130848-MAY 2013

Clinical Developments and Metabolic Insights in Total Bariatric Patient CareVolume 10, Number 5 May 2013

A P e e r - R e v i e w e d P u b l i c a t i o n

Inside

EDITORIAL MESSAGE ....................3

EDITORIAL BOARD ........................4

SURGICAL PEARLS

Vertical-banded Gastroplasty toRoux-en-Y Gastric Bypass withRemnant Gastrectomy .................8

ASK THE LEADERSHIP

The Cost-Effectiveness ofBariatric Surgery .......................10

JOURNAL WATCH ........................12

CHECKLISTS IN BARIATRIC

SURGERY

Gastro-gastric Fistula after Roux-en-Y Gastric Bypass...................13

NEWS AND TRENDS ....................16

ED MASON AT LARGE

The Mechanics of SleeveGastrectomy...............................20

ANESTHETIC ASPECTS OF

BARIATRIC SURGERY

Intraoperative Fluid Assessmentin Patients with Obesity.............26

INTERVIEW

Countdown to Obesity Week 2013:Interview #5: Daniel Herron, MD, FACS ............28

CALENDAR OF EVENTS................30

MARKETPLACE ...........................30

AD INDEX....................................31

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KS: Dr. Moorehead, please tellus about your history andposition at JFK Medical Center.

MM: First, thank you for your

service to the American Society for

Metabolic and Bariatric Surgery

(ASMBS) and for the opportunity to

share our program’s integrated

healthcare approach to bariatric

surgery with the readership of

Bariatric Times.

After I joined JFK’s hospital-based

program, we applied, were properly

surveyed, and became a Centers of

Excellence program. Soon after, I

applied to become board certified by

the American Board of Professional

Psychology (ABPP), the oldest

credentialing body for psychology in

North America, in the specialty field

of Clinical Health Psychology. I felt

strongly that while working in

integrated healthcare with the

surgical members, board certification

was a must. I would encourage

colleagues, who are licensed

psychologists and providing services

to the bariatric patient population, to

seek board certification with ABPP

as well by visiting www.abpp.org.

KS: Please walk us through thetypical process a bariatricsurgery candidate goes throughat your center.

MM: Once bariatric surgery

candidates at the center have an

initial consult with the surgeon, they

are scheduled with both the

psychology and nutrition

departments. I initially see bariatric

candidates in the preoperative

period for a psycho-educational

behavioral health interview and

screening.

Continued on Page 22

HOT TOPICS IN INTEGRATED HEALTH

Page 14

Stepping on the scale in the

bariatric clinic at Beth Israel

Deaconess Medical Center in

Boston, Massachusetts, used to be

an all-encompassing experience as

patients nervously anticipated

what the all-important number

would register.

Sighs of relief, smiles of joy,

self-deprecating comments, and

giggles of happiness are only a few

observations made during my

seven years of working as a

registered nurse in the bariatric

clinic.

Witnessing the scale

registering a significant 100-pound

weight loss in eight months or four

pounds in one week is not

uncommon in the early stages

following weight loss surgery.

Patients are most often very

pleased with these results. But as

patients’ eyes lower to the

important number on the scale in

the latter months, when weight

loss is not as drastic, patients

sometimes appear frightened,

puzzled, or, at worst, discouraged.

COMMENTARY

Bariatric

Patients Sew

Success with

Inspirational

Quilt

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THIS MONTH:

INTEGRATED HEALTHCARE AT JFK

MEDICAL CENTER BARIATRIC WELLNESS

AND SURGICAL INSTITUTE:

A Best-Practice Model

An interview with Melodie K. Moorehead, PhD, ABPP

Column Editor and Interviewer: Karen Schulz, RN, APNPresident of the Integrated Health Section of the ASMBS; Clinical

Nurse Specialist, University Hospitals of Cleveland, Cleveland, Ohio

Editorial Message 3Bariatric Times • May 2013

Dear readers of Bariatric Times:

I just returned from Baltimore,

Maryland, after attending the annual

meeting of the Society of American

Gastrointestinal and Endoscopic

Surgeons (SAGES). My congratulations

to SAGES President Dr. Scott Melvin for

an outstanding year as leader and to

program directors Drs. Fred Brody and

Santiago Horgan for an exciting and

perfectly executed academic program.

For me, the highlight of the meeting was

the luncheon hosted by the Fellowship

Council that was attended by the

leadership of the Accreditation Council

for Graduate Medical Education

(ACGME) and the American Board of

Surgery (ABS). If I may summarize my

opinion about this meal, “I left the table

with a bitter-sweet taste in my mouth.”

The great news is that the ABS has

acknowledged the outstanding job being

done by the non-ACGME fellowship

programs endorsed by organizations,

including SAGES, the American Society

for Metabolic and Bariatric Surgery

(ASMBS), Society for Surgery of the

Alimentary Tract (SSAT), American

Society of Colon and Rectal Surgeons

(ASCRS), and International Hepato-

pancreato-biliary Association (HPBA), on

programs in hepatobiliary, bariatric,

minimally invasive, and colorectal

surgeries that help prepare residents to

practice surgery. The sad news, however,

came from our industry partners who,

understandably due to the current

financial crisis and the unpredictable

adjustments to be made with the

upcoming healthcare reform, were forced

to significantly reduce their support to

the Foundation for Surgical Fellowships.

To further illustrate the magnitude of this

problem, if a company that produces

disposable equipment has an estimated

annual growth of four percent, the taxes

on their products will increase by 2.4

percent. It is obvious that adjustments

have to be made. So, what will happen

with non-ACGME accredited fellowships?

Will they disappear or perhaps just

become smaller? Who will pay for

postgraduate surgical education? If our

leaders at the ABS are telling us that a

Fellowship Council certified training

program is “vital” for a general surgery

resident to prepare for prime time, it is

unreasonable or impossible to reduce or

eliminate this training experience. It is

rumored that some are contemplating

prolonging the number of years required

as a surgical resident (according to the

Fellowship Council Survey presented this

year by Dr. Samer Mattar at the American

Surgical Association meeting) from 5 to 6

years, while others would rather keep the

training model the way it is and have

residents spend more time during their

chief year on the specialty they have

chosen.

Surgical education is in crisis and

there is obviously no easy solution to this

problem. Hopefully (though unlikely), the

United States government, hospitals,

providers, and we surgeons will step up

to the plate and financially support this

critical time of surgical education. In

addition, residencies will have to be re-

engineered so that after three years of

basic general surgery training, young

doctors can move on to their specialties,

such as colorectal, bariatrics, and acute

care.

Recalling my “three-in-three training,”

three general surgery residencies in three

different continents—South America,

Europe, and the United States—I

remember my time in Argentina where

we had to do post-residency training for

free or work for a certain amount of years

under the supervision of an expert before

we could sit for a subspecialty exam. In

Germany, the system was different. You

could estimate that after six years of

general surgery training, which included

two years of orthopedics, neurosurgery,

and other specialties, you would be board

eligible or board certified (if you were

lucky), and after that you would spend

two additional years doing a subspecialty.

The difference was that during residency,

the salary was one of a junior attending.

That allowed the chief to keep you

waiting for 7 or 8 years in training (and

even longer if he or she didn’t like you)

before you were board eligible . But

Germany has changed and they adopted

the three-in-three training model as I

mentioned previously.

The situation of surgical education is

delicate and critical. I encourage all

alumni from the Fellowship Council who

now hold positions as attending surgeons

to contribute to the Foundation for

Surgical Fellowships and get involved so

that we can maintain the funding for the

non-ACGME training programs. The

Fellowship Council voted unanimously

that, for the time being, the number of

funded fellowships will stay the same, but

the amount of funding made available will

have to significantly decrease.

I hope you enjoy this issue of

Bariatric Times, which is terrific.

Sincerely,

Raul J. Rosenthal, MD, FACS

Editor, Bariatric Times

Raul J. Rosenthal, MD, FACS, Clinical Editor,

Bariatric Times, Professor of Surgery and

Chairman, Department of General Surgery;

Director, The Bariatric and Metabolic Institute;

Director, General Surgery Residency Program

and Fellowship in Minimally Invasive and

Bariatric Surgery, Cleveland Clinic Florida,

Weston, Florida

Surgical Education is

in Crisis: Call for All

Alumni to Get Involved,

Contribute to the

Foundation for

Surgical Fellowships

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PartnerPatrick D. Scullin

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Vice President, Executive EditorElizabeth A. Klumpp

Managing EditorAngela M. Hayes

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4Bariatric Times • May 2013

Editorial Board

Editorial Advisory BoardCLINICAL EDITOR

Raul J. Rosenthal, MD, FACSProfessor of Surgery and Chairman, Department of General Surgery; Director,The Bariatric and Metabolic Institute;Director, General Surgery ResidencyProgram and Fellowship in MinimallyInvasive and Bariatric Surgery, ClevelandClinic Florida—Weston, Fort Lauderdale,Florida

EDITORIAL ADVISORY BOARD

Ahmed R. Ahmed, BSc(Hons),FRCS(Gen)Consultant Upper GI and Bariatric Surgeon,Charing Cross Hospital, London, UnitedKingdom

Peter Benotti, MD, FACSSt. Francis Medical CenterTrenton, New Jersey

Marc Bessler, MDSurgical Director, New York-PresbyterianHospital Center for Obesity Surgery,Columbia University College of Physiciansand Surgeons, New York, New York

Robin Blackstone, MD, FACS Associate Clinical Professor of Surgery,University of Arizona School of Medicine-Phoenix; Medical Director, ScottsdaleHealthcare Bariatric Center, Scottsdale,Arizona, .ASMBS, Past-President

Laura Boyer, RN, CBN Director of Clinical Systems,The SurgicalSpecialists of Louisiana; The SurgicalSpecialists of Mississippi, Covington,Louisiana

Jay B. Brodsky, MDProfessor (Anesthesia), Medical Director—Perioperative Services, Stanford UniversityMedical Center, Stanford, California

Rafael F. Capella, MD, FACSClinical Assistant Professor of Surgery, NewJersey Medical School, Newark, New Jersey

Ricardo Cohen, MDThe Center of Excellence for the SurgicalTreatment of Obesity and MetabolicDisorders- Oswaldo Cruz Hospital, SãoPaulo, Brazil

Lillian Craggs-Dino, MS, RD, LD/NBariatric and Metabolic Institute SupportGroup Coordinator, Cleveland ClinicFlorida

Eric J. DeMaria, MDNew Hope Wellness Center, Raleigh, NorthCarolina

Terrence M. Fullum, MD, FACSAssociate Professor of Surgery, HowardUniversity College of Medicine, Chief,Division of General Surgery, Chief, Divisionof Minimally Invasive and BariatricSurgery, Director, Howard University Centerfor Wellness and Weight Loss Surgery,Howard University Hospital, Washington,District of Columbia

Michel Gagner, MD, FRCSC, FACS,FASMBS, FICS, AFC (Hon.)Clinical Professor of Surgery; Chief,Bariatric and Metabolic Surgery, HamadGeneral Hospital, Doha, Qatar.

Susan Gallagher Camden, RN, MSN,MA, CWOCN, PhDHouston, Texas

Manoel Galvao Neto, MDGastro Obeso Center, São Paulo, Brazil

Alex Gandsas, MD, MBA, FACSProfessor and Chair, Department of Surgery,UMDNJ-SOM, Stratford, New Jersey

Liz Goldenberg, MPH, RDNutritionist, Weill Medical College of CornellUniversity; New York Presbyterian Hospital,New York, New York

Karen B. Grothe, PhD, ABPP, LP Assistant Professor of Psychology; ProgramDirector, Obesity Program; SpecialtyDirector, Clinical Health PsychologyFellowship; Mayo Clinic, Department ofPsychiatry and Psychology, Rochester,Minnesota

Giselle G. Hamad, MD, FACSAssistant Professor of Surgery, University ofPittsburgh, Pittsburgh, Pennsylvania

Leslie J. Heinberg, PhDProfessor, Cleveland Clinic Lerner Collegeof Medicine, BMI Director of BehavioralServices, Cleveland Clinic, Cleveland,Ohio

Kelvin Higa, MD, FACSClinical Professor in Surgery, UCSF-FRES-NO, Director, Bariatric and MinimallyInvasive Surgery, Fresno, California

Matthew M. Hutter, MD, MPHGeneral and Laparoscopic Surgery,Department of Surgery; Director, CodmanCenter for Clinical Effectiveness In Surgery,Massachusetts General Hospital WeightCenter, Massachusetts General Hospital,Boston, Massachusetts

Sayeed Ikramuddin, MD, FACSUniversity of Minnesota, Department ofSurgery, University of Minnesota MedicalSchool, Minneapolis, Minnesota

Thomas H. Inge, MD, PhD, FACS, FAAPProfessor of Surgery and Pediatrics,Surgical Weight Loss Program for Teens,Division of Pediatric General and ThoracicSurgery, Cincinnati Children’s HospitalMedical Center, Cincinnati, Ohio

Daniel B. Jones, MD, FACSChief, Section of Minimally InvasiveSurgery, Beth Israel Deaconess MedicalCenter; Professor, Harvard Medical School,Boston, Massachusetts

Stephanie B. Jones, MDAssociate Professor, Harvard Medical School;Vice Chair for Education and ResidencyProgram; Director, Department ofAnesthesia, Critical Care and PainMedicine, Beth Israel Deaconess MedicalCenter, Boston, Massachusetts

Gregg H. Jossart, MD, FACSDirector, Minimally Invasive Surgery,California Pacific Medical Center, SanFrancisco, California

Kazunori Kasama, MDDirector, Department of Weight LossSurgery, Minimally Invasive SurgeryCenter, Yotsuya Medical Cube, Tokyo Japan

Marina S. Kurian, MDMedical Director, Department of Surgery,Bariatric Division at New York University(NYU) Langone Medical Center, New York,New York

Edward Lin, DO, FACSDirector, Emory Endosurgery Unit, EmoryUniversity School of Medicine, Atlanta,Georgia

Emanuele Lo Menzo, MD, PhD, FACS,FASMBS Minimally Invasive and Bariatric Surgery,The Bariatric and Metabolic Institute,Cleveland Clinic Florida

David Mahony, PhD, ABPPSenior Psychologist, Industrial MedicineAssociates, Tarrytown, New York; Director ofBehavioral Healthcare AssessmentInstruments, Obesity Prevention, Policy andManagement, Chantilly, Virginia

Tracy Martinez, RN, BSN, CBNProgram Director, Wittgrove BariatricCenter, La Jolla, California

Samer G. Mattar, MD, FACS, FRCS,FASMBSAssociate Professor Surgery, IndianaUniversity; Medical Director, IU HealthBariatric & Medical Weight Loss; Director,Indiana University Advanced LaparoscopicFellowship Program, Indianapolis, Indiana

