|Clinicians take a multi-disciplinary approach to fighting obesity|
By Frank Fraiser
A lot can change at high altitudes. For David G. Davtyan, MD, FACS, FICS, the thin air at the 2001 Minimally Invasive Surgery Symposium (MISS) in Snowbird, Utah, caused him to become short of breath. He called his wife and gasped, “My fat is taking over my lungs!”
Davtyan had gradually reached a size that was causing him to tire easily, but because he was successful in his career and personal life, he wasn’t ashamed of his weight. It wasn’t until he attended an MISS presentation given by Guy-Bernard Cadiere, MD, PhD, on laparoscopic adjustable gastric banding that Davtyan considered undergoing the procedure.
“It seemed straight-forward and very simple,” says Davtyan. “This conference became a life-changing experience for me.”
Eric S. Bour, MD, FACS, FASMBS; Tyson Erlewine PT, MPT, OCS, CSCS; and John D. Scott, MD, FACS work together at Hillcrest Memorial Hospital, a Bariatric Surgery Center of Excellence
Patients at Hillcrest Memorial are provided a post-op handout stressing the importance of physical therapy and exercise following surgery to optimize weight loss. The handout contains a list of precautions following bariatric surgery, explains the benefits of strengthening exercises after surgery, offers tips to increase their daily steps, and recommends ways patients can form exercise programs that work for them.
Patients are also instructed on the importance of a good cardio program, continued strength training exercises, and finding routines that fit into their lifestyle and needs. “We stress to them the importance of making a regular exercise routine and the importance of diet changes that come with surgery,” Erlewine says. “Strength training boosts metabolism and burns calories throughout the day, makes their bodies stronger and leaner, assists in lowering their blood pressure, improves balance and coordination, and builds stronger bones to protect against osteoporosis. We encourage our patients to participate in 30 to 60 minutes of exercise/physical activity throughout the day, and exercise can be divided into several sessions per day.”
Co-morbidities, such as osteoarthritis and cardiopulmonary issues, are only two of the challenges clinicians may face when working with post-op bariatric patients. In those instances, Erlewine recommends low-impact exercises such as aquatic exercise, stationary cycling, or using an elliptical machine instead of walking. “We also educate them on using the rate of perceived exertion scale (RPE) for those with cardiopulmonary issues.” The RPE scale measures the intensity of a patient’s exercise on a scale of 0-10. In most cases, patients should exercise at a level that feels moderate to somewhat heavy.
Clinicians at the Hillcrest Memorial instruct patients to use their arms and legs as much as possible to transfer from sitting to standing positions in order to decrease the amount of stress on their abdomen and back. Prior to discharge, they are also instructed on stair negotiation to ensure safety.
“A vast majority of patients who have gone through bariatric surgery are very motivated to lose weight and are willing to work hard in physical therapy to achieve maximum results,” adds Erlewine. “This makes for a good rehab candidate because they are making a lifelong commitment to weight loss and improving their overall health.”
Clinicians at the Nikolov Center agree that motivation is one of the most important factors in bariatric rehabilitation. For Nikolov, the biggest challenge is making sure the patient is motivated. Those who view the surgery as a quick fix, says Nikolov, are not the best candidates. Davtyan estimates that of the 800 patients who have undergone the gastric banding procedure at the Nikolov Center only about 12 were unsuccessful. “The few who fail are those who confuse who the enemy is,” says Davtyan. “They continue to regard food as their best friend and they are so deeply in love with it that they can’t give it up.”
Post-op patients may also have to cope with vitamin deficiencies. Doctors at the Nikolov Center encourage those who undergo the gastric banding procedure to take vitamin supplements because certain fruits and vegetables will not digest easily once the band is in place. Citrus fruits can cause contraction of the gastric pouch and distal esophagus, and vegetables with fibrous consistencies sometimes have difficulty going down the band.
Weighing the Options
A number of adjustable gastric bands are on the market today, but gastric bypass surgery may be a more viable option for patients with co-morbidities and higher BMIs. Eric Bour, bariatric medical director at Hillcrest Hospital, says patients will often choose bypass due to metabolic co-morbidities such as diabetes.
“In higher BMI patients, the banding surgeries typically won’t lead to enough weight-loss to provide improvement or resolution of their co-morbidities,” says Bour. “The data now says that anyone with a BMI over 45 probably should not have a band.”
At Hillcrest Memorial, approximately 85 percent of their annual weight-loss surgeries were bypass procedures.
Davtyan, however, cautions against bypass surgery. The Roux-en-Y procedure requires four locations where the intestinal system is either stapled off or a connection is made between two loops of intestines. “The frequency of anastomotic leaks is not uncommon, and bypass is a much more complex procedure for which rehabilitation can be more difficult” he says.
While complications may arise in any surgical procedure, Bour asserts that the dangers of gastric bypass are often misconceptions. “This is a surgery that can be done safely and is really more appropriate for patients who have higher BMIs or metabolic problems,” he says. “Our incidence of leak is less than one percent, and the overall mortality rate that we’ve had in our program is less than one in one thousand.”
Erlewine’s recommendations are similar for patients undergoing bypass or gastric banding procedures. He says those who undergo laparoscopic banding typically have a shorter stay in the hospital than gastric bypass patients. Patients receiving a gastric band are typically in the hospital for 1 and a half days, and those undergoing bypass surgery will spend 2 and a half days there.
While at Hillcrest Memorial, patients work with physical therapy to improve their functional mobility and gait, as well as initiating an exercise routine to improve strength using low impact exercises and Thera-Band. Patients who have undergone the bypass procedure must be out of bed within 4 hours of the surgery to reduce the incidence of deep venous thrombosis, one of the most serious potential complications associated with bypass surgery. “Involving physical therapy early has led us to an incidence of blood clots that is far less than 1 percent, and normally you’d see numbers in the 4 percent range,” says Bour. “The reality is that those of us who perform a lot of bypass surgeries can keep the risk to a minimum while the rewards can be much greater in a certain patient population.”
Winning the War
Weight loss surgery isn’t a magical procedure that causes patients to cater to being fit and healthy, cautions Zerling. Surgery represents only a small portion of a patient’s journey toward a healthy lifestyle, a journey in which long-term changes in diet and activity are essential for success. Studies in the April edition of the Journal of American Dietetic Association have shown that a comprehensive approach from surgeons, PTs, and RDs provides the best care for those battling obesity.
At Hillcrest Memorial, patients are encouraged to attend support groups that emphasize psychological, behavioral, and nutritional changes. Following surgery, patients are instructed to use a pedometer to monitor their daily steps with a goal of 10,000 steps per day – about 5 miles. “We have them establish a baseline of steps once they return home; they are then instructed to increase their number of daily steps by 500 each week,” says Erlewine.
“To be effective in the fight against obesity,” Davtyan says, “I tell my patients that you need to understand that this is a war. The enemy is out there to kill you, and it will maim you before it kills you.”http://www.drnikolov.com/