Weight Loss Surgery Transforms the Patients, the Practice, and the Surgeon
an article written for a local magazine now out of print
General surgeon Wayne Westmoreland, MD enjoyed the distance he used to feel from his patients. “I didn’t want to see the patients after general surgery,” Westmoreland said. “I wanted to take out your gall bladder, do a wonderful operation, admire my work, put your disease in a bucket, and be through with you. And then go load up my bird dogs and head out the duck blind.”
After twenty years of surgery, however, he had an encounter on the Stones River Greenway that caused him to re-evaluate his life’s priorities. And his practice. “I was walking on the greenway trying to lose some weight I’d gained while I couldn’t exercise,” said Westmoreland, referring to his 90-day recovery from a broken collarbone in 2002. “I passed a morbidly obese lady on the path. I did something I’ve never done before—I looked at her face.” Westmoreland, trained at University of Tennessee at Memphis, paused and cleared his throat. “And what I saw surprised me. Here I am huffing and puffing with a 25 extra pounds. This lady has 200 extra pounds on her back. I don’t know how she was putting one foot in front of the other. If I were in her situation, I wouldn’t even stick my head out the door.”
In that moment, his perspective changed. “I had this feeling that, ‘There’s a person in there.’ And I thought, ‘Wow. She’s trapped. What can I do to help?’”
Clearing Misconceptions
For the first time, he thought seriously about adding weight loss surgery to his practice, Murfreesboro Surgical Specialists. His wife disagreed. The practice was thriving. When was he going to find the time to become an expert on a battery of new techniques? His curiosity about the procedures confused her as well because Westmoreland had been a vocal opponent. “I figured any surgeon worth his salt was doing ‘real’ surgery,” he smiled an I-should-of-known-better grin. “Once I realized that the surgeries could be accomplished laparoscopically, the rest of my objections went away.” Laparoscopic patients typically go home the same day as surgery and experience very little pain. “If we don’t cut their bellies open, it doesn’t matter what we do inside, they don’t hurt,” Westmoreland said.
Westmoreland and his partner, George Eckles, MD shared—and have heard others voice—many major objections to weight loss surgeries. They’ve sought to understand and overcome these issues through their practice. “Fear is the most common,” Eckles said. Patients fear the changes to their bodies. Doctors fear the lack of results. Some of these fears are supported. Westmoreland and Eckles have run into peers who haven’t used a multidisciplinary approach—including the primary care physician—in follow-up and recovery. Murfreesboro Surgery Specialists has carefully assembled a team to make sure no patients fall through the cracks.
Many opponents to the surgeries point next to assumed higher mortality rates in bariatric surgery compared to other surgeries. Eckles counters, “That’s just not true. A recent multi-center study shows that overall mortality is lower than knee-replacement. These surgeries carry a rate of only 3/10 of one percent.[FOOTNOTE]”
“If a doctor sees a colon cancer patient,” Westmoreland added, “he doesn’t say to the patient, ‘You’ve got a 10-15% mortality rate with your operation.’ They simply urge and encourage surgery.” Westmoreland leaned forward for emphasis. “They can do the same for weight loss surgery.”
The other objections grow out of the sensitive nature of the surgery. “Morbid obesity is a sneaky condition. People believe that everybody is just big now,” Westmoreland said. He believes that many shared his former, skewed attitude. “I’ve met doctors who don’t want to offend their patients by diagnosing them as morbidly obese. I’ve met others who don’t want to fail by recommending weight loss surgery only to have the patient refuse.”
Westmoreland and Eckles have seen doctors eyes light up with understanding as they’ve shared facts, figures, and case studies with them. They have a standing offer to travel to a doctor’s practice to share their experience. And doctors are always welcome in Murfreesboro for one of their frequent clinics for patients. “We make ourselves available to doctors however we can,” said Eckles.
When they considered these procedures for the first time, Westmoreland met many patients in every stage of recovery. “I saw patients that used to be insulin-dependent diabetics, who aren’t any more. I met patients who used to take a list of medicines as long as my arm, but don’t anymore. And I saw patients that couldn’t walk, run.”
The Procedures
Murfreesboro Surgical Specialists offers three weight loss surgeries in addition to their full cadre of general surgery: Gastric Bypass, Gastric Banding, and, a Laparoscopic Sleeve Gastrectomy, a procedure with amazing results. Adding them was a natural process of evolution of their practice. “We are recognized experts in advanced laparoscopic surgery,” said Westmoreland. “We’ve been operating on the GI tract since residency. These surgeries, after we cleared our misconceptions, made sense.”
