We recognised early on that full support enables the best possible outcomes. Our approach to weight loss surgery is to provide a multidisciplinary unit for the assessment, provision and follow up of all patients. Learn more about this and the process involved, should you wish to proceed with surgery.
Our Approach To Weight Loss Surgery
Video Transcription
Doctor, you have a large team here obviously for support. What can a patient expect from Mercy Bariatrics?
Dr. Leon Cohen: Yes, absolutely Dennis. That is so important. And I recognized the importance of a multidisciplinary team 12, 15 years ago when I started up, that this was not surgery that just a surgeon can do by themselves. And so over that time, I incorporated it into our practice, embedded it into our practice a dietician, an exercise physiologist, and we now have a purpose built gym next door to our practice which our patients are encouraged to use and that forms part of their assessment and their post-operative management.
We have bariatricians who are GPs with an interest in bariatric medicine. And they are involved in new patient assessment and with the follow-up. We have an education follow-up and success habits department, which is a training program for people after surgery to teach them to get the best out of their tool and also, to work with them if they are starting to regain with a back on track program.
And although we don’t have an in-house psychologist, we do refer to a team of psychologists who are skilled in this area in a selective way.
And so, what I think patients can expect when they come to see our practice is first of all, engagement, so that we engage all of these facets to optimize their outcome. I think they should expect enthusiasm about bariatrics because we are just so impressed with the outcomes we can deliver. This has become the dominant part of my practice.
And they can expect a great deal of experience that comes from managing over 4,000 bariatric patients doing over 2,000 bariatric operations including the more difficult side of bariatric practice which is revisional surgery for problem bands and problem sleeves and even problem bypasses.
And that is the culture that I have I think developed and want to see developed in this practice.
What do you say to people that have fears about operations?
Dr. Leon Cohen: Look, I think it’s very common for new patients to have fear, and that’s a very appropriate response particularly if they have never seen someone go through this surgery and they’re fearful that it will be painful, they’re fearful of the complications, they have heard about bad experiences in the past. And it only takes one death in the media and everyone thinks that’s going to happen to them. Fortunately, that’s not the case. And a lot of our time I think is spent assuaging those fears.
Now, that can be as simple as talking to other patients in the waiting room and not uncommonly, if I have a patient who is a new patient and they look a bit anxious and worried, I would just grab one of our old patients and say, “Would you mind talking to my new patient and just tell him about your experience?” Or they get some comfort from seeing the patient stories on our website and reading their blogs.
I think another great fear of patients is that the gastric sleeve surgery is not reversible in the way that the gastric band was. But in reality, this operation has to be not reversible because with the band, the minute you take the band out, the patient’s weight regains and all of their lost weight be regained typically in about six months despite their best intention. That’s what happens. Read more about weight regain.
But why would anyone want to have the operation reversed?
Dr. Leon Cohen: Patients say to me after a band, “Look, I’ve lost all this weight. I’ve learned new eating habits. Can I have the band taken out?” And I say, “The minute you do that, you will regain your weight.” No one learns new eating behaviour. They have that eating behaviour imposed on them.
And the body is always trying to get back to its peak weight. It has a sense of what the peak weight was due to a hormone called leptin which is made by fat cells. It’s all being controlled by the deepest, most primitive part of our brain, the hypothalamus, which controls most of our bodily systems like our pulse rate and our temperature and our respiration rate. And if you think you can beat an argument with your hypothalamus, just try holding your breath for three minutes and see who wins that one.
Are there times when you find the patient isn’t really suitable for surgery and you may have to reject them?
Dr. Leon Cohen: Surprisingly, a few. There are certainly some patients that we take a more circumspect approach. And so for example, the super obese is a good example of that. The hospitals in Perth at the moment, there is one hospital that will accept patients as high as 250 kilos.
I personally would not try and operate on someone just at 250 kilos. The largest patient I’ve operated on started off at 287 kilos. And aware of that 250 kilos, we committed to work with her to get it down below that threshold. And that process actually took about six months. And there were ups and downs but eventually, using our services, the dietician, the exercise physiologist, and her willpower, over a 6-month period, she lost down to 247 kilos and we did her surgery.
Because she was the largest patient I had operated on, I actually got her into the operating theatre the night before the surgery for a dummy run. And we were able to make sure that the transfer on to the table, all the setup was correct and efficient and smooth. And so when we came to do her surgery the following day, it really wasn’t all that much different to what I was used to doing.
