facility itself that is interesting (sounds like a new private cosmetic surgery mega-clinic).

It’s the statistics within the article that caught my eye.  I’m not sure how accurate these statistics are, but if true – it confirms much of what we’ve been saying here at Bogotá Surgery.  I’ve placed a direct quote from the article below:

“According to Colombia’s Ministry of Commerce, Industry and Tourism the most popular treatments sought by visitors are heart surgery (41%), general surgery (13%), gastric band surgery (10%), cosmetic surgery (10%), cancer treatment (6%), orthopedic treatment (4%, dental care (2%) and eyecare (1%).”

If this information is even remotely accurate – it confirms what many of within the medical tourism have been saying – and contradicts much of the popular media reports.

People aren’t just going overseas for breast implants and face-lifts – people are going overseas for essential lifesaving treatments, and procedures to improve their quality of life.

This is an important distinction to  make, but many people tend to see cosmetic procedures as frivolous, and consider the issues around medical tourism, and travel health to be equally unconcerning*.  So when they see flashy news stories (good or bad) about patients having overseas surgery (which the media usually portrays as plastic surgery) they shrug and change the channel.

Hmmm.. patient died of liposuction in Mexico (or Phoenix or India..)  Or Heidi whatshername had 26 procedures at a clinic overseas..

But as these statistics show – that’s not the reality of medical tourism – and that’s what makes all of the issues around it even more important.

People may not get fired up about insurance coverage for medical tourism for cosmetic surgery – but what about tumor resection?  or mobility restoring orthopedic procedures? Or as cited above, life-saving heart surgery?

When put into this context – the government (President Obama’s) stance against medical tourism looks a little less democratic – particularly given the state of American healthcare.

* This is not the opinion of the author – but an accurate reflection of statements made in multiple articles and news stories

 

In other news:  Joint Commission take note:  The Indian Health Commission plans to perform surprise health inspections of Indian facilities to ensure quality standards.  (Joint Commission announces their impending visits months ahead of time.)  Joint Commission is the organization that accredits most American hospitals.

The doctor won’t see you now..

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Ironically, just a few days ago we were talking about lung cancer and discrimination against patients with lung cancer in the post, The Pearl Ribbon.   Now a new article published in Physicians Money Digest,  suggests that one of the latest trends is discrimination against the obese.  As obese people can tell you – this discrimination has always existed in some form, and from all avenues in society including medicine.

However, this new trend consists of doctors avoiding accepting obese patients in their practice, mainly to avoid the increased workload related to obesity related complications.  That’s right – as discussed in the article by Laura Mortokowitz, which I have re-posted below -some doctors are avoiding caring for obese patients because they do not want to provide care to patients with higher risks of certain complications – diabetes, heart disease, etc.

As someone who works in heart surgery, I can see this issue from both sides.  As many of you know – I am sometimes disheartened by the sheer overwhelming volume of disease (due to diabetes) and the amount of suffering involved for my patients.  I am particularly distressed at times when I see the amount of preventable suffering, and damage my patients experience from not controlling their blood pressure, checking their glucose or taking their medications.  But my patients are already sick – that’s why the are seeing a heart surgeon.  So, I often mourn these lost opportunities to prevent disease (heart attacks, strokes etc.), and I can see how primary care providers, and other providers may feel emotional fatigue and frustration at times.

But, other the other hand –  not every obese person is a stroke or heart attack waiting to happen.  Many of these people can be helped – by education, counseling or even bariatric surgery.  If these people are aggressively followed and cared for, risk reduction can help prevent catastrophic complications – by managing medical conditions that may develop – with aggressive cholesterol control, blood pressure management, etc.

Lastly, medicine is not an exact science – while risks may be greatly increased in many obese people – it is not a guarantee.. Just as it’s a false assumption that all overweight people are sedentary (ie. ‘fat and lazy’), not all overweight people will develop any or all of the complications we’ve discussed before.   But it is guaranteed that these obese patients will suffer, if this trend continues and more and more doctors shun them.

But my door is always open.