Gastric Bypass
The Gastric Bypass, or Roux-en-Y, is the most common weight loss surgery. More than 140,000 were performed nationwide during 2006 comprising more than 80% of all weight loss surgeries [FOOTNOTE]. This aggressive surgery involves two advanced laparoscopic procedures. First, the surgeon uses staples to form a small pouch at the top of the stomach. The rest of the stomach is detached and sealed with staples. Then, the surgeon divides the small intestine. The pouch is connected directly to the final 100 centimeters of the small bowel. The rest of the stomach remains connected to the small intestine allowing digestive juices to be produced. The surgeon connects the small bowel to the same channel, the final 100 centimeters, allowing digestive juices to provide with food for a modicum of breakdown and absorption.
This malabsorption is the primary catalyst of weight loss. The patient eats less. What the patient does eat is not broken down as much nor does the body have adequate time to absorb all of the calories before the body expels the waste. Patients who elect the Gastric Bypass require a special diet to prevent rupturing or painful blockage. Daily multivitamins, mineral supplements, increasing protein, increasing fiber, and decreasing sugar are essential to recovery and surgical success.
Westmoreland believes in the power of this surgery. “A diabetic needs gastric bypass because it will cure Type II in the recovery room.” Many patients in their care have stopped needing insulin to control their blood sugar levels.
Adjustable Gastric Banding
Doctors Westmoreland and Eckles also perform a less aggressive surgery using Adjustable Gastric Banding or LapBand® technology. This laparoscopic surgery places an adjustable cuff around a few centimeters of the stomach reducing the amount of food that can be contained. In essence, the cuff creates a pouch similar to the one created surgically through Gastric Bypass. The constriction can be controlled by injecting or removing saline through a port that is under the skin but outside the muscle layer of the abdomen.
Westmoreland emphasized that this procedure is only as effective as the will of the patient. “It’s a food catcher, not a calorie catcher,” he said. “A patient with a LapBand can cheat the system by drinking milkshakes, sucking on Hershey’s kisses, or drinking Mountain Dew.” Some go around the system to get all the calories they used to. They don’t lose weight.”
LapBand patients should also follow a careful diet to avoid blockage. French fries are a particularly destructive food. Neither should patients drink while they eat. “We want the food to stay in that stomach,” Westmoreland said, “so they feel full and don’t continue to eat.”
Laparoscopic Sleeve Gastrectomy
Westmoreland believes that the Sleeve Gastrectomy is revolutionizing lives. Doctors—including his mentor in weight loss surgery, Dr. Ronald Clements—encountered some patients who were suffering from so many health problems they were not candidates for Gastric Bypass. They decided to stage the operation by only creating the small pouch. If the patient responded to the treatment, was successful in the new diet and exercise regime, and lost enough weight, the doctors could return and finish the entire Bypass. “In 90 percent of the cases, the rest of the surgery wasn’t needed,” said Westmoreland still full of joy over the discovery.
The Sleeve Gastrectomy removes 2/3 of the stomach—the fundus—and creates a sleeve similar to the Gastric Bypass. The fundus serves two purposes. It is the elastic capacity of the stomach expanding and contracting based on food intake. “When you remove that much of the stomach,” according to Westmoreland, “it doesn’t take much food to make you feel full.” In addition to the anatomic benefit, removing the fundus has a metabolic effect doctors didn’t witness in Gastric Bypass. “The fundus makes a hormone named ghrelin,” Westmoreland said. “Ghrelin stimulates appetite. The combination of these two results means that a patient isn’t as hungry as often and feels satisfied sooner.”
The Sleeve also reduces the body’s problems with malabsorption. “The sleeve doesn’t disrupt absorption,” Westmoreland said, “It’s business as usual for the body through the intestines just as God designed it.”
The Sleeve is also a safer procedure. Since adding the Sleeve to their practice in 2003, they have performed more than 200 surgeries. “And we haven’t lost anybody yet,” Westmoreland said with the intensity of a wartime commander intent on getting all of his soldiers home.
A Drastic Solution for a Desperate Problem
Many wonder at how the culture and media are influencing the increase in weight loss surgery. Dr. Eckles warns, “Morbid obesity is not a cosmetic issue whose treatment is merely discretionary.”
Westmoreland said, “Only 30–40% of general practice physicians refer qualifying patients for weight loss surgery.” Many struggle with the same objections Westmoreland and Eckles overcame when adding these procedures to their practice.
