Recovery-enhancing minimally invasive procedures by board-certified surgeons, along with high-level accreditation and lifelong follow-up, generate excellent outcomes for patients at St. Luke’s Cornwall Hospital’s (SLCH) Institute for Metabolic and Bariatric Surgery.
Wayne Weiss, MD, FACS, Medical Director of the Bariatric Surgery Program, leads an experienced team of surgeons and other providers in performing laparoscopic sleeve gastrectomy and laparoscopic gastric bypass, enabling local patients to receive leading-edge bariatric care without traveling significant distances. The Institute is a Comprehensive Center of Excellence under the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP), the nation’s highest standard of accreditation.
Bariatric Surgery is lifesaving for morbidly obese patients, notes Dr. Weiss, a former U.S. Navy surgeon and retired Captain in the Naval Reserve. Excess weight is associated with a host of health problems, from sleep apnea to diabetes to hypertension. Obese individuals have a 50 to 100 percent increased risk of premature death compared with individuals of healthy weight, according to the American Society for Metabolic and Bariatric Surgery (ASMBS).
Jaime Cepeda, MD, FACS, consults with a patient.
Addressing obesity and its comorbidities through Bariatric Surgery involves not only the procedure itself, but also comprehensive pre- and postoperative protocols that minimize complications. That is the level of care patients find at SLCH’s Institute for Metabolic and Bariatric Surgery.
“The success and safety of our Bariatric Program is the result of the multidisciplinary approach that looks at all the different angles and facets of care to optimize the outcome,” Dr. Weiss says.
Wayne Weiss, MD, FACS, meets with a patient.
Confronting an Epidemic
A National Institutes of Health study estimates 6.6 percent of U.S. adults are morbidly obese, with a BMI greater than 40; almost 40 percent of Americans are considered obese, having a BMI of 30–40. To qualify for Bariatric Surgery, a patient must be morbidly obese; however, if other health conditions, such as diabetes or sleep apnea, are present, someone with a BMI of 35–40 is also a candidate.
Most individuals who seek Bariatric Surgery have come to a realization that conventional weight-loss techniques are ineffective for them.
“They usually have health problems and are uncomfortable about their appearance and about what they can and can’t do — from not being able to go on a ride at the amusement park to not fitting into airplane seats,” Dr. Weiss says.
Negative social feedback often plays a role in their decision, as does positive feedback from family and friends who have successfully undergone Bariatric Surgery.
At the SLCH Institute for Metabolic and Bariatric Surgery, patients initially attend an informational seminar and evaluation, beginning a process that takes two to six months.
“After a thorough review of their medical history, patients meet with a cadre of professionals — physicians, nurse practitioners, dietitians, patient navigators, psychologists, psychiatrists — whatever is required to determine whether Bariatric Surgery is the right decision,” says Dr. Weiss, who has performed more than 2,000 such surgeries.
Patients learn about the results they can expect, as well as potential risks and the vital role they play in their own recovery.
“It’s full-circle care,” says Jaime Cepeda, MD, FACS, who has been performing Bariatric Surgery for a decade. “Patients are made aware of the types of foods they will eat in the future, and dietitians have them start the diet before surgery to acclimate them to it.”
They also receive presurgical counseling about any eating disorders or other behavioral issues associated with eating, which further fosters long-term success.
Another essential component of this process is alleviating concerns about the safety of the procedures. In the 1980s, before laparoscopic techniques lowered risks, Bariatric Surgery was rare because of mortality rates as high as 1 in 20.
“Most people weren’t willing to take the chance of dying to become healthy,” Dr. Weiss says. “The concept was fine; physicians just didn’t have the tools, the knowledge and the capability at the time.”
That changed radically in the intervening years with the advent of laparoscopic technology and comprehensive-care protocols. According to the ASMBS, today, gastric bypass patients’ life expectancy can improve by 89 percent, and the overall mortality rate for Bariatric Surgery is about 0.1 percent, making it safer than gall bladder (0.7 percent) or hip replacement (0.93 percent) surgery.
“In the 1980s, the risks of surgery outweighed the benefits,” Dr. Weiss says. “Today, it’s not even close; the surgery is so much more beneficial and lower-risk compared to not doing it.”