By Laura Mortkowitz, Wednesday, November, 16th, 2011
A recent move by Florida ob-gyn physicians to begin turning away overweight patients on the grounds that they were too risky might be the beginning of a new trend. According to Michael Nusbaum, MD, FACS, the health reform bill’s Accountable Care Organizations essentially de-incentivize physicians from taking on morbidly obese patients.
As they stand now, ACOs look at quality measures and they base reimbursements on complications. Doctors already know that a high complication rate will mean less money, and obese patients are considered high-risk patients by definition.
“Under the current bill, the Accountable Care Organizations are looking strictly at outcome measures, so unless that changes I don’t see the perception by physicians changing toward who they’re going to want to treat and who they’re not going to treat,” says Nusbaum, the Medical Director at The Obesity Treatment Centers of New Jersey.
This new practice is not something that would have occurred in the past for two reasons: one, physicians might be reluctant to treat an obese patient, but it was rare to turn them away completely; and two, it was very rare to treat a morbidly obese patient a couple of decades ago.
However, over the last 10 years, the percentage of the population that is overweight has increased dramatically. Today, close to 70% of the population is at least overweight, according to data from the Centers for Disease Control and Prevention. Even more concerning, is the fact that pediatric obesity has tripled over the last 20 years.
“Is the health care system to take care of morbidly obese patients? I would argue that it’s not,” Nusbaum says. “Pretty clearly it’s not. The problem with the health care system is that it lacks infrastructure.”
Most machines and tables can only hold up to 350 pounds, and any patients that exceed that weight might not even be able to get treated at a hospital that doesn’t have the equipment to handle an obese patient. According to Nusbaum, it should be a requirement that hospitals are equipped to treat any morbidly obese patient.
“Nobody is even talking about it,” he says. “Everybody is afraid to even talk about this.”
And it doesn’t seem as if new health laws are encouraging to the treatment of obesity. Under the new health bill’s Essentials Benefit Package, bariatric surgery is not covered because morbid obesity is being considered a poor lifestyle choice. As a result, insurance companies “have become emboldened to say, ‘Well, we’re not going to cover it either,’” Nusbaum says.
In New Jersey, Blue Cross/Blue Shield has 14 insurance policies, and eight of them do not cover bariatric surgery at all.
“What you’re seeing happening is a change in attitude to bariatric surgery and in my opinion a discrimination against those people who have weight issues,” Nusbaum says.
However, there was a rather positive turn of events in Michigan, where bariatric surgery will be covered in 2012 after it was dropped for all of this year.
“They noticed that while they were making money in the short term — they were saving money — they were losing more money by not taking care of these patients,” Nusbaum says. “[The patients] were getting sicker. It was very short sighted.”

//

Bariatric surgery for the whole family?

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No, researchers aren’t suggesting that entire families undergo bariatric surgery.  But a new study by Woodward, Encarnacion, Peraza, Hernandez – Boussard & Morton (2011) published last month suggests that when one family member underwent bariatric surgery – the rest of the family reaped benefits as well.

As explained in this article by Kristina Fiore at Medpage – there is a family-wide health benefit after bariatric surgery.  After one family member had surgery, other adult members in the family tended to modify their eating habits as well, and subsequently lost weight.  While this study was small, with just 35 families – it shows the huge impact that sociological factors (such as family dietary practices/ habits) have on obesity and health.

Bariatric surgery and cardiovascular risk reduction: Meta-analysis

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The American Journal of Cardiology just published a new meta-analysis (a study looking at a collection of other studies) that evaluates the effectiveness of bariatric surgery for cardiovascular risk reduction.  As we’ve discussed before, meta-analyses are often used to sort through large numbers of studies to look for trends and weed out aberrant results or poorly designed studies.  (This is particularly helpful when a poorly designed study gives conflicting results in comparison to the rest of the existing studies.) So, we are going to talk a bit more about the meta-analysis.

In this case, the authors started with 637 studies to evaluate, but ended up using the data from only 52 studies involving almost 17,000 patients.  The first step of a meta-analysis is to find every single study even remotely related to your topic. So the authors pulled out, printed and looked at every single study they could find talking about bariatric surgery.

Then the authors start eliminating studies that aren’t relevant to their topic because once you take a closer look; a lot of the studies initially gathered aren’t really related to your topic at all.  (For example: If the authors gathered all studies talking about Bariatric surgery outcomes – on closer examination – a study about the rate of depression in bariatric surgery patients wouldn’t have any information usable to evaluate cardiac risk in these patients.)  Otherwise it would be like comparing apples to oranges.

Once authors have narrowed the pool to studies that are only looking at relevant topics, with measurable results – the authors then examine the studies themselves.  The authors evaluate all aspects of the studies: what is the study design, what does it measure, (is it designed to measure what it is supposed to measure?), what are the results?  (were the results calculated correctly?)  what are the conclusions?  what are the limitations of the study?

Then the authors summarize all of the findings, and draw conclusions based on the results. (if 50 studies involving 16,900 people show one thing – and 2 studies involving 100 people show something completely different – the authors will discuss that.)

The strengths of meta-analyses are that they summarize all of the existing studies out there – and provide readers with fairly powerful results because they involve large numbers of people.

For researchers, meta-analyses are cheap – particularly in comparison to designing, conducting a large-scale study with hundreds or thousands of subjects.  A meta-analysis doesn’t require federal grants or institutional permissions.  It just requires a computer and journal access (along with a good knowledge of study design, statistics).

