Information for Referring Providers. Winchester Medical Center Bariatric Program

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1 Information for Referring Providers Winchester Medical Center Bariatric Program M

2 Winchester Medical Center Bariatric Program Providers Troy Glembot, MD, MBA, CPE, FACS, FASMBS Medical Director, Bariatric Surgeon Jim Wiedower, MD, FACS, FASMBS Bariatric Surgeon Angela Harden-Mack, MD Bariatric Medical Physician Patrick Rick Northcraft, MSN, RN, FNP-C, CBN Nurse Practitioner Pam Kuehl, LPC Behavioral Health Robyn Hensley, MS RD Program Dietitian Erika Romaine, RD Program Dietitian

3 Obesity is a chronic, life threatening disease that is the second leading cause of preventable death in the United States and one of the most difficult diseases to treat. Weight loss can be very challenging, and for those who are morbidly obese, sustained weight loss is often unattainable without medical or surgical intervention. Our mission is to improve the health of obese people by providing comprehensive treatment through medical, surgical, dietary, and educational intervention. Our goal is not short-term weight loss, but rather a longterm relationship with our patients, leading to life-long success. The Winchester Medical Center Bariatric Program offers services that can treat the life threatening diseases related to obesity. We practice a multidisciplinary team approach to treat the physiological consequences of obesity as well as the underlying psychological and emotional issues that often occur. We provide a unique, full spectrum of services for the treatment of obesity. Our program offers both medical and surgical treatment options for the disease of obesity. The International Diabetes Federation (IDF) announced that bariatric surgery should be offered for people with type 2 diabetes who have a body mass index of 35 kg/m2 or more. Additionally, the American Heart Association (AHA) released a statement that bariatric surgery can significantly reduce the risks of dying from cardiovascular and non-cardiovascular complications related to severe obesity. Program Here Aside from the usual diseases we track as medical professionals, obesity causes a significant emotional toll, evidenced by an overall poor quality of life. The latest research has shown bariatric surgery may lead to a better quality of life for many patients who suffer from this devastating illness. 1

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5 Medical Management Options Not all people who have a problem with their weight want or need surgery, and our medical management component is specifically designed for those people who: do not want surgery do not qualify for surgery want surgery, but have an insurance mandated diet before becoming eligible to receive benefits for bariatric surgery had bariatric surgery in the past, and need to improve their weight loss Patients who enroll in the medical component of the program have access to the full spectrum of specialists to ensure success on their weight loss journey. Physicians, dietitians, exercise specialists, behavioral health specialists, and mid-level providers all work together to provide the support and advice needed to address the complex disease of obesity. Medical Program Management Here Options 3

6 We tailor programs to patients based upon specific needs, capabilities and limitations. Patients may choose from one of several medical treatment options that include: Weight Wise: A physician-supervised weight loss program which uses short-term FDA approved weight-loss medications. Comprehensive Medical Weight Management: A 9-week program including weekly office visits, weekly education classes, and regular access to our dietitians and behavioral health specialists. The highly effective OPTIFAST meal replacements are used to assist with weight loss, as well as short-term FDA approved weight-loss medications when appropriate. Medical Program Management Here Options Metabolic Testing: We now offer metabolic testing for all of our patients. This test provides valuable information about a person s metabolic rate and ability to burn calories. The medical providers and Registered Dietitians can help assess an appropriate daily caloric level to maximize a patient s weight loss and maintenance. Although patients who manage their obesity medically usually do not have the same weight loss as those who have surgery, many are able to see significant improvements in their obesity related diseases with a weight loss of 15 to 20 pounds. Importantly, sustained weight loss of just 15 to 20 pounds, can have a dramatic effect on diseases like diabetes, high cholesterol and high blood pressure. 4

7 Surgical Management Options Surgery for morbid obesity is the only proven method that has resulted in long-term maintenance of weight loss. Many of the diseases that are made worse by being heavy improve or resolve after sustained weight loss following bariatric surgery. Moreover, since bariatric surgery has a relatively low risk of complications, the risks of staying obese are higher than the risks of surgery. Over 99% of all primary bariatric procedures at Winchester Medical Center are performed laparoscopically. This approach is less invasive and reduces pain, as well as the risk of wound complication. Recovery is usually more rapid, shortening the length of hospitalization Winchester Medical Center offers the following surgical options for weight loss: Surgical Management Options Roux-en-Y gastric bypass Adjustable gastric band Sleeve gastrectomy Duodenal switch Revision bariatric surgery 5

