Transcription:
Bariatric Surgery: Preoperative Evaluation, Optimizing Outcomes, and More

Melanie Cole (Host):  Welcome to Better Edge, a Northwestern Medicine podcast for physicians. I’m Melanie Cole and today, we’re discussing bariatric surgery, screening and outcomes. Joining me is Dr. Anjali Pandit. She’s an Assistant Professor of Medicine in the Division of Gastroenterology and Hepatology and Kaitlin Fiore. She is an Advanced Nurse Practitioner in the Division of Gastroenterology and Hepatology and they are both with Northwestern Medicine. Kaitlin, I’d like to start with you and thank you ladies for being with us so much. So, Kaitlin, what does the bariatric program at Northwestern Medicine offer and how does it differ from other programs around the country? What’s unique about what you’re doing at Northwestern Medicine?

Kaitlin Fiore, APN, FNP-BC (Guest):  I think the greatest thing about our program here at Northwestern is that we really do try to offer a comprehensive and integrated care plan to our patients. We recognize that weightloss and obesity are a really complex and sensitive medical condition. So, we try to offer a really integrated team of medical professionals to address obesity from every point of view. We have medical providers, dieticians, psychologists, and physical therapists just to name a few of the providers available to address this issue with our patients. And the fact that we’re housed within the digestive health center, allows us to have a physical space that’s appropriate to care for our patients. And an unlimited availability to collaborate with all members of the team to make sure that each patient is getting an individualized and personalized care plan. Dr. Pandit’s office is directly across from the work station that I sit at every day. So, if we have questions, we have that easy availability to just kind of float across the hallway and discuss our patients.

The weightloss surgery program at Northwestern has also been recognized by the accrediting body the American College of Surgeons and MBSHQIP which is the Metabolic and Bariatric Surgery accreditation and quality improvement program as a center of excellence. And this means that we meet really high standards of care both in our patient outcomes as well as in the preparation that we provide for our patients, the facilities that we have here at Northwestern and the education that we provide for both the patients and our staff to ensure the best possible outcomes for our patients.

Obesity is really an epidemic and there is a recent article that was published in the New England Journal of Medicine that predicts that by 2030, nearly one in two adults will have obesity. And that the prevalence will be higher than 50% in 29 states and not below 35% in any state. Those are really daunting numbers to consider. And really demonstrates the importance of a comprehensive obesity treatment program like the one we have here at Northwestern Medicine.

Host:  Wow those are daunting statistics Kaitlin. And really, it is such an epidemic and even with our children. So, tell us right now, in these unprecedented times, Kaitlin, how has the program evolved care for patients during this pandemic? How are you navigating the situation? What’s changed?

Kaitlin:  Our program like I think pretty much everyone out there, has had to really pivot quickly so that we could continue to provide quality and safe care to our patients. I am so proud of our team here and their ability to pivot really rapidly and effectively over to a primarily Telemedicine model. We’ve had really rapid instruction on the use of MS Teams and Doximity and we’ve been able to keep up with our patients virtually which has been really important to support them through this time of increased snacking and decreased exercise that I think most people are experiencing. We have switched all of our preoperative classes to a virtual classroom which still allows our patients to see and interact with our dietician class leaders. And we’ve also been able to create a virtual information session and virtual support groups to help new patients access our program and established patients continue to find the support they need all while being able to stay in the relative safety of their own homes.

Host:  Well it has certainly created a creativity in the healthcare setting that I imagine is just really new to everybody, but it has evolved so well and Dr. Pandit, what are you doing to optimize patient outcomes at this time?

