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Wendy Brown interview

The patient, not the procedure, is the key

Focus should be on patient care and follow up

Bariatric community can change the health and lives of many people around the world

 

Tuesday, February 19, 2013 - 12:12

Owen Haskins- Editor in chief, Bariatric News

The Centre for Obesity Research and Education (CORE), Monash University, Melbourne, Australia, recently published their 15-year Lap-Band outcomes which showed that the procedure is a safe and effective and resulting in 47% excess weight loss after 15 years. Bariatric News talked to Associate Professor Wendy Brown, director of CORE, about her experience with LAGB procedures, the importance of patient follow-up and why bariatric and metabolic surgeons need to concentrate on the benefits of all bariatric procedures.

According to Brown there are many important aspects to take into consideration when discussing bariatric surgery with patients, as part of their pre-operative assessment.

“I spend considerable time with patients before I operate and we talk about what their health problems are at the moment, their social situation, and what their expectations are from the band or any other bariatric procedure”, she says. “One important aspect of surgery is to manage people’s expectations; some patients expect to lose far more weight that is actually achievable, more than the 50-60 percent excess weight loss that we believe is possible.”

She stresses the importance of communicating to patients that the LAGB, or any other bariatric procedure for that matter, is not a ‘magic bullet’ solution:"It is simply not possible to perform any operation where by they can magically still eat and lose weight. What we emphasise to patients is that this is a life-changing procedure and we will be with them every step of the way,” said Brown. It is a life long journey.”

They also look at the patient’s home situation and whether they are in an environment where they are going to be supported. A support network – friends and family – is very important for patients.

She explained that at her institution, patients meet with the surgeon to discuss their options, prior to surgery. She also usually invites the patient to speak to a bariatric GP as patients often feel more comfortable about asking questions to a GP, rather than a surgeon. It also gives the patients the time and space to ensure they are ready for surgery, and they must be given every opportunity to ask the necessary questions.

Brown's centre does not offer patients a routine psychological evaluation, as she claims that there is little evidence this has any real value.

They have performed a study that found pre-operative psychological assessment did not add anything to the outcome of patients, it was an unnecessary cost and the psychologists did not find if particularly useful.

Although they have two psychologists at Brown’s clinic, they tend to see patients post-operatively to assess behavioural changes and assit with goal setting.

Interestingly, the team at Monash do not have regular multi-disciplinary team meetings. They have regular clinical meetings three to four times a year to discuss best clinical practice and difficult clinical issues, however, Brown explained that when they are discussing patients it tends to be very much on a one to one basis.

“My cancer multi-disciplinary team will discuss each and every patient," she said. "However, in our bariatric setting there is very little evidence that patient’s outcomes will improve if they are assessed and discussed by the whole team.”

A lot of patients would put weight on before surgery because they saw it as a last chance to eat the foods they enjoy. Prior to surgery, now Brown places her patients on a two week low-calorie diet. Although there is there no evidence that this results in better outcomes, she uses this as a marker to tell them two weeks before surgery that their journey starts now.

“I really wish we had a way of predicting how well a patient will do prior to surgery," she said. "We have looked at psychological indicators, physiological data, oesophageal manometry, metabolic make-up and syndrome, but we have not been able to identify any good preoperative predictors of who will do well and who will not."

Post-operative treatment

As their 15-year results demonstrated, LAGB is very effective. However, the team at Monash know that if a patient has not achieved about 25%EWL by three months, they are unlikely to achieve satisfactory weight loss.

“As a result, we are focusing more and more on intensive treatment in that early period, so if there are psychological issues or eating patterns or habits emerging, or other issues, we can address them early,” said Brown. “Usually, patients are still very motivated within the first three months and are very much part of the process so we try to attain as much weight loss as possible and hopefully this will carry on.”