8 Roux-en-Y Gastric Bypass Adjustable Gastric Band Surgical Management Options Roux-en-Y gastric bypass is the most frequently performed bariatric procedure in the US. It provides gastric restriction combined with some malabsorption. The first part of the procedure involves constructing a small pouch. This is done using a special stapling device. Next, the small intestine is divided, and one end (called the roux limb) is connected to the new stomach pouch. This connection is called a stoma (or anastomosis). Finally, the other end of the intestines is then reconnected to the roux limb, completing a Y shape. The average weight loss after a bypass is higher than pure restrictive operations. Poor absorption of iron and calcium can result because the duodenum is bypassed. Iron and calcium should be replaced through diet and oral supplements. A steady reduction in B12 is also common. Oral supplements or B12 injections are recommended. When compared to medical treatment, gastric bypass is the most effective way to treat Type 2 diabetes. 85% of morbidly obese patients who have a gastric bypass will no longer need medications for diabetes. The adjustable gastric band was approved by the FDA for use in the United States in June The band is placed around the upper part of the stomach, similar to the way a belt fits around your waist. The band creates a virtual pouch in the upper stomach that limits the intake of food. This operation is purely restrictive and there is no mal-absorption as with the gastric bypass. A small port is placed underneath the skin that allows adjustments to be made to the size of the band, and thus the volume of food that can be eaten. Even though the adjustable gastric band is reversible, it should be considered permanent. If the band is removed, weight re-gain can be expected. It will be important to follow a specific diet after the operation. On average, people lose about 40% of their excess weight by about 18 to 24 months after surgery. In general, the 30 day complication rate after placing the band is the lowest of all weight loss procedures. However, the long term complication rate is about the same or slightly higher than other weight loss procedures. 6

9 Sleeve Gastrectomy Duodenal Switch (DS) The sleeve gastrectomy was recognized in November of 2009 by the American Society for Metabolic and Bariatric Surgery as an appropriate primary procedure for the treatment of obesity. This procedure involves permanently removing about 90% of the stomach. The remaining ouch is about the size and shape of a peeled banana. Most people will lose about 60% of their excess weight at one year following the sleeve gastrectomy. In general, the operative risks of a sleeve gastrectomy are lower than with a gastric bypass and the weight loss is usually better than with an adjustable gastric band. There is no rearranging of the intestines as with the bypass. Since this operation is purely restrictive, there is a low risk of malnutrition and it is important to take vitamins and supplements as recommended. New to Winchester Medical Center in 2013, the duodenal switch limits food absorption by separating bile and pancreatic juices from food late in the small intestine. After removing a portion of the stomach, the small intestine is divided. Part of the small intestine is attached to the stomach to create the alimentary limb, which carries food from the stomach to the large intestine. Digestive juices are separated and they travel through the biliopancreatic limb, until joining food at the common channel. This type of surgery is more likely to cause frequent and liquid bowel movements as the intestines adapt, abdominal bloating and malodorous stool or gas. Lifelong monitoring for protein malnutrition, anemia and bone disease is important. Due to the nature of this procedure, patients must be compliant with vitamin and supplement therapies. There is an increased risk of gallstones and intestinal irritation. Surgical Management Options Revisional Bariatric Surgery Revisional bariatric surgery may be needed for some people who had bariatric surgery in the past, and now may need another highly specialized procedure to correct a complication or improve weight loss. 7

10 Obesity is a major contributor to diabetes, high blood pressure, cardiovascular disease, stroke, osteoarthritis of weight-bearing joints, respiratory problems, gallstones, urinary incontinence, swollen legs that may develop ulcers, and gastro-esophageal reflux. All of these diseases and conditions that are made worse by being heavy contribute to a shorter life expectancy. Studies show that people who are obese will have a longer life expectancy if they proceed with bariatric surgery when compared to those who do not have bariatric surgery. Criteria for Surgery Surgical Management Options 1. Patients must be at least 18 years of age. 2. Patients must have a Body Mass Index (BMI) of 40 or greater, or be at least 100 pounds overweight. 3. Candidates may have a BMI between 35 and 39 if they have two obesity related comorbidities. 4. Patients must weigh less than 400 pounds on the day of surgery. 5. Candidates must demonstrate sufficient cognitive understanding of the procedure, risks and postoperative behavioral modifications required. 6. Patients must attend all preoperative educational programs as outlined in the consent policy developed by Winchester Medical Center Bariatric Program. 7. Women who undergo bariatric surgery must understand the importance of avoiding pregnancy for at least 12 months after the procedure. 8. Patients must discontinue any nicotine usage at least 8 weeks preoperatively. 9. Patients must be free of any active substance abuse. 10. Patients who have a history of psychiatric illness must have documentation by their mental health provider that their illness is well controlled. 8

