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Notes from bariatric surgery orientation, surgeon Dr. Mark C. Takata, Scripps Hospital, 9/16/2019

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This is my intrepretation from the orientation. There may be content errors; consult with your surgeon if anything is different from what you've heard.

1. Marcia (mar-see-a) Chavez is the go-to person on insurance and what to do next steps.

2. Dr. Takata really enjoys being a bariatric surgeon because:
a. Bariatric surgery makes a giant impact on the lives of patients, more than many other areas, and akin to the impact that organ transplantation has on patients. It gives patients a second chance at life and the data shows that it saves lives, increases lifespan, decreases illness associated with morbid obesity.
b. It is an “enjoyable” surgery to perform with the advent of laparoscopic surgery. It is akin to comparing the technology in TV sets from 20 years ago compared to modern 4K HD TV. The amount of detail that can be seen during surgery is astounding compared to issues surrounding large incisions in traditional surgery. (My note: I assume that large traditional incisions cause issues with excess fat and other tissues obstructing the surgeon’s view, and the surgeon cannot “wear” a high definition camera on his eyes while operating during traditional surgery. We’ve all seen the capability of using even a smartphone to capture amazing detail that can be zoomed in to view details that your naked eye are not capable of seeing.)
c. Not much pathology in upper abdomen surgeries, where all bariatric surgeries are performed.

3. He recommended that patients have any bariatric surgery performed at a Center of Excellence, and that’s the case for any and all other types of surgeries. Scripps is a Center of Excellence, but there are others. (My note: the NIH defines Centers of Excellence as specialized programs within healthcare institutions which supply exceptionally high concentrations of expertise and related resources centered on particular medical areas and delivered in a comprehensive, interdisciplinary fashion—afford many advantages for healthcare providers and the populations they serve. To achieve full value from centers of excellence, proper assembly is an absolute necessity, but guidance is somewhat limited. This effectively forces healthcare providers to pursue establishment largely via trial-and-error, diminishing opportunities for success.)

4. Scripps Weight Management is a combination of multiple medical, surgical and research doctors as well as specialized nurses. Dr. Lee is my medical doctor (endocrinologist specializing in weight issues), Dr. Takata would be my surgeon. Karen Giuggio is Dr. Takata’s surgical nurse.

5. Body Mass Index (BMI) and classes of obesity:
a. (Didn’t write down the lower BMIs)
b. BMI 30 – 34.9: Class 1: no insurance coverage for bariatric surgery
c. BMI 35 – 39.9: Class 2: typically requires at least 1 co-morbidity (diabetes, apnea, high blood pressure, or high cholesterol/dyslipidemia) to qualify for insurance coverage
d. BMI 40 and above: Class 3: insurance coverage without co-morbidities

6. 5% or 15 million people in the U.S. are Class 2 and 3. This is a significant increase over the past 20 – 30 years.

7. Obesity and smoking are the 2 most preventable causes of death in the U.S.

8. Obesity has physical, social, psychological, and economic impacts to both the individual and the population.

9. Obesity has significant negative impact on every human body system: cardiologic, pulmonary, gastrointestinal, gynecological, urinary, metabolic, neurologic, and neoplastic (neoplastic diseases are conditions that cause tumor growth, both benign and malignant).

10. Just because you can control co-morbidities (diabetes, apnea, high BP, high cholesterol/ dyslipidemia) does NOT mean they aren’t damaging those 8 body systems. Damage and eventual death is likely to occur eventually from those co-morbidities. High BMI = earlier than normal death or at best, loss of mobility.

11. The risks associated with staying morbidly obese are far greater than the risks associated with getting bariatric surgery. (My note: a data chart was presented that completely stunned me to the point of not writing down any notes. It was at this point I lost most of my skepticism; I’m an engineer and scientist and am data driven.)

