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Patient choice, expectations and maximising outcomes
Dr Chandraratna has been practising bariatric surgery for over ten years. Although he originally trained as a liver and transplant surgeon, over the years he migrated into bariatric surgery as the number of cases increased to the extent that bariatric surgery has now taken over his practice.
“When patients first approach us about surgery, they are embarrassed because there is a perception that surgery is an easy way out. Frequently patients exhibit a lot of shame about their obesity. Society has taught us that obesity is due to over indulgence and laziness and this is just not true. I spend the first part of the consultation explaining to patients that this widely held belief is a gross misconception. Often patients don’t want to tell anyone about having bariatric surgery, but it becomes quite obvious when they start to lose considerable amounts weight that something has changed.”
He explains that over the last few years he has witnessed a significant change in attitude towards bariatric surgery by both the wider community and doctors, and that this is has contributed to the increase in the numbers of bariatric surgery procedures performed over the past few years. He believes the sleeve gastrectomy has also contributed to this as an operation that is highly effective but also easy to live with. Patients now believe that surgery is a treatment that actually works. Frequently we hear patients say, “I should have done this years earlier.”
Interestingly, he said that his centre has many patients who come from small clusters of communities and families, and these patients have been referred to the centre by previous patients who have whole-heartedly endorsed bariatric surgery. “What I tell my patients is that people will be inspired by your journey and by sharing your story and your experience, you could help inspire someone else in helping them make their decision regarding their treatment choice to combat their obesity.”
According to Dr Chandraratna, there is no single reason why people become obese, it is complex multifactorial disease. It’s more than just a matter of ‘calories in vs calories out’. He sees lots of patients who eat sensibly and have been dieting for many years, who exercise regularly, so it is not just about lifestyle. We also know from the research data that diets are not effective in providing adequate long term weight loss for the morbidly obese.
“We understand that obesity is a metabolic disease. Patients have a higher set point with a lower caloric requirement, a decreased sensitivity to gastric stretch. We now know from the animal research data that even the choice of foods high in fat and carbohydrate has been linked to gut hormonal influences. And amazingly patients often report change in their dietary choices after bariatric surgery that reflects the animal research models.”
His centre has also seen an increase in the number of patients who are coming for surgery because of work and occupation and health and safety issues. In Western Australia they have an economy driven by the mining industry and many people working in remote locations in difficult conditions. In a mine or on an oil rig and are dangerously close to exceeding the weight limits set down by occupational health and safety guidelines and are at risk of losing their jobs and income. Frequently, they see people whose weight stops them from getting get into a light aircraft or helicopter which is required to travel to their place of work or they are unable to get into the cabin of their work vehicle.
And then there is the strong association with depression.
“Not infrequently, patients will present for bariatric surgery either with undiagnosed depression, or others already on antidepressants. We know from our quality of life analysis that overweight people have significant reduced scores and this changes dramatically after surgery. And the relationship between obesity, depression and comfort eating begins a vicious cycle that without surgery is impossible to break. The other thing that patients often report is the social isolation of obesity. Obese individuals are paradoxically invisible in society. Patients will often report the experience of people approaching them in the street and engaging them conversations following their significant weight loss something that they never experienced prior to surgery.
“One of the most rewarding things about being a bariatric surgeon is when you see a patient a few months after surgery and they have lost weight and have a new personality and often a new fashionable wardrobe. Now that might sound superficial, but it is more about the way they are seeing themselves, they are happy, they are confident and they are starting to live their lives again. I think patients enjoy the cosmetic and social benefits of weight loss and I am suspicious that this is the primary motivation for a lot of my clients, but for me it’s about their health benefits and knowing that I have done something that will improve their health and prolong their lives.”
It’s the patient’s choice
He reveals that most people come to the clinic with a specific operative choice in mind. The vast majority arrive requesting a laparoscopic sleeve gastrectomy, primarily because they know someone who had the procedure and they want the same weight loss. This has changed over the last 5 years with a big shift away from adjustable gastric bands to now predominantly requesting a sleeve gastrectomy. Although the vast majority of the procedures they perform are sleeve gastrectomies (90%), they discuss all the options with patients and explain each procedure - the advantages and disadvantages, outcomes and risks.
“I don’t think as a surgeon it is a good idea to try and change someone’s mind. Because if I make the decision for them, they are eventually going to be dissatisfied with some component of the procedure. If they have a band they will complain about the dysphagia, if a sleeve the lack of reversibility or if a bypass the dumping, it is inevitable and everyone goes through a period of regret. So I give my patients the options, as much information as possible, tell them the probable outcomes and risks, educate them the best I can, so the patient can make an informed decision.”
At his centre, they carry out about 400 sleeves a year and a small number of gastric bypasses, in all cases the bypasses are a revisional procedure after a failed gastric band or a sleeve with inadequate weight loss or reflux.
After surgery he stressed the importance of seeing patients regularly as part of routine follow-up. This differs slightly depending on which procedure they have had. For example, for gastric band patients at his centre get seen regularly at least once a month, if not more often, for the first year and try and make sure they are adopting all the correct behaviours. However, he notes that it can be difficult to get patients into the clinic to see the allied health team.