Anjali Pandit, PhD, MPH (Guest):  At this time, certainly adapting to the circumstances. I would say a side benefit of doing a lot of my visits via video with patients is that I really get to see their environment. So, as a clinical health psychologist, I’m talking to patients about their lifestyle habits and so I kind of get to go to the patient’s home in a way to I think, further individualize treatment, really. I’ve had patients kind of show me their cupboards, take their weight while they’re on the phone with me. I can see their exercise equipment. So, that’s been a kind of really interesting way that we’ve been able to change the treatment or tailor the treatment given the circumstances. But overall, in terms of our program; I think one of the most important things that we can do to optimize a patient’s outcome as they are going through bariatric surgery, is actually get in the door sooner rather than later to open this door to the possibility of surgery. Which is part of the reason why I think this podcast is such a wonderful step to get the word out. Since often our patients come in as referrals from other providers.

As Kaitlin highlighted, the rate of obesity is rising which means that the average American is really likely to continue to gain weight if they don’t seek intervention. So, if that American choose bariatric surgery, they are actually choosing the most effective intervention for weightloss and being able to maintain their weightloss. So, really, the sooner that the patients gets in the door to at least get that evaluation, the better. And it’s important for our – the medical providers listening today to know there are some treatment non-responders to bariatric surgery, but most patients do very well. Most patients lose significant weight and improve their health, reducing comorbidities long term after bariatric surgery. And as you would expect, those patients who do the best are more likely to be adherent to all those recommended lifestyle changes, though there are sometimes, some physical reasons that patients don’t respond to surgery.

A challenge in this field is that it can be difficult to predict which patient will see which outcomes. And there’s also the problem on top of this of obesity being a relapsing disease. So, as our listeners are well aware of there are metabolic changes that maintain a person’s obesity and bariatric surgery is one of the best interventions that can kind of reset these metabolic changes. It can be overridden by not following a healthy lifestyle. So, we really have to think about optimizing the patient’s outcome in the long term. So, really, lifelong and this requires an ongoing assessment of a patient’s obesity or overweight status and recommending treatment as it’s needed.

The best way to do this is to continue to have patients follow up with us, their bariatric surgery program or an obesity specialty program like the Center for Lifestyle Medicine here at Northwestern. Since there’s really good evidence that in addition to lifestyle changes; many anti-obesity medicines are effective for use in these post-bariatric patients. I think another really great benefit of our bariatric program here is that we’re really co-located with the Center for Lifestyle Medicine team. So, the Obesity Program really works in tandem or hand in hand with each other. Another way we optimize outcomes is offering a monthly facilitated support group for our postoperative patients and what we know from the literature is that patients who attend support groups after surgery, tend to lose more weight compared to their non-attending counterparts.

So, we certainly offer that every month. And if I could just finally add to my answer about optimizing a patient’s outcome is again, reminding our providers listening that obesity really is a relapsing disease and there may be some shame associated with coming back to their bariatric program if the patient has regained some weight after their surgery. Attrition is a huge problem within bariatric programs nationwide. And that’s really unfortunate because one of the leading indicators of success is frequent and long term follow up. So, as much as other providers can encourage their patients to come back to see us, the better and that’s going to optimize the patients’ outcome in the long term.

Kaitlin:  And I would just like to add to what Anjali is saying is that in terms of keeping these patients coming back for follow up that we know is really helpful for their long term success; we really work to establish that relationship with our patients even before their surgery. Our preoperative program tends to run about three to six months in length with education classes and evaluations before our patients can even have surgery here with us. So, these patients really get to know and trust us as their team. And knowing that one of the leading indicators for success right after surgery is frequent and long term follow up; it’s so important to get these folks back in with us so that we can catch them sooner if we feel like they are starting to fall off track. So, we do reach out to our patients at a regular interval after surgery both by phone and electronically or in letter format to remind them that they are due for follow up visits and encouraging them to reach out for help and support and guidance as they need to.

Host:  So, important and good points all. So, let’s talk about some of the psychosocial factors. We’ve talked about them just a little bit and Kaitlin, tell us a little bit how you work with patients when you’re giving them their pre-bariatric assessment and what you want to know about their lives and what you want other providers to be able to help bring their patients forward.