The team at St. Luke’s Cornwall Hospital’s Institute for Metabolic and Bariatric Surgery uses cutting-edge technology to work with each patient individually to provide proper pre- and post-procedure support.
Minimally Invasive Techniques
The laparoscopic approach that makes modern Bariatric Surgery so much safer starts with four or five incisions that are all less than an inch in size. Physicians insufflate the abdomen to create a workspace without cutting through thick abdominal muscles.
“It offers more access to the crucial areas and better visualization of those large vessels or structures that you would have more difficulty seeing if this were an open procedure,” Dr. Cepeda says.
Because of their small surgical footprint, laparoscopic bariatric procedures are inherently less painful, but St. Luke’s Cornwall Hospital has instituted further measures to reduce postoperative pain — in most cases avoiding the use of narcotics altogether. During the operation, anesthesiologists administer a transversus abdominis plane block, and patients receive Tylenol before and after surgery.
Drs. Weiss and Cepeda are the surgical members of the multidisciplinary team that includes mental health professionals, patient navigators and nutrition counselors.
Both sleeve gastrectomy and gastric bypass — procedures that usually take two hours or less — reduce the size of the patient’s stomach, thereby reducing the amount of food needed for satiety.
About 90 percent of bariatric procedures performed at SLCH’s Institute for Metabolic and Bariatric Surgery are sleeve gastrectomies. which make the patient’s stomach about two-thirds smaller with a sleeve secured with staples.
Part of the reason for the emphasis on this procedure is its high success rate: Patients typically lose about 60 percent of excess body weight with minimal risk of long-term complications.
“As for short-term complications, very rarely there can be narrowing of the sleeve or even dilation of the sleeve if the patient overeats at times, but those complications would not require another operation,” Dr. Cepeda says.
Gastric bypass divides the stomach into two parts: a smaller portion that is then reattached to the small intestine and a larger part that is essentially a remnant. Gastric bypass is selected for two primary reasons. One is that some patients want to replicate the average 65 to 70 percent loss of excess weight they have observed in friends or family members who underwent the procedure. People with poorly controlled diabetes also benefit, seeing resolution of their condition that is 10 to 15 points higher than that observed even among those who undergo sleeve gastrectomy, Dr. Cepeda explains.
He discusses with patients two potential complications of gastric bypass that might require an operation in the long term: an internal hernia or a marginal ulcer that causes a perforation. Short-term risks for both surgeries are bleeding and leaks, but those risks virtually disappear within six weeks after surgery.
“There is no emergency Bariatric Surgery. We ensure the patient is ready, knows what to do before and after the procedure, and has been properly evaluated. Then we perform the surgery.”
— Wayne Weiss, MD, FACS, Medical Director of the Bariatric Surgery Program at St. Luke’s Cornwall Hospital’s Institute for Metabolic and Bariatric Surgery
Dr. Weiss is Medical Director of the Bariatric Surgery Program at St. Luke’s Cornwall Hospital’s Institute for Metabolic and Bariatric Surgery.
Minimal pain from either procedure allows patients to return home the day after surgery, once they are ambulatory and can tolerate liquids. They may engage in moderate household activity for two weeks, after which most are able to return to normal activities.
Patients remain on the liquid diet for two weeks as well. Typically, their dietary options expand at that point and every two weeks thereafter as long as healing progresses normally. They avoid solid food early in the process because the stomach’s pulverizing of food would endanger the healing of the staple line.
That disciplined increase in food types minimizes short-term complications.
“Our leak rate is significantly lower than the national average,” Dr. Cepeda says. “We have less than 1 percent, compared to a national average between 2.8 and upwards of 4.5 percent.”
The first six weeks after surgery are only the beginning of a lifelong relationship between patients and St. Luke’s Cornwall Hospital. After the initial period, patients generally check in quarterly, then eventually about once a year.
“It’s never just, ‘Goodbye, you’re done,’” Dr. Weiss says. “It’s forever because weight-loss surgery has long-term implications.”
Follow-up visits usually focus on healthy eating to keep patients accountable and help them maintain their weight-loss success.