Amir Mehran, MDDirector of Bariatric Surgery; AssociateClinical Professor of Surgery, UCLADepartment of Surgery, Los Angeles,California

Joseph Michaels V, MDPlastic Surgeon, Private Practice, NorthBethesda, Maryland

Marc P. Michalsky, MD, FACS, FAAP Associate Professor of Clinical Surgery;Surgical Director, Center for Healthy Weightand Nutrition, Nationwide Children’sHospital, The Ohio State University Collegeof Medicine, Department of PediatricSurgery, Columbus, Ohio

Karl Miller, MD, FACSAssociate Professor of Surgery, Head of theSurgical Department, Hallein Clinic,Hallein, Austria

Melodie K. Moorehead, PhD, ABPPBoard Certified in Clinical HealthPsychology, JFK Medical Center; BariatricWellness and Surgical Institute, Atlantis,Florida

John Morton, MD, MPH, FACSAssociate Professor of Surgery; SectionChief, Minimally Invasive Surgery; Directorof Quality, Surgery and Surgical Sub-Specialties; Director of Bariatric Surgery,Stanford School of Medicine, Stanford,California

Michel M. Murr, MD, FACSDirector of Bariatric Surgery, University ofSouth Florida College of Medicine, TampaGeneral Hospital, Tampa, Florida

Martin I. Newman, MD, FACSDepartment of Plastic Surgery, AssociateProgram Director, Education Director,Weston, Diplomate American Board ofSurgery, Diplomate American Board ofPlastic Surgery Weston, Florida

Ninh T. Nguyen, MDProfessor of Surgery, Chief, Division ofGastrointestinal Surgery, University ofCalifornia Irvine Medical Center, Irvine,California

Jürgen Ordemann, MD, PhDAssistant Professor of Surgery, Chief, Unit ofBariatric Surgery, Department of General,Visceral, Vascular and Thoracic Surgery,Charité, University Medicine Berlin,Germany

Edward Phillips, MD, FACSDirector, Center for Minimally InvasiveSurgery, Director of Endoscopic Surgery,Cedars-Sinai Medical Center, Los Angeles,California

Harry Pino, PhDDirector of Clinical Exercise PhysiologyProgram, RecoverHealth Center, New York,New York

Alfons Pomp, MD, FACS, FRCSCLeon C. Hirsch Professor; Vice Chairman,Department of Surgery; Chief, Section ofLaparoscopic and Bariatric Surgery; WeillMedical College of Cornell University; NewYork Presbyterian Hospital, New York, NewYork

Jaime Ponce, MD, FACSMedical Director, Bariatric SurgeryProgram, Hamilton Medical Center, Dalton,Georgia and Memorial Hospital,Chattanooga, Tennessee; ASMBS President;Chair, ASMBS Insurance Committee; Vice-President, ASMBS Tennessee State Chapter

Walter J. Pories, MD, FACSProfessor of Surgery, Biochemistry, Sportand Exercise Medicine, Director, BariatricSurgery Research Program, Brody School ofMedicine, East Carolina University

Craig B. Primack MD, FAAPMedical Bariatrician/Certified MedicalObesity Specialist/Co-Medical Director,Scottsdale Weight Loss Center PLLC,Scottsdale, Arizona

David A. Provost, MDProvost Bariatrics, Denton, Texas

Aurora D. Pryor, MD Professor of Surgery, Chief of GeneralSurgery, Laparoscopic, Bariatric, andGeneral Surgery, Stony Brook UniversityMedical Center, Stony Brook, New York

Almino C. Ramos, MDGastro Obeso Center, São Paulo, Brazil

Christine Ren-Fielding, MD Associate Professor of Surgery, NYU Schoolof Medicine, Director, NYU Langone WeightManagement Program, New York, New York

Alan A. Saber, MD, FACSAssociate Professor, Department of Surgery,Comprehensive Metabolic and BariatricTreatment Center, Case Western ReserveUniversity School of Medicine, Cleveland,Ohio

Michael G. Sarr, MDProfessor of Surgery, Division ofGastroenterologic and General Surgery,Gastrointestinal Research Unit (GU 10-01),Mayo Clinic, Rochester, Minnesota

David B. Sarwer, PhDAssociate Professor of Psychology,Departments of Psychiatry and Surgery,Director of Clinical Services, Center forWeight and Eating Disorders, PerelmanSchool of Medicine at the University ofPennsylvania, Philadelphia,Pennsylvania

Wendy Scinta, MD, MS, FAAFPMedical Director, Medical Weight Loss of NY,BOUNCE Program for Childhood Obesity,Fayetteville, New York; Clinical AssistantProfessor of Family Medicine, UpstateMedical University, Syracuse, New York

Michael Schweitzer, MD, FACSAssociate Professor of Surgery, JohnsHopkins University School of Medicine,Director of Minimally Invasive BariatricSurgery, Baltimore, Maryland

Shashank Shah, MBBS, MS, FAIS,FMAS (hon)Director, Department of Laparoscopic andBariatric Surgery-Ruby Hall Clinic, Pune,and Dr. L.H. Hiranandani Hospital,Mumbai, Maharastra, India

Edward Shang, MDProfessor of Surgery, Head of BariatricSurgery, Universityhospital Leipzig,Germany

Michele A. Shermak, MDThe Plastic Surgery Center of Maryland,Lutherville, Maryland

Scott Shikora, MDDirector, Bariatric Surgery, Brigham andWomen’s Hospital, Boston, Massachusetts

Christopher D. Still, DO, FACN, FACPDirector, Center for Nutrition and WeightManagement, Geisinger Health System,Danville, Pennsylvania

Prof. Dr. Michel SuterChief Surgeon, Hôpital du Chablais,Switzerland; Responsible surgeon forbariatric surgery, Department of VisceralSurgery, Lausanne, Switzerland

Samuel Szomstein, MD, FACSAssociate Director Bariatric and MetabolicInstitute and Division of MIS, DirectorBariatric Endoscopy, Cleveland ClinicFlorida; Clinical Assistant Professor ofSurgery, NOVA Southeastern University,Weston, Florida

Antonio J. Torres MD, PhD, FACS,FASMBSProfessor of Surgery, Hospital Clinico SanCarlos, Complutense University of Madrid,Spain

Olga Tucker, MD, FRCSIAcademic Department of Surgery, TheQueen Elizabeth Hospital, Edgbaston,Birmingham, United Kingdom

Andrew Ukleja, MD, AGAF, CNSPAssistant Professor of Medicine, FloridaAtlantic University, Boca Raton; Departmentof Gastroenterology, Cleveland ClinicFlorida, Weston, Florida

Rudolf A. Weiner, MDProfessor of Surgery, Frankfurt JohannWolfgang Goethe University, Head of theDepartement of Surgery of the FrankfurtSachsenhausen Hospital, Center ForBariatric Surgery, Center for MinimallySurgery, Frankfort, Germany

Noel N. Williams, MD, MCh, FRCSI,FRCSDirector of Bariatric Program, Departmentof Surgery, University of Pennsylvania,Philadelphia, Pennsylvania

Natan Zundel, MD, FACSClinical Professor of Surgery, FloridaInternational University College ofMedicine, Miami, Florida

6Bariatric Times • May 2013

Table of Contents May 2013 • Volume 10 • Number 5

EDITORIAL MESSAGE ...........................................................................................................................................3

EDITORIAL BOARD................................................................................................................................................4

SURGICAL PEARLS: TECHNIQUES IN BARIATRIC SURGERY.....................................................................................8

Vertical-banded Gastroplasty to Roux-en-Y Gastric Bypass with Remnant Gastrectomy

by Kelvin Higa, MD, FACS

ASK THE LEADERSHIP WITH RAUL J. ROSENTHAL, MD, FACS, FASMBS................................................................10

The Cost-Effectiveness of Bariatric Surgery

This month: An Interview with John M. Morton, MD, MPH, FACS, FASMBS, and Bruce M. Wolfe, MD

JOURNAL WATCH ...............................................................................................................................................12

CHECKLISTS IN BARIATRIC SURGERY .................................................................................................................13

Gastro-gastric Fistula after Roux-en-Y Gastric Bypass

by Raul J. Rosenthal, MD, FACS, FASMBS; Samuel Szomstein, MD, FACS, FASMBS;

and Emanuele Lo Menzo, MD, PhD, FACS, FASMBS

COMMENTARY ....................................................................................................................................................14

Bariatric Patients Sew Success with Inspirational Quilt

by Linda Trainor, RN, BSN

NEWS AND TRENDS............................................................................................................................................16

ED MASON AT LARGE .........................................................................................................................................20

The Mechanics of Sleeve Gastrectomy

HOT TOPICS IN INTEGRATED HEALTH ..................................................................................................................22

Integrated Healthcare at JFK Medical Center Bariatric Wellness and Surgical Institute:

A Best-Practice Model

An interview with Melodie K. Moorehead, PhD, ABPP

ANESTHETIC ASPECTS OF BARIATRIC SURGERY ..................................................................................................26

Intraoperative Fluid Assessment in Patients with Obesity

by Konstantin Balonov, MD

INTERVIEW.........................................................................................................................................................28

COUNTDOWN TO OBESITY WEEK 2013:

An Interview with Dr. Daniel Herron, MD, FACS

CALENDAR OF EVENTS .......................................................................................................................................30

MARKETPLACE CLASSIFIED ADVERTISING ..........................................................................................................30

ADVERTISER INDEX ............................................................................................................................................31

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8 Surgical Pearls Bariatric Times • May 2013

INTRODUCTIONThe vertical-banded gastroplasty

(VBG) is of historic importance.1 Its

development was one of observational

science attempting to purely “restrict”

caloric intake and was highly effective

in the short run. Less technically

challenging and safer than the early

gastric bypass, its popularity reigned in

the late 1980s. Unfortunately, this

operation failed to achieve long-term

weight maintenance due to lack of

satiety; many patients changed their

eating habits to include more easily

tolerated liquid calories and avoided

protein food sources for fear of

gastroesophageal reflux disease

(GERD) and regurgitation. Nondivided

staple lines were prone to breakdown

and the banded outflow tract was

associated with late-onset stenosis, not

amenable to endoscopic dilation.

Although not formally retired, few

centers are still performing this

operation. Because of its former

popularity, many patients are now

seeking help for weight recidivism,

inadequate weight loss, GERD, chronic

vomiting, pain, or a combination of the

above. Fortunately, conversion to

gastric bypass has been very successful

in correcting most of the complications

of this procedure, adding significantly

to the patient’s quality of life. Although

reports of conversion to adjustable

gastric banding and vertical sleeve

gastrectomy have been disappointing,

results of conversion to gastric bypass

are nearly as good as a primary

operation. However, overall operative

risks are significantly higher.2–5

Here, I describe my technical pearls

for conversion of VGB to RYGB. This

can be done open, but it is preferable to

refer the patient to a center that can

perform this operation laparoscopically,

which should be the standard approach.

It is of interest how several groups have

described this approach independent of

collaboration.6,7 This approach is not at

all intuitive, but after trying many other

methods, I have found this is the safest

and most effective means of conversion,

without compromise to the gastric

pouch construction common to re-

operative surgery.

It is irrelevant whether the vertical

staple line has broken down or if the

band used is silastic or marlex. In every

case, the pouch created is too large by

today’s standards, so by definition, a

new pouch must be created within the

confines of the previous pouch.

Thoughts of leaving behind previous

staple lines and prosthetic material

hinder one’s ability to accurately define

the residual anatomy and to preserve

the vascular supply to the new pouch,

often leading to increased risk of leaks

or compromising long-term results.

SURGICAL TECHNIQUEAs most VGB procedures have been

done through midline incisions, it is

prudent to place the first trocar

laterally, in anticipation of taking down

the omental adhesions to the incision.

Once these are freed, other trocars can

be placed appropriate to the particular

method of gastric bypass of which the

surgeon is most comfortable. For

revision surgery, it is important to

consider a manual or hand-sutured

anastomosis because of the discrepancy

of thickness of scar and other tissues

encountered.

There is usually an intense reaction

at the site of the prosthesis to the

undersurface of the left lobe of the liver.

It is more intense with marlex bands;

less so with silastic. In the past, some

surgeons have tried to interpose

omentum at this level, making

visualization even more difficult.

Staying in the correct plane of tissue to

avoid unnecessary bleeding from the

liver or serosal injury to the stomach is

key to a successful dissection. A most

important landmark is the caudate lobe

of the liver, which, once identified, is

the pathway to the lesser omentum and

then, the right crus of the diaphragm.

In all cases, the hiatus must be

identified and the esophagus mobilized

in order to correctly identify the

esophagogastric (EG) junction and

delineate the vertical staple line.

Fortunately, there will be a significant

hiatal hernia almost always present,

which helps, as this will be virgin

territory—no adhesions.

After the hiatus has been dissected

(Figure 1), the operation is

straightforward. The stomach is

transected below the previous staple

lines and prosthesis (Figure 2). (There

is no reason to preserve the fundus;

attempts to do so will compromise

formation of the gastric pouch.) The

short gastric vessels are taken down

(Figure 3) and the proximal stomach is

easily mobilized away from the

pancreas and splenic vessels (Figure 3).

Alternatively, the short gastric vessels

can be approached medially—at times

safer, with less potential injury to the

splenic hilum or pancreas (Figure 4).

At this time, the exposure is much the

same as with a standard sleeve

gastrectomy. As the greater curve is

mobilized, the lesser curve vessels can

be mobilized to a point proximal to the

prosthesis (Figure 5), 3 to 4cm distal to

the EG junction. This will define the

inferior aspect of the pouch (Figure 6).

The vertical staple line is invariably

hidden by gastro-gastric adhesions,

imbricating the “true” staple line deep

within the gastric tissue (Figure 7). It is

important to open this plane so as not

to include too much thicknesses of

stomach in the new vertical staple line.

This Month’s Featured Expert

KELVIN HIGA, MD, FACSClinical Professor of Surgery, University of California, San Francisco,Fresno, California, and Director, Minimally Invasive and BariatricSurgery, Fresno Heart and Surgical Hospital, Fresno, California

SURGICAL PEARLS:Techniques in Bariatric

Surgery

Column

Editors:

This column recruits expert surgeons to share step-by-step technical pearls on bariatric procedures.

THIS MONTH’S TECHNIQUE:

Vertical-bandedGastroplasty to Roux-en-YGastric Bypass withRemnant GastrectomyBariatric Times. 2013;10(5):8–9.

RAUL J.ROSENTHAL,MD, FACS,FASMBS

DANIEL B.

