at Putnam Hospital Center A Partnership for Lifelong Weight Loss Begins Mid Hudson

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1 Mid Hudson A BUSINESS & PRACTICE MANAGEMENT MAGAZINE ABOUT PHYSICIANS FROM PHYSICIANS FOR PHYSICIANS A Partnership for Lifelong Weight Loss Begins at Putnam Hospital Center

2 Ashutosh Kaul, MD, FRCS, FACS, minimally invasive and bariatric surgeon and Professor of Surgery and Co-Program Director of Minimally Invasive Surgery Fellowship Training at New York Medical College; and Jonathan Giannone, MD, DABS, bariatric surgeon, review a patient s information prior to sleeve gastrectomy surgery. A PARTNERSHIP By Michael Ferguson for Lifelong Weight Loss Begins at Putnam Hospital Center BARIATRIC SURGICAL SUCCESS ISN T SIMPLY A SURGICAL MATTER. EXCELLENT OUTCOMES ARE THE RESULT OF A LIFELONG COMMITMENT BETWEEN THE PATIENT AND A NETWORK OF DEDICATED PROVIDERS. THE ABILITY TO lose up to 80 percent of excess body weight is an extraordinary benefit for patients struggling with morbid obesity. Bariatric surgery facilitates such dramatic weight loss and frequently resolves obesity-related comorbidities, such as Type 2 diabetes. This life-changing metamorphosis affects every aspect of patients lives. As metabolic conditions resolve due to weight loss, the functionality of every organ in the body improves as well, says Ashutosh Kaul, MD, FRCS, FACS, minimally invasive and bariatric surgeon at Putnam Hospital Center and Professor of Surgery and Co-Program Director of Minimally Invasive Surgery Fellowship Training at New York Medical College. But patients and their surgeons can t do this alone. At Putnam Hospital Center, patients find bariatric surgical excellence complemented by an extensive support system ranging across Health Quest s network. Health Quest providers partner with patients to maximize the benefits of bariatric surgery, says Anthony Maffei, MD, FACS, Director of Bariatric Surgery, minimally invasive and bariatric surgeon at Putnam Hospital Center. Surgery is not a magic bullet solution. It s a tool we use as part of a comprehensive approach that leverages the expertise available at Putnam Hospital Center and throughout Health Quest s network. The partnership between Health Quest providers and patients is forged by shared determination to embark upon a lifelong journey to better health. Once patients decide to undergo a bariatric procedure, they begin meeting with a number of specialists, including cardiologists, pulmonologists, endocrinologists and psychiatrists, who monitor comorbid conditions and clear patients for surgery. Patients are often required to lose a significant amount of weight before surgery to demonstrate their commitment to changing behaviors that may influence weight gain, and Health Quest providers work with them to realize presurgical weight-loss goals. One of the most important aspects of the bariatric surgery process is pre- and postoperative meetings with nutritionists, who construct lifestyle transformation plans that include individualized educational

3 sessions promoting better eating practices and exercise regimens. We want patients to begin losing weight from the moment we meet with them, says Jonathan Giannone, MD, DABS, bariatric surgeon at Putnam Hospital Center. The more weight loss patients achieve before surgery, the better outcomes are. Marshaling our support services before surgery ensures that patients are safe candidates for a weight-loss operation and confirms each patient s commitment to undergo a lifealtering procedure. In addition to nutrition counseling, preoperative patients attend a weightloss seminar held at Putnam Hospital Center, Northern Dutchess Hospital or Vassar Brothers Medical Center, and led by the Bariatric Coordinator and the team of dietitians where they gain a better understanding of the process from postoperative patients who are at different points on their journeys. This fellowship between candidates for and beneficiaries of bariatric surgery allows preoperative patients the opportunity to hear firsthand accounts of each bariatric surgical option and learn about postoperative successes and setbacks that can occur. The opportunity to meet patients who have already undergone a bariatric surgery can play a major role in the preoperative patient s choice of procedure, Dr. Giannone says. While surgical candidates receive educational materials and lectures during the support group, talking with postoperative patients can open their eyes to another aspect of surgery they hadn t considered. For example, a patient who previously decided to have a laparoscopic gastric band procedure because of its minimally invasive nature may change direction and choose sleeve gastrectomy after hearing successful patients attest to the procedure s minimal pain and significant weight loss. Health Quest provides these services so patients in consultation with their surgeon can choose the operation