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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Start here…


This is a page re-post to help some of my new readers become familiarized with Latin American Surgery.com – who I am, and what the website is about..

As my long-time readers know, the site just keeps growing and growing.  Now that we have merged with one of our sister sites, it’s becoming more and more complicated for first time readers to find what they are looking for..

So, start here, for a brief map of the site.  Think of it as Cliff Notes for Latin American surgery. com

Who am I/ what do I do/ and who pays for it

Let’s get down to brass tacks as they say .. Who am I and why should you bother reading another word..

I believe in full disclosure, so here’s my CV.

I think it’s important that this includes financial disclosure. (I am self-funded).

I’m not famous, and that’s a good thing.

Of course, I also think readers should know why I have embarked on this endeavor, which has taken me to Mexico, Colombia, Chile, Bolivia and continues to fuel much of my life.

Reasons to write about medical tourism: a cautionary tale

I also write a bit about my daily life, so that you can get to know me, and because I love to write about everything I see and experience whether surgery-related or the joys of Bogotá on a Sunday afternoon.

What I do and what I write about

I interview doctors to learn more about them.

Some of this is for patient safety: (Is he/she really a doctor?  What training do they have?)

Much of it is professional curiosity/ interest: (Tell me more about this technique you pioneered? / Tell me more about how you get such fantastic results?  or just tell me more about what you do?)

Then I follow them to the operating room to make sure EVERYTHING is the way it is supposed to be.  Is the facility clean?  Does the equipment work?  Is there appropriate personnel?  Do the follow ‘standard operating procedure’ according to international regulations and standards for operating room safety, prevention of infection and  overall good patient care?

I talk about checklists – a lot..

The surgical apgar score

I look at the quality of anesthesia – and apply standardized measures to evaluate it.

Why quality of anesthesia matters

Are your doctors distracted?

Medical information

I also write about new technologies, and treatments as well as emerging research.  There is some patient education on common health conditions (primarily cardiothoracic and diabetes since that’s my background).  Sometimes I talk about the ethics of medicine as well.  I believe strongly in honesty, integrity and transparency and I think these are important values for anyone in healthcare.  I don’t interview or encourage transplant tourism because I think it is intrinsically morally and ethically wrong.  You don’t have to agree, but you won’t find information about how to find a black market kidney here on my site.

What about hospital scores, you ask.. Just look here – or in the quality measures section.

Cultural Content

I also write about the culture, cuisine and the people in the locations I visit.  These posts tend to be more informal, but I think it’s important for people to get to know these parts of Latin America too.  It’s not just the doctors and the hospitals – but a different city, country and culture than many of my readers are used to.

Why should you read this?  well, that’s up to you.. But mainly, because I want you to know that there is someone out there who is doing their best – little by little to try to look out for you.

How the site is organized

See the sidebar! Check the drop-down box.

Information about surgeons is divided into specialty and by location.  So you can look in plastic surgery, or you can jump to the country of interest.  Some of the listings are very brief – when I am working on a book – I just blog about who I saw and where I was, because the in-depth material is covered in the book.

information about countries can be found under country tabs including cultural posts.

Issues and discussions about the medical tourism industry, medical safety and quality are under quality measures

Topics of particular interest like HIPEC have their own section.

I’ve tried to cross-reference as much as possible to make information easy to find.

If you have suggestions, questions or comments, you are always welcome to contact me at k.eckland@gmail.com or by leaving a comment, but please, please – no hate mail or spam.  (Not sure which is worse.)

and yes – I type fast, and often when I am tired so sometimes you will find grammatical errors, typos and misspelled words (despite spell-check) but bear with me.  The information is still correct..

Thank you for coming.

New recommendations on the bariatric surgery and diabetes


Re-visiting a previous blog post on our sister site on the use of bariatric surgery in the war on diabetes.

Hidden Gem: Surgery in Cartagena, Colombia

New recommendations out of a recent conference in Austria as reported by the Heart.org.  This comes on the heels of the most recent changes in BMI recommendations, as we reported last month.

As reported by Steve Stiles over at the Heart.org,  in”Case made for metabolic bariatric-surgery eligibility criteria,”  new evidence and recommendations suggest that surgery should be done earlier in the course of the disease process (diabetes) in patients with lower BMIs.  Currently the BMI restriction criteria enforced in North America and Europe prevent the majority of diabetic patients from receiving gastric bypass surgery, which is the only proven ‘cure’ for diabetes.  That’s because the majority of type II diabetic patients are  overweight but not morbidly obese.

As reported previously on this site, Latin American bariatric surgeons have been at the forefront of the surgical treatment of diabetes.  Many of the surgeons previously interviewed for numerous projects…

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Anthony Bourdain does Colombia


It’s not his first visit – he’s done several other programs highlighting Colombia, but tonight’s episode on his new CNN show, “Parts Unknown” is definitely his best.  It’s the first time I think  he actually ‘got it’ and was really able to convey a real sense of Colombia to his viewers.

