Board-certified surgeons who are members of the American Society for Metabolic and Bariatric Surgery (ASMBS) provide treatments for obesity in partnership with a multidisciplinary team of professionals.
When referring patients for bariatric surgery, primary care physicians and internists need the confidence to know that each patient is received by a comprehensive team. This is especially true because bariatrics entails so many components: patient education, psychology, expert nutritional support, surgical skill and complexities such as emergencies and revisions. Lawrence Hospital Center’s Bariatric Center of Excellence offers all this and a circle of continuous patient care.
A division of Columbia University Physicians and Surgeons, the physicians of Lawrence Hospital Center perform surgery at both Lawrence Hospital Center and Columbia-Presbyterian Hospital.
“We treat patients ourselves at all our locations,” says Aaron Roth, MD, FACS, Assistant Professor of Clinical Surgery at Columbia University Medical Center. “While at some facilities, community surgeons may not be qualified to address all cases, we have the quality and capability to perform surgery in a specialized university setting if the need arises.”
For added safety, two board-certified surgeons attend all bariatric operations at Lawrence Hospital Center.
“We hold ourselves to the highest standard in our surgical practice. We have a strong code of ethics, we deliver excellent care to patients and we understand that a good bariatric surgery program includes a multidisciplinary approach to patient success.”
— Miguel Silva, MD, Chief of Surgery and Division Chief of the Center for Advanced Surgery at Lawrence Hospital Center
Surgeons of High Caliber
Lawrence Hospital Center bariatric physicians are highly educated and meet the quality standards set by their profession’s national organizations.
Miguel Silva, MD, Chief of Surgery and Division Chief of the Center for Advanced Surgery at Lawrence Hospital Center, performs a laparoscopic sleeve gastrectomy at Lawrence Hospital Center in Bronxville.
“We are accredited as a Center of Excellence with both the American College of Surgeons and the ASMBS,” says Leaque Ahmed, MD, Associate Clinical Professor of Surgery at Columbia University Medical Center. “To achieve these accreditations, we must have specialized equipment to perform CT and upper GI scans on patients who are overweight. Additionally, we are required to perform a minimum of 125 bariatric surgeries each year — a number which we vastly exceed.”
Dr. Ahmed, who personally performs more than 400 bariatric surgeries annually, notes that this level of experience leads to improved patient outcomes and the ability to deal with any complication that may arise.
“Bariatric surgery is a field in and of itself,” says Miguel Silva, MD, Chief of Surgery and Division Chief of the Center for Advanced Surgery at Lawrence Hospital Center. “As surgeons at a bariatric Center of Excellence, we understand it is not just doing the procedure that matters; successful bariatric surgery requires a group effort and multiple components, including good surgical outcomes, a sound patient support structure and awareness of current research.”
Sleeve Gastrectomy ‘Bypasses’ Laparoscopic Gastric Banding
Bariatric procedures are primarily done laparoscopically. Here, Dr. Silva performs a sleeve gastrectomy.
Until recently, laparoscopic gastric banding — the LAP-BAND being the most common system — was the popular option for bariatric surgery, both at Lawrence Hospital Center and nationwide. Patients perceived it as a less extreme approach to weight loss surgery than available alternatives, such as gastric bypass. In the past three years, though, sleeve gastrectomy has gained popularity. It is now the most commonly performed bariatric surgery at Lawrence Hospital Center.
Dr. Ahmed describes the competing benefits of each procedure.
“The advantage of the LAP-BAND, and the reason patients felt it was an easier and safer option for weight loss, is that it is considered reversible and adjustable. The downside: Weight loss occurs more slowly with the LAP-BAND, and comorbidities related to obesity will decrease only as the patient loses weight. Sleeve gastrectomy, on the other hand, does not require adjustments, and patients lose weight quickly. As with the LAP-BAND, surgeons do not need to re-route the intestines. If the surgeon performs the operation well, weight loss with a sleeve gastrectomy rivals that of a gastric bypass after six years. The disadvantage to the sleeve is that a portion of the stomach is removed, making it a permanent operation.”
“Bariatric surgery is not a cosmetic procedure. It is a metabolic surgery with a high likelihood of improving or resolving serious health conditions, such as high blood pressure, hyperlipidemia, obstructive sleep apnea and diabetes.”
— Leaque Ahmed, MD, Associate Clinical Professor of Surgery at Columbia University Medical Center
Dr. Roth sees clear advantages to sleeve gastrectomy, noting that more than 50 percent of patients who received laparoscopic gastric banding required surgery for a complication or failure within the first 10 years.