JONES, MD,

MS, FACS

ADDRESS FOR CORRESPONDENCE: Kelvin Higa, MD, FACS, Advanced Laparoscopic Surgery

Associates, 205 E. River Park Circle, Suite 460, Fresno, CA 93720; Phone: (559)-261-4500; Fax: (559)-261-4501

Vertical-Banded Gastroplasty. This diagram shows the steps of performing avertical banded gastroplasty: 1) transection of stomach distal to band and staplelines; 2) division of short gastric vessels; 3) stapling inferior aspect of pouch; and 4) vertical staple line inside previous staple lines.

9Surgical PearlsBariatric Times • May 2013

Figure 1.

Dissection of

hiatus

Figure 3.

Division of

short gastric

vessels

Figure 2.

Transection of

stomach distal

to band and

staple lines

Figure 5.

Perigastric

dissection

above ring

Figure 7.

Vertical staple

line inside

previous staple

line

Figure 8.

Gastrojejunostomy

Figure 6.

Transverse

staple line

proximal to ring

Figure 4.

Alternative,

medial approach

to short gastric

vessels

If the gastric pouch is huge, this is not

as big an issue as when it appears the

stomach to be small. In most cases, the

true staple line is 1 to 2cm deeper than

one thinks on visual inspection alone.

As the pouch is now created inside

the previous pouch, the resulting

specimen will include all the previous

staple lines as well as the prosthesis.

The gastric bypass and

gastrojejunostomy (GJ) anastomosis

can now be performed in a standard

fashion (Figure 8).

This method for conversion of the

VBG to the gastric bypass allows for

precise formation of the gastric pouch,

without compromise to its size,

orientation, blood supply, or

innervation. One would expect, then,

exactly the same results in a given

patient population as a primary gastric

bypass. These results are unusual in the

world of re-operative surgery and

perhaps, this is the only conversion

where one can observe such results.

REFERENCES

1. Mason EE. Vertical banded

gastroplasty for obesity. Arch Surg.

1982;117(5):701–706.

2. Vasas P, Dillemans B, Van

Cauwenberge S, De Visschere M,

Vercauteren C. Short- and long-term

outcomes of vertical banded

gastroplasty converted to Roux-en-Y

gastric bypass. Obes Surg.

2013;23(2):241–248.

3. Thill V, Khorassani R, Ngongang C, et

al. Laparoscopic gastric banding as

revisional procedure to failed vertical

gastroplasty. Obes Surg.

2009;19(11):1477–480.

4. Foletto M, Prevedello L, Bernante P,

et al. Sleeve gastrectomy as revisional

procedure for failed gastric banding

or gastroplasty. Surg Obes Relat Dis.

2010;6(2):146–151.

5. Suter M, Ralea S, Millo P, et al.

Laparoscopic Roux-en-Y gastric

bypass after failed vertical banded

gastroplasty: a multicenter

experience with 203 patients. Obes

Surg. 2012;22(10):1554–1561.

6. Gagné DJ, Dovec E, Urbandt JE.

Laparoscopic revision of vertical

banded gastroplasty to Roux-en-Y

gastric bypass: outcomes of 105

patients. Surg Obes Relat Dis.

2011;7(4):493–499.

7. Cadière GB, Himpens J, Bazi M, et al.

Are laparoscopic gastric bypass after

gastroplasty and primary laparoscopic

gastric bypass similar in terms of

results? Obes Surg.

2011;21(6):692–698.

FUNDING: There was no funding for the

preparation of this manuscript.

DISCLOSURES: The author reports no conflicts

of interest relevant to the content of this article.

10 Ask the Leadership Bariatric Times • May 2013

The Cost-effectivenessof Bariatric SurgeryBariatric Times. 2013;10(5):10.

Dr. Rosenthal: Drs. Morton andWolfe, what was your initialreaction to the study “Impactof bariatric surgery on healthcare costs of obese persons: a6-year follow-up of surgicaland comparison cohorts usinghealth plan data,”1 which waspublished online ahead on printin JAMA Surgery?

Drs. Morton and Wolfe: Our

initial reaction was concern that this

study was published at all. There

are several methodological flaws

with the study. The authors’

comparison cohort has not been

replicated and is predicated on

International Classification of

Diseases (ICD)9 codes associated

with obesity, not actual weight. In

addition, inclusion of patients with

unknown surgery is unsuitable given

that they could be cancer patients

or bariatric surgery revisions.

There is dramatic reduction in

follow up over the six years. Among

the 29,820 study patients, the follow

up at Years 2 through 6 is 65, 43, 25,

15, and seven percent respectively.

This exceedingly low, six-year

follow-up rate is exacerbated for

laparoscopic gastric bypass at 1.9

percent (217). It is entirely unclear

how many patients are available for

follow up or how to account for

missing data or patients without

cost claims.

Dr. Rosenthal: The article’smain conclusion was “bariatricsurgery does not reduceoverall healthcare costs in thelong term.” Do you agree with thisconclusion? Were there anyelements to the study that mayhave altered the findings, forinstance the fact that thegroup evaluated proceduresdone between 2002 and 2008(i.e., safety and effectivenessof procedures were differentand a greater percentage ofprocedures were performedopen compared to today)?Might researchers reach adifferent conclusion if, in thefuture, they evaluateprocedures done between 2008and 2014?

Drs. Morton and Wolfe: The

study time period predates modern

bariatric surgery, which includes the

accreditation initiative and

laparoscopic approach. The

laparoscopic approach renders

lower cost and complications. Open

procedures are excessive in this

study at 35 percent while current

rates are less than 10 percent.

Clearly, with improvement in safety

and effectiveness we would expect

to see cost savings.

Dr. Rosenthal: Do you feel it isimportant to evaluate the cost-effectiveness of bariatricsurgery? What articles existthat prove bariatric surgery iscost-effective?

Drs. Morton and Wolfe:Numerous publications

overwhelmingly support the cost-

benefit of bariatric surgery,

including a recent systematic review

by Wang et al2 and formal cost-

effectiveness analysis by Picot et al.3

Even with poor follow up and the

questionable comparison group in

the Weiner et al study,1 lower

pharmaceutical costs and equivalent

clinic visits were seen for the

surgical cohort. The only increase in

cost for the surgical cohort was for

surgery in the second and third

years, indicating that costs did not

emanate from the perioperative

period. This potentially increased

cost could be a reflection of “pent

up” demand for previously deferred

and needed services, such as joint

replacement or hernia repair.

Dr. Rosenthal: Do you think thisstudy and its findings mightimpact insurance coverage forbariatric procedures?

Drs. Morton and Wolfe: We

believe that a reasonable review of

the literature supports coverage for

bariatric surgery in the right

patients and in the right hands. We

fully anticipate that insurers will

continue to provide coverage for

this safe and effective procedure for

patients in need and without

recourse for their serious health

concerns. Moreover, it is medically

irresponsible to withhold needed

care when safe, effective therapy is

available. The larger question

regarding obesity discrimination

arises when bariatric surgery is held

to an inappropriate standard with

this flawed study and accompanying

editorial.

Dr. Rosenthal: Drs. Morton andWolfe, thank you for taking thetime to speak with me on thisimportant issue.

REFERENCES

1. Weiner JP, Goodwin SM, Chang

HY, et al. Impact of bariatric

surgery on healthcare costs of

obese persons: a 6-Year follow-up

of surgical and comparison

cohorts using health plan data.

JAMA Surg. 2013 Feb 20:1–8.

[Epub ahead of print].

2. Wang BC, Wong ES, Alfonso-

Cristancho R, et al. Cost-

effectiveness of bariatric surgical

procedures for the treatment of

severe obesity. Eur J Health

Econ. 2013 Mar 24.

3. Picot J, Jones J, Colquitt JL, et al.

The clinical effectiveness and

cost-effectiveness of bariatric

(weight loss) surgery for obesity:

a systematic review and economic

evaluation. Health Technol

Assess. 2009;13(41):1–190,

215–357, iii–iv.

FUNDING: No funding was provided in the

preparation of this manuscript.

FINANCIAL DISCLOSURES: The author

reports no conflicts of interest relevant to

the content of this article.

ADDRESS FOR CORRESPONDENCE:

John Morton, MD, MPH, FACS, Stanford

School of Medicine, 300 Pasteur Drive,

H3680, Stanford, CA 94305; Phone: (650)-

725-5247; Fax: 650-736-1663;

E-mail:[email protected]

http://med.stanford.edu/profiles/John_Morto

n

T h i s M o n t h ’ s I n t e r v i e w w i t h

JOHN M. MORTON, MD, MPH, FACS, FASMBSChief of the Section of Bariatric and Minimally Invasive Surgery,

Stanford University, Stanford, California, and Secretary-Treasurer of

ASMBS

BRUCE M. WOLFE, MD Professor of Surgery, Co-director of Bariatric Surgery, Oregon

Health and Science University, Portland, Oregon

Ask the

LEADERSHIP

RAUL J. ROSENTHAL, MD,FACS, FASMBS

with

This column is dedicated to sharing the vast knowledge and opinions of the American Society forMetabolic and Bariatric Surgery leadership on relevant topics in the field of bariatric surgery.

Submit Your Own Question

To submit a question for Dr. Rosenthal to “Ask the Leadership,” e-mail AngelaHayes at [email protected]. Include “Ask the Leadership” in the subjectline of your e-mail. All questions are reviewed by the editors and are selectedbased upon interest, timeliness, and pertinence, as determined by the editors.There is no guarantee a submitted question will be published or answered.Published questions are edited and may be shortened.

12 Journal Watch Bariatric Times • May 2013

The comparative effectiveness of

sleeve gastrectomy, gastric bypass,

and adjustable gastric banding

procedures for the treatment of

morbid obesity.

Carlin AM, Zeni TM, English WJ, et al.

Ann Surg. 2013;257(5):791–797.

Synopsis: The authors conducted a

study to evaluate the comparative

effectiveness of sleeve gastrectomy

(SG), laparoscopic gastric bypass

(RYGB), and laparoscopic adjustable

gastric banding (LAGB) procedures.

Citing limitations of published studies,

payers have been reluctant to provide

routine coverage for SG for the

treatment of morbid obesity. Using data

from an externally audited, statewide

clinical registry, the authors matched

2949 SG patients with equal numbers of

RYGB and LAGB patients on 23 baseline

characteristics. Outcomes assessed

included complications occurring within

30 days, and weight loss, quality of life,

and comorbidity remission at 1, 2, and 3

years after bariatric surgery. Matching

resulted in cohorts of SG, RYGB, and

LAGB patients that were well balanced

on baseline characteristics. Overall

complication rates among patients

undergoing SG (6.3%) were significantly

lower than for RYGB (10.0%, P<0.0001)

but higher than for LAGB (2.4%,

P<0.0001). Serious complication rates

were similar for SG (2.4%) and RYGB

(2.5%, P = 0.736) but higher than for

LAGB (1.0%, P<0.0001). Excess body

weight loss at 1 year was 13% lower for

SG (60%) than for RYGB (69%,

P<0.0001), but was 77% higher for SG

than for LAGB (34%, P<0.0001). SG

was similarly closer to RYGB than LAGB

with regard to remission of obesity-

related comorbidities.

The authors concluded that with better

weight loss than LAGB and lower

complication rates than RYGB, SG is a

reasonable choice for the treatment of

morbid obesity and should be covered

by both public and private payers.

PMID: 23470577

Neurodegenerative disease and

obesity: what is the role of weight

loss and bariatric interventions?

Ashrafian H, Harling L, Darzi A,

Athanasiou T. Metab Brain Dis. 2013

May 8. [Epub ahead of print]

Synopsis: Neurodegenerative diseases

are amongst the leading causes of

worldwide disability, morbidity and

decreased quality of life. They are

increasingly associated with the

concomitant worldwide epidemic of

obesity. Although the prevalence of both

Alzheimer’s disease (AD) and

Parkinson’s disease (PD) continue to

rise, the available treatment strategies

to combat these conditions remain

ineffective against an increase in global

neurodegenerative risk factors. There is

now epidemiological and mechanistic

evidence associating obesity and its

related disorders of impaired glucose

homeostasis, type 2 diabetes mellitus,

and metabolic syndrome with both AD

and PD. Here, the researchers describe

the clinical and molecular relationship

between obesity and neurodegenerative

disease. Secondly, they outline the

protective role of weight loss, metabolic

and caloric modifying interventions in

the context of AD and PD. The

researchers conclude that the

application of caloric restriction through

dietary changes, bariatric (metabolic)

surgery and gut hormone therapy may

offer novel therapeutic strategies against

neurodegenerative disorders.

Investigating the protective mechanisms

of weight loss, metabolic and caloric

modifying interventions can increase

our understanding of these major public

health diseases and their management.

PMID: 23653255

Warfarin users prone to

coagulopathy in first 30 days after

hospital discharge from gastric

bypass.

Bechtel P, Boorse R, Rovito P, et al.

Obes Surg. 2013 May 6. [Epub ahead of

print]

Synopsis: Lehigh Valley Health

Network (LVHN), a nonprofit tertiary

care facility in Allentown, Pennsylvania,

is an accredited American College of

Surgeons Bariatric Surgery Center

Network (ACSBSCN) Level 1 site

performing 400+ bariatric procedures

annually. Bariatric data submission

began in April 2008. Complication

review revealed that approximately 17

percent of patients on chronic

anticoagulation (warfarin) therapy

preoperatively were readmitted with

supratherapeutic international

normalized ratios (INRs), postsurgical

bleeding, anastomotic ulcer, or other

intraluminal hemorrhage. Opinion level

recommendations have been published

regarding the adjustment of warfarin

dosages post-bariatric procedures with

no widespread consensus. Case series

have been published detailing

perioperative hemorrhage risk for

bariatric patients on preoperative

anticoagulation. Little data of post-

discharge hemorrhage rates have been

published. With increasing numbers of

bariatric surgical procedures performed

annually, there is a potential for

developing serious coagulopathic

complications in those patients who

resume their anticoagulation therapy

postoperatively. Retrospective review of

LVHN data from the ACSBSCN database

was analyzed for 30-day readmissions

due to documented extra- or

intraluminal hemorrhage with INR and

coagulopathy. Follow-up INR and

warfarin doses were collected up to 6

months postoperatively. the authors

found that over a three-year period, 38

patients undergoing bariatric

procedures were identified as being on

preoperative warfarin therapy. Six of 38

developed hemorrhage within 30 days.

Two patients presented beyond 30 days

with bleeding. Supratherapeutic INR

was present in five of six readmitted

patients. Mean INR was 5.8. Warfarin

sensitivity was present in a statistically

significant higher number of patients

within 30 days of surgery. After 30 days,

a resistance to warfarin was

demonstrated. The authors concluded

that bariatric surgery patients taking

warfarin are prone to coagulopathy in

the early post-op period requiring

vigilant monitoring to prevent

supratherapeutic INR and

corresponding risk of hemorrhage.