“If they don’t have an outlet to talk to someone about changes in their diet, they tend to go back to old habits,” Dr. Cepeda says. “The comprehensive approach at St. Luke’s Cornwall is designed to prevent that.”
The SLCH Institute for Metabolic and Bariatric Surgery also wants to continue building relationships with patients’ primary care physicians and specialists, starting with collaborating with them for some testing before surgery and getting clearance from cardiologists. These partnerships are important aspects of the full spectrum of care at St. Luke’s.
Bariatric Surgery patients enjoy a decrease in premature mortality of 30 to 40 percent, according to ASMBS. That is due in significant part to stark reductions in comorbidities.
“It’s almost a surgical cure for diabetes for many patients,” Dr. Weiss says. “Their hypertension gets much easier to control or may resolve; the same is true of their sleep apnea.”
In addition, patients’ risks for breast, endometrial, pancreatic and other cancers are reduced, for an overall reduction in cancer mortality of 60 percent, according to the ASMBS. Chronic joint pain caused or exacerbated by excess weight is also alleviated.
“After the first month, patients’ weight can be down 50 pounds, and they say, ‘Oh my gosh, I can actually walk up the stairs now, or I can start to exercise,” Dr. Cepeda says.
This reverses the downward spiral in which extra pounds make it harder to move, and lack of movement leads to further weight gain. Patients also tend to miss work less.
“It’s not just that they’re losing weight — they’re happier, they use fewer medicines, they cost insurance companies less, and they cost society less,” Dr. Weiss says.
“Ours is a truly comprehensive program. We go out of our way to accommodate our patients in any way possible and to build relationships with them and their primary care providers so we can continue to improve health throughout the region.”
— Jaime Cepeda, MD, FACS, bariatric surgeon at St. Luke’s Cornwall Hospital’s Institute for Metabolic and Bariatric Surgery
Dr. Cepeda is a board-certified bariatric and vascular surgeon at St. Luke’s Cornwall Hospital’s Institute for Metabolic and Bariatric Surgery, based in Newburgh, New York.
Success on that level did not happen by accident, but came about after months of hard work and training culminating in the Institute’s certification as an MBSAQIP Bariatric Surgery Comprehensive Center of Excellence.
“This accreditation is a tribute not only to the high-quality care provided to our patients, but also to the collective efforts as an institution to build this program from the ground up with standards that are second to none,” Dr. Weiss says.
That meant hiring the right medical, technical and administrative staff, in addition to having the bariatric team undergo extensive training prior to certification, as well as annual recertification.
The certification itself arose from a recognition of inadequate oversight in the early days of laparoscopic Bariatric Surgery. Dr. Weiss cites a postsurgical death rate as high as 1 in 10 in the year 2000 in certain New York state locations.
“In very short order, multiple credentialing organizations realized Bariatric Surgery programs needed to set standards to protect patients and ensure quality,” he adds.
Now, the MBSAQIP Standards, according to MBSAQIP’s website, “ensure that bariatric surgical patients receive a multidisciplinary program, not just a surgical procedure, which improves patient outcomes and long-term success.”
The overall death rate for sleeve gastrectomy patients is 1 in 700, and SLCH’s Institute for Metabolic and Bariatric Surgery has had no deaths — quite a feat considering the medically complex patient pool, Dr. Weiss notes: “We’re not operating on 22-year-old Marines; these are people with diabetes, morbid obesity, hypertension, coronary artery disease and about 40 other problems. That track record is remarkable.”
Besides ensuring quality and long-term care, MBSAQIP enrolls every patient at a Comprehensive Center of Excellence in a database for lifelong follow-up. The database includes all health conditions and causes of death in order to track potential long-term risks and benefits. Keeping such an extensive record verifies that hospitals are maintaining a standard of excellence and identifies any issues they should address, Dr. Weiss says.
Drs. Weiss and Cepeda have more than 35 years of combined surgical experience.
The bariatric team at St. Luke’s Cornwall Hospital’s Institute for Metabolic and Bariatric Surgery is vigilant in upholding its certification — and in safeguarding patients’ health.
“Despite performing a significant number of bariatric procedures, we have had no patient deaths,” Dr. Weiss says. “We’re very proud of that.”
For additional information, visit stlukescornwallhospital.org.