As you can imagine, the downside of meta-analyses is that they don’t generate NEW knowledge, since they are summaries of other studies.  Meta-analyses are also limited by the AMOUNT of data already published.  If few researchers have written about a topic, then a meta-analysis isn’t very effective or powerful.  (A meta-analysis on three studies involving only 25 total patients, for example).

Now that we’ve discussed the purpose and function of the meta-analysis, let’s discuss the results of Heneghan’s reported results.

Now, readers need to be very careful when reading blogs, and other articles like mine reporting results such as this – because this is filtered, third-hand information by the time it’s published on blogs, or newspaper articles.  (First source is the meta-analysis itself – which as we’ve discussed is actually a summary evaluation of other work).  Secondary is the Medscape article which summarizes and discusses the results of Heneghan’s study.

Now, that means that anything you read here is essentially third-hand information – if it’s based on the Medscape article.  That’s why we provide links to our sources here at Cartagena Surgery – so readers can read it all first-hand.  This is important because just like the children’s game of telephone, as information is passed from source to source, it is edited, filtered and subtly changed (for reasons of space, editorial preference etc.)

heneghan’s meta-analysis results showed significant reductions in weight, blood pressure, cholesterol and hemoglobinA1c (blood glucose levels) after bariatric surgery.  The Framingham risk score (a score developed based on the landmark Framingham study) which predicts the risk of cardiovascular events (heart attacks, strokes) also showed a significant reduction (which would be expected if all the risk factors such as hypertension were improved).

Framingham Risk Score Calculator

Now, a lot of readers might say, “Wait a minute – isn’t this self-evident?  If you lose weight – shouldn’t all of these things (glucose, blood pressure, cholesterol) improve?”

Yes .- logical reasoning suggests that they should – but in medicine we require hard data, in addition to logical reasoning (ie. A should lead to B versus a study with ten thouand patients proving A does lead to B.)

We need to be particularly careful when suggesting or assuming causality from treatments (surgery) for conditions.  A good example of this is liposuction.  Since liposuction involves the removal of subcutaneous fat – and may result a (a small amount) of weight loss – many consumers assumed that this limited weight loss conferred additional health benefits associated with traditional weight loss.  Wrong!

Sucking fat out of your behind (liposuction) will not lower your blood pressure, cholesterol, or blood pressure and does not replace the health benefits of weight loss or exercise.  I can hear readers snickering now – but that’s because of my phrasing.  For years – many people, some health care providers themselves thought that weight loss, any weight loss lead to the above mentioned health benefits, and that included liposuction related weight loss.  It took several studies to disprove this.  So, in medicine – nothing is obvious – until we prove it is obvious!  (Remember: much of what was “obvious” in 1950’s medicine – is now considered absurd.)

Original Research Article Citation:

Heneghan HD, et al “Effect of bariatric surgery on cardiovascular risk profile” Am J Cardiol 2011; DOI:10.1016/j.amjcard.2011.06.076.  (abstract only – article for purchase).

Medpage Summary Article:

Bankhead, C. (2011). Medical News: Bariatric Surgery gets high marks for CVD risk reduction. Medpage Today.

Meeting of the minds – thoracic surgery

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Attended the monthly thoracic surgery meeting led by Dr. Juan Carlos Garzon yesterday for case discussions.. Several interesting cases presented.  More importantly, I met and set up interviews with the last few thoracic surgeons; Dr. Beltran and Dr. Rodolfo Barrios (that I hadn’t met previously).  Should be an interesting week in the south end of the city..

On the topic of thoracic surgery – I am soliciting articles from thoracic surgeons, and other practitioners on the site – not just here in Bogota, but from around the world as part of the mission of the site.  I’ve already had some great feedback from some American surgeons.

Over at cartagena surgery we are talking about the recent announcement by the International Diabetes Federation on treatment recommendations for diabetes including the endorsement of Bariatric Surgery.

International Diabetes Federation supports Bariatric Surgery for treatment of Diabetes

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In a 180 shift from the position adopted by the American Heart Association who remains firmly rooted in the idea of bariatric surgery as a ‘last resort when all options have been exhausted’ the International Diabetes Federation (IDF) has taken the unprecedented and progressive step forward to recommend bariatric surgery as a form of aggressive treatment for Diabetes, (which is now only suboptimally controlled with multiple medications in the majority of people.)

In a re-post from Medscape, an article by Robert Lowes “Bariatric Surgery Recommended for Obese Patients With Type 2 Diabetes” reports that surgery is now being endorsed to prevent the devastating complications of this disease.

In this ground-breaking move, hope is being offered to the millions of people diagnosed with this disease.

Article re-post below:

March 28, 2011 — Bariatric surgery is an appropriate treatment for people with type 2 diabetes who are obese, the International Diabetes Federation (IDF) announced today.

