June 3, 2010

Banding Together

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.”
He spoke to Cadiere, who invited him to Brussels to learn more about
gastric banding, and in October 2001, Davtyan underwent the procedure.
He says he was initially shocked by the efficacy of the band because it
had suppressed his hunger and taken away the urge to eat incessantly.
When he arrived home, he dusted off his treadmill and went back to his
personal trainer. “I became an exercise freak,” he says.

Davtyan’s story highlights a growing trend in bariatric treatment:
minimally invasive surgery for those struggling with weight loss. But
surgery is not a magic wand. Those hoping to undergo weight loss surgery
face many difficulties, including deciding which procedure to undergo,
maintaining healthy eating habits before and after the procedure, and
incorporating a lifestyle that promotes daily exercise. Now a surgeon at
the Nikolov Center for Plastic
Surgery in Beverly Hills, Calif., Davtyan is in a position to help
overweight individuals conquer obesity.

In the Spotlight

Obesity has recently become more prominent in the minds of Americans.
First Lady Michelle Obama has focused the nation’s attention on
childhood obesity with her February launch of the nationwide campaign,
“Let’s Move.” The campaign aims to empower families and communities to
make healthy decisions for their kids. In April, the Institute of Food
Technologists (IFT) offered its support for the president’s Task Force
on Childhood Obesity to raise awareness of the disease. In its
announcement, the IFT stresses the need to create a multi-disciplinary
dialogue on the science of obesity prevention.

But while prevention efforts and education are crucial tools in the
effort to curb childhood obesity, they do not address the needs of
adults who are struggling to control their weight. In some facilities,
surgeons, dietitians, and physical therapists are working together in
the battle against obesity by helping patients overcome the difficulties
that accompany drastic lifestyle changes.

A Multi-Disciplinary Approach

“You have to have a comprehensive approach to care,” says Nicholas
Nikolov, MD, owner of the Nikolov Center for Plastic Surgery. “It starts
with having an honest attempt at weight loss through nutritional
guidance before you perform the surgery.”

At the Nikolov Center, patients go through rigorous pre- and
post-operative measures, which include meeting with a dietitian and
fitness counselor before and after the surgery. “This is my disease that
I’m suffering from, so I’m committed to my patients and I want them to
be successful,” Davtyan says.

Jennifer Zerling, MS, CPT, fitness counselor at the Nikolov Center and
owner of JZ Fitness in Los Angeles, acts as a facilitator who
transitions patients from a sedentary to active lifestyle. It’s not just
about the surgery, she says, it’s about their commitment to making the
lifestyle change; they must first show that they are motivated.

“For a lot of people, talking about exercise and fitness is very
intimidating,” Zerling says. “My goal isn’t to say, ‘Ok it’s time to get
fit and make you a world-class athlete’ because that’s not going to
cause them to feel the motivation to make any changes.”

Starting small and incrementally increasing a patient’s regimen will
help maintain motivation and reduce intimidation, she says. Those coming
from sedentary lifestyles may have difficulty making the necessary
adjustments; therefore encouragement and positive reinforcement are
essential for a successful rehabilitation program.

Tyson Erlewine, PT, MPT, OCS, CSCS, supervisor of therapies at Hillcrest
Memorial Hospital, Simpsonville, S.C., says motivation and mobility are
two key challenges in helping bariatric patients. More than 1,500
bariatric surgeries have been performed at Hillcrest Memorial, a
Bariatric Surgery Center of Excellence. Hillcrest PTs work closely with
bariatric surgeons, Eric S. Bour, MD, FACS, FASMBS, and John D. Scott,
MD, FACS to optimize patients’ weight loss and recovery.

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.therapytimes.com/content=0502J84C4876BA8440A040441

– http://www.drnikolov.com/