Munson s Bariatric Surgery Program: Excellent Outcomes, Few Complications

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1 Munson s Bariatric Surgery Program: Excellent Outcomes, Few Complications A2 Reason to Celebrate Physicians and patients from outlying areas are seeing long-term success A3 A4 A5 A6 Going Full Tilt Patient gets second chance to live life right ; asks physicians to keep an open mind Who s It For? Primary care physicians play key role in identifying, following up with surgical patients The Diabetes Connection Bariatric surgery is having a significant impact on type 2 diabetes and other life-threatening diseases National Recognition A7 Munson named a Bariatric Surgery Center of Excellence by exceeding national standards Meet the Surgeons MunsonHealthcare.org The procedures and the surgeons who perform them

2 Canadian Perspective: Not One Patient Says They Wouldn t Do It Again I m seeing excellent results. Typical weight loss is 100 pounds in the first year. Linda Benedek, MD, CCFP, FCFP Diplomate of American Board of Bariatric Medicine Celebration Medical Weight Management Sault Ste. Marie, Ontario Three years ago, Linda Benedek, a family physician by training and a former Air Force flight surgeon, decided to focus her practice exclusively on weight management and the co-morbidities of obesity. Her own struggle with weight led her to seek additional medical training to become a diplomate of the American Board of Bariatric Medicine (ABBM). After becoming credentialed, she opened Celebration Medical Weight Management in Sault Ste. Marie, Ontario, and offers a six-month weight management program that, for some patients, dovetails with the Bariatric Surgery Program offered at Munson Medical Center. In the past 18 months, Benedek has referred 25 of her 300 patients to bariatric surgeons at Grand Traverse Surgery, PC. Her program uses a three-pronged approach to tackling obesity: behavior modification, diet, and exercise, with the goal of achieving a 5-10 percent weight loss within six months. She is her own walking testimonial, having lost 40 pounds and kept it off for three years. I don t refer anyone for bariatric surgery until they have completed the program, she said. Some patients, despite best behavior modification and diet changes, are unable to lose weight. We will look at bariatric surgery as an option, but the intent of my program is not just to prepare people for surgery. Mental and emotional issues with respect to food need to be properly addressed, as the surgery does not eliminate those. Benedek makes it clear to patients that bariatric procedures are only for rule followers. She screens out patients unlikely to succeed because they are non-compliant in other areas such as treatment for diabetes. So far, that approach has been highly successful. I m seeing excellent results, she said. Typical weight loss is 100 pounds in the first year. My patients have been very compliant. I take a lot of time teaching them about protein intake it s essential that they do what they re supposed to do. Benedek has observed improvement in all co-morbidities in her post-op patients. Most of my patients are able to discontinue their blood pressure, cholesterol, and diabetic medications, she said. Even insulin is often discontinued or markedly reduced. The symptoms of osteoarthritis in their knees and hips are significantly improved with much less discomfort. They re all delighted the ones with complications and the ones without. I have not had one patient say they wouldn t do it again. Support for Physicians and Patients in Outlying Areas Physicians and patients from outside of the Traverse City area can expect a high level of service from the team at Munson. I m three hours from Traverse City, Benedek said. I m very pleased with the service I get from Traverse City. They really do their best to minimize travel for my patients. They re very courteous, flexible, and amenable. continued on A4 A2 Benedek s Program: Behavior Modification Diet Exercise > 5-10% Weight Loss in Six Months