12. The outcomes are poor for non-surgical weight loss/management programs (i.e., formal programs, fasting, dieting, etc.; data charts were provided). Formal weight loss programs (e.g., Weight Watchers, Jenny Craig, Medifast, Optifast, Paleo, Whole 30, etc.) know that 97-98% of people will gain the weigh back. The people that are successful at those programs statistically are those who have very little weight to loss, in the 5 – 20 pound range.

13. The number of bariatric surgeries have increased in the U.S. Example: 2011 158,000; 2017 228,000.

14. Laparoscopic surgery has revolutionized surgery resulting in significantly lower complications. It is also a much more precise surgery than non-laparoscopic surgery.

15. Bariatric surgery is not a cosmetic surgery, nor should it be used as such. Bariatric surgery is a medical surgery used to prevent and reduce medical illnesses.

16. Bariatric surgery is not successful unless it is treated as a multi-disciplinary approach. The post-surgical programs must be followed, and the patient must put forth effort post-surgery.

17. Post-surgical patients should not view this as a way to achieve 100% Excess Weight Loss (EWL). It is likely and acceptable that most patients will not achieve 100% EWL. They will likely have an excess weight (example given: 10--20 pounds) above “ideal body weight”. Medically speaking struggling with and excess 10-20 pounds is acceptable compared to an excess 80 – 200+ pounds. The co-morbidity risks associated with an excess 20 pounds are relatively insignificant compared to the series co-morbidity risks of excess 80+ pounds.

18. Results:
a. Significant weight loss (% EWL and lower BMI)
b. Improvement in co-morbidities and survival
c. Quality of life increases
d. “Successful” results:
i. Excellent result (not common): BMI < 30, %EWL > 75%
ii. Good result (common and he found very acceptable: BMI 30 – 35, %EWL 40-75%

19. Most people will want to lose that last extra 10 – 15 pounds, but that is not the goal of bariatric surgery. That doesn’t mean not to keep trying; need to stick with the post-surgical multi-disciplinary efforts.

20. Overeating after surgery will NOT cause a rupture, but will definitely cause problems over time. The human stomach is one of the very few organs that can be significantly removed (i.e., 80%) without cause death or serious illness. You cannot do that with the liver, heart, lungs, etc. Humans essentially have an overly large of a stomach.

21. Roux-n-Y surgery explained and graphic provided. Small new stomach created from part of old stomach, size of a tangerine. The top part of the small intestine (duodenum? Appears to be about 6 inches) is cut, left attached to old stomach, and the shorter intestine is now attached to the new stomach. (my note: I asked why the detached stomach and duodenum is left inside the body; he inferred that they still perform functions such as creation of stomach acids, but it was unclear to me how those actually affect the new stomach because it appears to be completely detached; I didn’t press the issue and will research later.) Roux-n-Y works by:
a. Physical restriction of stomach size
b. Decreased appetite
c. Some malabsorption
d. Dumping

22. Sleeve surgery explained and graphic provided. A large portion of the stomach is removed and a new stomach is formed from the portion left intact. It has the appearance of a shirt sleeve vice a large bag that was the old stomach. The intestines remain intact and art not detached in any way. Sleeve works by:
a. Physical restriction of stomach size
b. Decreased appetite (my notes: I asked if due to decrease in ghrelin, leptin, and PPY hormones that stimulate appetite and are created by the stomach; he said partially)
c. NO MALABSORPTION (my note: this was important to me)
d. Did NOT list dumping

23. Comparison of techniques typical expected/historical outcomes:
a. Roux-n-Y: %EWL 70-80%
b. Sleeve: %EWL 60-70%
c. Band: %EWL 30-40%
d. Pharmaceutical: %EWL 10-20%

24. Which surgery is right for you? Decision based on:
a. personal medical conditions (other pre-existing)
b. co-morbidity conditions (e.g., reflux, diabetes)
c. patient preference
d. age
e. prior surgeries
f. “behaviors” such as sugar cravings (my note: discuss with surgeon: details about sugar v. starches, are they medically the same effect?)