“The gastric sleeve has almost the same effect in terms of restricting a patient’s ability to eat food as the LAP-BAND, with none of the long-term associated problems,” Dr. Roth says. “Additionally, we offer gastric bypass operations, which not only restrict the amount of food people can eat but also prevent absorption by rearranging the intestines.”
Physicians at Lawrence Hospital Center do not select surgeries unilaterally for their patients; instead, patients digest material provided in an informational seminar and then participate in an in-depth discussion with their surgeon before deciding which procedure is best for them.
Leaque Ahmed, MD, meets with a patient to discuss the clinical program she needs to follow.
Whatever bariatric procedure a patient selects, the surgery incorporates one of two aims: restricting food intake or limiting food absorption. Sleeve gastrectomy, aimed primarily at limiting intake, is typically performed laparoscopically under general anesthesia.
“We make five incisions, four of them of 5 millimeters and one of 1.5 centimeters,” Dr. Ahmed says. “We then insert a 40 French tube through the mouth into the stomach. Using the tube as a guide, we staple the stomach to create a long, narrow gastric pouch, which is 20 to 30 percent of the size of the original stomach. We remove the ‘stretchable’ part of the stomach and send it for pathological examination.”
Before the operation, surgeons check for hiatal hernia by performing an upper endoscopy. About half of hiatal hernias are identified this way. They are repaired during the same procedure as the sleeve gastrectomy. However, about half of hiatal hernias are not apparent until surgery. In either case, it is important for surgeons to repair them, lest they result in reflux and painful heartburn after sleeve gastrectomy.
The newly created stomach will give patients a feeling of fullness after they eat only 2–3 ounces of food. As a result, patients eat less, resulting in excellent weight loss. In one study, body mass index (BMI) decreased by an average of 15 points after sleeve gastrectomy. In another, BMI fell by about 13 points — 30 percent — after this surgery. And, while gastric bypass results in more rapid weight loss than sleeve gastrectomy, weight loss from the two procedures is typically the same a few years after surgery.
Revision Surgeries for Continued Weight-Loss Success
In addition to performing original metabolic procedures, surgeons at the Bariatric Center of Excellence do revision surgeries.
“About a third of the surgeries I perform are revision surgeries,” Dr. Roth says. “Some of these correct failures of LAP-BAND or other problems, while others are intended to return the patient to a course of weight loss or to enhance existing weight loss.”
More technically complicated than original bariatric surgeries, revision surgeries are often performed at Columbia-Presbyterian Hospital. Surgeons first determine what procedures the patient has already undergone and their results. Even with revision surgeries, bariatric physicians take a forward-looking approach, strategizing how to correct existing problems and return the patient to successful weight loss.
“All bariatric operations are tools to help patients lose weight,” Dr. Roth says. “We determine whether the tool — the previous surgery — is broken or whether it simply needs modification to make it a better tool. In the case of LAP-BANDs, the tool is usually broken, requiring the band to be removed or another procedure to be performed. The extent of damage dictates the next step. If there has been no damage, we typically advise a sleeve gastrectomy. If the patient has suffered damage, such as esophageal dilation, we remove the band and perform a gastric bypass.”
Bypass surgeries and sleeve gastrectomies may also require revision in the case of a fistula or other complication.
“With older bypass operations, patient anatomy may have changed,” Dr. Ahmed says. “Sometimes the stomach reattaches, causing gastric fistula, weight regain or peptic ulcer disease. In the case of gastrectomy, the pouch may increase and need to be reduced with a re-sleeving procedure or converted to a bypass.”
The Journey to Surgery
No matter where a patient is in his or her weight loss journey, at the Bariatric Center of Excellence, a community of caring, experienced professionals provides education, resources and support. This network of care stays with the patient for life, helping him or her through challenges and celebrating triumphs.
“There has to be a nucleus of support structures around patients to help them succeed,” Dr. Silva says. “This nucleus includes a nutritionist to educate them about healthy eating habits, support groups where they can share personal stories and tips, a psychologist, and a nurse practitioner to guide them through the process.”
“Every patient who has been on a diet and lost 20 or 30 pounds knows how good they feel with that weight loss. The problem is, they could not keep the weight off. With the tool of bariatric surgery, they are able to shed their extra weight and make that good feeling permanent.”
