Advancing the Field of Bariatric Surgery at University Hospitals

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1 Advancing the Field of Bariatric Surgery at University Hospitals More Sharing ServicesShare Share on facebookshare on share on favoritesshare on printrss Feed By: Alex Strauss Sunday, March 11, 2012 As many as 70 percent of Americans are now considered overweight or obese, putting them at risk for a host of co-morbidities, life-long health problems and even early death. Photo: Joe Smithberger, Smithberger Photography, North Canton The Health Benefits of Bariatric Surgery Obesity increases the risk of nearly every chronic disease, including the biggest killers: cancer, heart disease and diabetes. By giving patients a proven method for losing their excess weight, bariatric surgery improves not only patients body image, confidence and energy, but also their longevity. I can confidently tell all patients that problems like high blood pressure, diabetes and sleep apnea are going to be dramatically reduced, if not completely cured, says Dr. Khaitan. I see patients after bariatric surgery go from taking large amounts of insulin and medicines for high blood pressure and wearing a CPAP machine at night, to just taking a daily multivitamin. Bariatric patients not only enjoy a reduced risk of deadly diseases, but typically also see improved quality of life with the reduction of other health problems such as fatigue, gastrointestinal reflux, urinary incontinence and osteoarthritis pain. They report increased energy and mobility they never realized they had, according to Dr. Khaitan. While many patients have failed at long term weight loss with diet and exercise alone, weight loss surgery offers patients a greater than 90 percent success

2 rate in losing the majority of their excess weight and keeping it off. Multiple ongoing post-operative educational and counseling programs help them maintain a healthier weight for a lifetime. Patients who have had bariatric surgery tend to say that they have a whole new lease on life, says Dr. Khaitan. I had a patient who recently ran her first 5K race. She did not realize she could run prior to her surgery! These kinds of successes are very gratifying from a physician s standpoint. Unfortunately, most will never be able to resolve their weight problems and alleviate those risks on their own. Statistics suggest only 3 percent of those who attempt to lose weight through diet and exercise will succeed at losing at least 10 percent of their body weight and maintaining that weight loss for at least a year. As a result, an increasing number of patients are turning to the advancing field of bariatric surgery. University Hospitals (UH) Digestive Health Institute s Bariatric Surgery, Metabolic & Nutrition Center offers a proven path to long-term weight loss while helping patients live happier, healthier lives. Nationally accredited by the American Society of Metabolic and Bariatric Surgeons as a Bariatric Surgery Center of Excellence, the UH Center is at the forefront of minimally invasive weight loss surgery with laparoscopic sleeve gastrectomy, single-incision laparoscopic surgery (SILS) for bariatrics and now robotic-assisted bariatric surgery. In addition, the UH Center offers the highest level of individualized support to ensure patients not only lose weight, but keep it off. We offer the most advanced bariatric procedures available and so many other advantages to help patients succeed in their weight loss goals, says Alan Saber, MD, MS, FACS, FSMBS, director of the Bariatric Surgery, Metabolic & Nutrition Center at UH and director of Bariatric & Metabolic Surgery at UH Case Medical Center. Dr. Saber was fellowship-trained in bariatric and advanced minimally invasive surgery at Cleveland Clinic Foundation in Weston, Florida. Since joining UH two years ago, he has been an area leader in the development of minimally invasive bariatric procedures. We prepare patients thoroughly for the lifestyle changes they are going to need to make to lose weight and keep it off, says Dr. Saber. Working closely with many other disciplines, we do everything possible, including offering free educational seminars and free medical weight loss programs to set patients up for success. The Benefits of Bariatric Surgery In the early 1990s, the National Institutes of Health (NIH) acknowledged the benefits of bariatric surgery in select patients, including those with a body mass index (BMI) of 40 or over who have tried but failed nonsurgical weight loss programs. Patients with a BMI of and one or more high-risk co-morbidity, such as diabetes or hypertension, may also be considered for bariatric surgery.