PMID: 23645479

Moderate physical activity as

predictor of weight loss after

bariatric surgery.

Mundi MS, Lorentz PA, Swain J, et al.

Obes Surg. 2013 May 1. [Epub ahead of

print]

Synopsis: This study assessed whether

the short-form International Physical

Activity Questionnaire (IPAQ-SF) data

at 1 year postbariatric surgery would

correlate with success (defined as more

than 50 % excess weight loss (EWL))

after surgery. The IPAQ-SF

questionnaire provided assessment of

subjects’ activity level over the last

seven days, in four separate activity

domains: vigorous, moderate, walking,

and sitting. Questionnaires were

completed and collected at the 1-year

postbariatric surgery group visit. Then,

118 subjects who completed the IPAQ-

SF were subdivided based on loss of

greater than or less than 50 percent of

their excess weight, which in turn was

based on ideal body weight. The authors

concluded that physical activity does

correlate with success after bariatric

surgery, as measured by excess weight

loss (≥50 % EWL).

PMID: 23636999

Metabolic changes one year after

laparoscopic adjustable gastric

banding operation in morbidly

obese subjects.

Visockiene Z, Brimas G, Abaliksta T, et

al. Wideochir Inne Tech Malo

Inwazyjne. 2013;8(1):13–21. Epub

2012 Sep 29.

Synopsis: The researchers conducted a

prospective, nonrandomized single

center cohort study in morbidly obese

subjects to assess weight loss and

changes of metabolic parameters one

year after laparoscopic adjustable

gastric banding (LAGB). Physical

examination, body weight (BW)

parameters and metabolic profile were

assessed at baseline and one year after

LAGB in subjects with morbid obesity.

The incidence of MS was evaluated

according to National Cholesterol

Education Program Adult Treatment

Panel III criteria. One year after the

operation data from 90 patients out of

103 were available. Mean excess weight

(EW) loss of 33.1 percent was

associated with a significant

improvement in all metabolic

parameters: decrease of hypertension

by 15.8 percent, hypertriglyceridemia by

42.6 percent, and hyperglycemia by 46.3

percent; and increase in high density

lipoprotein cholesterol by 48.3 percent.

This resulted in the resolution of

metabolic syndrome (MS) in 44.2

percent of subjects. The significant

change in the distribution of MS

components was observed with the

highest frequency of four components

before and two components after

surgery. Patients with MS at baseline

lost 29.9 percent of EW compared to

44.3 percent in those without MS

(p=0.009). The authors concluded that

LAGB resulted in effective reduction of

BW parameters in morbidly obese

subjects one year after the operation.

Along with the weight loss, resolution of

MS and a significant shift towards

decrease in the number of MS

components was observed. Patients

with MS were more resistant to the

weight loss.

PMID: 23630549

Watch

Journal

A quick look at the

noteworthy articles

in bariatric and

metabolic research

13Checklists in Bariatric SurgeryBariatric Times • May 2013

Checklists in Bariatric Surgery

Welcome to “Checklists inBariatric Surgery.” Thiscolumn’s aim is to help

bariatric surgeons quickly reviewthe reasons for potentialproblems when caring forbariatric patients.

In this eighth installment ofthe column, we discuss gastro-gastric fistulas after Roux-enYgastric bypass (RYGB).

We hope you clip and save thisconvenient checklist and find ituseful as a reference tool in youreveryday practice.

Please stay tuned for morechecklists in upcoming issues ofBariatric Times.

FUNDING: No funding was provided.

DISCLOSURES: Dr. Rosenthal receives

educational grants from Covidien, Baxter,

Karl Storz, W.L. Gore, and Ethicon Endo-

Surgery. He is on the advisory board of

MST. Drs. Szomstein and Lo Menzo

report no conflicts of interest relevant to

the content of this article.

ADDRESS FOR CORRESPONDENCE:

Raul J. Rosenthal MD, FACS,

FASMBS, Cleveland Clinic Florida, 2950

Cleveland Clinic Blvd., Weston,

FL 33331; Phone (954) 659-5228; Fax

(954) 659-5256; E-mail: [email protected]

Column Editor

RAUL J. ROSENTHAL,

MD, FACS, FASMBS

Clinical Editor, Bariatric Times,Professor of Surgery and

Chairman, Department of General Surgery;Director, The Bariatric and MetabolicInstitute; Director, General SurgeryResidency Program and Fellowship inMinimally Invasive and Bariatric Surgery,Cleveland Clinic Florida, Weston, Florida

SAMUEL SZOMSTEIN,

MD, FACS, FASMBS

Associate Director of theBariatric Institute and Section ofMinimally Invasive Surgery at

the Cleveland Clinic in Weston, Florida, andClinical Associate Professor of Surgery,Florida International University

E. LO MENZO MD, PhD,

FACS, FASMBS

Staff Surgeon, The Bariatric andMetabolic Institute, Departmentof General Surgery, Cleveland

Clinic Florida, Weston, Florida.

Column Co-editorsREADER HANDOUT: Cut, copy, and distribute.

CHECKLIST #8

Gastro-gastric Fistula after Roux-en-Y Gastric Bypassby RAUL J. ROSENTHAL, MD, FACS, FASMBS; SAMUEL SZOMSTEIN, MD, FACS, FASMBS; and EMANUELE LO MENZO, MD, PhD, FACS, FASMBS

CHECKLIST #8

Gastro-gastric Fistula after Roux-en-Y Gastric BypassBariatric Times. 2013;10(5):13

P CHECKLISTS IN BARIATRIC SURGERY

Disclaimer: The information in this handout is for educational purposes only and should not be used as a primary source of treatment.

Please visit www.bariatrictimes.com to download thePDF of this handout OR scan the QR code to the rightfor a direct link to the Bariatric Times website.

Sponsored by Matrix MedicalCommunications

Publishers of

P

Bariatric Times. 2013;10(5):13

HISTORY:

__Recurrent marginalulcers refractory tomedical treatment orweight regain, abdominalpain, nausea, andvomiting

__If recurrent orrefractory marginal ulcer,rule out the presence ofhypersecretory states,such as gastrinoma(check gastrin levels),even if a G-G fistula isidentified

P DIAGNOSIS:

__UGI with Cleveland Clinic Florida G-G fistula protocol (oblique andprone pictures).

__Also assess pouch and anastomosis sizes, limb lengths.

__EGD looking for fistula.

__Also measure pouch, assess status of mucosa, presence of marginalulcers, distance of fistula opening from the GJ anastomosis.

__CT scanLook for presence of foreign bodies, gastric remnant distention withair and contrast

P

TREATMENT:

MedicalIf minimal symptoms andpresence of marginal ulcer:

__PPI__carafate__smoking and NSAIDscessation.

__Re-evaluate in 6 weeks

EndoscopicIf fistula <5 mm in diameter:

__attempt endoscopic closure (injection or fibrins glue, plasmacoagulation, clipping, stenting,and various endoscopic suturingtechniques).

• Larger fistulas will unlikelyclose with endoscopicinterventions.

Surgical

__Review original surgeryoperative report• presence of anastomoticforeign bodies, route of Rouxlimb, limb lengths, divided vs.nondivided

Approach__OPEN or __LAPAROSCOPIC

__If fistula high and no marginalulcer:

Resection of the fistuloustract

__If fistula by GJ anastomosis,persistent marginal ulcer, GJstricture:

Resect the entireanastomosis/fistula complex and re-do anastomosis.

__If documented acidhypersecretion:

Consider pouch trimming andtruncal vagotomy

__If resection involvessignificant portion of gastricremnant:

Considercompleteremnantgastrectomyto avoidretainedantrumsyndrome.

P

P

P

P

P

P

P

P

v Surgeon’s Tip: Adequate length of aretrocolic retrogastric Roux limb can beachieved by mobilization of the jejunum

as it passes through the transversemesocolon and pivoting around its

unmobilized mesentery.

v Surgeon’s Tip:In order to avoidmucoceles, do

not leave vascu-larized gastric tis-

sue without adrainage route.

a

a

14 Commentary Bariatric Times • May 2013

Continued from page 1

The fact is that the use of the scale

does provide an accurate body mass

index (BMI) for clinics, but clearly does

not have the capacity to speak to a

patient’s real success. In fact, I have

found that the scale can sometimes be

inversely proportionate to a patient’s

well-being. Even slight elevations in

weight, or staying at the same weight,

have bothered many patients, as their

eyes are glued to that number—rather

than on the prize of a better quality of

life.

I specifically recall discussing quality

of life changes with one puzzled patient

who was visibly shaken that the number

on the scale dared remain the same

after she incorporated an exercise plan

into her daily routine. She even asked if

she could remove all of her clothing and

put on a hospital gown to help register

greater weight loss.

“How would your life change if the

scale registered two pounds less

today?” I asked her. The patient

pondered the question for a moment

and answered, “Quite frankly, it

wouldn’t.”

It was a humbling moment for her as

a patient and for me as her nurse.

“Scales are for fish and not a true

indicator of success,” I explained. We

both laughed.

The mood shifted as we

concentrated on how her waistline was

slimmer and her dress size went from

24 to 16 in a matter of months. Most

heartwarming was when she shared

that she had recently attended Parent

Night at her child’s elementary school

and was able to sit in her child’s chair.

She shared how this moment spoke

volumes to improving her quality of life

compared to the number she just

witnessed on the scale.

Shy of having the scale thank

patients for their patronage and loyalty,

our bariatric team designed a way to

shift the focus away from a number at

the time that weight is measured, to the

quality of life the patient is

experiencing.

Staff and patients collaborated as a

team to create the “Now I Can” quilt.

The idea, which originated from the

multidisciplinary bariatric team, was to

have patients showcase their success

stories in a personal and profound way.

Patients were simply asked to

submit on an index card a “Now I

Can”—something specific that they

could not do prior to having weight loss

surgery. Patients were asked to include

only their date of surgery and initials

with their “Now I Can” statement.

One patient, a school teacher,

shopped for colorful material to create

the quilt squares. The finished

measurement of the quilt would be 10

feet by 10 feet, with 4 x 4-inch squares.

A larger square was placed in the

center of the quilt with a clear and

concise message: Now I Can. The

border proudly repeats a ceremonious

theme of endorsement: “I think I can. I

know I can. Now I can.”

Another patient, an artist,

volunteered to transcribe the many

messages from the index cards to the

squares of material, and then sew them

all together.

Patients who helped the project

along were happy to volunteer, saying

that it was their way to thank the

bariatric team for their continued

support prior to, during, and after their

respective weight loss surgeries.

The quilt not only fashions patients’

success stories, but also helps to create

a clinic without walls.

Many new patients as well as

postoperative patients are thrilled to

read the written messages on the quilt

that include such “Now I Can”

statements as the following:

• Have hope again

• Fly on an airplane without an

extension belt

• Dance

• Look in the mirror

• Live my life without taking

medications.

Our bariatric quilt was a collective

effort that serves to inspire patients to

change their perception. Our goal was

to bring awareness to real changes, in

real time, by real people.

The quilt hangs in the clinic right

next to the scale. Now, when patients

weigh in, they are squarely faced with

their bari buddies’ living testimonials of

their true measurements of success.

The result is the best of both worlds

because it cheerfully connects patients

together while bringing awareness to

individuals’ very own potential.

However, in addition to those many

inspirational testimonials colorfully

displayed on the front of the quilt, the

most heartwarming message is really

written on the back. It reads:

“This quilt is dedicated to the

brave men and women who have

empowered themselves through the

BIDMC weight loss program. Let this

inspire change …”

FUNDING: No funding was provided.

DISCLOSURES: The author reports no conflicts

of interest relevant to the content of this article.

AUTHOR AFFILIATION: Ms. Trainor is from

Beth Israel Deaconess Medical Center, Boston,

Massachusetts.

ADDRESS FOR

CORRESPONDENCE:

Linda Trainor, RN, BSN;

Phone: (617)-667-0115;

E-mail: Ltrainor@bidmc.

harvard.edu

Bariatric Patients

Sew Success with

Inspirational Quilt

by LINDA TRAINOR, RN, BSN

Bariatric Times. 2013;10(5):14. The “Now I Can” quilt, created by bariatric patients at the Beth Israel DeaconessMedical Center, Boston, Massachusetts

Example of “Now I Can” statements submitted by patients included their initials,date of surgery, and something specific they are now able to do as a result oftheir weight loss surgery.

“The “Now I Can” quilt, which was the brainchild of

Linda Trainor, was an awesome idea that has rallied our

patients together.”

-Dr. Dan Jones, Director of the BIDMC Bariatric Program

16 News and Trends Bariatric Times • May 2013

SOCIETY OF AMERICAN

GASTROINTESTINAL AND

ENDOSCOPIC SURGEONS ISSUES

STATEMENT ON BENEFITS OF

LAPAROSCOPIC OBESITY SURGERY

Governor Chris Christie’s Decision to

Undergo Procedure Provides Opportunity to

Educate Patients

LOS ANGELES, California—

Committed to enhancing overall patient

well-being, the Society of American

Gastrointestinal and Endoscopic

Surgeons (SAGES) issued a statement

on the benefits of laparoscopic obesity

surgery. “We echo the NIH consensus

that weight loss surgery is the only

effective, long-term method for the

treatment of obesity while diet

management and other systems achieve

temporary results,” said Dr. Scott

Melvin, Professor and Chief of

Gastrointestinal Surgery at Ohio State

University and the immediate past

President of SAGES. “For the right

patients, surgery for obesity is life

saving, improves quality of life, and may

even reduce healthcare costs over the

course of time. New Jersey Governor

Chris Christie’s decision to share his

experience has provided a valuable

opportunity for patients to educate

themselves and dialogue with their

physicians on such minimally invasive

surgical (MIS) procedures,” Dr. Melvin

said.

SAGES has been at the forefront of

best practices in laparoscopic obesity

surgery by researching, developing, and

disseminating the guidelines and

training for standards of practice in

surgical procedures. Both open and

laparoscopic bariatric operations are

effective therapies for morbid obesity

and represent complementary state-of-

the-art procedures; however, as is the

case with a majority of MIS procedures,

recovery is generally faster with MIS

and there are less complications.

Patients are encouraged to review

the SAGES Patient Information

Guidelines for Laparoscopic Surgery for

Severe (Morbid) Obesity at

http://www.sages.org/publications/patien

t_information to learn about treatment

options, the advantages of laparoscopic

obesity surgery and if they would be

considered as a candidate for this type

of surgery.

AMERICAN ASSOCIATION OF

CLINICAL ENDOCRINOLOGISTS

RELEASES NEW COMPREHENSIVE

DIABETES MANAGEMENT

ALGORITHM FOR TREATMENT OF

DIABETES AND PREDIABETES

PATIENTS

JACKSONVILLE, Florida—The

American Association of Clinical

Endocrinologists (AACE) announced

the publication of its new

comprehensive diabetes management

algorithm created to guide primary care

physicians, endocrinologists, and other

healthcare professionals in the

treatment of prediabetes and type 2

diabetes mellitus (T2DM) patients.

