While bariatric surgery has been performed for some time at Brookhaven Memorial Hospital Medical Center (BMHMC), the American College of Surgeons-accredited program has added surgeons and deepened collaborations to provide a true comprehensive bariatric care model.
BMHMC offers a wide range of metabolic surgeries performed by four board-certified bariatric surgeons, most of which are undertaken in a minimally invasive fashion. Patients also have access to a full spectrum of wrap-around services, including dietary support, counseling and medical weight-loss. Hundreds of patients receive bariatric care at BMHMC each year.
Konstantinos Spaniolas, MD, FACS, Director of Bariatric Surgery at BMHMC, Associate Professor of Surgery at Stony Brook University and Associate Director of the fellowship program in bariatric surgery at Stony Brook University, takes the time to discuss the range of minimally invasive metabolic surgical procedures with his patient.
“The hospital has offered bariatric surgery for many years,” says Konstantinos Spaniolas, MD, FACS, Director of Bariatric Surgery at BMHMC, Associate Professor of Surgery at Stony Brook University and Associate Director of the fellowship program in bariatric surgery at Stony Brook University. “About a year ago, the hospital began to strengthen its program to meet the quality indicators sought by national accreditation systems. While the hospital has been successfully managing patients with obesity for years, it now partners with Stony Brook University, which allows us to provide care for patients close to home.”
Aurora Pryor, MD, FACS, Professor and Vice Chair of Surgery at Stony Brook University, Fellowship Director of Stony Brook Bariatric and Weight Loss Center and on staff at BMHMC, arrived at Stony Brook in 2011 and was present when the bariatric programs at Stony Brook and BMHMC began their partnership in the last year.
“We’ve seen steady growth since the inception of the partnership,” she says. “The program fills a community need. By working together, BMHMC and Stony Brook offer Brookhaven’s patients the bariatric care they need.”
A Surgery for the Whole Person
While BMHMC refers to its surgical weight-loss program as Bariatric Surgical Weight Loss Care, Dr. Spaniolas prefers the term “metabolic surgery” to describe the range of procedures that alter the digestive tract to facilitate weight loss and amelioration or remission of metabolic syndrome.
Bariatric Specialist Andrew Bates, MD, (far left) presents an overview of his recommendations for a patient to fellow BMHMC/Stony Brook program members, including Daniel Gottfried, RN; Aurora Pryor, MD, FACS, Professor and Vice Chair of Surgery at Stony Brook University, Fellowship Director of Stony Brook Bariatric and Weight Loss Center and on staff at BMHMC; Program Director Mary Zotos; Clinical Reviewer Alexandra Manzo; Bariatric Specialist Salvatore Docimo and Dr. Spaniolas.
“There is a tremendous metabolic effect with bariatric surgery, which is something we have been observing for more than 20 years,” Dr. Spaniolas says. “But it hasn’t been until the last five years or so that we have had the highest quality, using prospective randomized trials, enabling the surgery to provide tremendous benefits to patients who have metabolic disease. We have commonly seen diabetes remission occur after metabolic surgery, meaning patients are considered disease-free, exhibiting no signs of the condition for years. Many studies have compared bariatric surgery to traditional diabetes treatments and have found the effects of surgery overwhelmingly positive. Patients are able to control their glucose levels better — often with no need for medication. We have evidence that patients are also at less risk for eye disease and kidney disease.”
In fact, the 2nd Diabetes Surgery Summit conducted a review of literature about bariatric surgery and diabetes treatment. They found that the surgery is so effective that, according to a consensus statement, “it should be recommended to treat T2D obesity in patients with class III (BMI≥40 kg/m2) and in those with class II obesity (BMI 35.0–39.9 kg/m2) when hyperglycemia is inadequately controlled by lifestyle and optimal medical therapy.”
The authors go on to suggest the surgery for patients with a BMI above 30 and uncontrolled Type 2 diabetes — a testimony to both the value of metabolic surgery and the seriousness of diabetes as a lifelong condition.
Numerous other metabolic benefits from weight-loss surgery have been well-attested, including amelioration or cure of sleep apnea and high blood pressure. Some researchers speculate the surgery creates its global effects by altering gut microbiota, which is connected to glucose metabolism and lipid metabolism. At any rate, metabolic surgery is more effective than diet, exercise or medical management at fostering weight loss, and its metabolic effects seem to exceed even those of equivalent nonsurgical weight loss.
“What I like best about bariatric surgery is that we establish a relationship with our patients. It really is a metabolic transformation. We all know the struggles extra weight can cause in terms of diabetes, hypertension, sleep apnea and other aspects of metabolic syndrome, and after surgery, patients often experience a new beginning — a whole new life. To be part of that process is very rewarding.”