And paradoxically, I often find it’s easier to operate on someone who has a very high BMI than someone who has a very low BMI because there’s more working room inside their abdomen and the whole thing isn’t as crowded. So the super obese is someone that we would certainly take a little more time.
The other challenging patient and increasingly we are seeing is other patients who have a very low BMI. So patients are coming to us with a BMI of 31, 32 saying, “I’ve seen the magic of bariatric surgery. I want a bit of this.” And we have to educate them and say to them, “Well, yes, it’s very powerful. But we’re going to be putting you in harm’s way. At the moment, if you only got a BMI of 31, 32 is really not much health risk from having a BMI like that. Bariatric surgery of the sleeve for someone with a low BMI is extraordinarily powerful and you’re going to lose a hundred percent or more of your excess. You’re going to get to a BMI down to 21, 22. You’re going to look and feel damn skinny. Are you sure you want to do that?”
And so for many of those patients faced with that reality, they will work with us with a non-bariatric surgery operation. So we have part of our service, it uses traditional methods of diet and exercise to get people to their goal weight. And that’s also very accessible and much easier for someone who starts off with a low BMI.
The really difficult patient of course is the BMI of 34. So what is the point of expecting or asking a patient to eat their way up to a BMI of 35, which they could do for you if you ask them just so they qualify for surgery? In many cases though of someone with that borderline BMI particularly if they have a comorbidity like diabetes or high blood pressure, that’s going to be their entry ticket into the surgery.
And also for other patient groups like patients of Asian and Indian descent, we recognize that they get their metabolic problems at a much lower BMI than European and Caucasians. And so, someone with a BMI of 32 who is Indian for example, they may have a full blown metabolic syndrome with diabetes and high blood pressure and sleep apnea and be a very deserving candidate for this surgery.
We modify our approach a little bit for the low BMI. So for those people, we would typically use the mid-size bougie and that gives a very satisfactory result. And using our data and these results graphs are available on our website, a patient of any particular BMI can pretty well work out where they’re going to be based on their starting BMI and the bougie size selection.
What if a patient doesn’t have private health insurance?
Dr. Leon Cohen: Well, bariatric surgery in the public centre at the moment is very limited. So Joondalup Hospital has a modest bariatric program and I think they’re allowed to do two or three hundred cases a year.
A lot of their case load is swamped by patients who previously had bands and have had complications with the bands and they’re trying to then fix those problems up.
In practical terms, you’re probably going to wait two or three years just to be seen in one of their clinics and another period of waiting a year or two just to get on their waiting list. So if patients don’t carry private insurance, we recommend a number of things.
The first is, take our private insurance. Wait a year and then you will be ready to have your surgery.
The second is that it is actually possible to access your superannuation account if you have money in that account, sufficient money, which can pay for the whole surgery or for the gap which is for us, around $6,000 to $7,000 on top of any private insurance that you have.
Additionally, a number of our aboriginal patients from up North have been able to benefit from various land rights monies that have been allocated to improve their health. And this is a legitimate use of it.
The reason that this surgery is not being done as it should be in public hospitals I think is largely due to this insane mismatch between the Commonwealth funding for health and the state funding for health. So the benefits – the Commonwealth pays for Medicare for the GP practices and for the drug budgets. The state is responsible for just about everything else including the running of the hospitals where the surgery can be done.
The benefit in terms of cost saving from bariatric surgery is in the reduced GP attendances and the reduced drug bill. And that’s a saving of about $10,000 a year just for a diabetic. So all the benefit flows to the Commonwealth but the expense for doing the surgery would be have to incurred by the state hospitals.
And their accountants and managers look at the expense of doing a bariatric operation, again, about $10,000 and they say, “Why should we be spending this money when we’re getting none of the benefit? Why should we be spending this money when we’ve got all the calls on our purse to carry out a cancer surgery or a service or a trauma service or a joint replacement service?”
And so, I tried for many years to get bariatric surgery into the public hospital where I worked. It was rejected. The compromise has been that there was one hospital doing it, Joondalup. They have a very limited service.
In practical terms, when you consider that there are probably over a million people in Australia who have a BMI over 35 who could do and should do put their hands up for bariatric surgery even if they turn all of the public hospitals full-time into doing bariatric operations, they wouldn’t be able to break the back of that.
Bariatric surgery is not the answer on a population level for the problem of morbid obesity. It can’t cope with a number of operations that we need to do. But for the individual, it is the best approach. And that’s why we continue to do it for those people who are lucky enough, determined enough, and have the resources to do it.