Recommendations in the algorithm,

published online at

https://www.aace.com/files/glycemic-

control-algorithm.pdf and in the

March/April 2013 issue of the

association’s peer-reviewed scientific

journal Endocrine Practice, consider

the whole patient, the spectrum of risks

and complications for the patient, and

evidence-based approaches to

treatment.

Specifically, the document provides

suggestions for treatment prioritization

News

and

TrendsMAY 2013

Bariatric Times. 2013;10(5):16–18

17News and TrendsBariatric Times • May 2013

and risk-reduction strategies while

addressing the following circumstances

and conditions that frequently are

precursors to, or are concurrent with,

a T2DM diagnosis:

• Management of diabetes and co-

existing diseases or disorders in the

prediabetic phase of disease

• A hierarchy of steps for the

management of high blood sugar

control using an approach that

balances age and comorbidities

while minimizing the adverse effects

of hypoglycemia and weight gain

• Complications-centric treatment of

the patient with overweight or

obesity, as opposed to a body mass

index (BMI)-centric approach,

including medical and surgical

treatments for greater weight loss

• Management of cardiovascular

disease risk factors, hypertension,

and hyperlipidemia (high lipid

levels) in those patients with

prediabetes or T2DM.

Among the algorithm’s key

recommendations is that a

comprehensive care plan for persons

with diabetes must now consider

obesity management as an integral

part of the overall treatment plan to

effectively reduce morbidity, mortality,

and disability in the majority of

patients with T2DM who are obese.

Also, while suggesting a blood sugar

goal of <6.5% as optimal for most

diabetes patients if it can be achieved

in a safe manner, the algorithm

recommends the target be

individualized based on numerous

factors, such as age, comorbid

conditions, duration of diabetes, risk of

hypoglycemia, patient motivation and

adherence, and life expectancy. Higher

targets may be appropriate for some

individuals and may change for a given

individual over time.

The algorithm includes every FDA-

approved class of medications for

diabetes and differentiates the choice

of therapies based on the patient’s

initial A1C.

“This algorithm is a definitive, point-

of-care tool for clinicians engaged in

the treatment of those who are at risk

for or have developed diabetes,” said

Alan Garber, MD, PhD, FACE, chair of

the algorithm task force and President

of AACE. “We have expanded on our

previous efforts to address broad-

reaching, critical factors that

accompany the disease and its

treatment.”

“With more than 100 million

suffering from diabetes and

prediabetes in the United States, there

simply are not enough endocrinologists

to care for all patients,” he added.

“Thus, this algorithm is essential to

assist and educate clinicians who are

charged with these patients’ care.”

To learn more about the AACE, visit

www.aace.com.

LOMA LINDA UNIVERSITY MEDICALCENTER UTILIZES NEW,INNOVATIVE SYSTEM TO TREATGASTROESOPHAGEAL REFLUXDISEASE

LOMA LINDA, California—Loma

Linda University Medical Center

(LLUMC) is the first medical facility in

the Inland Empire to utilize the LINX

Reflux Management System to treat

Gastroesophageal Reflux Disease

(GERD). LLUMC is one out of six

facilities that offer this specialized

procedure in California.

Dr. Marcos Michelotti, a minimally

invasive surgeon at Loma Linda

University Medical Center, is excited to

be able to offer such an innovative

technique to those suffering from

gastroesophageal reflux. “The LINX

system will prove itself beneficial to

our patients as it is supported through

robust research and will provide

economic benefits,” he said.

The LINX System is a small implant

comprising interlinked titanium beads

with magnetic cores. The magnetic

attraction between the beads

augments the existing esophageal

sphincter’s barrier function to prevent

reflux. The device is implanted with a

18 News and Trends Bariatric Times • May 2013

standard, minimally invasive,

laparoscopic procedure and is an

alternative to the more anatomically

disruptive fundoplication, commonly

used in surgical anti-reflux procedures.

To read the full press release, visit

http://www.prweb.com/releases/prweb20

13/4/prweb10636709.htm

For additional information on the

LINX system, including pictures and

animation visit

https://www.dropbox.com/s/112pitawprs

hvt0/LINX%20Center%20Media%20Kit2

.zip

For more information about this

procedure at LLUMC, please call 909-

558-4000, ext. 43616.

CAREFUSION LAUNCHES NEW

DRAINAGE PRODUCTS AT SOCIETY

OF INTERVENTIONAL RADIOLOGY

ANNUAL SCIENTIFIC MEETING

SAN DIEGO, California—

–CareFusion Corp., a global medical

technology company, introduced three

new products to help physicians with

the drainage of fluids for patients with

ascites and pleural effusions.

The new products were on exhibit in

at the 38th Annual Society of

Interventional Radiology (SIR) Scientific

Meeting being held in New Orleans,

April 15 to 17, 2013. Highlighted

products included the following:

• Denver® shunt 15.5 Fr percutaneous

access kit (PAK): Denver 15.5 Fr

shunts are now available in a procedure

tray containing updated components for

percutaneous placement. The new

procedure tray helps effectively manage

refractory ascites patients.

• New 5 Fr Thora-Para device: A

smaller version of CareFusion’s existing 8

Fr Thora-Para device, features an echo-

enhanced needle, which improves

visualization under ultrasound. The

device offers an optimized tip taper and a

new surface treatment, shown to

minimize insertion force. The catheter

offers large, spirally oriented drainage

holes that facilitate fast flow rates, which

may lead to decreased procedure time.

• PleurX® Catheter System: The PleurX

catheter system is easy to use for

managing recurrent pleural effusions and

malignant ascites at home. A new

supplemental catheter insertion kit will

help reduce the amount of fluid leakage

during catheter placement. The kit

includes an orange stylet designed to

occlude the openings in the catheter

during placement, and a valved

introducer that helps prevent air from

entering and fluid from leaking.

More information may be found at

www.carefusion.com.

MICROLINE SURGICAL LAUNCHES

ENHANCED MISEAL REPOSABLE

THERMAL LIGATING SYSTEM AT

SAGES 2013 ANNUAL MEETING

BEVERLY, Massachusetts—Microline

Surgical, Inc., a manufacturer of

reposable instruments for minimally

invasive surgery, launched an enhanced

version of its MiSeal Reposable Thermal

Ligating System at The Society of

American Gastrointestinal and

Endoscopic Surgeons (SAGES) 2013

Scientific Session and Postgraduate

Course in Baltimore, Maryland. MiSeal

comprises a reusable handle and

disposable tips, combining the precision

of a fully disposable instrument with the

economic benefits and quality of a fully

reusable handpiece. Leveraging

feedback from surgeons, Microline has

redesigned MiSeal to feature a more

ergonomic handle that can be locked

into position for continuous sealing to

minimize fatigue and improve the

surgeon’s experience when performing

long, complex surgical procedures.

For more information on MiSeal,

please visit www.microlinesurgical.com

PROGRAM DIRECTORS

CLEVELAND CLINIC FLORIDA

ORGANIZING FACULTY

PROGRAM DESCRIPTION

TARGET AUDIENCE

Jacqueline McCartney, RN,RM, CNOR, CBNCoordinator, Bariatric and MinimallyInvasive Surgery Operating RoomCleveland Clinic FloridaWeston, Florida

Raul J. Rosenthal, MDSamuel Szomstein, MDEmanuel Lo Menzo, MD

Andre Teixeira, MDMelodie K. Moorehead, PhDLisa Stewart, PhD, LMhCNatan Zundel, MD, FACSPaul Wizman, MD

INVITED FACULTY

CLEVELAND CLINIC FLORIDA

INVITED FACULTY

Karla Abregu, RN, BSNKarol BastiasNicole Berry, RN, BSNBev Capasso, RN MSNKaren Conigliaro, RN, CBNSteven Earle, MDDouglas FairmanCIndy HillSantiago Luis, MDNancy McGilvary, STSherwin Chang, PTJuliana Maso, CSTDeanna Raynolds, LPNMary Lou Schreiner, RN, CNORGricelle Vazquez-Navarro, RNAndrew Ukleja, MD, AGAF, CNSP

Lillian Craggs-Dino, DHA, RDN,LDNRegistered Dietician and Support GroupCoordinatorBariatric and Metabolic InstituteCleveland Clinic FloridaWeston, Florida

Mindy Mund, RN, CBNProgram Coordinator,Bariatric and Metabolic InstituteCleveland Clinic FloridaWeston, Florida

The Bariatric Institute at Cleveland Clinic Florida is pleased to invite you to participate in Allied Health

Course “The Bariatric Allied Health Professional’s Role in a Multidisciplinary Specialty.” Allied Health

professionals provide exemplary care to patients on a daily basis to patients having Metabolic Surgery.

The various specialties involved in creating successful outcomes for these patients will be highlighted in

this program. The ASMBS has identified new guidelines for the practice of these professionals where

patients can expect to receive safer and more effective surgical treatment. This program will emphasize

multidisciplinary care as well as discuss these guidelines as an integral and efficient approach to the

treatment of the bariatric patients.

The course is intended for allied health professionals including Nurses, Surgical Technicians, Dieticians,

Physical Therapists, Physician Assistants, Insurance Specialists, and Psychologists who are currently

involved in the treatment of bariatric patients and for those who are entering the specialty.

ACCREDITATION

Cleveland Clinic Florida is accredited by the Accreditation Council for Continuing Medical Education

(ACCME) to sponsor continuing medical education for physicians.

DESIGNATION OF CREDIT

Nurses: Approved for 8 hours of Continuing Nursing Education by the Florida Board of Nursing. NCE 2334.Surgical Technologists: This continuing education activity is approved by the Association of SurgicalTechnologists, Inc. for 7.5 CE credits for the CST and CFA.Dietitians: Approved by the Commission on Dietetic Registration for 7.5 CEUs.This continuing education activity is pending approval for the following:

• Physician Assistants• Physical Therapists• Coders

OBJECTIVES

As with any surgery, there are associated risks and complications with bariatric treatment.

Care is particularly challenging because morbid obesity usually involves a myriad of other medical prob-

lems that need to be addressed. We cannot eliminate all the unfortunate issues from happening, but we are

committed to making patient’s experience with bariatric surgery as safe and effective as possible.

At the conclusion of this program, the participants will be able to:

• Discuss the variety of obesity treatment options, including new surgical approaches and behavioral/

support programs, specific diets, physical activity recommendations, medications, surgery, and

identify strategies for promoting success

• Evaluate tools, and strategies which are useful when working with obese patients

• Describe important considerations when establishing a Bariatric practice

• Provide a new approach to enhancing quality and safety incorporating risk reduction strategies into

your practice

• Establish programs and processes that demonstrate quality and performance improvements

The Bariatric Allied Health

Professional’s Role In A

Multidisciplinary SpecialtyJULY 13, 2013 • HYATT PIER SIXTY-SIXFORT LAUDERDALE, FLORIDA

REGISTER NOW!

w w w . C l e v e l a n d C l i n i c F l o r i d a C M E . o r g

20 Ed Mason at Large Bariatric Times • May 2013

Could you talk about the mechanics ofsleeve gastrectomy?-Dr Girish JunejaDirector Bariatric Programme International Modern HospitalDubai, United Arab Emirates

Dr. Mason: Normal functions of both

stomach and duodenum are eliminated

by sleeve gastrectomy (SG).

Functionally, all that is left is a lesser

curvature tube from esophagus to

jejunum. This remaining sleeve of

stomach is equivalent to a segment of

small bowel used to replace the stomach

after total gastrectomy. What is

swallowed reaches the jejunum without

the elaborate regulation of gastric

emptying by osmolality and other

receptors in the duodenum. Highly

concentrated contents reaching the

upper small bowel cause an intestinal

flush to the distal bowel where the L

cells are stimulated by glucose to

secrete glucagon-like peptide 1

(GLP-1).

SG has the same effect as total

gastrectomy. In a study of total

gastrectomy, Miholic et al1 found a peak

GLP-1 secretion occurring 15 minutes

after the beginning of a standard meal.

There was no difference between Roux-

en-Y reconstruction, which bypasses the

duodenum, and insertion of a segment

of small bowel with passage of contents

through the duodenum. This means that

when the stomach is converted to a

tube, the duodenum also becomes a

functionless tube. The duodenal mixing

of swallowed contents with bile and

pancreatic juice is no longer regulated

to provide a diluted solution. The

discharge into the upper small bowel is

no longer regulated to provide for ideal

digestion and absorption for regulation

of the body’s optimum concentration of

circulating glucose.

Glucose and other stimulants of L

cells in a normal digestive tract are

absorbed before they reach the ileum

after the initial gush. Normally, the peak

elevation of plasma GLP-1 is reached in

15 minutes after the beginning of a

meal, which was difficult to explain until

Brener et al2 described the initial gastric

emptying gush, which provides

duodenal feedback and regulates

subsequent stomach emptying squirts.

Schirra et al3 demonstrated that there is

a glucose threshold for flushing. After

SG there is no initial gastric gush, but

there is unregulated and more frequent

flushing resulting in excessive GLP-1

secretion and improvement of type 2

diabetes (T2D).

In the early days of bariatric

surgery, operations were thought to

cause weight loss by restricting intake

or causing malabsorption or by a

combination. Surgeons also observed

that T2D no longer required medical

treatment after bariatric surgery. These

observations were made after intestinal

bypass in 1954 and again after gastric

bypass in 1966. In 1998, Näslund et al4

called attention to the importance of

GLP-1 in resolving T2D by intestinal

bypass. This paper suggested to me that

the common denominator between

intestinal and gastric bypass was rapid

movement of glucose to the ileum. I

suggested a study of moving the ileum

to a juxta duodenal position.5 Strader et

al6 performed the ileal transposition in

rodents and it increased postprandial

GLP-1 secretion. In 2011, Näslund’s

group that had demonstrated the

importance of GLP-1 in resolving T2D

by intestinal bypass provided a similar

study and result for gastric bypass.7

Glucose and other stimulants of GLP-1

secretion, which are normally absorbed

in the upper small bowel, were reaching

the ileal L cells.

Humans discover the same

important relationships at different

times according to their experience,

study, and problem-solving stress. My

experience with gastric dumping

prepared me for recognizing the

importance of rapid transit. However, I

did not know about Brener’s2 study of

individuals of normal weight of

gush/flush/GLP-1 secretion until I was

confronted with the question as to why

lean people, who supposedly did not

dump, were free of T2D. In fact, those

who are lean do dump. If there is no

gush and no flush then there is T2DM. If

you are having difficulty in following my

efforts to make dumping the key to a

new paradigm about T2D, you should

consult the study by Koopmans et al8

study on ileal transposition. This

prepared me for the recognition of the

importance of dumping. My concept of

serendipity is a mind prepared with the

experiences that need to fall in place in

solving a problem. Important pieces of a

puzzle need to be provided before they

can form a true picture.