“If we receive a referral for a sick gall bladder and serve that patient well,” said Westmoreland, “I still don’t have the footing to say, “You are struggling with morbid obesity. Have you considered bariatric surgery?’ They don’t listen. All I do is make them mad. However, if the primary care physician—who has a long-term relationship with the patient—recommends it, the patient responds with, ‘Dr. Smith cares for me.’”
Westmoreland and Eckles readily admit that surgery is a last option. “If medicine would cure appendicitis,” Westmoreland said, “I would never take out an appendix. But there are times when surgery is necessary. There are times when weight loss surgery is necessary.”
[SIDEBAR]
Is Your Patient a Candidate for Weight Loss Surgery?
1. What is your patient’s BMI? If greater than 40 or greater than 35 with co-morbidities, the patient is eligible. Co-morbidities include:
• Adult onset diabetes
• High blood pressure
• Heart disease
• Osteoarthritis of weight bearing joints
• Sleep apnea or other respiratory problems
• Gallstones
• Acid reflux (heartburn)
• Stroke
• Infertility
• Certain types of cancer
• Skin disease
• Urination problems
• Depression
• Other serious disorders
2. Has your patient tried and failed numerous non-surgical treatments for morbid obesity? If not, begin the patient on a program you supervise for at least six months. If the patient has tried and failed for longer than five years, surgery should be considered.
3. Is there a bariatric surgery clinic that takes a multidisciplinary approach—including the primary care physician—to the patients recovery and success?
4. Have you made and communicated a diagnosis of morbid obesity?
5. Does your patient have a desire to change?
Other factors play a role in choosing the right surgery. An ideal lap band candidate is younger, can exercise, and is not a diabetic. Older patients with worn out joints or medical conditions that won’t allow them to exercise need more aggressive treatment—especially if they’re diabetic. They should investigate Bypass and Sleeve.
[END SIDEBAR]
A Multi-disciplinary Approach to Recovery
“Weight loss surgery is a lifeline,” said Westmoreland. “If you’re drowning, I have to have a good rope to throw to you. I can’t throw you a noodle. If I don’t throw you a good, solid line, you’ll drown. But even after I’ve thrown you the line, you have a choice. You must reach out and hold on. Then those on the shore can pull you in.”
Westmoreland sees the multi-disciplinary team as those on the shore. In addition to the surgeon, a weight loss support group, psychologist, nutritionist, exercise physiologist, and the patient’s primary care physician all have weight to pull. These practitioners must work together. According to Dr. Eckles, “Some diets are incompatible with bariatric surgery. We must work with the primary care physician to help them treat the patient.”
The support groups offered at Murfreesboro Surgical Specialists produce lasting results and relationships. Eckles said, “The biggest advocate these patients will have is another patient.”
Westmoreland added, “Come to support groups if you’re doing well. There are others who are not doing well who will be there. You can help them. If you’re not doing well, come! There will be others there to encourage you. Don’t let shame keep you away.”
Westmoreland believes that prayer should also be a part of the recovery process. “I tell my patients that they should pray about their weight loss daily. Some say, ‘I don’t know how to pray.’ I tell them, ‘Then let’s learn how together.’”
Lifechanging Process. Lifelong Care
“We are never finished with our patient relationships,” said Westmoreland. “Even after you get to your ideal body weight, you can’t say you’re done. You have a lifelong commitment to healthy living. And we have a lifelong commitment to you.”
Recently, Dr. Westmoreland and Eckles sat down with a patient who had Sleeve surgery July. In the five months since surgery, she has lost 60 pounds. “She’s no longer a diabetic,” Westmoreland counted the changes on one hand and moved to the other. “Her arthritis is gone. Her esophageal reflux is gone. She’s off anti-depressants. She still has high blood pressure, but only takes half the dosage she did before the surgery. She looked brand new!”
Westmoreland took a deep breath then quieted his voice. “I told her about my wife asking, ‘Why do you want to do these surgeries?’ I told her the answer is: You! You’re the reason I want to do these surgeries.”
Through this process, he is more fired up about work than he’s ever been. And he’s developed the heart of a healer. “The goal of our program is more than being healthy, being skinny, or being well. We want people healed: body, mind . . . and soul.”
Footnotes:
1 Christina Frangou, Evidence Continues to Mount on Safety of Bariatric Surgery, www.generalsurgerynews.com, November 2007.
2. Matthew Hoffman, MD, What is Gastric Bypass Surgery, www.webmd.com, June 7, 2007.
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