It’s not vanity and it’s not easy: NHS agrees


As reported on Sky News and the New York Times, there has been a radical turn around regarding the use of bariatric surgery to prevent/ control and even “cure” diabetes.

vanity

Not a vanity procedure

Once relegated to the category of a” vanity” procedure, bariatric surgery has emerged as a legitimate,  life-saving intervention which has been scientifically proven to have multiple major health benefits.

For years, patients have had to jump numerous hurdles to be considered for this procedure.  One of the biggest hurdles was often that patients were not considered fat enough to qualify for this procedure.  The traditional guidelines restricted surgery to morbidly obese people, and then required these patients to perform numerous tasks to be considered eligible candidates of surgery such as attaining a diagnosis of “carbohydrate addiction” and losing weight prior to surgery as a sign of “commitment” to weight loss.  This was in addition to several months of therapy with nutritionists and counselors.

hoops

A punitive process

While including this ancillary education may have assisted patients post-operatively, it also felt punitive to people who were seeking medical help.  No one forces lung cancer patients to attend smoking cessation courses or counselling before having their cancer treatment nor do we require several sessions of pre-operative classes prior to a bowel resection.

No, not this kind of scale

New guidelines – perform surgery earlier (2012)

But as the data started to emerge that showed long-lasting health benefits of surgery-assisted weight loss, debates raged between International and American physicians.  Several years ago, several international organizations such as the International Diabetes Federation began to recommend lowering the eligibility criteria for bariatric surgery – particularly for patients with documented complications of obesity present (diabetes, coronary artery disease, severe orthopedic injuries).  But these recommendations were ignored by American medical societies and many physicians including the doctors responsible for initiating referrals to bariatric surgery programs.  Americans. it seemed were reserving the the more effective treatments (like gastric bypass or gastric sleeve) for the super-obese, and the prototypical 600 pound patients.

Obese patients who did not meet these rigid guidelines were often sent for less effective procedures like lap-band or balloon placement.  Insurance companies often denied payment stating that surgery in these patients were ‘not medically necessary’  and thus it was considered a ‘vanity’ procedure.  Additionally, in most cases, the procedures failed to produce meaningful or long-lasting results.

Adding stigma and shame to a medical condition

Patients who were overweight  and seeking definitive treatment were often made to feel “lazy” for being unable to lose weight without surgical assistance.  They were also told to return only if they continued to fail (or gain weight).

The Diabetes Pandemic

But as the obesity pandemic continued to escalate at breakneck speed along with obesity-related complications (and healthcare costs skyrocketed), the evidence began to become too overwhelming to ignore.

New guidelines were passed for eligibility criteria for gastric bypass procedures.  These guidelines reduced the necessary BMI to qualify for surgery, especially in patients with co-morbidities such as diabetes.  But it still ignored a large segment of people; non-morbidly overweight people with early diabetes – the very group that was most likely to have a high rate of success and immediate normalization of blood sugars*.

But now the government of the United Kingdom and the National Health Service (NHS) have adopted some of the most progressive recommendations world-wide; aimed at stemming the tide of diabetes and diabetes-related complications such as heart attacks, strokes, renal failure, non-alcoholic fatty liver disease (NASH) and limb ischemia leading to amputation.

The NHS should be commended for their early adoption of eligibility criteria that lowers the BMI requirement to 30 in diabetic individuals and eliminates this requirement entirely in diabetes of Asian descent**. Conservative estimates believe that this change will make an additional one million British citizens eligible for bariatric surgery.

* As a ‘cure’ for diabetes, gastric bypass is most successful in people who have had the disease for less than eight years.

Surge of patients but few surgeries

But can supply keep up with demand?  Last year, according to the our source article (NYT), only 9,000 bariatric procedures were performed in the UK.

**Diabetics of Asian and East Indian  heritage (India, Bangladesh, Pakistan) often develop a more severe, aggressive, rapidly progressive form of diabetes which is independent of BMI or obesity.