An immediate effect of SG is

resolution of GLP-1-dependent T2D

because it restores dumping. Both

intestinal and gastric bypass prevent

and cure T2D, which is a failure to

secrete sufficient GLP-1. GLP-1 cannot

be used to treat T2D because it is too

rapidly inactivated by circulating

dipeptidyl peptidase 4 (DPP4).

Operations that immediately expose the

distal bowel to glucose and other

stimulants of L-cell secretion have

shown us the cause of T2D, which is a

failure to secrete adequate amounts of

GLP-1. Appropriate medical treatment

of T2D should provide a modification of

GLP-1 or blockade of DPP4 inactivation

of endogenous GLP-1. For T2D in

people who are not severely obese, a

poorly absorbed oral glucose mimetic

taken before beginning each meal could

resolve T2D without a surgical

operation. There is one hexose that is

used as a sweetener in candy and sodas

that has been shown to increase plasma

GLP-1, but it has not been approved as

a nutraceutical or pharmaceutical.

Because of the size of the obesity

epidemic, less than one percent of

individuals with severe obesity are

provided a dumping type operation for

treatment of obesity and/or T2D. Today,

many millions of kidneys, limbs, eyes,

and lives could be saved by changing

medical treatment of T2D from insulin

to either a GLP-1 mimetic or to an

affordable, poorly-absorbed glucose

mimetic that would reach the distal

bowel at the beginning of a meal or

snack. Some of the effects of GLP-1 are

prolonged by GLP-1 receptors

expressed on the vagal nerve

innervating the portal vein where it

enters the liver. The ideal medical

treatment for T2D in people who are

not obese should be stimulation of the

secretion of the missing hormone at the

This ongoing column is dedicated to sharing with readers the life and experiences of Dr. Edward Mason.

EDMASON

Column Editor: Tracy Martinez, RN, BSN, CBN

Ms. Martinez is the Program Director for Wittgrove Bariatric Centerin La Jolla, California.

AT LARGE

Cal l for Case Reports!

To submit a case report, contact:

Angela Hayes, Managing Editor, Matrix Medical Communications

E-mail: [email protected], Phone: (484) 266-0702;

Toll-free: (866) 325-9907; Fax: (484) 266-0726

Do you have an unique case to share? Bariatric Times is seeking submissions!

Specifications:• At least 15 current references are recommended• Illustrative material is preferred• Must include abstract• Recommended length 1,000 to 3,000 words, not

including references.

Case reports are short presentations of unique cases that stimulate research and the exchange of information and

illustrate the signs and symptoms, diagnosis, and treatment of a disorder.

ALSO ACCEPTING VIDEO CLIPS WITH SUBMISSIONS.

If accepted, your video clip could be included in the Bariatric Times digital edition with your case report.

21Ed Mason at LargeBariatric Times • May 2013

beginning of a meal. An epidemic is

unlikely to resolve without an

appropriate paradigm, plan, and effort.

In the time of the dinosaurs there

was a lizard that is still living today. It

has a GLP-1 like hormone in its salivary

glands. In mammals, such cells must

have moved to the distal bowel.9 These

cells need to be stimulated at the

beginning of a meal. This is

accomplished by flushing of hypertonic

intestinal contents to the distal bowel.

L-cells are thus stimulated by glucose

and other GLP-1 stimulants in the

flushed hypertonic contents. Obesity

and age block hypertonic gush/flushing.

Current treatment of T2D is

available with a GLP-1 mimetic or by

blocking DPP4 (the circulating enzyme

that inactivates GLP-1). I treat my age-

related T2D with DPP4 blocking. I could

easily gain enough weight to qualify for

a dumping operation if I were younger

and desired a surgical procedure. I

would rather take an oral glucose

mimetic that stimulated secretion of

endogenous GLP-1. I encourage you to

study the references provided in this

and earlier columns and help with the

ongoing paradigm-shift. We can all

benefit from decreased disease.

Treatment of T2D by dumping has

been available since 1885 when Billroth

performed his second type of

gastrectomy. Dumping occurs in healthy

(i.e., nondiabetic) normal-weight people

before they are old, after RYGB, and

following SG. GLP-1 stimulates growth

of beta cells and secretion of insulin.

GLP-1 increases satiety. Today, before

treatment of patients with dumping

surgery, whose body mass index (BMI)

is less than 40kg/m2, failure of medical

treatment must be demonstrated. If the

medical treatment is not GLP-1 related

it should not qualify. T2D is not insulin

dependent. It is GLP-1 dependent. The

effectiveness of treating T2D with

dumping type obesity surgery compared

with more intensive medical treatment

is because the operations used cause

rapid transit of GLP-1 secretory

stimulants to the distal bowel. SG

results in exposure of the upper

jejunum to hypertonic contents

containing glucose and other stimulants

of L-cell secretion.

REFERENCES1. Miholic J, Orskov C, Holst JJ, et al.

Emptying of the gastric substitute,

glucagon-like peptide-1, and reactive

hypoglycemia after total gastrectomy.

Dig Dis Sci. 1991;36(10):1361–1370.

2. Brener W, Hendrix TR, McHugh PR.

Regulation of the gastric emptying of

glucose. Gastroenterology.

1983;85:76–82.

3. Schirra J, Katschinski M, Weidmann C

et al. Gastric emptying and release of

incretin hormones after glucose

ingestion in humans. J Clin Invest.

1996; 97:92–103.

4. Näslund E, Backman L, Holst JJ, et al.

Importance of small bowel peptides

for the improved glucose metabolism

20 years after jejunoileal bypass for

obesity. Obes Surg. 1998; 8:253–260.

5. Mason EE. Ileal transposition and

enteroglucagon/GLP-1 in obesity (and

diabetic?) surgery. Obes Surg.

1999;9:223–228.

6. Strader AD, Torsten PV, Ronald JJ, et

al. Weight loss through ileal

transposition is accompanied by

increased ileal hormone secretion and

synthesis in rats. Am J Physiol

Endocrinol Metab.

2005;288:E447–E453.

7. Falken Y, Hellstrom PM, Holst JJ,

Näslund E. Roux-e-Y gastric bypass

surgery for obesity at day three, two

months, and one year after surgery:

role of gut peptides. J Clin

Endocrinol Metab.

2011;96(7):2227–2235.

8. Koopmans HS, Sclafani A, Fichtner C,

et al. The effects of ileal transposition

on food intake and body weight loss in

VMH-obese rats. Am J Clin Nutr.

1982;35:284–293.

9. Mason EE. Gila monster’s guide to

surgery for obesity and diabetes. J

Am Coll Surg. 2008;206:357–360.

SUBMIT YOUR QUESTIONS FOR DR. MASON

To submit a question for “Ed Mason at Large,” e-mail AngelaHayes at [email protected]. Include “Mason at Large”in the subject line of your e-mail. All questions are reviewed bythe editors and are selected based upon interest, timeliness, andpertinence, as determined by the editors. There is no guarantee asubmitted question will be published or answered. Publishedquestions are edited and may be shortened.

Continued from page 1

Approximately two weeks before

surgery, each patient attends a two-hour

education class conducted by our

nursing department specific to each

patient’s procedure (e.g., laparoscopic

adjustable gastric banding, Roux-en-Y

gastric bypass)

Patients are seen by each member of

the integrated team during

hospitalization and in each of the

subsequent surgical follow-up

appointments. Immediately following

the patient’s postoperative follow-up

visit with the surgeon (and throughout

his or her involvement with the JFK

program), the surgeon or nurse escorts

patients to either the nutritionist or

myself. Following this disciplinary

consult (if seen by the nutritionist first),

nutrition will escort the patient to me or

visa versa.

KS: How does JFK practicemultidisciplinary care for thebariatric patient? What have youfound are the benefits of thisapproach?

MM: Historically, I have provided

multidisciplinary care when working

closely with different surgeons and

programs that were not housed under

one roof. In that setting, a patient might

come to my office after visiting his or

her surgeon and dietitian preoperatively.

Typically, and very early in my career, I

would not see the patient

postoperatively one-on-one. When

service delivery is provided by different

disciplines under the same roof it is

seen more as interdisciplinary care. This

type of care is beneficial to our patients

and, as evidenced by patient

testimonials, we find that they

appreciate it.

At JFK, we view bariatric surgery as

a behavioral surgery. We do everything

possible to reduce the prejudice often

times associated with psychological

services for bariatric patients. The field

of psychology can, at times, seem

mysterious and thus be very

misunderstood. We make every effort to

present ourselves as a unified team

during all stages of bariatric care (e.g.,

the monthly public information session,

initial surgical consultation, patient

education class, routine follow-up

appointments, support groups).

Implementing this model of care

provides patients with an opportunity to

have a healing, corrective experience

that can promote long-term

maintenance. The team, in psychological

terms, can represent to the patient a

recapitulation of their original family or

caretakers (i.e., people who were

responsible for their early childhood

care and development). We have

learned through evidenced-based

research that globally the bariatric

patient has often experienced different

forms of abuse and neglect. It is

important to further consider the

damage of living life with obesity (e.g.,

the burden of weight, prejudice, and

loss of quality of life) and encourage the

patient to be as part of the unified

bariatric team, thus fostering a healthy

healing environment. Despite our best

efforts to provide excellent care and

encourage long-term success, there will

always be patients who are challenged

and lost to follow up. In these instances,

we establish a safe environment in

which we welcome back the patients

with dignity and appreciation. This

builds upon the cohesiveness of the

program and the recapitulation factor

can be one of healing. In this way, all our

staff members get to know the patient

and his or her individual circumstances;

the patient senses his or her value,

worth, and being cared about. I always

feel rewarded when I hear a patient

comment to another that they feel their

program is like a family. Providing the

psychological arm in this integrated care

specialty format has proven life

enhancing, if not lifesaving, while it

offers us at JFK an opportunity to more

safely serve a broader patient

population.

Valuing life and understanding the

importance of professional collaboration,

integrated healthcare delivery of service

achieves the following: 1) promotes

safer environments in which to practice,

2) increases access of care for patients,

and 3) increases safety and feelings of

safety for patients.

KS: In your opinion and experience,where does psychology fit into thecare of bariatric patients? Whatmethods do you use in psychevaluation of bariatric candidates?

MM: In 2008, Bariatric Times

conducted an interview with Dr. Kelvin

Higa.1 He replied to a question about the

role of psychology in bariatric surgery

with the following answer, “I think that

the use of psychological evaluation as a

barrier to care is ethically wrong.” I

agree with this.

Rather than performing psychological

screening to rule out individuals from

having bariatric surgery, our focus is to

help prepare individuals for safe and

needed surgery while establishing a

therapeutic alliance that can be

advanced over time. The establishment

and availability of a clinical health

psychologist that learns the motivations,

fears, values, and goals of patients can

help address and resolve barriers to the

healthy long-term use of surgery and

promote weight loss maintenance.

Routine in-house psychological services

can be especially powerful and cost

effective during rocky times, when

challenges and negative consequences

impact or threaten the psychological

makeup and/or relational dynamics of

our patients.2

When a patient comes into our

program with established mental health

22 Hot Topics in Integrated Health Bariatric Times • May 2013

Column Editor: Karen Schulz, RN, APN

President of the Integrated Health Section of theASMBS; Clinical Nurse Specialist, University Hospitalsof Cleveland, Cleveland, Ohio.

THIS MONTH:

Integrated Healthcare at JFKMedical Center Bariatric Wellnessand Surgical Institute: A Best-Practice Model

An interview with Melodie K. Moorehead, PhD, ABPP

Bariatric Times. 2013;10(5):22–24.

This column is dedicated to covering a variety of topics relevant to the multidisciplinary care of the bariatric surgical patient.

Hot Topics in

INTEGRATED HEALTH

ABSTRACTDuring the 3rd Annual Cleveland Clinic Florida Allied Health Symposium, Dr. MelodieMoorehead discussed a best-practice model utilized by The Bariatric Wellness andSurgical Institute at JFK Medical Center, Lake Worth, Florida. Here, in an interview withKaren Schulz,RN, APN, President of the American Society for Metabolic and BariatricSurgery Integrated Health Section, Dr. Moorehead shares this best-practice model, whichincludes the routine delivery of psychological care within an integrated healthcareprogram. In addition, she shares various direct quotes, collected from the JFK ‘veterans’of bariatric surgery during a monthly support group meeting, regarding patients’perspective of such care.

KEYWORDSBariatric, integrated health, psychology, best-practice model

The JFK team discusses patient cases together during weekly interdisciplinary meetings.

Pictured here (clockwise from bottom left): Mary Frazee, RN, Nurse Specialist; Maria Hunte-Pope, RN, Bariatric Coordinator; Fred Simon, MD, FRCS, Bariatric Surgeon; Srinivas Kaza, MD,FACS, Bariatric Surgeon; Andrew Larson, MD, FACS, Medical Director, Bariatric Surgeon; IrisSenatore, Office Coordinator; Melodie Moorehead, PhD, ABPP, Clinical Health Psychologist;Valerie Riva, MS, RD, LDN, Dietitian; Catherine Olbrych, RN, Nurse Specialist; Beverly Lindsey,RN, JFK Director of Surgical Services.

23Hot Topics in Integrated HealthBariatric Times • May 2013

providers, we request letters of support.

This step helps broaden the safety net

of care while providing documentation

for the chart.3

Sometimes individuals present for

bariatric surgery with significant

underlying psychological issues or

medical problems that dramatically

influence his or her

emotional/behavioral presentation.

Rather than rule out even the most

difficult patients—some of whom may

be most in need of surgery—we strive

to either identify what help is essential

and establish an individualized safety

net of care or help patients self-select

out, thus protecting dignity. The

patient’s ability to cooperate and secure

such cooperation is paramount.

Cooperation, with proper supports, can

help the patient avoid unwanted

derailing from program protocol,

encouraging them to remain on track

with surgical goals and help pave the

way for positive long-term outcomes as

defined by the Bariatric Analysis and

Reporting Outcome System (BAROS).4

Each and every time a person comes

into the center, following their initial

psychological interview and with each

routine surgical follow-up the

Moorehead-Ardelt Quality of Life

Questionnaire II (MAII) is administered.4

During the initial psych interview,

psychological informed consent issues

are identified, addressed, discussed, and

documented. Patients read aloud to me

the following passages found on their

worksheet:

It is very important that you have

‘Psychological Informed Consent’ as

you are preparing for bariatric

surgery. There is a potential for

postoperative problems that may

impact your emotional well-being

including, but not limited to the

following:

• Spiking of depression or anxiety,

(some studies have stated

increased risk for suicide following

bariatric surgery)

• Changing dynamics of

relationships, including

divorce/separation

• What has become known as the

concept of: ‘Transfer of addiction.’