Although such operations cost anywhere from $20,000 to $30,000, they will reduce healthcare expenditures in the long run, according to a new IDF position paper on the subject. The surgery, the IDF explains, often normalizes blood glucose levels and reduces or avoids the need for medication.

Dr. Francesco Rubino

In addition, curbing diabetes can stave off costly complications such as blindness, limb amputations, and dialysis, said Francesco Rubino, MD, director of the IDF’s 2nd World Congress on Interventional Therapies for Type 2 Diabetes, meeting today in New York City.

“When we talk about whether we can afford bariatric surgery, we have to ask what will be the cost if we don’t treat the patient,” Dr. Rubino told Medscape Medical News. “Studies have shown the surgery to be cost-effective. So there is a return on investment.”

The IDF puts the lifetime cost of diabetes in the United States at $172,000 for a person diagnosed at age 50 years and $305,000 at age 30 years. More than 60% of this amount is incurred in the first 10 years after diagnosis.

Under the new IDF guidelines, patients with type 2 diabetes warrant bariatric surgery when their body mass index is 35 kg/m2 or higher, or when it is between 30 and 35 kg/m2 and their diabetes cannot be controlled by medicine and lifestyle changes. This latter indication is even stronger when there are other major cardiovascular risk factors, including hypertension, hyperlipidemia, and a history of heart attacks, said Dr. Rubino, chief of the Gastrointestinal Metabolic Surgery Program at New York-Presbyterian Hospital/Weill Cornell Medical Center.

The body mass index action points can be reduced by 2.5 kg/m2 for Asians.

The guidelines were drawn up by an IDF taskforce of diabetologists, endocrinologists, surgeons, and public health experts who met in December 2010.

Trials Needed to Compare Surgical Procedures

The new recommended indications for performing bariatric surgery on patients who are both diabetic and obese match those announced last month by the US Food and Drug Administration  for expanded use of the Lap-Band Adjustable Gastric Banding System (Allergan) to treat obesity.

The US Food and Drug Administration originally approved the product, designed for laparoscopic adjustable gastric banding (LAGB), for adults with a BMI of 40 kg/m2 or higher and those with a BMI of 35 kg/m2 or higher who have additional risk factors. Under the expanded indications, the LAGB system also can be used for adults with a BMI of 30 to 40 kg/m2 and 1 additional obesity-related condition who have failed to lose weight despite diet, exercise, and pharmacotherapy.

The use of bariatric surgery to treat diabetes has sparked controversy in healthcare circles. Critics question the wisdom of wielding a scalpel to solve a medical problem, especially when clinicians have more drugs at their disposal to deal with diabetes.

At the same time, a study published online last week in the Archives of Surgery has raised doubts about the efficacy of LAGB. Researchers following 151 patients who underwent LAGB for obesity concluded that the procedure yielded “relatively poor long-term outcomes,” with nearly half the patients needing their bands removed and 60% overall requiring some kind of reoperation. The authors, who performed the surgeries in question during the mid-1990s, added a caveat: they had used an older dissection technique.

“The band is only one option,” Dr. Rubino told Medscape Medical News, noting that gastric bypass procedures have demonstrated a greater endocrine effect than LAGB. “We are learning that some types of diabetes are well treated by lap-banding early in the disease process. The answer is in patient selection.”

The IDF taskforce calls for randomized controlled trials to compare different bariatric procedures for diabetes between themselves, “as well as emerging non-surgical therapies.”

Robert Lowes

Freelance writer, St. Louis, Missouri

Disclosure: Robert L. Lowes has disclosed no relevant financial relationships.

The Doctors Luna at Clinica Shaio

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Interviewed the father and son, Dr. Ruben Francisco Luna Romero and Dr. Ruben Daniel Luna Alvaro this morning, before following Dr. Luna (Alvaro) to the operating room. Dr. Luna was joined by the remaining doctor in the Grammo practice, Dr. Cesar Guevara.

Due to some technical issues – i will post photos later.

Update: 21 April 2011: Photos

Dr. Luna, general and transplant surgeon

Dr. Guevara (left) and Dr. Luna (right) during laparoscopic surgery

Dr. Cesar Guevara, Grammo

Gastric banding versus gastric bypass: Easy?

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Another example in the realm of surgery where easiest doesn’t equal most effective: gastric banding (lap-band). This is one of those procedures highly touted in American medicine – and heavily advertised on television as an ‘easy’ way to lose weight..

First, let’s get some things clear – the ‘easy’ mentality needs to go away in medicine, and so does the pushing of this concept with patients.. None of this; not surgery, weight loss drugs, or conventional treatment is easy for the patient..It’s all hard work, so don’t mislead your patients – that sets them up for failure..