While his previous shows were primarily about food, and local food culture – his episodes on Colombian cuisine were always very wide from the mark..  Sure, he had the names of dishes and such – but he didn’t really bring home the feel of Colombia and it’s people.

http://www.youtube.com/watch?v=qNiF0R1QJpk&feature=share&list=SP6XRrncXkMaVZxpButSnMywWvtINMmjXv

Or that Colombian food isn’t really about intense spices, it’s about the intense and rich flavors that comes from the rich textures of the foods themselves – without overpowering curries or heavy sauces..

Better quality, fresher ingredients and a wide variety make for richer flavors

Better quality, fresher ingredients and a wide variety make for richer flavors

Dr. Marco Sarinana and Dr. Joel Ramos,Bariatric surgeons


Busy day yesterday – spent the morning shift with Jose Luis Barron over at Mexicali General..  Then raced over to Hospital de la Familia for a couple of general and bariatric cases.

The first case was with the ever charming Drs. Horatio Ham, and Rafael Abril (who we’ve talked about before.)  with the always competent Dr. Campa as the anesthesiologist.   (Seriously – Dr. Campa always does an excellent job.)

Then as we prepared to enter the second case – the director of the hospital asked if I would like to meet Dr. Marco Sarinana G. and his partner, Dr. Joel Ramos..  well, of course.. (Dr. Sarinana’s name has a tilde over the first n – but try coaxing that out this antique keyboard..)

So off to the operating room with these three fellows.  (This isn’t my usual protocol for interviewing surgeons, etc. but sometimes it works out this way.)  Their practice is called Mexicali Obesity Solutions.

Dr. Marco Sarinana and Dr. Joel Ramos, Bariatric surgeons

Dr. Alejandro Ballesteros was the anesthesiologist for the case – and everything proceeded nicely.

After that – it was evening, and time to write everything down!

Today should be another great day – heading to IMSS with Dr. Gabriel Ramos for a big case..

Back in the OR with Drs. Ham & Abril, bariatric and general surgeons


My first case this morning with another surgeon was cancelled – which was disappointing, but I still had a great day in the operating room with Dr.  Ham and Dr. Abril.  This time I was able to witness a bariatric surgery, so I could report back to all of you.

Dr. Ham (left) and Dr. Abril

I really enjoy their relaxed but detail oriented style – it makes for a very enjoyable case.  Today they performed a sleeve gastrectomy** so I am able to report – that they (Dr. Ham) oversewed the staple line (quite nicely, I might add).  If you’ve read any of the previous books, then you know that this is an important step to prevent suture line dehiscence leading to leakage of stomach contents into the abdomen (which can cause very serious complications.)  As I said – it’s an important step – but not one that every doctor I’ve witnessed always performed.   So I was a pleased as punch to see that these surgeons are as world-class and upstanding as everything I’d seen already suggested..

** as long time readers know, I am a devoted fan of the Roux-en-Y, but recent literature suggests that the sleeve gastrectomy is equally effective in the treatment of diabetes.. Of course – we’ll be watching the research for more information on this topic of debate. I hope further studies confirm these results since the sleeve gives patients just a little less of a drastic lifestyle change.. (still drastic but not shot glass sized drastic.)

Dr. Ham

They invited me to the show this evening – they are having several clowns (that are doctors, sort of Patch Adams types) on the show to talk about the health benefits of laughter.  Sounds like a lot of fun – but I thought I better catch up on my writing..

I’ll be back in the OR with Los Doctores again tomorrow..

Speaking of which – I wanted to pass along some information on the anesthesiologist for Dr. Molina’s cases since he did such a nice job with the conscious sedation yesterday.  (I’ve only watched him just yesterday – so I will need a few more encounters, but I wanted to mention Dr. Andres Garcia Gutierrez all the same.

the Weight of a Nation: the obesity epidemic


There’s a new series on HBO that is a collaboration between the Institute of Medicine, the CDC and the National Institute of Health (NIH) that begins airing tomorrow night.  This is a huge undertaking that took over three years to bring to the screen.

As many of you know – Obesity, diabetes and bariatric surgery are some of the topics that have been covered fairly extensively here at Cartagena Surgery.  In fact – it’s the heart of Cartagena Surgery – since the very first surgeon interview I ever performed back in 2010 was Dr. Francisco Holguin Rueda, MD, FACS, the renown Colombia bariatric surgeon.  (Shortly after that first leap – came Drs. Barbosa and Gutierrez – which is how we ended up here today.)

I’ve also been spending time, both last week and this week in the company of several bariatric surgeons here in Mexicali. MX and plan to go to several surgeries this week – so it seemed only appropriate to publish a few articles on the topic.

Talking with Dr. Horacio Ham – Bariatric surgeon, part 1

Talking with Dr. Ham, part 2

(I’m still transcribing notes from another one of my recent interviews – with Dr. Jose Durazo Madrid, MD, FACS).

I’d also like to encourage readers to take a look at HBO’s new mini-series (four episodes over Monday and Tuesday).