3 MunsonHealthcare.org Bariatric Surgery Gives Patient A Second Opportunity to Live Life Right I feel fantastic. The other day a co-worker said, Oh, you re sitting in a chair with sides I ve never seen you do that. I ve discovered I actually have a tailbone I can feel it. Lesley Sawchyn, Sault Ste. Marie, Ontario Lesley Sawchyn was a chubby child ballerina who grew into a chunky teen basketball player. Despite being physically active, by the time Lesley was a 37-year-old mother, she weighed 330 pounds. She has a plea for primary care physicians: Be open minded and open hearted. If you are a thin physician and you ve never been overweight, you do not truly understand what it is like to be obese and how cruel society is to people who are. Really try to understand where your patient is coming from. Secondly: Be fully supportive, but put the onus back on the patient. There is no going back after making the decision for surgery. You basically have one chance the patient has to be responsible for their own success. Lesley, a sign language interpreter for the Canadian Hearing Society, completed a six-month weight management program in Sault Ste. Marie, Ontario. She lost 32 pounds. When she gained it all back, she had a heart-toheart with her physician, Linda Benedek, MD, in November Nothing, nothing, nothing was working for me, she said. I decided I m too vibrant to be weighed down by this weight. Lesley had a Roux-en-Y procedure at Munson Medical Center in March 2009, weighing 321 pounds. Ten months post-op, she weighed 193 pounds. Lesley before (above) and after (right) below national averages, they can happen. The wellestablished collaboration between her primary care physician and her surgeon became paramount when Lesley developed an ulcer and a stricture. Benedek referred her back to Munson Medical Center for immediate care. Despite complications, Lesley says she is extremely pleased with her results, grateful to her local primary care physician, and she s highly complimentary of the team at Grand Traverse Surgery. Lesley helps lead a lively bariatric support group in Sault Ste. Marie, encouraging others to adhere to the life-long dietary and exercise requirements. I d do it again in a heartbeat, Lesley said. I was always an active person, but now I can go full tilt. I m in such good hands. I ve been given a gift a second opportunity to live again and do it right. Once you have the surgery, you have an obligation to take care of yourself. Lesley had no co-morbidities. While complication rates for bariatric surgery at Munson Medical Center are well Roux-en-Y Procedure A3

4 A Guide for Primary Physicians A4 continued from A2 Patients are seen for an initial consultation, again for one pre-op visit that covers everything in a half-day appointment, and then they return for surgery. Patients who live more than three hours away are asked to stay in Traverse City until seven days post-op, when their drain is removed and they are sent home. Patients are usually hospitalized for three days, depending on their procedure. Follow-up care begins immediately with the primary care physician. Surgery notes are transcribed and faxed immediately, Benedek said. I have them in hand well before I see my patient I m really kept in the loop. It s a very smooth process for my patients. The back up support is excellent one of the four surgeons is always on call. If my patient runs into a problem at midnight, a surgeon is available for telephone advice. We have had some complications, such as a post-op leak and a bowel obstruction, both of which required surgery and those were promptly dealt with. Four Tips for Primary Care Physicians Based on her experience, Benedek offers the following advice: Evaluate all behavioral aspects before considering bariatric surgery if those issues aren t dealt with first, the surgery is less likely to be successful. Develop a rapport with a Bariatric Surgery Center so you are familiar with the process and the required follow-up for patients. Don t consider surgery for anyone who can t quit smoking. Patients must be non-smokers for at least two months before a referral should be considered. Make sure patients fully understand life-long nutrition and lifestyle requirements after surgery. Rule followers do well the non-compliant patient is not going to do well. As the first providers who can help improve or save a patient s life through bariatric care, primary care physicians are the gatekeepers for the Munson Medical Center (MMC) Bariatric Surgery Program. MMC has taken definitive steps to provide the best opportunity for patient success. The following criteria and steps can help physicians determine if patients are eligible, and what to expect. Bariatric Surgery Criteria MMC bariatric surgeons follow the National Institute of Health (NIH) guidelines for weight-loss surgery candidates to include one of the following: Body mass index (BMI) of 40 or greater (100 pounds or more above normal weight) BMI of 35 to 40 (50 to 100 pounds above normal weight) with two or more co-morbidities Patient age: years Patient record of unsuccessful attempts to lose weight in a medically-supervised program Patient obesity-associated co-morbidities under medical care Educational Seminar Patients who meet criteria must attend a two-hour educational seminar. The seminar is offered once a month and is an important opportunity to teach patients about the lifelong commitment to proper nutrition, exercise, smoking cessation, and other behavioral modifications, said Mary Kay Williams, MSN, FNP-C, Coordinator of the Munson Bariatric Surgery Program. Next Steps Once a patient makes the commitment, has the recommendation of their primary physician, and the support of their family, they enter the Bariatric Surgery Program. The next steps are consultation, psychological evaluation, preoperative classes, and the surgery. Long-term Care Management Comprehensive care is a critical component of MMC s Bariatric Surgery Program. By focusing on medical management, nutrition, exercise, nursing care, and psychological needs of each patient, the support staff offers patients the optimum opportunity to succeed. Post-op follow-up care occurs at one week, three weeks, six weeks, three months, six months, nine months, 12 months, 18 months, 24 months, then yearly thereafter. A lifelong connection to patients has proven to be essential to success. Support groups also offer information and encouragement to patients after surgery. Meeting with other patients who have undergone the surgery is vital to our patients success, said Williams. They share in each others struggles and victories, and that brings them comfort and strength.