Kaitlin:  So, my focus truly when I see patients for an intake evaluation is going to be on their medical status. So, making sure we’re calculating a good BMI, a height and weight calculation to get a good starting point for our patients. Evaluating all of those medical conditions that tend to go along with obesity to determine if they have high blood pressure, diabetes. I often do a lot of screening for these associated comorbidities. Lab work to check a hemoglobin A1C, sleep studies for sleep apnea screening to make sure that we have these folks in the healthiest state possible before they go into surgery. This often involves collaboration with other providers, their primary care doctors, referring folks over to our specialists here within Northwestern Medicine, whether that’s endocrinology or cardiology or my colleagues in gastroenterology. So, I’m really focusing on getting these folks in a good medical state for surgery.

I’m also starting to educate folks on the process for weightloss surgery. What these three to six months preoperatively are going to look like for patients, getting them set up for their dietary evaluation, getting them set up for their visits with our health psychologist like Dr. Pandit, advising them what our class structure will look like and even starting the conversation with our patients about contacting their insurance and making sure that bariatric surgery is a covered benefit for their plan.

So, I’m often the entry point for our program, so I do a lot of generalized education for our patients about what things will look like for them as well as continuing to serve as kind of that guide through the program. As they are working through the process, a lot of folks will reach out to me to help them establish what their next steps may be in the program to make sure they don’t get lost in this kind of daunting six month preoperative process.

Host:  And Dr. Pandit, as you’ve already told us about some of the post-bariatrics and the things that you’re looking for with your patients and really, adherence is a big issue and those lifestyle changes. Tell us a little bit how you handle revision cases.

Dr. Pandit:  So, as a psychologist working with patients who are seeking a revision surgery; obviously the patients meet with the full team again, kind of as they do for their primary surgery. But as either the psychologist, I spend a lot of time kind of talking to the patient about why they are seeking a revision, get a really thorough understanding of what happened to this person’s weight trajectory after their primary surgery. Did they not lose weight at all? Did they lose significant weight and then experience some life stressor and weight kind of went back up again? Did they sort of just drift away from those behavioral changes that we recommended after their first surgery?

I handle revision cases as really even more so case by case to get a sense of what happened after a patient’s primary surgery. And then I develop a treatment plan which again, really changes from patient to patient based on what they tell me. So, sometimes, I’ll recommend even more in-depth education about the necessary lifestyle changes. Oftentimes, I’ll encourage patients to have family members attend visits with them so they can also gain this information and reinforce to the patient while they are at home. Or sometimes, I’ll ask patients to address emotional concerns or disordered eating that’s led to – contributed to the weight regain that patients have had and that’s deemed necessary.

So, each patient is really unique in their story and they’ll need a different plan to prepare for their second surgery.

Host:  So important and Kaitlin, one of the big factors for bariatric surgery is this multidisciplinary approach. Tell us a little bit about the division of gastroenterology and hepatology and how they’re focused on engaging multidisciplinary teams to best treat patients. Who is involved and speak more about this approach.

Kaitlin:  I think that the weightloss surgery program here at Northwestern is a beautiful example of a multidisciplinary approach to patient care. Both our program and most insurance providers are going to require that bariatric surgery patients have a multidisciplinary evaluation. So, in our program, every patient has to meet with a medical provider to evaluate their medical status for surgery. Every patient has to meet with a dietician for evaluation for surgery and every patient needs to meet with a health psychologist for evaluation.

So, at a minimum, all of our patients are being met with these three specialties to ensure that all of these aspects of weightloss and obesity are being addressed for these patients before surgery. Now our interactions, our multidisciplinary approach often doesn’t start there. As we mentioned before, obesity is a very multifaceted illness. Most of these folks have significant medical comorbidities that are associated with their obesity. So, we are working with their primary care doctors to adjust medications. Dr. Pandit is often working with these folks. They have psychologists on their own and we need to work with them talking about medications after surgery. We’re referring to our gastroenterology team for preoperative endoscopies. We’re ensuring that our patients have had all their regularly scheduled health maintenance exams. So, often we are referring over to gynecology for mammograms or PAP smears that the patients aren’t up to date.