Find out more about costs and finance options for both public and private patients.
So what’s the process for someone that really wants to have the surgery?
Dr. Leon Cohen: So first of all, because we’re specialist centre, a patient must get a referral from their GP. And we continue to interact with their general practitioner and keep them informed of the process. Then they make an appointment to see either myself or one of my associates for the initial consultation.
That initial consultation usually takes place over about half an hour to 45 minutes, and that’s where we want to find out more about them, about their pattern of obesity, their weight history, what illnesses they have. It’s the time when we have a discussion about the pros and cons of the operation and the potential risks.
And most importantly, try and determine what the patient’s goals are, what weight they would like to be, where they see themselves in a year or two’s time. Because it’s very important that we are sure that we can match up their expectations to what we actually can deliver, and that people don’t have unreasonable and unrealistic expectations one way or the other about what their final weight is going to be.
At the end of that consultation, I say to them the same thing, “Go away and have a think about it.” I do not book cases on my first visit. I like to see a patient three times before their surgery. So we say, “Come back in two weeks and come with some questions. Come with your spouse. We’ll answer those questions. And at that stage if you’re committed to proceed, we will get the ball rolling.”
At that second interview, we then look in the diary and give them a date for their assessment day and usually a date for their surgery. And that gap is usually between two to four weeks. Now, some patients need a little more preparation, if they need to lose some weight before surgery, which we do to shrink their liver down. We might get that organized with the dietician.
They then come for the bariatric assessment day. And then they will see over the course of one hour each, the dietician, the exercise physiologist, and the bariatric assessor. Each of those people have a role to play in assessing them, educating them, and reporting back to their surgeon. They may need further investigations like an endoscopy or an ultrasound. They may need to go on a very low-calorie diet.
And then they come to their surgeon two or three days before their operation before what I call the final consenting visit where we run through the procedure, what’s going to happen to them in hospital and we run through the consent for the surgery.
The surgery takes place within a day or so. The operation now only takes us 30 minutes to an hour to do but the setup time before and after adds an hour to that. And so typically, we will do two or three cases on a session.
They can expect to be in hospital for typically two nights. They can expect to be in very little discomfort afterwards and to be self-caring from day one and to be started on a gradually increasing fluid intake and diet over the next two weeks, which is under the supervision of our dietician.
When they leave hospital, they are completely self-caring. If they’re in a desk job, they can be back at work in a week. If they’re doing a manual job then probably about two weeks. And we typically see them at the 2-week mark for our first review.
The other standard which I see it are for patients who come from the country. So we acknowledge that it’s more difficult for them to come down for these visits. And so, the initial consultation, we will commonly do by Skype or what other video setup that the general practice has and there was a medicare reimbursement for that.
They do need to come down at least once though for their assessment phase that has to be done physically here. And they need to come down of course for their surgery. And I also insist that sleeve patients, that they stay down in Perth for about two weeks during the time of their surgery. And that is because the period for maximum risk of complications from sleeve is in the first two weeks.
And the key to the management of those complications is speed. And I don’t want them sitting on a tarmac up in Karratha waiting for an RFDS (Royal Flying Doctor Service) flight, getting sicker and sicker so that by the time they get down here, they are really sick. So, I want them around me in Perth. If they were to get a complication, I can get into hospital quickly and get on to solving the problem.
And then they are seen in a structured way over the next two years. So typically, at six weeks post surgery, 3 months, 6 months, 12 months, 18 months, 2 years. And they will be seen by the rest of the team usually during those times. And there are things we’re going to be doing with them during that time like repeating their exercise test, like repeating their blood test, like doing a rice cream evaluation of their gastric volume that makes sure that they’re on track both nutritionally and metabolically and with their weight loss. And that is the beauty of our support service.
And typically, the patients who do best are those who take advantage of that structure and of that support.
Doctor, thanks for your time today. Where can people find out more about bariatric surgery?
Dr. Leon Cohen: Well, the best source of additional information actually is our website. We are updating that frequently both in the core of the website and with the various news and blogs that we have linked to that. This is where the videos are going to be housed and I think that that’s going to be a fantastic resource.
We also have a nurse practitioner and a success habits coordinator that can take phone calls if there are inquiries.
What we also want to share with you is the way the rest of the unit works. And so, I hope you’ll take this opportunity to see how the gym and the dietician and bariatrician all feed back into this program.
Weight Loss Surgery at Mercy Bariatrics Perth
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