Guest: Dr. Thomas K. Byrne - General and Gastrointestinal Surgery
Host: Dr. Linda Austin – Psychiatrist
Announcer: Welcome to an MUSChealth Podcast.
Dr. Linda Austin: I am Dr. Linda Austin. I am interviewing Dr. Thomas K. Byrne, who is the Medical Director of the Bariatric Surgery Program here at the Medical University of South Carolina. Doctor Byrne, bariatric surgery has offered hope for so many patients, who have had just phenomenal results with this surgery. How long have you been doing this surgery?
Dr. Thomas K. Byrne: I have been doing it here at MUSC since 1992.
Dr. Linda Austin: How many folks get this procedure every week?
Dr. Thomas K. Byrne: Well, it’s probably better to look at it on an annual basis. When we started doing that first, we would do maybe 20 procedures a year; last year we did 320. So, over the course of the last six years, the numbers have dramatically increased; in fact, our numbers are increasing by about 15% to 18% a year of patients, who are having this surgery.
Dr. Linda Austin: Who is a good candidate for this surgery?
Dr. Thomas K. Byrne: The National Institute of Health in 1991 established that patients with a body mass index of 40 or greater, who have failed the major weight loss program, are candidates for this surgery. In addition, patients with a body mass index of 35 or greater, who have failed the weight loss program, but have medical problems that are weight related such has diabetes, hypertension, or sleep apnea, are also candidates for this surgery.
Dr. Linda Austin: So, I would imagine the majority of your patients have really struggled with obesity for many, many years.
Dr. Thomas K. Byrne: Many of them have tried and failed multiple times and in fact many of our patients have been incredibly successful with weight loss programs and have lost lots of weight, but put it all back on again. They yo-yo back and forth. The procedures that we do tend to eliminate that completely.
Dr. Linda Austin: Why is that, I know you said in an earlier podcast that it is possible to gain your weight all back and I think everybody knows that people who lose large amounts of weight are very susceptible to gaining the weight back. Why is it that this surgery is so successful in helping people keep it off?
Dr. Thomas K. Byrne: Well, we don’t exactly know. Certainly, the operation is very successful in controlling portion sizes, but there is more to it than that. There is obviously a hormonal influence in it somewhere. We know that levels of ghrelin, which is a hormone that stimulates appetite are very, very, very low after a bariatric procedure such as a LAP-BAND or gastric bypass and this may be one reason that ghrelin levels are so low that appetite is not stimulated. In fact, if you ask a lot of these patients postoperatively about their dietary habits, they will tell you that sometimes they forget to eat; they lose interest in food completely. In that way, they are very successful with their weight loss.
Dr. Linda Austin: So, then, is it thought that there is a physiologic mechanism by which distention of the stomach, what decreases ghrelin levels, is that?
Dr. Thomas K. Byrne: Nobody quite knows why it is, why the ghrelin levels are decreased. We know they are decreased, but we don’t know the mechanism of it. The stretch part of it is important because initially we thought and we still do that, the stretch receptor sends signals to the hypothalamus, telling patients that they are full, so they stop eating, that’s one part of the mechanism. The ghrelin may be another part of the mechanism, but it’s still all undiscovered and very exciting from the research point of view.
Dr. Linda Austin: So, then, to take it one step further, the patients who are obese and have been so for many, many years, have they stretched their stomach? You hear people talk about that colloquially stretching your stomach or shrinking your stomach, does that actually happen with people who are morbidly obese for long periods of time?
Dr. Thomas K. Byrne: Yeah, I think it does. I think that patients to some extent stretch their stomachs out; although, the mechanism again is not quite clear. The patients eat and don’t get a feeling of satiety, not necessarily because their stomach is anyway larger, but there must be some signals and some place either through ghrelin or leptin or something else that sends signals to the brain to say that they are full and they don’t have this; so they may be lacking in this; again, the mechanism is not clear.
Dr. Linda Austin: So, in another words, it’s not just a direct physical stretching, it is something else.