25. Roux-n-Y results in the best weight loss, but the sleeve is very good as well. There may be reasons that the Roux-n-Y is not the best choice for you and may result in issues that far outweigh the benefit of losing a few extra pounds.

26. Complications: 10% experience general/minor (headache, nausea, etc.); 2-3% experience major (bleeding, infection, lung, heart, deep vein thrombosis, pulmonary embolism). The common complications for R-n-Y are leaking, obstruction, and stricture. The common complications for Sleeve is leaking (1-2%) and reflux (may not have had any reflux before surgery; not a good idea for those with reflux prior to surgery to have Sleeve surgery.)

27. Risk of death: from during surgery up to 30 days after is 0.09% (my notes: that is 9 of every 10,000 patients). Risk of death after 30 days is basically nil.

28. Weight regain (data chart provided): in the first year, most people lose most of their weight up to 80% of %EWL. In years 2- 5: people regain 15% of lost weight. Approximate statistical high data points on the chart of %EWL v. Years: year 1 80%, year 2 78%, year 7 65%, year 9 50%, year 10 78%, year 11 70%, year 12 60%.

29. The reason people regain weight is almost always a result of one or more changed behaviors:
a. eating too much
b. eating too much of the wrong things
c. eating too often
d. lack of movement/exercise.

30. Changed behavior may be a result of one of more issues:
a. lack of prolonged enthusiasm
b. traumatic life event
c. traumatic medical event
d. failing to adhere to post-surgical lifestyle
e. return of urges/appetite*

31. Re-emphasized that bariatric surgery is not enough; the correct approach is surgery coupled with diet and exercise (i.e., walking and enough mild exercise, not necessarily high intensity).

32. * My notes: discuss with surgeon: if that regain of weight due to appetite is scientifically been linked to a return/increase in hormones; Dr. Lee and I think that my weight issues are a result of excess appetite hormones which were greatly controlled in early days with pharmaceuticals, but pharma does not last over time. Previously I was able to control appetite hormones by intentional creating countering hormones through significant exercise; I cannot maintain this as I age.

33. The hormones signal you to eat can be part of the problem, made worse by eating too fast. The body does not register the hormone that tells you to stop eating until 20 minutes after you should stop eating. (My notes; discuss with surgeon: I need to work on slowing down my eating now. But I still have the problem that well after 20 minutes, say 1 hour, 2 hours later, I am getting large urges to eat again.)

34. Post-Surgery:
a. Let them know immediately if you experience any vomiting, fever, or pain.
b. Walking is important, but take it easy the first 6 weeks
c. Must be off of work the first 2-4 weeks (Sleeve), 4-6 weeks (R-n-Y)
d. No NSAIDS immediately after surgery at all, and no habitual NSAIDS for the rest of your life (occasional low dose, like 1/month, is ok). Must find alternate methods to manage inflammation pain. Otherwise will develop complications like ulcers or worse.
e. Join the monthly free support group.
f. Medications:
i. Sleeve: multivitamin, calcium w Vit D, protonix*
ii. R-n-Y: multivitamin, calcium w Vit D, protonix, iron, B12

35. My notes: ask surgeon: protonix (pantoprazole) is a proton pump inhibitor (PPI) prescribed after surgery as a prophylaxis. I read it is usually prescribed to all patients for 1 year following surgery. After the first year, the PPI is continued only in specific cases, such as patients who suffered from a marginal ulcer or reflux. Protonix helps heal acid damage to the stomach and esophagus, helps prevent ulcers, and may help prevent cancer of the esophagus. But prolonged use can cause B12 deficiencies due to malabsorption, new or worsening joint pain, increased bone fracture, lupus, or fundic gland polyps that can lead to cancer, and Barrett’s esophagus that can lead to cancer. I do not want to be on protonix. Sleeve surgery has a higher incident of reflux, so it may increase likelihood of need for protonix? Which surgery is less likely to involved prolonged protonix use? What is the % likelihood of prolonged/lifelong use?

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