More from the Diabetes & Bariatric Archive:

Life after bariatric surgery

Bariatric surgery and the family

Bariatric surgery and CV risk reduction

The Diabetes Pandemic

Part II

Diabetes as a surgical disease

Gastric bypass as a cure for diabetes

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Talking with Dr. Juan David Betancourt Parra, plastic surgeon


I met Dr. Betancourt Parra at IQ interquirofanos while observing surgery with Dr. Luis Botero,. Dr. Betancourt was friendly, and immediately amendable to an interview but it took a little while to coördinate our schedules.

In person, he reminds me a bit of Dr.Carlos Ochoa Gaxiola, the kind and talented Mexican surgeon who graciously permitted me to study with him at Hospital General de Mexicali for several months while writing the Mexicali book.

Maybe it was his laid-back and open conversational style, or the braces on his teeth, giving him a bit of boyish charm that belies his years of experience.  Maybe it was his enthusiasm for his work, but whatever it was, I found the discussion to be especially informative and interesting.

Aesthetic plastic and reconstructive surgery

Dr. Betancourt is a plastic surgeon in Medellin.  He performs a wide range of aesthetic and reconstructive plastic surgery including corporal (body) and facial procedures such as rhinoplasty (nose), face-lifts, blepharoplasty (eyelid lift), breast augmentation, liposuction etc. but his true love is post-bariatric surgery procedures.

He also performs reconstructive surgery such as breast reconstruction after breast cancer.

Post-bariatric practice

Post-bariatric surgery is a subspecialty area of plastic surgery (reconstructive surgery).  Many of these patients have lost very large amounts of weight (100+ pounds) and have large amounts of sagging, drooping and excess skin.

This skin is more than aesthetically displeasing – it can also contribute to the development of skin irritations such as intertriginous dermatitis and infections.   It is particularly prone to causing problems for females – due to an excess build up of moisture, and friction in the genital areas.  It can also make simple tasks like showering, getting dressed and cleaning after using the bathroom difficult.  Patients sometimes have to “tuck” loose skin from the abdomen into support garments to prevent this skin from slipping down to their thighs.  This excess of skin (and the resultant movement/ friction) can prevent people from participating in normal activities like exercise.

The psychological impact of the appearance of, and the challenges of daily living can be extremely distressing – especially for someone who have spent months or years trying to lose weight.

The group of procedures used to treat this problem is called “Body contouring”.  For the majority of patients – this body contouring process will require several months and several separate surgeries.

Body Contouring

One of the primary procedures for body contouring is called a “lower body lift/ /belt lipectomy/ torsoplasty”.  This is actually two separate but very similar techniques; with the belt lipectomy being a modified lower body lift procedure.  However, they are often grouped together to simplify discussions about body contouring procedures.   The lower body lift or belt lipectomy is usually one of the first procedures as part of the reconstructive process after massive weight loss.

This procedure is the core procedure – which removes the majority of excess skin and tissue which is usually in the abdominal/ torso area.  This is a dramatic and large surgical procedure which I liken to “the open heart surgery of plastic surgery.”  This procedure can take 2 to 6 hours, and often requires a 1 to 2 night hospital stay.

The remaining procedures are more of a ‘fine tuning;, as they are smaller procedures with lesser effects as they are aimed at smaller, more specific areas of the body.  These procedures include brachioplexy to remove excess skin (aka “batwings”) from the upper arm/ bicep area, reduction mammoplasty to remove excess skin and drooping from the breast area, or a thighoplasty, to remove excess skin from the thighs/ upper legs.

One year minimum wait after bariatric surgery

Dr. Betancourt requires a minimum of one year after bariatric surgery before patients begin considering body contouring procedures.

This is important for two reasons:

1. Patient’s weight should be stable prior to performing surgical procedures.

2. This period gives patients a chance to adjust to their new weight.  Several studies have demonstrated that it may take months to years to adjust the mind’s eye (mental image) to a person’s actual appearance.

For an excellent article by Salwar & Fabricatore (2008) on the psychological considerations for patients after massive weight loss – click here.