Dr. Thomas K. Byrne: Initially, we did think that’s what it was, but now the thought is that it’s much more than that. Now, it is fairly clear that if patient stretch their pouch out, if they have a gastric bypass for example and they overeat constantly, for example, if they try to eat to capacity in every single meal, clearly the stomach is a small muscular bag and will increase in size just like any muscle is exercised. Sometimes, we see these patients back and they have put the weight back on and we get some studies that indicates that their pouch has gotten much, much larger and then you find out that they have been stretching it out at every single opportunity and unfortunately they put the weight back on again. That’s one of the mechanism and the other mechanism for putting weight back on is the fact that they don’t eat the right kinds of food. They go back to eating junk food and high calory, high fat content food.
Dr. Linda Austin: So, here is the question for which the research also may not be available yet or the data may not be available yet. Conversely, if people diet and really eat small portions over a long, long period of time, this is people who have not been operated on; do they actually shrink their stomach or is that just an old wives? tale?
Dr. Thomas K. Byrne: I don’t think anybody really knows that. I don’t know if there is any evidence that suggests that their stomach does actually shrink.
Dr. Linda Austin: What is the largest person you have done this operation on?
Dr. Thomas K. Byrne: We have operated on a 28-year-old female, who weighed 1200 pounds, probably about eight years may be.
Dr. Linda Austin: And lost how much weight?
Dr. Thomas K. Byrne: Well, she was from a good ways from here, so her followup was a little sketchy, and I haven’t seen her for several years, but the last time I saw her, she was about 450. So, she had about a 700-pound weight loss.
Dr. Linda Austin: What is more typical profile of patient?
Dr. Thomas K. Byrne: On an average, BMI here is about 45. So, patients around the 300 mark are the commonest that we see; although, that hasn’t; in fact, that has decreased over the course of the last several years, but with the advent of LAP-BAND, the patients who are, what we would consider on the borderline of morbid obesity, are now electing to have the LAP-BAND. So, BMI has decreased somewhat.
Dr. Linda Austin: How long does the procedure take?
Dr. Thomas K. Byrne: The gastric bypass procedure laparoscopically takes us about an hour and a half and the LAP-BAND takes about a little over an hour or thereabout.
Dr. Linda Austin: Does insurance typically cover this?
Dr. Thomas K. Byrne: That really depends on most of the big insurance companies or plans will cover it, for example most of the Blue Cross Plans nationwide will cover bariatric surgery and patients come to the clinic and find that their insurance won’t cover it and then they get upset with their insurance carrier, but whether it is covered or not depends very much on what the patient’s employer has negotiated with the insurance company. So, an employer for example on of ? let’s pick for an example Wal-Mart or Kmart or Michelin or BMW may contract with Blue Cross or Blue Shield to cover a 5,000 employees and as part of that coverage package, they will ? whether they will cover bariatric surgery or not. So, one patient may have a Blue cross Plan and another may have another Blue cross Plan and they may both come; one may be covered and one may not be because of the fact that their employer hasn’t negotiated the package with it. Medicare covers the procedure as long as it is done and what’s called the Center of Excellence, which we are here at MUSC and Center of Excellence designation is an effort by the American Society for bariatric and metabolic surgery to control the quality of procedures and quality of followup and so on among surgeons who are doing bariatric surgery. So, several years ago, they instituted the Center of Excellence Program in order to apply for, we have to present our data over the course of many years that was examined and for complications rates, hospital stay, readmit rates, and so on and so forth and after a stringent examination including a site visit, centers are designated; we were designated in February 2005. Now, that meant that patients who have got Medicare can have surgery in the Center of Excellence. CMS decided that if Medicare patients are going to have surgery then they will have to have it at the Centre of Excellence. So, we have had a lot of Medicare patients over the course of the last year or so.
Dr. Linda Austin: Without insurance what is the cost, not a problem?
Dr. Thomas K. Byrne: The average cost for a gastric bypass at MUSC is about $27,000 which covers everything including hospitalization, anesthesia fees, surgeon’s fees, and so on and so forth.
Dr. Linda Austin: So, about the price of a good car.
Dr. Thomas K. Byrne: About the price of Japanese car.
Dr. Linda Austin: And I would imagine that the lifetime savings in healthcare costs alone are many, many times?