that will produce the greatest benefit for their medical needs and weight loss goals. Selecting the Right Operation Because each bariatric procedure engenders specific benefits, bariatric surgeons at Putnam Hospital Center counsel patients about the relative merits of a malabsorptive or restrictive surgery. During presurgical consultation, bariatric surgeons elicit important information pertaining to patients eating habits, weightloss goals and weight-related comorbidities. Patients who eat large portions benefit from all surgeries because each limits the stomach s size, whereas grazers those who eat small portions throughout the day likely benefit the most from malabsorptive Thomas Cerabona, MD, outside the pre-operative area of Putnam Hospital Center. Patients find bariatric surgical excellence complemented by an extensive support system ranging across Health Quest s network. surgeries, such as gastric bypass or duodenal switch, which facilitate earlier satiety and limit the absorption of calories. Rapid weight loss is the most visible benefit of bariatric surgery, but perhaps the most striking is the significant improvement or resolution of obesity-related comorbidities, including Type 2 diabetes, high blood pressure, heart disease and sleep apnea. When we began performing bariatric surgery, the goal was to help patients lose weight, Dr. Kaul says. Now, weight loss is only one aspect of success. The most significant benefit is the resolution of metabolic disorders. This patient population has the highest associated risks and sees the most dramatic benefits from bariatric surgery. An Increasingly Popular Surgery While gastric bypass and duodenal switch surgeries may be ideal for patients who have poorly controlled obesity-related comorbidities, sleeve gastrectomy has become one of the most commonly performed bariatric surgeries at Putnam Hospital Center because of its success in curbing appetite and facilitating portion control. MEETING THE CRITERIA BARIATRIC SURGERY ISN T a front-line treatment for weight loss. Patients are carefully vetted against stringent national guidelines to embark upon the process. Bariatric surgeons at Putnam Hospital Center perform Roux-en-Y gastric bypass, gastric banding or sleeve gastrectomy for patients who meet the following criteria: + + Body Mass Index (BMI) of 40 or greater + + BMI of 35 or greater and at least one weight-related comorbidity Primary care physicians should begin thinking about how patients might benefit from bariatric surgery, says Jonathan Giannone, MD, DABS, bariatric surgeon at Putnam Hospital Center. Assess the patients interest and refer them to us so we can consult with them and arrange for them to attend a presurgical seminar. There are no commitments, and patients can decide against surgery at any time. Referral can only help.

4 NATIONAL RECOGNITION Bariatric surgeons at Putnam Hospital Center have elevated the quality of care to a level that positions the facility among the top programs in the country. For five years in a row, Healthgrades has awarded the program its Bariatric Surgery Excellence Award and placed it among the top 5 percent of similar facilities in America. Dr. Kaul meets with former patient, Patricia Greenwood O Keefe, Director of Critical Care services at Putnam Hospital Center, in her office. Sleeve gastrectomy evolved into a standalone procedure from its origins as the first phase of the duodenal switch operation, Dr. Maffei explains. In the 1980s, surgeons performed sleeve gastrectomy to promote weight loss and resolve obesity-related comorbidities in the 12 to 18 months before the second phase, in which surgeons rerouted the intestines. Surgeons found that patients were losing significant amounts of weight with the sleeve gastrectomy alone, Dr. Maffei says. That s how it became a stand-alone procedure. Thus far, the bariatric surgeons at Putnam Hospital Center have successfully completed more than 360 cases since starting the program there in The laparoscopic procedure involves making five or six 1-centimeter-long keyhole incisions through which surgeons introduce cameras and instrumentation to the surgical site. This results in less pain and quicker recovery. Inflating the stomach with carbon dioxide allows optimal visibility, which has already been improved by reducing the liver s size through preoperative weight loss. The mechanical effect of sleeve gastrectomy comes from resizing the stomach, which not only restricts the amount of food patients can eat at one sitting, but also decreases hunger pangs. We reduce the size of the stomach from a football down to a banana, Dr. Maffei says. A sizing device introduced orally calibrates how large we want the stomach to be, and after we make the determination, we staple off the right side of the stomach, shrinking it by approximately 80 percent and reducing ghrelin production. Ghrelin is a hormone produced by cells lining the