11 Considerations for Providers Providing Post-Operative Care and Long-Term Medical Issues Related to Bariatric Surgery Abdominal pain in patients can be vague and misleading. Symptoms that should be managed in conjunction with a bariatric surgeon include: fever tachycardia shoulder pain recurrent cramping in upper abdomen disproportionate abdominal tenderness or pain shortness of breath (symptom of pulmonary embolism) vomiting/dry heaves bloating with hiccups pain out of proportion to exam inability to tolerate liquids for 24 hours Medication Considerations for Patients Who Have Had Bariatric Surgery Extended release and controlled release medications may not be properly absorbed, and it is advised that patients be switched to a regular release formulation. NSAIDS (including aspirin and COX-2 inhibitors) should be used only for short periods when medically necessary. There is an increased risk of gastrointestinal ulcers in bariatric surgery patients who use NSAIDS on a routine basis. Bisphosphonates should not be used due to increased risk of gastric ulcerations. Calcium citrate is the required calcium replacement, as other calcium preparations may not adequately absorb. Surgical Management Options Potassium supplementation, if required, should be given in liquid form or crushed. Pill size should be considered, as large pills may get stuck in the stomach pouch and cause ulceration. Psychiatric medications may require increased doses due to alterations in absorption. Anticoagulant medications: absorption is variable and all medications need to be monitored very carefully. Coumadin absorption is unreliable and dosing will change as weight decreases. Patients are asked to follow up with prescribing physicians as soon as possible after surgery. 9

12 Metabolic Considerations Bariatric surgery patients are at risk for several vitamin and micronutrient deficiencies (B12, folate, iron, vitamin D and calcium). Patients must be on a multivitamin, iron and calcium supplements (at least 1000 mg/day of calcium citrate) for the remainder of their lives. In addition, the duodenal switch patients are at a higher risk for malabsorption of fat soluble vitamins (Vitamins A,D,E, and K) Iron deficiency anemia is more common in these patients, particularly in menstruating women. Patients can usually be treated with oral iron supplementation, but occasionally require iron infusions. Surgical Management Options Chelated iron preparations (iron fumarate or iron gluconate) are better absorbed that non-chelate preparations (iron sulfate). Iron absorption will be enhanced if it is taken with 500mg of vitamin C Secondary hyperparathyroidism may develop because of poor calcium uptake. If significant weight gain occurs after surgery, the patient should be referred for reevaluation by the bariatric surgeon. Pregnancy Women are advised to wait at least 18 months post-operative before attempting conception. Should a woman become pregnant, it is important that she follow up immediately with our office, as there is a specific protocol she should follow. Long-term Follow-up Regular laboratory assessment for bariatric surgical patients is important to insure patients are not developing any biochemical or nutritional deficiencies during their first year after surgery. See recommended laboratory studies below. After the first year, annual monitoring is strongly recommended. Patients should visit with a bariatric surgeon annually for a review that should include labs, physical examination, and the latest information regarding their continuing care. 10

13 Recommended basic laboratory studies and intervals Study* 3 Months post op 6 Months post op 12 Months post op Annually for life CBC Chem-8 Magnesium Phosphate Lipid Panel Vitamin B12 Hepatic Panel Prealbumin HgA1c (diabetics) Folate Ferritin Parathyroid (PTH) level Serum Vitamin D Copper Surgical Management Options *Additional studies may be warranted if clinically indicated 11

14 Support Programs and Services Support Programs and Services Nutritional Services The Winchester Medical Center Bariatric Program is designed to allow patients to learn new behaviors in relationship to food and provide a solid foundation for a new and healthy eating pattern and lifestyle. Our patients are encouraged to take advantage of our nutritional guidance sessions through the monthly postoperative support group sessions and the weekly educational series for the medically managed patients. Behavioral and Lifestyle Coaching Our program has a behavioral health specialist on staff, located in the office full time, and is available to work with medical and surgical patients. 12

15 Wellness Center Valley Health s 55,000+ square foot wellness and fitness center located on the Winchester Medical Center Campus opened in September of This state of the art facility includes an indoor therapy pool, indoor lap pool, indoor track, extensive aerobic equipment and a variety of resistance training equipment. Wellness center staff has developed a specialized program for Bariatric Program participants. Individual exercise plans are developed for each person enrolled in the Bariatric Program by highly qualified exercise specialists. There are several options available to patients to help increase activity. Exercise treatment plans may be done individually or in class settings depending upon the patients abilities and comfort level. Support Programs Monthly surgical support group Monthly medical support group Monthly grocery store tours for all patients Back on Track Program held quarterly for 1-year post surgery patients struggling to maintain weight loss Grab n Gab a weekly lunch group discussion for post-surgery patients Support Programs and Services 13