For sleeve patients, they are seen regularly for the first three months and then every six to 12 months after that, mainly to ensure they are not suffering from nutritional deficiencies. The sleeve is not a ‘set and forget’ operation. It needs on-going monitoring and support.
His practice is no different from most centres in that the vast majority of patients are female (~80%) and he explained that he is blessed with a “wonderful team” and a practice nurse who is happy just to sit down and talk with patients about how they are feeling – which really makes a difference.
“There are four staff at our practice that have had bariatric surgery. Quite often, patients just need to talk with someone and we are fortunate enough to have staff who can reassure, understand what they are going through and provide information from their own personal journey.”
Another important aspect following surgery is getting support and understanding from family and friends, as quite often they do not understand that a patient’s eating habits will change dramatically. They frequently see sabotaging behaviour from friends and relatives who encourage the eating of high calorie foods and constant criticisms about being too thin. So there are many post-operative challenges that the patient will face – both expected and unexpected.
“I think some patients have it in their head that if they don’t eat they are going to die. I had a patient a couple of years ago who turned up 24 months or so after the procedure and said, ‘I think there was a problem with my operation, as I can’t eat anything’. So I talked to her about her eating habits and they were exactly what we would expect, her BMI was 26 but she had it in her head that she was not eating enough. So post-surgery, there is a need to educate patients about what they might experience, the changes – both physical and psychological - they will go through and try to help them manage their expectations.”
Banded Sleeve Gastrectomy
At IFSO 2015 in Vienna, Dr Chandraratna presented data from 765 banded sleeve gastrectomies. The largest series of banded sleeve gastrectomy patients in the world, and it is a procedure he readily endorses and believes is a safe way of achieving better short and long term results.
“At our practice, we recommend that patients have a banded sleeve gastrectomy for the simple reason that it makes the procedure more effective. We have seen so much data presented at IFSO this week clearly demonstrating better outcomes for patients who have had a banded procedure, whether a bypass or sleeve. I believe that if it will give my patients better outcomes then I will advocate its use – and banded procedures are clearly more effective.”
He adds that not all patients can have a banded procedure, if their anatomy is a little distorted through scarring from a previous surgery placement can be precarious. Nevertheless, at his practice some 90% of patients opt to have their sleeve banded.
“In my experience a sleeve needs to be snug, so we use a 38 French bougie and you need to get quite close to the pylorus. I know some surgeons advocate 4-7cm below the pylorus but I think this could allow the pouch to stretch overtime. I also tend to be snug at the bottom and a little loose stapling around the incisura to avoid strictures and kinking. Then to place the staple line away from the gastro-oesophageal junction. I think for the junior surgeon, these are three most important points when performing a sleeve gastrectomy.”
For the banded sleeve gastrectomy, Dr Chandraratna uses the MiniMizer Ring (Bariatric Solutions). He said that the design of the MiniMizer Ring makes it easy to place and secure, in addition it has the intra-operative flexibility allowing for adjustments to the desired diameter.
“For me, the MiniMizer Ring is a ‘sexy’ piece of equipment and the reason I say that is because it has a blunt, silicone covered introducing needle that simplifies placement, it gives you a lot of confidence that you are not going to cause an operative injury.” he explains. “When I first used the MiniMizer Ring I was conscious of perforating something, but the tip is really quite soft so after four or five procedures I had total confidence with the technique. Once you have performed a sleeve most of the dissection has already been done for the MiniMizer Ring so there are only a few millimetres of tissue you have to push the stylette through. When we first started using the MiniMizer Ring we were a little nervous so we were probably a bit loose with the placement, but as we gained in confidence we made the rings a little tighter. Ideally, you want to be able to put a 5mmm grasper through the ring with the Bougie in – that’s your comfort zone.”
He says that there is no doubt that patients who have a sleeve gastrectomy are more likely to develop reflux, however, the data from Germany from Dr Jodok Fink (Centre for Metabolic and Obesity surgery of the University of Freiburg) seems to suggest that the Ring may help to control reflux. It will be interesting to see if this can be confirmed with long term data.
“If you had told me that after nearly three years of using the MiniMizer Ring that we would not have had one instance of a tip perforating tissue, no Ring migration nor Ring erosion in our series of over 750 banded procedures, I would not have believed you!”
In total, he estimates that in this series there have been 15 Rings removed – most of those due to procedure complications, such as leak from the sleeve gastrectomy or a peri-gastric abscess, unrelated to the placement of the Minimizer Ring. The remaining ones were removed due to dysphagia, probably because the patients were overeating, not chewing sufficiently eating too fast and were struggling with their sleeve gastrectomy and removal of the ring did not significantly improve the symptoms.
“Overall, I think that our outcomes from banded sleeve gastrectomy are getting better and better as we improve our technique, especially when you consider the reduction in leak rates, and using staple-line reinforcement certainly helps,” he concludes. “In Australia we are fortunate that if a sleeve does not work, we can offer patients a further procedure such as a laparoscopic gastric bypass, a ‘luxury’ many of our colleagues in other countries do not have.”
In summary, he said that the MiniMizer ring is a safe adjunct to the sleeve gastrectomy that promises make the procedure more effective, and the early data suggests this to be the case.
“We look forward to IFSO 2016 in Brazil for an update on this cohort of patients.”