Mirror versus mind’s eye

This is why many people literally “do not see” recent changes in our weight / appearance (particularly subtle/ small changes) when looking in the mirror.  However, as time passes, the mind’s perception of our image/ appearance usually changes to accommodate changes in our ‘real’ appearance – whether weight loss/ gain, signs of aging (fine lines, wrinkles) or even the loss of a limb or appendage.

photo from uhs.uk

photo from uhs.uk

When the mental / mirror image “mismatch” is dramatic, long-lasting, accompanied by depression/ anxiety or leads to dangerous practices like anorexia, hypergymnasia or self-mutilation – it is called body dismorphic disorder (BDD).  Patients who have successfully adjusted to their new size and appearance are much more likely to have realistic expectations, be satisfied with surgical outcomes and be able to maintain their weight over the long-term.

Dr. Betancourt explained that he enjoys the intellectual challenges of caring for post-bariatric surgery patients for several reasons.  These patients, often differ greatly from the majority of plastic surgery patients due to the presence of multiple co-morbid conditions relating to their previous obesity.   Patients may also have body image issues following the initial bariatric surgery as they adjust to their new bodies.  These patients may require multiple procedures for a complete reconstruction, making treatment a somewhat lengthy process.

Dr. Betancourt states that this is what makes it so gratifying; to be able to provide patients with dramatic body changes, help improve their self-image and enable patients to successfully adjust to their new lives.  He also finds it very rewarding because of the high level of patient satisfaction after these procedures.

These patients account for approximately 1/3 of his practice.

Education and Training

Dr. Betancourt has been a plastic surgeon for twelve years.  For eleven years, he worked in a public hospital, Manuel Uribe Angel in Enviagado, providing reconstructive surgery services to all patients at all socio-economic levels in Antioquia, Colombia .  For the last several years, he has devoted a significant portion of his practice to the sub-specialty of post-bariatric surgery.  He has attended several post-bariatric surgery conferences to learn new techniques and exchange ideas with many of the leaders in the field including Dr. Alaly (USA),  Jean François Pascal (France) and Dr. Ricardo Baroudi (Brazil).

Dr. Betancourt attended medical school at Universidad CES (University of Health Sciences) and graduated in 1993.  He is currently a professor at CES.

He competed in general surgical residency at the public hospital, Hospital Ipiranga in Sao Paulo, Brazil before completing his plastic surgery fellowship at the Universidad Santo Amaro, (in Sao Paulo, Brazil).

He is a member of the Colombian Society of Plastic Surgery (SCCP), as well as the Brazilian Society of Plastic Surgery.

Dr. Betancourt speaks Portuguese and English in addition to his native Spanish. He reports some trepidation with his English but was readily able to communicate with me without difficulties.

Dr. Juan David Betancourt Parra

Torre de Especialistas Intermedica 

# 1816

Calle 7 No.39 – 137

Medellin

Tele: 352 0264

Email: plasticjdb1@une.net.co

Website: www.plasticjbd.com

International Patients

While the majority of Dr.Betancourt’s patients are from the local area, he does see international patients. After an initial contact by email, or via his internet page, Dr.Betancourt solicits a complete medical history including previous surgical reports (from previous bariatric or plastic surgery procedures) and current photos.  Patients will also need to have blood work, and EKG as part of the pre-operative evaluation.  Additional studies may be needed depending on the individual’s history and diagnostic test results. (Patients may be referred to Internal Medicine specialist, as needed).

Following the on-line/ email communications, patients will be seen, for an in-person consultation and full physical examination. Dr. Betancourt’s office will make arrangements for a translator and companion to accompany the patient, as needed.  With the patient’s assistance, a full surgical treatment plan will be designed at that time – which discusses how many surgeries and what the anticipated timeline and recovery will be.

As discussed above, the torsoplasty/ belt lipectomy is usually the first procedure performed, often followed by reduction mammoplasty/ mammoplexy.

With the torsoplasty, patients are usually hospitalized for 1 to 2 nights.  They are encouraged to be active and ambulatory as soon as possible after surgery to prevent post-operative complications such as thrombosis and pneumonia. Dr.Betancourt usually engages private nurses to assist patients following their discharge from the hospital.

Sufficient recovery from return travel usually requires 3 weeks, and is monitored by Dr.Betancourt.

Dr. Betancourt also provides psychological / counselling referrals as needed for patients.