In the article linked here (from the LA times, February 2011) the two doctors interviewed do their best to avoid answering the easy/ effective question. “I let the patient decide,” which is a royal cop-out. Patients come to doctors for expert opinions and recommendations not wishy-washy information that doesn’t present the facts and evidence. The picture accompanying the article is disturbing as well, since it’s captioned as a patient awaiting lap-band.. The patient is clearly morbidly obese – yet is undergoing the least effective option available!

What makes this frustrating to me – is that in talking to patients – is that it’s usually such a long road to even get to bariatric surgery.. Contrary to popular belief and tabloid reporting, the majority of overweight people don’t jump to bariatric surgery.. These patients spend years (sometimes decades) dieting, gaining and losing weight..
This isn’t always the case in other countries where surgery is more readily available – but in the USA where insurance coverage or lack there of, usually dictates care – bariatric surgery is usually the end of a long, frustrating road..

I know I’ve discussed this before on the site – but I feel that there needs to be transparency in treatment options – and that we need to do away with the ‘easy’ concept whether it’s bariatric surgery, stents or even medications.. Don’t sell people easy – give them safe, proven and effective.

I’ll be updating the article over the next few days with links for more information – and hard facts about surgical options and obesity surgery.

Related Articles: Free full-text links: (my titles, the actual titles are a bit longer)

1. It’s Not Easy – a study looking at the patients perspective, and perceptions before and 2 years after bariatric surgery.

2. Current treatment guidelines and limitations – a discussion of current treatment guidelines in the USA and Canada

3. German study with 14 year outcomes after gastric banding – this is a nice study because they use terms that are easily understood for laypeople – and shows decent outcomes for patients with this procedure

4. Single port bariatric surgery – this has been a hot topic over at the sister site. This article discusses the most recent innovations in surgical techniques for bariatric surgery.

5. A review of the current data (2008) surrounding bariatric surgery, obesity, and diabetes and the cost of care.
This is a particularly good article (reviews often are) because it gives a nice summary of multiple other studies – so intead of reading about eight patients in Lebanon or some other small group – you are getting a good general overview..also it gives a good idea the scope of the problem..

I’m trying to collect a wide range of articles for patient education; unfortunately, since surgeons in Latin America are on the forefront of bariatric surgery – a lot of the most interesting articles are in Spanish and Portuguese (or paid articles). i haven’t posted the translations since they are secondary source and all of the other citations are primary source.

Diabetes as a surgical disease

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There’s a great new article over at Medscape by David Lautz, MD; Florencia Halperin, MD; Ann Goebel-Fabbri, PHD; Allison B. Goldfine, MD
that was recently published in Diabetes Care 2011;34(3):763-770 entitled

“The Great Debate: Medicine or Surgery: What Is Best for the Patient With Type 2 Diabetes?”

It’s quite lengthy so I won’t repost here – but it’s definitely recommended reading for my diabetic readers out there. I have included some highlights from the discussion – which correlate with much of what we’ve previously discussed here.

Re-post from article:
“Recent observational studies demonstrate that bariatric surgical procedures reduce the incidence of type 2 diabetes and lead to substantial improvement or “resolution” for many patients with preexisting disease. Type 2 diabetes has “resolved” (defined in the surgical literature as maintenance of normal blood glucose after discontinuation of all diabetes-related medications, in most studies with HbA1c 35 kg/m2 and raise the question of whether surgical interventions should be considered earlier in the course of disease or for lesser magnitude of excess weight and specifically for the treatment of diabetes as opposed to treatment of obesity.”

It’s a nice well-balanced article, which discusses the theories behind the resolution of diabetes after surgery (Roux-en-Y gastric bypass), as well as the concerns of endocrinologists about the use of surgery for diabetes management. The authors give a nice detailed description of the various bariatric surgery procedures and nonsurgical treatment options, in a fair and balanced manner. It’s a timely article, coming on the heels of the recent AHA statement – which harks back to an era of blaming the patient and ignoring the problem..

In the the OR with Dr. Juan Pablo Umana & Dr. Ricardo Nasser

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Dr. Juan Pablo Umana, cardiac surgeon

Dr. Juan Pablo Umana

Cardiac Surgeon at Fundacion Cardioinfantil

Spent the morning in the operating room with Dr. Juan Pablo Umana. Dr. Umana is the Chief of Adult Cardiac Surgery at Cardioinfantil.

Ran into an old friend while I was there..

Dr. Jose Pomares, Anesthesia

Dr. Pomares was a anesthesia resident over at Medihelp in Cartagena, when I was writing hidden gem.. I recognized those emerald eyes right away.. (not sure if I would have recognized him without the mask.)

Dr. Umana had another case, but so did I – over at Santa Fe de Bogota..

Went back to see Dr. Ricardo Nasser, Chief of Bariatric Surgery. He just returned from the Bariatric Surgery conference in Cartagena, and was back at work, in the operating room.

