Arif Ahmad, MD, FACS, FRCS, relies on surgical experience, high standards of care and empathy for patients to lead the John T. Mather Memorial Hospital’s Center of Excellence in Metabolic & Bariatric Surgery.
Dr. Ahmad, Director of the Center of Excellence in Metabolic & Bariatric Surgery and Director of the Center of Excellence in Robotic Surgery at Mather Hospital, explains the reasons the program has maintained a Center of Excellence designation for almost a decade in the fast-moving field of bariatric surgery: surgical expertise, high volume, careful analysis of outcomes and judicial adoption of advanced techniques as they become available.
“The definition of a Center of Excellence has evolved over the past few years,” he says. “The accreditation requirements include continuous monitoring of outcomes, as well as the maintenance of strict standards that will ensure patients obtain optimal results.”
Varied Procedures Meet Patient Needs
Patients request bariatric and metabolic procedures for a variety of reasons. As Dr. Ahmad told MD News in 2010, some feel trapped in their own bodies, overwhelmed by their inability to lose weight. Others want to move more easily or to participate more effectively in personally meaningful activities. Some want to see aesthetic change and experience the related psychological boost. Many patients have struggled with health conditions, including high blood pressure, diabetes, painful joints and sleep apnea, and they want to make a change before these weight-related problems take a lasting toll on their lives. Some patients want to more easily conceive and carry a pregnancy to term. Patients hope weight-loss surgery will address these concerns, Dr. Ahmad says.
To meet these varied goals — and to respond to the variations in patient health going into surgery — Mather Hospital offers a number of procedures, each with specific benefits.
Arif Ahmad, MD, FACS, FRCS, Director of the Center of Excellence in Metabolic & Bariatric Surgery and Director of the Center of Excellence in Robotic Surgery at Mather Hospital, meets with a couple post procedure.
Before and after photos of two of Dr. Ahmad’s patients. He had the gastric bypass procedure, she the gastric sleeve.
Over time, the gastric sleeve has become the most popular bariatric procedure. This surgery balances the best of both worlds when it comes to bariatric operations. By creating a smaller stomach — about 15 percent the size of the original — the procedure helps people feel their appetites sated sooner; and it also provides some of the malabsorptive benefits of a Roux-en-Y gastric bypass (see below), though less drastically.
Patients at the Center of Excellence in Metabolic & Bariatric Surgery have contributed to the rising demand for sleeve gastrectomy; in fact, the center has seen remarkable growth in these procedures, according to Dr. Ahmad.
“In the last year alone, I performed more than 700 laparoscopic bariatric operations,” he says. “Of those, more than 500 were sleeve gastrectomies.”
The simplicity and durability of the surgery contribute to its growing popularity.
“With the advent of sleeve gastrectomy, we have an operation that is straightforward and associated with almost no long-term problems,” Dr. Ahmad says. “It will not affect the absorption of nutrients in a significant manner. It is extremely low maintenance in the long term.
“With this procedure, we have seen resolution of diabetes, hypertension and sleep apnea, though to a lesser degree than with Roux-en-Y gastric bypass.”
Sleeve gastrectomy can be performed laparoscopically, using extremely fine instruments introduced through a few small incisions. Dr. Ahmad, who is fellowship-trained in laparoscopic surgery, performs the procedure through extremely tiny entry-points, with the result of minimal scarring and a shorter and less painful recovery for patients.
“We first introduce a telescope through the incision and get a magnified view of the stomach and other internal organs,” Dr. Ahmad explains. “We are able to reduce the stomach’s size, which will encourage patients to eat much smaller meals. The operation also reduces the levels of ghrelin, which is primarily secreted from the fundus and the body of the stomach.”
The procedure takes only about 45 minutes, according to Dr. Ahmad. After an overnight stay, patients return home. They return to a normal diet in four to five weeks.
“My patients have marked reduction in cravings and are satisfied with less food than they were eating before the surgery,” Dr. Ahmad says.