Additional References / Reading and Resources on post-bariatric surgery

* Recommended reading:  Langer V, Singh A, Aly AS, Cram AE. (2011).   Body contouring following massive weight loss. Indian J Plast Surg [serial online] 2011 [cited 2013 Aug 11];44:14-20. Available from: http://www.ijps.org/text.asp?2011/44/1/14/81439

Excellent article with general overview of the issues and procedures with before and after photographs.

* Recommended reading:  Shrivastava P, Aggarwal A, Khazanchi RK. Body contouring surgery in a massive weight loss patient: An overview. Indian J Plast Surg [serial online] 2008 [cited 2013 Aug 11];41:114-29. Available from: http://www.ijps.org/text.asp?2008/41/3/114/43607

Additional Readings

Distressing skin problems” – a 2011 first person story about skin problems after massive weight loss from the UK paper, Daily Mail.

Aldaqal SM, Makhdoum AM, Turki AM, Awan BA, Samargandi OA, Jamjom H. (2013).   Post-bariatric surgery satisfaction and body-contouring consideration after massive weight loss.  N Am J Med Sci. 2013 Apr;5(4):301-5. doi: 10.4103/1947-2714.110442.

Giordano S, Victorzon M, Koskivuo I, Suominen E. (2013).  Physical discomfort due to redundant skin in post-bariatric surgery patients.  Plast Reconstr Aesthet Surg. 2013 Jul;66(7):950-5. doi: 10.1016/j.bjps.2013.03.016. Epub 2013 Apr 9.  [free full text not available].

Song AY, Rubin JP, Thomas V, Dudas JR, Marra KG, Fernstrom MH. (2006).  Body image and quality of life in post massive weight loss body contouring patients. Obesity (Silver Spring). 2006 Sep;14(9):1626-36. [no free full text available].

Dr. Ruben Francisco Luna Romero, MD and a sad day for the Colombian medical community


I received word today that Dr. Ruben Luna, general and transplant surgeon from Clinica Shaio in Bogotá, has passed away.

I met Dr. Luna a year ago while writing about Bogotá – he was a gracious and kind gentleman who didn’t mind taking the time to share some stories with an unknown writer.  So, today, I would like to share some of my notes from those interviews with Dr. Ruben Luna.

Dr. Ruben Francisco Luna Romero, MD was also the Chief of Surgery at the Shaio Clinic, and was a member of the Colombian Association for Obesity and Bariatric Surgery.

Almost an engineer

Dr. Luna was a general and transplant surgeon who helped pioneer kidney transplantation in Colombia. During our interviews, Dr. Luna reported that he was initially training to be an engineer and had entered his third year of study in Spain when he decided to switch to medicine.  He stated he had initially been dissuaded from medicine due to the long hours he saw his father work as a general surgeon.

Dr. Luna attended Universitario del Rosario for both medical school and his general surgery residency. He was working at San Rafael Hospital when he was approached by his department head who encouraged further specialization in Renal (kidney) and pancreatic transplant.

At that time, Dr.  Luna’s sister was the Heart – Lung Transplant Coordinator at the University of Minnesota, and she helped arrange for Dr. Luna to complete a transplant fellowship under the guidance of Dr. David Sutherland, an American legend in the field of solid organ transplant.  After his return to Colombia, Dr. Luna performed the first kidney transplant at Clinica San Rafael on Oct. 31, 1985.  He went on to perform the first kidney / pancreas transplant at San Pedro Claver in 1987, and was part of the team performing the first heart – kidney transplant at Clinica Shaio in 1997.

Commitment to patients & humanitarian efforts

He never forgot his commitment to his the care of his patients.  In fact, Dr. Luna started a foundation to support organ transplantation for children and performed over sixty transplants (for free as part of humanitarian efforts).  His organization also convinced several drug companies to provide anti-rejection medications to the children for free.  Dr. Luna helped to establish transplant surgery programs at Clinica Shaio, Colsubsido, San Pedro Claver and Clinica San Rafael.

Outstanding Young Person

In 1991 he was named the Outstanding Young Person of the World for medical innovation.  He also established the regional procurement program now in place in Bogotá.

