In this episode of PodMD, Melbourne-based surgeon, Associate Professor Sean Mackay will be discussing the topic of Patient Work Up for Obesity Surgery.
- Transcript
Please note this is a machine generated transcription and may contain some errors.
*As always, all in this PodMD podcast is intended for health professionals and the comments are of a general nature. Information given is not intended as specific medical advice pertaining to any given patient. If you have a clinical issue with one of your patients please seek appropriate advice from a colleague with expertise in the area.
Today I’d like to welcome to the PodMD studio, Sean Mackay. Sean is a Hepatobiliary, Upper GI and Bariatric Surgeon. His public appointment is at Eastern Health, where he’s a consultant surgeon at Box Hill Hospital. He is an Associate Professor in the Eastern Health Clinical School, which is part of Monash University. His private practice is based at Eastern Epworth Hospital. Sean is also one of the co-founders of PodMD. Sean, thank you for coming in and making this podcast today.
* We do hope you enjoy this podcast but please remember that the advice here is of a general nature and is not intended as specific advice about a given patient. The views and opinions expressed in this podcast are those of the doctor, not PodMD.
If you do have a patient on whom you require specific advice then please seek advice from a colleague with appropriate expertise in that area.
Sean:Thank you for the invitation.
The topic of today’s podcast is patient work up for weight loss surgery.
Sean:Yes, that’s right. I’d like to offer an overview of the process we undertake in getting someone ready for weight loss surgery. We’ve previously made a podcast on patient selection, and so today we will discuss what follows once we’ve decided that a given patient appears to be suitable for weight loss surgery.
Question 1
Yes. What is the first thing to consider?Sean: In my view, and it’s a practical rather than purely medical consideration, the first thing is to think about the patient’s health insurance and to make sure they will have adequate cover for the surgery. As with most procedures these days, there is a significant out-of-pocket cost associated with these surgical procedures. But we must remember that the greatest cost in terms of having an operation actually relates to the hospitalisation, and to the charges that the hospitals have to levy for bed days and for appropriate theatre fees. There are plenty of health policies that appear to have exclusions for weight loss surgery, and it’s important that a patient check with their fund. The funds will not deal with the medical practitioner directly, but we are able to supply the relevant CMBS item numbers, and the patient is then able to get exact information from their fund. If the patient’s policy has a specific exclusion for weight loss surgery, then it will be necessary for them to upgrade their cover and then sit out the necessary waiting period, which is typically 12 months. Well, I’m certainly not in the position to say that it’s 12 months for every policy from every health fund across the country.
Question 2
OK. And what about self-funded surgery?Sean: Yeah, I strongly discourage patients from the idea that they should self-fund their surgery. The problem is that any surgical complication that keeps the patient in hospital means that they will be accumulating cost and sometimes very rapidly, particularly if they have to go to the intensive care unit, or back to the operating room for further surgery. There are certain hospitals that offer some form of package which is based around an expected length of stay, and typically that seems to be a fairly short stay and that’s a cost that might seem affordable. But when I speak to the patients, it’s clear that most people who are finally looking forward to weight loss surgery, and they’ve probably been thinking about it for some considerable period of time before they came along, they’re only looking at the upside, and they haven’t really considered that in having self-funded surgery, they’re really setting in motion a very expensive taxi meter. So, my advice always is, for patients who are not with a private health insurer, that it’s best to take out appropriate health insurance and then use the 12-month waiting period in optimising every other aspect of their health, including through non-surgical weight loss with my physician colleagues.
Question 3
Thank you. I agree that these are important considerations and that many people will not be across everything in these matters. When you are moving forward with plans for surgery, Sean, what is the general process?Sean: In my practice, I will organise a gastroscopy. I will organise a consultation with my dietician colleague, and organise a consultation with my general medical and endocrinology colleague.
Question 4
What are you looking for at gastroscopy?Sean: Perhaps the main thing is to make sure that there is no substantial hiatal hernia. Any hiatus hernia should be repaired at the time of weight loss surgery, and a larger hernia can be very difficult to repair in an obese patient. If there is such a hernia, I need to be aware of that, and to talk to the patient about the added complexity of the surgery we’ve got planned. The second thing is to exclude malignant or pre-malignant disease before removing part of the stomach. There are numerous conditions to consider, and one example is Barrett’s esophagus, and we must remember that reflux is common in the obese population.
Question 5
Thank you. Could you tell us now about the role of the dietician?Sean: As we discussed before, weight loss surgery is only successful if it allows the patient to alter their diet and to do so on an ongoing basis. Hence, it’s important to analyse the patient’s diet at presentation and educate the patient in the diet that they will need to follow post-operatively. It’s also important to have someone manage the patient through the pre-operative phase. All of these patients have two weeks of a very low-calorie diet prior to the surgery. We’re looking to cause some shrinkage of the left lobe of the liver, which sits directly in front of the proximal stomach. When the liver is fatty and enlarged, it can be quite stiff, and this stiffness will impair our access to the stomach for the surgery. The dietitians look after the prescription and supervision for the very low-calorie diet. And of course, the Dietetic input is vital post-operatively as the patient works back to a normal diet, and then in terms of ongoing supervision. In my practice, I have all of my patients who are having a major operation seen by perioperative physician. In the obesity surgical area, I asked my patients to see one of my colleagues pre-operatively, to make sure that they are expertly assessed for their fitness for surgery and their fitness for that surgery is optimised. Particularly if there’s anything we can do in terms of cardiac, respiratory or endocrine conditions. Of course, comorbidities are common given that obesity is a risk factor for cardiovascular disease and diabetes. My colleague will see all the patients and liaise with any existing treating doctors, and then hand back care to those doctors once we’ve discharged them from hospital. Recently there’s been a lot of interest in medical weight loss therapy and there are some drugs coming to the market which show significant benefit, although not to the extent that they will replace surgery for people in the surgical weight range. But there is increasing interest in the idea of treating patients in the lead up to surgery and then for a period of time afterwards – and there are trials underway. Early results suggest that this regime of neoadjuvant and adjuvant treatment, if you will, will improve long term outcomes, but we do need to wait for those trials to mature.
Question 6
That seems to be a very comprehensive process and entirely appropriate for major surgery in what is overall a relatively high-risk population. What is the final part of the assessment?Sean: After I’ve performed the scope and the patients have seen my 2 colleagues, I bring them back to the office for a face-to-face consultation. I go over all the results and explain any significant implications and put those in the context of my usual discussion of the surgery, and what patients can expect in the preoperative phase. Then we are in a position to finalize the theatre booking, and go ahead with the operation.
Question 7
Thank you. And we do have in the pipeline of podcasts about the perioperative experience of weight loss surgery, so that will be available on the site fairly soon. Just to sum things up for us, could you give us your three take home messages from today’s podcast on patient work up for obesity surgery?Sean: Of course, I think the first thing is that we need to help our patients to understand the costs involved in the surgery, and make sure that they have appropriate private health insurance for the operation. The second thing is to acknowledge that this is major surgery in a higher risk population, and that a multidisciplinary approach with a dietician and physician colleague will maximise patient safety and optimise long-term outcomes. And the third thing, although I’ve only mentioned it briefly today, I think the growing interest in the use of medication in the lead up to surgery and in the post-operative phase is going to be the next big development in obesity surgery. And therefore, in the treatment of the morbidly obese. We will be preparing a podcast on that topic for the library very soon as well.
We look forward to that podcast. Sean, thanks again for coming in and giving us your thoughts on patient work up for the surgery.
Sean: It’s a pleasure. Thanks again for the invitation.