stomach. After a significant portion of the stomach is removed, patients see their appetites significantly abate. We highly recommend sleeve gastrectomy for restrictive procedures, Dr. Giannone says. Gastric banding can result in complications that, while not life threatening, require revision operations to repair. There s definitely a population indicated for the gastric band especially those patients who don t want 80 percent of their stomach removed but if they re on the fence between sleeve gastrectomy and gastric band, we recommend the sleeve. Stacking Up Favorably Malabsorptive procedures gastric bypass and duodenal switch have traditionally been thought to produce the most dramatic metabolic results. But as sleeve gastrectomy rose in popularity, a team of physicians, including Drs. Maffei, Kaul and Thomas Cerabona, MD, FACS, minimally invasive and bariatric surgeon at Putnam Hospital Center, sought to compare the procedure s efficacy in resolving obesity-related comorbidities with that of gastric bypass. The team collected data from 558 patients who underwent gastric bypass or sleeve gastrectomy to treat morbid obesity at Westchester Medical Center within a twoyear span. Data from 30-day, six-month and one-year outcomes showed that sleeve gastrectomy compared favorably with gastric bypass, and even exceeded resolution rates for some conditions. At one year postop, the team found that 86.2 percent of patients had resolution of one or more comorbidities after sleeve gastrectomy, while 83.1 percent saw remission after gastric bypass. When the team drilled down to specific disease processes, they found that sleeve gastrectomy improved remission rates for sleep apnea and hyperlipidemia, and achieved similar results in Type 2 diabetes, hypertension and musculoskeletal disease. Mortal Misconceptions No pharmaceutical intervention achieves quicker or more sustained resolution of obesity-related comorbidities, and yet the misconception persists that bariatric surgery is a dangerous endeavor. Considering that this patient population is at high risk for any Bariatric surgery is a life-altering treatment. Not only does an operation change patients lives in many cases, it saves them. Anthony Maffei, MD, FACS, Director of Bariatric Surgery, minimally invasive and bariatric surgeon at Putnam Hospital Center surgical intervention, this is an understandable assumption. But it s false. While bariatric surgery has been portrayed as risky, and mortality rates have erroneously been reported as high as 1 percent, the chance of dying during a weight-loss surgery is roughly 30 times less than that of open-heart surgery and roughly five times less than that of gall bladder

5 Dr. Giannone and Dr. Maffei review patient records at Putnam Hospital Center. THE UNSUNG BENEFITS OF BARIATRIC SURGERY WEIGHT LOSS AND rapid resolution of metabolic disorders may be the bestknown benefits of bariatric surgery, but a number of other health improvements result from these operations. Many conditions you may not realize, such as infection rates and lifetime cancer risk, dramatically decrease with significant weight loss, says Ashutosh Kaul, MD, FRCS, FACS, minimally invasive and bariatric surgeon at Putnam Hospital Center and Professor of Surgery and Co-Program Director of Minimally Invasive Surgery Fellowship Training at New York Medical College. A BMI greater than 40 increases cancer risk to one in two. Adjusted hormone levels are one of many processes improved by bariatric surgery that reduce the chance of cancer. Obesity is linked to many cancer types, including breast (after menopause), colon and rectum, esophageal, kidney and gallbladder, and is thought to contribute to more, including cervical and ovarian cancers. Obesity-related cases vary by cancer type but can be as high as 40 percent, according to the National Cancer Institute. removal, Dr. Maffei notes. We ve developed safer procedures and less-invasive surgical techniques since bariatric surgery s inception thus far, 100 percent of the bariatric operations we performed at Putnam Hospital Center have been done laparoscopically, with zero mortality, leak or infection rate. A study published in the August 2011 issue of the Journal of the American College of Surgeons tracked the marked increase of laparoscopic bariatric procedures between 2003 and As laparoscopic surgeries increased, mortality rates decreased from 0.21 percent to 0.1 percent. The study s authors used data from the Nationwide Inpatient Sample and found that in 2003, little more than 20 percent of bariatric surgeries were performed laparoscopically. In just five years, the number had increased to 90 percent. In large part, misconceptions about the risks associated with bariatric surgery are relics from the discipline s infancy, when operations were performed with large incisions, which posed significant complication risks. Because morbidly obese patients have more subcutaneous