Hard work took its toll

However, all of these achievements took their toll; at 36, Dr. Luna had his first heart attack.  Despite two subsequent heart attacks and cardiac surgery, Dr. Luna continued to maintain a full-time surgical practice.  In his spare time, he enjoyed playing golf.

His son, Dr. Ruben Daniel Luna Alvaro, MD maintains his legacy. He is a third generation general surgeon and maintains an active general surgery practice in addition to performing bariatric surgery and kidney transplantation as a staff physician at Clinica Shaio.  He has been operating since 2005.

** This was not the first kidney transplant in Colombia, which dates back to the 1960’s, at Hospital San Juan de Dios.

Meeting of the minds – thoracic surgery


Attended the monthly thoracic surgery meeting led by Dr. Juan Carlos Garzon yesterday for case discussions.. Several interesting cases presented.  More importantly, I met and set up interviews with the last few thoracic surgeons; Dr. Beltran and Dr. Rodolfo Barrios (that I hadn’t met previously).  Should be an interesting week in the south end of the city..

On the topic of thoracic surgery – I am soliciting articles from thoracic surgeons, and other practitioners on the site – not just here in Bogota, but from around the world as part of the mission of the site.  I’ve already had some great feedback from some American surgeons.

Over at cartagena surgery we are talking about the recent announcement by the International Diabetes Federation on treatment recommendations for diabetes including the endorsement of Bariatric Surgery.

The Doctors Luna at Clinica Shaio


Interviewed the father and son, Dr. Ruben Francisco Luna Romero and Dr. Ruben Daniel Luna Alvaro this morning, before following Dr. Luna (Alvaro) to the operating room. Dr. Luna was joined by the remaining doctor in the Grammo practice, Dr. Cesar Guevara.

Due to some technical issues – i will post photos later.

Update: 21 April 2011: Photos

Dr. Luna, general and transplant surgeon

Dr. Guevara (left) and Dr. Luna (right) during laparoscopic surgery

Dr. Cesar Guevara, Grammo

In the the OR with Dr. Juan Pablo Umana & Dr. Ricardo Nasser


Dr. Juan Pablo Umana, cardiac surgeon

Dr. Juan Pablo Umana

Cardiac Surgeon at Fundacion Cardioinfantil

Spent the morning in the operating room with Dr. Juan Pablo Umana. Dr. Umana is the Chief of Adult Cardiac Surgery at Cardioinfantil.

Ran into an old friend while I was there..

Dr. Jose Pomares, Anesthesia

Dr. Pomares was a anesthesia resident over at Medihelp in Cartagena, when I was writing hidden gem.. I recognized those emerald eyes right away.. (not sure if I would have recognized him without the mask.)

Dr. Umana had another case, but so did I – over at Santa Fe de Bogota..

Went back to see Dr. Ricardo Nasser, Chief of Bariatric Surgery. He just returned from the Bariatric Surgery conference in Cartagena, and was back at work, in the operating room.

Dr. Ricardo Nasser

Bariatric Surgeon – Fundacion Santa Fe de Bogota

Dr. Richard Nasser, Bariatric surgeon

More Bariatrics please!


If you’ve been following my reports on Cartagenasurgery.wordpress.com then you know I’ve been meeting with bariatric surgeons across the city. Today I met with Dr. Richardo Nassar Bechara, who is the Chief of the Bariatric Surgery program at Fundacion Santa Fe de Bogota. He is part of a comprehensive Obesity Clinic program which includes multiple specialties and comprehensive medical and surgical treatment for obesity and metabolic syndrome.

Right now he is preparing for the upcoming Latin American Congress on Obesity and Obesity Surgery so he has no surgery planned for several days. (Don’t worry – I’ll be going to the OR soon so I can report back to all of you.)

The program stresses lifestyle change and includes cardiology, endocrinology, physical therapy, nutrition, psychiatry and internal medicine.

Part of the program includes the VidActiva gym which offers personalized training programs with cardiovascular exercise, weight training, complimentary health services such as tai chi, dance, pilates, acupuncture and massage therapy. The clinic is staffed full-time with a sports medicine physician.