16 Annual Data Annual Data Medical Director Report Troy Glembot, MD, MBA, CPE, FACS, FASMBS Our success is due to the dedicated people who support our mission every day; to improve the health of obese people by providing comprehensive treatment through medical, surgical, dietary, and educational intervention. I am very proud to be a part of this team of amazing people who ensure our patients receive the best care possible. We know that our patients, their families, and their referring healthcare providers trust us to provide outstanding service, and we take that responsibility very seriously. In 2012 for the Winchester Medical Center Bariatric Program achieved several milestones. In March, the program underwent a vigorous review of policies, procedures and outcomes and was again designated as a Bariatric Surgery Center of Excellence by the American Society of Metabolic and Bariatric Surgery. In December, the program was recognized as a Cigna 3-Star Quality Bariatric Center. We also have been recognized as a Blues Distinction Center for Bariatric Surgery since These awards demonstrate our commitment to provide patient centered care using state of the art medical and surgical weight loss services in the safest and most effective way possible. Additionally we have been recognized as a leader in providing bariatric surgical care, and our program has been designated as an official Ethicon training site for bariatric surgery. Surgeons and practices from around the country may visit our program to learn the latest in surgical techniques, perioperative care, and office management. 14

17 We have been a leader in providing innovative bariatric care to keep our patients safe and improve outcomes. In 2012, we developed and implemented a clinical decision support system to automatically alert nurses if a hospitalized bariatric surgical patient has a change in their condition after surgery. This state of the art system is part of a national project spearheaded by the Patient Safety Committee of the American Society for Metabolic and Bariatric Surgery. We also created a protocol to improve perioperative nutrition for those having bariatric surgery to help reduce perioperative complications. Finally, we have a metabolic cart in our office so that accurate measurements of caloric needs can be determined on individual patients. Armed with this technology and information, our treatment team can help develop specific dietary plans to help people achieve and maintained sustained weight loss. Looking forward, we are well prepared to be the market leader in providing excellent bariatric medical and surgical care for our region. Troy Glembot, MD, MBA, CPE, FACS, FASMBS Medical Director, Bariatric Surgeon Annual Data

18 Medical Weight Loss Options Today more than ever, the health risks associated with obesity are widely recognized. Many people who struggle with excess weight do not need, or do not want surgical treatment options. We offer a variety of medical treatment options that are specifically developed for individuals who want to achieve a healthier weight without surgery. Our Weight Wise program is the most popular non-surgical weight loss option. It utilizes FDA approved weight loss medications along with regular office visits with our medical providers. Percentage of Patients Enrolled in Medical Weight Management Programs for 2012 Comprehensive Medical Weight Management Our Comprehensive Medical Weight Management Program uses the meal replacement product, Optifast, 12.8% Annual Data along with nutrition, exercise, and behavioral counseling. This treatment option is highly effective. On average, patients who complete the comprehensive program reduce their body mass index by more than six points. 87.2% Weight Wise Average BMI of Comprehensive Medical Weight Management Patients 2012 Our medical program is also available to help those people who have an insurance mandated diet before having bariatric surgery Avera Avera 34 Average BMI at Initial Consult 32 Average BMI at Last App't. 30 Patients who attended 3 to 15 of the recommended 18 Sessions Patients who completed 16 or more of the recommended 18 Sessions 16

19 Surgical Weight Loss Options Trusted by our referring provider and our patients The most important recognition we receive is the trust and confidence from our community. Overall, 87% of our patients learn about our program from their referring healthcare professionals or word of mouth from family members or friends. With the advent of the information age, many people seek information about our program online. Understanding today s world, we have enhanced our internet presence, and this has become the third most common way people learn about us. How Did You Hear About Us? Newspaper/Magazine 2.4% Outside Program or Hospital 2.1% Insurance 2.1% Internet 5.0% Other 1.2% Physician/Medical Provider 45.4% Experience Word of Mouth 41.8% Annual Data Drs. Glembot and Wiedower have performed over 1500 bariatric surgical procedures in their careers. 1,059 primary procedures have been completed since the program started in WMC Bariatric Program Primary Procedure Volume by Year 250 Laparoscopic Roux en Y Gastric Bypass Laparoscopic Sleeve Gastrectomy Laparoscopic Adjustable Gastric Band Open Roux en Y Gastric Bypass Open Sleeve Gastrectomy