3 Weight loss surgery procedures can now be done with extremely low morbidity and mortality less than 1 percent, according to recent research. It is no longer considered to be high risk, and the health benefits [see sidebar on next page] are overwhelming, says Leena Khaitan, MD, MPH, FACS, associate director of the Bariatric Surgery, Metabolic & Nutrition Center at UH and director of Bariatric & Minimally Invasive Surgery at UH Geauga Medical Center in Chardon. Fellowship trained in minimally invasive surgery at Vanderbilt University, and director of Bariatric Surgery at Emory prior to coming to UH, Dr. Khaitan has been part of UH s surgical staff since There used to be a much higher risk of hernia, wound infection, blood loss and pain with bariatric surgeries, she explains. Now that we can do them with just a few small incisions, or even a single incision, those risks are minimal. Patients are up and walking around much sooner and are back to work within a couple of weeks. Over the past decade, bariatric surgery has rapidly evolved as new procedures including one pioneered by Dr. Saber, continue to offer more options for minimally invasive weight loss. These include laparoscopic sleeve gastrectomy, single incision laparoscopic bariatric surgery and roboticassisted bariatric surgery. Sleeve Gastrectomy Laparoscopic sleeve gastrectomy involves removal of the lateral 90 percent of the stomach to restrict food intake and decrease appetite. According to Dr. Saber, the hormonal effects of sleeve gastrectomy can be more prominent than those of the most standard bariatric procedure, i.e. Rouxen-Y gastric bypass. He says there is also greater appetite suppression and excess weight loss with sleeve gastrectomy when compared with gastric bypass. A recent study reported a weight loss from sleeve gastrectomy of 69 percent excess body weight at 12 months compared to 60 percent after Roux en Y gastric bypass. (Karamanakos SN, Vagenas K, Kalfarentzos F, Alexandrides TK. Weight loss, appetite suppression, and changes in fasting and postprandial ghrelin and peptide-yy levels after Roux-en-Y gastric bypass and sleeve gastrectomy: a prospective, double blind study. Ann Surg Mar;247(3):401-7.) Sleeve gastrectomy has several advantages over current weight loss procedures, Dr. Saber explains. Unlike gastric bypass, sleeve gastrectomy does not involve rerouting of the intestine or malabsorption, thus it does not affect absorption of food, vitamins or medications. In addition, gastric sleeve does not have the risk of internal hernia, marginal ulcer or dumping syndrome. Sleeve gastrectomy is also different from adjustable gastric banding, even though both bariatric procedures involve stomach restriction. With gastric banding, the surgeon places a belt-like band around the stomach that is periodically tightened or loosened by the addition or subtraction of saline solution through a small access port below the skin. Sleeve gastrectomy does not require placement of a device nor adjustments.

4 The simplicity of the procedure and the decreased risk profile make gastric sleeve very appealing, says Dr. Saber. Single-Incision Bariatric Surgery Single incision laparoscopic surgery (SILS) is considered to be one of the greatest advances in minimally invasive surgery. As indicated by its name, SILS involves a single incision through which two or more ports for surgical tools are placed. The incision is usually in the umbilicus, so the scar is hidden, which is why SILS is often referred to as scarless surgery. Initially basic laparoscopic procedures such as cholecystectomy or appendectomy were done with this approach. Now more advanced laparoscopic procedures such as colorectal procedures and bariatric procedures are being done this way, says Dr. Khaitan, who reports that both adjustable gastric banding and the gastric sleeve procedure have been successfully performed by UH surgeons using the SILS approach. Bariatric procedures are technically challenging even when done with the traditional laparoscopic approach. The single incision approach requires even more unique surgical skills from the surgeon. Dr. Saber, who is credited with developing the single-incision laparoscopic sleeve gastrectomy, agrees. The single incision approach to bariatric surgery requires a certain set of surgical skills. In expert hands, it is safe and feasible and results in less postoperative pain, less need for analgesic, shorter hospital stay and quicker recovery than the conventional laparoscopic approach. Placing the incision inside the umbilicus, provides a better cosmetic result, as well. Robotic-Assisted Bariatric Surgery The newest frontier in bariatric surgery involves the use of a robotic surgery system for better visibility of anatomy and improved maneuverability of surgical instruments. According to Dr. Saber, excess fatty tissue can make surgery more complicated. The 3D high-definition imaging and improved surgical precision which are the hallmarks of robotic surgical systems, however, can make bariatric surgery easier on the surgeon and the patient. The robot gives the surgeon the advantage of better visualization and dexterity, says Dr. Saber, who was one of the first in the Cleveland area to perform robotic-assisted bariatric surgery. The freedom of movement of the robotic wrists and endoscopic tools (which are operated by the surgeon from a control console in the surgery room) is even greater than that of human hands. And the 3D visualization and magnification of the surgical site allows the surgeon to really see the depth of the structures. According to Dr. Saber, the robotic system is ideal for the gastric sleeve procedure. For patients with the right anatomy, this can be an excellent option.

5 Each patient is carefully evaluated to determine which bariatric surgery will offer the best results for surgical success, long-term health and cosmetic outcome. When developing each patient s individualized plan of care, UH pulmonologists, cardiologists, endocrinologists and others may also be consulted. After surgery, patients are provided with an ongoing range of other critical services, including counseling, nutritional services and exercise therapy. We have assembled a great team, all of whom have a lot of experience dealing with bariatric patients, says Dr. Khaitan. And we feel that we can offer the highest level of personalized care here at UH. We have seen tremendous growth in our program in recent years, says Dr. Saber. The number of bariatric cases has tripled in the past three years, and we expect that number to continue to increase next year. Free informational seminars on options for surgical weight loss are held regularly across Northeast Ohio for prospective patients and their families. For upcoming dates and locations, visit UHhospitals.org/weightlossinfo.