Some people have reported that

following bariatric surgery they

turned to excessive and destructive

behaviors such as, but not limited

to excessive alcohol use, smoking,

gambling, shopping, and exercise.

If you notice any of these behaviors

in yourself after your surgery

remember to call your doctors

immediately to secure help

• Excess skin folds.

When closing out the initial

psychological interview, the value of

cooperation and teamwork is stressed to

the patient. Modeling cooperation, I may

consult the patient regarding any

possible need or potential benefit that

might be gained by recommending

additional psychiatric/psychotherapeutic

referrals while preparing for surgery.

Certainly, recommendations prove

useful and help me feel more

comfortable, at times, with the

responsibilities I have, both to my

patient and their program. We also

provide to each patient a two-disc audio

CD that I developed titled, The Gift and

The Tool: A Personal Guide for a

Lifelong Journey.

KS: What are your thoughts onaccess to care?

MM: More patients on

Medicare/Medicaid are presenting for

surgery. Many people on Social Security

disability are on such for psychiatric

reasons. Unfortunately, some individuals

on Social Security disability for

psychiatric reasons have not been

properly treated or managed for years.

Psychiatric disorders can be challenging

enough to an individual or family,

particularly when not properly

diagnosed or treated. Still, when such a

person presents for treatment at JFK,

we recognize the extra burden that

weight, loss of quality of life, and other

significant stressors can also have on a

person’s life. We strive to secure

cooperation from the patient and/or

family and tap the spirit within their

desire for health that brought them to

us. We establish a plan of action,

securing appropriate referrals to safely

prepare for surgery and its aftermath.

There are wonderful opportunities for

increased health and well being for such

patients beyond what surgery alone can

afford.

KS: What other aspects of the JFKprogram would you like to address

24 Hot Topics in Integrated Health Bariatric Times • May 2013

that elucidates the integratedhealthcare approach?

MM: The surgeons, of course, are the

head of the team, and the surgery is the

central event. Our nurses are the

keystone of the entire program. Working

collaboratively with our nutritionist has

proven critically valuable to me. She has

provided numerous consults that have

given me a heads up regarding a

patient’s alcohol use or family dynamics,

as they may evidence during a

nutritional consult. Our front office staff

presents the very first impression in this

integrated healthcare approach, thus

requiring consistent, even mannered,

delivery of service that produces a sense

of confidence and safety for our

patients.

The weekly interdisciplinary team

meeting is a hallmark of integrated

health at JFK. All patients are

conferenced (i.e., every patient on the

surgical schedule is individually

discussed by each discipline), providing

each member of the team specific

information to help them better know

the patient as a whole person. There

may be times when the dietitian or I,

respectively, may simply say, “Patient

cleared for surgery from a nutritional

point of view,” or “I anticipate

cooperation from this person.” When

the surgeon decides surgery is

indicated, even when psychological

recommendations have not been put in

place, I might say, “wavier of psych

recommendations is required” and I will

have elucidated the specifics of the case

so that the entire team understands my

concerns and also has informed consent.

When psychological waivers occur, I

request closer follow up. I work hard at

keeping the power in the hands of the

surgeon who decides when surgery will

occur (rather than insurance

companies). Each patient is case

conferenced two weeks and one week

prior to their surgery. Every member of

the team is present, including key

hospital personnel. Surgeons and

psychologists may approach the patient

with different perspectives on

healthcare and this factor can prove

challenging regarding communication.

Integrated care teams must encourage

both disciplines to learn how to

communicate effectively together thus

having all staff members on the same

page, greatly enhancing patient care.5

At times and very unexpectedly,

spontaneous communication can occur

among the nonsurgical team members

around the water cooler. This type of

communication can be very valuable

regarding patient care and an immediate

way to pass on relevant patient

information.

Lastly, at JFK we have two monthly

support groups (primary and veterans

of surgery focus), both of which I

facilitate. All patients and their loved

ones are encouraged to attend both

support groups pre- and postoperatively

to help gain perspective on the process.

Humbly, facilitation of support groups is

one of my favorite trained skills. I have

run groups monthly since the beginning

of my career in bariatrics (1985). I hope

one day to share what we, as

professionally trained providers, might

do to enhance the therapeutic value of

the support group for the patient and

family. In the meantime, the JFK groups

are open to the entire community and

are widely attended by

pre/postoperative patients and family

members.

KS: You have recently accepted aninvitation to present on the topic“Is Psychological Clearance ReallyNecessary in Bariatric Surgery” atthe upcoming Cleveland ClinicFlorida Annual Bariatric AlliedHealth Professional Course, “TheBariatric Allied HealthProfessional's Role in aMultidisciplinary Specialty.” Whatwill be your focus?

MM: I am honored to have been invited

to speak at this symposium and

appreciate this controversial topic,

which was assigned by Dr. Raul J.

Rosenthal. I hope to secure and report

on various perspectives. We are facing

many changes in the global delivery of

healthcare, and those of us involved in

organizations, such as the American

Society for Metabolic and Bariatric

Surgery (ASMBS) and International

Federation for the Surgery of Obesity

and Metabolic Disorders (IFSO), have

worked hard to establish healthcare

guidelines that meet the needs of the

bariatric patient. I mentioned before

that psychology is often misunderstood;

even some highly qualified psychologists

may practice in ways that prevent

people from having lifesaving surgery. I

have found that surgeons care deeply

about safety. Fifteen or more years ago I

remember giving a lecture, poorly

attended, on another topic regarding

psychological services during which a

surgeon was presenting a parallel

session down the hall. His lecture topic

was how to oversew an anastamosis and

his audience was overflowing into the

hallway. Some might say this is how it

should be. Now, I feel our society is in a

critical time. When it comes to safety,

everyone (including bariatric programs,

educational institutions, and

governments) must recognize that

psychological services, provided by well-

trained individuals, can help save lives,

keep us safer, and provide economical

solutions. Examining whether and if

psychology is best to be used as gate

keepers by insurance companies is

another topic worth discussing. I am

sure the symposium will be energizing

and well attended.

KS: Dr. Moorehead, thank you fortaking the time to speak with us.

AUTHOR ACKNOWLEDGMENT: This article was

prepared with great appreciation for Gina Melby,

CEO, JFK Medical Center, and in honor of my

mother, Joyce Williams. I am also grateful to

Phyllis DeBiase of Manhattan, New York.

EDITOR’S NOTE: While the title of this article

states that it is a “best-practice model,” this is

merely a description of one practice and Bariatric

Times does not endorse it as the only standard of

care.

REFERENCES1. Higa K. An Interview with Kelvin Higa, MD,

FACS. Bariatric Times. 2008.

http://bariatrictimes.com/an-interview-with-

kelvin-higa-md-facs/. Accessed April 16,

2013.

2. Anderson P. Higher-than-expected suicide

rate following bariatric surgery. Medscape

News Today. October 23, 2007.

http://www.medscape.com/viewarticle/5647

18 Accessed April 16, 2013.

3. Pitombo C, Jones K, Higa K, Pareja J.

Obesity Surgery Principles and Practice.

McGraw Hill Medical, 2008: 75–81.

4. Oria HE, Moorehead MK. Updated

Bariatric Analysis and Reporting Outcome

System (BAROS). Surg Obes Relat Dis.

2009;5:60–66.

5. Frank RG, Baum A, Wallander JL, eds.

Handbook of Clinical Health Psychology,

Volume 3: Models and Perspectives in

Health Psychology. Washington, DC:

American Psychological Association; 2004.

FUNDING: No funding was provided.

FINANCIAL DISCLOSURES: Dr. Moorehead is

the author of the The Gift and the Tool, the

Moorehead-Ardelt Quality of Life Questionnaire II

(MAII), and the Bariatric Analysis and Reporting

Outcome System (BAROS)

AUTHOR AFFILIATION

Dr. Moorehead is from JFK Medical Center, Lake

Worth, Florida.

ADDRESS FOR

CORRESPONDENCE

Dr. Melodie Moorehead,

www.drmoorehead.com;

E-mail: [email protected]

“I think the integrated program is the best choice for bariatricsurgery and is the best choice for people who are having thissurgery. All your questions and needs are met under one roof.”

“I have found that the multidisciplinary approach has been mosthelpful. It is so important to be able to air my feelings about allareas of my bariatric journey at one time. When I leave the office Iam completely confident that all of my concerns have been met.”

“Integrated care is a great idea. It puts all the services on the sameday-same trip basis, which is a great time saver and it keeps youfocused so all of your questions can be answered by the nurse,doctor, nutritionist, or psychologist. It is very easy to take care ofeverything all at one time. It is very convenient for me and ensuresthat no part of the process is overlooked.”

“The integrated healthcare model is better because it meets moreneeds than one without. There is more to obesity than just weightissues and the problem needs to be attacked from all angles to fixthe cause. Diets, lack of exercise, and psychological issues allcontribute to the problem so they should be addressed as the curetoo. People tend to take the easiest path and if it is nonintegrated,then certain issues may not be addressed.”

“I had adjustable gastric banding and it did not work out for meand I did not have any help after surgery. I feel that this (integratedhealthcare model) might be the right help I need.”

“I don’t believe I would have had nearly the same level of successwith a nonintegrated program. The availability of multipledisciplines in one location is fabulous and very convenient!”

“I found that the integrated experience that I had was verybeneficial to my progress. Having fellow members who have gonethrough the bariatric experience and access to mental healthprofessionals was extremely helpful. First learning from theveterans group as a newbee and then progressing through theprogram has made the experience very good.”

“An integrated plan for bariatric surgery is the key that unlocksyour potential for losing weight. The integrated approach combinesthe outside (food and exercise) with the inside (emotions,psychology, strategy, etc).”

PATIENT TESTIMONIALS ON INTEGRATEDHEALTHCARE AT JFK MEDICAL CENTER

26 Anesthetic Aspects of Bariatric Surgery Bariatric Times • May 2013

INTRODUCTIONEstimation of intravascular volume is

one of the most important clinical skills

of the anesthesiologist. Management of

the fluid balance in patients with

morbid obesity remains controversial,

which, to great extent, can be

attributed to the lack of randomized

controlled studies. Current paradigms

for fluid management in this patient

population are based on studies that

mostly compared liberal to restrictive

approaches in a nonobese population.

FLUID MANAGEMENT APPROCHES:BENEFITS AND RISKS

Liberal fluid management can

produce a positive fluid balance, weight

gain, and congestive heart failure while

a more restrictive approach may

increase the risk of acute tubular

necrosis and rhabdomyolysis. The

benefits of the liberal approach as

demonstrated in studies by Ettinger et

al,1 Schuster et al,2 and Oggunnaike et

al3 include the prevention of

rhabdomyolysis and a decrease in

postoperative nausea and vomiting.

Patients with more liberal fluid

management (40mL/kg vs. 15mL/kg

totak body weight [TBW]) also

produced significantly higher urine

output in the operating room, in the

post-anesthesia care unit (PACU), and

on Postoperative Days 0 and 1 as

demonstrated by Wool et al.4 However,

the same study failed to prove any

changes in the incidence of

rhabdomyolysis.4

On the other hand, a restrictive

approach to intra- and postoperative

fluid management has been advocated

by Brandstrup et al.5 Surgical patients

whose fluid balance was managed in the

more restrictive fashion demonstrated

faster recovery of gastrointestinal (GI)

function, better wound healing, and

improvement in pulmonary function

and tissue oxygenation. In the bariatric

setting, as proposed by McGlinch et al,6

limiting intravenous fluids reduced the

incidence of postoperative pulmonary

dysfunction and hypoxia, and

shortened hospital stay.

Recently, urine output as a guide for

perioperative fluid management has

been challenged. A study by Matot et al7

demonstrated low urine output in

bariatric patients regardless of relatively

high-volume fluid therapy. The authors

concluded that their results potentially

invalidate urine output as a reliable

indicator of the fluid status in the

patients with obesity and further

investigation is required.

Steep head-up (reverse

Trendelenburg) position in the

presence of pneumoperitoneum

represents another challenge for the

intraoperative assessment of fluid

balance. Under general anesthesia, this

position is associated with a gravity-

induced shift of blood volume to the

lower part of the body, which frequently

results in a significant decrease of

cardiac output and blood pressure.8,9

GUIDING PARAMETERS FORADMINISTERING FLUIDS TOPATIENTS WITH OBESITY

While administering fluids in patients

with morbid obesity undergoing

bariatric procedures or any other type

of surgeries, a promising technique is to

assess fluid responsiveness, and include

this parameter in the concept of goal-

directed therapy (GDT), as proposed

by many authors.10,11 GDT encompasses

a technique involving intensive

monitoring and aggressive management

of intraoperative hemodynamics. It is

based on the achievement of certain

values rather than estimating fluid

status and calculating interventions.

Fluid responsiveness is defined as an

ability of the heart to increase stroke

volume in response to volume

expansion.

Dynamic parameters such as pulse

pressure variation (PPV) and stroke

volume variation (SVV), derived from

arterial waveform analysis, have been

suggested as the most reliable

indicators of fluid responsiveness in

mechanically ventilated patients as long

as sinus rhythm is maintained. A recent

study by Jain and Dutta12 demonstrated

the value of SVV in the bariatric

population. PPV or SVV values greater

than 13 percent indicate fluid

responsiveness, while patients with PPV

below nine percent should be

considered nonresponders.12 Twenty-

five percent of the patients with PPV

value between 9 and 13 percent

represent the so called “gray zone,”

when fluid responsiveness cannot be

reliably predicted.13

Plethysmographic waveform

variation (PWV) obtained from the

pulse oximetry waveform is a

completely noninvasive dynamic

parameter that can also be used to

assess fluid responsiveness as described

by Pizov et al.14 Its noninvasive nature,

minimal additional cost, and practically

universal availability represents a major

benefit for its use. However, compared

to arterial waveform analysis, the

authors found some delay in detecting

hypovolemia. In other words, PWV may

be useful at levels of more profound

hypovolemia. There are other new

technologies for noninvasive

assessment of the cardiac output, PPV,

and SVV, such as the ccNexfin

(Edwards Lifesciences, Amsterdam,

Netherlands) that uses a finger cuff for

assessment of blood pressure and

derived variables. Based on a recent

publication by Fischer et al,16 this

technology was not sufficiently useful in

a postoperative cardiac surgical

population. On the other hand, early

results from intraoperative use in a

bariatric population suggest that

ccNexfin may be comparable to

invasive PPV determination.17

The FloTrac (Edwards Lifesciences)

is a minimally invasive system that

calculates vascular tone and cardiac

output by analyzing the waveform

derived from the arterial line. Along

with the SVV, it provides continuous CO

and central venous oxygen saturation

(ScvO2) if connected to a central

venous line. The additional parameters

provided by the FloTrac can be used in

bariatric patients with significant

cardiac comorbidities.