Roux-en-Y Gastric Bypass
A procedure that has stood the test of time, the Roux-en-Y gastric bypass was first performed in the 1960s. Of commonly performed bariatric surgeries, it promotes the most weight loss. Typically, patients lose about half their excess weight and are able to sustain the weight loss up to five years. This venerable procedure has seen considerable advancements, including the use of robotic assistance.
“The use of the da Vinci robot gives us the advantage of precision in suturing,” Dr. Ahmad says. “Since we began performing Roux-en-Y gastric bypasses with robotic assist, the advantage has been the ability to have freedom of movement within the abdomen due to the robotic arms, as well as 3-D visualization of the organs. This combination enhances the efficacy and safety of the procedure.”
In a Roux-en-Y gastric bypass, the surgeon creates a stomach pouch with the capacity of about 1 ounce from the top of the stomach. The surgeon then separates the small intestine, connecting the lower part to the new micro-stomach. A second connection joins the upper part of the small intestine — conveying digestive enzymes from the lower, unused part of the stomach — further along the intestine, allowing the stomach acids to rejoin the food after it leaves the stomach. The patient sees a triple weight-loss benefit: The smaller stomach feels full sooner; part of the absorptive lining of the small intestine is bypassed; and hormonal shifts promote earlier feelings of satiety. These hormonal changes also lead to reduction in diabetes, independent of weight loss.
Image © Intuitive Surgical
Laparoscopic Gastric Banding
Though less popular than in years past, gastric banding, or the LAP-BAND is still requested by many patients. In this procedure, an inflatable band is introduced into the body and placed around the stomach. Filled with a saline solution, the band reduces stomach capacity and helps the patient feel fuller sooner. It can be adjusted at need, and has the benefit of being reversible.
Patients who want to lose weight gradually, or prefer the procedure that alters the body the least, are excellent candidates for this safe, FDA-approved approach.
Endoscopic Gastric Balloon
The endoscopic gastric balloon is FDA approved for patients whose BMI is 30–40 with one comorbidity. Dr. Ahmad is certified for placing the Obera weigh loss balloon.
As patients and their physicians select a bariatric surgery, they consider many factors. Maximizing weight loss is extremely important, but is only one part of the behavioral, physical and emotional puzzle.
“In order to determine which procedure is best for a particular patient, we consider medical, physical and lifestyle issues,” Dr. Ahmad says.
Some medical conditions point to fairly obvious solutions. For instance, Roux-en-Y surgeries often result in dramatic resolution of Type 2 diabetes.
“Patients with severe diabetes or acid reflex are most suitable for Roux-en-Y procedures, compared with sleeve gastrectomy,” Dr. Ahmad says. “The resolution of diabetes is more profound and more durable with Roux-en-Y gastric bypass, and acid reflux also resolves completely. With the sleeve gastrectomy procedure, reflux may or may not be resolved.”
Dr. Ahmad also notes that weight loss is also superior with Roux-en-Y procedures than with the gastric sleeve. In general, he recommends patients with extremely high BMI, older patients, those with diabetes and patients with acid reflux should select a Roux-en-Y gastric bypass, if possible.
“In addition to the profound psychological benefits of weight loss — not to mention the difference a newfound ease of movement can play in a patient’s life — patients who suffer from diabetes, hypertension and sleep apnea have seen resolution or marked improvement in their diseases as a result of bariatric surgery. That was true in 2010, and it has been repeatedly validated since.”
— Arif Ahmad, MD, FACS, FRCS, Director of the Center of Excellence in Metabolic & Bariatric Surgery and Director of the Center of Excellence in Robotic Surgery at John T. Mather Memorial Hospital
Nicole Drepaniotis, MS, RDN, CDN conducts nutrition counseling with a patient.
Dr. Ahmad meets with a patient prior to her procedure.
Dr. Ahmad and Janet Domke, RN, BSN, discuss a patient’s progress.