fat, which has low blood supply and poor resistance to infection, they tend to have higher infection rates and seroma formation which is fluid leaking from the wound after large incisions, Dr. Kaul says. Additionally, because intra-abdominal pressure is greater, the rate of hernia development following a large, midline incision is as high as 30 percent. Approaching procedures laparoscopically, we reduce that risk to 1 percent. Furthermore, laparoscopic approaches actually improve visualization over open surgery, according to Dr. Kaul. Open approaches to bariatric surgery are much more difficult on the larger patients, he says. We have to start the surgery higher in the gastrointestinal junction, and it s more difficult to achieve the amount of exposure that s possible with the laparoscopic camera. The move to laparoscopy also decreases postoperative pain and facilitates quicker recovery. When sleeve gastrectomy and gastric bypass were performed with large incisions, it wasn t uncommon for patients to stay in the hospital for as long as two weeks, Dr. Maffei says. Following laparoscopic surgery, the average hospitalization is two nights. Patients are out of bed and walking the same night as surgery, and they tend to require less pain medication. Because this is a high-risk patient population, bariatric surgeons at Putnam Hospital Center emphasize safety, and to that end, each surgeon maintains expertise in performing each operation. The bariatric surgeons of Putnam Hospital Center and Advanced Surgeons: (L-R) Ashutosh Kaul, MD, FRCS, FACS, minimally invasive and bariatric surgeon and Professor of Surgery and Co-Program Director of Minimally Invasive Surgery Fellowship Training at New York Medical College; Anthony Maffei, MD, FACS, Director of Bariatric Surgery, minimally invasive and bariatric surgeon; and Jonathan Giannone, MD, DABS, bariatric surgeon

6 (L-R) Cheryl Madonna, bariatric coordinator; Margaret Sheehan, Director of Surgical Services; Dominick Buono, surgical technician; Ed Krauss, robotic team leader; Krystyna Kuchtar, operating room nurse; and Daryl Joy Esposito, operating room nurse, inside a state-of-the-art operating suite at Putnam Hospital Center. This cultivates a somewhat standardized approach to surgery and provides expertise available 365 days a year. Morbidly obese patients allow for very small margins of error because their systems are already working overtime, Dr. Kaul explains. Each surgeon in our department essentially performs every surgery the same way, and because we collectively have performed more than 5,000 bariatric surgeries, we can tell which patients are at risk for specific complications and prevent them. The Long Journey After While surgical excellence is a point of pride among bariatric surgeons at Putnam Hospital Center, optimal weight loss and resolution of comorbidities largely depend on postsurgical dedication of the patient and the team of providers. Immediately after surgery, patients start on a diet of JELL-O, Italian ice and broth. For two weeks, their diet is mostly liquid, the bulk of nutritional content supplied by protein shakes. After a two-week checkup, bariatric surgeons recommend replacing one protein shake with a soft protein meal per day and then encourage more as tolerated. Six weeks after surgery, patients participate in a nutrition class, led by Health Quest dietitians, who also see patients every three months to monitor vitamin levels and ensure proper nutritional maintenance. Patients meet with their surgeons every two to three months for the first year after surgery and then one to two times per year if everything goes well. To encourage sustained success, the Health Quest support network that welcomed patients before surgery plays an integral role in shepherding patients through the postsurgical journey. Weight loss is a lifelong process, Dr. Kaul says. We emphasize that surgery is only part of the process and complement our surgical capabilities with a team of dedicated, passionate providers who care for each patient. During preoperative counseling, dietitians and psychologists prepare patients for life after surgery, which can be challenging as they adjust to a new lifestyle. Morbid obesity doesn t spare patients from temptation they may want to relapse into, even after surgery, Dr. Maffei says. Our support groups are critical to helping patients move through the tough times. There, they can talk about any challenges they face if they gained a few pounds, they can talk to their peers who have overcome the same obstacles. But it s not all about the trials. During support group meetings helmed by Health Quest dietitians, patients exchange information about what healthy foods they enjoy and what exercises work for them as they reshape their lives. For more information about bariatric surgery at Putnam Hospital Center and Health Quest s expansive support network, visit n Reprinted from Mid Hudson MD NEWS