“I sometimes think the information we provide before an operation is like reading a travel guide before you go to Paris. you read the information before you get there but it does not make much sense” said Brown. “Then you arrive in Paris and you read it again and it makes much more sense. So we try and put in a process so they can refer to the preoperative information after the operation, and have opportunity to revisit the information as they continue their journey.”

Patients do not routinely see the dietician pre-operatively: Brown feels as it offers no benefit to the overall outcome. The surgeon provides the patient with information about their diet, there is a concern that an additional meeting with the dietician would add to the "information overload" before the operation.

Patients see the dietician within the first few weeks of surgery so they can help them make the transition from semi-solid to solid food. Dieticians at their clinics run different programmes from one-on-one sessions to group sessions that offer advice on eating at restaurants, shopping and dealing with social situations, so it depends on the patient’s individual requirements and needs as to how often they require advice.

Similarly, the psychologist is very much on a needs basis, so if the patient is struggling with their eating or they have behavioural changes then they can arrange an appointment.

A patient’s first formal visit to the surgeon is about four weeks after their procedure, and this is when they usually have their first adjustment.

“We really make the focus of our visits about what they are eating and why, not about the band adjustment," says Brown.

They are encouraged to come back every three to four weeks for the first six months depending on their hunger, because controlling huger is seen as a key to success. After the first six months they are usually seen every three to four months, in some cases once or twice a year.

“There is a real emphasis on never losing touch," she says. "We want to make sure there are no complications and care for them as a metabolic surgeon should.”

She added that in Australia aftercare provision is paid for as part of thenational insurance coverage, allowing patients to receive excellent and extended follow-up.

The focus of patient treatment is on aftercare and Brown and her colleagues have adopted a holistic approach, which includes opening satellite clinics across Melbourne so patients can visit GPs or dieticians near their homes. The easier it is for patients to have access to advice on eating patterns, the more they feel involved.

Brown said that one positive aspect of the LAGB is that patients perceive the need to come in for a check-up as there is a prosthesis in place that needs occasional adjustment. Bypass or sleeve patients do not feel the necessity to visit their surgeon as they typically lose weight regardless of the visit.

Obesity is a chronic disease, and all procedures have better outcomes with a strong aftercare programme. The fact that the patient perceives a need for follow up with a band makes it easier to framework their care as a chronic disease.

Following patients in to the long term with intermittent phone calls is insufficient, she says, as they could have severe nutritional problems that the surgeon would be unaware of, and typically patients underestimate their weight.

“As with any chronic disease you need a chronic care plan. There has been an inappropriate perception in Australia that a patient who has a sleeve gastrectomy does not require follow-up, the so called “Sleeve and Leave” procedure. As metabolic surgeons we are changing a patient’s metabolism and we therefore have a professional responsibility to provide adequate after care for teh rest of that patient's life.”

With over 15 years experience with LAGB, the team at Monash University has written extensively on how the band work and movement of the bolus through the band. Now, they not only advise patients on what to eat but how to eat, emphasising to patients how important it is to eat slowly, chew your food.

“We are constantly re-enforcing the need to make the correct food choices and stressing the need to follow our 20/20/20 rule," says Brown. "Serve up your food on a small plate, use a small fork, chew the food 20 times, put the fork down for 20 seconds and it should take 20 minutes to eat that plate of food."

Bariatric community

Every treatment in medicine has an upside and a downside, and bariatric and metabolic surgery is no different. Obesity is a multi-factorial disease with biological, psychological and sociological contributors, and is very hard to control.

“Eventually, there will be some magic pill that fixes a patients metabolism," says Brown. “But until then, I think the message we need to tell patients, payers and referring doctors is that all bariatric surgery - whether it’s a band, bypass or sleeve - is safe, its effective and its far better than the any of the alternatives.

“The bariatric community has done itself a dis-service by focusing on which procedure instead of focusing on the benefits of all bariatric procedures. We have a great future as a profession, with enormous potential to change the health and lives of many people around the world, if we only we could stand together and stop fighting with each other.”

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