Dr. Thomas K. Byrne: Yeah, and that’s been a very well study as a matter fact and several studies have come out within the last couple of years. Many of the insurance carriers failed to, for example the State Plan in South Carolina does not cover the surgery and the contention is that the surgery is too expensive and it doesn’t save money, but many studies have come out over the course of the last couple of years, which have shown that at about three years after the procedure in a patient with maybe three or four comorbidities such as diabetes and hypertension, the lines between the cost of surgery and the cost of medications and doctor’s visit crisscross and after that, the savings occur. So, if your are looking short-term over the course of a year, there is not much in the way of savings because certain amount of money has been paid off for the procedure. Well, after three years, the savings are phenomenal, not to talk of the benefit at the patients health.
Dr. Linda Austin: Absolutely.
Dr. Thomas K. Byrne: So, that has been studied in detail with thousands of patients and it is definitely cost effective. The other thing that has been studied recently is two groups were studied, a group that had bariatric surgery and cohort group of the same age, basically the same vague were studied in Canada and it was clear that the mortality in the patients who had bariatric surgery was dramatically lower than the patients who did not have surgery over the course of the 5-year period, dramatically different.
Dr. Linda Austin: What’s the oldest patient you have operated on and generally is there any upper age limit for this surgery?
Dr. Thomas K. Byrne: We really don’t have an upper age limit, we have operated on patients in their 70s.
Dr. Linda Austin: How about the youngest?
Dr. Thomas K. Byrne: We have done probably 20 teenagers, youngest being 13, and we are seeing more and more teenagers coming to our clinic now for surgery and for evaluation.
Dr. Linda Austin: Nationally, how many cases have been done?
Dr. Thomas K. Byrne: Well, last year approximately 1,77,000 cases were done nationwide. We did about 320 here and it is estimated that those numbers will go up some, but they have dramatically increased over the course of the last five years; four or five years ago, we did 1,20,000 cases a year in the US. Now, it is 1,77,000. The limiting factor is not that people don’t want to have it done, the limiting factor is their insurance coverage. If you look at the national demographics, there are approximately 15 million people in the US, who are considered morbidly obese with comorbidities. Right now, to have over 1% of those patients who are having surgery, 1%. For every bariatric surgeon in the country right now, there are 20,000 patients that would benefit from bariatric surgery and the limiting factor is not because people don’t want it and not because the procedures are not safe or effective, it’s because the insurance companies for the most part have not figured out that this is effective and cost effective in the long run.
Dr. Linda Austin: What do you think is the future for bariatric surgery?
Dr. Thomas K. Byrne: I think that there are some new procedures that are beginning to evolve, so I think there will be an armamentarium of maybe four or five procedures within the course of the next 10 years that are performed commonly. I think the way of the future is that when a patient comes to our office, they will slip into an algorithm of what procedure will suit them best and that will only come about when we have collected the data that the SRC, which is the part of the Center of Excellence Program are collecting, so that we can look at the data and say this procedure works best for this particular patient, that procedure will work best for that particular patient; for example, I think that probably the best procedure for teenagers would be the laparoscopic adjustable gastric band; however, right now, it’s not sanctioned for use in patients under 18 by the FDA. I think that will break fairly soon with some of the data that we have, there have been some trails in teenagers using the band and it has been very successful. So, I think of teenagers come to our office, we would be offering them the LAP-BAND. It may well be that patients who are incredibly morbidly obese with very, very high risk of complications, will have a procedure done, which is called the laparoscopic sleeve procedure; a procedure that was done in the past, but has now sort of come back and the world began, which essentially removes part of the stomach and creates a long tube along the lesser curvature of the stomach. There is a gold standard right now in the US is the laparoscopic gastric bypass, which has stood the test of time. It’s a resilient operation, it’s low in complications, and provide that patients get out of the hospital and do okay, it’s low in nutritional complications, which is a tremendous advantage, but there are some new procedures that are beginning to be looked at. So, I think it’s going to evolve certainly a population of morbidly obese people, it would appear as not going to decrease anytime soon.
Dr. Linda Austin: Dr. Byrne, thank you so much for talking with us today.
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