5 MunsonHealthcare.org Bariatric Surgery: A Cure for Diabetes? Mounting evidence suggests bariatric surgery may be among the most effective treatments for conditions including type 2 diabetes, hypertension, high cholesterol, non-alcoholic fatty liver disease, and obstructive sleep apnea, according to the American Society for Metabolic and Bariatric Surgery (ASMBS). Surgery for severe obesity goes way beyond weight loss, said Kelvin Higa, MD, President of ASMBS. This surgery results in the complete remission or significant improvement of type 2 diabetes and other life-threatening diseases in most patients. Surgeons at Grand Traverse Surgery, PC, who participate in Munson Medical Center s (MMC) Bariatric Surgery Program, are optimistic about use of gastrointestinal surgery as a treatment for diabetes. We are seeing evidence that bariatric surgery results in type 2 diabetes remission. A high percentage of our patients have normalization of their hemoglobin AIC within two months of gastric bypass. Michael Nizzi, DO, Medical Director MMC Bariatric Surgery Program Gastric bypass and other malabsorption procedures (intestinal bypass) will become the procedure of choice for type 2 diabetes mellitus remission, Nizzi said. This is still investigational, but consensus is growing to decrease the BMI threshold of which patients are candidates for surgery. New research indicates metabolic surgery may improve insulin resistance and secretion by mechanisms independent of weight loss most likely involving changes in gastro intestinal hormones. Many patients with type 2 diabetes experience complete remission within days of surgery, long before significant weight comes off. This has led to new thinking that surgery may be appropriate for diabetic patients who are of normal weight or only slightly overweight. In the American Diabetes Association s (ADA) 2009 Standards of Care Clinical Guidelines, the ADA bolstered its section on bariatric surgery and its effect on type 2 diabetes and said bariatric surgery should be considered for adults with BMI greater than 35 and type 2 diabetes. ASMBS and many other national medical organizations also support using bariatric and metabolic surgery in type 2 diabetes patients with BMIs of less than 35 under a research protocol. An article in the January 2008 issue of the Journal of the American Medical Association (JAMA), written by David Cummings, MD, and David Flum, MD, MPH, both from the University of Washington in Seattle, reported on a two-year randomized controlled trial involving type 2 diabetes patients with a BMI of 30 to 40: Complete remission of diabetes at two years was achieved in 73 percent of the patients in the laparoscopic adjustable gastric banding group versus only 13 percent in the medical/behavioral therapy group. The surgical group experienced larger reductions in blood glucose levels, glycated hemoglobin levels, estimated insulin resistance, use of diabetes medication, and several features of the metabolic syndrome. Among the 84 percent of patients with diabetes whose disease remits entirely after Roux-en-Y gastric bypass, one-third have blood glucose levels within reference range without use of anti-diabetes medications before discharge from their surgical hospitalization, at an average of less than three post-operative days. A5