20 Average Procedure Time In 2012, the average time for a laparoscopic gastric bypass was 115 minutes, and the average time for the sleeve gastrectomy was 87 minutes. WMC Bariatric Program Average Procedure Time in Minutes Annual Data Average Length of Stay Laparoscopic Roux en Y Gastric Bypass Laparoscopic Adjustable Gastric Band Laparoscopic Sleeve Gastrectomy In 2012, the average length of stay after laparoscopic gastric bypass surgery was 2.6 days. The average length of stay following a laparoscopic sleeve was 2.3 days. Starting in 2011, we developed a protocol that enables some patients to go home after just one night in the hospital following their laparoscopic gastric bypass. WMC Bariatric Program Average Length of Stay in Days Laparoscopic Roux en Y Gastric Bypass Laparoscopic Adjustable Gastric Band Laparoscopic Sleeve Gastrectomy 18

21 Percent Excess Weight Loss Our goal is to help people achieve a healthier weight. While there are many ways to achieve this goal, it is important to understand the amount of weight loss usually expected after bariatric surgery. On average, people will lose over 75% of their excess weight 5 years after laparoscopic gastric bypass surgery. For a person who is one hundred pounds overweight, this means they would lose about 75 pounds. WMC Bariatric Program Percentage of Excess Weight Loss by Primary Procedure from Initial Surgery Date % 76% 72% 73% % 24% 16% 1 month 41% 40% 23% 3 months 60% 59% 29% 30% 6 months 71% 74% 57% 9 months 35% 1 2 months 31% 24 months 34% 36 months Laparascopic Roux en Y Gastric Bypass Laparoscopic Sleeve Gastrectomy Laparoscopic Adjustable Gastric Band Annual Data Education On October 12th, 2012 we held our 6th Annual Bariatric and Diabetes Regional Symposium that was attended by over 120 healthcare professionals. The theme of the symposium was Obesity and Diabetes: Diseases of chronic inflammation. This educational event featured lectures on how the diseases of obesity and diabetes share many features of chronic inflammation, and how treatment of these complicated diseases affect the immune system. 19

22 Rate of Readmission within 30 Days After Surgery We collect dozens of data points on all patients including age, gender, weight, medical conditions, weight loss, complications, and even what medications are being taken before and after weight loss. We submit our data to a national database through the American College of Surgeons and compare our data to over 400 other programs that have achieved or are in the process of achieving Bariatric Surgery Center of Excellence. By doing this, we are able to not only contribute vital information about the safety of bariatric surgery, but we are also able to show that our outcomes compare very favorably to our peers. Our dedication to providing the safest care possible is supported by data collection and analysis that helps us continue to identify best practices. WMC Bariatric Program Rate of Readmission within 30 days of Primary Surgery 14% 12% National Benchmark 10% 10% Annual Data 8% 6% 4% 2% 0% WMC Bariatric Program Percentage of Reoperations within 30 days of Primary Surgery 20% 18% 16% 14% 12% 10% 8% 6% 4% 2% 0% National Benchmark 5%

23 2012 WMC Bariatric Program Percentage of Complications within 30 Days of Primary Procedure 10% 8% 6% 4% 2% Complication Rate within 30 days of Surgery 2012 WMC Bariatric Program Complication % Occurrence Anastomotic Leakage 1.3% Infection 5.3% Peritoneal Abscess 0.9% Pulmonary Embolus 0.4% Pulmonary Collapse 0.0% BENCHMARK 8% 8.0% 0% Anastomotic Leakage Infection Peritoneal Abscess Pulmonary Embolus Pulmonary Collapse Revisional Procedures Revisional bariatric surgery may be needed for some people who had bariatric surgery in the past, and now may need another highly specialized procedure to correct a complication or improve weight loss. Most of these procedures can also be completed using minimal access laparoscopic techniques. Over the last several years, our program has gained substantial experience in this highly specialized field of bariatric surgery. Annual Data 2012 WMC Bariatric Program Revisional Procedures by Year

24 Patient Referral Patient Referral All patients interesting in pursuing bariatric surgery or medical weight loss must register and attend a patient information session. This is the first step in the process. Surgical information sessions are held two Wednesdays a month at Winchester Medical Center, located at 1840 Amherst Street, Winchester, VA. This presentation is given by our medical physician. Medical information sessions are held once a month in the Program office, located at 347 Westside Station Drive, Winchester, VA. This presentation is given by our medical physician and one of our dietitians. Patients may register for information sessions online at or by calling the office at Patients should bring a copy of driver s license and insurance card to the information session. For more information: Winchester Medical Center Bariatric Program 347 Westside Station Drive, Winchester, VA Phone: Fax:

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36 347 Westside Station Drive Winchester, VA