— Aaron Roth, MD, Assistant Professor of Clinical Surgery at Columbia University Medical Center
Soon after referral, patients view a video describing the fundamentals of metabolic surgery, either in an informational session or online. Next, patients meet with a surgeon or nurse practitioner to discuss their options. These providers refer patients to a multidisciplinary team that evaluates them medically and psychologically for surgery. Patients weighing 400 or more pounds, and those undergoing complex or revision procedures, will have surgery at Columbia-Presbyterian Hospital. There, they experience the same benefits and are operated on by the same surgeons as patients who have surgery at Lawrence Hospital Center.
Mian Catalano, RD, offers pre- and postsurgery diet advice to patients.
After this preliminary evaluation, patients undertake an educational process, which may include three to six months of medically supervised weight loss, as well as resolution of some comorbidities.
Throughout this introductory process, special consideration is granted to the needs of obese patients. Ample chairs allow for comfortable seating, while other medical equipment is also scaled appropriately. Nurses and staff members respond to patients with sensitivity.
“Obesity is one of the last prejudices among some people,” Dr. Ahmed says. “Our patients have been assumed to be lazy or good-for-nothing. It is far from the truth. Patients have different problems, including psychological, cultural and genetic issues. Everyone at the Bariatric Center of Excellence treats patients with respect as fellow human beings. This allows them to be comfortable with articulating their problems and looking together for solutions.”
Aaron Roth, MD, FACS, is one of three Columbia University surgeons who perform bariatric surgery at Lawrence Hospital Center.
The journey to surgery requires a compassionate and experienced guide, and at the Bariatric Center, Jane Alexander, NP, takes that role. Tasked with supervising the pre-surgery weight loss program — collecting data for Center of Excellence accreditation, educating patients before and after surgery, rounding on hospitalized patients, and generally overseeing the program — she is an essential resource for patients.
“She has vast experience in managing post-bariatric patients,” Dr. Ahmed says. “She is very friendly and helps patients cope appropriately. Patients follow up with her as their nurse practitioner every three months for the rest of their lives.”
A New Life, a New Family
After surgery, education continues with detailed nutritional advice and ongoing psychological counseling. Successful weight loss, Dr. Silva explains, entails its own mental and emotional challenges.
Following surgery, Jorge Reynoso, PA, meets with a patient to discuss discharge plans and what she can expect during her first days home.
“Patients develop stronger self-esteem after metabolic surgery,” he says. “Often, they do not allow themselves to be abused anymore. Matrimonial issues may occur. Patients can discuss these issues privately with a psychologist or in the context of a support group.”
The Bariatric Center of Excellence’s support groups help patients in other ways, too. Patients bring recipes, exercise ideas and even clothing to swap. An annual bariatric reunion has grown to about 100 bariatric surgery veterans. Patients share before and after pictures and support each other in a community setting, forming what Dr. Silva refers to as “a family bond.”
Nutritionally, patients must make lifelong modifications after surgery. They need extensive education and support. At the Bariatric Center of Excellence, a full-time nutritionist works with patients to develop and maintain healthy eating habits. This is a free service for life to everyone who undergoes bariatric surgery at Lawrence Hospital Center.
Performing surgery at a community hospital means these world-class bariatric physicians see their patients regularly in non-medical settings, increasing the sense of family. Dr. Ahmed frequently encounters one former patient in particular out in the community.
“Her BMI was close to 50 and is now less than 30,” he says. “Not only is she happy, she has influenced her colleagues to lose weight through diet and exercise. Some have come to us for bariatric surgery. She has made a big difference to the people around her with her example of success and empowerment.”
The Center for Advanced Surgery office team — Laura Marroquin, Administrative Assistant; Zylena Stevenson, Medical Assistant; Flavia Watkins, Medical Biller; and Kara McLaughlin-Mitchell, Practice Manager — is there to help guide the patient through the bariatric program.
The community spirit extends beyond patients. Referring physicians will find excellent partners in Lawrence Hospital Center bariatric surgeons.
“We are a community program, and we want to work with other physicians here,” Dr. Roth says. “We endeavor to make each patient’s physician a part of our team, which includes cardiologists, pulmonologists and other specialists as well as primary care physicians. We work together for the best results.”
“If an internist or primary care physician has a patient who has failed all conservative attempts at weight loss, that physician may wish to refer the patient to the Bariatric Center of Excellence,” Dr. Silva says. “We will not put patients who have not exhausted all other options through the program. That said, patients who have failed other weight loss attempts, have diabetes or other weight-related conditions, or who are at risk for these conditions, usually find their health improves following bariatric surgery.”
To learn more about bariatric surgery at Lawrence Hospital Center, please visit www.lawrencehealth.org.