Why, then, is the sleeve the most common surgery at the Center of Excellence in Metabolic & Bariatric Surgery at Mather Hospital?
One reason is the strong malabsorptive properties of gastric bypass procedures. While malabsorption is desirable in terms of reducing calories retained by the body, patients will find they handle nutrients very differently after the procedure. They will need to take nutritional supplements for life, and some may be in danger of mineral deficiencies.
“Younger patients, especially younger women, are more suitable candidates for gastric sleeves because of the potential for them to develop iron-deficiency anemia after a gastric bypass,” Dr. Ahmad says. “This is especially problematic for menstruating women after Roux-en-Y gastric bypass.”
Similarly, plans for a pregnancy also influence which procedure is best. Many women undergo bariatric surgery because they find that their weight interferes with their ability to get pregnant, or because they wish to have a healthier pregnancy. For those patients, Dr. Ahmad unequivocally recommends sleeve gastrectomy.
“Sleeve gastrectomy does not significantly interfere with absorption of nutrients, so it is not associated with any issues related to absorption during pregnancy,” he says.
Dr. Ahmad notes that there are plenty of requests for the LAP-BAND as well, mostly among patients who are “not desirous of having a procedure that alters their anatomy in any way.”
Gastric banding, he observes, requires regular follow-up for the surgeon to adjust the band.
“The LAP-BAND requires greater commitment from the patient,” he says. “We have to follow up and make adjustments regularly in order to ensure the band is a perfect fit, not too tight or to loose, either of which can result in overeating. In deciding which patients should receive the LAP-BAND, we consider the patient’s lifestyle, ability to follow up and eating behavior.”
A Supportive Environment
Guidance in the choice of a procedure is one of many elements in the multidisciplinary care patients at the Center of Excellence in Metabolic & Bariatric Surgery receive before and after their surgery.
“A psychologist and nutritionist consult with each patient before surgery,” Dr. Ahmad says. “If necessary, patients receive preliminary care to help them become eligible for a particular procedure. Our health professionals and counselors also educate them so they have an accurate understanding of the procedure and the correct attitude for long-term success.”
Patients don’t typically stay long in the hospital for the surgery itself — they might spend one to two nights, depending on the surgery they have. However, while they’re there, they benefit from high-quality, patient-centered care. John T. Mather Memorial Hospital’s nursing staff has earned the Magnet award from the American Nurses Credentialing Center. This recognition is awarded for “nursing excellence and innovations in professional nursing practice.”
Nicole Geiss, BSN, RN-BC; Dr. Ahmad; AnnaMarie Braslow, RN, BS, CCRN, CBN, EMBA; Alisa Caliendo MSN, RN; Margaret Bartsh, CNA; and Cynthia Dunn, CNA
Members of the Bariatric Center of Excellence team at John T. Mather Memorial Hospital
During and after their stay, patients receive positive reinforcement necessary to sustain the lifestyle changes they’ll need for long-term success.
“We follow up at two weeks and then every four weeks for the first months after surgery,” he says. “After that, we see patients every three months for at least two years. We encourage them to continue seeing us at least three times a year thereafter.”
These follow-ups ensure the patient is healing well and enhances the weight-loss process by reducing the risk from complications following surgery. Psychological and nutritional counseling are available and encouraged as part of regular follow-up, and patients may join support groups made up of their peers. A medical bariatrician also oversees patients’ weight-loss progress before and after surgery.
As mounting evidence attests, bariatric surgery is a swift, safe and durable solution to obesity and its related health conditions. The Center of Excellence in Metabolic & Bariatric Surgery at John T. Mather Memorial Hospital, headed by a fellowship-trained surgeon with 30 years of experience, welcomes patients who are considering this life-changing surgery.
To learn more about the Center of Excellence in Metabolic & Bariatric Surgery at John T. Mather Memorial Hospital with Dr. Ahmad, visit matherhospital.org/bariatric-services.php.
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Individual results may vary. As with any surgery, there are risks. Please consult your doctor.