Dr. Ricardo Nasser

Bariatric Surgeon – Fundacion Santa Fe de Bogota

Dr. Richard Nasser, Bariatric surgeon

Bariatic surgery, revisited

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In honor of the Latin-American Bariatric Surgery Congress, currently in progress in Cartagena – (since I couldn’t make time in my research to go) I am posting a brand new article about bariatric surgery and the severely obese. It seems American medicine is finally starting to catch up, and take notice..

It’s hard concept out there – and I still have trouble with it myself, sometimes.. In our society, it seems we are too busy blaming ourselves, and others for being overweight and attaching labels; ‘lazy’, to really see how fundamentally things need to change to improve our health as a nation.

From my perspective, down here in Bogota – it’s interesting, because I am seeing Colombians just beginning to start to struggle with obesity – as more and more imported snack foods, and fast foods replace traditional diets. Obese people are still very rare here – and after several months, I can still say I’ve not seen a single super-obese person here, but the ‘chubbies’ are starting to grow in number..

At the same time, by being in such a walkable city, and having access to (cheap!), delicious, ripe fruit every day, I’ve managed to lose over ten pounds with almost no effort.. I’ve been tracking my walking, and I walk about 6 to 10 miles a day with my various errands. But these are things that aren’t readily available – in the urban sprawl of American life.. A week’s worth of fruit for several meals for ten dollars? Not hardly, unless you gorged yourself on bananas every single day..

Surgery as a solution seems drastic to American healthcare providers, myself including.. Removing/ destroying a perfectly functioning organ.. But then – when you look at the drastic effects, and the desperate states our patients are in – Bariatric surgery really is as lifesaving as cardiac surgery for many people.. Until we change society as a whole (which may never happen), we need to help these individuals regain their health,and their lives..

Bariatric Surgery for the Severely Obese

In the meantime, everyone, stay away from soft drinks (all soft drinks, including ‘diet drinks’, juices and fruit drinks, sweet tea) and stick to water, plain tea. Coffee too – if you remember not to load it up with too many calories.. Try it for a month, and I wager you will be unable to go back to the supersurgery drinks you formerly enjoyed out cringing..

Bogota notes

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Re-post from sister site.

January 27th, 2011 – Surgical Tourism in Bogota, Colombia

Fundacion Cardioinfantil

Currently working on my latest project – here in Bogota, Colombia.  So far everyone I’ve contacted has been wonderfully gracious – even with very little notice! 

Chief of (adult) Cardiac Surgery, Dr. Juan Pablo Umana and Chief of Pediatric Cardiac Surgery, Dr. Nestor Sandoval; Fundacion Cardioinfantil
January 31, 2011
Spending some more time over at Cardioinfantil this afternoon. I have been contacting surgeons all over the city, and my schedule is quickly filling up. 
Talked with Dr. Renato Bresciano, a very nice (talented) pediatric cardiovascular surgeon, and visited one of his patients in the NICU this afternoon – a little baby girl just out of the operating room.  Spoke with the nursing staff – it’s great how nurses from everywhere  – we all connect, and all care and worry about the same things.
 
I’ll be over at the Shaio Clinic later this week.
10 February 2011 –
It’s been a busy week – at Clinica Shaio, Cardioinfantil, Clinica del Country (San Sebastian) and tomorrow SaludCoop.. In between all of that – I’ve been hitting the pavement to check out some private clinics..
12 February 2011
Not enough hours in the day – racing around Bogota, all day, everyday, meeting new people, taking notes, photos..  talking to patients in hospitals, shaking hands – trying to get a glimpse inside at the everyday workings..  Then back to the apartment at night, typing, typing, typing.. Researching, emailing, requesting more interviews..
My main expense these days is the cab fare..  Already booked up with meetings for the next two weeks, but I’ll try to squeeze as many as possible in – without crowding.. Still going to the ORs – since that’s the real reality for our patients.. Spending as much time as I can at each site, going back for second, third, fourth, even fifth visits  – until I almost feel like staff sometimes..
Next week – Bariatric week..
with Dr. Urazon, Plastic Surgeon

 

15 February 2011 – wow – what a different an hour makes..
when you are in the company of Dr. Chaux, Bariatric surgeon.. I spent much of the day with Dr. Chaux and his group – in the operating room, observing.. All procedures in under an hour.. (Roux N Y gastric bypass, sleeve ect..) Don’t worry – he certainly wasn’t rushed about it – just efficient, meticulous..

24 February 2011
Been too busy meeting physicians, spending time in the OR and writing to keep up.. Spent time with a talented young Thoracic surgeon today, Dr. Juan Carlos Garzon. Sorry, no pictures this time – too busy to stop and take any! (which frequently happens).