So, we really do kind of reach out and have interactions with providers from all different walks of the medical field.

Host:  As we wrap up ladies and what a great, great topic. Dr. Pandit, I’d like to start with you, and I’ll give you each a chance to have a final thought here. But tell us about any research that would impact the future of bariatrics, anything you’d like other providers to know and when you feel it’s important that they refer their patients.

Dr. Pandit:  One of the things that I look out for the most in post-bariatric patients and something that I do truly think that our listeners can potentially help us out with is to look for some of these psychological phenomenon’s that occur in patients after they have had bariatric surgery. So, there are actually unfortunately really well documented increases in the risk of alcohol and substance abuse disorders in post-bariatric patients. Alcohol specifically, the latest literature shows that new alcohol use disorders can show up at a rate as high as 20% in post-bariatric patients. And similar trends at a lower level can be seen in substance and opioid use. So, mechanisms for this are really due to the pharmacokinetic changes that occur in a patient’s body as they are processing alcohol and different substances which we think leads to an increased drive for consumption of those substances.

But I’m brining this up because I really am hopeful that other providers if they note that a patient has had bariatric surgery to ask these sorts of questions about a patient’s health habits, specifically with alcohol and substance use, even mood. Again, unfortunately, there’s a higher rate of suicidality in patients who’ve had bariatric surgery. So, again, if other providers can start asking these questions about a patient’s mood; then at least we can get these patients directed to where they need to go to get intervention and treatment.

So, I think that’s one thing that I certainly like to add and then finally, just to encourage people to continue to bring up obesity and overweight with their patients to actually reduce the shame that patients might feel about it in order to get them to a place for their accepting of intervention for their weight because I think a lot of patients don’t really like to talk about their weight. But the more providers can open up that dialogue and offer patients really, really good treatment for obesity; the sooner that patient can get the treatment and improve their health and their lives. So, I think the more that we can do to reinforce to patients that obesity really is a multifactorial disease and it’s not just all about lifestyle habits. There are so many physiological changes that happen in a patient’s body that lead to obesity and we can offer medications and surgery certainly as an option for treatment, the better off these patients will be.

Kaitlin:  And I would just like to add from the research point of view, that our program is always looking for ways to improve our program, improve our patient outcomes. We’ve recently rolled out an enhanced recovery protocol for our bariatric surgery patients to reduce complications after surgery. So, surgical site infections, blood clots, we’re looking to reduce postoperative pain and opioid use as outlined by Dr. Pandit. And we’re really trying to decrease the length of an inpatient stay for our patients to allow them to return to normal activity as soon as possible.

We’ve also recently begun the MBSHQIP, the patient reported outcomes measure or PROMs which is a pilot program to measure the health and quality of life improvements for patients after surgery. Through a series of targeted surveys which allow us to monitor and track the improvements that this surgery has on the patient’s life outside of what we may monitor during a medical visit. So, outside of the pounds lost, outside of the improvement in lab values; these measures really start to track things like patient’s overall happiness. One of the things that I enjoy most in my job, besides patients coming back and saying they fit in different clothes or they are reducing their medications is I’ve had patients come back to say that they were finally able to go to an amusement park and fit in the rides with their children. Or they are finally able to reach down and tie their shoes comfortably. They are able to go on an airplane without being embarrassed about having to ask for a seat belt extender. And these are some of the aspects that we don’t always capture in a medical visit but have had such a profound effect on our patient’s life and just ability to kind of function. And it’s so nice to see and I’m so happy that we’re able to participate in this study that’s going to start tracking some of these quality of life indicators.

Host:  What great information. Ladies, thank you so much for joining us today and telling us about the bariatric program through Northwestern Medicine. It’s fascinating information and thank you for listening to Better Edge, a Northwestern Medicine podcast for physicians. To refer your patient please visit www.nm.org/dhc for more information and to get connected with one of our providers. Please also remember to subscribe, rate and review this podcast and all the other Northwestern Medicine podcasts. I’m Melanie Cole.