6 Munson Bariatric Program Nationally Recognized for Excellent Outcomes The Agency for Healthcare Research and Quality reports that the number of bariatric surgeries increased 400 percent from 1998 to More than 1,500 bariatric surgeries have been performed at Munson Medical Center (MMC) since the program began in Munson and surgeons from Grand Traverse Surgery, PC, were named a Bariatric Surgery Center of Excellence based on demonstrated short- and long-term outcomes and advanced treatment that exceeds national standards for bariatric surgical care. In addition, MMC was designated a Blue Distinction Center for Bariatric Surgery by Blue Cross Blue Shield of Michigan and is an approved provider for the Ontario Health Insurance Plan (OHIP) for Canadian patients. Total surgeries by type 2009 Low Complication Rates RNY Open 10 RNY Lap 193 Lap-Band 172 Lap Sleeve 36 Open Sleeve 1 Revisions 1 Nationally, bariatric surgery complication rates declined 21 percent between 2002 and Complication rates at Munson Medical Center were 2.51 percent in 2008, well below national rates. With the exception of gastric banding, all other primary and revisional bariatric procedures are performed by two surgeons, rather than being assisted by a physician extender or surgical assistant, said Michael A. Nizzi, DO, Medical Director of Munson s Bariatric Surgery Program. The clinical pathway at Munson ensures that all patients receive equal evidence-based therapies that limit omissions in the care plan that could possibly lead to sub-optimal results. About 400 bariatric procedures are performed annually at MMC. Bariatric surgery is successful if the patient achieves a 50 percent loss of excess body weight within 18 months following surgery. With comprehensive support provided by Munson s bariatric team, patients consistently exceed that average most reach a 75 percent excess weight loss within 12 to 18 months post-surgery. Munson s weight loss program includes experienced surgeons who perform an average of eight bariatric procedures each week, said Roche J. Featherstone, MD, bariatric surgeon. We practice extensive patient screening, education, and follow-up, which leads to our patients success, as well as our recognized success as a team. A6 Additionally, laparoscopic procedures now account for more than 90 percent of our cases, Nizzi said. Physicians considering making a referral for bariatric surgery at Munson Medical Center should feel very confident that their patient will be safe and successful because we have established a program that is achieving or exceeding all national benchmarks.

7 Meet the Bariatric Surgeons Total Surgeries Performed at Munson Medical Center Roche Featherstone, MD The LAP-BAND System This minimally-invasive adjustable gastric banding procedure is the only reversible, FDAapproved surgical obesity treat- Lap Band ment. A silicone band is placed around the upper part of the stomach to create a new, smaller stomach pouch. The band also narrows the stomach outlet, limiting the flow of food. It reduces appetite and slows digestion. LAP-BAND is appropriate for patients who have a lower BMI and limited co-morbidities. Although current procedures yield above-average success for MMC patients, the bariatric team looks to advancements that include genetic therapy, gastric pacemaker, and intragastric balloons, all of which provide options to widen the bariatric care MMC provides. Roux-en-Y Surgeons perform this laparoscopic procedure through tiny incisions, during which the stomach is made into a small pouch that restricts food intake. The duodenum and first portion of the jejunum are bypassed, thereby reducing calorie Roux-en-Y and nutrient absorption, so careful attention is placed on patient education and dietary evaluation post-surgery. Vertical Sleeve Gastrectomy Vertical sleeve gastrectomy surgery involves only the stomach, and consists of reshaping it from a pouch into a long narrow tube and removing two-thirds of the stomach. The narrower stomach restricts food intake by allowing Vertical Sleeve only a small amount of food at one time. New connections are not made between the stomach and small intestine, and there is no re-routing of the intestine, or reduced absorption of nutrients. Medical School: Wayne State University School of Medicine, Detroit, Mich. Residency: St. John Hospital, Detroit, Mich. Joined MMC Staff: 1996 David Kam, MD Medical School: Wayne State University School of Medicine, Detroit, Mich. Residency: Butterworth Hospital, Spectrum Health, Grand Rapids, Mich. Fellowship: University of Pittsburgh, Pittsburgh, Pa. Joined MMC Staff: 2008 Michael Nizzi, DO Medical School: DesMoines University Osteopathic Medical Center, Des Moines, Iowa Residency: Michigan State University College of Osteopathic Medicine, East Lansing, Mich. Joined MMC Staff: 1999 Steven Slikkers, MD Medical School: Loma Linda School of Medicine, Loma Linda, Calif. Residency: Mayo Graduate School of Medicine, Rochester, Minn. Joined MMC Staff: 2004 Referrals and Consults To refer patients for a consultation or specialized care, or for a surgical consult, please call (231) For 24/7 hospital transfers, please call A7