Met quite a few terrific surgeons, spending a lot of time on my feet, peeking over their shoulders so I can tell my readers everything they need to know. A couple more surgeries tomorrow and a full weekend too..

More Bariatrics please!

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If you’ve been following my reports on Cartagenasurgery.wordpress.com then you know I’ve been meeting with bariatric surgeons across the city. Today I met with Dr. Richardo Nassar Bechara, who is the Chief of the Bariatric Surgery program at Fundacion Santa Fe de Bogota. He is part of a comprehensive Obesity Clinic program which includes multiple specialties and comprehensive medical and surgical treatment for obesity and metabolic syndrome.

Right now he is preparing for the upcoming Latin American Congress on Obesity and Obesity Surgery so he has no surgery planned for several days. (Don’t worry – I’ll be going to the OR soon so I can report back to all of you.)

The program stresses lifestyle change and includes cardiology, endocrinology, physical therapy, nutrition, psychiatry and internal medicine.

Part of the program includes the VidActiva gym which offers personalized training programs with cardiovascular exercise, weight training, complimentary health services such as tai chi, dance, pilates, acupuncture and massage therapy. The clinic is staffed full-time with a sports medicine physician.

More news on Bariatric Surgery & Diabetes

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I’ve re-posted the lastest medical article from medscape on Bariatric Surgery in Diabetes Mellitus.  As many of you know, I have a special interest in Bariatrics/ Diabetes due to the increased incidence of cardiovascular complications.  However, here in the USA – it’s easier to get cardiac bypass surgery then gastric bypass..

So – instead of helping people with real medical problems – we wait for drastic complications (heart attacks etc.)  Even then, society in general and medical society in particular can be rather judgemental about obese patients.  In stead of judging – make the information more available, and give people an opportunity to decide for themselves.

This is a straight cut and paste, with no editing or editorializing (except my comments above) for my interested readers.  Also – please let me know what other surgical procedures you are interested in hearing about and I will post articles with helpful information.

Authors and Disclosures :Journalist Daniel M Keller, PhD Daniel M. Keller is a freelance writer for Medscape. Daniel M. Keller has no disclosures.

From Medscape Medical News:

 Remission of Type 2 Diabetes Can Occur Within a Week of Gastric Bypass Surgery

Daniel M. Keller October 1, 2010 (Stockholm, Sweden) — Twelve patients with type 2 diabetes had improvements in insulin sensitivity and beta cell function just 1 week after Roux-en-Y gastric bypass surgery (RYGB), with concomitant reductions in fasting and 2-hour postprandial plasma glucose levels, compared with preoperative levels, according to a poster presentation here at the European Association for the Study of Diabetes 46th Annual Meeting. Lead author Nils Bruun Jørgensen, MD, from the Department of Endocrinology at Hvidovre Hospital in Denmark, showed evidence that the improvements in insulin sensitivity and beta cell function were associated with a 16-fold increase in secretion of glucagon-like peptide 1 (GLP-1). Type 2 diabetes patients with fasting plasma glucose of more than 7.0 mmol/L at the beginning of the study were given a mixed-meal tolerance test 1 to 3 days before and 4 to 6 days after surgery. The 200 mL, 1260 kJ liquid meal provided 15% of energy from protein, 50% from carbohydrate, and 35% from fat. The average age of the patients was 51.8 years, 7 were male, and they had diabetes for an average of 5.2 years. Significant reductions in fasting and in 120-minute postprandial plasma glucose levels occurred after surgery, compared with preoperative values (see table). Similarly, there were decreases in both fasting insulin and C-peptide serum levels. Subject Characteristics and Laboratory Values Before and After RYGB Surgery Variables Pre-RYGB Post-RYGB Change P value Glycated hemoglobin 7.0 ± 0.3 Fasting plasma glucose (mmol/L) 8.8 ± 0.7 7.0 ± 0.3 –21.2% .005 120-min plasma glucose (mmol/L) 11.4 ± 0.8 8.2 ± 0.7 –28.5% <.001 Fasting serum insulin (pmol/L) 132 ± 22 73 ± 9 –44.6% .006 Fasting serum C-peptide (pmol/L) 1542 ± 151 1175 ± 172 –23.8% <.001 Weight (kg) 129.8 ± 4 127 ± 3.8 –2.2% .001 Body mass index (kg/m2) 43.3 ± 1.5 42.4 ± 1.5 –2.1% .001 Waist (cm) 130.8 ± 2.9 131.3 ± 2.6 0.4% .734 Hip (cm) 121.0 ± 2.9 118 ± 2.7 –2.5% .051 Using the homeostasis model assessment of insulin resistance (HOMA-IR), Dr. Jørgensen determined that insulin resistance decreased by 54%, from 6.9 ± 1.0 before to 3.2 ± 0.43 after RYGB (P = .001). The Matsuda Index, a measure of tissue insulin sensitivity, increased in parallel with the decrease in insulin resistance, going from 2.58 ± 0.38 before to 4.16 ± 0.55 after RYGB (P = .01). “We also looked at the C-peptide levels in response to the meal, and although we couldn’t show any significant difference in the individual postprandial sample points, what we did get was an impression of the changed secretion dynamics, and we could show an increased incremental area under the curve for C-peptide,” he said. The area under the curve of concentration for C-peptide over time increased significantly after surgery (P = .04). The disposition index, a measure of the relation between the sensitivity of beta cells to glucose and tissue sensitivity to insulin, “improved dramatically,” according to the investigators. “We found a significant increase in the beta cell function, and when we related this to the ambient insulin resistance, we found a 3-fold increase in the disposition index,” according to Dr. Jørgensen — from 54 ± 12 before to 157 ± 30 after RYGB (P = .001). To determine the underlying cause of these improvements, the researchers investigated secretion of incretins, and “found a significant and very dramatic increase in the GLP-1 secretion after surgery,” he said. GLP-1 peak plasma levels increased 5.6-fold after surgery, compared with preoperative values (P < .001), and the incremental area under the curve for plasma GLP-1 was 16 times greater after than before RYGB (P < .001). There was no observed change in gastric inhibitory polypeptide. In conclusion, “gastric bypass surgery significantly reduced fasting plasma glucose levels and 2-hour postprandial glucose levels. These changes were associated with increased insulin sensitivity and beta cell function, and may involve the increased secretion of GLP-1,” Dr. Jørgensen told the audience. Discussion leader Ele Ferrannini, MD, professor of medicine at the University of Pisa Medical School in Italy, asked Dr. Jørgensen about the potential influence of caloric deprivation on the findings, “which would mimic these data almost perfectly,” Dr. Ferrannini said. Dr. Jørgensen replied that he could not dissect such a proposed mechanism from the results he saw after RYGB. Dr. Ferrannini noted that the literature contains studies of patients with type 2 diabetes who were subjected to low-calorie diets in the range used in this study. “And their findings, with the exception of the release of GLP-1, were precisely what is here, so this is a confounder in this particular finding,” he said. An audience member noted that the patients in this study had diabetes for an average of a little more than 5 years, and wondered what would be the result if one performed RYGB on patients who had their disease and had been on insulin much longer, in essence, questioning whether there would be enough preserved beta cell function to see effects similar to those in this study. Dr. Ferrannini replied that “there is evidence that . . . the longer the duration of diabetes, . . . the lower the remission rate, particularly if you look a year later. Any diabetic will go into remission if you starve them, but when they start eating again [after they lost weight], a year later or 2 years later, some will be in remission, others will not be in remission or will be halfway between remission and nonremission. Those that have had the disease the longest . . . may relapse if they remitted initially.” “And then to the point of the insulin secretion — it’s true that it’s not really very much higher, but this is in the face of lower glucose levels. So if you construct a kind of relationship between the insulin and the concomitant glucose levels, there will be an input, and this can be attributed also to the GLP-1. What you cannot ascribe to the increased GLP-1 levels is any improvement in insulin sensitivity, because of a lack of evidence that GLP-1 has any influence on insulin action,” Dr. Ferrannini said.

Dr. Jørgensen reports that his doctoral studies were partially funded by Novo Nordisk, and that 2 of his coauthors are Novo Nordisk employees. Dr. Ferrannini has disclosed no relevant financial relationships. European Association for the Study of Diabetes (EASD) 46th Annual Meeting: Abstract 668. Presented September 23, 2010. Medscape Medical News © 2010 WebMD, LLC

Bariatric surgery in the medical news

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New article on Medscape (a medical literature website for health care providers) discussing the benefits of bariatric surgery.  In this article they cite a surgery cost of at least $30,000 which is out of reach for many of the people who need it;  as morbid obesity and related complications push up health care costs for individuals.

I’ve posted the link for you to read it for yourself:

http://www.medscape.com/viewarticle/726966?src=mp&spon=22&uac=63155MX

this website does require registration, (which I think is free.)

But as my readers know, there are more cost-effective alternatives, as mentioned in the entire chapter devoted to bariatric surgery in Cartagena.

As readers know, in that chapter, I introduce you to one of Latin America’s most famous surgeons, Dr. Holguin, a former trauma surgeon at Maryland’s Shock Trauma hospital in Baltimore, MY in addition to several other excellent surgeons.  Most North Americans don’t know it but Cartagena is fast gaining a reputation for excellence in bariatric surgery, and is becoming a destination of choice for gastric bypass, lap-band, sleeve resection and other bariatric surgery procedures.