— Konstantinos Spaniolas, MD, FACS, Director of Bariatric Surgery at Brookhaven Memorial Hospital Medical Center, Associate Professor of Surgery at Stony Brook University and Director of the fellowship program in bariatric surgery at Stony Brook University
Dr. Docimo and Dr. Spaniolas collaborate as they review a patient’s diagnostic imaging.
“There has been talk worldwide and nationwide about offering metabolic surgery to people with diabetes or severe complications at lighter weights than the consensus guidelines,” Dr. Pryor says, noting that BMHMC, in most cases, follows National Institutes of Health guidelines for recommending surgery. “We have found if you intervene earlier in the course of diabetes, you can cure it long-term.”
Earlier bariatric surgery can also reduce organ damage that results from diabetes. The day-to-day effects of weight loss are just as important.
“Most people lose 70 percent of their extra weight, Dr. Pryor says. “Also 90 percent of people experience resolution of diabetes and 85 percent of patients with high blood pressure are able to stop taking their blood pressure medications. Plus, patients get their lives back.”
Treatments for the Weight-Loss Journey
BMHMC, in partnership with Stony Brook University, is able to offer a wide range of obesity treatments. From diet and exercise counseling and medical weight loss options to endoscopic bariatric procedures and metabolic surgeries, physicians work with each patient to determine the best option for his or her situation.
Dr. Bates and Dr. Spaniolas spend a few moments together reviewing postsurgical follow-up care.
“We offer broad bariatric care focused on minimally invasive techniques,” Dr. Spaniolas says. “In fact, we perform 99 to 100 percent of first-time cases in minimally invasive fashion. It benefits patients because they typically experience a shorter hospital stay, and an accelerated recovery.”
Weight-loss services and procedures are performed as a mix of office-based and hospital-based, with patients seen at the lowest level of acuity necessary. Routine surgeries typically take place at BMHMC, whereas revision surgeries are most often performed at Stony Brook.
Office-based options for weight loss are rising in popularity, with balloon therapies and endoluminal options becoming a possibility for less-heavy patients, Dr. Pryor says. Balloon devices, which are placed endoscopically, expand at the top of the stomach, creating sensations of fullness. These reversible procedures have been found to be effective, though there is less long-term data than for traditional metabolic surgery. They result in about 10 percent weight loss, Dr. Spaniolas says, making them an excellent option for patients who want to lose limited amounts of weight. Another endoscopic procedure reduces the size of the stomach or the anastomosis of a previous bariatric procedure, making it a less invasive alternative to traditional weight-loss surgery.
The most common procedure performed at the bariatric program at BMHMC is the sleeve gastrectomy, in which the surgeon removes most of the stomach. This procedure limits absorption and creates sensations of fullness.
“This is the majority first-time bariatric surgery procedure for people who want to lose weight,” Dr. Pryor says. “Sleeve gastrectomy results in the least dietary intolerance after surgery. People feel normal, but become full earlier. The surgery has excellent metabolic results, similar to more traditional procedures.”
“We have seen the elimination of the laparoscopic gastric band as a sustaining procedure,” Dr. Spaniolas says. “In its place, the sleeve gastrectomy has increased further, to the point where we are now seeing fewer gastric bypass procedures, which has been traditionally the gold standard for weight-loss surgery. However, we do still perform a large number of gastric bypass procedures in our centers, depending on patient preference and goals of care.”
Gottfried, along with Zotos, Dr. Docimo and Dr. Spaniolas, review the day’s cases in the ASU/PACU of the Knapp Center.
Gastric bypass is particularly useful for patients who have counterindications for sleeve gastrectomy. With a gastric bypass procedure, the surgeon creates a stomach pouch that can contain only 30 milliliters or so of food, then bypasses the existing stomach by joining the lower portion of the small intestine to the stomach. The majority of the stomach and upper half of the small intestine are thus disconnected from the digestive tract, rerouting the food’s path and limiting absorption.
“There is some evidence of GERD progression after a sleeve gastrectomy,” Dr. Spaniolas says. “We see referrals for patients who experience worsening GERD after a sleeve procedure performed elsewhere. We will often convert the sleeve to gastric bypass in these cases, or even offer endoscopic therapies for GERD when able. One of the advantages for patients being evaluated by an experienced group such as our own is that we offer every procedure, giving patients a full range of options for obesity care and obesity surgery specifically. We really tailor the approach to specific characteristics and goals for each patient. The surgeons of BMHMC also offer revision surgeries. “In our practice, we see significant numbers of patients who are unhappy with results from surgery at other places,” Dr. Pryor explains. “We help these patients find better solutions for their weight-loss needs.”