Pulse-contour analysis-based

techniques, such as PiCCO (Pulsion

Medical Systems SE, Munich, Germany)

are a comprehensive modality for

perioperative cardiovascular

assessment as they provide not only

real-time measurement of PPV, SVV,

and cardiac output, but also useful

newer parameters, such as Global End-

Diastolic Index, intrathoracic blood

Column Editor: Stephanie B. Jones, MD

Dr. Jones is Associate Professor, Harvard MedicalSchool and Vice Chair for Education, Department ofAnesthesia, Critical Care and Pain Medicine, Beth IsraelDeaconess Medical Center, Boston, Massachusetts.

THIS MONTH:

Intraoperative FluidAssessment in Patientswith Obesityby KONSTANTIN BALONOV, MD

Bariatric Times. 2013;10(5):26–27.

This ongoing column is authored by members of the International Society for the Perioperative Care of the Obese Patient (ISPCOP), an organization dedicated to the bariatric patient.

ANESTHETICASPECTS of Bariatric Surgery

ABSTRACTIntraoperative fluid management in morbidly obese patients remains a controversial andunder-researched topic. Minimizing the risk of the intraoperative complications requiresprecise assessment of the patient’s volume status. This article reviews current scientificviews and concepts regarding fluid management in morbid obesity. Goal-directed therapyappears to be the most accurate approach in guiding fluid management. Dynamicparameters such as pulse pressure variation are considered to be the most reliable in

assessing volume status and fluid responsiveness of the patient.

KEYWORDSbariatric surgery, fluids, intravascular volume

27Anesthetic Aspects of Bariatric SurgeryBariatric Times • May 2013

volume, and extravascular lung water.

This technology can be used in patients

when certain conditions (e.g.,

significant arrhythmia) limit use of PPV

or in high-risk patients with morbid

obesity undergoing high-risk surgical

procedures. Due to the high cost and

invasiveness, these devices are often

reserved for the sickest patients

undergoing major surgical

interventions.

CONCLUSIONWhen making decisions for

intraoperative fluid management in

patients with morbid obesity one should

consider the following:

1. Potentially high incidence of

rhabdomyolysis and acute tubular

necrosis

2. Beneficial effect of limiting

perioperative fluids on GI recovery

and hospital stay

3. In laparoscopic bariatric procedures,

urine output is an unreliable

indicator

4. Pneumoperitoneum and head-up

position have a significant negative

effect on venous return

5. In low-to-moderate risk patients

undergoing laparoscopic bariatric

procedures, PWV can be used to

estimate fluid responsiveness

6. Minimally invasive monitoring, such

as PPV, is a reliable indicator of fluid

responsiveness and should be used

widely in bariatric patients with

significant cardiac comorbidities or

undergoing more invasive surgery.

7. In high-risk patients with morbid

obesity undergoing high-risk surgical

procedures, consider the use of

advanced, invasive monitoring, such

as FloTrack or PiCCO

REFERENCES1. Ettinger JE, Filho PV, Azaro E, et al.

Prevention of rhabdomyolysis in bariatric

surgery. Obes Surg. 2005;15:874–879.

2. Schuster R, Alami RS, Curet MJ, et al.

Intra-operative fluid volume influences

postoperative nausea and vomiting after

laparoscopic gastric bypass surgery. Obes

Surg. 2006;16:848–851.

3. Ogunnaike BO, Jones SB, Jones DB, et al.

Anesthetic considerations for bariatric

surgery. Anesth Analg.

2002;95:1793–1805.

4. Wool DB, Lemmens HJM, Brodsky JB, et

al. Intraoperative fluid replacement and

postoperative creatine phosphokinase

levels in laparoscopic bariatric patients.

Obes Surg. 2010;20:698–701.

5. Brandstrup B, Tønnesen H, Beier-

Holgersen R, et al. Effects of intravenous

fluid restriction on postoperative

complications: comparison of two

perioperative fluid regimens. Ann Surg.

2003;238:641–648.

6. McGlinch BP, Que FG, Nelson JL, et al.

Perioperative care of patients undergoing

bariatric surgery. Mayo Clin Proc.

2006;81:S25–S33.

7. Matot I, Paskaleva R, Eid L, et al. Effect of

the volume of fluids administered on

intraoperative oliguria in laparoscopic

bariatric surgery. Arch Surg.

2012;147:228–234.

8. Gelman S. Venous function and central

venous pressure. A physiologic story.

Anesthesiology. 2008;108:735–748.

9. Smith BR, Nguyen NT. (2010)

Pathophysiology of the

pneumoperitoneum. In: Alvarez A, Brodsky

JB, Lemmens HJM, Morton JM, eds.

Morbid Obesity: Perioperative

Management. Cambridge: Cambridge

University Press; 2010:44–52.

10. Chappell D, Jacob M, Hoffmann-Kiefer K,

et al. A rational approach to perioperative

fluid management. Anesthesiology.

2008;109:723–740.

11. Lopes MR, Oliveira MA, Pereira VO, et al.

Goal-directed fluid management based on

pulse pressure variation monitoring during

high-risk surgery: a pilot randomized

controlled trial. Crit Care. 2007;11:R100.

12. Jain AK, Dutta A. Stroke volume variation

as a guide for fluid management in

morbidly obese patients undergoing

laparoscopic bariatric surgery. Obes Surg.

2010;20:709–715.

13. Cannesson M, Le Manach Y, Hofer CK, et

al. Assessing the diagnostic accuracy of

pulse pressure variations for the prediction

of fluid responsiveness. A “gray zone”

approach. Anesthesiology.

2011;115:231–241.

14. Pizov R, Eden A, Bystritsky D, et al.

Arterial and plethysmographic waveform

analysis in anesthetized patients with

hypovolemia. Anesthesiology.

2010;113:83–91.

15. Forget P, Lois F, de Kock M. Goal-directed

fluid management based on the pulse

oximeter-derived pleth variability index

reduces lactate levels and improves fluid

management. Anesth Analg.

2010;111:910–914.

16. Fisher MO, Coucoravas J, Truong J, et al.

Assessment of changes in cardiac index

and fluid responsiveness: a comparison of

Nexfin and transpulmonary. Acta

Anaesthesiol Scand. 2013 Mar 25 [Epub

ahead of print]

17. Personal communication, Roman

Schumann, MD, Tufts Medical Center,

04/03/2013.

FUNDING: No funding was provided.

DISCLOSURES: The authors do not have any

conflicts on interest relevant to the content of

this article.

AUTHOR AFFILIATION

Dr. Balonov is Assistant Professor of

Anesthesiology, Tufts University School of

Medicine, Department of Anesthesiology, Tufts

Medical Center, Boston, Massachusetts.

ADDRESS FOR CORRESPONDENCE

Konstantin Balonov, MD, 800 Washington St.,

Box #298, Boston, MA 02111; Phone: (617)-

636-0544; Fax: (617)-638-8384; E-mail:

[email protected]

28 Interview Bariatric Times • May 2013

Dr. Herron, thank you for takingthe time to talk with us aboutObesity Week. Please sharewith us how you becameinvolved in bariatric surgery.

I was a resident of at Tufts

Medical Center (which was called

New England Medical Center at the

time) in Boston, Massachusetts.

They had a great bariatric program,

so I got a very intensive introduction

to bariatric surgery with Drs. Scott

Shikora and Peter Benotti . I have

vivid memories of assisting Dr.

Shikora, as a chief resident, in his

first several laparoscopic gastric

bypass procedures. At that time,

laparoscopic gastric bypass surgery

was the most challenging minimally

invasive operation we could

imagine—the Mount Everest of

laparoscopic surgery. Beyond the

technical challenges of the surgery,

what appealed to me about bariatric

surgery was seeing patients’

comorbid conditions, such as type 2

diabetes mellitus (T2DM),

obstructive sleep apnea (OSA,) and

hypertension, improve or even

vanish after bariatric surgery. It is a

life-changing process and I felt it

was a perfect place to be for a

surgeon like myself who really

wanted to help patients in a visible

and dramatic way.

Please tell us about your role inthe planning of this event.

I currently serve as Co-Chair if

the Program Committee for the

ASMBS. I have a history in meeting

planning for other organizations as

well. In 2010, I was the Program

Chair for the Society of American

Gastrointestinal and Endoscopic

Surgeons (SAGES) and the World

Congress of Endoscopic Surgery. As

ASMBS Program Co-chair, I work

closely with Dr. Ninh Nguyen, who is

currently ASMBS Program Chair and

President-Elect. Next term, when

Dr. Nguyen becomes ASMBS

President, I will step up as ASMBS

Program Chair. In planning Obesity

Week, I am responsible for setting

up the post-graduate courses while

Dr. Nguyen manages plenary

sessions. All of the sessions have to

be planned far in advance. We keep

on schedule during monthly

conference calls, where we discuss

what has been done and what still

needs to be done. It is a huge

undertaking and is now an even

bigger job since we are interfacing

with The Obesity Society to host

Obesity Week.

How is the Board of Managersplanning on appealing to allaudiences during ObesityWeek? Is there any overlapbetween sessions or eventsheld by both organizations thatyou can tell us about? While surgeons will most likely want

to hear about surgery and members

of integrated health will want to

hear about topics most concerning

to their profession, Obesity Week

will offer sessions and events that

appeal to all attendees. For instance,

we are looking into having keynote

speakers involved in national health

decisions, which will bring everyone

together. The post-graduate courses

will focus on both surgery and

integrated health, so there is sure to

be a lot of parallel play and

combined interaction.

Would you encourage attendeesof Obesity Week to exploreareas of the field in which theydo not work (e.g., medicalweight loss professionalsattending sessions on surgicalinterventions?)

Absolutely. Obesity Week will be a

tremendous opportunity for

attendees to be exposed to a

remarkable interdisciplinary faculty

of international experts. I would

encourage people to attend different

sessions outside their specialty to

learn as much as possible. Even

though it might be scary to walk into

a session on surgery if you are an

internist, knowledge of other

disciplines can help you better

customize patient care. If a surgeon

can use this meeting to gain a better

understanding of medical

interventions, he or she will be

better equipped to understand and

treat patients who might be better

suited for non-surgical metabolic

therapies and vice versa.

What is your hope for ObesityWeek 2013?

My hope, and my expectation, is

that it will be a huge success. I hope

that it mirrors other successful

interdisciplinary meetings of its kind

like Digestive Diseases Week

(DDW). I feel it is a great

opportunity for everyone involved in

treating obesity to get together and

discuss what is going on in the field.

I hope that it will raise internists’

awareness of surgery and vice versa.

COUNTDOWN TO OBESITY WEEK 2013

Interview #5: Daniel Herron, MD, FACSBariatric Times. 2013;10(5):28–29.

Starting in 2013, the

American Society for

Metabolic and Bariatric

Surgery (ASMBS) and The

Obesity Society (TOS) will co-

locate their respective annual

meetings under one roof.

Obesity Week™ 2013 marks the

beginning of an annual

collaborative event addressing

obesity—a chronic and

multifaceted metabolic disease.

Leading up to Obesity Week

2013, Bariatric Times will

feature interviews with

members of the leadership

team involved in organizing

this historic event. This month,

we feature an interview with Dr.

Daniel Herron, Program Co-

Chair of ASMBS.

EXCLUSIVE INTERVIEW SERIES

29InterviewBariatric Times • May 2013

I also hope that is improves

everyone’s understanding of the

physiological causes and effects of

obesity and its treatments.

Ultimately, I hope that Obesity Week

takes advantage of the synergy and

overlap of disciplines, conserves

resources, and brings minds

together that are focused on the

same thing—the prevention and

treatment of obesity.

What would you say toencourage people to attendObesity Week 2013?

It is going to be the first time in

history where thousands of people

from different obesity-related

disciplines are side-by-side learning

about and discussing surgical and

medical interventions for metabolic

disease and obesity. You just can’t

miss it!

Dr. Herron, thank you again forspeaking with us. We lookforward to seeing you atObesity Week 2013.

To learn more about Obesity Week

2013, please visit

www.obesityweek.com.

Obesity Week Upcoming Dates

and Venues

Obesity Week 2013

Atlanta, Georgia

November 11–16

Obesity Week 2014

Boston, Massachusetts

November 2–7

Obesity Week 2015

Los Angeles, California

November 1–7

The 30th Annual

Meeting of the

ASMBS will be

moved to

November 11–16,

2013 and will

take place during

Obesity Week in

Atlanta, Georgia!

We look forward

to seeing you

there!

A REMINDER

FROM THE

AMERICAN

SOCIETY OF

METABOLIC AND

BARIATRIC

SURGERY

www.obesityweek.com

Calendar of Events30Bariatric Times • May 2013

CALENDAR OF EVENTS

VII CONGRESO INTERNACIONAL DECIRUGÍA BARIATRICA Y METABÓLICAMay 2–4, 2013

Mendoza, Argentina

http://www.congresobariatrica.com.ar/

index.php

AMERICAN SOCIETY FOR METABOLICAND BARIATRIC SURGERY SPRINGEDUCATIONAL EVENTMay 30–June 2, 2013

New Orleans, Louisiana

http://asmbs.org/2012/11/spring-

educational-event-2013/

18TH WORLD CONGRESS OF THEINTERNATIONAL FEDERATION FORTHE SURGERY OF OBESITY ANDMETABOLIC DISORDERS (IFSO)August 28–31, 2013

Istanbul, Turkey

http://www.ifso2013.com

YOUR WEIGHT MATTERS NATIONALCONVENTIONAugust 15–18, 2013

Phoenix, Arizona

http://www.ywmconvention.com/

AMERICAN COLLEGE OF SURGEONS99TH ANNUAL CLINICAL CONGRESSOctober 6–10, 2013

Washington, DC

http://www.facs.org/clincon2013/index

.html

OBESITY WEEK 2013November 11–16, 2013

Atlanta, Georgia

http://www.obesityweek.com/

THE SCIENCE AND BUSINESS OFWEIGHT MANAGEMENT FOR THENEW OR EXPERIENCEDPRACTITIONERJuly 25–27, 2013

Philadelphia, Pennsylvania

http://www.weightconference.com/

THE BARIATRIC ALLIED HEALTHPROFESSIONAL’S ROLE IN AMULTIDISCIPLINARY SPECIALTYJuly 13, 2013

Fort Lauderdale, Florida

http://www.ClevelandClinicFloridaCM

E.org

Marketplace, Ad Index 31Bariatric Times • May 2013

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