“Primary care providers should refer any patient who qualifies for or is interested in bariatric surgery or medical weight-loss options for a consultation. They can be referred with no specific option in mind — in fact, it makes it easier not to have that discussion first. At Brookhaven Memorial Hospital Medical Center, patients receive expert care provided by friendly physicians in a comfortable setting.”
— Aurora Pryor, MD, FACS, Professor and Vice Chair of Surgery at Stony Brook University, Fellowship Director of Stony Brook Bariatric and Weight Loss Center, and on staff at Brookhaven Memorial Hospital Medical Center
High-Volume, Expert Surgeons
All four of BMHMC’s bariatric surgeons are board-certified, and they come with strong backgrounds in bariatrics, minimally invasive surgery and related fields.
“I attended the University of Rochester, which has a very rich program in minimally invasive surgery,” Dr. Spaniolas says. “Following that, I received specialized training in bariatric and minimally invasive advanced gastrointestinal surgery, and also completed a research fellowship at Harvard University.”
Dr. Spaniolas spent time on the faculty at East Carolina University, which he terms the “birthplace of contemporary metabolic surgery.”
Similarly, Dr. Pryor has extensive experience in her field, including more than 100 publications and a number of patents in surgical technologies. An expert in minimally invasive gastroenterological conditions, she brings additional insight to cases of obese patients with comorbidities such as hernia or reflux.
“We treat upper abdominal conditions and diseases of the esophagus and stomach, often in the same patient,” she says. “Hiatal hernia and acid reflex often occur in patients who seek bariatric surgery, so knowledge of those conditions expands our range of options.”
“The partnership between BMHMC and Stony Brook University allows Long Island patients to avail themselves of a mix of highly experienced and established tertiary level bariatric surgeons,” Dr. Spaniolas says.
The result is a program with a high-quality index, verified by the American College of Surgeons as a comprehensive bariatric center, the organization’s highest level of recognition, Dr. Spaniolas notes.
An Ambiance of Compassionate Care
High-level care close to home is the best of both worlds, which Dr. Pryor recommends to patients, not only for the excellent surgical care, but also for the compassionate environment and patient-centered wrap-around services.
“Our dietitians, psychologists and medical providers are all under the same roof, providing a full spectrum of care with a solution for each individual,” Dr. Pryor says. “We work with a medical weight-loss program run by a nurse practitioner and dietitian who both advise patients about medical weight loss, exercise, lifestyle and food choices. From there, patients may come back to us for surgery. Then after the procedure, we have ongoing follow-up and monthly assessments with each patient.”
The team supporting each patient’s weight-loss journey is professional and compassionate, Dr. Pryor continues.
Members of the OR, ASU and PACU team includes (left to right), Yao Ting Hsien (Stanley), PNA OR; Louis Rey, Peri-Operative Nursing Associate; Fern Starr, Clinical Coordinator; Gerry McKinney, RN OR; Carolyn Holecek, RN OR; Ashanti Peacock, Environmental Services; Fred McFaulds, OR Technician; and Rocio (Rosa) Carcelen, PNA OR; with Drs. Bates, Docimo and Spaniolas (center).
“We have a team that gets along and works well together,” she says. “Everyone I hire is compassionate about what they do. We give 110 percent to our program. I respect the clinical judgment of our nurse practitioner and our dietitian — it’s our collective intelligence that makes us smarter as a team. Together, we help patients get ready for surgery, both mentally and physically. By the time patients undergo metabolic surgery, they’re ready, committed and excited to start their new lives.”
This team takes candidates for bariatric surgery into a structured program of presurgical education, meaning that each person knows what to expect and how to prepare for the procedure.
“Patients learn how to use the surgery appropriately,” Dr. Spaniolas says, his choice of words to suggest that surgery is a tool to be employed by the patient, not a panacea that fixes everything on its own. In fact, patients learn a lot about what to eat after surgery, how to incorporate exercise into their daily lives and how to manage psychological challenges they may face.
As part of the team’s compassionate ethic, they’re zealous about helping patients reach the best metabolic health possible.
“Of the programs a primary care provider might point to in Long Island, ours offers truly multidisciplinary care,” Dr. Spaniolas says. “We assess patients not only for obesity but for related comorbidities. We provide an array of options. Some patients choose diet and counseling, others pharmacotherapy, while others select endoscopic treatments or surgery.”
To learn more, visit brookhavenhospital.org/newu/.